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研究生:黃琬菁
研究生(外文):Wen-Ching Huang
論文名稱:第1型糖尿病童之醫囑遵從行為評估:比較24小時回溯記錄和7天醫囑遵從行為日誌
論文名稱(外文):Assessing adherence behaviors in Type 1 diabetes children and adolescent: Compare the 24 –hour recall technique and 7-day diary records methods
指導教授:葉昭幸葉昭幸引用關係
指導教授(外文):Chao-Hsing Yeh
學位類別:碩士
校院名稱:長庚大學
系所名稱:護理學研究所
學門:醫藥衛生學門
學類:護理學類
論文種類:學術論文
論文出版年:2005
畢業學年度:94
語文別:中文
論文頁數:59
中文關鍵詞:第1型糖尿病醫囑遵從行為評估24小時回溯記錄7天醫囑遵從行為日誌
外文關鍵詞:Type 1 diabetesadherence behaviors24-hour recall7-day diary records
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本研究目的為:(1)比較24小時回溯記錄和7天醫囑遵從行為日誌中量表之信效度、(2)描述第1型糖尿病童之醫囑遵從行為結果的狀況(包含胰島素注射與飲食間隔時間、血糖自我監測次數、飲食攝取總熱量、三大營養素熱量攝取比例(醣類、脂肪、蛋白質)及運動時間)、(3)探討第1型糖尿病童的醫囑遵從行為與血糖控制結果之關係。研究對象包括北部某兒童醫院門診59位10至18歲之第1型糖尿病病童,以結構式問卷收集資料,包含第1型糖尿病童24小時及7天醫囑遵從行為日誌、第1型糖尿病童基本資料表及病歷摘要;資料處理方法為:以描述性統計探討人口學資料(病童年齡、性別、身高、體重、身體質量指數(BMI)、教育程度、家庭社經地位)、臨床生理檢查結果、醫囑遵從行為結果等;運用廣義估計方程式(Generalized Estimating Equations, GEE)以重複測量(repeated measure)之觀念,檢定每位研究對象24小時回溯記錄與7天醫囑遵從行為日誌中,各項醫囑遵從行為結果比較;利用集群分析(Cluster analysis)及單因子變異數分析(one way ANOVA)方法以比較不同集群之間各項醫囑遵從行為是否具有差異。
本研究結果顯示:在比較24小時回溯記錄和7天醫囑遵從行為日誌中量表之信效度方面,以24小時回溯記錄結果為參考組,自變項為不同的時間點,依變項則為各項醫囑遵從行為,結果顯示:胰島素注射與飲食間隔時間、血糖自我監測、飲食總熱量、醣類攝取比例、脂肪攝取比例、蛋白質攝取比例並未有顯著差異;運動時間部分,則仍舊是有體育課之平常日的運動時間確實具有顯著差異;由此可知,第1型糖尿病童之醫囑遵從行為中,除了運動時間外,可以24小時回溯記錄的方式予以評估。
第1型糖尿病童之醫囑遵從行為結果的狀況,以24小時回溯的研究結果顯示:不論使用何種胰島素,病童胰島素注射與飲食間隔時間仍未在理想時間內,例如使用速效胰島素者,其24小時回溯胰島素注射與飲食間隔時間為20.19分(理想時間為少於15分);使用短效胰島素者,其24小時回溯則間隔時間為25分(理想時間為30分鐘-60分鐘);血糖自我監測方面,24小時回溯則為2.22次;飲食評估方面,24小時回溯進食總熱量平均為1435.7卡、醣類熱量進食比例為57.2%、脂肪熱量進食比例方面為27.5%、蛋白質熱量進食比例為15.3%;運動時間方面,24小時回溯運動時間平均為33分,但運動時間與學校生活有密切相關,有體育課時運動時間有顯著的差異(有體育課之平常日為47.2分、無體育課之平常日為16分)。
病童醫囑遵從行為與血糖控制結果之關係方面,結果顯示短期(最近三個月)糖化血色素(HbA1c)平均值為9.9%,可見在血糖控制方面仍有待改善。為了瞭解血糖控制結果與醫囑遵從行為的關係,進一步以集群分析(Cluster analysis)將病童血糖控制結果區分為:控制較好者(N=14、短期糖化血色素平均為7.3%)、需監控者(N=37、短期糖化血色素平均為10.0%),與亟需監控者(N=8、短期糖化血色素平均為13.9%)三個族群;結果顯示各族群中,需監控者、亟需監控者,其各項醫囑遵從行為表現較差,例如:血糖監測次數方面,控制較好者為監測3次/天,需監控者的測試頻率2.1次/天、亟需監控者僅1.5次/天;運動時間方面控制較好者平均為49.3分,需監控者為28.9分,亟需監控者為23.1分;但是,若進一步比較不同集群(控制較好者、需監控者與極需監控者)的醫囑遵從行為表現是否具有差異,則僅血糖自我監測具有顯著差異,其餘則無。
本研究結果建議:(1)護理人員評估第1型糖尿病童之醫囑遵從行為時,應可以24小時回溯記錄方式,方能獲取較具代表性的醫囑遵從行為;(2)護理人員可藉由醫囑遵從行為評估,瞭解個案對於不同層面其醫囑遵從行為表現,可進一步發掘個案目前較欠缺之衛教項目及其執行自我照顧所面臨的困難與障礙,甚至可從中適時提醒醫師再次檢視和修正醫囑遵從行為。
Diabetes mellitus is one of the most frequently occurring
chronic diseases in childhood and adolescent. The purpose of this study is:(1) To compare the validity of the medical adherence behaviors by using the 24-hour recall technique and 7 day diary record methods (2) To examine the relationship between medical adherence behaviors and glycemic control outcome (HbA1c).The data were collected in the outpatient clinics of a children hospital in north Taiwan. In total, 59 patients with type 1 DM, aged from 10 to 18, were recruited in this study. The patients completed 3 structural questionnaires which contain the medical adherence behavior records (24- hour and 7 days), and demographic information. In addition, medical information about the patients also collected from medical charts review records. The medical adherence behaviors records include the subjects’ inject-meal timing, blood glucose monitoring frequency, calories consumption (including percentage of calories from carbohydrates, fat, protein) and physical activity. Descriptive statistic was used to present the demographic information and each measures. Generalized Estimating Equations(GEE), Cluster analysis, and one way ANOVA were used to examine the relationship of adherence behaviors and HbA1c.
The results showed that twenty-four hour recall methods has the comparable reliability and validity when comparing with 7-day diary, except the total physical activity time. This finding suggested that 24 -hour recall method is a better way for collecting adherence behaviors in terms of saving time. The adherence behaviors are presented by using 24 hours recall methods. For insulin injection time, no matter using what kind of insulin, subjects can’t inject within the suggestion time. The average glucose monitoring frequency, the mean is 2.22 test times per day, which is still far beyond the 4 times a day. For the dietary consumption, the mean of total intake calories would be 1425.7 kcal, with 57.2% in glucose, 27.5 % in fat and 15.3% in protein. However, these calories consumption are less than their ideal calories. In physical activity,in 24-hour recall diary, the mean activity time for a day was 33 minutes, however, the physical classes at school play an important effecting factor, significant associations were found between moderate physical activity and physical classes.
For glycemic control status, the subjects’ mean HbA1c in short period (latest 3 months) was 9.9% indicating that these subjects didn’t have well glycemic control. Cluster analysis was used to identify the characteristics of patients’ adherence behaviors, according to the glycemic control outcomes. Three groups of patients were identified according to the HbA1c results. For group 1 (N=14), named as well control group, who’s mean HbA1c would be 7.3%, For group 2 (N=37), named as need to control group, who’s mean HbA1c would be 10.0%. For group 3 (N=8), named as egrets to control group, who’s mean HbA1c would be 13.9%. The result indicated that in these three groups; need to control group and egret to control group show poor adherence behaviors. For example, in glucose monitoring frequency, well control subjects monitor 3 times a day, however, for need to control subjects, and egrets to control ones, the glucose monitoring frequency is only 2.1 times a day and 1.5 times; whereas in physical activity, well control subjects exercise 49.3 minutes, however, for need to control subjects, and egrets to control ones, the time is only 28.9 minutes and 23.1 minutes. But, after comparing these three groups in these different adherence behaviors, only glucose monitoring frequency as the significant variables, others are not.
Based on this result, it is suggested that, healthcare providers can use 24-hour recall technique to obtain patients’ adherence behaviors. In order to understand and improve patients’ medical adherence behaviors, healthcare providers should conduct comprehensives evaluations.
目 錄
第一章 序論…………………………………………………………………………………….. 1
1.1 研究動機與重要性……………………………………………………………………... 1
1.2 研究目的………………………………………………………………………………... 3
1.3 名詞解釋…………………………………………………………………...................... 4
第二章 文獻查證……………………………………………………………………………….. 6
2. 1 簡介第1型糖尿病……………………………………………………………..……… 6
2. 2 簡介醫囑遵從概念………..…………………………………………………………… 8
2. 3 第1型糖尿病之醫囑遵從行為……………………………………………………….. 9
2. 4醫囑遵從行為與疾病控制結果之關係……………………………………………….... 17
第三章 研究方法……………………………………………………………………………… 18
3.1 研究架構………………………………………………………………........................ 18
3.2 研究對象及場所………………………………………………………........................ 19
3.3 研究工具………………………………………………………………………………. 20
3.4 資料收集步驟…………………………………………………………………………. 23
3.5 資料分析過程…………………………………………………………………………. 27
3.6 研究倫理考量…………………………………………………………………………. 28
第四章 研究結果……………………………………………………………………………… 29
4.1 第1型糖尿病童之基本資料、疾病特性及病童父母之基本資料…………………. 30
4.2 比較24小時回溯記錄和7天醫囑遵從行為日誌之結果……………...................... 35
4.3 第1型糖尿病童之血糖控制結果……………………………………………………. 41
4.4 第1型糖尿病童之醫囑遵從行為與血糖控制結果之關係…………........................ 43
第五章 討論……………………………………………………………………....................... 46
5.1 探討第1型糖尿病童之醫囑遵從行為結果…………………………........................ 47
5.2 探討第1型糖尿病童之醫囑遵從行為與血糖控制結果之關係……………………. 54
第六章 結論與應用建議……………………………………………………………………… 56
6.1結論…………………………......................………………………….......................... 56
6.2研究限制與建議…….................................................................................................. 57
6.3護理應用與建議…………………………................................................................... 59
參考文獻…………………………………………………………………….………………….. 60
附錄……………………………………………………………………………………...........… 68

圖 表 目 錄
表2-1 胰島素施打時間………………………………………………………………………… 10
表2-2 胰島素作用時間………………………………………………………………………… 10
表2-3 運動時飲食、胰島素的調整原則……………………………………………………… 16
圖3-1 第1型糖尿病童醫囑遵從行為與血糖控制結果之關係……………………………… 18
圖3-2 資料收集步驟…………………………………………………………………………… 26
表4-1 第1型糖尿病童之基本資料與疾病特性……………………………………………… 32
表4-2 有無加入照護網之第1型糖尿病童其基本資料與血糖控制結果…………………… 31
表4-3 第1型糖尿病童之雙親及其家庭基本資料…………………………………………… 34
表4-4 第1型糖尿病之醫囑遵從行為結果(胰島素注射、血糖自我監測)………………… 36
表4-5 第1型糖尿病之醫囑遵從行為結果(飲食、運動)…………………………………… 37
表4-6 比較7天醫囑遵從行為日誌中,同為假日時之醫囑遵從行為……………………… 37
表4-7 比較7天醫囑遵從行為日誌中,同為有體育課之平常日的醫囑遵從行為………… 38
表4-8 比較7天醫囑遵從行為日誌中,同為無體育課之平常日的醫囑遵從行為………… 38
表4-9 比較7天電話訪談中,假日、有體育課、無體育課之醫囑遵從行為……………… 39
表4-10 比較24小時回溯記錄與7天醫囑遵從行為日誌之醫囑遵從行為(1)…………… 39
表4-11 比較24小時回溯記錄與7天醫囑遵從行為日誌之醫囑遵從行為(2)…………… 40
表4-12 第1型糖尿病童之糖化血色素(HbA1c)……………………………………………… 42
表4-13 不同集群之糖化血色素結果…………………………………………………………… 43
表4-14 不同集群之醫囑遵從行為……………………………………………………………… 45
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