目的：探討多重代謝症候群相關疾病之長者在「慢性病自我管理」計畫方案介入後於慢性病自我管理、慢性病管理自我效能、健康狀態(身體功能、自覺健康、衰弱、生理組成、疾病控制狀況)與生活品質的成效及長期影響。
方法：本研究於南部某醫學中心以所羅門四組研究設計(Solomon four groups design)，並以隨機區組設計（Block randomization）方式進行收案，共收得實驗組及對照組共130人，實驗組接受慢性病自我管理計畫方案以及每月電訪以追蹤個案，控制組給予傳統衛教。實驗組I和控制組I在基準點收案，並在接受介入措施後三、六、十二、十八個月追蹤，而實驗組II與控制組II則在介入措施後三個月追蹤。介入方案成效透過生理測量其生理組成及慢性病控制狀況與以日常生活活動量表(ADLs)、工具性日常生活活動量表(IADLs)、衰弱量表(Kihon checklist)、慢性病自我管理、慢性病自我效能、生活品質及自覺健康量表進行問卷調查。
結果：從實驗組I和對照組I的前後測結果發現，實驗組I受試者在慢性病自我管理(總分、執行自我照顧活動以及情緒處理範疇)之主要結果，健康狀況(Kihon 總分和體力評分下降，尿酸測試值顯著下降）之次要結果與生活品質(心理範疇)之最終結果有顯著改善。接受介入計畫後，實驗組II在後測中Kihon營養、口腔和憂鬱、下肢肌肉力量的結果優於對照組II。在慢性病自我管理-問題解決和Kihon-口腔方面，實驗組II表現顯著優於對照組I。在沒有前測效應的情況下檢視成效，發現實驗組在Kihon營養、口腔和憂鬱、慢性病自我管理總分和慢性病自我管理-夥伴關係方面的結果明顯優於對照組。至於對長期的影響，與對照組I相比，實驗組I在追蹤的第3個月於慢性病自我管理-問題解決和慢性病自我管理-自我照顧方面有顯著進步和達差異顯著。與對照組I相比，慢性病管理自我效能方面在追蹤第18個月有顯著進步。實驗組I與對照組I相比，在追蹤第12、18個月的體脂肪亦有明顯改善。
結論/實務影響：部分慢性病自我管理方案成效優於傳統健康教育。儘管事實上有些效果未達到顯著差異，此方案仍可作為未來臨床實踐制定相關健康教育計劃的參考。

Purpose. The purpose of this study was to explore the effectiveness and long-term effect of the chronic disease self-management intervention program among older adults with metabolic syndrome related chronic disease on chronic disease self-management and self-efficacy, health status (physical functions, perceived health, frailty, physiological composition, and condition of disease control) and quality of life.
Methods. The Solomon four-group design was used in this study, and block randomization was applied to recruit participants in a medical center in southern Taiwan. A total of 130 participants were recruited andassigned to the experimental groups and control groups. The experimental groups were provided with the chronic disease self-management program and monthly telephone interviews for follow-ups while the control groups were provided with traditional health education. The experimental group I and the control group I were received at baseline, and were followed up at 3 months, 6 months, 12 months and 18 months after the begingof the study; while the experimental group II and the control group II were followed up only at 3 months after the begingof the study. The effectiveness of the program was measured through research instruments of physiological measurements, body composition, condition of chronic disease control and questionnaires included ADL, IADL, Kihon checklist, Chronic disease self-management, chronic disease self-efficacy, quality of life, and perceived health status.
Results. From the results of the pre-test and post-test of the experimental group I and the control group I, it was found that significant improvement was observed in subjects’ primary outcomes: chronic disease self-management (total score, self-care domain, and emotional processing domains), secondary outcomes: health status (decreasing in total Kihon score and physical strength scores and the significant decreased in uric acid test values), and final outcome: quality of life (psychological domain).in the experimental group I. The experimental group II had better results in Kihon nutrition, oral, and depression, and lower extremities muscle strength than the control group II at the post-test. In terms of the chronic disease self-management- problem solving, and the Kihon-oral, the experimental group II performed significantly better than the control group I at the posttest. In reviewing the effects without pretesting, it was found that the experimental groups had significantly better results in Kihon nutrition, oral, and depression, total score of chronic disease self-management, and chronic disease self-management-partnership than the control groups at the posttest. As for the long-term impact, the experimental group I had significant progress in chronic disease self-management- problem solving and chronic disease self-management-self-care at the 3 months after the beginning of the study compared with the control group I, and significant difference was reached. As for the self-efficacy of chronic disease management, drastic progress was observed in the experimental group I at the 18 months compared with the control group I. The experimental group I had significant progress in the body fat in the 12th and 18th months compared with the control group I.
Conclusions/ Implications for Practice. Part of the chronic disease self-management program had better effects than traditional health education. Despite the fact that some effects did not reach significant difference, this program can still serve as a reference for future development of relevant health education plans in clinical practice.

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