目標︰台灣地區糖尿病盛行率逐年增加，2007年糖尿病成為國人十大死因的第四名。自我管理是糖尿病病友預防保健之首要，適當衛教模式的介入，可促使病患實施自我照護行為。本研究主要在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研究對象，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。照護模式整合組織、社區保健志工團體與糖尿病友團體與專業醫療團體介入等三方資源，?教介入係根據社會支持理論與糖尿病自我管理原則所發展的情境學習課程。於課程介入前後、介入六個月後觀察病友的改善情形。資料收集包括病友人口學資料及身體代謝指標、糖尿病認知、自我管理照護行為、課後滿意度等。
研究結果：衛教課程介入後，病友之糖尿病認知得分由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3.0分提升至3.8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。結合社會支持團體與情境教學的衛教模式，能使病友清楚瞭解衛教內容，並實際應用於生活中。 OBJECTIVES — The purpose of this 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 South 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 health educational program, it contained three components: organizing health care communities volunteer, organizing diabetic patient group and integrating these resources by 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 raised from 15.2 to 19 points (total score 20 points; p< 0.05). The average score of self- management behavior did raise from 3.0 to 3.8 points (total score 4 points; p< 0.05).
CONCLUSIONS — Application of community-oriented primary care, intervention of medical professional team and cooperation of health care communities volunteer provide “professional” and “accessibility” health service to diabetic patients in community. Social support group and situated learning program let diabetic patients clearly realize education subject and actually apply to their life. Our study verified the effectiveness of this intervention program.
