[[alternative]]Effectiveness of self-management for patient with pre-End stage renal disease following the implementation of a self-management program based on self efficacy theory.

[[abstract]]慢性腎臟病（Chronic kidney disease, CKD）是世界上各國重要的公共健康議題。台灣長年因末期腎臟病（End stage renal disease, ESRD）高盛行率及高發生率，背負著｢洗腎王國｣稱號。慢性腎臟病對國人生命健康、心理問題的威脅及社會負荷，嚴然已成為不可忽視健康議題。對於臨床腎臟病照護者而言，如何協助CKD病人控制好原本的慢性病、因應疾病衝擊、延緩腎臟病惡化，促使執行自我管理行為並確保有生活品質是一大挑戰。而國內、外慢性腎臟病研究中缺乏運用自我效能理論基礎的自我管理方案，因此，本研究透過CKD自我管理方案系統文獻回顧後，發展適用於CKD病人以自我效能為中心之自我管理方案(self management program based on self efficacy theory, SMPSET)為介入措施，探討生理(臨床控制指標)、心理(自我效能、焦慮與憂慮)及社會(社會支持)及自我管理的成效。研究地點與對象為東北部某區域教學醫院之末期腎臟病前期(pre- End Stage Renal Disease ,pre-ESRD) CKD3b~5分期的病人。以類實驗性設計(qusi-experimental study)，收案人數為91人，實驗組36人及對照組55人，實驗組接受SMPSET(四個單元計400分鐘的團體活動；為期四週，每一週一次，每次100分鐘；每月電話追蹤)；對照組接受常規照護。結構式問卷包括人口學屬性、臨床控制指標、慢性腎臟病自我效能量表、慢性腎臟病自我管理量表、醫院焦慮與憂鬱量表、醫療社會支持量表；成果測量時間為一個月及三個月後。臨床指標的成效採用一般線性模式之單因子共變數分析，其他成效以廣義估計方程式分析。研究結果如下:(一)收案對象:以高齡已婚的男生居多、無職業、道教信仰、與家人同住、教育程度以小學居多，過去病史方面多數具有高血壓、蛋白尿、高血糖、CKD期數以3b居多。(二)生理層面(臨床指標):顯示三個月後能有減緩腎功能指標之肌酸酐(Cre)與蛋白尿(UPCR)惡化(p<0.05)。(三)心理層面:提升自我效能且效果可達三個月(p<0.001)；焦慮部份在一個月無成效，三個月時可顯著下降焦慮得分(p<0.05)，為介入措施有對降低焦慮有延遲性(三個月後)的效果；憂鬱部分則在一個月可顯著下降憂鬱得分(p<0.05)，但在三個月未見成效，無法達到延續的效果成效。(四)社會層面:能有效提升社會支持(p<0.001)，效果可達三個月(p<0.05)。(五)自我管理部分:可顯著提升且效果可達三個月(p<0.001)。結論:研究證實SMPSET可提供臨床照護者除了個案管理外，另一個具備實證證據的方案可運用，故建議可推廣至腎臟病病友會、取代傳統團體衛教，期望能促使病人達到與疾病和平共存及幸福安適的最終目標。建議:(一)延長追蹤時間六個月至一年後以檢視方案的縱貫長期成效，以及未來可進行大型研究及遍佈全國之隨機分派實驗研究，以驗證此方案更強實證成效；(二)臨床推廣此方案於腎臟病病友會；在職教育如，腎臟會醫學會舉辦「慢性腎臟病衛教師訓練班」，可增設增進自我效能訓練以協助腎臟病個案管理師學習帶領增進自我效能諮商團體；(三)建議未來國家保險設定為給付項目；考慮增設定期舉辦病友諮商團體照護獎勵費，以提高舉辦諮商團體的比率與成效。[[abstract]]Chronic kidney disease (CKD) is an important public health issue in various countries around the world. Due to the long-term high prevalence and high incidence of end stage renal disease (ESRD), Taiwan is known as “kingdom of dialysis.” The influence on national life and health, menace of psychological issues, and social burden caused by CKD have become health issues that cannot be ignored. To caregivers of clinical kidney disease, it is a great challenge to assist patients with CKD in controlling original chronic disease, responding to the impact of disease, delaying the worsening of kidney disease, implementing self-management behaviors, and ensuring quality of life. There is a lack of self-management programs based on self-efficacy theory in foreign and domestic studies on CKD. Therefore, according to the literature review on CKD self-management programs, this study developed self-management program based on self-efficacy theory applicable to patients with CKD as the intervention measure to investigate the effectiveness on physiological aspect (clinical control index), psychological aspect (self-efficacy, anxiety, and depression), social aspect (social support), and self-management. The subjects and the study site were the patients with pre-end stage renal disease (pre-ESRD) of CKD 3b~5 stages in a certain regional teaching hospital in the northeastern Taiwan. This quasi-experimental study enrolled 91 subjects, with 36 subjects in the experimental group and 55 subjects in the control group. The experimental group participated in the SMPSET (a 400-minute group activity with 4 units; this 4-week activity was held once weekly, with 100 minutes per time; monthly telephone follow-up was performed). The control group received routine care. The structured questionnaire included demographic attributes, clinical control index, CKD self-efficacy scale, CKD self-management scale, hospital anxiety and depression scale, and medical social support scale. The results were measured at Month 1 and Month 3 after the implementation of intervention. One-way ANOVA of general linear model was used to analyze the effectiveness of clinical index. Generalized estimating equation was used to analyze the effectiveness of other aspects. The research results are as follows: (1) subjects: most of the subjects were male, elderly, married, unemployed patients who believed in Taoism and lived with family. The level of education of the subjects was mainly elementary school. As for the past medical history, most of them suffered from hypertension, proteinuria, and hyperglycemia. In terms of the stage of CKD, most of them suffered from CKD 3b; (2) physiological aspect (clinical index): The results showed that, the progression of creatinine (Cre) and proteinuria (UPCR) of kidney function index was significantly alleviated at Month 3 (p<0.05); (3) psychological aspect: self-efficacy was improved and the effect lasted for 3 months (p<0.001); anxiety was not affected at Month 1. However, anxiety score was significantly reduced at Month 3 (p<0.05), suggesting that intervention measure had a delayed effect on reduction of anxiety. As for depression, depression score was significantly reduced at Month 1 (p<0.05). However, it was not affected at Month 3, suggesting that the intervention measure did not have a continuous effect; (4) social aspect: social support was significantly improved (p<0.001), and the effect lasted for 3 months (p<0.05); (5) self-management: self-management was significantly improved, and the effect lasted for 3 months (p