上海市慢性病自我管理实施效果及可持续性发展研究
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摘要
慢性病问题不仅是健康问题,也是经济问题、发展问题。2005年,世界卫生组织提出要建立以预防为主的慢性病管理创新模式,形成由患者、卫生保健机构、社区和政府一起参与的慢性病长期管理机制,并特别指出要加强病人和卫生保健人员的交流,充分调动社区资源,使患者及其家庭、初级卫生保健团队以及社区支持者之间形成一种新型的伙伴关系,共同应对慢性病问题。因此,探索一条适合我国国情的慢性病患者管理方法,广泛开展健康促进和群体预防,从而有效遏制慢性病的患病和死亡是当务之急。慢性病自我管理是指用自我管理的方法来控制慢性病,帮助慢性病患者在得到医生更有效的支持下,主要依靠自己解决慢性病给日常生活带来的各种躯体和情绪方面的问题。该项目的有效性得到了全世界范围的普遍证实。美国、英国、澳大利亚、加拿大等国已经逐渐把慢性病自我管理融入初级卫生保健中。从2007年下半年起,上海市健康促进委员会办公室、爱国卫生运动委员会办公室在复旦大学公共卫生学院的支持下,推广了“社区高血压自我管理健康教育项目”的成果。截至2010年底,已发展至5048个居(村)委,组建了9762个小组,166158人参与活动,覆盖99.55%的街道(镇),95.93%的居(村)委,希冀通过这种“社区倡导、居委实施、专业机构指导”的自我管理小组活动,形成慢性病群防群控模式。面对参与自我管理小组人群的不断扩大,组员需求的不断提高,如何提升组员对小组活动的满意度,如何动员社区居民积极参与；社区卫生服务工作者如何把自我管理小组的工作与日常的慢性病管理工作、家庭医师责任制有效结合,提高服务质量和工作效率；爱卫系统作为健康促进与健康教育工作的生力军,如何发挥自身优势,克服障碍,担负起健康教育与慢性病防控的责任,是保证慢性病自我管理小组可持续发展的关键所在。本研究将重点针对上述问题,围绕自我管理小组实施效果,归纳总结目前工作中的成功经验和不足,为促进慢性病自我管理小组可持续性发展提供科学依据。
研究目的
通过对上海慢性病自我管理小组开展状况的研究,围绕其实施效果,分析其运行现状,总结经验和有效方式,探讨主要影响因素,为慢性病自我管理小组可持续发展提供科学依据,为慢性病群防群控提出政策建议。
研究目标
●评估慢性病自我管理小组实施效果及影响因素；
●运用生态学模型,从个体、人际、社区、组织四个层面分析慢性病自我管理
小组运行现状,挖掘障碍,探讨机遇,寻求解决方案。
研究对象
分阶段随机抽取上海市5个区中150个自我管理小组,对其组员、组员家人、一般居民、小组骨干(小组长、居委干部、社区指导医生)以及爱卫干部进行相关调查。
研究内容
1.上海市慢性病自我管理小组实施与推广过程
2.上海市慢性病自我管理小组实施效果
3.上海市慢性病自我管理小组可持续性发展研究
研究方法
本研究利用横断面调查的方式,采用定量和定性相结合的方法。定量研究主要是问卷调查,定性研究包括焦点组访谈等方式。资料分析采用描述性与分析性研究相结合的方法。主要分析方法包括：描述性分析、单因素分析、多重线性回归分析、二分类Logistic回归分析、有序多分类Logistic回归分析、社会网络分析、多水平统计分析、定性分析方法、问题树分析方法。
主要研究结果
本研究三个主体部分的研究结果如下：
一、上海市慢性病自我管理小组实施与推广过程
根据上海市爱卫办提供的资料,总结上海市慢性病自我管理小组实施与推广过程,结果如下：慢性病自我管理小组作为一种把社区干预试验研究推广成为参与人数16万人、覆盖到95.93%居(村)委的一项慢性病群防群控行动是非常成功的。回顾扩散过程,强有力的政策支持、运行机制各方职责明确、各层面相关人群的积极参与是关键所在。
二、上海市慢性病自我管理小组实施效果
1.5种技能
对150个小组的问卷调查结果发现,63.6%的慢性病自我管理小组具备交互性健康素养。一般社区居民的调查发现,参与自我管理小组的居民具备交互性健康素养的比例(76.9%)高于未参加小组的居民(68.2%)。性别、年龄、文化程度、患有慢性病、自我效能等因素均与组员健康素养得分有关。
2.疾病／行为管理
在目前的自我管理小组中,除了17.1%未患慢性病的健康组员之外,其他组员慢性病患病情况各异。本研究对小组中患病率最高的高血压病进行了分析,高血压组员的血压控制率为79.3%。性别、社会支持与血压控制率有关。在被调查的自管小组组员中,分别有34.6%及45.1%的组员体力活动量“明显增加”及“稍微增加”；分别有32.5%及46.0%的组员蔬菜水果摄入量“明显增加”及“稍微增加”；分别有24.9%及58.0%的组员食盐摄入量“明显减少”及“稍微减少”；分别有28.3%及55.4%的组员食油摄入量“明显减少”及“稍微减少”。女性较男性而言,生活行为方式改善状况更好。
3.情绪管理
定性访谈结果提示,组员在参加自我管理小组之后,组员间的相互交流,向家人传播健康知识获得家人的支持,“心情好了”、“心态好了”是参加小组活动最大的收获之一。定量分析提示,文化程度、自我效能、交互性健康素养、社会支持等因素均与组员复原力得分有关。
4.社会／角色管理
定量和定性研究发现,组员参与社区活动广泛,一半以上的组员(58.8%)参加了志愿者组织,50.6%的组员较多参与居委、街道组织的各种活动,47.8%的组员较多参与兴趣活动组织(如老年大学、老年活动中心)等。偏相关分析得到的结果为,结构性社会资本与认知性社会资本水平存在正相关关系,结构性社会资本(社会联系、参与等)水平越高,认知性社会资本(信任、互惠、归属等)水平越高。目前小组组员社会资本属于高社会资本型(参与程度越高,信任水平越高)。研究也发现,组员的社会角色活动能力受限与结构性社会资本有关,组员的社会支持水平与认知性社会资本有关。
三、上海市慢性病自我管理小组可持续性发展研究
1.个体层面
从定量和定性的研究结果来看,目前自我管理小组已通过多种多样的活动形式来丰富小组活动内容,组员对小组长、社区医生、居委的工作比较满意,对小组活动比较满意。组员经常参与小组活动形式或内容有“相互交流”“医生咨询”“健身活动”“专题讨论”“茶话会”“健康烹饪”等。对小组活动需求越来越高,上课人数较多、缺乏基本的资金保障是目前面临的主要问题。
2.人际层面
一般社区人群的调查发现,77.4%的社区人群“知道”自我管理小组,50.9%的社区人群愿意参加自我管理小组。对组员家人的访谈发现,几乎所有的组员家人都支持他们参加自我管理小组,组员也把健康知识传播给家人,家人看到了组员在心情、身体健康方面的改善。15个小组的社会网络分析结果提示,9个小组的网络中心人物为小组长、居委干部以及社区医生,其余6个小组以组员为网络中心。在三分之二的小组中,组长、居委干部、社区医生作为小组网络的中心、最有影响力的人,发挥着传递信息、情感、信任等作用,或以中介的身份发挥着桥梁的作用。组长为中心型的小组其客观指标如血压控制率、结构性社会资本水平较其他类型好；组员为中心型的小组其主观指标如认知性社会资本、复原力等较其他类型好。
3.社区层面
定量和定性调查的结果提示,目前自我管理小组行动在社区层面存在的主要问题有获取资源能力欠缺；外部支持的渠道局限于街道镇以及社区卫生服务中心,社区卫生服务中心缺乏对医生参与小组工作明确的实质性考核制度与奖惩机制；与他人联系不足,表现为小组、居委与社区卫生服务中心没有建立一个真正的资源共享、伙伴关系的平台；小组之间、居委之间缺乏交流；小组骨干需要知识、技能的进一步培训。虽然只有2个小组克服障碍,解决了九个维度的所有相关问题,但是,150个小组中有131个小组(87.3%)已经意识到存在的问题,具备了一定的社区能力。从社区增权理论的5点连续统一体理论来看,目前自我管理小组行动的社区增权水平处于从小规模兴趣组织迈入社区组织的阶段。
4.组织层面
在个人健康促进能力方面,尽管大多数爱卫干部来自非医学专业的教育背景,但经过系列培训,已对健康、健康促进的基本知识有一定了解,但普遍反映缺乏健康促进实践技能；由于缺乏有力抓手,与在职人群沟通欠缺,无法在在职人群中普遍开展自我管理小组；另外,工作压力较大,没有充足的时间深入开展工作。定量调查提示,个人健康促进能力中优势是“态度”,劣势是“资源”。在组织健康促进能力方面,整个组织体系都很重视自我管理小组的工作以及与其他部门的伙伴关系,但缺乏政策、制度的保障；人力资源极为缺乏,不利于健康促进工作的长期性、规划性。定量调查提示,组织健康促进能力中优势是“承诺”,劣势是“资源”。环境健康促进能力方面,大多数爱卫干部认为政府投入不够；虽然居民健康意识明显提升,但参与程度不够；与其他部门组织的沟通协调不够。定量调查提示,环境健康促进能力优势是“舆论与民意支持”,劣势是“理念普及”。
5.运用多水平分析模式探讨社区层面的社区能力与组织层面的健康促进能力对小组实施效果的影响,分析结果发现,组织层面的健康促进能力与组员健康状况呈正向相关。
6.各层面存在的主要问题提示,共性问题是对自我管理小组的资源与制度保障支持欠缺,应首先从这两个方面予以努力。从长远角度看,提高政府重视程度、从政策上把自我管理融入初级卫生保健、培养健康促进队伍是解决问题的根源。
研究结论
上海市慢性病自我管理实施效果显著,自我管理小组已具备可持续发展的基础：小组组员对小组活动、小组骨干的工作比较满意、小组在人际间传播良好、各层面相关人员通过基本的培训及几年来的实践已具备保障小组活动顺利实施的能力。把自我管理融入到常规卫生服务中以及持续的人员及资金保障是今后努力的方向。
Today, noncommunicable diseases (NCDs) represent a leading threat to human health and development, causing about35million deaths each year-60%of all deaths globally-with80%in low-and middle-income countries. These diseases are preventable. Research has demonstrated that people who take the lead themselves in managing their chronic disease-with good support from health service providers have improved health and that incapacity is is reduced. Chronic disease self-management programme means that patients learn the skills necessary to take on active role in caring for their own chronic conditions and assume some medical and preventive tasks with the support of health professionals. The successful experiences from domestic and international researches indicated that patient-centered chronic disease self-management programme (CDSMP) is a cost-effective strategy to improve patients'health functioning and quality of life. Many countries such as, the United States, the British, Australia and Canada, have integrated self-management into primary health care gradually. In the second half year of2007, the Office of Patriotic Health Campaign Committee of Shanghai adopted the recommendation from the study of "community-based project of self-management of hypertension" by School of Public Health, Fudan University. There were totally5048villages,9762groups,166158people participating in these activities, which covered99.55%streets,95.93%villages till2010. Under the principles of doctor-patient cooperation, mutual aid, self-management, CDSMP aims to create a supportive environment for chronic disease prevention and control. In order to make CDSMP sustainable, we have to combine the self-management support with the routine disease management and responsibility system of family doctors. In another aspect, Patriotic Health Campaign Committee system, as the main force of health education and health promotion, how to give full play to their own advantages, to overcome obstacles and shoulder the health education and the responsiblilty of the prevention and control of chronic disease, is the key to the sustainable development. This study would focus on the abve problems, around implementation effect, summarizes the present work experiences of success and the insufficiency to promote CDSMP sustainable development.
Goal
The present study aim to sum up experience and effective method, explore the main influencing factors for the implementation effect, and provide the scientific basis on policy recommendation for CDSMP sustainable development and prevention and control for chronic disease.
Targets
·To evaluate CDSMP's effectiveness and the influencing factors;
·With the guide of ecological model, to analyze the operational status of CDSMP, main obstacles and opportunities, and to seek solutions from individual, interpersonal, community and organization four levels.
Subjects
Group members and group leaders from150self-management groups, members' relatives, community residents and Patriotic Health Campaign Committee'stuff were randomized selected by stages.
Contents
1. Implementation and spread process for CDSMP in Shanghai
2. Implementation effect of CDSMP in Shanghai
3. Sustainable development study of CDSMP in Shanghai
Methods
A cross-sectional research design was applied. The quantitative and qualitative analysis was used in this research. The quantitative method involves questionnaire survey. The qualitative analysis included focus group discussion. We use descriptive and analytical assessment in data analysis, including descriptive analysis, univariate analysis, multivariate linear regression, binary logistic regression, ordinal logistic regression, social network analysis, multilevel analysis and Fault Tree Analysis (FTA).
Results
Section1Implementation and spread process for CDSMP in Shanghai
Based on the collection of the document provided by the Patriotic Health Campaign Committee office, we sum up the development process of CDSMP. The result showed that CDSMP as a community intervention experimental research becomes an action for prevention and control for chronic illness, is very successful. Powerful policy support, defined responsibilities of operation parties and active participation of relevant population are keys.
Section2Implementation effectiveness of CDSMP in Shanghai
1.5Core Skills
The results showed that63.6%of group members have sufficient interactive health literacy. The suvey of community residents indicated that the percent of residents who participate in the chronic disease self-management groups with sufficient interactive health literacy is higher than those who did not attend. Gender, age, education, having chronic disease or not, self-efficacy are related with interactive health literacy score.
2. Disease and Behavior management
17.1%of members don't have any chronic disease in self-management groups at present. In all chronic disease group members have, hypertension has the highest morbidity. Others are arthritis, cerebrovascular disease and diabetes in sequence. The control rate of hypertension is79.3%. Gender and social support are related with the control of hypertension.34.6%of group members increase their phycial activity significantly, and45.1%increase phycial activity slightly.32.5%of members increase their vegetable and fruit intake significantly and46.0%increase intake slightly.24.9%and58.0%of members decrease their salt intake significantly and slightly respectively.28.3%and55.4%of members decrease their oil intake significantly and slightly respectively. Women are better in life behavior improvement than men.
3. Emotional management
The qualitative analysis showed that, after members participated in self-management group, mutual exchange and having a good mood are biggest harvest. The quantitative results showed that education, self-efficacy, interactive health literacy and social support are influencing factors for resilience.
4. Social and Role management
The quantitative and qualitative analysis indicated that group members participate in community activities widely.58.8%of members take part in volunteer organization,50.6%take part in activities organized by residents'committees or street agency,47.8%participate in interest activities.Partial correlation analysis presented that structural social capital is positively correlated with cognitive social capital. The more members participate in social activites, the higher reciprocity and trust degree they will have. And the social role limitation is related with structural social capital, the social support members obtain is related with cognitive social capital.
Section3Sustainable study of CDSMP in Shanghai
1. Individual level
Chronic Disease self-management groups have been enriched in the content through the various activities. Members are satisfied with the efforts taken by group leader, instruct doctor and Neighborhood cadre, also satisfied with the group activities. Interaction, consulation, fitness activities, seminar, tea party, healthy cooking are regular activities. Higher demand and lack of limitation and funding are the main problems facing at present.
2. Interpersonal level
77.4%of community residents have heard of self-management group.50.9%of community residents would like to attend. Focus group interview on the members' family indicated that almost all the family members support self-management group, they all see group members'improvement in physical and emotional health. And they also received health knowledge from members. Social network analysis on15self-management groups showed that group leader are the social network's centers in9groups'network graph, ordinary members are the centers in the other6groups' network graph. As the center and intermediary of network, group leaders transfer information, emotion and trust. They also play the role of bridge. Objective indicators such as blood pressure control, structural social capital levels in leader-centered group are better than other groups.While subjective indicators such as cognitive social capital, resilience and self-perceived health status in member-centered group are better than other groups.
3. Community level
The main problems in this level are lack of the abilities of obtaining resources, limitation of external support channel, lack of substantive appraisal system and clear rewards and punishments mechanism, lack of connection with others and lack of interaction among groups or communities. Group leaders also need further training. In the150groups,130groups (87.3%) have realized existing problems and have basic community ability,2groups have higer degree of community ability. Based on the community empowerment as a5point continuum, Community empowerment' phrase of CDCMP enters a stage from small groups to community organizations.
4. Organization level
In individual health promotion capacity, Patriotic Health Campaign Committee'stuff have already understood health promotion basic knowledge although they aren't medical professionals. But lack of practical skills and enough time to carry out in-depth work is a popular problem. The strength of individual capacity is attitude, the weakness is resource. In organizational health promotion capacity, the whole organization system has paid great attention with the work but lack of policy security. Lack of human resources goes against health promotion long-term planning. The strength of organizational capacity is commitment, the weakness is resource. In environmental health promotion capacity, stuff reported that government's input is insufficient. Residents'health consciousness has been raised, but participation is not enough.The third obstacle is shortage of communication and coordination with other sectors. Public opinion and ideas, concept popularity are the strength and the weakness in environmental health promotion capacity respectively.
5. Environmental factors' influence on implementation effect of CDSMP
Two-level linear multilevel model was adopted to analyze the influence of community capacity and health promotion capacity on effect of CDSMP. The results indicated that health promotion capacity is positively related with members' health status.
6. Fault Tree Analysis on CDSMP
The main problem of four levels is lack of the resources and mechanism security. We should make great efforts in these two aspects. In the longer term, the attention of the government, involving self-management into primary health care and cultivation of health promotion team are the root of problem.
Conclusions
The implementation effectiveness of CDSMP in Shanghai is remarkable, and CDSMP has already had the base for the sustainable development. Group members are satisfied with the activities and efforts taken by group leaders and CDSMP is spreaded widely.Through the basic training and practice in the past few years, relevant personnel have the capacity to guarantee the implementation of CDSMP. Involvement in regular health services and continuous security of human resources and fund are the direction.
研究目的
通过对上海慢性病自我管理小组开展状况的研究,围绕其实施效果,分析其运行现状,总结经验和有效方式,探讨主要影响因素,为慢性病自我管理小组可持续发展提供科学依据,为慢性病群防群控提出政策建议。
研究目标
●评估慢性病自我管理小组实施效果及影响因素；
●运用生态学模型,从个体、人际、社区、组织四个层面分析慢性病自我管理
小组运行现状,挖掘障碍,探讨机遇,寻求解决方案。
研究对象
分阶段随机抽取上海市5个区中150个自我管理小组,对其组员、组员家人、一般居民、小组骨干(小组长、居委干部、社区指导医生)以及爱卫干部进行相关调查。
研究内容
1.上海市慢性病自我管理小组实施与推广过程
2.上海市慢性病自我管理小组实施效果
3.上海市慢性病自我管理小组可持续性发展研究
研究方法
本研究利用横断面调查的方式,采用定量和定性相结合的方法。定量研究主要是问卷调查,定性研究包括焦点组访谈等方式。资料分析采用描述性与分析性研究相结合的方法。主要分析方法包括：描述性分析、单因素分析、多重线性回归分析、二分类Logistic回归分析、有序多分类Logistic回归分析、社会网络分析、多水平统计分析、定性分析方法、问题树分析方法。
主要研究结果
本研究三个主体部分的研究结果如下：
一、上海市慢性病自我管理小组实施与推广过程
根据上海市爱卫办提供的资料,总结上海市慢性病自我管理小组实施与推广过程,结果如下：慢性病自我管理小组作为一种把社区干预试验研究推广成为参与人数16万人、覆盖到95.93%居(村)委的一项慢性病群防群控行动是非常成功的。回顾扩散过程,强有力的政策支持、运行机制各方职责明确、各层面相关人群的积极参与是关键所在。
二、上海市慢性病自我管理小组实施效果
1.5种技能
对150个小组的问卷调查结果发现,63.6%的慢性病自我管理小组具备交互性健康素养。一般社区居民的调查发现,参与自我管理小组的居民具备交互性健康素养的比例(76.9%)高于未参加小组的居民(68.2%)。性别、年龄、文化程度、患有慢性病、自我效能等因素均与组员健康素养得分有关。
2.疾病／行为管理
在目前的自我管理小组中,除了17.1%未患慢性病的健康组员之外,其他组员慢性病患病情况各异。本研究对小组中患病率最高的高血压病进行了分析,高血压组员的血压控制率为79.3%。性别、社会支持与血压控制率有关。在被调查的自管小组组员中,分别有34.6%及45.1%的组员体力活动量“明显增加”及“稍微增加”；分别有32.5%及46.0%的组员蔬菜水果摄入量“明显增加”及“稍微增加”；分别有24.9%及58.0%的组员食盐摄入量“明显减少”及“稍微减少”；分别有28.3%及55.4%的组员食油摄入量“明显减少”及“稍微减少”。女性较男性而言,生活行为方式改善状况更好。
3.情绪管理
定性访谈结果提示,组员在参加自我管理小组之后,组员间的相互交流,向家人传播健康知识获得家人的支持,“心情好了”、“心态好了”是参加小组活动最大的收获之一。定量分析提示,文化程度、自我效能、交互性健康素养、社会支持等因素均与组员复原力得分有关。
4.社会／角色管理
定量和定性研究发现,组员参与社区活动广泛,一半以上的组员(58.8%)参加了志愿者组织,50.6%的组员较多参与居委、街道组织的各种活动,47.8%的组员较多参与兴趣活动组织(如老年大学、老年活动中心)等。偏相关分析得到的结果为,结构性社会资本与认知性社会资本水平存在正相关关系,结构性社会资本(社会联系、参与等)水平越高,认知性社会资本(信任、互惠、归属等)水平越高。目前小组组员社会资本属于高社会资本型(参与程度越高,信任水平越高)。研究也发现,组员的社会角色活动能力受限与结构性社会资本有关,组员的社会支持水平与认知性社会资本有关。
三、上海市慢性病自我管理小组可持续性发展研究
1.个体层面
从定量和定性的研究结果来看,目前自我管理小组已通过多种多样的活动形式来丰富小组活动内容,组员对小组长、社区医生、居委的工作比较满意,对小组活动比较满意。组员经常参与小组活动形式或内容有“相互交流”“医生咨询”“健身活动”“专题讨论”“茶话会”“健康烹饪”等。对小组活动需求越来越高,上课人数较多、缺乏基本的资金保障是目前面临的主要问题。
2.人际层面
一般社区人群的调查发现,77.4%的社区人群“知道”自我管理小组,50.9%的社区人群愿意参加自我管理小组。对组员家人的访谈发现,几乎所有的组员家人都支持他们参加自我管理小组,组员也把健康知识传播给家人,家人看到了组员在心情、身体健康方面的改善。15个小组的社会网络分析结果提示,9个小组的网络中心人物为小组长、居委干部以及社区医生,其余6个小组以组员为网络中心。在三分之二的小组中,组长、居委干部、社区医生作为小组网络的中心、最有影响力的人,发挥着传递信息、情感、信任等作用,或以中介的身份发挥着桥梁的作用。组长为中心型的小组其客观指标如血压控制率、结构性社会资本水平较其他类型好；组员为中心型的小组其主观指标如认知性社会资本、复原力等较其他类型好。
3.社区层面
定量和定性调查的结果提示,目前自我管理小组行动在社区层面存在的主要问题有获取资源能力欠缺；外部支持的渠道局限于街道镇以及社区卫生服务中心,社区卫生服务中心缺乏对医生参与小组工作明确的实质性考核制度与奖惩机制；与他人联系不足,表现为小组、居委与社区卫生服务中心没有建立一个真正的资源共享、伙伴关系的平台；小组之间、居委之间缺乏交流；小组骨干需要知识、技能的进一步培训。虽然只有2个小组克服障碍,解决了九个维度的所有相关问题,但是,150个小组中有131个小组(87.3%)已经意识到存在的问题,具备了一定的社区能力。从社区增权理论的5点连续统一体理论来看,目前自我管理小组行动的社区增权水平处于从小规模兴趣组织迈入社区组织的阶段。
4.组织层面
在个人健康促进能力方面,尽管大多数爱卫干部来自非医学专业的教育背景,但经过系列培训,已对健康、健康促进的基本知识有一定了解,但普遍反映缺乏健康促进实践技能；由于缺乏有力抓手,与在职人群沟通欠缺,无法在在职人群中普遍开展自我管理小组；另外,工作压力较大,没有充足的时间深入开展工作。定量调查提示,个人健康促进能力中优势是“态度”,劣势是“资源”。在组织健康促进能力方面,整个组织体系都很重视自我管理小组的工作以及与其他部门的伙伴关系,但缺乏政策、制度的保障；人力资源极为缺乏,不利于健康促进工作的长期性、规划性。定量调查提示,组织健康促进能力中优势是“承诺”,劣势是“资源”。环境健康促进能力方面,大多数爱卫干部认为政府投入不够；虽然居民健康意识明显提升,但参与程度不够；与其他部门组织的沟通协调不够。定量调查提示,环境健康促进能力优势是“舆论与民意支持”,劣势是“理念普及”。
5.运用多水平分析模式探讨社区层面的社区能力与组织层面的健康促进能力对小组实施效果的影响,分析结果发现,组织层面的健康促进能力与组员健康状况呈正向相关。
6.各层面存在的主要问题提示,共性问题是对自我管理小组的资源与制度保障支持欠缺,应首先从这两个方面予以努力。从长远角度看,提高政府重视程度、从政策上把自我管理融入初级卫生保健、培养健康促进队伍是解决问题的根源。
研究结论
上海市慢性病自我管理实施效果显著,自我管理小组已具备可持续发展的基础：小组组员对小组活动、小组骨干的工作比较满意、小组在人际间传播良好、各层面相关人员通过基本的培训及几年来的实践已具备保障小组活动顺利实施的能力。把自我管理融入到常规卫生服务中以及持续的人员及资金保障是今后努力的方向。
Today, noncommunicable diseases (NCDs) represent a leading threat to human health and development, causing about35million deaths each year-60%of all deaths globally-with80%in low-and middle-income countries. These diseases are preventable. Research has demonstrated that people who take the lead themselves in managing their chronic disease-with good support from health service providers have improved health and that incapacity is is reduced. Chronic disease self-management programme means that patients learn the skills necessary to take on active role in caring for their own chronic conditions and assume some medical and preventive tasks with the support of health professionals. The successful experiences from domestic and international researches indicated that patient-centered chronic disease self-management programme (CDSMP) is a cost-effective strategy to improve patients'health functioning and quality of life. Many countries such as, the United States, the British, Australia and Canada, have integrated self-management into primary health care gradually. In the second half year of2007, the Office of Patriotic Health Campaign Committee of Shanghai adopted the recommendation from the study of "community-based project of self-management of hypertension" by School of Public Health, Fudan University. There were totally5048villages,9762groups,166158people participating in these activities, which covered99.55%streets,95.93%villages till2010. Under the principles of doctor-patient cooperation, mutual aid, self-management, CDSMP aims to create a supportive environment for chronic disease prevention and control. In order to make CDSMP sustainable, we have to combine the self-management support with the routine disease management and responsibility system of family doctors. In another aspect, Patriotic Health Campaign Committee system, as the main force of health education and health promotion, how to give full play to their own advantages, to overcome obstacles and shoulder the health education and the responsiblilty of the prevention and control of chronic disease, is the key to the sustainable development. This study would focus on the abve problems, around implementation effect, summarizes the present work experiences of success and the insufficiency to promote CDSMP sustainable development.
Goal
The present study aim to sum up experience and effective method, explore the main influencing factors for the implementation effect, and provide the scientific basis on policy recommendation for CDSMP sustainable development and prevention and control for chronic disease.
Targets
·To evaluate CDSMP's effectiveness and the influencing factors;
·With the guide of ecological model, to analyze the operational status of CDSMP, main obstacles and opportunities, and to seek solutions from individual, interpersonal, community and organization four levels.
Subjects
Group members and group leaders from150self-management groups, members' relatives, community residents and Patriotic Health Campaign Committee'stuff were randomized selected by stages.
Contents
1. Implementation and spread process for CDSMP in Shanghai
2. Implementation effect of CDSMP in Shanghai
3. Sustainable development study of CDSMP in Shanghai
Methods
A cross-sectional research design was applied. The quantitative and qualitative analysis was used in this research. The quantitative method involves questionnaire survey. The qualitative analysis included focus group discussion. We use descriptive and analytical assessment in data analysis, including descriptive analysis, univariate analysis, multivariate linear regression, binary logistic regression, ordinal logistic regression, social network analysis, multilevel analysis and Fault Tree Analysis (FTA).
Results
Section1Implementation and spread process for CDSMP in Shanghai
Based on the collection of the document provided by the Patriotic Health Campaign Committee office, we sum up the development process of CDSMP. The result showed that CDSMP as a community intervention experimental research becomes an action for prevention and control for chronic illness, is very successful. Powerful policy support, defined responsibilities of operation parties and active participation of relevant population are keys.
Section2Implementation effectiveness of CDSMP in Shanghai
1.5Core Skills
The results showed that63.6%of group members have sufficient interactive health literacy. The suvey of community residents indicated that the percent of residents who participate in the chronic disease self-management groups with sufficient interactive health literacy is higher than those who did not attend. Gender, age, education, having chronic disease or not, self-efficacy are related with interactive health literacy score.
2. Disease and Behavior management
17.1%of members don't have any chronic disease in self-management groups at present. In all chronic disease group members have, hypertension has the highest morbidity. Others are arthritis, cerebrovascular disease and diabetes in sequence. The control rate of hypertension is79.3%. Gender and social support are related with the control of hypertension.34.6%of group members increase their phycial activity significantly, and45.1%increase phycial activity slightly.32.5%of members increase their vegetable and fruit intake significantly and46.0%increase intake slightly.24.9%and58.0%of members decrease their salt intake significantly and slightly respectively.28.3%and55.4%of members decrease their oil intake significantly and slightly respectively. Women are better in life behavior improvement than men.
3. Emotional management
The qualitative analysis showed that, after members participated in self-management group, mutual exchange and having a good mood are biggest harvest. The quantitative results showed that education, self-efficacy, interactive health literacy and social support are influencing factors for resilience.
4. Social and Role management
The quantitative and qualitative analysis indicated that group members participate in community activities widely.58.8%of members take part in volunteer organization,50.6%take part in activities organized by residents'committees or street agency,47.8%participate in interest activities.Partial correlation analysis presented that structural social capital is positively correlated with cognitive social capital. The more members participate in social activites, the higher reciprocity and trust degree they will have. And the social role limitation is related with structural social capital, the social support members obtain is related with cognitive social capital.
Section3Sustainable study of CDSMP in Shanghai
1. Individual level
Chronic Disease self-management groups have been enriched in the content through the various activities. Members are satisfied with the efforts taken by group leader, instruct doctor and Neighborhood cadre, also satisfied with the group activities. Interaction, consulation, fitness activities, seminar, tea party, healthy cooking are regular activities. Higher demand and lack of limitation and funding are the main problems facing at present.
2. Interpersonal level
77.4%of community residents have heard of self-management group.50.9%of community residents would like to attend. Focus group interview on the members' family indicated that almost all the family members support self-management group, they all see group members'improvement in physical and emotional health. And they also received health knowledge from members. Social network analysis on15self-management groups showed that group leader are the social network's centers in9groups'network graph, ordinary members are the centers in the other6groups' network graph. As the center and intermediary of network, group leaders transfer information, emotion and trust. They also play the role of bridge. Objective indicators such as blood pressure control, structural social capital levels in leader-centered group are better than other groups.While subjective indicators such as cognitive social capital, resilience and self-perceived health status in member-centered group are better than other groups.
3. Community level
The main problems in this level are lack of the abilities of obtaining resources, limitation of external support channel, lack of substantive appraisal system and clear rewards and punishments mechanism, lack of connection with others and lack of interaction among groups or communities. Group leaders also need further training. In the150groups,130groups (87.3%) have realized existing problems and have basic community ability,2groups have higer degree of community ability. Based on the community empowerment as a5point continuum, Community empowerment' phrase of CDCMP enters a stage from small groups to community organizations.
4. Organization level
In individual health promotion capacity, Patriotic Health Campaign Committee'stuff have already understood health promotion basic knowledge although they aren't medical professionals. But lack of practical skills and enough time to carry out in-depth work is a popular problem. The strength of individual capacity is attitude, the weakness is resource. In organizational health promotion capacity, the whole organization system has paid great attention with the work but lack of policy security. Lack of human resources goes against health promotion long-term planning. The strength of organizational capacity is commitment, the weakness is resource. In environmental health promotion capacity, stuff reported that government's input is insufficient. Residents'health consciousness has been raised, but participation is not enough.The third obstacle is shortage of communication and coordination with other sectors. Public opinion and ideas, concept popularity are the strength and the weakness in environmental health promotion capacity respectively.
5. Environmental factors' influence on implementation effect of CDSMP
Two-level linear multilevel model was adopted to analyze the influence of community capacity and health promotion capacity on effect of CDSMP. The results indicated that health promotion capacity is positively related with members' health status.
6. Fault Tree Analysis on CDSMP
The main problem of four levels is lack of the resources and mechanism security. We should make great efforts in these two aspects. In the longer term, the attention of the government, involving self-management into primary health care and cultivation of health promotion team are the root of problem.
Conclusions
The implementation effectiveness of CDSMP in Shanghai is remarkable, and CDSMP has already had the base for the sustainable development. Group members are satisfied with the activities and efforts taken by group leaders and CDSMP is spreaded widely.Through the basic training and practice in the past few years, relevant personnel have the capacity to guarantee the implementation of CDSMP. Involvement in regular health services and continuous security of human resources and fund are the direction.
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