基于计划行为理论的北京市社区2型糖尿病患者服药依从性影响因素研究

Factors Associated with Medication Adherence in Beijing Community-dwelling Residents with Type 2 Diabetes:a Study Using the Theory of Planned Behavior

背景国家基本公共卫生服务项目要求社区卫生服务中心为糖尿病患者提供健康管理服务,促进患者有效控制血糖。定期按时服药是控制糖尿病病情的主要手段之一,因此,探究社区糖尿病健康管理服务对服药依从性的影响有一定的现实意义。目的了解北京市社区2型糖尿病患者的社区糖尿病健康管理服务利用情况、服药依从性现状,分析服药依从性的影响因素。方法于2018年7—8月,采用方便抽样法选取北京市6家社区卫生服务中心的2型糖尿病患者1218例作为研究对象,利用自编量表进行问卷调查,问卷内容包括一般人口学情况、社区糖尿病管理服务利用情况、服药依从性情况(包括服药依从性量表和基于计划行为理论的服药意向问卷)3部分。运用结构方程模型探讨2型糖尿病患者服药依从性的影响因素。结果共发放问卷1218份,回收有效问卷1156份,有效回收率为94.91%。1156例患者中,892例(77.16%)服药依从性为中等依从和高依从性(视为服药依从)。经检验,将面对面随访次数、糖尿病用药指导作为协变量纳入修正后的结构方程模型,拟合优度指标近似残差均根(RMSEA)=0.041,拟合优度指标(CFI)=0.893,简约规范适配指标(PNFI)=0.639,临界样本数值(CN)=499,拟合结果良好。面对面随访、糖尿病用药指导分别通过影响对服药的态度(0.09)、主观规范(0.08)对服药依从行为产生间接效应,标化后的总效应为0.01(P=0.013)、0.01(P=0.011)。结论社区医务人员提供的糖尿病健康管理服务可间接影响2型糖尿病患者服药依从性,接受用药指导可提高患者坚持服药的行为意向,面对面随访可增强患者坚持服药的信念,从而提高服药依从行为发生的可能性。

Background In accordance with the regulations of China's national essential public health services,community health centers(CHCs)are required to deliver health management services to diabetic patients to effectively achieve glycemic control.Taking medications regularly and on time is one of the main means to control diabetes.So it is of practical significance to explore the impact of community-based diabetes health management services on medication adherence of diabetic patients.Objective To investigate the utilization status of community-based diabetes health management services and medication adherence in Beijing community-dwelling residents with type 2 diabetes,and to analyze the possible influencing factors of medication adherence.Methods A face-to-face questionnaire survey was conducted between July and August 2018 with 1218 diabetic patients selected by use of convenient sampling from six CHCs in Beijing using a questionnaire developed by our research group for collecting the patients'general demographics,utilization of community-based diabetes management services and medication adherence(including MMAS-8 and a questionnaire of intention to take medication based on the theory of planned behavior).The structural equation modeling was used to explore the influencing factors of medication adherence.Results Altogether,1156 cases(94.91%)who effectively completed the survey were included for final analysis,and the medication adherence of them was 77.16%(892/1156).After verification,the number of face-to-face follow-ups and guidance on antidiabetic medications were included as covariates into the modified structural equation model.The values of RMSEA(0.041),CFI(0.893),PNFI(0.639),and CN(499)of the final model indicated that the goodness-of-fit of the model was excellent.Face-to-face follow-up and diabetes medication guidance affected the attitude towards medication(0.09)and subjective norms(0.08)respectively.Face-to-face follow-up indirectly affected medication adherence with an overall standardized effect size of 0.01(P=0.013).Guidance on antidiabetic medications also indirectly influenced medication adherence with an overall standardized effect size of 0.01(P=0.011).Conclusion Community-based diabetes health management services indirectly affected the medication adherence of type 2 diabetics.Receiving medication guidance increased the patients'behavioral intention to adhere to medication,and face-to-face follow-ups enhanced the patients'belief in medication adherence,consequently,increasing the possibility of developing medication compliance behaviors.