充能自我管理方案於糖尿病早期腎病變病人之成效

背景：糖尿病腎病變是一種漸進惡化的疾病，若控制不良將進展為末期腎病，須接受透析治療或腎移植，造成醫療資源的負擔，故及早有效地落實糖尿病病人的腎病管理，實是刻不容緩的健康議題。目的：旨在檢視糖尿病早期腎病變病人於「充能自我管理方案」介入後，對自我效能、自我管理、生理指標 (即: 體重、身體質量指數、腰圍及血壓)與生化指標 (即: 糖化血色素、總膽固醇、低密度脂蛋白、腎絲球過濾率及尿液白蛋白與尿液肌酸酐比值)之成效。方法：本研究為二組前後測、縱貫性類實驗設計，採便利取樣，以南部四家醫院之腎臟科及新陳代謝科門診的糖尿病早期腎病變病人為研究對象，共收案71位(實驗組35人、對照組36人)。對照組接受原先醫療院所的常規照護，實驗組除接受原先常規照護外，另接受六週的「充能自我管理方案」，介入方案完成後當日、滿3個月、滿6個月及滿12個月分別進行後測。結果：受試者平均年齡為54.97歲（SD=9.99歲），除糖尿病之外，平均另患有1.52個（SD=1.04）慢性病。在介入成效方面，於慢性腎臟病自我效能及自我管理變項上，在介入完成後滿3個月、滿6個月及滿12個月實驗組皆顯著高於對照組；於生理指標上，體重及身體質量指數於介入完成後滿3個月顯著低於對照組；腰圍、收縮壓及舒張於介入完成後滿3個月、滿6個月及滿12個月實驗組顯著低於對照組。於生化指標方面，糖化血色素於介入完成後滿3個月、滿6個月及滿12個月實驗組顯著低於對照組；於介入完成後滿3個月，對照組之膽固醇及低密度蛋白顯著高於實驗組；兩組腎功能未達顯著差異。結論/臨床應用：本研究所發展的「充能自我管理方案」係以充能理念為基礎，在夥伴關係基礎下，透過探討個人自我管理的問題、設定行為目標、發展行動計畫、評值與回饋行動成果等策略，可增進糖尿病早期腎病變病人的自我效能、自我管理行為及改善與疾病進展相關之生理及生化指標。本研究所發展的方案可做為腎臟保健機構推動糖尿病早期腎病變照護的参考。

關鍵字

自我管理；充能；早期腎病變；糖尿病

並列摘要

Background: Diabetic nephropathy (DN) is a progressively worsening disease. Without vigorous treatment it can advance to end-stage renal disease (ESRD), and require lifelong renal replacement therapy for the maintenance of physical functions. This will cause the heavy cost burden for medical treatment covered by Taiwan’s health insurance. Since this is the case, how to conduct effective kidney disease management as early as possible for diabetics in order to prevent the advance to ESRD and then to reduce the heavy burden on society’s medical treatment costs is truly an important policy matter in relation to DN prevention. Objective: To evaluate the long-term effectiveness of an empowerment-based self-management (EBSM) program on self-efficacy, self-management, physical measures (i.e., body weight, body mass index, waist, systolic blood pressure and diastolic blood pressure) and biochemical measures (i.e., glycated hemoglobin, total cholesterol, low density lipoprotein, glomerular filtration rate and urine albumin/ creatinine ratio) in diabetic patients with early nephropathy. Method: This was a pretest– posttest, repeated-measures, and longitudinal study with quasi-experimental design. Seventy-one patients were recruited from four hospitals in southern Taiwan by convenience sampling. The comparison group received the usual care administered to patients with early DN, while the experimental group received the EBSM program on top of the usual care. All of the patients underwent testing the day of the end intervention and at 3, 6 and 12 months after complete a six-week intervention. Results: The mean age of the participants was 54.97years (SD=9.99 years), and the mean number of comorbidities per patient was 1.52 (SD=1.04). After adjustment for baseline and covariate, the EBSM program resulted in significant improvements in CKD self-efficacy scores, and CKD self-management scores at 3, 6 and 12 months after complete a six-week intervention as compared to the comparison group. Regarding the physical indicators, results showed that, in the experimental group than in the comparison group the body weight and body mass index were significantly decreased at 3 months and the waist, systolic blood pressure and diastolic blood pressure showed significantly decreased at 3, 6 and 12 months follow-up after complete intervention, respectively. Regarding the biochemical indicators, the experimental group resulted in significant improvements in glycated hemoglobin levels throughout 12 months than the comparison group. Additionally, in the comparison group, total cholesterol levels and low density lipoprotein were significantly higher at 3 months than in the experimental group. No significant differences in glomerular filtration rate and urine albumin/ creatinine ratio were observed between the groups. Conclusion/ Practice implications: Lays the foundation for partnership, the EBSM group which used the empowerment approach to help patients find out self-management problems, set goals and make evaluation to their CKD self-management plans. The study results show that the EBSM program for patients with DN had positive effects on self-efficacy, self-management behavior, physical and biochemical indicators. Empirical data suggest EBSM programs that may produce better health outcomes and could be used as references for the national department of health in the planning of policies for kidney disease prevention programs