| Summary: | 博士 === 國立臺北護理健康大學 === 護理研究所 === 104 === Background: The prevalence of end-stage renal disease of Taiwan is in first place around the world, and its incidence is in third place around the world. In order to effectively reduce the occurrence of complications of end-stage renal disease, the implementation of self-management programs can effectively reduce medical cost and improve quality of life.
Purpose: Stage 1 of the research project (stage of empirical extraction): Stage 1 assessed and analyzed the comprehensive analysis results of the “effectiveness of intervention of self-management programs for patients with chronic renal disease” based on the empirically extracted data. Stage 2 of the research project (stage of intervention and assessment): Stage 2 assessed the effectiveness of intervention of “self-management programs” in patients with end-stage renal disease. Stage 3 of the research project (stage of longitudinal follow-up): Stage 3 used generalized estimating equation to perform a longitudinal follow-up, as well as to investigate the change in effectiveness of intervention of “self-management programs” in patients with ESRD at different time points according to the longitudinal data.
Method: This study is a 3-stage research project. Stage 1 performed a systematic literature review, and assessed and analyzed the comprehensive analysis results of effectiveness of intervention of self-management programs in patients with chronic renal disease extracted from empirical database, in order to find out relevant variables which can effectively control end-stage renal disease. This study intended to include such variables affecting effectiveness into Stage 2 of the research project for further measurement as basis of empirical literature. Stage 2 of the research project assessed the effectiveness of intervention of “self-management programs” in patients with ESRD, and used 2×2 randomized controlled trial with pre and post-testing experimental research design to enroll a total of 58 samples. This study used double-blind randomization to divide the subjects into the control group (30 subjects; routine program) and experimental group (28 subjects; self-management programs). Firstly, this study performed a pretest on the two groups, and collected data, including variables, such as physiological indices, self-care behavior, self-efficacy, depression, spiritual well-being, and quality of life. This study measured the effectiveness 3 months after the intervention. Stage 3 of the research project is the extensive investigation of stage 2 of the research project. Stage 3 used generalized estimating equation (GEE) to analyze the effect of intervention and test the change in effectiveness on variables of patients with ESRD at different time points (3 months, 6 months, and 9 months later) according to the longitudinal data. The variables of “self-management programs” included intervention physiological indices (e.g. hypertension, urea nitrogen, creatinine, and estimated glomerular filtration rate), psychological indices (self-care behavior, self-efficacy, and depression), spiritual well-being (self-efficacy and life scheme), and quality of life (physical dimension and mental dimension).
Results: Stage 1 of the research project: The comprehensive analysis results showed that, a self-management program significantly impacted CKD patients' depression and mental quality-of-life dimension, with effect size of .298 [95% confidence interval (CI) (0.07,0.53)] and -.424 [95% CI (-0.75,-0.10)], with moderate effects. However, the intervention of a self-management program had no significant effect on patients' eGFR as well as physical quality of life dimensions (Research results have been published in SCI & SSCI journal - Asian Nursing Research, Accepted for publication Date: Apr, 15, 2016). Stage 2 of the research project: The research subjects enrolled in this study were mainly middle-agers and the elderly. Their occupation was mainly unemployed. Their religious belief was mainly Buddhism. Their marital status was mainly married, and they mainly lived with family members. Their educational background was mainly vocational/senior high school or junior college. 50% of the subjects were male, and 50% of them were female. For past disease history, most of them suffered from hypertension and hyperglycemia. After the intervention of self-management programs, for the improvement of effectiveness on clinical control over indices of experimental group, except that the effectiveness on control over increase in weight change between two dialysis sessions was achieved (F=22.40, p<0.001, partial eta2=0.332), there was no significant difference in other clinical control over indices. The intervention of self-management programs had an effect on improving patients’ self-care behavior (F=20.73, p<0.001, partial eta2=0.325) and self-efficacy (F=5.85, p<0.05, partial eta2=0.120), and did not have a significant effect on other variables. Stage 3 of the research project: according to the follow-up on longitudinal data at different time points (3 months, 6 months, and 9 months later), the increase in weight change between two dialysis sessions was reduced to achieve the effectiveness of control. Moreover, after the intervention, the effect lasted for as long as 9 months (B=-1.34, SE=.30, p<0.001). However, the intervention did not have any effect on other clinical indices. The intervention enabled patients to improve their self-care behavior, and significantly improve their self-efficacy. In addition, after the intervention, the effect lasted for as long as 9 months (B=21.05, SE=1.23, p<0.001), (B=36.34, SE=13.83, p=0.009). For the improvement of level of depression in patients, level of depression was not significantly improved after the 1st posttest. However, it was improved after the 2nd and 3rd posttests. The effect after intervention lasted for 9 months (B=-5.82, SE=2.5, p=0.035). The intervention did not have any effect on other variables of spiritual well-being and quality of life.
Conclusion: The research results proved that, application of self-management programs achieved the effectiveness of control over increase in weight change between two dialysis sessions in patients with ESRD to improve their self-care. In terms of psychological dimension, it significantly improved self-care behavior, improved self-efficacy, reduced depression, and further improved the adaptation to self-confidence in self-care to reduce the occurrence of depression of patients with ESRD. To get along with patients with ESRD peacefully can indirectly reduce financial burden of national health insurance, as well as problems in various dimensions derived from society, family, and individuals.
Clinical and Practical Applications: The intervention of self-management programs can improve the effective control over disease in patients with ESRD in Taiwan, reduce complications, and improve disease self-management. In addition to traditional health education program, an empirically based self-management programs can also be provided for clinical healthcare personnel’s application according to the research results.
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