General Information
We established the IGPDP prospective study cohort and completed a 24-month. Random cluster sampling and random sampling were used for sampling. Those who met the inclusion criteria in each community health service center within one month were included in this study in turn, until the number reached the requirements.
Sampling steps: Firstly, cluster sampling was carried out for the community health service centers in the five administrative regions of Shenyang with a population of more than 100,000 and an average daily outpatient volume of more than 50. Then, a certain number of community health service centers were randomly selected in each administrative region to be included in this study. Finally, the subjects were randomly divided into a control group or a test group as shown in the table below (Table 1). The Medical Ethical Commission of the China Medical University approved this study. The consent we obtained from study participants was written.
Table 1 Source and grouping of research samples
Inclusion and exclusion criteria
A prospective cohort study was carried out, and the inclusion and exclusion criteria as shown in the table below (Table 2).
Table 2 Inclusion and exclusion criteria
Intervention methods
IGPDP was used in the test group and traditional health management service model was used in the control group. In the control group: carry out an annual physical examination according to the medical examination package for the subjects, provide group health consultation for the subjects, and coordinate specialist referral as required. In the test group, the one-year intervention cycle was divided into a two-month strengthening phase, a one-month consolidation phase and a nine-month stable phase (Fig. 2). According to the individual condition of the subjects, we made a health plan for them, and provide personalized diet and exercise guidance according to the plan. After a period of intervention, the health plan was modified or reformulated according to the changes in the subjects' health status. The implementation effect was evaluated by analyzing the subjects' questionnaire results and clinical indicator results at baseline, 12 months, and 24 months.
Fig. 2 Technology road map
Evaluation index system
We evaluated the effect of IGPDP from three aspects: "disease prevention", "health protection" and "health promotion". Results at baseline, 12 months after intervention, and 24 months after intervention were collected by measuring clinical indicators and questionnaires. Data were collected by trained investigators (Table 3).
Table 3 Evaluation index system
Specific information of questionnaires
Health risk assessment questionnaire
The questionnaire was used to collect the subjects' basic information, behavioral risk factors, biological risk factors and other related indicators. The questionnaire included the subjects' basic information, disease history, family history, tobacco use, alcohol consumption, daily diet and exercise, sleep quality, psychological status and living environment, as well as basic physical indicators (waist circumference, BMI, blood pressure, blood lipid, fasting blood glucose, etc.).
National Residents' Health Literacy Monitoring Questionnaire
The questionnaire was used to measure participants' health literacy. The questionnaire covers three dimensions: basic knowledge and concept, healthy lifestyle and behavior, and basic skills. It is specifically divided into six categories: health science concept, prevention and treatment of infectious diseases, prevention and treatment of chronic diseases, basic medical treatment, safety and first aid, and access to health information. The scoring standard of the questionnaire is 1 point for each question of judgment and single choice. Two points for each multiple-choice question. More than 80% of the accuracy is considered to have health literacy.
Health status SF-36 Questionnaire
The questionnaire was used to measure the quality of life of the subjects. It comprehensively measured the quality of life of the subjects from 8 aspects: physical enginery, physiological function, physical pain, general health, energy, social function, emotional function and mental health. In addition, it also included health change indicators to evaluate the overall changes in subjects' health status over the past year. According to the choice weight or score of SF-36 questionnaire, the total score of SF-36 is 145.
Basic Health Service Demand Questionnaire
This questionnaire is used to investigate the needs of community residents for basic medical and health services. The questionnaire included three aspects, basic medical and health service, general practitioner and community health service center. It provides a reference for improving the services of general practitioners and making them better meet the needs of the public.
Statistical analysis
Each monitoring and investigation in this study has gone through the process of data cleaning, data verification and standard database establishment. Epidata 3.1 software was used to establish a database. Logical error checking was conducted after data entry, and the outliers were returned to the original research institution for verification against the original questionnaire. Then, randomly select data and original data at a rate of 20% for verification. Finally, lock the database for statistical analysis. SPSS 22.0 software was used for statistical analysis of the data. The measurement data were described as mean ± standard deviation, and rate was used to described the counting data. The t-test of two independent samples was used to compare the measurement data between the two groups, and the chi-square test was used to compare the rate. One-way analysis of variance was used to compare the measurement data among multiple groups. Test level α=0.05.