以社區導向的基層照護模式提供社區糖尿病友團體整合性服務之前驅性研究

Effectiveness of integration service by applying community-oriented primary care to diabetic patient group in community

研究目的：探討社區導向的基層照護模式對糖尿病友建立社會支持系統與健康的生活型態的成效。研究方法：採用立意取樣，以南部某社區的第二型糖尿病友為對象，共有18位完成收案。資料收集時間從 2007年8月至2007年10月間進行，並於六個月後再追蹤成效。介入模式包含組織社區保健志工團體與糖尿病友團體，透過專業醫療團體介入整合三方資源，根據社會支持理論、應用糖尿病自我管理及發展情境學習衛教課程。資料收集包括病友人口學資料及身體代謝指標、糖尿病疾病認知、自我管理照護行為、課後滿意度調查。研究結果：衛教課程介入後，病友之疾病認知得分由15.2分提升至19分 （總分20分），達顯著差異 （p＜0.05）。自我管理照護行為分數由3.02分提升至3.72分 （滿分4分），達顯著差異 （p＜0.05）。結論：透過專業醫療團隊之衛生教育介入與社區保健志工團體結合的社區導向基層照護模式，可提供社區糖尿病病友『專業性』及『可近性』的健康服務。以社會支持團體與情境教學模式，能使病友清楚瞭解衛教內容，並實際應用於生活中。

OBJECTIVE — The purpose of the research was to evaluate the effectiveness of community-oriented primary care for diabetic patients by building a social support system and a healthy lifestyle. RESEARCH DESIGN AND METHODS — The research sample enrolled 18 patients with type 2 diabetes, from one community in Southern Taiwan. Data was collected from August 2007 to October 2007 and the effectiveness was re-evaluated 6 months later. The intervention model was based on social support theory, application of diabetes self-management and development of situated learning in an educational health program, where it contained three components: organizing health care communities volunteers, organizing diabetic patient groups and integrating these resources by a medical professional team. Data collection included patient's demographic, physical examination, cognition in diabetes, self-management behavior and satisfaction in the education program. RESULTS — After completing such a program, the score of accuracy in healthcare cognition was raised from 15.2 to 19 points (total score 20 points; p<0.05). The average score of self- management behavior went from 3.0 to 3.8 points (total score 4 points; p<0.05). CONCLUSIONS — Application of community-oriented primary care,intervention of a medical professional team and cooperation of health care community volunteers provide a ‘professional’ and ‘accessible’health service to diabetic patients in the community. Social support groups and situated learning programs let diabetic patients clearly realize the educational subject and actually can apply it to their lives. Our study verified the effectiveness of this intervention program.