【作者】 张颖；

【导师】 牛巧红；

【作者基本信息】 山西医科大学 ， 护理（专业学位）， 2024， 硕士

【摘要】 目的:本研究以行为改变轮(Behavior Change Wheel,BCW)理论为指导框架,从“能力、动机、机会”三方面选择相应的变量进行直肠癌保肛术后肠道症状自我管理行为现状调查和影响因素分析,以此为基础构建干预方案并进行评价,为改善保肛术后患者的肠道症状自我管理行为、肠道功能和生活质量提供理论和实践基础。方法:第一部分:横断面研究。2023年2月～6月,采用便利抽样法,通过门诊随访和电话随访的方式选取山西省某三级甲等医院的238例直肠癌保肛术后患者作为调查对象。使用一般资料调查表、直肠癌保肛术后肠道症状自我管理行为问卷(BSSBQ)、慢性病病人健康素养调查量表(He LMS)、中文版患者积极度量表(PAM)、领悟社会支持量表(PSSS)进行调查,以了解其肠道症状自我管理行为现状并分析相关影响因素。第二部分:方案构建。以BCW理论为基础,总结前期横断面研究结果,结合文献回顾制定直肠癌保肛术后患者自我管理干预方案初稿。通过专家会议和预试验对方案初稿修订完善,形成基于BCW理论的自我管理干预方案终稿。第三部分:类实验研究。采用便利抽样法,选取2023年8月～11月山西省某三级甲等医院结直肠外科96例行直肠癌保肛手术的患者为研究对象。对照组实施常规护理,试验组除常规护理外,增加了前期构建的BCW自我管理干预方案,比较两组干预前(术后第2日)、干预结束后即刻(出院后3个月)、干预结束后1个月(出院后4个月)BSSBQ、中文版MSKCC肠道功能问卷、结直肠癌患者生活质量测定量表(FACT-C)的得分差异。结果:1.横断面研究结果:(1)BSSBQ得分为(25.93±4.57)分,处于较低水平。(2)单因素分析结果显示:年龄、职业、文化程度、居住地、医疗保险类型、术后时间及家庭人均月收入对患者的肠道症状自我管理行为有显著影响(P<0.05)。(3)相关分析显示,BSSBQ与He LMS、PAM、PSSS得分呈正相关(r=0.722、0.685、0.672,P<0.05)。(4)多元回归分析结果显示:文化程度、术后时间、健康素养、积极度、领悟社会支持水平是其肠道症状自我管理行为的独立影响因素。2.方案构建结果:经专家会议和预试验修改后形成基于BCW理论的自我管理干预方案,包括动机干预、能力干预和机会干预3方面。干预时长为术后第2日～出院后3个月,干预时间点为住院期间、出院后每周至少一次远程干预,其余时间动态干预。3.类实验研究结果:(1)干预前两组患者的一般资料、BSSBQ、MSKCC肠道功能问卷以及FACT-C得分差异无统计学意义(P>0.05),具有可比性。(2)干预结束后即刻(出院后3个月)、干预结束后1个月(出院后4个月)试验组BSSBQ评分均高于对照组,差异具有统计学意义(P<0.001);两组BSSBQ评分存在显著时间效应、组间效应和交互效应(P<0.05)。(3)干预结束后即刻(出院后3个月)、干预结束后1个月(出院后4个月)试验组MSKCC肠道功能问卷得分均高于对照组,差异具有统计学意义(P<0.001);两组肠道功能评分存在显著时间效应、组间效应和交互效应(P<0.05)。(4)干预结束后即刻(出院后3个月)、干预结束后1个月(出院后4个月)试验组FACT-C得分均高于对照组,差异具有统计学意义(P<0.001);两组FACT-C评分存在显著时间效应、组间效应和交互效应(P<0.05)。结论:直肠癌保肛术后患者肠道症状自我管理行为受多种因素的影响,医务工作者可在考虑其影响因素的基础上制定针对性的干预措施。本研究以BCW理论为指导构建的自我管理干预方案能有效改善患者的肠道症状自我管理行为,进一步促进患者肠道功能恢复和提高生活质量,具有良好的临床适用性。更多还原

【Abstract】 Objective:In this study,using the behavioral change wheel theory as a guiding framework,we selected the corresponding variables from the three aspects of "ability,motivation,and opportunity" to investigate the current status of self-management behavior of intestinal symptoms after proctocolectomy for rectal cancer and analyze the factors affecting it,and then constructed an intervention program based on it and evaluated it,in order to provide a practical basis for the improvement of self-management,intestinal function and the quality of life.Methods:1.Cross-sectional study.238 post-proctocolectomy patients with rectal cancer in a tertiary-level hospital in Shanxi Province were selected as survey subjects from February to June 2023 by convenience sampling method through outpatient follow-up and telephone follow-up.A general information questionnaire,the Bowel Symptom Self-Management Behavior Questionnaire after proctocolectomy for rectal cancer(BSSBQ),the Health Literacy Management Scale(He LMS),the Chinese version of the Patient Activation Measure(PAM),and the Perceived Social Support Scale(PSSS)were used for the survey in order to understand the current status of their bowel symptom self-management behaviors and analyze the relevant influencing factors.2.Program construction.Based on the BCW theory,summarize the results of the previous cross-sectional study,and combine with the literature revision to formulate the first draft of the self-management intervention program for patients after proctocolectomy for rectal cancer.The first draft of the program was revised and improved through expert meetings and pretests to form the final draft of the self-management intervention program based on BCW theory.3.Class experimental study.Convenience sampling method was used to select patients who underwent 96 cases of rectal cancer anal preservation surgery in the colorectal surgery department of a tertiary-level A hospital in Shanxi Province from August to November2023 as the study subjects.The control group implemented routine care,and the experimental group added the preconstructed BCW self-management intervention program in addition to routine care,comparing the differences in the scores of the BSSBQ,the Chinese version of the MSKCC Bowel Function Questionnaire,and the Functional Assessment of Cancer Therapy-Colorectal(FACT-C)in the two groups before the intervention,the immediate after the end of the intervention,and 1 month after the end of the intervention.Results:1.Results of cross-sectional survey:(1)The BSSBQ score was(25.93 ± 4.57),which was at a low level.(2)The results of univariate analysis showed that age,occupation,education level,place of residence,type of health insurance,postoperative period,and per capita monthly family income had a significant effect on patients’ self-management behaviors of intestinal symptoms(P<0.05).(3)Pearson correlation analysis showed that the BSSBQ was positively correlated with He LMS,PAM,and PSSS scores(r = 0.722,0.685,0.672,P<0.05).(4)The results of multiple regression analysis showed that literacy,postoperative time,health literacy,positivity,and level of comprehension social support were all independent influences on their bowel symptom self-management behavior.2.Results of program construction: A self-management intervention program based on BCW theory was formed after expert meetings and pre-test modifications,including 3aspects of motivation intervention,ability intervention and opportunity intervention.The intervention duration was from postoperative day 2 to 3 months after discharge,and the intervention time points were remote intervention at least once a week during hospitalization,after discharge,and dynamic intervention for the rest of the time.3.Results of the intervention study:(1)The differences in general information,BSSBQ,MSKCC intestinal function questionnaire,and FACT-C scores between the two groups before intervention were not statistically significant(P>0.05)and were comparable.(2)The BSSBQ scores of the experimental group were higher than those of the control group immediately after the end of the intervention(3 months after discharge)and 1 month after the end of the intervention(4 months after discharge),and the differences were statistically significant(P<0.001);there were significant time effects,between-group effects,and interaction effects in the BSSBQ scores of the two groups(P<0.05).(3)The MSKCC Bowel Function Questionnaire scores of the experimental group were higher than those of the control group immediately after the end of the intervention(3 months after discharge from the hospital)and 1 month after the end of the intervention(4 months after discharge from the hospital),and the differences were statistically significant(P<0.001);there was a significant time effect,a between-group effect,and an interaction effect in the Bowel Function Scores of the two groups(P<0.05).(4)The FACT-C scores of the experimental group were higher than those of the control group immediately after the end of the intervention(3 months after discharge from the hospital)and 1 month after the end of the intervention(4 months after discharge from the hospital),and the difference was statistically significant(P<0.001);there was a significant time effect,a between-group effect,and an interaction effect for the FACT-C scores of the two groups(P<0.05).Conclusion:The low self-management behavior of bowel symptoms in patients after proctocolectomy for rectal cancer was influenced by a variety of factors.It is suggested that medical workers can develop targeted interventions based on consideration of their influencing factors.In this study,the self-management intervention program constructed under the guidance of BCW theory can effectively improve the self-management behavior of patients after proctocolectomy for rectal cancer,thus promoting the recovery of intestinal function and the improvement of quality of life.更多还原