摘要
背景：久坐不动的生活型态已经成为了影响全球健康的一个重要问题，而健康促进是改变这一慢性病危险因素最具成本效益的干预方式。国外从上世纪七八十年代开始就有关于Healthy Doctor=Healthy Patient的研究，大量研究证明了Healthier Doctor Habits=Better Patient Counseling Attitudes/Practices Of SuchHabits，这一趋势在医生（尤其是全科医生）体力活动研究中得到验证。但是护士作为开展健康促进的重要群体，有关护士体力活动水平、她们如何看待体力活动健康促进、是否开展相关实践的研究十分有限，国内尚为空白，本课题正是基于上述背景开展的。
研究目的：本课题旨在通过现况调查，了解中英两国护士体力活动的态度、行为、达标水平，以及她们开展体力活动健康促进的知识、态度与实践现状，探讨护士自身体力活动与进行体力活动健康促进的关系，以及影响两国护士开展体力活动健康促进的因素。希望研究结果为下一步开展护士体力活动健康促进提供参考，并通过护士自身体力活动知识、态度、行为的改变进一步提升针对病人的体力活动健康促进。
研究方法：主要采用了文献研究、现况调查的方法。在文献回顾和现有量表的基础上研制调查问卷。英国部分调查以King’s College London护理学院所有继续教育课程的注册学生为对象，在通过伦理审查，得到模块负责人允许后，课前向学生发放调查问卷，当堂或课后回收问卷。中国部分采用方便抽样的办法，整群抽取3所医院，对所有护士进行调查。全部资料使用SPSS19.0(SPSS Inc., Chicago,IL, USA)建库管理，并进行统计分析。单因素分析中，分类变量的比较使用卡方检验，两个样本分布的比较使用曼-惠特尼检验。连续性变量比较使用t检验。影响因素的分析使用logistic（enter，forward LR或backward wald）回归。遗失数据未进行均值或其它替代。显著性检验水平设定在p<0.05。开放性问题答案借鉴质性研究分类、编码的方法进行分析。
研究结果：英国部分发放问卷744份，回收631份，应答率为83.9%。中国部分共发放问卷1100份，回收888份，应答率74%。
1．护士一般健康状况及健康行为
绝大多数英国护士(94.2%)认为自己健康状况良好，86.3%的人表示她们不存在任何影响活动的慢性病，这一数字在中国护士中相对偏低，分别为73.8%和70.2%，表明中国护士与英国护士相比，感知的自我健康情况较差（p=0.000）。英国护士的吸烟比例明显高于中国护士（11.0%vs0.6%，p=0.000）。50.7%的英国护士都被划分为有害饮酒者，而中国护士饮酒频率大于4次/月的仅占1.5%。英国护士普遍比中国护士体型偏胖（Z=-10.2，p=0.000）。
2.护理工作情况
虽然英国护士为两班制（每班12小时），但是70%的英国护士每周工作时间在20-40小时之间，而近60%的中国护士每周工作时间超过40小时，因此从总体来看，中国护士的工作时间长于英国护士（OR=4.8，p=0.000）。英国护士在工作中站立或行走时间大于8小时的比例显著高于中国护士（51.9%vs21.3%，OR=3.2，p=0.000）。两国护士中需要上夜班的人数比例比较接近，但是每周夜班班次大于2次的比例中国护士略高(OR=1.3，p=0.020)。两国护士在每天攀爬楼梯以及抬搬重物的频率上没有显著差别。从现有数据来看，还不足以判断两国护士工作方面的体力消耗有何差别。
3.护士体力活动的态度与行为
英国护士处于规律活动阶段的比例明显高于中国护士（55.0%vs22.5%，OR=2.3，p=0.000），超过半数的中国护士处于意向阶段和前意向阶段。
在体力活动行为方面，英国护士进行体力锻炼的习惯明显优于中国护士，33.9的中国护士从不进行任何小强度体力锻炼，不进行中、高强度锻炼的比例都超过60%。英国护士不进行任何中高强度锻炼的比例为34%，而中国护士相应比例达到54.5%。步行作为最简单易行的锻炼方式在中国护士当中的流行率也低于英国，尤其是长时间行走的比例更低（χ2=120.6，p=0.000）。本研究还发现中国护士不仅是园艺活动比例低于英国护士，从事一般家务劳动的比例也显著低于英国护士（低强度家务χ2=323.2，p=0.000；高强度家务χ2=156.7，p=0.000）。
以WHO体力活动推荐量为标准，英国护士体力活动的达标比例明显高于中国护士（65.8%vs45.6%,OR=2.5，p=0.000），达到高度活跃的英国护士也显著多余中国（英国41.2%vs中国24.4%，χ2=63.9，p=0.000）。由于中国护士体力活动测量更为精细，在剔除了不满10min的部分后，中国护士体力活动达标率由45.6%下降到20.9%。
英国护士运动的益处与障碍量表（EBBS）的平均得分为28.1±6.3，中国护士得分为32.3±6.0，中国护士感知到的运动障碍高于英国护士（p=0.000）。感知运动障碍与个人体力活动相关，体力活动达标的护士的感知运动障碍得分较低(英国p=0.000，中国p=0.001)，同样处于规律运动阶段的护士感知运动障碍较低(英国p=0.000，中国p=0.010)。
个人体力活动变化阶段与个人体力活动达标水平显著相关（r=0.369，p=0.000），并有一定的预测能力。英国护士中体力活动变化阶段与达标情况的一致比例为73.4%，中国护士中为75%。
影响英国护士体力活动达标的因素包括种族（白人达标率更高，OR=2.1，p=0.005），EBBS（感知障碍高的个体达标可能性较低，OR=0.9，p=0.000），体型（体型偏胖或偏瘦的护士达标率低，OR=0.6，p=0.076），护理工作时间（每周工作时间大于40小时的达标率低，OR=0.5，p=0.021）以及夜班频率（每周夜班大于2次的护士达标率更高，OR=2.4，p=0.007）。
影响中国护士体力活动达标水平的影响因素包括性别（女性达标率低，OR=0.1，p=0.015），工作年限（工作时间长的护士达标率低，OR=0.969，p=0.004），知识水平（体力活动知识得分高的达标率高，OR=2.0，p=0.076），EBBS（感知障碍高的护士达标率低，OR=0.968，p=0.050），健康状况（自感健康的护士达标率高，OR=1.5，p=0.008）。
4.护士体力活动健康促进实践的知识、态度、行为
英国护士对自身在体力活动健康促进中的角色认同、知识掌握以及自信心均高于中国护士，进一步分析两国护士体力活动健康促进变化阶段发现，英国护士规律进行体力活动健康促进的护士不到一半（47.4%），中国护士相应比例为30.3%，显著低于英国护士（OR=0.5，p=0.000）。
两国护士对于体力活动障碍因素的认知有较大差异，除“病人希望通过药物来治疗他们的健康问题”题目外，中国护士对每项障碍因素的认同比例均高于英国护士（p=0.000）；英国护士认为影响健康促进的因素前三项依次为：病人更希望得到药物治疗（71.2%），针对医护人员进行的体力活动相关的教育培训不足（67.8%），提供给病人的体力活动健康教育材料不足(63.4%)，；中国护士认为影响开展健康促进的因素前三项为：缺乏健康教育材料（91.1%），缺乏培训（90.6%），希望得到奖金激励（75.9%）。
5.护士自身体力活动与体力活动健康促进的相关性
英国护士体力活动变化阶段与体力活动健康促进变化阶段显著相关（p=0.002），处于在规律将活动的护士与处于不规律运动阶段的护士相比，进行体力活动健康促进的优势比为1.8；体力活动达标水平与体力活动健康促进也存在显著相关性（p=0.000），体力活动达标的护士与不达标的相比，开展体力活动健康促进的优势比为2.1。
中国护士中，体力活动变化阶段与体力活动健康促进变化阶段显著相关（p=0.016），规律活动的护士进行体力活动健康促进的优势比为1.5；体力活动达标水平与体力活动健康促进也存在显著相关性（p=0.011），体力活动达标的护士与不达标的相比，进行健康促进的优势比为1.5。
6.体力活动健康促进的影响因素
英国护士体力活动健康促进的正向影响因素包括：角色认同（OR=7.6，p=0.030）、体力活动变化阶段（OR=4.7，p=0.018）、年龄（OR=3.8，p=0.098）3个变量；“病人希望通过药物来治疗他们的健康问题”（OR=0.4，p=0.102）、种族（OR=0.1，p=0.012）以及肥胖（OR=0.018，p=0.006）为负向影响因素。
中国护士体力活动健康促进的正向影响因素包括：体力活动变化阶段（OR=3.1，p=0.009）、自信心（OR=11.0，p=0.000）、认为缺乏健康教育材料（OR=2.8，p=0.081）、管理者（OR=3.8，p=0.099）；而没有时间（OR=0.3，p=0.003）、需要奖金激励（OR=0.4，p=0.059）、认为病人希望接受药物治疗（OR=0.6，p=0.111）、肥胖（OR=0.2，p=0.071）和从事护理工作的年限（OR=0.926，p=0.003）是体力活动健康促进的负向影响因素。
7.开放性问题分析结果
开放性问题分析表明：护理工作是影响中英两国护士体力活动的重要原因，英国护士对于体力活动的理解更为深入，对于健康促进角色有较强的认同感。中国护士对于自身体力活动的关注高于健康促进，缺乏体力活动的主观能动性。两国护士均希望医院能为医护人员提供活动场所或机会。
结论：本研究在中英两国调查中均验证了护士自身体力活动水平与体力活动健康促进之间的相关性。总体来说中国护士的体力活动水平明显低于英国护士，感知到的锻炼的障碍明显高于英国护士。在体力活动健康促进中，中国护士报道的知识、态度、角色认同普遍低于英国护士，处于规律促进阶段的比例明显低于英国护士。除自身体力活动水平与肥胖外，影响两国护士开展健康促进实践的因素各不相同。开放性问题表明：护理工作是影响护士参与体力活动的重要障碍因素；两国护士均希望医院能够提供支持性的锻炼环境；英国护士对于体力活动健康促进有着较为深刻的认识。今后应当结合研究结果针对护士开展体力活动方面的教育培训和健康促进，同时也应对于护士职业性体力活动进行更为深入的研究。
Background: Physical inactivity has been identified as major risk factor for theprevalence of non-communicable diseases worldwide. Many studies have shown thatengaging regularly in moderate physical activity can improve health, and decreasemortality. Encouraging health professionals to promote physical activity (PA) is amore cost-effective and safer approach in public health. An empirical link betweenhdoctors’ personal health habits and their tendency to raise health issues with clientshas been proved in many studies since1970s. However, most of these studies havefocused on doctors’ health behaviours and health promotion. While there is a growingbody of evidence about doctor involvement in physical activity counselling, less isknown about nurses’ practice.
Objective: The purpose of this studies was to examine the attitudes toward, behaviorsof nurses’ physical activity (PA) from UK and China, and evaluate the proportion ofnurses’ who meet WHO’s physical activity guideline. Also it examins the theknowledge of, attitudes toward, confidence in, and practices of nurses’ PA healthpromotion from both country, and explores the relationship between personal PAlevel and associated health promotion.
Method: This research project was mainly based on a cross-sectional survey design.We used a structured questionnaire established on comprehensive literature review tocollect the data. In UK, the sample included qualified nurses who enrolled on modulesin King’s College London Waterloo Campus. With the consent of the module leaders,the researcher met and provided the potential participants with information about thestudy and gives them each an information sheet. One week later, the researcherpersonally handed out the questionnaires, which will take approximately about10minutes to complete. Completed questionnaires will be collected immediately orreturned in the mail to the researcher. In China, nurses from3hospitals in Shanghaiwere invited to participate in the survey using a convenience sampling method.
The data were analysed by SPSS19.0. Chi-square test and Mann-Whitney U testwere adopted for analysis of categorical variable. T test was used for analysis ofcontinuous variable. Binary logistic regression (enter，forward LR or backward wald)analysis was carried out to explore the factors may influence nurses’ own physical activity and their PA health promotion. All reported differences were at the P<0.05level unless otherwise stated. Missing data was excluded in the data analysis. Thequalitative data from open-ended question was analyzed by the sorting and codingmethod.
Results: The response rate was83.9%(631out of744) in UK and74%in China(888out of1100).The major findings of this study were as follows:
1. General health and lifestyle
Most UK nurses rated their health as good or very good (94.2%), and86.3%ofthem reported they didn’t have any long term health problems that limit their physicalactivity. However, nurses from China reported significant lower rate of good healthand higher rate of long term health problems (p=0.000). The percentage of currentsmoker in UK nurses was11.0%, but only0.6%in China (p=0.000). The drinkinghabit in each sample has dramatic difference with50.7%hazardous drinker in UK andonly1.5%prevalence of “drinking more than4times per month” in Chinese nurses.The body shape of UK nurses was significant larger than Chinese nurses.
2. Nursing work
More Chinese nurses’ reported they worked more than40hrs per week than theircounterparts(OR=4.8，p=0.000). However, more UK nurses reported higherpercentage of walking or standing≥9hrs during the shift(51.9%vs21.3%，OR=3.2，p=0.000). The percentage of nurses worked with night shifts in both sample wassimilar, but the frequency of night shifts in UK nurses was significant lower thanChinese nurses(OR=1.3，p=0.020). The steps nurse climbed up each day and theirlifting behavior didn’t demonstrate any significant differences in both samples.
3. The attitude toward and behavior of nurses’ PA
More UK nurses reported being in the "maintenance" stage or “action”stage thanChinese nurses (55.0%vs22.5%，OR=2.3，p=0.000). More than half of the Chinesenurses were in “Precontemplation”or “Contemplation”stage.
Comparing with Chinese nurses, UK nurses had good exercise habit. One thirdChinese nurses never participated in light exercise, and percentage of not taking partin moderate or vigorous PA was more than60%. The percentage of Chinese nursesreported neither did moderat PA nor did vigorous PA was54.5%, significantly higherthan the prevalence in UK nurses. As the most popular approach of exercise,prevalence of walking in Chinese nurse was significant lower than that of UK nurses (χ2=120.6，p=0.000). Out of our expectation, Chinese nurses reported lower rate ofany kinds of household PA (p<0.000).
The percentage of meeting WHO’s PA guideline was65.8%in UK nurses，and45.6%in Chinese nurses(OR=2.5，p=0.000). The percentage of highly active UK nurses wasalso more than that of Chinese nurses(41.2%in UK vs24.4%in China，χ2=63.9，p=0.000). when we excluede PA component of less than10min bouts from the totalPA, the percentage of Chinese nurses who met WHO’s guideline decreased to20.9%.
The mean score of EBBS of UK nurse was28.1±6.3，significantly lower than thatof Chinese nurses(32.3±6.0)，p=0.000. EBBS score was related with personal PA.Nurses reported sufficient PA got lower score of EBBS(p=0.000in UK, p=0.010inChina). Also, nurses in regular active stage reported less barriers of PA(p=0.000ofUK nurses，p=0.010in Chinese sample).
Personal dichotomized PA stage was correlated with personal PA level. The predictconsistency between these two variables was73.4%and75%, respectively.
The factors affected UK nurses were, PA level(OR=2.1，p=0.005)，EBBS(OR=0.9，p=0.000)，actual bodyshape(OR=0.6，p=0.076)，work time as a nurse(OR=0.5，p=0.021)and frequency of night shifts(OR=2.4，p=0.007).
Factors that influenced Chinese nurses own PA were sex(OR=0.1，p=0.015)，yearsas RN(OR=0.969，p=0.004)，knowledge of PA(OR=2.0，p=0.076)，EBBS(OR=0.968，p=0.050)，andgeneral health(OR=1.5，p=0.008).
4. Knowledge of，attitude toward，and behavior of PA health promotion(HP)UK nurses showed higher acceptance of own PA HP role model，better knowledgeof PA HP，and stronger PA HP confidence. Moreover，more UK nurses were in regularpromoting stage than Chinese nurses(OR=0.5，p=0.000).
The first three HP barriers frequently reported by UK nurses were：“Patients expectdrug treatments for their health problems”(71.2%)，“There is a lack of availableeducation for health professional regarding physical activity promotion”(67.8%)，and“Educational materials for patients are insufficient”(63.4%). Those reported byChinese nurses were：“Educational materials for patients are insufficient”(91.1%)，“There is a lack of available education for health professional regarding physicalactivity promotion”(90.6%)，and “I would be more likely to promote physical activityif there was a financial incentive”(75.9%).
5. The relationship between nurses’ own PA and associated HP
UK nurses in regular active PA stage (OR=1.8, p=0.002), or personally met theWHO recommendation (OR=2.0, p=0.000) reported higher propotion of regular HPpromotion.
Chinese nurses in regular active PA stage (OR=1.5, p=0.016), or personally met theWHO recommendation (OR=1.5, p=0.011) reported higher propotion of regular HPpromotion.
6. The predictors of nurses’ PA HPThe positive predictors of UK nurses’ HP practice were：acceptance of own rolemodel (OR=7.6，p=0.030), PA stage of change(OR=4.7，p=0.018), and age(OR=3.8，p=0.098)；the negative preditors were “Patients expect drug treatments for their healthproblems”(OR=0.4，p=0.102),race(OR=0.1，p=0.012)and obesity(OR=0.018，p=0.006)
The positive predictors of Chinese nurses’HP practice were：PA stage ofchange(OR=3.1，p=0.009)、confidence(OR=11.0，p=0.000)、“Educational materialsfor patients are insufficient”(OR=2.8，p=0.081)、manager(OR=3.8，p=0.099)；thenegative preditors were“lack of time”(OR=0.3，p=0.003)、“financialincentive”(OR=0.4，p=0.059)、“Patients expect drug treatments for their healthproblems”(OR=0.6，p=0.111)、obesity(OR=0.2，p=0.071)and years as RN(OR=0.926，p=0.003).
7. Results from analysis of open-ended question answer
Nurses felt the heavy workload of nursing work was an important barrier for theirpersonal PA. UK nurses demonstrated comprehensive understanding of PA and PA HP,and reported positive attitude toward their own role model in PA HP. Chinese nursesconcerned more about their own PA than their PA HP, and they were lack ofmotivation to participate in PA. Nurses from both country appealed the institutionshould provide PA facilities or easy access to gym or other sport center.
Conclusion：This study tested the empirical relationship between nurses’ own PA andassociated HP. there were significant differences among UK and Chinese nurses withregard to key study variables (Behavior, Attitudes, and Knowledge of physical activity,and physical activity health promotion).The PA level of Chinese nurses wassignificantly lower than UK nurses，and their barrier score of EBBS was significantly attitude toward，confidence in，and salient role identity. Chinese nurses reportedpositive view to the HP statements，but demonstrate lower rate of regular promotionbehavior. Except personal PA，other influential factors of PA HP were obviouslydifferent between UK nurse and Chinese nurse. Implications for future research andpractice are noted
引文
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