社区糖尿病患者自我管理干预效果研究
发布时间：2018-08-28 20:31
【摘要】：研究背景工业化、城镇化和人口老龄化的不断发展带来了生活方式的巨大转变,与之相关的慢性病及其危险因素也在快速增加。糖尿病作为一种与生活方式密切相关的慢性病,已经成为影响社会发展和居民健康的重大公共卫生问题。2010年中国慢性病及其危险因素监测报告显示：2010年18岁及以上居民糖尿病患病率为9.7%,知晓率仅为36.1%,控制率仅为34.7%,可见居民糖尿病知晓和控制情况不甚乐观。在我国,庞大的糖尿病患病人群和相对紧缺的卫生资源决定了患者自身必须承担大部分疾病管理的工作。国际上的大量研究已经证明：采取以健康教育为主要手段的综合措施,社区糖尿病自我管理能提高糖尿病患者的自我效能、激发患者的主动性和潜能,有效得帮助他们进行血糖控制,进而预防和减少并发症,减轻家庭和社会的疾病负担。另一方面糖尿病的自我管理本身就体现了“从单纯治疗到健康管理和疾病管理”、“从专业行动到群众行动”等新型慢性病防治理念,契合了新型的“生理-心理-社会”医学模式。为此,本研究在糖尿病自我管理干预的国内外研究的基础上,继续深入探讨以社区为基础的糖尿病自我管理干预的模式与效果,并对其近期成本-效果进行分析,为进一步完善糖尿病自我管理模式提供科学参考,为政策制定者提供实践参考和证据支持。研究目的1.研究社区糖尿病患者自我管理干预在增加糖尿病相关知识、增强自我效能、改善行为方式、改善糖尿病相关体格测量指标和生化指标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预效果的影响因素。3.探讨社区糖尿病患者自我管理干预模式的优势和不足,为进一步完善推广提供证据支持。研究方法和内容选择从北京市房山区4个街道共17个社区/村招募到的510名2型糖尿病患者作为研究对象。将510名研究对象在每个村内随机分组,形成17个干预组和17个对照组。以中国疾病预防控制中心慢病中心编写的《慢性病患者自我管理实践—糖尿病》(ISBN 978-7-117-18927-9/R·18928)一书作为教材,对干预组研究对象实施糖尿病患者自我管理小组活动干预。在实施干预之前和之后一个月分别在510名研究对象中开展基线调查和终末调查,采用体格测量、实验室检测和问卷调查的方式收集数据和信息。选取糖尿病患者知识得分、自我效能得分、相关行为、体格测量指标和生化指标作为效果指标,并对相应指标进行近期成本-效果分析和干预效果的影响因素分析。采用Epidata3.1软件建立数据库,对调查问卷进行双录入；清洗数据后形成最终的数据库。运用SAS9.3软件对数据进行统计分析,计量资料如服从正态分布则采用均数、标准差描述其集中趋势和离散趋势,采用t检验对组间均数和自身前后均数进行比较,并采用多元线性回归分析某些指标的影响因素,如不服从正态分布则采用中位数描述其集中趋势,采用秩和检验对组间均数和自身前后均数进行比较；计数资料采用率或构成比进行统计描述,采用χ2或Fisher确切概率法进行组间率和自身前后率的比较。参数估计和假设检验的水准为a=0.05.研究结果1.一般情况终末调查时共收集到合格有效问卷500份,其中干预组259份,对照组241份。全部研究对象的平均年龄61.66±7.64岁,最大年龄84岁,最小年龄31岁。其中男性174人(34.80%),女性326人(65.20%)。两组研究对象在重要人口学特征(性别、年龄、文化程度、婚姻状况、家庭人均月收入等)上经检验差异无统计学意义(P0.05)。2.效果及近期成本-效果2.1知识：干预后干预组在“三多一少”症状、空腹血糖正常范围、慢性并发症、体重指数正常范围、自我血糖监测、低血糖成因、血压推荐控制目标、食物交换中的一份和合理的行动计划9道题目正确回答率均高于对照组(P0.05)；干预后干预组知识总得分为82.32±15.10分,对照组为66.31±22.01分,干预组高于对照组(P0.01)。2.2自我效能：干预后干预组在饮食自我效能、运动自我效能、药物自我效能、血糖监测自我效能、足部护理自我效能、高低血糖的预防和处理自我效能及总自我效能方面的得分分别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,对照组的得分分别为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,且干预组得分均高于对照组(P0.05)。2.3行为：2.3.1血糖自我监测：干预后干预组掌握自我血糖监测方法的率和家中备有血糖仪的率分别为87.26%和69.50%,对照组为63.07%和57.68%,干预组均高于对照组(P0.05)；干预后干预组和对照组自我血糖监测频率分别为2天/周和1天/周,干预组均高于对照组(P0.01)。2.3.2足部护理：干预后干预组在合适温度的水洗脚、水平得剪指甲、使用护肤类油膏和定期找医生检查足执行率分别为98.07%、84.94%、69.50%、42.47%,对照组分别为87.97%、72.61%、50.62%、31.12%,干预组均高于对照组(P0.05)；干预后干预组和对照组足部自我检查频率分别为7天/周和5天/周,干预组均高于对照组(P0.01)。2.3.3健康饮食：干预后干预组和对照组遵循健康饮食要求的频率分别为6天/周和5天/周,干预组高于对照组(P0.01)；干预后干预组和对照组食用高膳食纤维食物的频率分别为为3天/周和2天/周,干预组高于对照组(P0.01)。2.3.4有氧运动：干预后干预组和对照组做30分钟及以上的有氧运动频率分别为7天/周和6天/周,干预组均高于对照组(P0.01)。2.3.5服药和吸烟饮酒：服药方面,干预后干预组和对照组在自行停药率上低于对照组,差异有显著性(P0.05)。吸烟方面,干预前干预组的吸烟率高于对照组,差异有显著性(P0.05),干预后两组间吸烟率差异无显著性(P0.05)。饮酒方面,干预前后干预组和对照组的饮酒率差异均无显著性(P0.05)。2.4体格测量指标和生化指标干预前后干预组的平均体重降低1.49kg,对照组升高1.14kg,差异有显著性(P0.05)；干预后干预组和对照组在糖尿病相关生化指标上差异无显著性(P0.05)。2.5近期成本-效果糖尿病自我管理干预使自我效能提高一分的总成本为8795.55元,人均成本为33.96元；使每周自我监测血糖天数增加一天的总成本为70012.60元,人均成本为270.32元；使每周自我检查足部天数增加一天的总成本为70012.60元,人均成本为270.32元；使每周遵循糖尿病健康饮食天数每增加一天的总成本为70012.60元,人均成本为270.32元；使每周进行30分钟及以上有氧运动天数增加一天的总成本为70012.60元,人均成本为270.32元；使体重每降低lkg的总成本为26620.76元,人均成本为102.78元。3.干预效果影响因素3.1糖尿病患者自我管理知识得分干预效果的影响因素为基线知识得分、年龄(岁)、文化程度、家庭人均月收入(元)、对小组活动的整体评价和社区医生参与频率(P0.05)。3.2糖尿病患者自我管理自我效能得分干预效果的影响因素为基线自我效能得分、小组活动总体评价、活动内容的难易程度(P0.05)。3.3糖尿病患者自我管理体重干预效果的影响因素为基线体重(kg)、性别、家庭人均月收入(元)(P0.05)。4.满意度和意向4.1干预组满意度和自我评估干预组研究对象对自我管理小组活动的总体满意度为96.14%,84.94%的干预组研究对象表示会继续参加自我管理小组活动。在吸引糖尿病患者参加自我管理小组活动的原因中,排在首位的是“能学到有用的知识”,在导致糖尿病患者缺席的原因中,排在首位的是“家庭或工作事务太多”。在8项自我管理的任务中,干预组研究对象认为自己“做得最好”和“做得最差”排在首位的分别是“适量运动”和“掌握胰岛素注射技巧”。4.2对照组意向和自我评估80.08%的对照组研究对象表示如果以后开展糖尿病自我管理活动“会愿意参加”。在8项自我管理的任务中,干预组研究对象认为自己“做得最好”和“做得最差”的排在首位的分别是“适量运动”和“自我血糖监测”。研究结论本研究在国内首次运用统一规范的教材实施社区糖尿病患者自我管理干预,采用患者小组长和社区医生配合的形式带领小组活动,设立平行对照组对其干预效果及近期成本-效果进行评价,结果发现社区糖尿病患者自我管理干预在提高糖尿病患者知识、自我效能、改善行为方面有效。建议将社区糖尿病患者自我管理干预纳入基本公共卫生服务,以保证其长效发展。本研究还发现糖尿病患者在“自我血糖监测”、“足部护理”、“掌握胰岛素注射技巧”和“运动强度的评估”等方面的知识、自我效能、行为或自我评价相对较差,建议在以后开展社区糖尿病患者自我管理活动时对以上方面予以针对性加强。
[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.
【学位授予单位】：中国疾病预防控制中心
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R587.1
本文编号：2210534
[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.
【学位授予单位】：中国疾病预防控制中心
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R587.1
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