臺灣博碩士論文加值系統

論文摘要
論文名稱：運用改良式都治策略照護模式於門診肺結核病患之成效探討
研究所名稱：臺北醫學大學護理研究所
研究生姓名：董孟冠
畢業時間：九十四學年度第二學期
指導教授：張文英 臺北醫學大學護理研究所 副教授
肺結核病是屬於高盛行率及高醫療利用之疾病，然在目前的醫療體制下，醫療院所要做都治策略有其困難，因所花費之人力、物力及財力是非常龐大的。因此本研究希望能建立一適合本國醫院門診之結核病患及符合病患及家屬需求之結核病改良式都治策略照護計劃，並比較門診肺結核都治策略病患與一般門診病患於疾病認知程度、服藥遵從性、就醫失聯率、完治率、服務滿意度之差異，以提升肺結核病患之服藥遵從性與照護品質。
本研究設計採兩組前後比較，以中部某兩家區域級醫院為研究場所，因擔心研究對象會互通疾病訊息，污染研究對象，故將619床之醫院做為實驗組；另一家595床之醫院做為對照組。實驗組採改良式都治策略照護模式，而對照組僅接受一般門診的照護模式。於實施照護方案前及後六個月，收集資料以比較不同照護模式之疾病認知程度、服藥遵從性、就醫失聯率、完治率及服務滿意度之差異。研究資料以SPSS10.0及SAS for Window 9.1套裝軟體處理，統計方法以描述性統計及卡方檢定、t檢定、配對t檢定及GEE Model等進行資料分析。
本研究收案時間為94年10月21日至95年5月31日止，共收案63人，實驗組32人；對照組31人。研究對象中，性別以男性佔多數，共40人；佔63.5%，年齡分佈以60歲以上者居多，共33人；佔52.4%，教育程度以國小以下者居多，共28人；佔44.4%，婚姻狀況以有配偶者居多，共49人；佔77.8%，居住以住透天厝者居多，共53人；佔84.1%，職業以無職業者居多，共39人；佔61.9%，抽煙習慣以無抽煙者居多，共46人；佔73.0%，以上變項均無顯著性差異(p ＞.05)。在肺結核疾病認知程度方面：實驗組在改良式都治策略照護模式未介入前對疾病認知程度之平均得分為76.88分(總分為100分)，介入後提昇為94.69分，達統計上之顯著差異(p＝.000)；而對照組在改良式都治策略照護模式未介入前對疾病認知程度之平均得分為74.19分，介入後提昇為81.29分，亦達統計上之顯著差異(p＝.001)。在服藥遵從性、完治率方面，實施改良式都治策略照護模式之實驗組與一般門診之對照組在統計上未達顯著差異(p ＞.05)。就醫失聯率方面，實施改良式都治策略照護模式之實驗組無失聯情形發生，而一般門診之對照組有1人失聯，失聯率為3.22%。服務滿意度方面，實驗組對於服務滿意度之平均總得分為52.4分（滿分60分）；而對照組之平均總得分為48.2分，兩組在統計上具有顯著差異(p＝.019）。
本研究結果發現改良式都治策略照護模式可提升門診肺結核病患之疾病認知程度與服務滿意度，故建議未來改良式都治策略照護模式在肺結核之照護上應廣為推廣，以提升結核病患者之照護品質。

關鍵詞：改良式都治策略照護、肺結核、門診、成效

Abstract
Title of Thesis: The Effectiveness of the Modified DOT Short couurse care
Model on patients with Tuberculosis at Outpatient
Departments
Institution: Graduate Institute of Nursing, Taipei Medical University
Author：Men-Kung Dong
Thesis directed by：Wen-Yin Chang, Associate Professor

Tuberculosis is a highly infectious disease and costly. However, under current Health care system, it is very difficult to implement Directly Observed Treatment,Short Course since it requires enormous manpower,resources, and financial investment. Therefore, the purposes of this study were to establish a
Suitable DOTS for patients with tuberculosis in Taiwan, and to compare the
differences in knowledge of tuberculosis, drug compliance, the percentage of discontinuity, and completion of treatment, and service satisfaction between patients with and without receiving DOTS.
The design was two groups pre-and post comparison. Subjects were chosen from two regional medical teaching hospitals in central Taiwan. In order to prevent any bias resulted from communications between groups, one hospital with 619 beds was selected as experimental group, and another hospital with 595 beds as control group. For patients who were in the experimental group received the Modified DOTS care and the control group was treated with routine care. Data were collected before and after six months of intervention . The differences of the knowledge of tuberculosis, drug compliance, the percentage of discontinuity and completion of treatment, and service satisfaction between two groups were then compared. Data were processed with SPSS 10.0 and SAS for window 9.1 and analyzed using descriptive statistics, chi-square, t-test, paired t-test, and GEE model correlation.
The results were shown as follows. There were 63 patients in total, with
32 from experiment group and 31 from control group. Data were collected from October of 2005 to May of 2006. Of these 63 patients, 40 were males (63.5%); 33 (52.4%) were 60 years old and above. 28 (44.4%) were only elementary graduates or below and 49 (77.8%) were married. 53 (84.1%) were living in town house and 39 (61.9%) were jobless. 46 (73.0%) were non-smoker. However, no significant differences were found between groups in the above mentioned variables (p＞.05).For the experimental group, the average scores of the tests on the knowledge of tuberculosis for before-Modified DOTS and after-Modified DOTS were 76.88 , 94.69
respectively (p＝.000). For control group, the average score was 74.19 before -Modified DOTs care and 81.29 after the treatment (p＝.001).For drug compliance and rate of completion, the results from experimental group were better than that of control group with no significant difference was found (p＞.05).For rate of discontinuity, no single case was found in the experimental group and only one (3.22%) was found in the control group.For service satisfaction, the average score for the experimental group was 52.4 out of 60 in total and 48.2 for the control group (p＝.019).
The findings of this study demonstrate that the Modified DOTS care surely increase the knowledge and satisfaction for patient with tuberculosis. Therefore, it is recommended that the Modified DOTs care should be implemented in clinical settings to improve the quality of patient care.

Key words: Modified DOTS, Tuberculosis, Outpatient Department, Effectiveness.

目 錄
頁 數
致 謝……………………………………………………………..I
中文摘要……………………………………………………………..III
英文摘要……………………………………………………………..V
目 錄……………………………………………………………..VII
圖表目次……………………………………………………………...X

第一章 緒論………………………………………………1
第一節 背景與動機………………………………………2
第二節 研究目的………………………………………....3
第三節 研究假設………………………………………....4
第四節 操作型定義………………………………………5
第二章 文獻查證…………………………………………7
第一節 肺結核的相關概念………………………………7
第二節 都治策略之相關概念……………………………12
第三節 都治策略的相關研究……………………………15
第四節 服藥遵從性的相關概念…………………………20
第五節 研究概念架構…………………………………….23
第三章 研究方法………………………………………….24
第一節 研究設計………………………………………….24
第二節 研究對象………………………………………….26
第三節 研究工具………………………………………….27
第四節 兩組照護模式之介入措施……………………….30
第五節 研究進行步驟…………………………………….32
第六節 資料分析………………………………………….36
第四章 結果……………………………………………….37
第一節 研究樣本之基本屬性……………………………..37
第二節 兩組照護模式對病患疾病認知程度之成效……..40
第三節 兩組照護模式對病患服藥遵從性之成效………..44
第四節 兩組照護模式對病患就醫失聯率之成效………..46
第五節 兩組照護模式對病患完治率之成效……………..48
第六節 兩組照護模式對病患服務滿意度之成效………..50
第七節 討論………………………………………………..54
第一節 兩組照護模式對病患疾病認知程度之比較……...54
第二節 兩組照護模式對病患服藥遵從性之比較………...55
第三節 兩組照護模式對病患就醫失聯率之比較………...56
第四節 兩組照護模式對病患完治率之比較……………...57
第五節 兩組照護模式對病患服務滿意度之比較………...60
第六章 結論與建議……………………………………….61
第一節 結論………………………………………………..61
第二節 未來貢獻…………………………………………..63
第三節 研究限制及建議…………………………………..64

參考資料………………………………………………………………..65
中文部份…………………………………………………………..65
英文部份…………………………………………………………..67

附錄
附錄一 肺結核病患認知程度問卷表………………………..71
附錄二 致專家效度鑑定函……………………………………….74
附錄三 肺結核病患認知程度問卷表之專家效度評分表……….76
附錄四 肺結核病患認知程度問卷表內容之專家效度及建議….78
附錄五 肺結核病患自我照護指引手冊………………………….80
附錄六 肺結核病患自我照護指引手冊之專家效度評分表…….85
附錄七 肺結核病患自我照護指引手冊主題內容效度評分結果.87
附錄八 肺結核病患自我照護指引手冊主題內容之專家效度
及建議…………………………………………………….88
附錄九 肺結核疾病管理照護登錄表…………………………….89
附錄十 家屬觀察藥物日誌表…………………………………….91
附錄十一 病患服務滿意度問卷調查表…………………………….92
附錄十二 病患服務滿意度問卷調查表之專家效度評分表……….93
附錄十三 病患服務滿意度問卷調查表之專家效度及建議……….97
附錄十四 研究同意書(實驗組)……………………………………..99
附錄十五 研究同意書(對照組)……………………………………..100










圖表目次
圖一 改良式都治策略照護模式於門診肺結核病患成效之概念架
構……………………………………………………………….23
圖二 研究進行流程圖……………………………………………….35
圖三 疾病認知程度之成效分析…………………………………….43
表一 紐約結核病患服藥遵從性小於80%之評定標準…………….19
表二 研究實驗組與對照組前後實驗設計………………………….25
表三 門診肺結核病患兩組基本資料之比較……………………….39
表四 兩組肺結核病患在介入前後對疾病認知程度得分之差異比較
…………………………………………………………………..41
表五 實驗組與對照組疾病認知程度之GEE Model分析……….…42
表六 兩組門診肺結核病患服藥遵從性之比較……………………..45
表七 兩組門診肺結核病患失聯率之比較…………………………..47
表八 兩組門診肺結核病患完治率之比較…………………………..49
表九 兩組門診肺結核病患服務滿意度之比較……………………..52
表十 兩組門診肺結核病患服務滿意度之排序比較………………..53

參考資料
中文部份
王曼溪(2000)．如何製作好懂易讀的書面衛教資料．台灣醫學，4(3)，334-337。
王任賢(2004) ．中部地區結核病防治計畫，行政院衛生署疾病管制局，2004年年報。
行政院衛生署疾病管制局(2002)．結核病防治工作手冊，台北，行政院衛生署疾病管制局。
行政院衛生署疾病管制局(2004)．結核病防治工作手冊，台北，行政院衛生署疾病管制局。
江振源(2000)．DOTS-結核防治之最佳策略．胸腔醫學，15(4)，172-176。
江振源、李仁智、索任(2004)．結核病診治指引．台北，行政院衛生署疾病管制局。
李如萍(1996)•花蓮地區肺結核病人之服藥遵從性及其相關因素之探討•護理雜誌，45(1)，63-68。
何延鑫(1998)．運用護理指導增進門診結核病個案服藥之遵從行為．榮總護理，15(3)，1-9。
索任(2001)．原住民肺結核問題的探討.原住民傳統和現代醫療．財團法人台灣原住民文教基金會，129-148。
索任(2003)．結核病的病理發生與防治策略．台灣胸腔學會雜誌，5(3)，36-48。
陸希平、王乃弘、郝宏恕(2004).病案管理與疾病管理，台灣醫界，
46(10)，51-56。
曾惠明、楊長興、李淑雅(2001)．病人滿意度與醫療照護者工作滿意度．醫院，34(4)，16-23。
蘇維鈞(2002)．抗結核藥物使用須知．臨床醫學，50(3)，140-151。

英文部份
Ailinger, R. L. , Lasus, H., & Dear, M. (2001). Americans＇Knowledge and perceived risk of tuberculosis. Public Health Nurs, 20(3), 211-215.
Berroa, J. (1998). Case management A nursing point of view. International Journal of Tubercle Lung Disease, 2(9), S53-S56.
Blanc, L., Chaulet,P., ＆ Espinal,M. (2003). Treatment of tuberculosis: guidelines for national programmes. World Health Organization, 3rd ed, 313.
Chaulk, C. P., Moore-Rice, K., Rizzo, R., & Chaisson, R. E. (1995).
Eleven Years of the community-based directly observed therapy for tuberculosis. Journal of the American Medical Association, 274(12).
945-951.
Caminero, J. A., Pavon, J.M., Rodriguezde Castro, F., Diaz, F., Julia, G., Cayla, J.A. et al. (1996). Evaluation of a directly observed six months fully intermittent treatment regimen for tuberculosis in patients suspected of poor compliance. Thorax, 51(11), 1130-1133.
Chaulk, C.P.,& Pope, D. S. (1997). The Baltimore city health deparment Program of directly observed theraphy for tuberculosis. Clinics in Chest Medicine, 18(1), 149-154.
Carr, D.D. (2000). Case management for the subacte patient in a skilled nursing facility. Nursing Case Management, 5(2), 83-92.
Dorsinville, M. S. (1998). Case management of tuberculosisprograms. Bulletin of the International Union Against tuberculosis & Lung Disease, 66(4), 195-200.
Diana, G. (2002). Tuberculosis Update:A Changing disease. Dermatology
Nursing News, 14(5), 339.
Deriemer, K., Garcia ,L., Bobadilla-del-valle, M., Palacios-Martinze, M., Gamboa, A., Small , PM. et al (2005). Does DOTs work in populations with drug-resistant tuberculosis? Lancet Journal, 365(9466), 1239-1245.
Dick, M., Anne, F., Lillian, Y., & Mark,F. (2003). American Thoracic Society/ Center for Disease Control and Prevention/Infectious Disease Society of America:Treatment of Tuberculosis. American Journal of Respiratory and Critical Care Medicine, 167(4), 603-662.
El-sadr, M., Medarrd, F., & Barthaud, V. (1996). Directly observed therapy for tuberculosis: The Harlem hospital experience, American Journal of Public Health, 86, 1146-1149.
Grzybowski , S., & Enarson, D. A. (1978). The fate of pulmonary tuberculosis under various treatment programmes. Bulletin International Union Tubercle and Lung Disease, 53(2), 70-75.
Hodge, R. R. (2000). An investigation of behavioral factors related to successful adherence of tuberculosis patients to directly obsereved therapy. Unpublished Doctoral Dissertation, Temple University.
Helen, M. S. (2005). Co-infection with HIV and TB: double trouble.
Intemational Journal of STD & AIDS, 16(2), 95-101.
Laramee, A. S., Levinsky, S. K., Sargent, J., Ross, R., & Callas, P. (2003).
Case management in a heterogeneous congestive heart failure population: a randomized controlled trial. Archives Internal Medicine, 163(7), 809-817.
Mathema, B. P., Jochem, K., Hoston, R. A , Smith, I., Bam, D. S & McGowan, J. E. (2001). Tuberculosis treatment in nepal: A rapid assessment of governational centers using different types of patient supervision. International Journal of Tuberculosis & Lung Disease, 5(10), 912-919.
Mayer, G. G. (2002). Writing easy-to-raed teaching aids. Nursing, 2(3), 48-49.
Olle-Goig , J. E. & Alvared, J. (2001). Treatment of tuberculosis in a rural area of Haiti: Directly observed and non observed regimens. The experience of H pital Albert Schweizer. International Journal of Tuberculosis & Lung Disease, 5(2), 137-141.
Pozsik, C. J. Kinney, J.Breeden, D. Nivin, B. & Davis,T. (1993). Compliance with tuberculosis therapy. Medical Clinics of North American, 7(6),
1289-1301.
Paramasivan C.N., & Venkataraman, P. (2004). Drug resistance in tuberculosis in India. India Journal of Medical Research, 120(4), 377.
Schluger, N., Ciotoli, C., Cohen, D., Johnson, H., & Rom, W.M. (1995).
Comprehensive tuberculosis control for patients at high risk for noncompliance. American Journal of Respiratory Critical Care Medicine, 151(5), 1486-1490.
Thrupp, L.,.Bradley, S., Smith, P., ＆Simor, A. (2004). Tuberculosis Prevention and Control in Long-Term-Care Facilities for Older Adults. Infection Control and Hospital Epidemiology, 25(12), 1097-1109.
Wilkinson, D. (1994). High-compliance tuberculosis treatment in rural community. Lancet journal, 343, 647-648.
World Health Organization. (1999). What is DOTS? A guide to understanding the WHO-recommended TB control strategy known as DOTS. in World Health Organization, The World Health Report. symposium conducted at the meeting of the World Health Organization, Geneva, Switzerland.
Wares, D. F., Akhtar, M., & Singh, S. (2001). DOT for patients with limited access to health care facilities in ahill district of eastern Nepal. International Journal of Tuberculosis and Lung Disease, 5(8), 732-740.
World Health Organization. (2004). Excutive Summary Third Global
Report. August 15. from report xec.pdf.
World Health Organization.(2005). Stop T.B At the Source The World Health Report. symposium conducted at the meeting of the World Health Organization, Geneva, Switzerland.
Xianyi, C., Fengzeng, Z., Hongjin, D., Liya, W., Lixia, W., Xin, D., Daniel,
P. C. et al. (2002). The DOTS Strategy in chia:Result and lessons after 10 years. Bulletin of world health organization, 80(6), 430-436.