研究目的

  （1）了解社区老年2型糖尿病患者自我管理现状，分析影响自我管理行为的相关因素，为开展基于智慧健康处方的社区干预研究提供支持。

  （2）开展基于智慧健康处方的社区干预研究，探讨该社区健康管理模式对社区老年2型糖尿病患者的干预效果，为其进一步完善与扩大应用奠定基础。

研究方法

（1）社区老年2型糖尿病患者自我管理现状研究中，整群抽取北京市东城区13个卫生服务中心内符合纳入排除标准的研究对象1810例，通过相关问卷及量表开展现况调查，采用统计描述、单因素分析、回归分析、中介效应分析等方法分析患者自我管理行为现状及其影响因素。

（2）基于智慧健康处方的社区干预研究中，单纯随机抽取基线调查的13个卫生服务中心中的8个卫生服务中心，利用随机数表法分为对照组、干预组，根据纳入排除标准，每组各纳入研究对象60例，分别实施常规社区健康管控模式及基于智慧健康处方的社区健康管理模式。在为期6个月的干预结束后对比两组患者疾病相关知识、自我管理态度、自我管理行为及临床检查指标，评价干预效果。

研究结果

（1）社区老年2型糖尿病患者自我管理行为各维度得分水平不一，饮食维度得分最高为（4.09±2.24），足部护理维度得分最低为（2.51±2.04），吸烟维度中，吸烟的患者占45.64%；性别、文化程度、糖尿病病程、糖尿病并发症、治疗方式、疾病相关知识、自我管理态度是自我管理行为的主要影响因素；自我管理态度在疾病相关知识和自我管理行为中起部分中介作用。

（2）与常规社区健康管控模式相比，基于智慧健康处方的社区健康管理模式能够显著改善患者的饮食、血糖监测、足部护理自我管理行为（P<0.01），提高疾病相关知识知晓程度（P<0.05），提高自我管理态度（P<0.01），降低糖化血红蛋白、收缩压、空腹血糖水平（P<0.05）；但对患者运动自我管理行为的改善，以及对患者总胆固醇、甘油三酯、BMI的控制达标效果不显著（P>0.05）。

研究结论

社区2型老年糖尿病患者自我管理水平不佳并受多种因素影响，基于智慧健康处方的社区干预能够改善患者自我管理行为，降低血糖水平。

Objectives

(1) To understand the self-management status of elderly type 2 diabetics in the community and analyze the factors that influence self-management behavior of diabetes patients, thereby providing a basis for conducting community intervention research based on intelligent health prescriptions.

(2) Carry out community intervention research based on intelligent health prescriptions to explore the intervention effect of this new community health management model on elderly patients with type 2 diabetes in the community, laying the foundation for its further improvement and expanded application.

Methods

(1) In the study on the self-management status of elderly type 2 diabetics in the community, 1810 research subjects who met the inclusion and exclusion criteria were selected from 13 health service centers in Dongcheng District of Beijing as a cluster. The status survey was carried out through relevant questionnaires and scales, using statistical description, single factor analysis, regression analysis, mediation effect analysis and other methods were used to analyze the current status of patients' self-management behavior and its influencing factors.

(2) In the community intervention study based on intelligent health prescriptions, 8 health service centers out of the 13 health service centers in the baseline survey were simply randomly selected and divided into a control group and an intervention group using the random number table method. According to the inclusion and exclusion criteria, 60 subjects were included in each group, and the conventional community health control model and the community health management model based on intelligent health prescriptions were implemented respectively. After the 6-month intervention, the disease-related knowledge, self-management attitude, self-management behavior and clinical indicators of the two groups of patients were compared to evaluate the intervention effect.

Results

(1) The scores of various dimensions of self-management behavior of elderly type 2 diabetics in the community vary. The highest score in the diet dimension is (4.09±2.24), and the lowest score in the foot care dimension is (2.51±2.04). In the smoking dimension, patients who smoke accounting for 45.64%. Gender, education level, duration of diabetes, complications of diabetes, treatment methods, disease-related knowledge, and self-management attitude are the main influencing factors of self-management behavior. Self-management attitude plays a partial mediating role in disease-related knowledge and self-management behavior.

(2) Compared with the conventional community health management and control model, the community health management model based on intelligent health prescriptions can significantly improve patients’ diet, blood glucose monitoring, and foot care self-management behaviors (P<0.01), and improve their awareness of disease-related knowledge (P<0.05), improve self-management attitude (P<0.01), also reduce glycosylated hemoglobin, systolic blood pressure, and fasting blood glucose levels (P<0.05); but the improvement of patients' exercise self-management behavior, as well as the improvement of patients' total cholesterol and triglycerides, and the effect of controlling BMI is not significant (P>0.05).

Conclusion

The level of self-management among elderly type 2 diabetics in the community is low and influenced by many factors. Community intervention based on intellegent health prescriptions can improve patients' self-management behavior and reduce blood glucose levels.