【摘要】：研究背景工業(yè)化、城鎮(zhèn)化和人口老齡化的不斷發(fā)展帶來(lái)了生活方式的巨大轉(zhuǎn)變,與之相關(guān)的慢性病及其危險(xiǎn)因素也在快速增加。糖尿病作為一種與生活方式密切相關(guān)的慢性病,已經(jīng)成為影響社會(huì)發(fā)展和居民健康的重大公共衛(wèi)生問(wèn)題。2010年中國(guó)慢性病及其危險(xiǎn)因素監(jiān)測(cè)報(bào)告顯示：2010年18歲及以上居民糖尿病患病率為9.7%,知曉率僅為36.1%,控制率僅為34.7%,可見(jiàn)居民糖尿病知曉和控制情況不甚樂(lè)觀。在我國(guó),龐大的糖尿病患病人群和相對(duì)緊缺的衛(wèi)生資源決定了患者自身必須承擔(dān)大部分疾病管理的工作。國(guó)際上的大量研究已經(jīng)證明：采取以健康教育為主要手段的綜合措施,社區(qū)糖尿病自我管理能提高糖尿病患者的自我效能、激發(fā)患者的主動(dòng)性和潛能,有效得幫助他們進(jìn)行血糖控制,進(jìn)而預(yù)防和減少并發(fā)癥,減輕家庭和社會(huì)的疾病負(fù)擔(dān)。另一方面糖尿病的自我管理本身就體現(xiàn)了“從單純治療到健康管理和疾病管理”、“從專業(yè)行動(dòng)到群眾行動(dòng)”等新型慢性病防治理念,契合了新型的“生理-心理-社會(huì)”醫(yī)學(xué)模式。為此,本研究在糖尿病自我管理干預(yù)的國(guó)內(nèi)外研究的基礎(chǔ)上,繼續(xù)深入探討以社區(qū)為基礎(chǔ)的糖尿病自我管理干預(yù)的模式與效果,并對(duì)其近期成本-效果進(jìn)行分析,為進(jìn)一步完善糖尿病自我管理模式提供科學(xué)參考,為政策制定者提供實(shí)踐參考和證據(jù)支持。研究目的1.研究社區(qū)糖尿病患者自我管理干預(yù)在增加糖尿病相關(guān)知識(shí)、增強(qiáng)自我效能、改善行為方式、改善糖尿病相關(guān)體格測(cè)量指標(biāo)和生化指標(biāo)方面的效果及近期成本-效果。2.研究糖尿病患者自我管理干預(yù)效果的影響因素。3.探討社區(qū)糖尿病患者自我管理干預(yù)模式的優(yōu)勢(shì)和不足,為進(jìn)一步完善推廣提供證據(jù)支持。研究方法和內(nèi)容選擇從北京市房山區(qū)4個(gè)街道共17個(gè)社區(qū)/村招募到的510名2型糖尿病患者作為研究對(duì)象。將510名研究對(duì)象在每個(gè)村內(nèi)隨機(jī)分組,形成17個(gè)干預(yù)組和17個(gè)對(duì)照組。以中國(guó)疾病預(yù)防控制中心慢病中心編寫(xiě)的《慢性病患者自我管理實(shí)踐—糖尿病》(ISBN 978-7-117-18927-9/R·18928)一書(shū)作為教材,對(duì)干預(yù)組研究對(duì)象實(shí)施糖尿病患者自我管理小組活動(dòng)干預(yù)。在實(shí)施干預(yù)之前和之后一個(gè)月分別在510名研究對(duì)象中開(kāi)展基線調(diào)查和終末調(diào)查,采用體格測(cè)量、實(shí)驗(yàn)室檢測(cè)和問(wèn)卷調(diào)查的方式收集數(shù)據(jù)和信息。選取糖尿病患者知識(shí)得分、自我效能得分、相關(guān)行為、體格測(cè)量指標(biāo)和生化指標(biāo)作為效果指標(biāo),并對(duì)相應(yīng)指標(biāo)進(jìn)行近期成本-效果分析和干預(yù)效果的影響因素分析。采用Epidata3.1軟件建立數(shù)據(jù)庫(kù),對(duì)調(diào)查問(wèn)卷進(jìn)行雙錄入；清洗數(shù)據(jù)后形成最終的數(shù)據(jù)庫(kù)。運(yùn)用SAS9.3軟件對(duì)數(shù)據(jù)進(jìn)行統(tǒng)計(jì)分析,計(jì)量資料如服從正態(tài)分布則采用均數(shù)、標(biāo)準(zhǔn)差描述其集中趨勢(shì)和離散趨勢(shì),采用t檢驗(yàn)對(duì)組間均數(shù)和自身前后均數(shù)進(jìn)行比較,并采用多元線性回歸分析某些指標(biāo)的影響因素,如不服從正態(tài)分布則采用中位數(shù)描述其集中趨勢(shì),采用秩和檢驗(yàn)對(duì)組間均數(shù)和自身前后均數(shù)進(jìn)行比較；計(jì)數(shù)資料采用率或構(gòu)成比進(jìn)行統(tǒng)計(jì)描述,采用χ2或Fisher確切概率法進(jìn)行組間率和自身前后率的比較。參數(shù)估計(jì)和假設(shè)檢驗(yàn)的水準(zhǔn)為a=0.05.研究結(jié)果1.一般情況終末調(diào)查時(shí)共收集到合格有效問(wèn)卷500份,其中干預(yù)組259份,對(duì)照組241份。全部研究對(duì)象的平均年齡61.66±7.64歲,最大年齡84歲,最小年齡31歲。其中男性174人(34.80%),女性326人(65.20%)。兩組研究對(duì)象在重要人口學(xué)特征(性別、年齡、文化程度、婚姻狀況、家庭人均月收入等)上經(jīng)檢驗(yàn)差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。2.效果及近期成本-效果2.1知識(shí)：干預(yù)后干預(yù)組在“三多一少”癥狀、空腹血糖正常范圍、慢性并發(fā)癥、體重指數(shù)正常范圍、自我血糖監(jiān)測(cè)、低血糖成因、血壓推薦控制目標(biāo)、食物交換中的一份和合理的行動(dòng)計(jì)劃9道題目正確回答率均高于對(duì)照組(P0.05)；干預(yù)后干預(yù)組知識(shí)總得分為82.32±15.10分,對(duì)照組為66.31±22.01分,干預(yù)組高于對(duì)照組(P0.01)。2.2自我效能：干預(yù)后干預(yù)組在飲食自我效能、運(yùn)動(dòng)自我效能、藥物自我效能、血糖監(jiān)測(cè)自我效能、足部護(hù)理自我效能、高低血糖的預(yù)防和處理自我效能及總自我效能方面的得分分別25.80±3.58分、17.37±2.83分、13.89±1.90分、15.38±3.29分、22.36±3.18分、18.10±2.44分和112.9±14.58分,對(duì)照組的得分分別為23.27±-4.51分、16.10±3.70分、13.51±2.13分、13.57±3.70分、20.57±4.64分、16.90±3.01分和103.9±17.98分,且干預(yù)組得分均高于對(duì)照組(P0.05)。2.3行為：2.3.1血糖自我監(jiān)測(cè)：干預(yù)后干預(yù)組掌握自我血糖監(jiān)測(cè)方法的率和家中備有血糖儀的率分別為87.26%和69.50%,對(duì)照組為63.07%和57.68%,干預(yù)組均高于對(duì)照組(P0.05)；干預(yù)后干預(yù)組和對(duì)照組自我血糖監(jiān)測(cè)頻率分別為2天/周和1天/周,干預(yù)組均高于對(duì)照組(P0.01)。2.3.2足部護(hù)理：干預(yù)后干預(yù)組在合適溫度的水洗腳、水平得剪指甲、使用護(hù)膚類油膏和定期找醫(yī)生檢查足執(zhí)行率分別為98.07%、84.94%、69.50%、42.47%,對(duì)照組分別為87.97%、72.61%、50.62%、31.12%,干預(yù)組均高于對(duì)照組(P0.05)；干預(yù)后干預(yù)組和對(duì)照組足部自我檢查頻率分別為7天/周和5天/周,干預(yù)組均高于對(duì)照組(P0.01)。2.3.3健康飲食：干預(yù)后干預(yù)組和對(duì)照組遵循健康飲食要求的頻率分別為6天/周和5天/周,干預(yù)組高于對(duì)照組(P0.01)；干預(yù)后干預(yù)組和對(duì)照組食用高膳食纖維食物的頻率分別為為3天/周和2天/周,干預(yù)組高于對(duì)照組(P0.01)。2.3.4有氧運(yùn)動(dòng)：干預(yù)后干預(yù)組和對(duì)照組做30分鐘及以上的有氧運(yùn)動(dòng)頻率分別為7天/周和6天/周,干預(yù)組均高于對(duì)照組(P0.01)。2.3.5服藥和吸煙飲酒：服藥方面,干預(yù)后干預(yù)組和對(duì)照組在自行停藥率上低于對(duì)照組,差異有顯著性(P0.05)。吸煙方面,干預(yù)前干預(yù)組的吸煙率高于對(duì)照組,差異有顯著性(P0.05),干預(yù)后兩組間吸煙率差異無(wú)顯著性(P0.05)。飲酒方面,干預(yù)前后干預(yù)組和對(duì)照組的飲酒率差異均無(wú)顯著性(P0.05)。2.4體格測(cè)量指標(biāo)和生化指標(biāo)干預(yù)前后干預(yù)組的平均體重降低1.49kg,對(duì)照組升高1.14kg,差異有顯著性(P0.05)；干預(yù)后干預(yù)組和對(duì)照組在糖尿病相關(guān)生化指標(biāo)上差異無(wú)顯著性(P0.05)。2.5近期成本-效果糖尿病自我管理干預(yù)使自我效能提高一分的總成本為8795.55元,人均成本為33.96元；使每周自我監(jiān)測(cè)血糖天數(shù)增加一天的總成本為70012.60元,人均成本為270.32元；使每周自我檢查足部天數(shù)增加一天的總成本為70012.60元,人均成本為270.32元；使每周遵循糖尿病健康飲食天數(shù)每增加一天的總成本為70012.60元,人均成本為270.32元；使每周進(jìn)行30分鐘及以上有氧運(yùn)動(dòng)天數(shù)增加一天的總成本為70012.60元,人均成本為270.32元；使體重每降低lkg的總成本為26620.76元,人均成本為102.78元。3.干預(yù)效果影響因素3.1糖尿病患者自我管理知識(shí)得分干預(yù)效果的影響因素為基線知識(shí)得分、年齡(歲)、文化程度、家庭人均月收入(元)、對(duì)小組活動(dòng)的整體評(píng)價(jià)和社區(qū)醫(yī)生參與頻率(P0.05)。3.2糖尿病患者自我管理自我效能得分干預(yù)效果的影響因素為基線自我效能得分、小組活動(dòng)總體評(píng)價(jià)、活動(dòng)內(nèi)容的難易程度(P0.05)。3.3糖尿病患者自我管理體重干預(yù)效果的影響因素為基線體重(kg)、性別、家庭人均月收入(元)(P0.05)。4.滿意度和意向4.1干預(yù)組滿意度和自我評(píng)估干預(yù)組研究對(duì)象對(duì)自我管理小組活動(dòng)的總體滿意度為96.14%,84.94%的干預(yù)組研究對(duì)象表示會(huì)繼續(xù)參加自我管理小組活動(dòng)。在吸引糖尿病患者參加自我管理小組活動(dòng)的原因中,排在首位的是“能學(xué)到有用的知識(shí)”,在導(dǎo)致糖尿病患者缺席的原因中,排在首位的是“家庭或工作事務(wù)太多”。在8項(xiàng)自我管理的任務(wù)中,干預(yù)組研究對(duì)象認(rèn)為自己“做得最好”和“做得最差”排在首位的分別是“適量運(yùn)動(dòng)”和“掌握胰島素注射技巧”。4.2對(duì)照組意向和自我評(píng)估80.08%的對(duì)照組研究對(duì)象表示如果以后開(kāi)展糖尿病自我管理活動(dòng)“會(huì)愿意參加”。在8項(xiàng)自我管理的任務(wù)中,干預(yù)組研究對(duì)象認(rèn)為自己“做得最好”和“做得最差”的排在首位的分別是“適量運(yùn)動(dòng)”和“自我血糖監(jiān)測(cè)”。研究結(jié)論本研究在國(guó)內(nèi)首次運(yùn)用統(tǒng)一規(guī)范的教材實(shí)施社區(qū)糖尿病患者自我管理干預(yù),采用患者小組長(zhǎng)和社區(qū)醫(yī)生配合的形式帶領(lǐng)小組活動(dòng),設(shè)立平行對(duì)照組對(duì)其干預(yù)效果及近期成本-效果進(jìn)行評(píng)價(jià),結(jié)果發(fā)現(xiàn)社區(qū)糖尿病患者自我管理干預(yù)在提高糖尿病患者知識(shí)、自我效能、改善行為方面有效。建議將社區(qū)糖尿病患者自我管理干預(yù)納入基本公共衛(wèi)生服務(wù),以保證其長(zhǎng)效發(fā)展。本研究還發(fā)現(xiàn)糖尿病患者在“自我血糖監(jiān)測(cè)”、“足部護(hù)理”、“掌握胰島素注射技巧”和“運(yùn)動(dòng)強(qiáng)度的評(píng)估”等方面的知識(shí)、自我效能、行為或自我評(píng)價(jià)相對(duì)較差,建議在以后開(kāi)展社區(qū)糖尿病患者自我管理活動(dòng)時(shí)對(duì)以上方面予以針對(duì)性加強(qiáng)。
[Abstract]:Background Industrialization, urbanization and population aging have brought about tremendous changes in lifestyle, and the related chronic diseases and risk factors are also increasing rapidly. In 2010, the prevalence rate of diabetes was 9.7%, the awareness rate was only 36.1%, and the control rate was only 34.7%. This shows that the awareness and control of diabetes is not very optimistic. In China, a large number of diabetic patients and relatively scarce health resources determine the patients themselves. A large number of international studies have proved that community diabetes self-management can improve the self-efficacy of patients with diabetes, stimulate their initiative and potential, effectively help them to control blood glucose, and then prevent and reduce diabetes. On the other hand, self-management of diabetes itself embodies the new concept of chronic disease prevention and treatment, from simple treatment to health management and disease management, from professional action to mass action, and accords with the new "physiological-psychological-social" medical model. Based on the research of self-management intervention on diabetes mellitus at home and abroad, the model and effect of community-based self-management intervention on diabetes mellitus were further explored, and its short-term cost-effectiveness was analyzed to provide a scientific reference for further improving the self-management model of diabetes mellitus and provide practical reference and evidence support for policy makers. Objective 1. To study the effect and short-term cost-effectiveness of self-management intervention on diabetes related knowledge, self-efficacy, behavior, physical and biochemical indexes. 2. To study the influencing factors of self-management intervention on diabetic patients. The research method and content selected 510 type 2 diabetic patients recruited from 17 communities/villages in 4 streets of Fangshan District in Beijing as the subjects. 510 subjects were randomly divided into 17 intervention groups in each village. The self-management practice of patients with chronic diseases - diabetes mellitus (ISBN 978-7-117-18927-9/R.18928), written by the Center for Chronic Diseases of the Center for Disease Control and Prevention of China, was used as a textbook. The participants in the intervention group were intervened in the activities of self-management group of diabetes mellitus patients before and one month after the intervention. Baseline and final surveys were conducted among the subjects. Data and information were collected by physical measurement, laboratory tests and questionnaires. Knowledge score, self-efficacy score, related behavior, physical measurement index and biochemical index of diabetic patients were selected as the effect indicators, and the short-term cost-effectiveness analysis of the corresponding indicators was carried out. Establish a database with Epidata 3.1 software, double-input the questionnaire, and form the final database after cleaning the data. Use SAS 9.3 software to analyze the data. If the measurement data obey normal distribution, use mean, standard deviation to describe its centralized trend and discrete trend, and use t-test. The mean between groups was compared with the mean before and after themselves, and the influencing factors of some indexes were analyzed by multiple linear regression. If not obeying normal distribution, the median was used to describe the centralized trend, and the rank sum test was used to compare the mean between groups and the mean before and after themselves. Results 1. A total of 500 valid questionnaires were collected at the end of the general survey, including 259 in the intervention group and 241 in the control group. There were 174 males (34.80%) and 326 females (65.20%). There was no significant difference between the two groups in demographic characteristics (gender, age, education, marital status, per capita monthly income, etc.) (P 0.05). 2. Effect and short-term cost-effectiveness 2. The rate of correct answers to 9 questions of fewer symptoms, normal range of fasting blood glucose, chronic complications, normal range of body mass index, self-monitoring of blood glucose, causes of hypoglycemia, recommended control targets of blood pressure, a reasonable plan of action in food exchange was higher than that of the control group (P 0.05), and the total score of knowledge in the intervention group was 82.32 (15.10), the control group. The self-efficacy of the intervention group was higher than that of the control group (P 0.01). The self-efficacy of the intervention group was higher than that of the control group (P 0.01). The self-efficacy of the intervention group in diet self-efficacy, exercise self-efficacy, drug self-efficacy, blood glucose monitoring self-efficacy, foot care self-efficacy, prevention and treatment self-efficacy of high and low blood glucose, and total self-efficacy were 25.80 + 3.58, 17. The scores of control group were 23.27 (- 4.51), 16.10 (- 3.70), 13.51 (- 2.13), 13.57 (- 3.70), 20.57 (- 4.64), 16.90 (- 3.01) and 103.9 (- 17.98), respectively. The scores of intervention group were higher than those of control group (P Monitoring: After intervention, the rate of self-monitoring blood glucose in intervention group and the rate of equipped with blood glucose meter in home were 87.26% and 69.50% respectively, and 63.07% and 57.68% in control group. The frequency of self-monitoring blood glucose in intervention group and control group were higher than that in control group (P 0.05). 2.3.2 Foot care: After intervention, the intervention group washed feet with water at the right temperature, and the level of nail clipping, using skin care ointment and regular doctor check feet were 98.07%, 84.94%, 69.50%, 42.47% respectively. The control group was 87.97%, 72.61%, 50.62%, 31.12% respectively. The intervention group was higher than the control group (P 0.05). The frequency of self-examination was 7 days/week and 5 days/week respectively, and the intervention group was higher than the control group (P 0.01). 2.3.3 Healthy diet: The frequency of the intervention group and the control group following the healthy diet requirements were 6 days/week and 5 days/week respectively, and the intervention group was higher than the control group (P 0.01). Intervention group was higher than control group (P 0.01). 2.3.4 Aerobic exercise: After intervention, the frequency of aerobic exercise for 30 minutes and more in intervention group and control group were 7 days/week and 6 days/week respectively. Intervention group was higher than control group (P 0.01). 2.3.5 medication and smoking and drinking: medication, intervention group and control group were self-medication after intervention. Smoking rate of intervention group was higher than that of control group (P 0.05). There was no significant difference in smoking rate between intervention group and control group (P 0.05). Indicators and biochemical indicators before and after intervention, the average weight of intervention group decreased by 1.49 kg, the control group increased by 1.14 kg, the difference was significant (P 0.05); intervention group and control group in diabetes related biochemical indicators were not significantly different (P 0.05). 2. The total cost of increasing the days of self-monitoring blood glucose per week was 70012.60 yuan, and the average cost was 270.32 yuan. The total cost of increasing the days of self-examination feet per week was 70012.60 yuan and the average cost per capita was 270.32 yuan. The total cost was 70012.60 yuan and the per capita cost was 270.32 yuan. The influencing factors of intervention effect were baseline knowledge score, age (age), education level, per capita monthly income (yuan), the overall evaluation of group activities and the frequency of community doctor participation (P 0.05). 3.2 The influencing factors of intervention effect were baseline self-efficacy score and group activities overall evaluation. The baseline weight (kg), sex, monthly income per capita (yuan) (P 0.05). 4. Satisfaction and intention 4.1 in intervention group and self-evaluation intervention group were 96.14% and 84.9% respectively. Four percent of the participants in the intervention group said they would continue to participate in self-management group activities. In the intervention group, 80.08% of the control group and 80.08% of the control group indicated that they would be willing to participate in diabetes self-management activities if they did the best and the worst respectively. Among the eight self-management tasks, participants in the intervention group rated themselves as the best and worst performers as "moderate exercise" and "self-monitoring of blood sugar", respectively. A parallel control group was set up to evaluate the intervention effect and the short-term cost-effectiveness. The results showed that the self-management intervention was effective in improving the knowledge, self-efficacy and behavior of diabetic patients. This study also found that diabetic patients had relatively poor self-efficacy, behavior or self-evaluation in terms of "self-monitoring of blood glucose", "foot care", "mastery of insulin injection skills" and "evaluation of exercise intensity". It was suggested that community development should be carried out in the future. The above aspects should be strengthened in the self-management activities of diabetic patients.
【學(xué)位授予單位】：中國(guó)疾病預(yù)防控制中心
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R587.1

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