| BackgroundDiabetes has become a global public health problem that affects people’s health and economic development. Curing the epidemic of diabetes and its complications has become an bounden responsibility of governments and health workers at all levels. Due to the large number of diabetics and the relative shortage of health resources in China, diabetics have to assume self-management responsibilities and master the related knowledges and skills. Many studies have confirmed that community diabetes self-management program (hereafter be "CDSMP") can be very helpful to improve self-management ability of diabetics and their family members. And then utilization of health resources and economic burden of diabetic families can be substantially reduced.From the beginning of2011, National Center for Chronic and Non-communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention has implemented pilot CDSMP in six provinces such as Beijing,Shanghai. It is very necessary to evaluate this program with an appropriate method for understanding the implementation process and outcome and then promoting more extensive application of the program. The RE-AIM framework is a comprehensive evaluation model for public health program, which contains process evaluation, outcome evaluation and impact evaluation. It has been widely used in the evaluation of foreign public health program since1999when the framework was firstly put forward. Not only the effectiveness, but also some critical issues such as participation’s enthusiasm of patients and health institutions, real implementation process and feasibility for transformation to the daily work of community health institutions can be well understood through a RE-AIM analysis of certain intervention. In addition of promoting more extensive application of certain program, it can also provide a scientific basis for the adjustment of community intervention and health resource allocation. Based on the above reasons, the RE-AIM framework was used to evaluation the CDSMP, which is the first application in China. Objective1. To evaluate the effectiveness of CDSMP in relative large population and provide a scientific basis for more extensive application of the program.2. To evaluate the implementation process of CDSMP in the current medical environment in order to promote its improvement.3. To explore the application of RE-AIM framework in the field of public health program evaluation through its pilot application in CDSMP.MethodsQuantitative and qualitative method were used together to collect evaluation data in this study. The program leaders of47counties or districts and84community health service institutions as well as96leaders of self-management groups were reviewed to understand the specific implementation process of CDSMP. Meanwhile, self-efficacy, self-management behaviors and quality of life of1603diabetics was investigated before and after the program to evaluate the effectiveness of CDSMP.On the basis of related research abroad, a RE-AIM evaluation system of CDSMP with100score for each dimension was developed in this study. Then a comprehensive evaluation of CDSMP in2013was carried out through analysis on the five dimensions:Reach, Effectiveness, Adoption, Implementation, Maintenance. And the public health impact of the CDSMP in six pilot provinces was compared.Results1. AdoptionIn2013,47of390counties/districts participated in the implementation of CDSMP in the6provinces.84of804community health service institutions carried out the program in these counties or districts. The participation rate of the staffs in these institutions was67.0%(177out of264). Adoption of CDSMP in2013was7.0. Support from leadership was an important advantages for these institutions to carry out the program.2. Reach In2013, the recruited1653patients were only accounted for1.71%of all the diabetics that managed by community health service institutions. The demographic representativeness of them was99.93%. Reach of CDSMP in2013was1.7. The reasons that attracted these diabetics into self-management intervention activities were mainly as below:the knowledge gained from the activities very helpful for diabetes control, convenient communication with health workers and other diabetics, free blood glucose testing and so on.3. ImplementationIn2013, the implementation rates of the four elements of CDSMP were66.7%(128/192) for recruitment of group leaders,96.9%(124/128) for training of leaders,100.0%(576/576) for number of group activities and82.3%(474/576) for activity contents, respectively. The implementation rates of the six activity contents were ranked from the highest to the lowest as:diet control, physical activity, prevention of complications, drug treatment, blood glucose monitoring and emotion management. Implementation of CDSMP in2013was86.0. The main problems occur in the implementation process were as follows:absence of policy support and coordination from the relevant departments; insufficient number of community healthcare providers; inadequate group leaders; low participation enthusiasm of diabetics.55of84community healthcare providers thought the implementation of CDSMP brought them more workload.4. Effectiveness1603of1653diabetics completed two questionnaires before and after the intervention. Among them,994were women and1156were aged60and above. In addition,1230diabetics had education background below the junior middle school and962diabetics had duration longer than3years.56.4%of them had hypertension and71.8%were free of related complications.80.2%of these diabetics had not participated self-management intervention in any form before.1115diabetics completed all the six activities of CDSMP, which accounted for69.6%of the total number. The overall satisfaction on the intervention activities of diabetics was97.6%and the satisfaction on the form and contents were97.0%and97.3%, respectively. Through self-management intervention activities, self-efficacy of diabetics increased from87(71,103) up to103(85,115) and the difference was proved statistically significant (F=53.46,P<0.01). Moreover, the effect had no difference for different patient subgroups in gender and age (P>0.05). Frequency of blood glucose monitoring by diabetics and hospitals were improved(P<0.01). The proportion of diabetics with daily foot examination increased from12.4%to29.3%with a statistically significance(χ2=139.03, P<0.01). The proportion of diabetics with daily exercise time less than30minutes decreased from38.0%to27.9%with a statistically significance(χ2=36.59, P<0.01). Quality of life of diabetics was improved from607(495.1,676.9) to631.8(549.8,692.8) and the difference was also statistically significant (F=100.20, P<0.01) and the improvement of each dimension was also significant(P<0.01). Effectiveness of CDSMP in2013was25.0.5. Maintenance74of84community health service institutions that carried out CDSMP in2013were willing to implement self-management intervention as routine work.1419of1603diabetics that participated in intervention activities in2013were willing to take part in group activities afterwards. Sufficient financial support was badly needed if community health service institutions were asked to implementation the CDSMP routinely. And some other support such as technology, policy, manpower were also needed.6. RE-AIM averageIn2013, RE-AIM average of CDSMP was30.1. Except for Maintenance, which was failed to be evaluated due to time constraints, the scores of the remaining dimensions of RE-AIM framework were ranked from the highest to the lowest as Implementation, Effectiveness, Adoption and Reach. RE-AIM averages of CDSMP in pilot six provinces were also ranked from the highest to the lowest as follows: Chongqing and Jiangsu, Zhejiang, Beijing, Guangdong, Shanghai. Conclusion1. Self-efficacy and quality of life of diabetics were both improved through CDSMP and community health service institutions are able to implement the Intervention well. While recruitment and training of group leaders as well as activities contents should be further perfect.2. The proportion of community health services institutions that carried out CDSMP is small and the number of diabetics covered by the program is also very low. Publicity and policy guidance should be strengthened to provide a support environment for community to carry out CDSMP. And diabetes self-management intervention is advised to be incorporated into basic public health services.3. RE-AIM framework can be used to comprehensively evaluated implementation process and effectiveness of certain public health program and should be paid more attention to promote more extensive applications in China. |
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