Article(id=1322168954479563050, tenantId=1146029695717560320, journalId=1220038315760373764, issueId=1322168481081049284, articleNumber=null, orderNo=null, doi=10.12102/j.issn.1009-6493.2026.09.025, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1750608000000, receivedDateStr=2025-06-23, revisedDate=1768579200000, revisedDateStr=2026-01-17, acceptedDate=null, acceptedDateStr=null, onlineDate=1793159243459, onlineDateStr=2026-10-28, pubDate=1778342400000, pubDateStr=2026-05-10, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1793159243459, onlineIssueDateStr=2026-10-28, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1793159243459, creator=13701087609, updateTime=1793159243459, updator=13701087609, issue=Issue{id=1322168481081049284, tenantId=1146029695717560320, journalId=1220038315760373764, year='2026', volume='40', issue='9', pageStart='1425', pageEnd='1616', issueExtLink='null', onlineDate='null', pubDate='1778342400000', pubDateStr='2026-05-10', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=null, createTime=1793159130592, creator='13701087609', updateTime=1793159130592, updator='13701087609', preIssue=null, nextIssue=null, articleTotal=null, ext=null, issueFiles=null, downloadFileDto=null}, startPage=1603, endPage=1608, ext={EN=ArticleExt(id=1322168954651529515, articleId=1322168954479563050, tenantId=1146029695717560320, journalId=1220038315760373764, language=EN, title=Application progress on socio-ecological model of adolescent and young adults readiness for transition, columnId=1220689485315101342, journalTitle=Chinese Nursing Research, columnName=Review Articles, runingTitle=null, highlight=null, articleAbstract=

It summarized current application of the Socio-Ecological Model of Adolescent and Youth Transition Readiness(SMART) among adolescents with chronic diseases.It reviewed the model's roles in assessing transition readiness,identifying needs,developing intervention programs,and creating evaluation tools,while also discussing its challenges and future directions.

, authors=Wenqi LI1, Huijing CHEN1, Siqi LI1, Yujiao TAN1, Xiuli CHEN1, Minmin CHANG1, Weijuan LIU2, Tao LI1, authorsList=Wenqi LI, Huijing CHEN, Siqi LI, Yujiao TAN, Xiuli CHEN, Minmin CHANG, Weijuan LIU, Tao LI, authorCompany=null, correspAuthors=Tao LI, authorNote=null, correspAuthorsNote=null, copyrightStatement=null, copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, fund=null), CN=ArticleExt(id=1322168956811596078, articleId=1322168954479563050, tenantId=1146029695717560320, journalId=1220038315760373764, language=CN, title=青少年及青年过渡期准备度社会生态模型的应用进展, columnId=1220689485482873504, journalTitle=护理研究, columnName=科研综述, runingTitle=null, highlight=null, articleAbstract=

总结青少年及青年过渡期准备度社会生态模型(SMART)在慢性病青少年中的应用现状,总结其在评估准备度、识别需求、构建干预方案以及开发评估工具等方面的作用,并探讨其挑战与未来发展方向。

, authors=李文琪1, 陈慧菁1, 李思琦1, 谭玉娇1, 陈秀丽1, 常敏敏1, 刘卫娟2, 李桃1, *, *, authorsList=李文琪, 陈慧菁, 李思琦, 谭玉娇, 陈秀丽, 常敏敏, 刘卫娟, 李桃, authorCompany=null, correspAuthors=李桃, authorNote=

李文琪,硕士研究生

, correspAuthorsNote=
李桃,E-mail:
LI Tao, E-mail:
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青少年及青年过渡期准备度社会生态模型的应用进展
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李文琪 1 , 陈慧菁 1 , 李思琦 1 , 谭玉娇 1 , 陈秀丽 1 , 常敏敏 1 , 刘卫娟 2 , 李桃 1, *, *
护理研究 | 科研综述 2026,40(9): 1603-1608
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护理研究 |科研综述 2026 , 40 (9) : 1603 -1608
青少年及青年过渡期准备度社会生态模型的应用进展
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李文琪1, 陈慧菁1, 李思琦1, 谭玉娇1, 陈秀丽1, 常敏敏1, 刘卫娟2, 李桃1, *, *
作者信息
  • 1广州医科大学护理学院,广东 510180
  • 2广州医科大学附属第一医院
通讯作者:
李桃,E-mail:
LI Tao, E-mail:
作者简介:

李文琪,硕士研究生

Application progress on socio-ecological model of adolescent and young adults readiness for transition
Wenqi LI1, Huijing CHEN1, Siqi LI1, Yujiao TAN1, Xiuli CHEN1, Minmin CHANG1, Weijuan LIU2, Tao LI1
Affiliations
  • 1School of Nursing, Guangzhou Medical University, Guangdong 510180 China
  • 2The First Affiliated Hospital of Guangzhou Medical University
出版时间: 2026-05-10 doi: 10.12102/j.issn.1009-6493.2026.09.025
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总结青少年及青年过渡期准备度社会生态模型(SMART)在慢性病青少年中的应用现状,总结其在评估准备度、识别需求、构建干预方案以及开发评估工具等方面的作用,并探讨其挑战与未来发展方向。

青少年  /  过渡期准备度  /  社会生态模型  /  综述

It summarized current application of the Socio-Ecological Model of Adolescent and Youth Transition Readiness(SMART) among adolescents with chronic diseases.It reviewed the model's roles in assessing transition readiness,identifying needs,developing intervention programs,and creating evaluation tools,while also discussing its challenges and future directions.

adolescents  /  transition readiness  /  socio-ecological model  /  review
李文琪, 陈慧菁, 李思琦, 谭玉娇, 陈秀丽, 常敏敏, 刘卫娟, 李桃. 青少年及青年过渡期准备度社会生态模型的应用进展. 护理研究, 2026 , 40 (9) : 1603 -1608 . DOI: 10.12102/j.issn.1009-6493.2026.09.025
Wenqi LI, Huijing CHEN, Siqi LI, Yujiao TAN, Xiuli CHEN, Minmin CHANG, Weijuan LIU, Tao LI. Application progress on socio-ecological model of adolescent and young adults readiness for transition[J]. Chinese Nursing Research, 2026 , 40 (9) : 1603 -1608 . DOI: 10.12102/j.issn.1009-6493.2026.09.025
随着患慢性病青少年人数的增加,如何确保其从儿童医疗体系平稳过渡至成年人医疗体系已成为全球公共卫生的重要议题[1-2]。青少年在从儿科向成年人医疗体系过渡期间,常面临生理、心理及社会适应等多维挑战。此转型期的特殊性在于个体需同步应对生长发育、心理调适、家庭角色转变及医疗服务转换等复杂需求。若适应不良,可导致疾病自我管理能力不足、复发风险增加,进而引发身心健康损害,加重家庭社会经济负担等问题,对远期预后产生不良影响[3-4]。既往过渡护理方案多聚焦年龄、疾病知识与技能等单一维度,忽视了社会文化、家庭互动及心理社会支持等系统性因素的影响[5]。为了更全面地理解和改善青少年及青年的过渡准备度,Schwartz等[6]于2011年基于社会生态模型发展了青少年及青年过渡期准备度的社会生态模型(Social-Ecological Model of Adolescents and Young Adults Readiness for Transition,SMART)。该模型通过整合个体、家庭、医疗系统等多层次因素,为慢性病青少年过渡期研究提供了系统性框架。研究表明,基于SMART模型的干预方案提升了青少年过渡成功率,但其在疾病特异性与文化适应性方面的局限性仍需进一步探索[7]。现综述SMART模型在慢性病青少年过渡期中的应用现状,探讨其挑战与未来发展方向。
社会生态模型首次由Bronfenbrenner[8]提出,是指个体与其所处的多层次环境之间的相互作用,这些环境系统从最直接的微观层面到更广泛的宏观层面,共同影响个体的行为和发展。慢性病青少年的医疗保健向成年人的医疗保健的过渡是一个非常复杂的过程,从模型可以看出,从最直接到最远端的环境系统都对这一过渡有影响。基于这一理论框架,Schwartz等[6]整合社会生态理论、慢性护理模型[9]和医学创伤压力模型[10],通过文献回顾和专家共识,于2011年首次提出了SMART模型。相比传统评估方法,SMART模型将视角拓展至个体与环境的交互作用,系统整合了可促进因素和不可促进因素,明确了医疗团队可以直接干预的领域,为临床护理干预提供了理论基础与实践指导[11]。
SMART模型由两个主要层次构成:不可促进因素和可促进因素。1)不可促进因素:包括社会人口学特征、文化、机会/安全保障、病人的医疗状况和风险、认知/智商等。这些因素通常难以通过短期干预改变,但对病人的过渡准备度具有深远影响。2)可促进因素:可促进因素是SMART模型的核心,包括病人的知识、技能、信念/期望、目标、与病人的医疗保健提供者、照护者的关系、社会心理功能、发展成熟度等[6]。这些因素能够通过教育、培训、沟通与支持策略加以改善,以提高病人的过渡准备度并促进顺利转移至成年人医疗体系[12-14]。①知识:指病人、家长和医护人员对疾病管理、医疗过渡过程的了解程度。加强健康教育可帮助病人更好地适应成年人医疗体系。②技能/效能感:指病人对自身健康管理能力的信心。提高病人的自我效能感,有助于其更主动地参与医疗决策并独立管理健康。③信念/期望:包括病人和家长对成年人医疗系统的认知与态度。消除对新医疗环境的不信任感,能够降低过渡过程中可能出现的焦虑和抵触情绪。④目标:明确过渡期的目标,如提高自我管理能力、建立独立的医疗联系等,有助于病人逐步适应成年人医疗体系。⑤关系:包括病人与家长、医护人员及同伴之间的互动关系。通过建立良好的沟通机制,增强病人与成年人医疗体系的联系,有助于提高医疗过渡的顺利程度。⑥社会心理功能:包括病人的心理健康状况、家庭支持、社会适应能力等。针对心理压力大的病人,应提供情感支持及心理干预,以减少过渡期的负面影响。SMART模型强调,医疗过渡不仅是个体因素的变化过程,更是一个涉及多重社会生态系统的动态互动过程[15]。因此,在临床应用中,医疗机构可根据病人个体特点结合SMART模型的可促进因素,制定个性化的过渡计划,以提高过渡的成功率并改善长期健康结局。SMART模型具体见图1。
SMART模型可应用于评估过渡准备度,分析不同疾病青少年及青年过渡准备度的影响因素,为临床干预提供理论依据。由于疾病特征、文化背景及医疗体系的差异,影响因素的作用机制和权重可能存在异质性,需通过跨疾病、跨文化的理论实证研究进一步厘清关键变量及其交互关系,从而为临床干预提供精准化、本土化的理论依据。Smith等[16]采用SMART模型评估癫痫青少年的过渡准备度,分析了年龄、认知功能和病症知识等因素与过渡准备度的关系。该研究验证了SMART模型在癫痫病人中的适用性,并强调了认知功能和知识提升对过渡成功的重要性,为临床干预提供了理论依据。Zhou等[17]基于SMART模型,通过描述性定性研究分析了中国青少年炎症性肠病(IBD)病人、父母和医疗提供者的不同观点,研究发现,该模型中的多个因素(如疾病接受度、过渡意识、自我效能等)对过渡过程有影响;研究还指出,SMART模型中的某些方面(如文化背景和社会支持)在中国背景下的应用可能需要适当调整,以适应中国的医疗和文化环境。Porter等[18]使用SMART模型分析了镰状细胞贫血(SCD)青少年的过渡准备度。通过焦点小组讨论收集了19例SCD病人的观点,研究发现疾病相关的社会污名和疼痛管理在该群体中尤为突出,焦点小组中提到的主题与SMART模型中的大多数领域一致,可见该模型有助于解释病人的过渡经验。然而,目前的研究仍然局限于特定疾病群体,且大多采用横断面研究或质性研究,缺乏长期追踪和干预效果评估,难以全面验证模型的因果机制[19]。因此,未来研究应结合纵向研究设计,追踪病人从青少年到成年的健康轨迹,以提升青少年过渡期护理的科学性和有效性。
由于过渡期病人及其家庭在医疗资源获取、心理支持和社会适应等方面存在多层次需求[6],这些需求直接影响病人的过渡准备度与长期健康结局。SMART模型能够有效分类和分析这些需求,为医疗团队提供清晰的干预方向,从而提升过渡护理的整体效果。Cui等[20]通过混合方法研究分析中国癫痫青少年的过渡准备度,结合SMART模型识别了病人在自主管理、家长支持和医疗沟通方面的核心需求,强调家庭在促进过渡期健康管理中的关键作用,并建议构建更加便捷的信息共享平台以满足个体化需求。Gray等[21]以SMART模型的核心维度为基础,分析了非儿科医生在接收过渡期病人时面临的障碍,研究发现,病人及家长对医生角色的认知存在偏差、获取医疗信息的途径有限,且对保险和精神健康服务的可及性需求较高。尽管SMART模型被证实可系统性分类需求与障碍,但其多维度整合能力在复杂临床场景中的应用仍依赖人工解读,易受护理人员主观经验影响,尚未形成标准化干预路径。未来可通过机器学习技术将SMART模型的多维度数据转化为自动化决策支持工具,减少人工干预偏差。
SMART模型可提供构建和实施过渡期护理方案的整体框架或关键要素,通过提高病人的疾病知识、技能、信念和期望等,提升青少年的过渡期准备度水平,有效帮助他们从儿童向成年人的平稳过渡,并具有较高的可实施性。Steinway等[7]以SMART模型为理论框架,开发了一款名为iManage SCD的移动健康应用程序,该应用程序旨在支持患有SCD的青少年在从儿科过渡到成年人医疗系统期间的自我管理;研究将SMART模型的核心要素(如知识和自我管理技能)转化为APP功能,增加了疼痛追踪、情绪管理等模块,帮助用户进行健康评估、学习和监测。该研究不仅验证了SMART模型的实践价值,还体现了以用户为中心、促进健康公平的护理措施。Zanoni等[22]结合SMART模型中的核心概念,设计了互动过渡支持工具InTSHA,以支持南非人类免疫缺陷病毒(HIV)青少年病人的过渡护理。研究聚焦目标设定、关系支持和病人成熟度等核心概念,探索了数字社交媒体平台与传统行为干预相结合的创新模式,有效改善了HIV感染青少年的过渡体验,为未来过渡干预方案的研究与应用提供了新方向。吴钰君[23]基于SMART模型,从家庭、医疗团队和病人个体层面的多维度视角构建了青少年癫痫病人过渡期准备度的干预方案。该干预方案从专业的角度为青少年癫痫病人及其家属提供病人所需要的过渡支持,满足了病人的过渡需求,有助于病人参与过渡及干预的积极性,提高病人的自我管理能力。目前,该理论在国外多种慢性病过渡期的研究中被广泛应用,我国尚处于探索阶段。护理科研人员可结合我国医疗实际,基于该模型开发本土化过渡管理方案,并通过实证研究验证其适用性,从而推动慢性病过渡期管理体系的优化发展。
既往过渡期护理模式普遍存在干预维度单一、措施碎片化等问题[24],在此背景下,SMART模型凭借其系统化框架优势,为精准分类干预和跨团队协作实施提供了新思路。Kreindler等[25]通过11个维度的分类,揭示了心理社会因素、家庭环境及医患关系对过渡体验的深远影响,为慢性病病人的医疗过渡提供了理论支持和实践指导。Tang等[26]基于SMART模型框架,对孤独症谱系障碍和注意缺陷多动障碍青少年群体的过渡期障碍因素及促进因素进行了系统性分析,验证了该模型在多层次分析中的实用性,为制定有效的过渡支持策略提供了实证支持。
通过SMART模型的分类框架,研究能够有效识别干预内容中的不足与潜力领域。例如,Ma等[27]在回顾儿童癌症幸存者的过渡期干预研究时指出,模型对知识、技能、信念及目标设定等关键因素的整合仍需细化,特别是在跨疾病、跨文化场景中的适用性有待验证。Cadogan等[28]通过对Duke综合护理诊所过渡计划的系统性评估发现,虽然模型各领域文档的整体覆盖率达94.58%,但“信念与期望”维度的覆盖率仅为67%;研究表明,该计划对病人和家长的支持效果显著,但在提升过渡信心和技能自我效能方面仍需加强。综上所述,SMART模型通过其系统化、多维度的分析框架,不仅弥补了既往过渡护理模式的局限性,更为精准识别干预重点、优化资源配置提供了科学依据,展现了其在复杂医疗过渡场景中的重要应用价值。
SMART模型在过渡期评价工具的开发与实施中展现了较好的应用效果,可确保工具涵盖多层次因素,为全面评估病人过渡准备度提供科学框架。2017年,Schwartz等[29]基于SMART模型开发了过渡准备度评估工具(Transition Readiness Inventory,TRI),涵盖信念、期望及心理社会功能等多维度因素,为儿童癌症幸存者及其父母提供了多角度的综合性评估工具,有助于提升评估的全面性与实用性。Zhang等[30]通过系统评价验证了过渡准备度评估问卷(TRAQ)等工具的有效性和可靠性,并强调SMART模型在工具设计中整合多层次因素的重要性,为理解多方交互因素对过渡准备度的影响提供了理论支持。此外,South等[31]通过比较现有工具与扩展SMART模型(Expanded SMART)的契合度,揭示了现有工具[TRAQ、自我管理和过渡期准备问卷(STARx)、TRxANSITION综合评估问题(TRxANSITION Index)]在心理社会方面的不足,为未来开发更全面的评估工具指明了方向。我国学者陈海丽[32]于2023年结合马斯洛需要层次理论与SMART模型,开发了青少年癫痫患儿过渡需求问卷,涵盖疾病知识、心理支持、社会支持等6个维度,全面考虑了病人、父母及医护人员的互动,为制定个性化过渡护理计划提供了科学依据。然而,模型在不同文化背景和医疗体系中的适用性仍需进一步验证[28],今后研究者可基于SMART模型开发更具针对性和特异性的过渡准备度评估工具,并在全国范围内展开调查,了解目前我国慢性病青少年的过渡需求,为优化过渡期护理模式提供指导和建议。
SMART模型虽包含心理功能维度,但对个体发展阶段的动态特征及社会心理需求的演变规律响应不足,忽视了情感调节、动机形成等隐性心理过程,其静态框架难以满足青少年过渡期复杂的隐性心理需求[33]。研究表明,现有模型需要强化心理社会干预模块。例如,过渡期病人面临的社会污名化问题需针对性心理支持模块[18],HIV青少年群体则亟须加强隐私管理能力和社会归属感等心理功能的干预支持[34-35]。
埃里克森的心理社会发展理论和自我决定理论(SDT)可为理解青少年的发展特征提供更全面的视角。埃里克森心理社会发展理论强调青春期身份认同、亲密关系建立等核心心理任务[36],将其融入SMART模型的目标设定维度,可使干预措施更契合青少年的阶段性特征[37]。自我决定理论则揭示了自主型动机对健康行为维持的关键作用[38],其核心要素(自主支持、能力感、归属感)的引入不仅可增强青少年的内在动机,还可通过预测过渡准备度提升干预持续性[39]。未来的研究应更加重视心理社会层面的细化,尤其是在家庭互动、情绪支持和社会支持方面,进一步完善模型中的心理社会模块,以便更有效地促进青少年群体的适应和过渡。
SMART模型在慢性病青少年过渡期护理中具有重要价值,但其在国内的应用仍面临挑战[20,40]。一方面,需解决青少年家庭依赖度高、医患角色适应困难等本土化问题[13,41];另一方面,需应对青少年病人过渡期间需求随病程、环境动态变化的复杂性。针对国内实践,可采取以下改进措施。1)进行本土化调整:在模型中增加“家庭沟通”“共同决策”等符合中国家庭特点的维度[42]。2)开展多中心纵向研究,延长随访时间,观察不同慢性病青少年病人群体需求的变化规律,及时优化护理方案。
病人需求变化常受复杂心理社会因素驱动,需通过混合研究方法提升研究深度。可结合潜变量增长模型与深度访谈深入了解病人需求:前者分析病人群体的需求变化轨迹[43],后者可解释深层动因。Porter等[18]采用混合研究方法探索SCD青年病人的过渡经验和准备情况,利用模型探索了在从儿科到成年人护理过渡中面临的挑战、需求及对现有过渡项目的评价,展示了如何通过定性和定量研究结合更全面地验证SMART模型,为模型的运用提供了参考。建议未来研究将SMART模型与多种研究方法联合使用,既能增强模型对复杂临床场景的解释力,也为制定分级分类干预策略提供循证依据,最终实现从标准化护理向精准动态支持的实践升级。
数字健康干预正逐步改变传统医疗健康服务模式。《“健康中国2030”规划纲要》明确支持“互联网+医疗健康”发展[44],为慢性病青少年过渡护理提供了新思路。研究表明,基于SMART模型的数字工具(如iManage SCD[7]和InTSHA系统[22])整合了教育、训练和支持功能,提升了病人的自我管理能力。这些工具通过精准信息推送和数字化医患互动,有效补充了传统过渡护理模式的不足[45-46],为未来开发更多创新型数字化干预工具提供了重要参考。
未来数字健康干预的深化发展应重点推进以下方向。首先,组建儿科-成年人科医护人员、心理医师及医务社会工作者构成的多学科团队,护理人员需全程参与数字健康干预的需求分析、功能设计和体验评估,协调多学科团队合作,促进数字技术与临床实践的有效融合。其次,需要完善数字干预方案设计,充分考虑青少年病人的认知特征和实际需求,通过持续优化用户体验增强干预的有效性和依从性。第三,需构建智能化动态干预体系,将SMART模型中自我效能、目标设定等理论要素与机器学习技术结合,依据病人所处过渡阶段动态调整任务难度及反馈机制。综上,未来应着力推进多学科深度合作,通过深化技术创新与临床需求的融合,促进慢性病青少年实现从被动治疗向主动健康管理的转变,从而有效提升其生活质量。
尽管SMART模型已为青少年慢性病病人的过渡期提供了理论框架和实践指导,未来的研究仍需在增强隐性心理支持、强化临床价值、拓展数字健康干预等方面进行深入探索。通过不断完善和调整SMART模型,能够更好地满足青少年病人在过渡期面临的复杂挑战,推动慢性病领域过渡护理的理论创新与实践发展。

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doi: 10.12102/j.issn.1009-6493.2026.09.025
  • 接收时间:2025-06-23
  • 首发时间:2026-10-28
  • 出版时间:2026-05-10
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  • 收稿日期:2025-06-23
  • 修回日期:2026-01-17
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    1广州医科大学护理学院,广东 510180
    2广州医科大学附属第一医院

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