2型糖尿病患者慢性并发症健康行为生态学模型的构建及Triangle分层干预策略研究

T2DM慢性并发症发生率与致残致死率高，给社会与家庭带来沉重负担，健康行为影响因素的研究对改善健康结局转归意义重大。现阶段研究尚未分析生理、心理、卫生服务和社会环境等因素共同作用对T2DM慢性并发症健康行为的总效应，尚未形成健康行为分层干预体系。因此本研究引入“健康生态学理论”，借助结构方程模型深入探究“个人特质、心理行为、人际网络、生活和工作条件、环境政策”各个因素相互作用，形成T2DM慢性并发症健康行为生态学模型。结合模型，引入“Triangle 分层分级管理”理念，借助多学科协作和e-Health技术平台，从行为管理目标，干预方式、内容、频次与对象，实施者及效果评价等维度制定健康行为Triangle分层干预策略，实现不同健康行为危险分层提供按比例分配的专业医疗护理与患者自我授权管理。以期降低T2DM患者慢性并发症发生率，持续改善健康支持性环境，全方位提升患者健康素养。

With the high incidence of chronic complications and the high rate of disability and mortality, T2DM brings heavy burden to the society and family. The research on the influencing factors of health behavior is of great significance for improving health outcomes. At present, the total effect of physiological, psychological, health services and social environment factors on health behaviors of chronic complications of T2DM has not been analyzed, and the stratified intervention system of health behaviors has not been formed. Therefore, this study will introduce the "health ecological theory" to build health behavioral ecological model in T2DM with chronic complications from the aspects of "personal traits, psychological behavior, interpersonal network, living and working conditions, and environmental policies", and analyze the interaction paths among various factors with structural equation model. On the basis of that, introducing "Triangle hierarchical classification management" concept, building multidisciplinary team management mode and e-health platform, health behavioral Triangle stratified intervention strategies will be realized from the dimensions of behavioral management goal, means and contents of intervention, intervention frequency, intervention objects, the perpetrators, effect evaluation. It is expected to reduce the incidence of chronic complications in T2DM patients，continuously improve the health supportive environment and comprehensively enhance the health literacy of patients.