多病共存慢性病个性化健康教育模式的探讨

曹琳; 杨振华; 肖卫忠

doi:10.16766/j.cnki.issn.1674-4152.003014

多病共存慢性病个性化健康教育模式的探讨

doi: 10.16766/j.cnki.issn.1674-4152.003014

曹琳¹,
杨振华¹,
肖卫忠^{1, 2, ,}

1.
北京大学第三医院全科医学科，北京 100191
2.
北京大学第三医院神经内科

基金项目:

2021年全国全科医学教育教学研究课题 B-YXGP20210201-01

详细信息

通讯作者:
肖卫忠，E-mail: weizhongx@sina.com

中图分类号: R473.59 R193
计量
- 文章访问数: 217
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- PDF下载量: 18
- 被引次数: 0
出版历程
- 收稿日期: 2022-09-06
- 网络出版日期: 2023-08-26

Discussion on the personalized health education model for chronic diseases with multimorbidity

1.
General Practice Department, Peking University Third Hospital, Beijing 100191, China

摘要

摘要: 近年来多病共存患病率逐年增加，与单种慢性病患者相比其疾病负担更重、预后更差，已成为全球医疗卫生难题。针对多病共存患者的复杂病情，以疾病为中心的被动医疗服务模式难以满足患者主动健康的需要，以及更好地改善患者疾病预后、提高其生活质量。目前国内外没有多病共存个性化健康教育的统一模式，但单种慢性病健康教育处方的简单叠加，并不适用于病情复杂的多病共存患者。在此背景下，需要建立一种科学可行的多病共存患者个性化健康教育模式，在充分评估患者临床资料、运动睡眠、营养膳食、精神心理、疾病负担等的基础上，对患者的药物治疗、健康行为和生活方式进行个性化的健康教育指导，最后在长期随访过程中不断评价健康教育效果，调整患者的健康教育方案。随着我国医药卫生体制改革的推进，分级诊疗制度、家庭签约服务等基本公共卫生服务建设基本完善，全科医生已有能力进行包括个性化健康教育在内的多病共存综合健康管理服务。因此，针对多病共存患者的共性问题，本文综合国内外慢性病健康教育的相关研究，从健康教育评估、处方制订、效果评价三方面对多病共存的个性化健康教育模式进行探讨，以期为制订我国多病共存健康教育处方提供参考。
- 多病共存 /
- 慢性病 /
- 健康教育 /
- 教育模式
Abstract: Chronic diseases with multimorbidity refers to one person concurrently suffers from two or more chronic diseases. Recent years have witnessed an increasing prevalence of multimorbidity, which results in a heavier burden and a worse patient prognosis compared with a single chronic disease, becoming a global healthcare challenge. In view of the complex medical conditions of patients with multimorbidity, the disease-centered passive care model is difficult to meet the proactive care needs of these patients, and to better their prognosis and quality of life. There is still no a unified personalized health education model for multimorbidity, but the health education model derived from simply merged health education prescriptions for single chronic diseases is not suitable for patients with multimorbidity. Thus, it is necessary to establish a scientific and feasible personalized health education model for patients with multimorbidity, which can provide the patients with personalized health education guidance involving pharmacological treatment, health behaviors and lifestyle based on a thorough assessment of their clinical data, exercise and sleep quality, nutritional status and diet, mental and psychological status and disease burden. The health education plan can be adjusted according to its effectiveness continuously evaluated during a long-term follow-up. In China, with the promotion of healthcare and pharmaceutical reform, the development of hierarchical medical system and family doctor services and other public health services has been improved basically, and general practitioners are capable to provide comprehensive health management services including personalized health education for patients with multimorbidity. Considering the common health problems in patients with multimorbidity, we reviewed studies on chronic disease health education, and discussed three aspects (health education assessment, health prescription development, effectiveness assessment) that should be focused on in the development of a personalized health education model for multimorbidity, with a view to providing a reference for the formulation of health education prescriptions for Chinese patients with multimorbidity.
- Multimorbidity /
- Chronic diseases /
- Health education /
- Education model

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参考文献(44)

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