臺灣博碩士論文加值系統

研究背景：心房纖維顫動（atrial fibrillation, AFib）患者會以口服抗凝血劑減少中風機會，而服用抗凝血劑者常有用藥知識不足的問題，因此，提供有效的安全服藥指導極為重要。
研究目的：本研究目的針對AFib服用抗凝血劑患者，探討個案於接受健康信念模式為理論基礎的多元互動式健康指導方案後，在抗凝血劑服藥認知、健康信念、服藥滿意度、生活品質及醫療健康狀況的成效及其影響因素。
研究方法：本研究為隨機控制實驗，於北部兩所醫學中心心臟內科門診收案，採立意取樣，研究對象為AFib正在口服抗凝血劑患者，以診區時段為單位隨機分派分為實驗組與對照組。收案期間為2015年7月至2016年1月，研究控制變項為：人口學特質及醫療健康史。研究工具為：服藥認知及健康信念 (自擬量表)、服藥滿意度 (Duke Anticoagulation Satisfaction Scale, DASS)、生活品質 (Short Form-12, SF-12) 與醫療健康狀況，除認知問卷及醫療健康狀況採前測、第一個月、第二個月及第三個月後測外，其餘量表測量前測及第三個月後測。實驗組介入措施為：於門診一對一指導如何安全服用抗凝血劑，並以健康信念模式為健康指導的理論基礎、運用健康指導資訊系統、每月電話追蹤及提供服藥識別卡等。對照組則僅提供衛教單張及服藥識別卡。資料以描述性統計呈現研究對象基本屬性、各項量表得分及接受與運用抗凝血劑相關資訊狀況，推論性統計以t-test、ANOVA、Chi-square test、McNemar test、Pearson correlation分析，以Generalized Estimating Equation (GEE)及effect size分析介入措施的成效，以multiple linear regression分析成效指標之預測因子。
研究結果：前測時收案164位，平均年齡為65.71 ± 9.84歲，以男性及小學教育程度居多，除了癌症比率為實驗組多於對照組外，兩組前測資料無顯著差異。第三個月後測個案數為159人，實驗組79人，對照組80人。認知總分：實驗組於後測三個時間點皆顯著高於對照組，每一個時間點皆呈現高的介入措施成效量，並於較複雜的飲食及藥物交互作用、生活安全及副作用議題上呈現明顯成效。健康信念總分：實驗組進步幅度多於對照組，呈現中等的介入措施成效量，次量表中以「自我效能」的成效最好。行動線索：實驗組有複習視聽教材投影片、有使用APP及臉書者的抗凝血劑認知總分較無使用者高，有使用服藥識別卡比無使用者的認知及健康信念總分高。服藥滿意度總分：實驗組由前測到第三個月後測的服藥滿意度提升，但為低的介入措施成效量。生活品質：兩組的生理及心理生活品質於三個月間分數變化不大，且兩組差異不明顯。醫療健康狀況：兩組的出血及國際標準化比值 (international normalized ratio, INR) 於治療標準內的人數無差異，研究期間無人發生中風。認知與健康信念呈現明顯介入措施成效，探討其進步分數的影響因素：認知與健康信念進步分數互為正相關，認知進步分數的重要預測因子為實驗組 (B = 5.87)、服用新型抗凝血劑 (B = 3.37)、低的前測自覺威脅感 (B = -0.08) 與自我效能 (B = -0.06) 及高的前測服藥滿意度 (B = -0.05) (低的DASS總分)，總解釋力為58.4%；健康信念進步分數的預測因子為低的前測認知總分 (B = -0.68) 及實驗組 (B = 6.63)，總解釋變異量為14.3%。
結論：本研究以健康信念模式為理論基礎的多元互動式健康指導方案，比僅提供衛教單張的方式在抗凝血劑服藥認知、健康信念上有明顯的成效，服藥滿意度、生活品質及醫療健康狀況的成效則不明顯。健康指導介入措施涵蓋適當的理論架構及多元的方式是提升認知及健康信念的關鍵，尤其適用於較複雜的安全服用抗凝血劑議題。提升服藥認知程度可藉由關注服用不同抗凝血劑患者的需求，增加其對服用抗凝血劑的警覺性、遵循注意事項的信心及減少服藥的衝擊與負荷，而認知與健康信念息息相關，服藥知識的增加也能同時提升正向的健康信念。

Background: Patients with Atrial fibrillation (AFib) are often prescribed oral anticoagulants (OACs) to reduce the risk of stroke. However, considering the general lack of medical knowledge among patients taking OACs, adequate medication instruction is crucial.
Purpose: This study examined patients on taking OACs for AFib to determine the effectiveness of a multiple interactive health education program, which was developed based on the Health Belief Model (HBM) and incorporated information technologies. The program’s effectiveness was evaluated according to outcome indicators: the patients’ knowledge regarding OACs, health beliefs, satisfaction over the anticoagulant taken, quality of life (QoL), and health status. Factors that influenced these indicators were also examined.
Methodology: A randomized controlled study was conducted on the cardiology outpatients of two medical centers in northern Taiwan. The patients were recruited through purposive sampling. They had been diagnosed with AFib and were receiving OACs. The patients were divided according to the blocks of clinic hours and assigned randomly to the experimental group or control group. The control variables involved demographic characteristics and medical history. The dependent variables and their corresponding research instruments were medication knowledge and health beliefs (questionnaires designed by the research team), medication satisfaction (Duke Anticoagulation Satisfaction Scale, DASS), QoL (Short Form-12, SF-12), and health status. Other than the medication knowledge questionnaire, which was assessed monthly, all the measurement instruments were applied twice: first in a pretest, and again in a posttest administered at the third month. The interventions administered to the experimental group were one-on-one instruction and HBM-driven strategies, health information technology system, monthly telephone follow-ups, and providing medication cards. Patients in the control group only received brochure and medication cards. The data were analyzed using descriptive statistics and inferential statistics (t-test, ANOVA, Chi-square test, McNemar test and Pearson correlation). The effectiveness of the interventions was analyzed using Generalized Estimating Equation (GEE) and effect size. Predictors of the effectiveness were analyzed using multiple linear regression.
Results: In total, 164 participants were recruited, and their average age was 65.71 ± 9.84 years. The majority of the patients were men and had an educational level of elementary school. Other than cancer history, the two groups exhibited no difference in pretest. Regarding the posttests, 159 participants were involved, of whom 79 belonged to the experimental group and 80 to the control group. For “knowledge of anticoagulants”, the experimental group’s posttest scores higher than those of the control group for all three posttests. This effectiveness indicated that the instruction program had a high effect size. Of the related complicated and safety issues of interactions between diet or medication exhibited the greatest effectiveness. Regarding the total score of health beliefs, the experimental group’s score of improvement was higher than that of the control group, and the experimental group’s posttest score was higher than the control group significantly. In terms of these effectiveness, the related interventions were deemed to be moderate effect size, and were most effective in the aspect of “self-efficacy”. With regard to “cues to action”, experimental group patients who studied the medical instruction slideshows and who used mobile applications and Facebook revealed a higher total score in knowledge of anticoagulants than those who did not. Those who used medication cards revealed higher total scores in knowledge and health belief. For “medication satisfaction”, the posttest score of the experimental group revealed an increase, but the related interventions were of low effectiveness. Regarding “QoL”, both groups exhibited little difference over the three months, and the difference between the two groups was also nonsignificant. For “health status”, no difference was observed between the two groups in the number of members that experienced bleeding and the international normalization ratio, none of the participants experienced a stroke during the study period. The results of the factors that influenced the effectiveness indicators revealed that the improvements of total scores for knowledge of anticoagulants and health belief were positively correlated. Predictors for high improvement in knowledge included experimental group (B = 5.87), taking non-vitamin K antagonist OACs (B = 3.37), lower perceived severity (B = -0.08), lower self-efficacy (B = -0.06) and higher medication satisfaction (B = -0.05) (lower total score of DASS) in the pretest, and the total variance explained was 58.4%. The predictors for high improvement in health belief were lower medication knowledge pretest score (B = -0.68) and experimental group (B = 6.63), and the total variance explained was 14.3%.
Conclusion: This study determined that the multiple interactive health education program, which was developed on the theoretical basis of the Health Belief Model, was significantly more effective than mere provision brochure in improving patients’ knowledge of anticoagulants and patients’ health beliefs. However, the program’s effectiveness was low in terms of patients’ medication satisfaction and QoL. Providing health education based on theory and multiple methods is imperative to improve medication knowledge and health beliefs. It is especially suitable for complicated issues of anticoagulants. Health providers should pay more attention to the different needs among patients who are taking variant anticoagulants, increasing patients’ awareness of taking anticoagulants, self-efficacy for performing precautions, and decreasing the impacts and burdens of taking OACs when designing an educational intervention, which are essential factors for advancement in medication knowledge. The improvements of knowledge of anticoagulants and health belief were correlated. Promoting patients’ medication knowledge will also improve their health beliefs.

口試委員審定書.................................................................................................. i
致謝...................................................................................................................... iii
中文摘要.............................................................................................................. v
英文摘要.............................................................................................................. vii
目錄...................................................................................................................... xi
圖目錄.................................................................................................................. xiii
表目錄.................................................................................................................. xiv
第一章 緒論........................................................................................................ 1
第一節 研究背景......................................................................................... 1
第二節 研究重要性及研究動機................................................................. 3
第三節 研究問題、研究目的與研究假設................................................. 4
第四節 名詞界定......................................................................................... 6
第二章 文獻查證................................................................................................ 9
第一節 心房纖維顫動患者的抗凝血劑藥物介紹..................................... 9
第二節 抗凝血劑服藥指導措施之設計..................................................... 12
第三節 健康指導介入措施評價指標及其研究工具................................. 17
第三章 研究方法................................................................................................ 21
第一節 研究設計......................................................................................... 21
第二節 研究架構......................................................................................... 22
第三節 研究場所及對象............................................................................. 23
第四節 研究步驟......................................................................................... 25
第五節 介入措施......................................................................................... 27
第六節 研究工具......................................................................................... 32
第七節 資料處理及分析............................................................................. 37
第八節 倫理考量......................................................................................... 39
 
第四章 研究結果................................................................................................ 41
第一節 研究個案基本資料及前測量表總分............................................. 43
第二節 健康指導介入措施前後於抗凝血劑認知分數變化及成效......... 48
第三節 健康指導介入措施前後於服用抗凝血劑之健康信念分數變化 及成效............................................................................................
57
第四節 健康指導介入措施前後於抗凝血劑服藥滿意度分數變化及成
效....................................................................................................
93
第五節 健康指導介入措施前後於服用抗凝血劑患者之生活品質分數變化及成效....................................................................................
102
第六節 抗凝血劑患者之醫療健康狀況追蹤............................................. 108
第七節 影響成效指標之因素..................................................................... 111
第五章 討論........................................................................................................ 117
第一節 健康指導介入措施對認知與健康信念結果指標之成效............. 118
第二節 健康指導介入措施於服藥滿意度、生活品質及醫療健康狀況 之成效............................................................................................
125
第三節 影響健康指導介入措施成效之因素............................................. 127
第六章 結論與建議............................................................................................ 131
第一節 結論................................................................................................. 131
第二節 研究結果之運用............................................................................. 133
第三節 研究限制及建議............................................................................. 135
參考文獻.............................................................................................................. 137
一、中文文獻............................................................................................... 137
二、英文文獻............................................................................................... 138
附錄...................................................................................................................... 149
附錄一 APP 畫面....................................................................................... 149
附錄二 各項量表......................................................................................... 151
附錄三 人體試驗倫理委員會同意書及問卷授權同意使用函................. 167
附錄四 認知各題項兩組前後測得分比較及成效分析............................. 170

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