臺灣博碩士論文加值系統

掌握影響糖尿病足部自我照護行為之因素，可據以擬定有效措施，提升患者足部自我照護行為，然而關於糖尿病足部自我照護行為影響因素之實證資料不多。本研究目的為探討糖尿病足部照護行為之解釋因素，以及測試假設的糖尿病足部照護行為預測模式的適配性。
本研究以橫斷式之調查研究設計，自2010年3月1日至2011年5月31日進行收案，共收案295位糖尿病併發足部感覺神經病變患者。以Smilkstein（1978）的家庭關懷度量表（Family APGAR）、害怕溫度計（fear thermometer）、以及研究者自擬之四個量表（糖尿病足部照護行為量表、糖尿病足部照護知識量表、糖尿病足部照護自我效能量表、糖尿病足部潰瘍健康信念量表）蒐集個案資料，並以複迴歸分析及結構方程式進行資料分析
研究結果顯示：足部照護自我效能較高、曾接受足部檢查、曾被提醒需注意足部照護、足部照護障礙信念較低、接受過足部照護教育以及有下肢截肢病史之研究對象，其足部照護行為較佳。六個解釋變項共可解釋足部照護行為31.1%的變異量，其中，自我效能的解釋力最大，可解釋足部照護行為14.4%的變異量。
筆者依據Becker（1974）健康信念模式假設之糖尿病足部照護行為預測模式與研究資料適配性不佳，模式修正後，絕對適配指標漸進殘差均方和平方根（RMSEA）為 .068，卡方自由度比（CMIN/DF）為2.379，比較適配指數（CFI）為 .897，規準適配指數（NFI）為 .837，適配度指數（GFI）為 .908，調整後適配度指數（AGFI）為 .873。本研究最終修正後模式中達統計上顯著之影響路徑為：足部照護自我效能藉影響足部潰瘍威脅信念而影響足部照護行為，足部照護知識藉影響「足部照護利益減去障礙信念」及足部潰瘍威脅信念而影響足部照護行為，家庭支持藉影響「足部照護利益減去障礙信念」而影響足部照護行為。
本研究足部照護行為的解釋變項中，足部照護自我效能的解釋力最大。建議臨床人員應運用心理支持緩解患者對於執行足部照護之負向情緒，並建立患者成功執行足部照護之經驗，以提升患者足部照護自我效能，進而增進糖尿病患者足部照護行為之執行。

Identification of the factors affecting the foot self-care behaviors of diabetic individuals can be helpful in designing foot-care promotion strategies for diabetic patients. However, such evidence-based data is rare. The purposes of this study were to explore the predictors of foot-care behaviors and to test the model fit of a proposed prediction model for diabetic foot-care behaviors.
A cross-sectional design was utilized. Two hundred and ninety-five patients with diabetic neuropathy were recruited from March 1, 2010, to May 31, 2011. Data were collected using the Smilkstein (1978) Family APGAR, the fear thermometer, and four questionnaires designed by the researcher (specifically, a diabetes foot self-care behavior scale, a diabetes foot self-care knowledge scale, a diabetes foot self-care self-efficacy scale, and a diabetic foot ulcer health belief scale). The multiple regression and structural equation model were used to analyze the data.
The results showed that the following factors were associated with better diabetic foot-care behavior: Higher foot-care self-efficacy, having had the foot examined by a clinician, having received advice on taking care of the foot, fewer foot-care barrier beliefs, having received foot care education, and lower limb amputation. The above six predictors explained 31.1% of the variance in foot-care behavior. Among them, the foot-care self-efficacy was the most powerful predictor, explaining 14.4% of the variance in foot-care behavior.
The proposed prediction model had a poor model fit. After modification, the fitting index were improved (root mean square error of approximation = .068, CMIN/DF = 2.379, comparative fit index = .897, normal fit index = .837, goodness-of-fit index = .908, and adjusted goodness-of-fit index = .873). According to the modified model, the foot-care self-efficacy indirectly influences foot-care behaviors by influencing the foot ulcer threat beliefs. Family support indirectly influences foot-care behaviors by influencing the “foot-care benefit beliefs minus barrier beliefs”. Foot-care knowledge indirectly influences foot-care behaviors by influencing the “foot-care benefit beliefs minus barrier beliefs” and foot ulcer threat beliefs.
In this study, foot-care self-efficacy was found to be the most powerful predictor of foot-care behavior in the regression model. We suggest that in order to promote patients’ foot-care behaviors, clinicians should promote patient foot-care self-efficacy by providing mental support to relieve patients’ negative emotions regarding foot care and by establishing patients’ successful experiences in foot self-care.

目 錄
指導教授推薦書…………………………………………………
口試委員會審定書………………………………………………
授權書…………………………………………………………… iii
誌謝……………………………………………………………… iv
中文摘要………………………………………………………… v
英文摘要………………………………………………………… vii
目錄……………………………………………………………… ix
圖表目錄………………………………………………………… xi
第一章 緒論…………………………………………………… 1
第一節 研究背景及重要性…………………………………... 1
第二節 研究問題與研究目的………………………………... 3
第三節 名詞界定…..…………………………………………. 5
第二章 文獻查證……………………………………………… 7
第一節 糖尿病周邊感覺神經病變…………………………... 7
第二節 糖尿病足部自我照護行為…………………………... 10
第三節 健康信念與糖尿病足部自我照顧行為……………... 21
第四節 影響糖尿病足部自我照顧行為之相關因素………... 26
第五節 文獻總結……………………………………………... 43
第三章 研究方法……………………………………………… 45
第一節 研究架構………………………………………………. 45
第二節 研究設計…………………………………………...… 48
第三節 研究對象與取樣方法…………………………………. 49
第四節 研究變項的操作性測量……………………...……… 50
第五節 研究工具之信效度測試………………...…………… 54
第六節 資料收集方法與過程……………………………...… 78
第七節 資料分析………………………………………………. 79
第八節 研究倫理的考量………………………………………. 81
第四章 研究結果…………………………………………….. 83
第一節 研究變項的描述性資料……………………………... 83
第二節 足部照護行為之影響因素與預測因子……………... 86
第三節 足部自我照護行為模式驗証分析…………………... 91
第五章 討論……………………………………………………. 97
第一節 糖尿病足部自我照顧行為之相關因素………..……. 97
第二節 模式之適配性………………………………………... 106
第六章 結論與建議…………………………………………… 108
第一節 結論…………………………………………………... 108
第二節 護理應用……………………………………………... 109
第三節 研究限制與建議……………………………………... 113
參考文獻………………………………………………………… 115
附錄……………………………………………………………… 131


圖 表 目 錄
圖 3-1糖尿病患者足部照顧行為影響因素之概念架構……… 46
圖 3-2健康信念模式…………………………………………… 47
圖 3-3研究架構：假設的糖尿病周邊感覺神經病變患者足部
照護行為預測模式 ……………………………………… 48
圖 3-4糖尿病足部照護行為測量結構分析結果........... 69
圖 3-5糖尿病足部照護自我效能測量結構分析結果………… 70
圖 3-6糖尿病足部照護健康信念測量結構分析結果....... 73
圖 4-1研究對象足部照護行為之標準化殘差次數分配直方圖 89
圖 4-2研究對象足部照護行為之標準化殘差值的常態機率分
佈圖..................................... 90
圖 4-3研究對象足部照護行為之預測值與殘差值之散佈圖… 90
圖 4-4足部自我照護行為預測模式結構分析結果…………… 96

表3-1糖尿病足部照護知識量表項目分析結果………………. 57
表3-2糖尿病足部照護行為量表項目分析結果………………. 58
表3-3糖尿病足部照護自我效能量表項目分析結果…………. 60
表3-4健康信念量表項目分析結果……………………………. 61
表3-5 KMO及Bartlett’s球形檢定……………………….. 64
表3-6糖尿病足部照護行為量表構面因素之萃取……………. 64
表3-7糖尿病足部照護自我效能量表構面因素之萃取………. 65
表3-8糖尿病足部潰瘍健康信念量表構面因素之萃取………. 65
表3-9 行為量表、自我效能量表以及健康信念量表各題得分
之常態性檢定…………………………………………… 67
表3-10糖尿病足部照護行為量表之模式適配度指標……….. 69
表3-11 糖尿病足部照護行為量表觀察變項之非標準化迴歸
係數與標準化因素負荷量摘要表…………………….. 69
表3-12足部照護自我效能量表觀察變項之非標準化迴歸係數
與標準化因素負荷量摘要表…………………………… 70
表3-13足部照護自我效能量表的模式適配度指標…………… 70
表3-14糖尿病足部潰瘍健康信念量表之模式修正原因……… 71
表3-15糖尿病足部潰瘍健康信念量表之模式適配度指標…… 71
表3-16糖尿病足部潰瘍健康信念量表觀察變項之非標準化迴
歸係數與標準化因素負荷量摘要表……………………. 72
表3-17聚歛效度測試結果……………………………………… 74
表3-18效標關聯效度測試結果………………………………… 75
表3-19眾知群體效度測試結果………………………………… 76
表3-20研究者自擬量表之信度測試結果……………………… 77
表3-21 資料分析方法與內容…………………………………. 81
表4-1 基本屬性………………………………………………… 83
表4-2 疾病及治療變項………………………………………… 84
表4-3 足部照護教育與服務狀況……………………………… 84
表4-4 足部照護行為各項得分情況…………………………… 85
表4-5 足部照護自我效能、足部照護知識、足部照護健康信
念、害怕截肢與家庭支持的得分情況………………… 86
表4-6 個人、醫療與疾病等因素與足部照護行為之相關性… 87
表4-7足部照護自我效能、足部照護知識、足部照護健康信念、
害怕截肢、家庭支持與足部照護行為的相關性………… 88
表4-8 研究對象之足部照護行為複迴歸分析及共線性診斷結果 90
表4-9 足部照護知識總分、害怕截肢以及家庭支持得分之常
態性檢定………………………………………………… 92
表4-10足部自我照護行為模式適配度指標之比較…………… 93
表4-11最終足部自我照護行為模式中變項間之非標準化迴歸係
數值..................................... 94
表4-12 足部自我照護行為模式各變項間之標準化迴歸係數估
計值..................................... 94
表4-13 最終修正版足部自我照護行為模式各變項間之決定
係數..................................... 95
表4-14 最終足部自我照護行為模式各變項對足部自我照護行
為的直接、間接及總影響係數………………………… 95

一、中文部分
王璟璇（1996）‧門診初診斷之非胰島素依賴型糖尿病患者的自我照顧行為、血糖控制及其相關因素之探討‧高雄：高雄醫學院護理學研究所碩士論文
王璟璇、王瑞霞、林秋菊（1998）‧門診診斷初期非胰島素依賴型糖尿病患者的自我照顧行為及其相關因素之探討‧護理雜誌，45（2），60–73。
江鳳葦（2003）‧非胰島素依賴型糖尿病患者家庭支持、生活滿意度、自我照顧行為與糖尿病控制之研究‧長庚科技學刊，2，27–50。
李雪如（2006）‧兩種不同衛教方案介入對促進糖尿病患者足部自我照顧效果之評價．台中：弘光科技大學護研所碩士論文。
吳明隆（2009）‧結構方程模式的操作與應用‧台北：五南。
周騰達、蕭添木、黃洽鑽、劉宏文（1991）‧家庭關懷度指數的初步研究‧高雄醫學科學雜誌，7，27-31。
林冠品（2004）‧與公衛護士互動關係感受、疾病知識、疾病態度與糖尿病自我照顧行為的關係‧台灣衛誌，23（6），479–486。
林淑君（1997）‧護理介入方案對增進糖尿病人足部自我照顧知識與行為之成效探討‧台北：台灣大學護理研究所碩士論文。
官蔚菁（2004）‧台灣健康信念模式研究之統合分析‧台南：國立成功大學護理學研究所碩士論文。
胡月娟（2010）‧內分泌系統疾病之護理‧於劉雪娥總校閱，成人內外科護理（五版，615-715頁）‧台北：華杏。
柯舜娟、孫麗娟、劉波兒、王潤清、袁光霞（1999）‧糖尿病患足部照護知識、態度、行為及其影響因素之探討‧弘光學報，34，193–221。
邱皓政（2006）‧量化研究與統計分析‧台北：五南。
邱馨誼（2001）‧社區第2型糖尿病患者之自我照顧行為與健康信念關係之研究‧未發表的碩士論文．台北：台灣大學護理研究所。
高宓憶、許青翎、吳英黛（2007）‧糖尿病患者足部週邊神經病變之測試‧物理治療，32（1），25–32。
孫建安主持（2008）‧2007年台灣地區高血壓、高血糖、高血脂之追縱調查研究（國民健康局研究計劃成果報告，DOH95-HP-2103）‧2009年10月19日取自http://grbsearch.stpi.org.tw/GRB/result.jsp?id=RG9712-0189&;plan_no=DOH95-HP-2103&;plan_year=97&;projkey=PG9708-0015&;target=report&;highStr=糖尿病盛行率&;check=0&;pnchDesc=2007年台灣地區高血壓、高血糖、高血脂之追縱調查研究
陳怡伶（2005）‧衛教方案介入對原住民第二型糖尿病患者足部照護知識、自我效能與行為之成效評估‧花蓮：慈濟大學原住民健康研究所碩士論文。
陳滋茨、張媚、林豔君（1998）‧自我效能、社會支持與糖尿病病人居家自我照顧行為相關之探‧護理研究，6（1），31–43。
章淑娟、傅振宗（2004）‧花蓮縣糖尿病照護品質病患成果評估及其預測因子‧慈濟護理雜誌，3（4），38–48。
黃美娟、林麗娟、洪志秀（2008）‧第二型糖尿病患自我照顧行爲及其相關因素之探討‧長期照護雜誌，12(2)，191–201。
黃瀞儀、鄭惠美、沈德昌（1998）‧門診糖尿病患對糖尿病知識、態度、行為與糖尿病衛教需求之研究‧健康促進暨衛生教育雜誌，18，25–35。
謝湘俐、孫嘉玲、張春鳳、楊惠娟、薛雅菁、黃小玲（2006）‧足部照護教育課程對血液透析合併糖尿病病患之成效‧台灣腎臟護理學會雜誌，5（2），31–43。
郭寶蓮、蔡秀鸞、陽琪（2002）‧充能訓練對糖尿病患者糖化血色素、自我效能和照護之成效‧臺灣醫學，6（6），848-857。
蔡奉宏、陳清惠、顏妙芬、唐福瑩（2006）‧第二型糖尿病患足部潰瘍之相關因素探討‧實證護理，2（2），137–145。
樓美玲、李怡娟、葉明珍、張彩秀（2004）‧社區非胰島素依賴型糖尿病患者家庭支持與自我照顧行為‧長期照護雜誌，8（2），195–212。
樓美玲（1999）‧社區非胰島素依賴型糖尿病患者家庭支持與自我照顧行為之相關性探討‧台北：陽明大學護理研究所碩士論文。
黎少琪（2005）‧護理指導對糖尿病患足部自我照顧知識、健康信念及行為之成效‧花蓮：慈濟大學護理研究所碩士論文。
蕭淑貞（1997）‧情境家庭健康護理評估指導手冊‧台北：台大醫學院護理學系所。
蕭淑貞、陳月枝、蔡世澤、林瑞祥、李燕晉、宣立人等（1994）‧胰島素依賴型糖尿病病患自我照顧之情形及對糖尿病控制之影響‧中華公共衛生雜誌，13（3），276-283。
盧道寬（2007）‧台灣地區糖尿病足部潰瘍感染之住院盛行率，醫療耗用及其影響因素之研究-從1996年~2004年‧高雄：高雄醫學大學醫務管理學研究所碩士論文。
蘇玲華、張桂美（2004）‧足部護理‧於財團法人糖尿病關懷基金會‧糖尿病足部照護（65-73頁）‧台北：健康文化

二、英文部分
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Apelqvist, J., Bakker, K., van Houtum, W. H., Nabuurs-Franssen, M. H., &; Schaper, N. C. (2000). International consensus and practical guidelines on the management and the prevention of the diabetic foot. Diabetes Metabolism Research and Reviews, 16 (supple 1), S84-S92.
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Bandura, A. (1982). The assessment and predictive generality of self-percepts of efficacy. Journal of Behavior Therapy &; Experimental Psychiatry, 13(3), 195-199.
Bandura, A. (1997). Self-efficacy: the exercise of control. New York: W. H. Freeman &; Company.
Bandura, A. (2004). Health promotion by social cognitive means. Health Education &; Behavior, 31, 143-164.
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