【摘要】：目的建立并評價基于互聯(lián)網(wǎng)的社區(qū)高血壓自我管理干預(yù)模式,探索在互聯(lián)網(wǎng)新媒體背景下的慢性病管理服務(wù)新模式,進一步提升慢性病防控效果。方法本研究組建研發(fā)小組,結(jié)合《慢性病自我管理實踐》等指南或著作內(nèi)容,形成基于互聯(lián)網(wǎng)的社區(qū)高血壓自我管理干預(yù)模式的主要結(jié)構(gòu)與內(nèi)容,方案完全自主設(shè)計,委托廣東福來健康科技有限公司按設(shè)計方案開發(fā)。該模式主要框架內(nèi)容有血壓、心率、運動、膳食、心理風險等實時監(jiān)測,健康綜合評價,個性化運動、膳食、心理處方的制定,行動計劃與目標的制定,波動異常提醒建議與制定,健康教育內(nèi)容的制定與推送,健康咨詢等內(nèi)容,最后形成以互聯(lián)網(wǎng)為媒介,以社區(qū)自我管理干預(yù)系統(tǒng)為平臺,以手機微信客戶端為監(jiān)測載體,以智能運動手環(huán)、智能電子血壓計為監(jiān)測工具的新型自我管理干預(yù)模式。本研究以居委為單位,對廣州市番禺區(qū)東環(huán)街社區(qū)衛(wèi)生服務(wù)中心所有管轄居委隨機抽取三個居委(富豪、東環(huán)、番藝),隨機分組。共招募高血壓患者106例,富豪居委招募53例為實驗組,番藝居委和東環(huán)居委分別招募27例、26例為對照組。實驗組接受基于互聯(lián)網(wǎng)的社區(qū)高血壓自我管理干預(yù)模式,對照組接受常規(guī)自我管理干預(yù)模式。實驗組和對照組干預(yù)時間均為6個月。干預(yù)前對兩組高血壓患者進行基本情況調(diào)查,包括性別、年齡、婚姻狀況、文化程度、服藥情況、每月醫(yī)藥費、遺傳史等內(nèi)容。對兩組高血壓患者干預(yù)前后評價指標進行測量,包括血壓,體適能,身體活動量,行為改變階段,膳食,心理,生化指標、自我效能和疾病認知等內(nèi)容測量。膳食評價采用3天24小時膳食回顧和家庭膳食食譜登記相結(jié)合的方法,心理和自我效能評價采用生存質(zhì)量量表、抑郁量表、焦慮量表、長谷川式簡易智能評定表、自我效能量表評價。數(shù)據(jù)收集與分析:運用SPSS 21.0軟件對數(shù)據(jù)整理和統(tǒng)計分析,采用定量和定性分析相結(jié)合的方法對基于互聯(lián)網(wǎng)的社區(qū)高血壓自我管理干預(yù)模式進行效果評價。率的比較采用卡方檢驗和確切概率法,計量資料采用t檢驗方法,定性研究采用小組訪談法。結(jié)果1.基于互聯(lián)網(wǎng)的高血壓自我管理干預(yù)模式本研究利用自主研發(fā)的“互聯(lián)網(wǎng)+”社區(qū)高血壓自我管理平臺,建立一種以社區(qū)為基礎(chǔ)、以互聯(lián)網(wǎng)為載體、以智能可穿戴設(shè)備為監(jiān)測工具,以患者為中心,以個性化干預(yù)為措施的高血壓自我管理干預(yù)模式。該模式主要由醫(yī)生決策系統(tǒng)、個性化干預(yù)決策系統(tǒng)和自我管理手機應(yīng)用系統(tǒng)(微信客戶端)組成。醫(yī)務(wù)人員通過該平臺實時監(jiān)測患者的血壓、心率、膳食、運動、心理、癥狀等指標,綜合評估,為患者及時提供個性化指導和精準健康支持,并實時監(jiān)測和推送個性化健康評價報告、個性化膳食處方、個性化運動處方、個性化心理指導、高血壓知識圖文消息、減脂目標、線上線下健康咨詢等�；颊邎�(zhí)行健康計劃和目標,并實時反饋。期間,醫(yī)務(wù)人員與患者不斷交流反饋,修改目標和計劃,直到找到適宜自身的個性化干預(yù)。2.兩組高血壓患者干預(yù)前后干預(yù)效果比較(1)兩組干預(yù)前后血壓、控制率、服藥率變化:實驗組干預(yù)后的收縮壓較干預(yù)前減少5.8mm Hg,差異有統(tǒng)計學意義(p0.05);對照組干預(yù)后的收縮壓較干預(yù)前減少2.9 mm Hg,差異無統(tǒng)計學意義(p0.05)。實驗組和對照組干預(yù)前后舒張壓、控制率、服藥率差異均無統(tǒng)計學意義(p0.05)。實驗組干預(yù)前后收縮壓差值、舒張壓差值、控制率、服藥率與對照組比較差異均無統(tǒng)計學意義(p0.05)。(2)兩組干預(yù)前后生化指標變化:實驗組干預(yù)前后紅細胞差值、血清肌酐差值、血鉀濃度差值、同型半胱氨酸差值、血清低密度脂蛋白膽固醇差值和血清高密度脂蛋白膽固醇差值與對照組比較差異有統(tǒng)計學意義(p0.05)。實驗組干預(yù)后的同型半胱氨酸、紅細胞較干預(yù)前有所改善,差異有統(tǒng)計意義(p0.05);對照組干預(yù)后的白蛋白、同型半胱氨酸、血鉀濃度、血鈉濃度、血清高密度脂蛋白膽固醇與干預(yù)前比較差異均有統(tǒng)計意義(p0.05)。實驗組和對照組干預(yù)前后其他生化指標差值與對照組比較差異均無統(tǒng)計學意義(p0.05)。(3)兩組干預(yù)前后體適能、身體活動量、行為改變階段、腰圍、BMI變化:實驗組干預(yù)前后肺活量差值、選擇反應(yīng)時差值、身體活動量差值、腰圍差值比對照組有所改善,差異有統(tǒng)計學意義(p0.05)。實驗組的肺活量、選擇反應(yīng)時、身體活動量、行為改變階段、腰圍干預(yù)前后比較差異均有統(tǒng)計學意義(p0.05)。對照組的閉眼單腳站立干預(yù)前后比較差異有統(tǒng)計學意義(p0.05)。實驗組干預(yù)前后BMI差值、握力差值、坐位體前屈差值和閉眼單腳站立差值與對照組比較差異均無統(tǒng)計學意義(p0.05)。(4)兩組干預(yù)前后膳食變化:實驗組干預(yù)前后谷薯類實際攝入量差值、水果類差值、鈣差值、碘差值較對照組有所改善(-91.2g、38.4g、181.7mg、0.3mg)差異均有統(tǒng)計學意義(p0.05)。實驗組蔬菜類、谷薯類、畜禽水產(chǎn)品、鹽、膽固醇、鈣、鉀、碘的實際攝入量干預(yù)前后比較差異均有統(tǒng)計學意義(p0.05)。對照組各類食物和營養(yǎng)素實際攝入量干預(yù)前后比較差異均無統(tǒng)計學意義(p0.05)。實驗組其他各類食物、能量和營養(yǎng)素實際攝入量干預(yù)前后差值與對照組比較差異均無統(tǒng)計學意義(p0.05)。(5)兩組干預(yù)前后生存質(zhì)量、抑郁、焦慮、認知功能變化:實驗組干預(yù)前后活力差值、社會功能差值、情感職能差值、心理健康差值、焦慮差值和認知功能差值與對照組比較差異有統(tǒng)計學意義(p0.05)。實驗組干預(yù)后的軀體疼痛、情感職能得分較干預(yù)前高(10.0分、23.9分),焦慮、抑郁得分較干預(yù)前低(-14.0分、-4.4分),差異均有統(tǒng)計意義(p0.05);對照組干預(yù)后的生存質(zhì)量、抑郁、焦慮、認知功能得分與干預(yù)前比較差異均無統(tǒng)計意義(p0.05)。實驗組干預(yù)前后生理功能差值、生理職能差值、軀體疼痛差值、總體健康差值、健康變化差值、抑郁差值與對照組比較差異均無統(tǒng)計學意義(p0.05)。(6)兩組干預(yù)前后自我效能、疾病認知變化:實驗組干預(yù)前后自我效能差值、疾病認知差值與對照組比較差異有統(tǒng)計學意義(p0.05)。實驗組干預(yù)后的疾病認知、癥狀管理、一般疾病管理比干預(yù)前得分高(2.0分、5.4分、1.7分),差異均有統(tǒng)計意義(p0.05);對照組干預(yù)后的疾病認知、癥狀管理、一般疾病管理與干預(yù)前比較差異均無統(tǒng)計意義(p0.05)。3.定性研究:醫(yī)務(wù)人員均認為基于互聯(lián)網(wǎng)的社區(qū)高血壓自我管理干預(yù)模式可以拉近醫(yī)患關(guān)系,提高醫(yī)生健康服務(wù)質(zhì)量和效率,提高社區(qū)高血壓管理率。高血壓患者也對該模式比較滿意,認為能解決他們實際健康問題,能滿足他們的需求。結(jié)論本研究發(fā)現(xiàn),針對社區(qū)高血壓患者自我管理而言,基于互聯(lián)網(wǎng)的社區(qū)高血壓自我管理干預(yù)模式在血壓、體適能、身體活動量、行為改變階段、膳食、生化指標、心理、疾病認知和自我效能等方面較常規(guī)自我管理干預(yù)模式有更好的干預(yù)效果,且具有實時性、參與性、個性化、普及性等優(yōu)點。因此,在社區(qū)大力推廣基于互聯(lián)網(wǎng)的社區(qū)高血壓自我管理干預(yù)模式是一項可行的慢性病防控新舉措。
[Abstract]:Objective to establish and evaluate the self-management intervention model of community hypertension based on the Internet, explore a new model of chronic disease management under the background of Internet new media, and further improve the effectiveness of chronic disease prevention and control. The main structure and content of the self-management intervention model of the community hypertension self-management, the scheme is completely designed and commissioned by Guangdong Fulai Health Science and Technology Co., Ltd. according to the design scheme. The main frame of the model is the real-time monitoring of blood pressure, heart rate, exercise, diet, psychological risk, health comprehensive evaluation, personalized exercise, diet, psychological prescription. The formulation, the formulation of the action plan and the target, the suggestion and the formulation of abnormal fluctuation, the formulation and push of the health education content, the health consultation and so on, and finally form the Internet as the medium, the community self management intervention system as the platform, the mobile WeChat client as the monitoring carrier, the intelligent sport ring, the intelligent electronic sphygmomanometer A new type of self-management intervention model of monitoring tools was used in this study. In this study, we randomly selected three residential committees (the rich, the east ring, and the art) in the community health service center of Panyu District east ring street, Guangzhou, at random, recruited 106 cases of hypertensive patients, and 53 cases were recruited by the rich residence Committee as the experimental group, the Committee of the Fang Yi Ju and the east ring residence. The group received 27 cases and 26 cases as the control group. The experimental group accepted the self-management intervention model of community hypertension based on the Internet, and the control group received routine self management intervention. The intervention time of the experimental group and the control group were 6 months. Before the intervention, the basic situation of two groups of hypertensive patients, including sex, age, marital status, was studied. Two groups of hypertensive patients were measured before and after intervention, including blood pressure, physical fitness, physical activity, behavior change stage, diet, psychology, biochemical index, self-efficacy and cognition of disease. Dietary evaluation adopted 3 days and 24 hours diet review and family. The method of combination of dietary diet registration, psychological and self-efficacy evaluation adopted quality of life scale, depression scale, anxiety scale, Kyohko Hasegawa simple intelligence assessment table, self-efficacy scale evaluation. Data collection and analysis: using SPSS 21 software for data sorting and statistical analysis, the method of combining quantitative and qualitative analysis to the basis of the method The effect evaluation on the self-management intervention model of hypertension in the community was conducted. The ratio of the rate was compared with the chi square test and the exact probability method, the t test method was used in the measurement data, and the qualitative research was conducted by the group interview. Results 1. the self-developed "Internet +" community based on the independent research and development of the self-developed "Internet +" community based on the Internet based hypertension self management intervention model was used. The self management platform of hypertension is based on the community as the basis, the Internet as the carrier, the intelligent wearable equipment as the monitoring tool, the patient as the center, and the individualized intervention as the measure of self management intervention. The model is mainly composed of the doctor decision-making system, the personalized intervention decision system and the self managed mobile application department. The medical staff can monitor the patient's blood pressure, heart rate, diet, exercise, psychology, symptoms and so on through this platform, to provide personalized guidance and accurate health support for patients in time, and to monitor and push personalized health evaluation report in real time, personalized diet prescription, individualized exercise prescription and personality. Psychological guidance, hypertension knowledge graphic message, fat reduction target, online and offline health counseling. Patients perform health plans and goals, and real-time feedback. During the period, medical staff and patients continue to exchange feedback, modify target and plan, until the intervention effect ratio of two groups of hypertension patients before and after intervention are found to be suitable for their own individual intervention. Compared with (1) the two groups, the blood pressure, control rate, and drug rate were reduced before and after the intervention: the systolic pressure of the experimental group was reduced by 5.8mm Hg than before the intervention (P0.05); the systolic pressure of the control group decreased by 2.9 mm Hg before the intervention (P0.05). The diastolic pressure, control rate, and drug rate before and after the intervention of the experimental group and the control group were not statistically significant. The difference was not statistically significant (P0.05). There was no significant difference in the difference of systolic pressure, diastolic pressure difference, control rate and drug rate between the experimental group and the control group before and after intervention (P0.05). (2) the changes of biochemical indexes before and after the intervention of the two groups: the difference of red blood cells, the difference of serum creatinine, the difference of blood potassium concentration, and the difference of homocysteine before and after the intervention of the experimental group The difference between the difference of serum low density lipoprotein cholesterol and serum HDL-C was statistically significant (P0.05). The prognosis of homocysteine in the experimental group was better than that before the intervention, and the difference was statistically significant (P0.05). The difference of blood sodium concentration and serum HDL cholesterol before intervention was statistically significant (P0.05). There was no significant difference in the difference of other biochemical indexes between the experimental group and the control group before and after the intervention (P0.05). (3) the body activity, the change of behavior, the waist circumference, and the change of BMI: the experimental group. The difference of vital capacity before and after intervention, the difference value of reaction time, the difference value of body activity and the difference between the waist circumference, and the difference were statistically significant (P0.05). The vital capacity of the experimental group, the physical activity and the behavior change stage in the experimental group were statistically significant (P0.05) before and after the waist circumference intervention (P0.05). The closed eye of the control group was closed to the single foot. There was significant difference between before and after standing intervention (P0.05). There was no significant difference in the difference value of BMI, the difference of grip strength, the difference of the front flexion of the sitting body and the difference between the close eye and the single foot before and after the intervention of the experimental group (P0.05). (4) the dietary changes before and after the intervention of the two groups: the difference between the actual intake of the potato and the fruit before and after the intervention of the experimental group, and the poor fruit The difference of -91.2g, 38.4g, 181.7mg, 0.3mg was statistically significant (P0.05). The difference of the actual intake of vegetable, valley, potato, animal and poultry, salt, cholesterol, calcium, potassium and iodine was statistically significant (P0.05) in the experimental group (P0.05). The actual intake of food and nutrients in the control group was significant (P0.05). There was no statistical difference before and after intervention (P0.05). There was no significant difference in the difference of the actual intake of energy and nutrients between the experimental group and the control group before and after intervention (P0.05). (5) the quality of life, depression, anxiety, cognitive function before and after the intervention of the two groups: the difference of vigor and social function before and after the intervention of the experimental group Difference, emotional function difference, mental health difference, anxiety difference and cognitive function difference were statistically significant (P0.05). The scores of emotional function in the experimental group were higher than before intervention (10, 23.9), anxiety and depression were lower than before intervention (-14.0, -4.4), and the difference was statistically significant (P0.05). There was no statistically significant difference in quality of life, depression, anxiety, cognitive function scores and before intervention in the control group (P0.05). There was no significant difference in the difference of physiological function, the difference of physiological function, the difference of physical pain, the difference of physical pain, the difference of total health, the difference of health, the difference of health and the difference of depression with the control group (6). (P0.05). The difference of self efficacy before and after the intervention of the two groups: the difference of self efficacy before and after the intervention of the experimental group, the difference of the difference between the disease cognition and the control group was statistically significant (P0.05). The disease cognition, the symptom management and the general disease management in the experimental group were higher (2, 5.4, 1.7), and the difference was statistically significant (P0.05) The difference of disease cognition, symptom management and general disease management before intervention in the control group had no statistical significance (P0.05).3. qualitative research: the medical staff thought that the community hypertension self-management intervention model based on the Internet could close the doctor-patient relationship, improve the health service quality and efficiency of the doctors, and improve the community hypertension management. The study found that the self-management intervention model of community hypertension based on the Internet is in the blood pressure, physical fitness, physical activity, behavior change stage, diet, and diet based on the self management of hypertension patients in community. Food, biochemical indicators, psychology, disease cognition and self-efficacy have better intervention effects than the conventional self-management intervention models, and have the advantages of real time, participatory, individualized and universal. Therefore, it is a feasible and feasible way to prevent and control chronic disease prevention and control in community based on the Internet based community hypertension self management intervention model. Move.
【學位授予單位】：暨南大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R544.1

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