关键词: 行为分阶段转变理论, 延续护理, 慢性肾脏病, 自我管理, 自我效能

Abstract: Objective: To explore the effectiveness of the Theory of Phased Behavior Transformation in continuing care for patients with chronic kidney disease (CKD). Methods: A total of 160 outpatients with CKD were selected as study subjects and randomly divided into control group (n=80) and observation group (n=80). The control group received outpatient support combined with education through online official account, while the observation group received interventions based on the Theory of Phased Behavior Transformation. Both interventions lasted for 6 months. Changes in self-management ability, self-efficacy, and laboratory indicators were analyzed for both groups before the intervention, after 6 months of intervention, and at the 6-month follow-up. Results: After 6 months of intervention and at the 6-month follow-up, significant differences were observed between the two groups in self-management ability, self-efficacy, systolic blood pressure, serum creatinine, serum potassium, serum phosphorus, hemoglobin, and albumin (P<0.05). At the 6-month follow-up, significant differences were also found between the two groups in diastolic blood pressure and serum uric acid levels (P<0.05). Conclusion: The implementation of continuing care based on the Theory of Phased Behavior Transformation can effectively improve self-management ability and self-efficacy in CKD patients, thereby delaying the progression of the disease.

Key words: Theory of Phased Behavior Transformation, Continuing care, Chronic kidney disease, Self-management, Self efficacy