基于本土化的慢性病自我管理模式对南京社区糖尿病患者管理的效果评价

Evaluation of the effectiveness of diabetes self-management program based on Chinese local patients in Nanjing community

目的 了解本土化的慢性病自我管理模式在南京社区糖尿病患者中的实施效果。 方法 2014年4—6月，以街道（社区）为单位，通过从健康档案中筛选居民、发放邀请函、张贴招募海报、电话通知等多种宣传方式，共成立53个糖尿病自我管理小组。活动内容参考上海复旦大学公共卫生学院借鉴美国斯坦福大学患者教育研究中心创建的慢性病患者自我管理项目（CDSMP）所建立的中国本土化的CDSMP。分别在基线（活动前）和活动后3个月进行2次问卷调查、血压测量和实验室检测。 结果 共登记愿意参加自我管理小组的糖尿病患者636例，完成全部6次小组活动的患者603例，应答率为94.8%。参与者在糖尿病防治知识10道题目中有9道知晓率活动后高于活动前（P均＝0.000），自我管理行为的6方面活动后均显著提高（P均＝0.000）；生活质量的生理总评分[（47.51±9.47）分vs.（49.10±8.27）分，t＝6.170，P=0.000]和心理总评分[（47.09±11.95）分vs.（49.13±10.74）分，t ＝5.157 ，P=0.000]活动后均显著提高；而收缩压、舒张压、空腹血糖和总胆固醇分别降低了（1.42±0.52） mmHg（1 mmHg=0.133 kPa）、（0.98±0.34）mmHg、（0.66±0.16）mmol/L、（0.15±0.56）mmol/L ，差异均有统计学意义（t分别为3.935、2.030、4.889、4.899，P〈0.05）。 结论 南京社区参考本土化CDSMP所推行的糖尿病自我管理项目可提高参与者知识知晓情况、自我管理行为和生活质量，改善患者健康状况，值得进一步推广。

Objective To evaluate the diabetes self-management program based on Chinese local patients in Nanjing community. Methods From April 2014 to June 2014, diabetes patients were recruited through health records system screening in the community health service centers, letter invitation, poster announcements at communities, and telephone notification. A total of 53 self-management groups were established. Nanjing diabetes self-management program included six 1-1.5 hours sessions scheduled on consecutive weeks, based on the blueprint of Shanghai Chronic Disease Self-Management Program （CDSMP） developed at Stanford University. Baseline and three-month later interviews were conducted respectively. Results A total of 636 patients were recruited and agreed to enter CDSMP; 603 completed the 6-session activities, with the response rate being 94.8%. Compared to baseline, nine of the patients＇ the awareness rate of diabetes-related knowledge, six of self-management behaviors, the scores of quality of life in physical component summary [（47.51±9.47） vs. （49.10± 8.27） points, t=6.170, P=0.000] and mental component summary [（47.09± 11.95） vs. （49.13± 10.74） points, t = 5.157, P=0.000] were all higher after three months （all P values〈0.05）. Three months after implementation, the level of systolic blood pressure, diastolic blood pressure, fasting plasma glucose and total cholesterol decreased respectively by （1.42±0.52） mmHg （1 mmHg=0.133 kPa）, （0.98±0.34） mmHg, （0.66±0.16） mmol/L, （0.15±0.56） mmol/L, the differences werestatistically significant （tpaired values were 3.935, 2.030, 4.889, 4.899, all P values〈0.05）. Conclusion The diabetes self-management program based on Chinese local patients for Nanjing may improve patients＇ awareness rate of diabetes-related knowledge, self-management behavior, the quality of life, and health status. CDSMP could be applied efiectively in Nanjing.