The family doctor team integrated peer support groups, as one type of social prescribing models, can effectively address the fundamental challenges posed by social factors in the chronic disease prevention and control. With advantages such as strong sustainability, it alleviates the tension between the shortage of rural health workforce resources and the low self-management adherence among chronic disease patients, holding the potential to further unlock the effectiveness of the county health system reform, thereby. However, research on the sustainability mechanisms of the intervention effects remains limited within the social context of rural China.

To conduct an in-depth analysis of the multiple pathways and dynamic processes through which this intervention model exerts a sustained impact on the self-management behaviors of chronic disease patients in real rural social settings.

An embedded single-case study was adopted, with the health mutual aid group project in T Village, F Province, from December 2022 to June 2024 as the primary unit of analysis. Secondary units of analysis included key actors and specific types of self-management behaviors. The study was grounded in an integrated framework of social cognition theory and related theories, utilizing questionnaires, in-depth interviews, and non-participant observation for data collection. Crisp-set qualitative comparative analysis (csQCA) served as the core analytical method to identify pathways. Large language models (LLMs) and retrieval-augmented generation (RAG) were employed during the process to assist in preliminary analysis. One outcome (R0) and six causal conditions (CV1-CV6) were defined.

(1) The consistency for the perceived harmfulness of non-health behavior (CV1), perceived usefulness of health behavior (CV2), perceived ease of practicing health behavior (CV3), and localized doctor-patient social support (CV4) met or exceeded 90%. (2) The overall consistency and coverage for the three pathways of sustained self-management behavior among rural residents were 80.00% and 93.33%, respectively: The primary pathway had a consistency of 83.25% and coverage of 46.67%, including CV1-CV4 and localized neighborhood social support (CV6) ; Secondary pathway A had a consistency of 81.82% and coverage of 30.00%, including CV1-CV2 and CV4-CV6; Secondary pathway B had a consistency of 71.43% and coverage of 16.67%, including CV1-CV4 and CV5.

This model, through collaboration between family doctor teams and localized social support networks—including village doctors, families, and neighbors—can continuously enhance perceived benefits and ease of self-management behavior, bridge the "digital divide", and ensure the sustainability of intervention effects. Therefore, in rural chronic disease prevention and control, it is feasible to explore the integration of essential health services under formal institution with the development of localized social support networks. Specifically, in remote areas such as mountainous regions, family doctor teams can conduct institutionalized regular visits, stimulate volunteers by natural village units, and leverage their localized social support networks to establish mutual aid groups for chronic disease patients. These groups can regularly conduct interactive health education and guide health-oriented daily interactions and mutual assitune practice.

家医团队联合同伴支持小组作为社会处方干预措施，可应对部分社会因素对慢性病防控带来的根本挑战，并具备良好可持续性等优势，因而有望缓解农村全科医护资源短缺与慢性病患者自我管理依从性偏低的矛盾，进一步释放紧密型县域医共体改革效能。然而，在我国农村独特社会文化情境下，该模式干预效果可持续机制研究较为薄弱。

深入分析真实农村社会情境中，该干预模式对慢性病患者自我管理行为持续影响的多元路径与动态过程。

采用嵌入式单案例研究，以2022年12月—2024年6月F省T村健康互助组项目为主分析单位，嵌入关键行动者、特定类型自我管理行为两层的次级分析单位；以社会认知及其相关理论整合为基本分析框架，采用问卷调查、深度访谈与非参与式观察收集资料；以清晰集定性比较分析（csQCA）为核心分析方法识别路径组合，在过程中辅助运用大语言模型（LLMs）和检索增强生成技术（RAG）开展预分析，设定1个结果变量（R0）与6个条件变量（CV1~CV6）。

（1）非健康行为问题化感知（CV1）、健康行为有用性感知（CV2）、健康行为易用性感知（CV3）、在地化医患社会支持（CV4）的一致性率均不低于90%；（2）农村居民持续自我管理行为三类路径总体一致性率为80.00%、覆盖率为93.33%：首要路径一致性率为83.25%、覆盖率为46.67%，包括CV1~CV4、在地化邻里社会支持（CV6）；次要路径A一致性率为81.82%、覆盖率为30.00%，包括CV1~CV2、CV4~CV6；次要路径B一致性率为71.43%、覆盖率为16.67%，包括CV1~CV4、CV5。

该模式可通过家医团队与村医、家庭、邻里等在地化社会支持网络有效协作，持续提升慢性病患者自我管理行为收益与易用感知，并弥合"数字鸿沟"，保障干预效果可持续。因此，在农村慢性病防控工作中，可探索正式制度保障下的基本医疗卫生服务与在地化社会支持网络建设的融合机制与路径。具体而言，在山区等偏远地区，依托家医团队开展制度化巡诊，以自然村为单位动员志愿者，借助其在地化社会支持网络组建慢性病患者互助小组，定期开展互动式健康教育，引导健康导向日常交往与互助实践等。