医护合作型团队对社区慢性病的干预效果

摘要

Objective To explore the intervention mode of physician-nurse collaborative team in prevention and cure of chronic disease in community.Methods Prevalence and risk factors of chronic disease among patients in the community of twin towers of Suzhou were investigated,and intervention measures were formulated.Physician-nurse collaborative team provided group education and individual consulting for 120 patients with hypertension and (or) diabetes.Patients' knowledge about chronic disease,satisfaction with service after intervention,as well as exercise,compliance and dietary salt before and after intervention were evaluated and compared.Results After intervention,90％ patients learned the knowledge about chronic disease with 82％ accuracy.Ninety-two percent patients were satisfied with group education,and 98％ were satisfied with individual consulting.Patients' physical exercise improved from 61.67％ to 82.50％,medical compliance improved from 49.17％ to 75.83％ after intervention,and the differences were statistically significant (x2 =12.941,18.204,respectively; P＜0.05).Dietary salt was also reduced from(6.5125 ±0.865)g/d to(5.000 ±0.501)g/d six months after intervention,and the difference was statistically significant (t =33.352,P ＜ 0.05).Conclusions Physician-nurse collaborative team can improve patients' health knowledge,attitude,belief,and practice level,which can provide empirical basis for community intervention in the future.%目的 探讨医护合作型团队对社区慢性病的防治干预模式.方法 2011年9月调查苏州市双塔社区人群高血压和糖尿病慢性病人群的患病情况及危险因素,针对调查结果,制定干预措施,组织医护合作型团队对社区120例高血压和(或)糖尿病患者进行团体教育和个案咨询,对干预后患者慢性病相关知识知晓率、服务的满意度以及干预前后患者的运动情况、服药依从性、摄盐情况进行评价.结果 干预后现场评估患者慢性病相关知识知晓率为90％,准确率为82％；患者对团体教育的满意度为92％,对个案咨询的满意度为98％；干预后患者的运动依从性(82.50％比61.67％)及服药依从性(75.83％比49.17％)较干预前明显改善,干预前后比较,差异有统计学意义(x2值分别为12.941,18.204;P ＜0.05)；干预后6个月患者的食盐摄入量由(6.5125±0.865) g/d降至(5.000±0.501) g/d,干预前后比较,差异有统计学意义(t =33.352,P＜0.05).结论 医护合作型团队能够提高社区慢性病人群的知识、信念和行为水平,可为未来社区慢性病干预提供指导.