广州市农村地区慢性病自我管理模式效果初探

Self-management Mode for Chronic Disease in Rural Areas of Guangzhou

目的评价慢性病自我管理小组活动实施6个月后的效果,探讨慢性病自我管理在农村地区实施的可行性。方法采用香港复康会慢性病自我管理模式,在广州市番禺区小谷围村和沙公堡村各成立1个慢性病自我管理小组（小谷围村组30人,沙公堡f村组21人）,每组由2名小组长按照指导手册组织开展小组活动。活动前和活动完成6个月后对参加活动的患者进行问卷调查和实验室检测,比较活动前后患者慢性病相关知识知晓率、慢性病相关危险因素和身体指标的变化情况。结果共51名患者接受问卷调查和体检,其中男性27人,女性24人,年龄34~86（65.47±11.51）岁;自我管理小组活动后6个月与活动前相比高血压、糖尿病标准知晓率分别提高了11.76%和17.64%,糖尿病标准知晓率活动前后差别有统计学意义（χ2=4.55,P〈0.05）;慢性病相关危险因素（控制体重人数、饮食咸淡适中情况、药物治疗情况）短期改善效果明显,活动前后差别均有统计学意义;活动后6个月与活动前相比患者的收缩压、空腹血糖、体重指数、血清总胆固醇分别下降了5.16 mmHg、0.22 mmol/L、0.33和0.22 mmol/L,舒张压和血清甘油三酯分别上升了1.17 mmHg和0.11 mmol/L,但各指标在活动前后差别均无统计学意义。结论该慢性病自我管理模式短期内可明显增加参与者慢性病相关知识,适当改善慢性病患者身体功能以及健康相关行为;提示慢性病自我管理模式可以在经济欠发达的农村地区推广。

Objective To evaluate the effectiveness of self-management mode for chronic disease in rural areas and to explore its feasibility. Methods Model of Hong Kong Rehabilitation Organization was adopted to exert self-management for chronic disease in rural areas of Guangzhou. Before and after 6 months＇ intervention, questionnaire survey and laboratory testing were conducted to evaluate the awareness of chronic disease patients, health status and risk factors. Results Altogether 51 patients were recruited in the intervention. The awareness rate of chronic disease patients on hypertension and diabetes mellitus improved by 11. 76% and 17. 64% respectively,and the awareness rate of diabetes mellitus knowledge was significant different（ χ2 =4. 55, P 0. 05）. The risk factors such as overweight,unhealthy diet and medication were improved. The blood pressure, fasting blood glucose,body mass index and serum total cholesterol decreased by 5. 16mmHg,0. 22mmol / L,0. 33 and 0. 22mmol / L,respectively. Diastolic blood pressure and serum triglyceride improved by 1. 17mmHg and 0. 11mmol / L,but with no significant differences before and after the intervention. Conclusion The self-management program is of effectiveness and thus worthy of popularization in rural areas,yet the long-term effect remain to be tested in practice.