临床治疗联合多重干预对社区2型糖尿病综合管理效果的研究

发布时间：2018-03-26 19:28

  本文选题：多重干预　切入点：社区　出处：《上海交通大学》2015年硕士论文

【摘要】：研究目的:随着经济水平和生活质量的不断提高,生活方式的改变和老龄化情况的不断加重,使得越来越多的人罹患2型糖尿病。目前,中国面临糖尿病患病数量巨大,控制问题异常严峻的现状。尽管,近年来各地政府着重强调社区诊疗,家庭医生规范管理的积极作用,但仍然无法满足日益增长的患病群体的控制问题。2型糖尿病的发生发展不仅受到遗传和环境的双重作用,由于疾病本身的长期性,患者往往存在各种心理问题,其中以抑郁最为多见。同时,由于身心问题的交织,对患者的生活亦产生了很多负面影响,睡眠问题在糖尿病合并抑郁的患者中呈现高发比例。由糖尿病引起的病理生理变化、各种心理问题,以及不良的生活方式等,使糖尿病良好控制面临很大挑战。面对复杂的患有身心疾病的个体,除了要不断探索有效的糖尿病诊治技术外,加强患者的健康教育和行为支持至关重要,促进健康生活方式的建立至关重要。近年,专业领域在同伴支持、移动医疗技术和舒缓音乐对慢性疾病自我管理支持方面的研究正在兴起。同伴支持作为患者互助和社会支持的一种形式,有助于优化糖尿病的管理,持续为糖尿病患者提供社会和情感支持,协助病患更好地改进日常生活中的健康行为;移动医疗通过移动信息技术支持临床治疗和健康管理,通过智能应用程序,可以帮助医师更好地了解患者日常控制情况及困扰及时给予指导,使糖尿病管理更加个体化,提高疾病的管理效率;舒缓音乐疗法作为一种特定的治疗手段,被应用在很多心理疾病上,在一些合并身心疾患的慢性病个体,针对某些症状,如睡眠障碍,舒缓音乐通过激活大脑边缘系统可改善生理心理状态,进而可收到良好的改善症状的效果。本研究针对社区2型糖尿病,比较常规社区临床治疗联合同伴支持、移动医疗技术和舒缓音乐等多重干预对患病个体在临床指标、健康行为以及特定合并状态,如抑郁、睡眠障碍等的综合管理效果,评价多重干预在社区糖尿病管理中付诸实践之必要性和可行性。研究方法:(1)第一阶段(0-6月):在上海市黄浦区瑞金二路街道社区卫生服务中心建档的1492名2型糖尿病患者中,根据项目入选/排除标准,招募193名自愿参加项目的研究对象。按照随机化原则,将所有入组患者分成同伴支持组(96名)和常规社区治疗组(97名)。同伴支持组分成6个小组,每个小组配备2名经考核合格的同伴支持小组组长,开展为期6个月的观察。评价两组患者hba1c、糖尿病相关知识、糖尿病自我管理行为和自我效能的前后差异。(2)第二阶段(7-13月):在以上患者中,经过一个月的洗脱期(第7个月),再行筛选存在抑郁状态和睡眠障碍患者45名,将其分成多重干预组(22名)和常规社区治疗组(23名)。多重干预组分成3个小组,每小组由2名同伴组长组织日常活动,多重干预组的患者均使用手机,并安装糖尿病健康管理平台。第8-10个月,社区医生、同伴组长和同伴小组成员利用智能健康管理平台,加强糖尿病治疗和自我管理支持,重点就心理舒缓、睡眠健康管理等给予指导。第11-13个月,多重干预组在同伴支持、移动医疗技术基础上再指导给予睡前舒缓音乐治疗。第8-13个月,常规社区治疗组患者接受常规社区疾病治疗和健康教育。分别在第8、10、13个月时进行评估,比较两组患者血糖控制(hba1c)、睡眠质量(psqi量表)、抑郁症状(phq-9抑郁量表)、糖尿病知识、糖尿病自我管理行为和自我效能变化。研究结果:(1)临床治疗单纯联合同伴支持组的患者较常规社区治疗组,其hba1c在6个月时改善效果更好,且统计学差异(7.15±1.04vs7.53±1.63,p0.05);其自我效能亦有所提升,两组得分有统计学差异(109.20±13.88vs102.09±14.67,p0.05)。(2)临床治疗联合同伴支持和移动医疗技术后,用phq-9评价患者抑郁干预效果,多重干预组较常规社区治疗组在改善抑郁方面效果更为显著,且与第二阶段初始时比较,自身前后有明显改善(4.43±4.09vs8.09±2.45,p0.05);用psqi评价患者睡眠质量干预效果,多重干预组较常规社区治疗组在改善患者睡眠质量效果上更为显著;自身前后亦有改善(9.62±4.04vs12.36±4.00,p0.05);在多重干预的基础上再联合舒缓音乐后,睡眠量表评价显示多重干预对改善抑郁的效果又有进一步的提升(2.55±1.67vs5.95±4.02,p0.05);且多重干预组自身睡眠质量也有改善(8.81±4.43vs12.36±4.00,p0.05)。研究结论:(1)在常规临床治疗基础上,联合多重干预,如同伴支持、移动医疗技术和舒缓音乐,对帮助社区2型糖尿病患者进一步改善临床治疗效果、自我管理行为以及疾病相关伴随状态等具有良好效果;(2)在社区开展糖尿病综合防止中,应该全力推动多重干预手段的实践和应用,以进一步提升糖尿病防控效果,同时也将为其他慢性病的防控和管理积累经验,丰富干预手段,不断提升临床效果,以及推动改善卫生经济学成效发挥良好作用。
[Abstract]:Purpose: with the quality level of the economy and improvement of life, change the way of life and the aging situation continues to increase, making more and more people suffering from type 2 diabetes. At present, the prevalence of diabetes China facing huge amount, control problem serious. Although in recent years, local governments emphasize community clinics, actively the role of family doctors standardized management, but still can not meet the occurrence and development of type.2 diabetes control group of growing not only influenced by both genetic and environmental, due to the long-term nature of the disease itself, often with various psychological problems, including depression is the most common. At the same time, by interleaving the physical and mental problems. Also produced a lot of negative impact on the lives of patients, showing a high incidence of sleep problems in the proportion of diabetes with depression patients. Pathology caused by diabetes students Physical changes, a variety of psychological problems, and the bad way of life, to make good control of diabetes facing great challenges. In the face of the complex with the individual physical and mental diseases, in addition to continuously explore effective techniques for diagnosis and treatment of diabetes patients, strengthen the health education and behavior support is crucial, it is important to establish and promote a healthy lifestyle. In recent years, the field of professional in peer support, mobile medical technology and soothing music on chronic disease self-management support research is on the rise. Peer support as a form of mutual aid patients and social support, help to optimize the management of diabetes, continue to provide social and emotional support to patients with diabetes, to help patients better improvement in daily life health behavior; mobile medical support clinical treatment and health management through mobile information technology, through the intelligent application, can help physicians To better understand the daily control and distress in patients with timely guidance, make diabetes management more individualized, improve disease management efficiency; soothing music therapy as a specific treatment method, is used in many mental illnesses, in some individuals with physical and mental disorders of chronic disease, the symptoms, such as sleep disorders, soothing the music through the activation of the limbic system can improve the physiological and psychological state, and received good effect can improve symptoms. In this study, the community type 2 diabetes, compared with conventional clinical treatment combined with community peer support, mobile medical technology and soothing music intervention on multiple affected individuals in clinical indicators, health behavior and the specific combined state, such as depression and sleep disorders such as the comprehensive management effect, the necessity of the evaluation of multiple intervention into practice in community management of diabetes in the study and feasibility. Methods: (1) the first stage (0-6 months) in 1492 patients with type 2 diabetes mellitus in Shanghai city of Huangpu District road two Ruijin street community health service centers, according to the inclusion / exclusion criteria, the recruitment of 193 volunteer subjects. According to the principle of randomization, all 20 patients were divided into peer support group (96) and conventional treatment group (97 cases) community. Peer support group was divided into 6 groups, each group with 2 certified peer support team leader, to carry out the observation period of 6 months. The two groups were evaluated by HbA1c, diabetes related knowledge, self-management of diabetes and self-efficacy before and after difference. (2) the second phase (7-13 months): in these patients, one month after the washout period (seventh months), and for screening patients with depression and sleep disorder in 45, divided into multiple intervention group (22 cases) and conventional treatment group (23 patients in community ). Multi intervention group was divided into 3 groups, each group consisted of 2 peer leader is to organize daily activities, multiple intervention group of patients using the mobile phone, and install the health management platform for diabetes. The 8-10 months of community doctors, peer peer leader and team members using intelligent health management platform, strengthen the treatment of diabetes mellitus and self management support and focus on psychology, sleep health management guidance. In 11-13 months, the intervention group in multiple peer support, based on the mobile medical technology to guide to bedtime soothing music therapy - 8-13 months, conventional community treatment received routine community disease treatment and health education were assessed in the first 8,10,13. Months respectively, compared two groups of patients with blood glucose control (HbA1c), sleep quality (PSQI scale), depressive symptoms (PHQ-9 Depression Scale), diabetes knowledge, self-management behavior changes in diabetes and self-efficacy. Results: (1) the clinical treatment of simple combined with peer support group of patients than the conventional community treatment group, the HbA1c has better effect in 6 months, and the statistical difference (7.15 + 1.04vs7.53 + 1.63, P0.05); the self efficiency is also improved, there is significant difference between the two groups score (109.20 + 13.88vs102.09 + 14.67, P0.05). (2) clinical treatment combined with peer support and mobile medical technology, with the effect of depression in patients with intervention of PHQ-9 evaluation, multiple intervention group compared with the conventional community treatment group in improving depression effect is more significant, and compared with second initial stage, significantly improved before and after (4.43 + 4.09vs8.09 + 2.45, P0.05 the effect of the sleep quality of the patients); PSQI intervention evaluation, multiple intervention group compared with the conventional community in improving the patients' sleep quality effect is more obvious; there are also self improvement (9.62 + 4.04vs12.36 + 4, P0.05); in the multi intervention 鐨勫熀纭，

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