从理论到实践：老年慢病延续护理网络平台的构建
|
摘要
背景
中国人口老龄化和老年人慢性病的高发趋势使我国面临着极大的挑战,作为一种新型的信息服务途径,网络媒介因其具有的主动性和实效性,逐步获得大众的认可。如何将现代科技手段与科学有效的健康管理模式相结合,实现一种具有较高经济及社会效益的延续护理新模式,是我们思考的问题。有效的健康管理和延续护理模式需要考虑病人自身的疾病体验和为病人的健康赋权。慢性病患者比医务人员更了解自己的生活和疾病特殊规律,了解自己身心的感受和需求,患者自身才是最主要的照护者。老年慢性病患者的延续护理也需要从了解病人自身的生活体验以及如何挖掘自身内在力量出发,了解患者对疾病的认知-适应过程,以实现自我管理能力的提高。然而,目前对于患者对疾病的认知的理解多种多样,认知的文化社会属性也会影响到不同文化背景下人们对认知内涵的理解,目前我国在老年慢病患者的健康管理及护理领域,对老年慢病患者的疾病认知与应对模式,以及网络延续护理方式尚有待进一步研究。
据国际糖尿病联盟(International Diabetes Federation,IFD)2011年统计,全球糖尿病患病人数为3.66亿,而估计到2030年,有关人数将激增至5.52亿。糖尿病的死亡率亦非常高,世界上每十秒便有一人因糖尿病相关原因而死亡。糖尿病是我国最普遍的非传染病之一,2010年我国成人糖尿病的患病率为9.7%,患者总数已超过9000万,成为世界第一的糖尿病大国。糖尿病无论对患者、其家人或社会医疗都造成沉重的负担,协助糖尿病患者及其家人正确面对和适当管理疾病,是非常重要和有意义的任务。所以本研究项目选择老年糖尿病患者作为课题的出发对象,为今后其他慢病管理研究提供前期经验和数据。
目的
本研究的目的在于从探索老年糖尿病患者的疾病认知、应对策略及自我效能的关系出发,了解老年糖尿病患者疾病适应的过程,构建和发展适合我国老年糖尿病患者的疾病适应模型和护理干预模式理论框架,为进一步发展老年糖尿病患者及其他慢病患者的延续护理提供理论依据。同时将理论引入实践,希望设计出一个适合老年慢病患者的延续护理网络平台,实现从医院到社区护理的延伸,优化慢病患者的健康管理,强化患者的自我管理能力。研究问题包括：老年糖尿病患者的对疾病的看法如何?他们对疾病的看法有没有影响其对疾病的适应过程?自我效能在整个过程中起到什么作用?他们在自我管理过程中有没有调动挖掘自己的内在潜能作出积极调整?有哪些因素会影响患者对疾病的看法?如何帮助患者实现对疾病的适应?怎样将护理的理论模型引入到网络信息技术中去?
方法
研究分为三个部分：
1.理论框架与研究假设
以Roy的适应模式为框架,对现代护理中两个被广泛认可的认知理论——Leventhal的常识模式和Bandura的自我效能理论进行结合,通过理论研究构建老年糖尿病患者疾病适应模式,确定研究变量与研究假设。
2.患者疾病描绘、自我效能、应对策略与健康水平关系的研究
方便抽样选取广州市某三级综合医院糖尿病门诊和内分泌科的250名老年,采用糖尿病患者基本资料表、简易疾病认知问卷(Brief-IPQ)、慢性病自我效能量表(SECD6)、医学应对问卷(MCMQ)、糖尿病患者自我管理行为量表(SDSCA)和欧洲五维健康量表(EQ-5D-5L),收集其一般资料并对其疾病认知、应对策略、自我效能及健康水平进行调查。探讨老年糖尿病患者一般情况、疾病认知、自我效能、应对策略与健康总体状况的关系,分析老年糖尿病患者在应对糖尿病这一应激源的过程中,适应的心理过程。对本研究提出的理论假设进行验证和修订,并根据研究结果就护理人员如何更有效地对糖尿病患者开展延续护理提出建议。
3.老年慢病延续护理网络平台的初步搭建
以本研究的提出的护理概念模型为理论基础,借鉴国外延续护理成功模式,依托信息网络平台,设计搭建了一种适合我国老年人的延续护理服务平台。
结果
1.理论框架与研究假设
常识模式和自我效能两种理论都强调了患者的个人经验、自我原有认知及对疾病和治疗的个体化反应。相较于疾病的严重程度,患者的信念在疾病康复过程中有着更为显著的影响。两个理论最大不同之处在于二者在治疗干预过程中的运用,这种差异体现了两种理论所侧重的对患者信念的影响源不同。基于二者的相似点和不同点,我们把二者结合起来,运用到同一个护理模型中具有可行性。
疾病描绘是个体在患病最初对疾病的描述和说明,疾病描绘的大部分内容是在疾病发生前就已存在的,体现了患者短期的应对反应；自我效能研究的是患者对适应健康状况改变以及维持行为改变能力的感知,体现了患者长期的应对反应。因此两种理论应当有先后顺序,在不同的时期,应该关注对应的理论,如果两者之间存在联系,更应该按照两者的顺序进行安排。本研究提出的慢病适应模型认为疾病的认知可以影响患者的自我效能。从理论逻辑上看,疾病认知先于自我效能发生,因为相对于健康行为的实际变化,常识模式预测的是患者行为变化的意图,而Bandura自我效能理论的研究则以患者长期实际的行为改变为基础。
二者的时序差异为我们提供了这样一个关系假设,即疾病的认知能够影响患者的长期自我效能,为我们制定出对这两种理论相结合的护理模式和干预措施提供了逻辑框架。我们通过结合两者理论建立出新的更为整体性的理论模式(23页,图2-4),以求达到同时关注和干预患者对疾病的认知和对自身应对能力的认知的目的。我们通过将疾病认知和自我效能合并为一个新的护理概念模式,为进一步的研究提供了一个明确的理论框架。
2.患者疾病描绘、自我效能、应对策略与健康水平关系的研究
本次调查共发放问卷250份,回收246份,有效问卷233份,有效率93.2%。有效完成问卷的233例老年糖尿病患者中,年龄60～91岁,平均年龄69.03±7.86岁,1型糖尿病4例,2型糖尿病216例,其他类型或不清楚具体类型者13例。患者病程114.42±93.25个月。
老年糖尿病患者对糖尿病描绘中,疾病时间线、可控性、结果方面得分较高,而疾病辨识、综合和情绪描绘得分较低。说明大多数患者认为疾病是长期的、可以控制的、糖尿病对生活有一定影响。自身对糖尿病已有一定的理解,自觉对糖尿病了解程度一般。在对病因的认知方面,大多数患者认为饮食、日常生活方式及遗传是导致糖尿病的主要原因,但也有部分患者对病因的理解存在误区。
不同人口学和疾病特征会从不同方面对患者疾病描绘产生影响。U检验表明,女性患者的情绪描绘得分高于男性(Z=-2.986,P=0.003),生活无伴侣患者的情绪描绘得分高于有伴侣患者(Z=-1.963,P=0.0496),非在岗工作患者时间线、结果和情绪描绘得分较在岗工作患者高(Z=-2.986,P=0.003)。Spearman相关分析表明,年龄与结果描绘呈正相关(r=0.149,P=0.023),与个人控制和医疗控制描绘呈负相关(均P<0.05)；文化程度与情绪描绘呈负相关(Sr=--O.170,P=0.009)；经济负担与时间线、结果、情绪描绘呈正相关(均P<0.05)；病程与时间线、综合描绘呈正相关(均P<0.05),与个人控制描绘呈负相关(Sr=--0.170,P=0.009)；并发症数量与辨识、结果、情绪描绘呈正相关(均P<0.01),与个人控制描绘呈负相关(Sr=-0.196,P=0.003)；治疗方式同辨识、结果、医疗可控性、综合理解、情绪描绘呈正相关(均P<0.05),与个人可控性呈负相关(Sr=-0.146,P=0.026)。回归分析表明,辨识的影响因素包括并发症数量和治疗方式,时间线的影响因素包括工作状态、经济负担及治疗方式,结果的影响因素包括治疗方式、经济负担、并发症和工作状态,个人可控性的影响因素包括年龄、病程和并发症数量,医疗可控性的影响因素是治疗方式,综合理解的影响因素包括病程、治疗方式,情绪描绘的影响因素包括并发症、工作状态和文化程度。
结果显示,患者的疾病描绘和自我效能,与应对策略之间三者存在显著的关系,疾病描绘可影响患者的应对策略的选择,自我效能在疾病描绘和应对策略间起到中介作用。Spearman相关分析表明,面对应对与结果描绘呈负相关(Sr=-0.171,P=0.009),与个人可控性、医疗可控性及自我效能呈正相关(均P<0.05)；回避应对与结果描绘呈正相关(Sr=0.162,P=0.013),与个人可控性、医疗可控性以及自我效能呈负相关(均P<0.05)；屈服应对与结果描绘、情绪描绘呈正相关(均P<0.05),与辨识描绘、个人可控性描绘以及自我效能呈负相关(均P<0.05)。自我效能在疾病认知与应对策略之间的中介作用检验表明,自我效能在患者疾病结果描绘、个人可控性描绘和情绪描绘,与面对应对的选择间起到完全中介作用(中介效应=-0.112、0.222、0.149,效应比=0.147、0.965、0.296)；在医疗可控性描绘与面对应对的选择间起到部分中介作用(中介效应=-0.091,效应比=0.653)；在患者的疾病结果描绘、医疗可控性描绘对回避应对的选择间起到部分中介作用(中介效应=0.043、-0.072,效应比=0.288、0.531)；在患者情绪描绘与屈服应对的选择间起到部分中介作用(中介效应=0.021,效应比=0.054)。
通过以上结果我们初步验证了第一部分提出的概念模型,并根据概念模型提出了全息护理干预模式(55页,图2-8),可以有效指导延续护理临床干预的研究设计。
3.老年慢病延续护理网络平台的初步搭建
将本研究提出的延续护理的全息干预模式应用于网络平台(60页,图3-3),从设计上实现了将全息干预模式融入到依托于网络的护理服务中。网络全息护理干预通过档案管理、随访管理、交流沟通3个环节来实现医务人员与患者之间的互动,设计搭建了包含用户登录和注册模块、患者档案管理模块、患者个人中心模块、健康广场4个功能模块的网络平台,介入患者的认知-应对适应过程,提高患者的自我效能,最终达到改善患者对疾病的自我认知,帮助患者建立积极的应对策略,从而提高患者自我管理能力,改善患者健康水平的目的。讨论
本研究以适应模式为框架,结合常识模式和自我效能理论,提出并初步证实了老年糖尿病患者的疾病适应模型。证实了老年糖尿病患者认知-应对情况对自我管理行为与健康水平的影响,并部分揭示了其内在过程,为临床开展老糖尿及其他慢病患者自我管理护理干预提供了理论依据。
根据研究结果,我们提出了以下重点建议：
①从疾病描绘出发评价患者的疾病认知,疾病描绘指所罹患疾病在患者中所描绘的意义,以疾病描绘描述患者对疾病的体验,可从患者的角度重新认识患者对疾病的认识。
②关注不同特征患者的疾病认知需求,研究结果显示不同特征患者对疾病认知不同,所以在临床护理中,我们应当关注不同特征患者的疾病认知特点,以采取个体化的健康教育形式,提高护理干预质量。
③重视自我效能的作用,本研究证明,自我效能在患者认知与应对策略的选择间起到完全或部分的中介作用,老年糖尿病患者自我效能感与应对策略的选择紧密相关。增强老年糖尿病患者自我效能感,一方面要注重提高患者糖尿病相关认知水平,针对患者认知薄弱点加强健康教育；另一方面要注重提高患者健康信念,通过增强患者自我效能感的护理途径和方法,增强患者自我管理活动执行信心。
④本研究提出的糖尿病患者慢病描绘-应对适应模型(54页,图2-6)和全息护理干预模式(55页,图2-8),可为糖尿病或其他慢性病患者的临床护理和延续护理方案的制定提供理论指导。本研究将提出的护理模式应用于网络平台设计的过程,证明新的慢病适应模型和全息护理干预模式从理论到实践的尝试是可行的。
结论
本研究通过理论研究提出老年糖尿病患者疾病适应模型的假设,并对理论模型雏形进行初步验证,提出了老年糖尿病患者的认知-应对适应模型的理论模型。在该理论模型中,患者的对疾病的适应过程是一个认知-应对过程,患者的一般资料会影响患者对疾病的认知,患者对疾病的认知会导致患者采取不同的策略应对疾病,从而影响患者的自我管理行为和健康状况。患者的健康结局又反馈性地对患者的认知产生影响。自我效能预期在疾病的认知和应对过程中起到一定的中介作用。基于此模型,我们提出了老年糖尿病患者的延续护理全息干预模式,强调对患者认知-应对这一适应过程的全面干预。最后尝试将延续护理全息护理模式应用于网络平台,落脚于实践,优化老年慢病患者的延续护理服务。
Background
China is facing great challenges about aging tendency of population and high incidence of elderly chronic disease. Network media as a new way of information services, for its initiative and effectiveness, was gradually gained the acceptance of the most users. How to combine the modern technology with scientific and effective health management models to achieve a new transitional care model with high economic and social benefits is what we think about. The illness experience and health empowerment of patients should be considered in the effective health management or transitional care models. Compared to professional medical personnel, chronic patients have a better understand about their own lives and specific disease rules, and a clearer feeling of needs physiologically and psychologically, so that the patient's own was the primary caregiver. To improve self-management ability, fully understanding the own life experiences and discovering the patient's own inner capacity should be involved in elderly chronic patients with transitional care models as well as understanding the patient's cognitive-adapt processes of disease. Due to the different cultural background, there are diverse explanations of patient's disease cognitive. In area of health management, the disease cognitive and response model of elderly patients with chronic disease and transitional care network approach remain to be further studied in China.
According to the International Diabetes Federation (IFD)2011statistics, the global number of diabetes was366million, and estimated that in2030the number will grow to552million. Diabetes mortality rate is very high; there will be one people in every ten seconds die due to diabetes-related causes. Diabetes is one of the most prevalent non-communicable diseases. In2010, adult diabetes prevalence rate is9.7%, the total number of patients has more than90million, and China is now home to the most cases worldwide. Diabetes is a heavy burden to patients, their families and Social medical institutions. It is a very important and meaningful task to help patients and their families facing the correct and proper management of diabetes. Therefore, this research chooses elderly diabetic patients as our target subject, to provide an initial experience and data for the future research of other chronic diseases.
Objective
The purpose of this study is to explore the relationship between disease cognitive, coping strategies and self-efficacy in elderly patients with diabetes, understand the adapt process of patients, build and develop theory framework of nursing intervention mode and diabetes adaptation model which is suitable for Chinese elderly patients, that provides a theoretical basis for the further development of transitional care model for elderly patients with diabetes and other chronic disease. Meanwhile, combining the theory and practice, we hope to design a transitional care network platform which was suitable for elderly patients with chronic disease, extend the health care from hospital to community, and strengthen the patient's capacity of self-management. The research issues include:What the perception of the disease in elderly patients with diabetes? Have the perception of disease effect on process of adaptation and response to the disease? What is the role of self-efficacy in the process? Have patient's potential been mobilized to make a positive adjustment in the self-management process? Are there any factors would affect the patient's perception of the disease? How to help patients achieve adaptation to the disease? How to introduce the care theoretical model to the network information technology?
Method
The study consists of three parts.
1. Theoretical framework and research hypothesis
The study based on the Roy's adaptation model, combined the Leventhal's common sense model and Bandura's theory of self-efficacy to build an adaptation model of elderly diabetics, and the research hypothesis was also confirmed as well as research variables.
2. The relationship between illness perception, self-efficacy, coping strategies and health conditions.
Total250samples were collected through convenience sampling questionnaire from diabetic outpatients and endocrinology in certain grade-three general hospital in Guangzhou, illness perception, self-efficacy, coping strategies and health conditions were investigated and the relationship was explored by diabetes patients basic information table, by the assessment tools of Brief Illness Perception Questionnaire(Brief-IPQ), Self-Efficacy for Managing Chronic Disease6-Item Scale (SECD6), Medical Coping Modes Questionnaire (MCMQ), The Summary of Diabetes Self-Care Activities Measure (SDSCA) and EQ-5D-5L. The study validated and revised the hypothesis and proposed some suggestions about the effectively transitional care model for patients with diabetes according to research results.
3. Preliminary establishment of transitional care network platform of elderly chronic disease.
To design and establish A transitional care service network platform based on nursing conception model proposed by this study, referenced successful model of transitional care in other countries.
Results
1. Theoretical framework and research hypothesis
Common sense model and self-efficacy, both theories emphasize personal experience, pre-construction of self, individual response to illness and treatment, and that the patients'beliefs are more influential in their recovery than the severity of the illness. Where the theories are most divergent is their application to therapeutic interventions, which reflect the different sources of influence that each theory emphasizes. Based on their similarities and differences it is possible to integrate the two theories into a conceptual care model.
Illness representation offers a general perspective of an individual's initial interpretation of their illness, as the representation components are largely formed before their experience of the illness and have been shown to have a predictive value in terms of short-term patient responses; self-efficacy explores how a patient perceives their own ability to adopt and maintain health behaviors require in the treatment of their condition, and has been shown to have a predictive value in terms of long-term patient responses. Therefore, there is a chronological sequence to the focus that each theory adopts and if there is a relationship between the two then it should follow this chronology. The chronic disease adaptation model put forward by this study proposes that illness perception components predict self-efficacy. This sequence appears theoretically logical, as the illness perception model tends to predict the intention of health behavior change rather than the actual behavior change, while Bandura's self-efficacy research is based on predicting actual long-term behavior change.
These time scales provide a chronological framework for the integrated design of care interventions, suggesting the direction of the relationship-the illness representation components influence the long-term perception of the patient's self-efficacy-creating a more holistic regime to manage both the patients'initial conceptualization of their condition and to develop their perceived ability to cope with their condition and its treatment over the longer term. By incorporating both illness perception and self-efficacy into a single conceptual care model, an explicit framework has been provided for further research.
2. The relationship between illness perception, self-efficacy, coping strategies and health conditions.
The questionnaires were issued for250, recycled246. The valid questionnaires are233. Effective recovery ratings are93.2%.233individuals who have type2(n=216,92.7%), type1(n=4,1.7%) and other types (n=13,5.6%) diabetes mellitus participated in this study. Participants'age range from60～91, the average age was69.03±7.86years. On average, length of diagnosis with diabetes was114.42±93.25months.
In the different dimension of illness representation of elderly diabetes, timeline, cure/control and consequences has higher scores, meanwhile identity, coherence, and emotional representation has lower scores. Suggest that most patients think the diabetes mellitus is long-term and controllable; diabetes has certain influence to life. Their perceived degree of understanding of diabetes was normal. In terms of understanding of the etiology, most patients think diet, daily lifestyle and genetics is the major cause of diabetes, but there is also some wrong understanding of the etiology in patients.
Different demographic and disease characteristics will have an impact on different aspects of diseases depicted. U test showed that female patients have higher emotional representation score than male patients (P<0.01); the patient without partner have higher emotional representation score than patients have a partner (P <0.05); patients without job have higher timeline, consequences and emotional representation score than patients with job (P<0.01). Spearman correlation analysis showed that age was positively correlated with consequences and was negatively correlated with personal control (P<0.01) and treatment control (P<0.05); Education level was positively correlated with emotional representation (P<0.05); Economic burden was positively correlated with; Duration of diabetes was positively correlated with timeline (P<0.05) and emotional representation (P<0.01), and was negatively correlated with personal control (P<0.01); Number of complications was positively correlated with identity, consequences and emotional representation (P<0.01), was negatively correlated with personal control (P<0.01); Treatment modalities was positively correlated with identity (P<0.01), consequences(P<0.01), treatment control(P<0.05) and coherence (P<0.01), was negatively correlated with personal control (P<0.05). Regression analysis showed that the patient's disease is characterized mainly affected by age, education, work status, economic burden, duration of disease, complications, and treatment modalities.
The results show that there is a significant relationship between the patients' illness representations, self-efficacy and coping strategies. Illness representations can affect the selection of coping strategies, self-efficacy plays an intermediary role between the illness representations and coping strategies depicted. Spearman correlation analysis showed that facing was negatively correlated with consequences strategies personal control, treatment control and self-efficacy (P<0.01); Avoidance was positively correlated with consequences (P<0.05), and was negatively correlated with personal control, treatment control and self-efficacy (P<0.05or P<0.01); Yielding was positively correlated with consequences and emotional representation(P <0.05or P<0.01), and was negatively correlated with identity, personal control and self-efficacy(P<0.05or P<0.01). Test of the intermediary role of self-efficacy showed that self-efficacy completely mediated the associations of consequences, personal control, emotional representation and facing strategy (mediating effect=-0.112,0.222,0.149, effect ratio=0.147,0.965,0.296), and partially mediated the associations of treatment control and facing strategy (mediation effect=-0.091, effect ratio=0.653).Self-efficacy partially mediated the associations of consequences, treatment control and avoidance strategy (mediating effect=0.043,-0.072, effect ratio=0.288,0.531). Self-efficacy partially mediated the associations of emotional representation and Yielding strategy (mediation effect=0.021, effect ratio=0.054).
These results verified our initial conceptual model proposed in the first part, and an explicit framework has been provided for further research and its effectiveness can be intervention research designed for extendant care..
3. Preliminary establishment of a transitional care network platform for patients with elderly chronic disease.
The holographic intervention model proposed in this study is applied to the network platform to achieve applying the theoretical model into transitional care practice. Network holographic care intervention achieves interaction between medical staff and patients through three aspects:file management, follow-up management and communication. Four functional modules was designed including user login and registration, patient file management, individual patient center and Health Plaza, which involve in the patient's perception-coping process with the adaptation process, to improve the patient's self-efficacy, and ultimately to improve patient self-awareness of the disease and help patients develop positive coping strategies to improve patient self-management ability.
Discuss
In this study, we use adaptation model as a framework, combined with common sense model and self-efficacy theory, present and preliminary test the adaptive mode of elderly diabetes. We verified the impact of patients'perception-coping process on self-management and health behavior. We partially revealed its inner processes of adaption of elderly diabetes, which provides a theoretical basis for clinical self-care intervention of patients with diabetes and other similar chronic disease.
Based on the results, we made the following key recommendations:
①Assessment patients'illness perception starting from the evaluation of patients' illness representations, which refers to the meaning of their disease portrayed by patients. We can obtain new understanding of the disease from the patients'perspective by portraying disease by illness representations.
②Pay attention to the different characteristics of patients' illness perception demand. The study showed that different illness perception in patients with different characteristics. So in clinical care, we should be concerned about the illness perception characteristics in patients with different characteristics, in order to take individualized health education, improve the quality of nursing intervention.
③Pay attention to the role of self-efficacy. This study demonstrated that self-efficacy plays a completely or partially intermediary role in illness perception and the choice of coping strategies among elderly patients with diabetes. Self-efficacy and coping strategies are closely related. Enhance self-efficacy in elderly patients with diabetes, on the one hand, should focus on improving diabetes-related perception level, to strengthen health education for patients with cognitive weak point; On the other hand, should to focus on improving patient health beliefs, in order to enhance patients' confidence in self-management activities.
④This study proposes a theoretical model to provide theoretical guidance for developing clinical care and transitional care programs for diabetes or other chronic diseases.In this study, the practice of using Holographic Care Model in network platform design process prove that the attempt that make theoretical model from theory to practice is feasible.
Conclusion
In this study, we hypothesize a new adaptation model for elderly diabetic patients through theoretical studies and preliminary validate the prototype of theoretical model, present theoretical perception-coping adaptation model in elderly diabetic patients. In the theoretical model, the process of adaptation to the patient's disease is a perception-coping process, general information will affect the patient's perception of the disease, and patients with different illness representation take different strategies to coping with the disease, thus affecting the self-management behaviors and health status of the patient. Patient health outcomes are feedback to illness perception. Self-efficacy is expected to play a mediation role in the illness perception and coping strategy to the disease adaption process. Based on this model, we propose a Holographic Care Model for elderly patients with diabetes, emphasis a comprehensive on patient perception-coping of the adaptation process. Finally, we try to use Holographic Care Model in transitional care network platform, settled in practice, optimizing transitional care services for the elderly with chronic diseases.
中国人口老龄化和老年人慢性病的高发趋势使我国面临着极大的挑战,作为一种新型的信息服务途径,网络媒介因其具有的主动性和实效性,逐步获得大众的认可。如何将现代科技手段与科学有效的健康管理模式相结合,实现一种具有较高经济及社会效益的延续护理新模式,是我们思考的问题。有效的健康管理和延续护理模式需要考虑病人自身的疾病体验和为病人的健康赋权。慢性病患者比医务人员更了解自己的生活和疾病特殊规律,了解自己身心的感受和需求,患者自身才是最主要的照护者。老年慢性病患者的延续护理也需要从了解病人自身的生活体验以及如何挖掘自身内在力量出发,了解患者对疾病的认知-适应过程,以实现自我管理能力的提高。然而,目前对于患者对疾病的认知的理解多种多样,认知的文化社会属性也会影响到不同文化背景下人们对认知内涵的理解,目前我国在老年慢病患者的健康管理及护理领域,对老年慢病患者的疾病认知与应对模式,以及网络延续护理方式尚有待进一步研究。
据国际糖尿病联盟(International Diabetes Federation,IFD)2011年统计,全球糖尿病患病人数为3.66亿,而估计到2030年,有关人数将激增至5.52亿。糖尿病的死亡率亦非常高,世界上每十秒便有一人因糖尿病相关原因而死亡。糖尿病是我国最普遍的非传染病之一,2010年我国成人糖尿病的患病率为9.7%,患者总数已超过9000万,成为世界第一的糖尿病大国。糖尿病无论对患者、其家人或社会医疗都造成沉重的负担,协助糖尿病患者及其家人正确面对和适当管理疾病,是非常重要和有意义的任务。所以本研究项目选择老年糖尿病患者作为课题的出发对象,为今后其他慢病管理研究提供前期经验和数据。
目的
本研究的目的在于从探索老年糖尿病患者的疾病认知、应对策略及自我效能的关系出发,了解老年糖尿病患者疾病适应的过程,构建和发展适合我国老年糖尿病患者的疾病适应模型和护理干预模式理论框架,为进一步发展老年糖尿病患者及其他慢病患者的延续护理提供理论依据。同时将理论引入实践,希望设计出一个适合老年慢病患者的延续护理网络平台,实现从医院到社区护理的延伸,优化慢病患者的健康管理,强化患者的自我管理能力。研究问题包括：老年糖尿病患者的对疾病的看法如何?他们对疾病的看法有没有影响其对疾病的适应过程?自我效能在整个过程中起到什么作用?他们在自我管理过程中有没有调动挖掘自己的内在潜能作出积极调整?有哪些因素会影响患者对疾病的看法?如何帮助患者实现对疾病的适应?怎样将护理的理论模型引入到网络信息技术中去?
方法
研究分为三个部分：
1.理论框架与研究假设
以Roy的适应模式为框架,对现代护理中两个被广泛认可的认知理论——Leventhal的常识模式和Bandura的自我效能理论进行结合,通过理论研究构建老年糖尿病患者疾病适应模式,确定研究变量与研究假设。
2.患者疾病描绘、自我效能、应对策略与健康水平关系的研究
方便抽样选取广州市某三级综合医院糖尿病门诊和内分泌科的250名老年,采用糖尿病患者基本资料表、简易疾病认知问卷(Brief-IPQ)、慢性病自我效能量表(SECD6)、医学应对问卷(MCMQ)、糖尿病患者自我管理行为量表(SDSCA)和欧洲五维健康量表(EQ-5D-5L),收集其一般资料并对其疾病认知、应对策略、自我效能及健康水平进行调查。探讨老年糖尿病患者一般情况、疾病认知、自我效能、应对策略与健康总体状况的关系,分析老年糖尿病患者在应对糖尿病这一应激源的过程中,适应的心理过程。对本研究提出的理论假设进行验证和修订,并根据研究结果就护理人员如何更有效地对糖尿病患者开展延续护理提出建议。
3.老年慢病延续护理网络平台的初步搭建
以本研究的提出的护理概念模型为理论基础,借鉴国外延续护理成功模式,依托信息网络平台,设计搭建了一种适合我国老年人的延续护理服务平台。
结果
1.理论框架与研究假设
常识模式和自我效能两种理论都强调了患者的个人经验、自我原有认知及对疾病和治疗的个体化反应。相较于疾病的严重程度,患者的信念在疾病康复过程中有着更为显著的影响。两个理论最大不同之处在于二者在治疗干预过程中的运用,这种差异体现了两种理论所侧重的对患者信念的影响源不同。基于二者的相似点和不同点,我们把二者结合起来,运用到同一个护理模型中具有可行性。
疾病描绘是个体在患病最初对疾病的描述和说明,疾病描绘的大部分内容是在疾病发生前就已存在的,体现了患者短期的应对反应；自我效能研究的是患者对适应健康状况改变以及维持行为改变能力的感知,体现了患者长期的应对反应。因此两种理论应当有先后顺序,在不同的时期,应该关注对应的理论,如果两者之间存在联系,更应该按照两者的顺序进行安排。本研究提出的慢病适应模型认为疾病的认知可以影响患者的自我效能。从理论逻辑上看,疾病认知先于自我效能发生,因为相对于健康行为的实际变化,常识模式预测的是患者行为变化的意图,而Bandura自我效能理论的研究则以患者长期实际的行为改变为基础。
二者的时序差异为我们提供了这样一个关系假设,即疾病的认知能够影响患者的长期自我效能,为我们制定出对这两种理论相结合的护理模式和干预措施提供了逻辑框架。我们通过结合两者理论建立出新的更为整体性的理论模式(23页,图2-4),以求达到同时关注和干预患者对疾病的认知和对自身应对能力的认知的目的。我们通过将疾病认知和自我效能合并为一个新的护理概念模式,为进一步的研究提供了一个明确的理论框架。
2.患者疾病描绘、自我效能、应对策略与健康水平关系的研究
本次调查共发放问卷250份,回收246份,有效问卷233份,有效率93.2%。有效完成问卷的233例老年糖尿病患者中,年龄60～91岁,平均年龄69.03±7.86岁,1型糖尿病4例,2型糖尿病216例,其他类型或不清楚具体类型者13例。患者病程114.42±93.25个月。
老年糖尿病患者对糖尿病描绘中,疾病时间线、可控性、结果方面得分较高,而疾病辨识、综合和情绪描绘得分较低。说明大多数患者认为疾病是长期的、可以控制的、糖尿病对生活有一定影响。自身对糖尿病已有一定的理解,自觉对糖尿病了解程度一般。在对病因的认知方面,大多数患者认为饮食、日常生活方式及遗传是导致糖尿病的主要原因,但也有部分患者对病因的理解存在误区。
不同人口学和疾病特征会从不同方面对患者疾病描绘产生影响。U检验表明,女性患者的情绪描绘得分高于男性(Z=-2.986,P=0.003),生活无伴侣患者的情绪描绘得分高于有伴侣患者(Z=-1.963,P=0.0496),非在岗工作患者时间线、结果和情绪描绘得分较在岗工作患者高(Z=-2.986,P=0.003)。Spearman相关分析表明,年龄与结果描绘呈正相关(r=0.149,P=0.023),与个人控制和医疗控制描绘呈负相关(均P<0.05)；文化程度与情绪描绘呈负相关(Sr=--O.170,P=0.009)；经济负担与时间线、结果、情绪描绘呈正相关(均P<0.05)；病程与时间线、综合描绘呈正相关(均P<0.05),与个人控制描绘呈负相关(Sr=--0.170,P=0.009)；并发症数量与辨识、结果、情绪描绘呈正相关(均P<0.01),与个人控制描绘呈负相关(Sr=-0.196,P=0.003)；治疗方式同辨识、结果、医疗可控性、综合理解、情绪描绘呈正相关(均P<0.05),与个人可控性呈负相关(Sr=-0.146,P=0.026)。回归分析表明,辨识的影响因素包括并发症数量和治疗方式,时间线的影响因素包括工作状态、经济负担及治疗方式,结果的影响因素包括治疗方式、经济负担、并发症和工作状态,个人可控性的影响因素包括年龄、病程和并发症数量,医疗可控性的影响因素是治疗方式,综合理解的影响因素包括病程、治疗方式,情绪描绘的影响因素包括并发症、工作状态和文化程度。
结果显示,患者的疾病描绘和自我效能,与应对策略之间三者存在显著的关系,疾病描绘可影响患者的应对策略的选择,自我效能在疾病描绘和应对策略间起到中介作用。Spearman相关分析表明,面对应对与结果描绘呈负相关(Sr=-0.171,P=0.009),与个人可控性、医疗可控性及自我效能呈正相关(均P<0.05)；回避应对与结果描绘呈正相关(Sr=0.162,P=0.013),与个人可控性、医疗可控性以及自我效能呈负相关(均P<0.05)；屈服应对与结果描绘、情绪描绘呈正相关(均P<0.05),与辨识描绘、个人可控性描绘以及自我效能呈负相关(均P<0.05)。自我效能在疾病认知与应对策略之间的中介作用检验表明,自我效能在患者疾病结果描绘、个人可控性描绘和情绪描绘,与面对应对的选择间起到完全中介作用(中介效应=-0.112、0.222、0.149,效应比=0.147、0.965、0.296)；在医疗可控性描绘与面对应对的选择间起到部分中介作用(中介效应=-0.091,效应比=0.653)；在患者的疾病结果描绘、医疗可控性描绘对回避应对的选择间起到部分中介作用(中介效应=0.043、-0.072,效应比=0.288、0.531)；在患者情绪描绘与屈服应对的选择间起到部分中介作用(中介效应=0.021,效应比=0.054)。
通过以上结果我们初步验证了第一部分提出的概念模型,并根据概念模型提出了全息护理干预模式(55页,图2-8),可以有效指导延续护理临床干预的研究设计。
3.老年慢病延续护理网络平台的初步搭建
将本研究提出的延续护理的全息干预模式应用于网络平台(60页,图3-3),从设计上实现了将全息干预模式融入到依托于网络的护理服务中。网络全息护理干预通过档案管理、随访管理、交流沟通3个环节来实现医务人员与患者之间的互动,设计搭建了包含用户登录和注册模块、患者档案管理模块、患者个人中心模块、健康广场4个功能模块的网络平台,介入患者的认知-应对适应过程,提高患者的自我效能,最终达到改善患者对疾病的自我认知,帮助患者建立积极的应对策略,从而提高患者自我管理能力,改善患者健康水平的目的。讨论
本研究以适应模式为框架,结合常识模式和自我效能理论,提出并初步证实了老年糖尿病患者的疾病适应模型。证实了老年糖尿病患者认知-应对情况对自我管理行为与健康水平的影响,并部分揭示了其内在过程,为临床开展老糖尿及其他慢病患者自我管理护理干预提供了理论依据。
根据研究结果,我们提出了以下重点建议：
①从疾病描绘出发评价患者的疾病认知,疾病描绘指所罹患疾病在患者中所描绘的意义,以疾病描绘描述患者对疾病的体验,可从患者的角度重新认识患者对疾病的认识。
②关注不同特征患者的疾病认知需求,研究结果显示不同特征患者对疾病认知不同,所以在临床护理中,我们应当关注不同特征患者的疾病认知特点,以采取个体化的健康教育形式,提高护理干预质量。
③重视自我效能的作用,本研究证明,自我效能在患者认知与应对策略的选择间起到完全或部分的中介作用,老年糖尿病患者自我效能感与应对策略的选择紧密相关。增强老年糖尿病患者自我效能感,一方面要注重提高患者糖尿病相关认知水平,针对患者认知薄弱点加强健康教育；另一方面要注重提高患者健康信念,通过增强患者自我效能感的护理途径和方法,增强患者自我管理活动执行信心。
④本研究提出的糖尿病患者慢病描绘-应对适应模型(54页,图2-6)和全息护理干预模式(55页,图2-8),可为糖尿病或其他慢性病患者的临床护理和延续护理方案的制定提供理论指导。本研究将提出的护理模式应用于网络平台设计的过程,证明新的慢病适应模型和全息护理干预模式从理论到实践的尝试是可行的。
结论
本研究通过理论研究提出老年糖尿病患者疾病适应模型的假设,并对理论模型雏形进行初步验证,提出了老年糖尿病患者的认知-应对适应模型的理论模型。在该理论模型中,患者的对疾病的适应过程是一个认知-应对过程,患者的一般资料会影响患者对疾病的认知,患者对疾病的认知会导致患者采取不同的策略应对疾病,从而影响患者的自我管理行为和健康状况。患者的健康结局又反馈性地对患者的认知产生影响。自我效能预期在疾病的认知和应对过程中起到一定的中介作用。基于此模型,我们提出了老年糖尿病患者的延续护理全息干预模式,强调对患者认知-应对这一适应过程的全面干预。最后尝试将延续护理全息护理模式应用于网络平台,落脚于实践,优化老年慢病患者的延续护理服务。
Background
China is facing great challenges about aging tendency of population and high incidence of elderly chronic disease. Network media as a new way of information services, for its initiative and effectiveness, was gradually gained the acceptance of the most users. How to combine the modern technology with scientific and effective health management models to achieve a new transitional care model with high economic and social benefits is what we think about. The illness experience and health empowerment of patients should be considered in the effective health management or transitional care models. Compared to professional medical personnel, chronic patients have a better understand about their own lives and specific disease rules, and a clearer feeling of needs physiologically and psychologically, so that the patient's own was the primary caregiver. To improve self-management ability, fully understanding the own life experiences and discovering the patient's own inner capacity should be involved in elderly chronic patients with transitional care models as well as understanding the patient's cognitive-adapt processes of disease. Due to the different cultural background, there are diverse explanations of patient's disease cognitive. In area of health management, the disease cognitive and response model of elderly patients with chronic disease and transitional care network approach remain to be further studied in China.
According to the International Diabetes Federation (IFD)2011statistics, the global number of diabetes was366million, and estimated that in2030the number will grow to552million. Diabetes mortality rate is very high; there will be one people in every ten seconds die due to diabetes-related causes. Diabetes is one of the most prevalent non-communicable diseases. In2010, adult diabetes prevalence rate is9.7%, the total number of patients has more than90million, and China is now home to the most cases worldwide. Diabetes is a heavy burden to patients, their families and Social medical institutions. It is a very important and meaningful task to help patients and their families facing the correct and proper management of diabetes. Therefore, this research chooses elderly diabetic patients as our target subject, to provide an initial experience and data for the future research of other chronic diseases.
Objective
The purpose of this study is to explore the relationship between disease cognitive, coping strategies and self-efficacy in elderly patients with diabetes, understand the adapt process of patients, build and develop theory framework of nursing intervention mode and diabetes adaptation model which is suitable for Chinese elderly patients, that provides a theoretical basis for the further development of transitional care model for elderly patients with diabetes and other chronic disease. Meanwhile, combining the theory and practice, we hope to design a transitional care network platform which was suitable for elderly patients with chronic disease, extend the health care from hospital to community, and strengthen the patient's capacity of self-management. The research issues include:What the perception of the disease in elderly patients with diabetes? Have the perception of disease effect on process of adaptation and response to the disease? What is the role of self-efficacy in the process? Have patient's potential been mobilized to make a positive adjustment in the self-management process? Are there any factors would affect the patient's perception of the disease? How to help patients achieve adaptation to the disease? How to introduce the care theoretical model to the network information technology?
Method
The study consists of three parts.
1. Theoretical framework and research hypothesis
The study based on the Roy's adaptation model, combined the Leventhal's common sense model and Bandura's theory of self-efficacy to build an adaptation model of elderly diabetics, and the research hypothesis was also confirmed as well as research variables.
2. The relationship between illness perception, self-efficacy, coping strategies and health conditions.
Total250samples were collected through convenience sampling questionnaire from diabetic outpatients and endocrinology in certain grade-three general hospital in Guangzhou, illness perception, self-efficacy, coping strategies and health conditions were investigated and the relationship was explored by diabetes patients basic information table, by the assessment tools of Brief Illness Perception Questionnaire(Brief-IPQ), Self-Efficacy for Managing Chronic Disease6-Item Scale (SECD6), Medical Coping Modes Questionnaire (MCMQ), The Summary of Diabetes Self-Care Activities Measure (SDSCA) and EQ-5D-5L. The study validated and revised the hypothesis and proposed some suggestions about the effectively transitional care model for patients with diabetes according to research results.
3. Preliminary establishment of transitional care network platform of elderly chronic disease.
To design and establish A transitional care service network platform based on nursing conception model proposed by this study, referenced successful model of transitional care in other countries.
Results
1. Theoretical framework and research hypothesis
Common sense model and self-efficacy, both theories emphasize personal experience, pre-construction of self, individual response to illness and treatment, and that the patients'beliefs are more influential in their recovery than the severity of the illness. Where the theories are most divergent is their application to therapeutic interventions, which reflect the different sources of influence that each theory emphasizes. Based on their similarities and differences it is possible to integrate the two theories into a conceptual care model.
Illness representation offers a general perspective of an individual's initial interpretation of their illness, as the representation components are largely formed before their experience of the illness and have been shown to have a predictive value in terms of short-term patient responses; self-efficacy explores how a patient perceives their own ability to adopt and maintain health behaviors require in the treatment of their condition, and has been shown to have a predictive value in terms of long-term patient responses. Therefore, there is a chronological sequence to the focus that each theory adopts and if there is a relationship between the two then it should follow this chronology. The chronic disease adaptation model put forward by this study proposes that illness perception components predict self-efficacy. This sequence appears theoretically logical, as the illness perception model tends to predict the intention of health behavior change rather than the actual behavior change, while Bandura's self-efficacy research is based on predicting actual long-term behavior change.
These time scales provide a chronological framework for the integrated design of care interventions, suggesting the direction of the relationship-the illness representation components influence the long-term perception of the patient's self-efficacy-creating a more holistic regime to manage both the patients'initial conceptualization of their condition and to develop their perceived ability to cope with their condition and its treatment over the longer term. By incorporating both illness perception and self-efficacy into a single conceptual care model, an explicit framework has been provided for further research.
2. The relationship between illness perception, self-efficacy, coping strategies and health conditions.
The questionnaires were issued for250, recycled246. The valid questionnaires are233. Effective recovery ratings are93.2%.233individuals who have type2(n=216,92.7%), type1(n=4,1.7%) and other types (n=13,5.6%) diabetes mellitus participated in this study. Participants'age range from60～91, the average age was69.03±7.86years. On average, length of diagnosis with diabetes was114.42±93.25months.
In the different dimension of illness representation of elderly diabetes, timeline, cure/control and consequences has higher scores, meanwhile identity, coherence, and emotional representation has lower scores. Suggest that most patients think the diabetes mellitus is long-term and controllable; diabetes has certain influence to life. Their perceived degree of understanding of diabetes was normal. In terms of understanding of the etiology, most patients think diet, daily lifestyle and genetics is the major cause of diabetes, but there is also some wrong understanding of the etiology in patients.
Different demographic and disease characteristics will have an impact on different aspects of diseases depicted. U test showed that female patients have higher emotional representation score than male patients (P<0.01); the patient without partner have higher emotional representation score than patients have a partner (P <0.05); patients without job have higher timeline, consequences and emotional representation score than patients with job (P<0.01). Spearman correlation analysis showed that age was positively correlated with consequences and was negatively correlated with personal control (P<0.01) and treatment control (P<0.05); Education level was positively correlated with emotional representation (P<0.05); Economic burden was positively correlated with; Duration of diabetes was positively correlated with timeline (P<0.05) and emotional representation (P<0.01), and was negatively correlated with personal control (P<0.01); Number of complications was positively correlated with identity, consequences and emotional representation (P<0.01), was negatively correlated with personal control (P<0.01); Treatment modalities was positively correlated with identity (P<0.01), consequences(P<0.01), treatment control(P<0.05) and coherence (P<0.01), was negatively correlated with personal control (P<0.05). Regression analysis showed that the patient's disease is characterized mainly affected by age, education, work status, economic burden, duration of disease, complications, and treatment modalities.
The results show that there is a significant relationship between the patients' illness representations, self-efficacy and coping strategies. Illness representations can affect the selection of coping strategies, self-efficacy plays an intermediary role between the illness representations and coping strategies depicted. Spearman correlation analysis showed that facing was negatively correlated with consequences strategies personal control, treatment control and self-efficacy (P<0.01); Avoidance was positively correlated with consequences (P<0.05), and was negatively correlated with personal control, treatment control and self-efficacy (P<0.05or P<0.01); Yielding was positively correlated with consequences and emotional representation(P <0.05or P<0.01), and was negatively correlated with identity, personal control and self-efficacy(P<0.05or P<0.01). Test of the intermediary role of self-efficacy showed that self-efficacy completely mediated the associations of consequences, personal control, emotional representation and facing strategy (mediating effect=-0.112,0.222,0.149, effect ratio=0.147,0.965,0.296), and partially mediated the associations of treatment control and facing strategy (mediation effect=-0.091, effect ratio=0.653).Self-efficacy partially mediated the associations of consequences, treatment control and avoidance strategy (mediating effect=0.043,-0.072, effect ratio=0.288,0.531). Self-efficacy partially mediated the associations of emotional representation and Yielding strategy (mediation effect=0.021, effect ratio=0.054).
These results verified our initial conceptual model proposed in the first part, and an explicit framework has been provided for further research and its effectiveness can be intervention research designed for extendant care..
3. Preliminary establishment of a transitional care network platform for patients with elderly chronic disease.
The holographic intervention model proposed in this study is applied to the network platform to achieve applying the theoretical model into transitional care practice. Network holographic care intervention achieves interaction between medical staff and patients through three aspects:file management, follow-up management and communication. Four functional modules was designed including user login and registration, patient file management, individual patient center and Health Plaza, which involve in the patient's perception-coping process with the adaptation process, to improve the patient's self-efficacy, and ultimately to improve patient self-awareness of the disease and help patients develop positive coping strategies to improve patient self-management ability.
Discuss
In this study, we use adaptation model as a framework, combined with common sense model and self-efficacy theory, present and preliminary test the adaptive mode of elderly diabetes. We verified the impact of patients'perception-coping process on self-management and health behavior. We partially revealed its inner processes of adaption of elderly diabetes, which provides a theoretical basis for clinical self-care intervention of patients with diabetes and other similar chronic disease.
Based on the results, we made the following key recommendations:
①Assessment patients'illness perception starting from the evaluation of patients' illness representations, which refers to the meaning of their disease portrayed by patients. We can obtain new understanding of the disease from the patients'perspective by portraying disease by illness representations.
②Pay attention to the different characteristics of patients' illness perception demand. The study showed that different illness perception in patients with different characteristics. So in clinical care, we should be concerned about the illness perception characteristics in patients with different characteristics, in order to take individualized health education, improve the quality of nursing intervention.
③Pay attention to the role of self-efficacy. This study demonstrated that self-efficacy plays a completely or partially intermediary role in illness perception and the choice of coping strategies among elderly patients with diabetes. Self-efficacy and coping strategies are closely related. Enhance self-efficacy in elderly patients with diabetes, on the one hand, should focus on improving diabetes-related perception level, to strengthen health education for patients with cognitive weak point; On the other hand, should to focus on improving patient health beliefs, in order to enhance patients' confidence in self-management activities.
④This study proposes a theoretical model to provide theoretical guidance for developing clinical care and transitional care programs for diabetes or other chronic diseases.In this study, the practice of using Holographic Care Model in network platform design process prove that the attempt that make theoretical model from theory to practice is feasible.
Conclusion
In this study, we hypothesize a new adaptation model for elderly diabetic patients through theoretical studies and preliminary validate the prototype of theoretical model, present theoretical perception-coping adaptation model in elderly diabetic patients. In the theoretical model, the process of adaptation to the patient's disease is a perception-coping process, general information will affect the patient's perception of the disease, and patients with different illness representation take different strategies to coping with the disease, thus affecting the self-management behaviors and health status of the patient. Patient health outcomes are feedback to illness perception. Self-efficacy is expected to play a mediation role in the illness perception and coping strategy to the disease adaption process. Based on this model, we propose a Holographic Care Model for elderly patients with diabetes, emphasis a comprehensive on patient perception-coping of the adaptation process. Finally, we try to use Holographic Care Model in transitional care network platform, settled in practice, optimizing transitional care services for the elderly with chronic diseases.
引文
[1]全国老龄工作委员会办公室.中国人口老龄化发展趋势预测研究报告[R].,2006.
[2]Hooyman N, Kiyak H A. Social Gerontology:A Multidisciplinary Perspective (9th Edition) [M]. Pearson,2010.
[3]中华医学会糖尿病学分会.中国2型糖尿病防治指南(2010版)[M].北京：北京大学医学出版社,2010.
[4]人民网-健康卫生频道.我国是世界第一糖尿病大国患病人数超九千万[Z].2012.
[5]华中科技大学同济医学院糖尿病防控评估研究小组.中国糖尿病防控蓝皮书[M].2011.
[6]英辛克莱.老年糖尿病学[M].第3版.成都：四川科学技术出版社,2011.
[7]Hor Y, Huang C, Guo J. A Study Psychosocial Adjustment, Coping Styles and Health Education Needs among Diabetic Patient[J]. Evidence-based nursing. 2005,1(3):165-175.
[8]Stack R J, Bundy C, Elliott R A, et al. Patient perceptions of treatment and illness when prescribed multiple medicines for co-morbid type 2 diabetes [J]. Diabetes Metab Syndr Obes.2011,4:127-135.
[9]李燕,崔琼,薛为贞.68例老年2型糖尿病人的应对心态分析及其干预[J].中国行为医学科学.2003,12(4)：464.
[10]梁建耀.老年糖尿病患者知识认知的现状与对策[J].医学信息：上旬刊.2012,25(9)：303.
[11]石红丽,张小曼,张开利,等.社区老年糖尿病病人胰岛素笔自我注射相关知识和行为的调查[J].护理研究：上旬版.2012,26(11)：2913-2915.
[12]胡宏伟.老年2型糖尿病患者的应对策略与主观幸福感的相关性研究[J]. 中外健康文摘.2011,08(15).
[13]van Walraven C, Oake N, Jennings A, et al. The association between continuity of care and outcomes:a systematic and critical review[J]. J Eval Clin Pract.2010, 16(5):947-956.
[14]Dreiher J, Comaneshter D S, Rosenbluth Y, et al. The association between continuity of care in the community and health outcomes:a population-based study[J]. Isr J Health Policy Res.2012,1(1):21.
[15]Kietzman K G, Pincus H A, Huynh P T. Coming full circle:Planning for future pathways of transitions of care for older adults [M]. New York:Springer,2011.
[16]徐建秀.我国延续护理模式研究进展[J].中国护理管理.2012,12(9)：18-19.
[17]盛荣,王世英,沈锡珊,等.延续护理在出院糖尿病患者中的应用[J].解放军护理杂志.2009,26(20)：6-7.
[18]Prentice J C, Graeme F B, Miller D R, et al. Primary care and health outcomes among older patients with diabetes[J]. Health Serv Res.2012,47(1 Pt 1):46-67.
[19]Manns B J, Tonelli M, Zhang J, et al. Enrolment in primary care networks: impact on outcomes and processes of care for patients with diabetes[J]. CMAJ. 2012,184(2):E144-E152.
[20]Katon W J, Lin E H, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses[J]. N Engl J Med.2010,363(27):2611-2620.
[21]Brown A F, Mangione C M, Saliba D, et al. Guidelines for improving the care of the older person with diabetes mellitus[J]. J Am Geriatr Soc.2003,51(5 Suppl Guidelines):S265-S280.
[22]Bazzazian S, Besharat M A. An explanatory model of adjustment to type I diabetes based on attachment, coping, and self-regulation theories [J]. Psychol Health Med.2012,17(1):47-58.
[23]覃桂荣.出院患者延续护理的现状及发展趋势[J].护理学杂志：综合版.2012,27(2)：89-91.
[24]中国互联网络信息中心.第31次中国互联网发展状况统计报告[Z].2013.
[25]Fox S, Rainie L. The online health care revolution:How the Web helps Americans take better care of themselves[R]. Washington, D.C:Pew Internet & American Life Project,2007.
[26]Wantland D J, Portillo C J, Holzemer W L, et al. The effectiveness of Web-based vs. non-Web-based interventions:a meta-analysis of behavioral change outcomes[J]. J Med Internet Res.2004,6(4):e40.
[27]Desa-Ecosoc. Madrid Plan of Action and its Implementation[M]. New York: United Nations ,2002.
[28]李旭初,刘兴策,张揆一,等.新编老年学词典[M].武汉：武汉大学出版社,2009.
[29]Conrad P. The meaning of medications:another look at compliance [J]. Social science & medicine.1985,20(1):29-37.
[30]Hunt L M, Jordan B, Irwin S, et al. Compliance and the patient's perspective: controlling symptoms in everyday life[J]. Culture, medicine and psychiatry. 1989,13(3):315-334.
[31]Ternulf Nyhlin K. A contribution of qualitative research to a better understanding of diabetic patients [J]. Journal of Advanced Nursing.1990,15(7): 796-803.
[32]Hagger M S, Orbell S. A meta-analytic review of the common-sense model of illness representations [J]. Psychology and Health.2003,18(2):141-184.
[33]严祥,袁治,荔志云,等.汉英医学常用词表达词典[M].兰州：兰州大学 出版社,2008.
[34]中国社会科学院语言研究所词典编辑室.现代汉语词典[M].6.北京：商务印书馆,2012.
[35]Folkman S, Lazarus R S, Gruen R J, et al. Appraisal, coping, health status, and psychological symptoms[J]. J Pers Soc Psychol.1986,50(3):571-579.
[36]孙晓敏,黄晓萍,袁翠萍,等.2型糖尿病患者自我管理行为及应对策略相关性研究[J].护士进修杂志.2012,27(12)：1084-1086.
[37]Bandura A. Human agency in social cognitive theory[J]. Am Psychol.1989, 44(9):1175-1184.
[38]Bandura A. The anatomy of stages of change[J]. Am J Health Promot. 1997, 12(1):8-10.
[39]Beach E F, Williams W, Gilliver M. A qualitative study of earplug use as a health behavior:the role of noise injury symptoms, self-efficacy and an affinity for music[J]. J Health Psychol.2012,17(2):237-246.
[40]Shortell S M, Rundall T G, Hsu J. Improving patient care by linking evidence-based medicine and evidence-based management J]. JAMA.2007, 298(6):673-676.
[41]黄金月.出院后延续护理所需的护理剂量及能达到的成效：2006中国护理大会[Z].北京：2006.
[42]高灿芬.应用Roy适应模式对1例截肢、2型糖尿病合并上消化道出血患者的护理[J].西南军医.2011(06)：1120-1121.
[43]王丽萍,郭晓丽,何丽.罗伊适应模式在1型糖尿病患者护理中的应用[J].新疆医科大学学报.2006(07)：650.
[44]高晨晨,姜安丽.罗伊适应模式理论新进展评介[J].护理研究.2013(11)：964-966.
[45]彭学叶.Roy适应模式的研究现状及存在的问题[J].全科护理.2010(03)：254-256.
[46]Tolson D, Mcintosh J. The Roy Adaptation Model:a consideration of its properties as a conceptual framework for an intervention study.[J]. Journal Of Advanced Nursing.1996,24(5):981-987.
[47]Dixon E L. Community health nursing practice and the Roy Adaptation Model.[J]. Public Health Nursing (Boston, Mass.).1999,16(4):290-300.
[48]Leventhal H, Meyer D, Nerenz D. The common sense model of ilness danger[J]. Medical psychology.1980(2):7-30.
[49]Cameron L D, Leventhal H. The common-sense model of self-regulation of health and illness [M]. London:Routledge,2003.
[50]Farmer K C. Leventhal's common-sense model and medication adherence[J]. Res Social Adm Pharm.2012,8(5):355-356.
[51]Kucukarslan S N. A review of published studies of patients' illness perceptions and medication adherence:Lessons learned and future directions [J]. Res Social Adm Pharm.2012,8(5):371-382.
[52]Hale E D, Treharne G J, Kitas G D. The common-sense model of self-regulation of health and illness:how can we use it to understand and respond to our patients' needs?[J]. Rheumatology (Oxford).2007,46(6): 904-906.
[53]Martin S. Hagger S O. A Meta-Analytic Review of the Common-Sense Model of Illness Representations[J].,18(2):141-184.
[54]Broadbent E, Petrie K J, Main J, et al. The brief illness perception questionnaire[J]. J Psychosom Res.2006,60(6):631-637.
[55]Petrie K J, Weinman J, Sharpe N, et al. Role of patients' view of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study[J]. BMJ.1996,312(7040):1191-1194.
[56]Llewellyn C D, Mcgurk M, Weinman J. Illness and treatment beliefs in head and neck cancer:is Leventhal's common sense model a useful framework for determining changes in outcomes over time?[J]. J Psychosom Res.2007,63(1): 17-26.
[57]Meyer D, Leventhal H, Gutmann M. Common-sense models of illness:the example of hypertension[J]. Health Psychol.1985,4(2):115-135.
[58]Gonder-Frederick L A, Snyder A L, Clarke W L. Accuracy of blood glucose estimation by children with IDDM and their parents[J]. Diabetes Care.1991, 14(7):565-570.
[59]Johnson J A, King K B. Influence of expectations about symptoms on delay in seeking treatment during myocardial infarction[J]. Am J Crit Care.1995,4(1): 29-35.
[60]Jadack R A, Keller M L, Mims F. Genital herpes:the disease experience over the first 6 months[J]. Appl Nurs Res.1991,4(2):85-87.
[61]Shaw C. A framework for the study of coping, illness behaviour and outcomes[J]. J Adv Nurs.1999,29(5):1246-1255.
[62]Petrie K J, Weinman J, Sharpe N, et al. Role of patients'view of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study[J]. BMJ.1996,312(7040):1191-1194.
[63]Scharloo M, Kaptein A A, Weinman J, et al. Patients'illness perceptions and coping as predictors of functional status in psoriasis:a 1-year follow-up[J]. Br J Dermatol.2000,142(5):899-907.
[64]Herda C A, Siegeris K, Basler H D. The Pain Beliefs and Perceptions Inventory: further evidence for a 4-factor structure[J]. Pain.1994,57(1):85-90.
[65]Skevington S M. The experience and management of pain in rheumatological disorders[J]. Baillieres Clin Rheumatol.1993,7(2):319-335.
[66]Williams D A, Robinson M E, Geisser M E. Pain beliefs:assessment and utility[J]. Pain.1994,59(1):71-78.
[67]Hampson S E, Glasgow R E, Zeiss A M. Personal models of osteoarthritis and their relation to self-management activities and quality of life[J]. J Behav Med. 1994,17(2):143-158.
[68]Jensen M P, Turner J A, Romano J M. What is the maximum number of levels needed in pain intensity measurement?[J]. Pain.1994,58(3):387-392.
[69]Pollock S E. Adaptation to chronic illness:a program of research for testing nursing theory[J]. Nurs Sci Q.1993,6(2):86-92.
[70]Gilutz H, Bar-On D, Billing E, et al. The relationship between causal attribution and rehabilitation in patients after their first myocardial infarction. A cross cultural study[J]. Eur Heart J.1991,12(8):883-888.
[71]Shi X L, Dalal N S. The role of superoxide radical in chromium (VI)-generated hydroxyl radical:the Cr(VI) Haber-Weiss cycle[J]. Arch Biochem Biophys. 1992,292(1):323-327.
[72]Flor H, Behle D J, Birbaumer N. Assessment of pain-related cognitions in chronic pain patients[J]. Behav Res Ther.1993,31(1):63-73.
[73]Marshall G N. A multidimensional analysis of internal health locus of control beliefs:separating the wheat from the chaff?[J]. J Pers Soc Psychol.1991,61(3): 483-491.
[74]Pastor M A, Salas E, Lopez S, et al. Patients' beliefs about their lack of pain control in primary fibromyalgia syndrome[J]. Br J Rheumatol.1993,32(6): 484-489.
[75]Schussler G. Coping strategies and individual meanings of illness[J]. Soc Sci Med.1992,34(4):427-432.
[76]Cooper A, Lloyd G, Weinman J, et al. Why patients do not attend cardiac rehabilitation:role of intentions and illness beliefs[J]. Heart.1999,82(2): 234-236.
[77]Petrie K J, Cameron L D, Ellis C J, et al. Changing illness perceptions after myocardial infarction:an early intervention randomized controlled trial[J]. Psychosom Med.2002,64(4):580-586.
[78]Williams A C, Nicholas M K, Richardson P H, et al. Evaluation of a cognitive behavioural programme for rehabilitating patients with chronic pain[J]. Br J Gen Pract.1993,43(377):513-518.
[79]Scharloo M, Kaptein A A, Weinman J A, et al. Predicting functional status in patients with rheumatoid arthritis[J]. J Rheumatol.1999,26(8):1686-1693.
[80]Petrie K J, Cameron L D, Ellis C J, et al. Changing illness perceptions after myocardial infarction:an early intervention randomized controlled trial [J]. Psychosom Med.2002,64(4):580-586.
[81]Mcandrew L M, Mora P A, Quigley K S, et al. Using the Common Sense Model of Self-Regulation to Understand the Relationship Between Symptom Reporting and Trait Negative Affect[J]. International Journal of Behavioral Medicine.2014:1-6.
[82]Bandura A. Self-efficacy:toward a unifying theory of behavioral change[J]. Psychol Rev.1977,84(2):191-215.
[83]Bandura A. The assessment and predictive generality of self-percepts of efficacy[J]. J Behav Ther Exp Psychiatry.1982,13(3):195-199.
[84]Bandura A. Comments on the crusade against the causal efficacy of human thought[J]. J Behav Ther Exp Psychiatry.1995,26(3):179-190.
[85]Bandura A. The anatomy of stages of change[J]. Am J Health Promot.1997, 12(1):8-10.
[86]Maddux J F, Hoppe S K, Costello R M. Psychoactive substance use among medical students [J]. Am J Psychiatry.1986,143(2):187-191.
[87]Strecher V J, Devellis B M, Becker M H, et al. The role of self-efficacy in achieving health behavior change[J]. Health Educ Q.1986,13(1):73-92.
[88]Schwarzer A C, Wang S C, Bogduk N, et al. Prevalence and clinical features of lumbar zygapophysial joint pain:a study in an Australian population with chronic low back pain[J]. Ann Rheum Dis.1995,54(2):100-106.
[89]Sanz A, Villamarin F. The role of perceived control in physiological reactivity: self-efficacy and incentive value as regulators of cardiovascular adjustment[J]. Biol Psychol.2001,56(3):219-246.
[90]Bandura A. Health promotion by social cognitive means [J]. Health Educ Behav. 2004,31(2):143-164.
[91]Wright S L, Perrone Mcgovern K M, Boo J N, et al. Influential Factors in Academic and Career Self-Efficacy:Attachment, Supports, and Career Barriers[J]. Journal of Counseling & Development.2014,92(1):36-46.
[92]Chin Y F, Huang T T, Hsu B R S. Impact of action cues, self-efficacy and perceived barriers on daily foot exam practice in type 2 diabetes mellitus patients with peripheral neuropathy [J]. Journal of clinical nursing.2013,22(1-2):61-68.
[93]Mansyur C L, Pavlik V N, Hyman D J, et al. Self-efficacy and barriers to multiple behavior change in low-income African Americans with hypertension[J]. Journal of behavioral medicine.2013,36(1):75-85.
[94]Cardenas V, Abel S, Bowie C R, et al. When Functional Capacity and Real-World Functioning Converge:The Role of Self-Efficacy[J]. Schizophrenia bulletin.2013,39(4):908-916.
[95]Glasgow R E, Peeples M, Skovlund S E. Where is the patient in diabetes performance measures? The case for including patient-centered and self-management measures[J]. Diabetes Care.2008,31(5):1046-1050.
[96]Foster G D, Wadden T A, Lagrotte C A, et al. A randomized comparison of a commercially available portion-controlled weight-loss intervention with a diabetes self-management education program[J]. Nutr Diabetes.2013,3:e63.
[97]Glasgow R E, Fisher L, Skaff M, et al. Problem solving and diabetes self-management:investigation in a large, multiracial sample[J]. Diabetes Care. 2007,30(1):33-37.
[98]Jones H, Edwards L, Vallis T M, et al. Changes in diabetes self-care behaviors make a difference in glycemic control:the Diabetes Stages of Change (DiSC) study[J]. Diabetes Care.2003,26(3):732-737.
[99]Funnell M M, Brown T L, Childs B P, et al. National standards for diabetes self-management education[J]. Diabetes Care.2008,31 Suppl 1:S97-S104.
[100]Mcauley E, Mullen S P, Szabo A N, et al. Self-regulatory processes and exercise adherence in older adults:Executive function and self-efficacy effects[J]. American journal of preventive medicine.2011,41(3):284-290.
[101]Mosher C E, Lipkus I, Sloane R, et al. Long-term outcomes of the FRESH START trial:exploring the role of self-efficacy in cancer survivors' maintenance of dietary practices and physical activity [J]. Psycho-Oncology. 2012.
[102]Phua J. Participating in Health Issue-Specific Social Networking Sites to Quit Smoking:How Does Online Social Interconnectedness Influence Smoking Cessation Self-Efficacy?[J]. Journal of Communication.2013,63(5):933-952.
[103]Breaux-Shropshire T L, Brown K C, Pryor E R, et al. Prevalence of blood pressure self-monitoring, medication adherence, self-efficacy, stage of change, and blood pressure control among municipal workers with hypertension. [J]. Workplace health & safety.2012,60(6):265.
[104]Grossman H Y, Brink S, Hauser S T. Self-efficacy in adolescent girls and boys with insulin-dependent diabetes mellitus[J]. Diabetes Care.1987,10(3): 324-329.
[105]Lorig K R, Ritter P, Stewart A L, et al. Chronic disease self-management program:2-year health status and health care utilization outcomes[J]. Med Care. 2001,39(11):1217-1223.
[106]Anderson R M, Funnell M M. Patient empowerment:reflections on the challenge of fostering the adoption of a new paradigm [J]. Patient Educ Couns. 2005,57(2):153-157.
[107]Noll A N, Glenn L L. Self-efficacy and management in type 2 diabetes mellitus[J]. J Diabetes Complications.2012,26(6):562,562-563.
[108]King D K, Glasgow R E, Toobert D J, et al. Self-efficacy, problem solving, and social-environmental support are associated with diabetes self-management behaviors[J]. Diabetes Care.2010,33(4):751-753.
[109]牟利宁,边苗苗,牟利凤.动机访谈路线图提高糖尿病患者自我效能的效果研究[J].中华护理杂志.2012(10)：892-895.
[110]赵晓霜,李春玉,李彩福.社区糖尿病患者健康素养和自我效能对健康状况影响的路径分析[J].中华护理杂志.2013(1)：63-65.
[111]Dusseldorp E, van Elderen T, Maes S, et al. A meta-analysis of psychoeduational programs for coronary heart disease patients [J]. Health Psychol.1999,18(5):506-519.
[112]Linden W, Stossel C, Maurice J. Psychosocial interventions for patients with coronary artery disease:a meta-analysis[J]. Arch Intern Med.1996,156(7): 745-752.
[113]Wiles R. Patients' perceptions of their heart attack and recovery:the influence of epidemiological "evidence" and personal experience[J]. Soc Sci Med.1998, 46(11):1477-1486.
[114]Lau-Walker M. Relationship between illness representation and self-efficacy [J]. J Adv Nurs.2004,48(3):216-225.
[115]Keogh K M, Smith S M, White P, et al. Psychological family intervention for poorly controlled type 2 diabetes[J]. Am J Manag Care.2011,17(2):105-113.
[116]Mc Sharry J, Moss Morris R, Kendrick T. Illness perceptions and glycaemic control in diabetes:a systematic review with meta-analysis[J]. Diabetic Medicine.2011,28(11):1300-1310.
[117]Dracup K, Moser D K, Eisenberg M, et al. Causes of delay in seeking treatment for heart attack symptoms[J]. Soc Sci Med.1995,40(3):379-392.
[118]Wood R, Bandura A. Impact of conceptions of ability on self-regulatory mechanisms and complex decision making[J]. J Pers Soc Psychol.1989,56(3): 407-415.
[119]Lorig K R, Sobel D S, Ritter P L, et al. Effect of a self-management program on patients with chronic disease[J]. Eff Clin Pract.2001,4(6):256-262.
[120]孙慧伶,张瑜.糖尿病患者自我效能测量工具的研究进展[J].护理学杂志.2012(21)：92-95.
[121]沈晓红,姜乾金.医学应对策略问卷中文版701例测试报告[J].中国行为医 学科学.2000(01)：22-24.
[122]汪向东,王希林,马弘.行为医学量表手册[M].北京：中国心理卫生杂志社,1999.
[123]李延飞,陈伟菊,许万萍,等.2型糖尿病患者自我管理行为量表的改良及其信效度检验[J].现代医院.2011(3)：148-150.
[124]Toobert D J, Hampson S E, Glasgow R E. The summary of diabetes self-care activities measure:results from 7 studies and a revised scale[J]. Diabetes Care. 2000,23(7):943-950.
[125]万巧琴,尚少梅,来小彬,等.2型糖尿病患者自我管理行为量表的信、效度研究[J].中国实用护理杂志.2008,24(7)：26-27.
[126]李明晖,罗南.欧洲五维健康量表(EQ-5D)中文版应用介绍[J].中国药物经济学.2009(01)：49-57.
[127]Janssen M F, Pickard A S, Golicki D, et al. Measurement properties of the EQ-5D-5L compared to the EQ-5D-3L across eight patient groups:a multi-country study[J]. Qual Life Res.2012.
[128]罗娅珺,方芸,丁选胜.采用EQ-5D评估2型糖尿病患者的生活质量及影响因素研究[J].中国药物经济学.2009(02)：12-18.
[129]邢亚彬,马爱霞.欧洲五维健康量表EQ-5D-3L和EQ-5D-5L中文版比较的实证研究[J].上海医药.2013(07)：27-31.
[130]温忠麟,张雷,侯杰泰,等.中介效应检验程序及其应用[J].心理学报.2004,36(5)：614-620.
[131]Nefs G, Pouwer F, Denollet J, et al. The course of depressive symptoms in primary care patients with type 2 diabetes:results from the Diabetes, Depression, Type D Personality Zuidoost-Brabant (DiaDDZoB) Study [J]. Diabetologia.2012,55(3):608-616.
[132]Kimbro L B, Steers W N, Mangione C M, et al. The Association of Depression and the Cardiovascular Risk Factors of Blood Pressure, HbAlc, and Body Mass Index among Patients with Diabetes:Results from the Translating Research into Action for Diabetes Study[J]. Int J Endocrinol.2012,2012:747460.
[133]杨春琴.上海市闸北社区慢性阻塞性肺疾病病人疾病认知和护理服务需求调查[J].护理研究：中旬版.2009,23(2)：395-396.
[134]中国2型糖尿病防治指南(2010年版)[J].中国糖尿病杂志.2012(01)：81-117.
[135]马爱霞.糖尿病患者的自我效能水平及其影响因素分析[D].山东大学,2008.
[136]Wick J Y. Why do I need to know this? Reaching the adult learner[J]. Consult Pharm.2012,27(7):518-522.
[137]Trento M, Trevisan M, Raballo M, et al. Depression, anxiety, cognitive impairment and their association with clinical and demographic variables in people with type 2 diabetes:a 4-year prospective study[J]. J Endocrinol Invest. 2014,37(1):79-85.
[138]Fisher L, Chesla C A, Mullan J T, et al. Contributors to depression in Latino and European-American patients with type 2 diabetes [J]. Diabetes Care.2001, 24(10):1751-1757.
[139]刘安诺,李惠萍,周利华,等.2型糖尿病患者生活质量及其影响因素分析[J].护理学报.2010(03)：74-76.
[140]陈向韵,王永利,岳鹏,等.社区2型糖尿病患者心理痛苦及相关因素分析[J].护理学杂志：综合版.2012,27(11)：74-76.
[141]Al-Khawaldeh O A, AI-Hassan M A, Froelicher E S. Self-efficacy, self-management, and glycemic control in adults with type 2 diabetes mellitus[J]. J Diabetes Complications.2012,26(1):10-16.
[142]Strychar I, Elisha B, Schmitz N. Type 2 Diabetes Self-Management:Role of Diet Self-Efficacy[J]. Canadian Journal of Diabetes.2012,36(6):337-344.
[143]Johnson M D, Anderson J R, Walker A, et al. Common dyadic coping is indirectly related to dietary and exercise adherence via patient and partner diabetes efficacy[J]. J Fam Psychol.2013,27(5):722-730.
[144]Kroese F M, Adriaanse M A, Vinkers C D, et al. The effectiveness of a proactive coping intervention targeting self-management in diabetes patients [J]. Psychol Health.2013,29(1):110-125.
[145]Feifel H, Strack S, Nagy V T. Coping strategies and associated features of medically ill patients.[J]. Psychosomatic Medicine.1987,49(6):616-625.
[146]彭鑫,崔焱,董玲,等.糖尿病儿童青少年应对策略与血糖控制及生活质量的相关性研究[J].护理研究.2010,24(16)：1421-1423.
[147]Thompson D R, Bowman G S, Kitson A L, et al. Cardiac rehabilitation services in England and Wales:a national survey[J]. Int J Cardiol.1997,59(3):299-304.
[148]Glasgow R E, Tracy Orleans C, Wagner E H, et al. Does the chronic care model serve also as a template for improving prevention?[J]. Milbank Quarterly.2001, 79(4):579-612.
[149]Dickman K, Milligan R, Kodadek M. Chronic care model:a framework for experiential learning during clinical rotation[J]. J Nurs Educ.2013,52(11): 663-664.
[150]Loring K. Chronic disease self-management:a model for tertiary prevention[J]. Kango Kenkyu.1998,31(1):23-29.
[151]Lorig K, Ritter P L, Pifer C, et al. Effectiveness of the chronic disease self-management program for persons with a serious mental illness:a translation study[J]. Community Ment Health J.2014,50(1):96-103.
[152]朱静芬,戴李华,恬沈.以自我效能理论为基础的糖尿病高危人群干预效果分析[J].上海交通大学学报(医学版).2014,34(1)：83.
[153]谭晓青.应用奥马哈系统构建居家访视流程和记录模式以及访视成效评价的研究[D].南方医科大学,2011.
[154]卫生部疾病控制司.全国疾病预防控制机构工作规范[Z].2001.
[2]Hooyman N, Kiyak H A. Social Gerontology:A Multidisciplinary Perspective (9th Edition) [M]. Pearson,2010.
[3]中华医学会糖尿病学分会.中国2型糖尿病防治指南(2010版)[M].北京：北京大学医学出版社,2010.
[4]人民网-健康卫生频道.我国是世界第一糖尿病大国患病人数超九千万[Z].2012.
[5]华中科技大学同济医学院糖尿病防控评估研究小组.中国糖尿病防控蓝皮书[M].2011.
[6]英辛克莱.老年糖尿病学[M].第3版.成都：四川科学技术出版社,2011.
[7]Hor Y, Huang C, Guo J. A Study Psychosocial Adjustment, Coping Styles and Health Education Needs among Diabetic Patient[J]. Evidence-based nursing. 2005,1(3):165-175.
[8]Stack R J, Bundy C, Elliott R A, et al. Patient perceptions of treatment and illness when prescribed multiple medicines for co-morbid type 2 diabetes [J]. Diabetes Metab Syndr Obes.2011,4:127-135.
[9]李燕,崔琼,薛为贞.68例老年2型糖尿病人的应对心态分析及其干预[J].中国行为医学科学.2003,12(4)：464.
[10]梁建耀.老年糖尿病患者知识认知的现状与对策[J].医学信息：上旬刊.2012,25(9)：303.
[11]石红丽,张小曼,张开利,等.社区老年糖尿病病人胰岛素笔自我注射相关知识和行为的调查[J].护理研究：上旬版.2012,26(11)：2913-2915.
[12]胡宏伟.老年2型糖尿病患者的应对策略与主观幸福感的相关性研究[J]. 中外健康文摘.2011,08(15).
[13]van Walraven C, Oake N, Jennings A, et al. The association between continuity of care and outcomes:a systematic and critical review[J]. J Eval Clin Pract.2010, 16(5):947-956.
[14]Dreiher J, Comaneshter D S, Rosenbluth Y, et al. The association between continuity of care in the community and health outcomes:a population-based study[J]. Isr J Health Policy Res.2012,1(1):21.
[15]Kietzman K G, Pincus H A, Huynh P T. Coming full circle:Planning for future pathways of transitions of care for older adults [M]. New York:Springer,2011.
[16]徐建秀.我国延续护理模式研究进展[J].中国护理管理.2012,12(9)：18-19.
[17]盛荣,王世英,沈锡珊,等.延续护理在出院糖尿病患者中的应用[J].解放军护理杂志.2009,26(20)：6-7.
[18]Prentice J C, Graeme F B, Miller D R, et al. Primary care and health outcomes among older patients with diabetes[J]. Health Serv Res.2012,47(1 Pt 1):46-67.
[19]Manns B J, Tonelli M, Zhang J, et al. Enrolment in primary care networks: impact on outcomes and processes of care for patients with diabetes[J]. CMAJ. 2012,184(2):E144-E152.
[20]Katon W J, Lin E H, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses[J]. N Engl J Med.2010,363(27):2611-2620.
[21]Brown A F, Mangione C M, Saliba D, et al. Guidelines for improving the care of the older person with diabetes mellitus[J]. J Am Geriatr Soc.2003,51(5 Suppl Guidelines):S265-S280.
[22]Bazzazian S, Besharat M A. An explanatory model of adjustment to type I diabetes based on attachment, coping, and self-regulation theories [J]. Psychol Health Med.2012,17(1):47-58.
[23]覃桂荣.出院患者延续护理的现状及发展趋势[J].护理学杂志：综合版.2012,27(2)：89-91.
[24]中国互联网络信息中心.第31次中国互联网发展状况统计报告[Z].2013.
[25]Fox S, Rainie L. The online health care revolution:How the Web helps Americans take better care of themselves[R]. Washington, D.C:Pew Internet & American Life Project,2007.
[26]Wantland D J, Portillo C J, Holzemer W L, et al. The effectiveness of Web-based vs. non-Web-based interventions:a meta-analysis of behavioral change outcomes[J]. J Med Internet Res.2004,6(4):e40.
[27]Desa-Ecosoc. Madrid Plan of Action and its Implementation[M]. New York: United Nations ,2002.
[28]李旭初,刘兴策,张揆一,等.新编老年学词典[M].武汉：武汉大学出版社,2009.
[29]Conrad P. The meaning of medications:another look at compliance [J]. Social science & medicine.1985,20(1):29-37.
[30]Hunt L M, Jordan B, Irwin S, et al. Compliance and the patient's perspective: controlling symptoms in everyday life[J]. Culture, medicine and psychiatry. 1989,13(3):315-334.
[31]Ternulf Nyhlin K. A contribution of qualitative research to a better understanding of diabetic patients [J]. Journal of Advanced Nursing.1990,15(7): 796-803.
[32]Hagger M S, Orbell S. A meta-analytic review of the common-sense model of illness representations [J]. Psychology and Health.2003,18(2):141-184.
[33]严祥,袁治,荔志云,等.汉英医学常用词表达词典[M].兰州：兰州大学 出版社,2008.
[34]中国社会科学院语言研究所词典编辑室.现代汉语词典[M].6.北京：商务印书馆,2012.
[35]Folkman S, Lazarus R S, Gruen R J, et al. Appraisal, coping, health status, and psychological symptoms[J]. J Pers Soc Psychol.1986,50(3):571-579.
[36]孙晓敏,黄晓萍,袁翠萍,等.2型糖尿病患者自我管理行为及应对策略相关性研究[J].护士进修杂志.2012,27(12)：1084-1086.
[37]Bandura A. Human agency in social cognitive theory[J]. Am Psychol.1989, 44(9):1175-1184.
[38]Bandura A. The anatomy of stages of change[J]. Am J Health Promot. 1997, 12(1):8-10.
[39]Beach E F, Williams W, Gilliver M. A qualitative study of earplug use as a health behavior:the role of noise injury symptoms, self-efficacy and an affinity for music[J]. J Health Psychol.2012,17(2):237-246.
[40]Shortell S M, Rundall T G, Hsu J. Improving patient care by linking evidence-based medicine and evidence-based management J]. JAMA.2007, 298(6):673-676.
[41]黄金月.出院后延续护理所需的护理剂量及能达到的成效：2006中国护理大会[Z].北京：2006.
[42]高灿芬.应用Roy适应模式对1例截肢、2型糖尿病合并上消化道出血患者的护理[J].西南军医.2011(06)：1120-1121.
[43]王丽萍,郭晓丽,何丽.罗伊适应模式在1型糖尿病患者护理中的应用[J].新疆医科大学学报.2006(07)：650.
[44]高晨晨,姜安丽.罗伊适应模式理论新进展评介[J].护理研究.2013(11)：964-966.
[45]彭学叶.Roy适应模式的研究现状及存在的问题[J].全科护理.2010(03)：254-256.
[46]Tolson D, Mcintosh J. The Roy Adaptation Model:a consideration of its properties as a conceptual framework for an intervention study.[J]. Journal Of Advanced Nursing.1996,24(5):981-987.
[47]Dixon E L. Community health nursing practice and the Roy Adaptation Model.[J]. Public Health Nursing (Boston, Mass.).1999,16(4):290-300.
[48]Leventhal H, Meyer D, Nerenz D. The common sense model of ilness danger[J]. Medical psychology.1980(2):7-30.
[49]Cameron L D, Leventhal H. The common-sense model of self-regulation of health and illness [M]. London:Routledge,2003.
[50]Farmer K C. Leventhal's common-sense model and medication adherence[J]. Res Social Adm Pharm.2012,8(5):355-356.
[51]Kucukarslan S N. A review of published studies of patients' illness perceptions and medication adherence:Lessons learned and future directions [J]. Res Social Adm Pharm.2012,8(5):371-382.
[52]Hale E D, Treharne G J, Kitas G D. The common-sense model of self-regulation of health and illness:how can we use it to understand and respond to our patients' needs?[J]. Rheumatology (Oxford).2007,46(6): 904-906.
[53]Martin S. Hagger S O. A Meta-Analytic Review of the Common-Sense Model of Illness Representations[J].,18(2):141-184.
[54]Broadbent E, Petrie K J, Main J, et al. The brief illness perception questionnaire[J]. J Psychosom Res.2006,60(6):631-637.
[55]Petrie K J, Weinman J, Sharpe N, et al. Role of patients' view of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study[J]. BMJ.1996,312(7040):1191-1194.
[56]Llewellyn C D, Mcgurk M, Weinman J. Illness and treatment beliefs in head and neck cancer:is Leventhal's common sense model a useful framework for determining changes in outcomes over time?[J]. J Psychosom Res.2007,63(1): 17-26.
[57]Meyer D, Leventhal H, Gutmann M. Common-sense models of illness:the example of hypertension[J]. Health Psychol.1985,4(2):115-135.
[58]Gonder-Frederick L A, Snyder A L, Clarke W L. Accuracy of blood glucose estimation by children with IDDM and their parents[J]. Diabetes Care.1991, 14(7):565-570.
[59]Johnson J A, King K B. Influence of expectations about symptoms on delay in seeking treatment during myocardial infarction[J]. Am J Crit Care.1995,4(1): 29-35.
[60]Jadack R A, Keller M L, Mims F. Genital herpes:the disease experience over the first 6 months[J]. Appl Nurs Res.1991,4(2):85-87.
[61]Shaw C. A framework for the study of coping, illness behaviour and outcomes[J]. J Adv Nurs.1999,29(5):1246-1255.
[62]Petrie K J, Weinman J, Sharpe N, et al. Role of patients'view of their illness in predicting return to work and functioning after myocardial infarction: longitudinal study[J]. BMJ.1996,312(7040):1191-1194.
[63]Scharloo M, Kaptein A A, Weinman J, et al. Patients'illness perceptions and coping as predictors of functional status in psoriasis:a 1-year follow-up[J]. Br J Dermatol.2000,142(5):899-907.
[64]Herda C A, Siegeris K, Basler H D. The Pain Beliefs and Perceptions Inventory: further evidence for a 4-factor structure[J]. Pain.1994,57(1):85-90.
[65]Skevington S M. The experience and management of pain in rheumatological disorders[J]. Baillieres Clin Rheumatol.1993,7(2):319-335.
[66]Williams D A, Robinson M E, Geisser M E. Pain beliefs:assessment and utility[J]. Pain.1994,59(1):71-78.
[67]Hampson S E, Glasgow R E, Zeiss A M. Personal models of osteoarthritis and their relation to self-management activities and quality of life[J]. J Behav Med. 1994,17(2):143-158.
[68]Jensen M P, Turner J A, Romano J M. What is the maximum number of levels needed in pain intensity measurement?[J]. Pain.1994,58(3):387-392.
[69]Pollock S E. Adaptation to chronic illness:a program of research for testing nursing theory[J]. Nurs Sci Q.1993,6(2):86-92.
[70]Gilutz H, Bar-On D, Billing E, et al. The relationship between causal attribution and rehabilitation in patients after their first myocardial infarction. A cross cultural study[J]. Eur Heart J.1991,12(8):883-888.
[71]Shi X L, Dalal N S. The role of superoxide radical in chromium (VI)-generated hydroxyl radical:the Cr(VI) Haber-Weiss cycle[J]. Arch Biochem Biophys. 1992,292(1):323-327.
[72]Flor H, Behle D J, Birbaumer N. Assessment of pain-related cognitions in chronic pain patients[J]. Behav Res Ther.1993,31(1):63-73.
[73]Marshall G N. A multidimensional analysis of internal health locus of control beliefs:separating the wheat from the chaff?[J]. J Pers Soc Psychol.1991,61(3): 483-491.
[74]Pastor M A, Salas E, Lopez S, et al. Patients' beliefs about their lack of pain control in primary fibromyalgia syndrome[J]. Br J Rheumatol.1993,32(6): 484-489.
[75]Schussler G. Coping strategies and individual meanings of illness[J]. Soc Sci Med.1992,34(4):427-432.
[76]Cooper A, Lloyd G, Weinman J, et al. Why patients do not attend cardiac rehabilitation:role of intentions and illness beliefs[J]. Heart.1999,82(2): 234-236.
[77]Petrie K J, Cameron L D, Ellis C J, et al. Changing illness perceptions after myocardial infarction:an early intervention randomized controlled trial[J]. Psychosom Med.2002,64(4):580-586.
[78]Williams A C, Nicholas M K, Richardson P H, et al. Evaluation of a cognitive behavioural programme for rehabilitating patients with chronic pain[J]. Br J Gen Pract.1993,43(377):513-518.
[79]Scharloo M, Kaptein A A, Weinman J A, et al. Predicting functional status in patients with rheumatoid arthritis[J]. J Rheumatol.1999,26(8):1686-1693.
[80]Petrie K J, Cameron L D, Ellis C J, et al. Changing illness perceptions after myocardial infarction:an early intervention randomized controlled trial [J]. Psychosom Med.2002,64(4):580-586.
[81]Mcandrew L M, Mora P A, Quigley K S, et al. Using the Common Sense Model of Self-Regulation to Understand the Relationship Between Symptom Reporting and Trait Negative Affect[J]. International Journal of Behavioral Medicine.2014:1-6.
[82]Bandura A. Self-efficacy:toward a unifying theory of behavioral change[J]. Psychol Rev.1977,84(2):191-215.
[83]Bandura A. The assessment and predictive generality of self-percepts of efficacy[J]. J Behav Ther Exp Psychiatry.1982,13(3):195-199.
[84]Bandura A. Comments on the crusade against the causal efficacy of human thought[J]. J Behav Ther Exp Psychiatry.1995,26(3):179-190.
[85]Bandura A. The anatomy of stages of change[J]. Am J Health Promot.1997, 12(1):8-10.
[86]Maddux J F, Hoppe S K, Costello R M. Psychoactive substance use among medical students [J]. Am J Psychiatry.1986,143(2):187-191.
[87]Strecher V J, Devellis B M, Becker M H, et al. The role of self-efficacy in achieving health behavior change[J]. Health Educ Q.1986,13(1):73-92.
[88]Schwarzer A C, Wang S C, Bogduk N, et al. Prevalence and clinical features of lumbar zygapophysial joint pain:a study in an Australian population with chronic low back pain[J]. Ann Rheum Dis.1995,54(2):100-106.
[89]Sanz A, Villamarin F. The role of perceived control in physiological reactivity: self-efficacy and incentive value as regulators of cardiovascular adjustment[J]. Biol Psychol.2001,56(3):219-246.
[90]Bandura A. Health promotion by social cognitive means [J]. Health Educ Behav. 2004,31(2):143-164.
[91]Wright S L, Perrone Mcgovern K M, Boo J N, et al. Influential Factors in Academic and Career Self-Efficacy:Attachment, Supports, and Career Barriers[J]. Journal of Counseling & Development.2014,92(1):36-46.
[92]Chin Y F, Huang T T, Hsu B R S. Impact of action cues, self-efficacy and perceived barriers on daily foot exam practice in type 2 diabetes mellitus patients with peripheral neuropathy [J]. Journal of clinical nursing.2013,22(1-2):61-68.
[93]Mansyur C L, Pavlik V N, Hyman D J, et al. Self-efficacy and barriers to multiple behavior change in low-income African Americans with hypertension[J]. Journal of behavioral medicine.2013,36(1):75-85.
[94]Cardenas V, Abel S, Bowie C R, et al. When Functional Capacity and Real-World Functioning Converge:The Role of Self-Efficacy[J]. Schizophrenia bulletin.2013,39(4):908-916.
[95]Glasgow R E, Peeples M, Skovlund S E. Where is the patient in diabetes performance measures? The case for including patient-centered and self-management measures[J]. Diabetes Care.2008,31(5):1046-1050.
[96]Foster G D, Wadden T A, Lagrotte C A, et al. A randomized comparison of a commercially available portion-controlled weight-loss intervention with a diabetes self-management education program[J]. Nutr Diabetes.2013,3:e63.
[97]Glasgow R E, Fisher L, Skaff M, et al. Problem solving and diabetes self-management:investigation in a large, multiracial sample[J]. Diabetes Care. 2007,30(1):33-37.
[98]Jones H, Edwards L, Vallis T M, et al. Changes in diabetes self-care behaviors make a difference in glycemic control:the Diabetes Stages of Change (DiSC) study[J]. Diabetes Care.2003,26(3):732-737.
[99]Funnell M M, Brown T L, Childs B P, et al. National standards for diabetes self-management education[J]. Diabetes Care.2008,31 Suppl 1:S97-S104.
[100]Mcauley E, Mullen S P, Szabo A N, et al. Self-regulatory processes and exercise adherence in older adults:Executive function and self-efficacy effects[J]. American journal of preventive medicine.2011,41(3):284-290.
[101]Mosher C E, Lipkus I, Sloane R, et al. Long-term outcomes of the FRESH START trial:exploring the role of self-efficacy in cancer survivors' maintenance of dietary practices and physical activity [J]. Psycho-Oncology. 2012.
[102]Phua J. Participating in Health Issue-Specific Social Networking Sites to Quit Smoking:How Does Online Social Interconnectedness Influence Smoking Cessation Self-Efficacy?[J]. Journal of Communication.2013,63(5):933-952.
[103]Breaux-Shropshire T L, Brown K C, Pryor E R, et al. Prevalence of blood pressure self-monitoring, medication adherence, self-efficacy, stage of change, and blood pressure control among municipal workers with hypertension. [J]. Workplace health & safety.2012,60(6):265.
[104]Grossman H Y, Brink S, Hauser S T. Self-efficacy in adolescent girls and boys with insulin-dependent diabetes mellitus[J]. Diabetes Care.1987,10(3): 324-329.
[105]Lorig K R, Ritter P, Stewart A L, et al. Chronic disease self-management program:2-year health status and health care utilization outcomes[J]. Med Care. 2001,39(11):1217-1223.
[106]Anderson R M, Funnell M M. Patient empowerment:reflections on the challenge of fostering the adoption of a new paradigm [J]. Patient Educ Couns. 2005,57(2):153-157.
[107]Noll A N, Glenn L L. Self-efficacy and management in type 2 diabetes mellitus[J]. J Diabetes Complications.2012,26(6):562,562-563.
[108]King D K, Glasgow R E, Toobert D J, et al. Self-efficacy, problem solving, and social-environmental support are associated with diabetes self-management behaviors[J]. Diabetes Care.2010,33(4):751-753.
[109]牟利宁,边苗苗,牟利凤.动机访谈路线图提高糖尿病患者自我效能的效果研究[J].中华护理杂志.2012(10)：892-895.
[110]赵晓霜,李春玉,李彩福.社区糖尿病患者健康素养和自我效能对健康状况影响的路径分析[J].中华护理杂志.2013(1)：63-65.
[111]Dusseldorp E, van Elderen T, Maes S, et al. A meta-analysis of psychoeduational programs for coronary heart disease patients [J]. Health Psychol.1999,18(5):506-519.
[112]Linden W, Stossel C, Maurice J. Psychosocial interventions for patients with coronary artery disease:a meta-analysis[J]. Arch Intern Med.1996,156(7): 745-752.
[113]Wiles R. Patients' perceptions of their heart attack and recovery:the influence of epidemiological "evidence" and personal experience[J]. Soc Sci Med.1998, 46(11):1477-1486.
[114]Lau-Walker M. Relationship between illness representation and self-efficacy [J]. J Adv Nurs.2004,48(3):216-225.
[115]Keogh K M, Smith S M, White P, et al. Psychological family intervention for poorly controlled type 2 diabetes[J]. Am J Manag Care.2011,17(2):105-113.
[116]Mc Sharry J, Moss Morris R, Kendrick T. Illness perceptions and glycaemic control in diabetes:a systematic review with meta-analysis[J]. Diabetic Medicine.2011,28(11):1300-1310.
[117]Dracup K, Moser D K, Eisenberg M, et al. Causes of delay in seeking treatment for heart attack symptoms[J]. Soc Sci Med.1995,40(3):379-392.
[118]Wood R, Bandura A. Impact of conceptions of ability on self-regulatory mechanisms and complex decision making[J]. J Pers Soc Psychol.1989,56(3): 407-415.
[119]Lorig K R, Sobel D S, Ritter P L, et al. Effect of a self-management program on patients with chronic disease[J]. Eff Clin Pract.2001,4(6):256-262.
[120]孙慧伶,张瑜.糖尿病患者自我效能测量工具的研究进展[J].护理学杂志.2012(21)：92-95.
[121]沈晓红,姜乾金.医学应对策略问卷中文版701例测试报告[J].中国行为医 学科学.2000(01)：22-24.
[122]汪向东,王希林,马弘.行为医学量表手册[M].北京：中国心理卫生杂志社,1999.
[123]李延飞,陈伟菊,许万萍,等.2型糖尿病患者自我管理行为量表的改良及其信效度检验[J].现代医院.2011(3)：148-150.
[124]Toobert D J, Hampson S E, Glasgow R E. The summary of diabetes self-care activities measure:results from 7 studies and a revised scale[J]. Diabetes Care. 2000,23(7):943-950.
[125]万巧琴,尚少梅,来小彬,等.2型糖尿病患者自我管理行为量表的信、效度研究[J].中国实用护理杂志.2008,24(7)：26-27.
[126]李明晖,罗南.欧洲五维健康量表(EQ-5D)中文版应用介绍[J].中国药物经济学.2009(01)：49-57.
[127]Janssen M F, Pickard A S, Golicki D, et al. Measurement properties of the EQ-5D-5L compared to the EQ-5D-3L across eight patient groups:a multi-country study[J]. Qual Life Res.2012.
[128]罗娅珺,方芸,丁选胜.采用EQ-5D评估2型糖尿病患者的生活质量及影响因素研究[J].中国药物经济学.2009(02)：12-18.
[129]邢亚彬,马爱霞.欧洲五维健康量表EQ-5D-3L和EQ-5D-5L中文版比较的实证研究[J].上海医药.2013(07)：27-31.
[130]温忠麟,张雷,侯杰泰,等.中介效应检验程序及其应用[J].心理学报.2004,36(5)：614-620.
[131]Nefs G, Pouwer F, Denollet J, et al. The course of depressive symptoms in primary care patients with type 2 diabetes:results from the Diabetes, Depression, Type D Personality Zuidoost-Brabant (DiaDDZoB) Study [J]. Diabetologia.2012,55(3):608-616.
[132]Kimbro L B, Steers W N, Mangione C M, et al. The Association of Depression and the Cardiovascular Risk Factors of Blood Pressure, HbAlc, and Body Mass Index among Patients with Diabetes:Results from the Translating Research into Action for Diabetes Study[J]. Int J Endocrinol.2012,2012:747460.
[133]杨春琴.上海市闸北社区慢性阻塞性肺疾病病人疾病认知和护理服务需求调查[J].护理研究：中旬版.2009,23(2)：395-396.
[134]中国2型糖尿病防治指南(2010年版)[J].中国糖尿病杂志.2012(01)：81-117.
[135]马爱霞.糖尿病患者的自我效能水平及其影响因素分析[D].山东大学,2008.
[136]Wick J Y. Why do I need to know this? Reaching the adult learner[J]. Consult Pharm.2012,27(7):518-522.
[137]Trento M, Trevisan M, Raballo M, et al. Depression, anxiety, cognitive impairment and their association with clinical and demographic variables in people with type 2 diabetes:a 4-year prospective study[J]. J Endocrinol Invest. 2014,37(1):79-85.
[138]Fisher L, Chesla C A, Mullan J T, et al. Contributors to depression in Latino and European-American patients with type 2 diabetes [J]. Diabetes Care.2001, 24(10):1751-1757.
[139]刘安诺,李惠萍,周利华,等.2型糖尿病患者生活质量及其影响因素分析[J].护理学报.2010(03)：74-76.
[140]陈向韵,王永利,岳鹏,等.社区2型糖尿病患者心理痛苦及相关因素分析[J].护理学杂志：综合版.2012,27(11)：74-76.
[141]Al-Khawaldeh O A, AI-Hassan M A, Froelicher E S. Self-efficacy, self-management, and glycemic control in adults with type 2 diabetes mellitus[J]. J Diabetes Complications.2012,26(1):10-16.
[142]Strychar I, Elisha B, Schmitz N. Type 2 Diabetes Self-Management:Role of Diet Self-Efficacy[J]. Canadian Journal of Diabetes.2012,36(6):337-344.
[143]Johnson M D, Anderson J R, Walker A, et al. Common dyadic coping is indirectly related to dietary and exercise adherence via patient and partner diabetes efficacy[J]. J Fam Psychol.2013,27(5):722-730.
[144]Kroese F M, Adriaanse M A, Vinkers C D, et al. The effectiveness of a proactive coping intervention targeting self-management in diabetes patients [J]. Psychol Health.2013,29(1):110-125.
[145]Feifel H, Strack S, Nagy V T. Coping strategies and associated features of medically ill patients.[J]. Psychosomatic Medicine.1987,49(6):616-625.
[146]彭鑫,崔焱,董玲,等.糖尿病儿童青少年应对策略与血糖控制及生活质量的相关性研究[J].护理研究.2010,24(16)：1421-1423.
[147]Thompson D R, Bowman G S, Kitson A L, et al. Cardiac rehabilitation services in England and Wales:a national survey[J]. Int J Cardiol.1997,59(3):299-304.
[148]Glasgow R E, Tracy Orleans C, Wagner E H, et al. Does the chronic care model serve also as a template for improving prevention?[J]. Milbank Quarterly.2001, 79(4):579-612.
[149]Dickman K, Milligan R, Kodadek M. Chronic care model:a framework for experiential learning during clinical rotation[J]. J Nurs Educ.2013,52(11): 663-664.
[150]Loring K. Chronic disease self-management:a model for tertiary prevention[J]. Kango Kenkyu.1998,31(1):23-29.
[151]Lorig K, Ritter P L, Pifer C, et al. Effectiveness of the chronic disease self-management program for persons with a serious mental illness:a translation study[J]. Community Ment Health J.2014,50(1):96-103.
[152]朱静芬,戴李华,恬沈.以自我效能理论为基础的糖尿病高危人群干预效果分析[J].上海交通大学学报(医学版).2014,34(1)：83.
[153]谭晓青.应用奥马哈系统构建居家访视流程和记录模式以及访视成效评价的研究[D].南方医科大学,2011.
[154]卫生部疾病控制司.全国疾病预防控制机构工作规范[Z].2001.