标题：社区家庭健康支持系统对社区糖尿病患者病情控制的影响

      作者：杨堂河 1，徐军妮 1，缪梓超 1，梁倩雯 1，周 萍 2
    (1.深圳市福田区人民医院社康管理办公室，广东 深圳 518000；
2.香港大学深圳医院全科，广东 深圳 518000)

      卷次： 2015年26卷16期

      【摘要】 目的 探讨社区家庭健康支持系统对社区糖尿病患者病情控制的影响。方法 以我院所在地福
田区的翠海社区糖尿病患者(观察组，n=92)和碧海云天社区的糖尿病患者(对照组，n=81)为研究对象，对照组予
规范化管理的模式，观察组在此基础上加强对患者家庭成员的糖尿病预防保健知识健康教育，比较两组患者和
家属的糖尿病健康知识知晓率、患者血糖及糖化血红蛋白控制情况。结果 干预1年后，观察组患者及家属糖尿
病健康知识知晓率为86.96%、83.70%，患者血糖达标率为53.35%，均明显高于对照组的74.07%、70.37%、37.04%，
差异均有统计学意义(P<0.05)；观察组患者空腹血糖、餐后2 h血糖及糖化血红蛋白水平均明显低于对照组，总体
生活质量评分明显高于对照组，差异均有统计学意义(P<0.05)。结论 社区家庭健康支持系统可明显提高患者
及患者家属对糖尿病健康知识的知晓率，进而提高糖尿病患者血糖达标率、更加有效的控制血糖在理想范围，减
少并发症的发生，改善患者生活质量。

      【关键词】 社区家庭健康支持；糖尿病；干预

      【中图分类号】 R587.1 【文献标识码】 A 【文章编号】 1003—6350（2015）16—2464—03


Study of community home health support system in the disease control in patients with diabetes.
YANG Tang-he 1,
XU Jun-ni 1, MIAO Zi-chao 1, LIANG Qian-wen 1, ZHOU Ping 2. 1. Community Health Management Office, the Fourth
People’s Hospital of Shenzhen, Shenzhen 518000, Guangdong, CHINA; 2. Department of General Practice, the University
of Hong Kong-Shenzhen Hospital, Shenzhen 518000, Guangdong, CHINA

【Abstract】 Objective To investigate the impact of community home health support system in the disease con-
trol in patients with diabetes. Methods Patients with diabetes in Cuihai community (observation group, n=92) and Bi-
haiyuntian communities (control group, n=81) were studied. The control group was treated with standardized manage-
ment model, and the observation group applied standardized management model combined with health education of dia-
betes in family members. The knowledge awareness rate of patients and their families, glycemic and HbA1c control in pa-
tients were compared between the two groups. Results After intervention for one year, the knowledge awareness rate of
patients and their families in the observation group was 86.96% and 83.70% , and the blood glucose control rate was
53.35%, which were significantly higher than 74.07%, 70.37%, 37.04% in the control group (P<0.05). The fasting plas-
ma glucose (FPG), 2 h postprand plasma glucose (2 hPG), HbAlc levels in the observation group were significantly lower,
while the overall quality of life scores were significantly higher than the control group, with statistically significant differ-
ences (P<0.05). Conclusion The community family support system can significantly improve the health of knowledge
in patients and family members, improve the blood glucose standard rate, control the blood glucose in the ideal range, re-
duce the complications, and also improve the quality of life.

      【Key words】 Community family health support; Diabetes; Intervention