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中文摘要: 目的：观察医院—社区—家庭慢性病管理（HCFM-CD）对老年代谢综合征（MS）患者运动和社会功能的影
响。方法：选择2018年6月—2019年6月上海中医药大学附属曙光医院收治的82例MS患者，采用简单随机分组法将其分为
对照组 41例和观察组 41例。对照组患者采用常规护理方法，观察组患者在对照组的基础上采用 HCFM-CD管理模式，均持
续干预 6个月。分别于干预前后，调查患者体重指数（BMI）、收缩压（SBP）、舒张压（DBP）、空腹血糖、甘油三酯（TG）等水 平，抑郁自评量表（SDS）和焦虑自评量表（SAS）评估两组抑郁和焦虑情绪，匹兹堡睡眠质量指数（PSQI）评价睡眠质量，自我
管理知信行量表评估自我管理能力，运动依从性量表评估运动依从性，运动自我效能感量表（ESEs）评估自我效能，个体和社
会功能量表（PSP）量表评估社会功能。结果：观察组和对照组患者干预后的SBP和TG水平明显低于干预前，差异有统计学意
义（P＜0.001），自我管理能力、运动依从性、ESEs和PSP评分明显高于干预前（P＜0.05），SDS、SAS和PSQI评分明显低于干
预前（P＜0.01）；干预后，观察组患者的SDP和TG水平明显低于对照组，差异有统计学意义（P＝0.01），自我管理能力、运动
依从性、ESEs和PSP评分明显高于对照组（P＜0.05），SDS、SAS和PSQI评分明显低于对照组（P＝0.040）。结论：HCFM-CD
管理模式可以提高老年MS患者的运动依从性和自我效能，提升社会功能。
Abstract:OBJECTIVE To observe the effects of hospital-community-family management model for chronic disease
（HCFM-CD）on exercise and social function of elderly patients with metabolic syndrome （MS）. METHODS 82 MS patients who
were admitted to the hospital from June 2018 to June 2019 were selected. They were divided into control group （41 cases） and ob⁃
servation group （41 cases） by simple random group method. The control group was treated with routine nursing, while observation
group was treated with HCFM-CD on basis of control group. All were continuously intervened for 6 months. Before and after inter⁃
vention, levels of body mass index （BMI）, systolic blood pressure （SBP）, diastolic blood pressure （DBP）, fasting blood glucose, tri⁃
glyceride （TG） and high-density lipoprotein-cholesterol （HDL-C） were investigated. The the depression and anxiety in both
groups were evaluated by Self-Rating Depression Scale （SDS） and Self-Rating Anxiety Scale （SAS）. The sleep quality was as⁃
sessed by Pittsburgh Sleep Quality Index （PSQI）. The self-management ability was evaluated by self-management KAP scale. The
exercise compliance was evaluated by exercise compliance scale. The self-efficacy was evaluated by Exercise Self-Efficacy Scale
（ESES）. The social function was evaluated by personal and social performance scale （PSP） . RESULTS After intervention, levels of
SDP and TG in both groups were significantly decreased（P＜0.05） , self-management ability, exercise compliance, ESES and PSP
scores were significantly increased（P＜0.05） , SDS, SAS and PSQI scores were significantly decreased（P＜0.05）. After interven⁃
tion, levels of SDP and TG in observation group were significantly lower than those in control group（P＜0.05）; self-management
ability, exercise compliance, ESES and PSP scores were significantly higher than those in control group（P＜0.05）; SDS, SAS and
PSQI scores were significantly lower than those in control group（P＜0.05） . CONCLUSION HCFM-CD could improve exercise
compliance and self-efficacy of elderly MS patients, and enhance social function.
文章编号：3202106008 中图分类号：R589 文献标志码：
基金项目:
| 作者 | 单位 |
| 杨燕冰① 孙 青① 张晓天① |
| Author Name | Affiliation |
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