徐林莉+宋慧君+徐枫+严丽敏

摘 要 目的：研究家庭醫生制服务对2型糖尿病患者的健康干预效果。方法：选择2015年7月—2016年6月已纳入社区卫生服务中心糖尿病随访管理签约的200例2型糖尿病患者，随机分为干预组和对照组，每组100例。对干预组实行签约家庭医生制服务，每月开展各种形式的健康教育、专题讲座、答疑、诊疗咨询等进行个性化健康干预，同时每三个月进行血糖检测；对照组根据糖尿病随访管理签约的要求，每季度一次开展糖尿病随访管理。两组干预并观察12个月。结果：干预1年后，干预组的健康知识知晓率、各项疾病自我管理能力得分均优于对照组，差异均有统计学意义（P<0.05）；干预组的血糖值指标也较干预前下降，血糖值控制改善；对照组各对应值比较，差异无统计学意义（P>0.05）。结论：个性化的家庭医生制服务健康干预能有效提升2型糖尿病患者的相关疾病预防知识，提高患者自我管理能力，改变患者的遵医行为，从而提高糖尿病治疗的效果。

关键词 2型糖尿病；健康教育；干预效果

中图分类号：R587.1 文献标志码：A 文章编号：1006-1533（2017）02-0046-03

Analysis of the effect of family doctor system service on the health intervention for the patients with type 2 diabetes mellitus in community

XU Linli， SONG Huijun， XU Feng， YAN Limin

（Huaihaizhonglu Community Health Service Center of Huangpu District， Shanghai 200025， China）

ABSTRACT Objective： To study the effect of the family doctor system service on the health intervention for the patients with type 2 diabetes mellitus. Methods： From July 2015 to June 2016， 200 cases of type II diabetes who signed the contract and were included in the community health service center for diabetes follow-up management were selected and randomly divided into an intervention group and a control group with 100 cases each. The contract family doctor system service was implemented for the patients of the intervention group， and various forms of health education， lectures， answering questions， counseling and other personalized health intervention were carried out every month. At the same time， blood sugar was detected every three months. According to the requirements of the follow-up management contract， the management of diabetes was carried out for the control group once every quarter. The two groups were intervened and observed for 12 months. Results： After 1 year of intervention， the awareness rate of health knowledge and self management ability of each disease in the intervention group were better than those in the control group， and the differences were statistically significant（P<0.05）. The blood glucose indexes also decreased compared with those before the intervention and the blood sugar level was improved in the intervention group. Compared with the corresponding values of the control group， the differences were not statistically significant（P>0.05）. Conclusion： Personalized family doctor system service health intervention can effectively improve the related disease prevention knowledge in the patients with type 2 diabetes， improve the self-management ability and change the compliance behavior of the patients so as to improve the effect of diabetes treatment.

KEY WORDS type 2 diabetic patient； health education； intervention effect

随着我国人民生活水平的不断提高，目前危害人民群众的主要健康问题逐渐向慢性病转变，心脑血管疾病、代谢性疾病等常见慢性病占据社区居民死因及经济负担的相当比重，2014年中国卫生论坛慢病防控会议上提出慢病防控刻不容缓。世界卫生组织估计2005年至2015年中国由于糖尿病及相关心血管疾病导致的经济损失达5 577亿美元。但遗憾的是，即使在发达的国家，也有约2/3的糖尿病患者得不到有效管理[1]。加强糖尿病管理，努力遏制我国糖尿病及其并发症造成的危害刻不容缓。……