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研究生:李尹暘
研究生(外文):Yin-yang Lee
論文名稱:信任、遵醫囑行為與健康結果於慢性病患之縱貫式研究
論文名稱(外文):A Longitudinal Study of Trust in Physicians, Adherence, and Health Outcomes in Patients with Chronic Illness
指導教授:林麗娟林麗娟引用關係李伯皇李伯皇引用關係
指導教授(外文):Julia L. LinPo-Huang Lee
學位類別:博士
校院名稱:義守大學
系所名稱:管理研究所博士班
學門:商業及管理學門
學類:企業管理學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:英文
論文頁數:145
中文關鍵詞:健康結果遵醫囑性結果預期信任自我效能預期
外文關鍵詞:adherence to recommendationshealth outcomesoutcome expectationsPatients'''' trust in physiciansself-efficacy expectations
相關次數:
  • 被引用被引用:3
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  • 下載下載:313
  • 收藏至我的研究室書目清單書目收藏:0
信任是促進病患健康行為和健康照顧品質的一個重要因子。之前較少研究探討信任與健康結果之間的關係;同時目前仍不清楚在這個關係中可能存在的中介或調節變數。此外,多數的信任研究採用了自陳式的健康量表與橫斷面分析,然而在慢性病患的醫療照護上,醫病關係卻是有長期的影響。
本研究的目的在於探討信任與慢性病患主客觀健康結果之間的關係,以及可能影響這個關係的變數。研究中我們假設信任醫師的病患可以有較強的自我效能預期與結果預期,進而增加病患的遵醫囑性,並且影響臨床的治療結果。高信任的病人也因為自我效能的強化而自覺有較佳的疾病控制與健康狀態。同時,我們也推論信任和患者預期之間的關係將會受到病患個人自主偏好(決定參與偏好、資訊偏好)的影響。
我們在臺灣針對 614名糖尿病患者進行了一年的縱貫式研究分析。結果顯示信任可以預測病患持續性的醫療照護。在我們控制初始的健康變數後,迴歸分析的結果發現信任仍可以正向地影響病患的血糖控制與生理健康生活品質。潛在成長模型(latent growth modeling)更進一步的顯示出,病患在一年的觀察中其生理健康生活品質會受到信任影響:高信任的病患有較佳的初始生理健康生活品質和更高的健康生活品質增長率。
我們在中介效果迴歸與拔靴法(bootstrapping)的分析結果中驗證了自我效能預期在信任和遵醫囑性之間,以及在信任和心理健康生活品質之間的中介角色。同時,較高的遵醫囑性可以影響病患的血糖控制。我們的結果也支持三因子的交互作用(信任 × 決定參與偏好 × 資訊偏好)可以正向影響自我效能。在使用 Preacher 等學者發展的中介性調節效果(mediated moderation)模式分析中,我們更進一步發現資訊偏好的高低可以影響信任─病患預期─遵醫囑性之間的中介關係強度。
雖然未來仍需要更多研究來確定這些關係的強弱與探索仍可能存在的干擾因子。本研究對於相關醫病關係議題的貢獻在於:我們釐清了信任與不同的類型的健康結果之間的關係,並且提出信任醫師可以影響病患生活品質與疾病控制的證據。同時,研究的結果也建議「信任,但要確認 (trust, but verify)」的醫病關係將使患者更成功地達到他們的健康期望。
Trust is a fundamentally important factor predicting a range of patient behaviors and the quality of care. However, it has been relatively unexplored in trust-outcome relationships. Few studies have investigated the factors that mediate or moderate these relationships. In addition, most trust research has made use of self-rated health and approached based on a cross-sectional analysis, whereas patient care is inherently longitudinal.
This study tested a theoretical model of variables influencing the relations of trust to both objective and self-rated health in patients with chronic illness. We hypothesized that patients who trust their physicians more were likely to have stronger self-efficacy expectations and outcome expectations. This, in turn, was associated with better treatment adherence and objective health outcomes. High trusting patients were also likely to report better health status through enhanced self-efficacy belief. Further, the relationship between trust and patient expectations would be more pronounced for patients with high autonomy preferences.
We conducted a one-year longitudinal analysis of 614 diabetic patients in Taiwan. Patients were assessed at four time points. Our analysis revealed that trust significantly predicted patient continuity. After adjusting for the corresponding outcome variable at Time 1, trust was found to be associated with patients’ glucose control and physical health related quality of life (HRQoL) at Time 4. The results of latent growth model demonstrated that physical HRQoL trajectories in diabetes patients continued to be shaped by patient trust. Higher levels of trust were associated with both better physical HRQoL at baseline and higher rates of increase over time.
The mediation roles of self-efficacy expectations between trust and mental HRQoL and between trust and adherence were confirmed by the results of Baron and Kennys’ mediation procedure and bootstrap analyses. Further, increased adherence behaviors were associated with better blood glucose control. Our results also supported the three-way interaction (Trust × Decisional preference × Information preference) in predicting patient self-efficacy. Using K. J. Preacher, D. D. Rucker, and A. F. Hayes’ (2007) mediated moderation framework, the analyses further revealed that informational preference moderated the strength of the mediated relationships between patient trust and adherence via self-efficacy or outcome expectations.
This study clarifies the association of trust with different types of health outcomes and provides the empirical evidence that trust in physicians is associated with both self-rated health and therapeutic response. We concluded that patient trust can contribute to both objective and self-rated outcomes. In particular, “trust, but verify” approach might put patients in the best position for achieving their health expectations. However, more research is necessary to precisely determine both the strength and boundary conditions of these relationships.
CHAPTER 1. INTROCUCTION
1.1 Background1
1.2 Purpose of the Study2
1.3 Significance of Research3
1.4 Research Questions4
CHAPTER 2. THEORETICAL BACKGROUND
2.1 What Is Patient Trust?5
2.2 Trust and Health Outcomes6
2.3 Process Model Linking Trust to Adherence8
2.4 Health Outcomes as Consequences of Patient’s Adherence and Self-Efficacy13
2.5 The Dangers of Naïve Trusting Behavior15
2.6 Autonomy Preferences18
2.7 Coexistence of Trust and Autonomy Preferences20
2.8 The Moderating Role of Autonomy Preferences22
CHAPTER 3. RESEARCH DESIGN AND METHODOLOGY
3.1 Research Site and Participants26
3.2 Procedure26
3.3 Measure27
3.4 Data Analysis32
CHAPTER 4. RESULTS
4.1 Participants35
4.2 Descriptive statistics and zero-order correlation37
4.3 Trust and Outcomes38
4.4 Latent Growth Models56
4.5 Linking Trust to Adherence and Outcomes67
4.6 Moderating Roles of Autonomy Preferences74
4.7 Tests of Mediated Moderation Models80
4.8 Structural Models83
CHAPTER 5. DISCUSSION
5.1 Trust and Outcomes87
5.2 Linking Trust to Adherence and Outcomes89
5.3 Moderating Roles of Autonomy Preferences91
CHAPTER 6. CONCLUSION
6.1 Theoretical Implication96
6.2 Practical Implication97
6.3 Limitation and Future Research102
6.4 Conclusion106
REFERENCES
References108
APPENDIX
Survey Questionnaires128
LIST OF TABLES
TABLE 1 Descriptive statistics and zero-order correlation36
TABLE 2 Regression results of trust on physical HRQoL40
TABLE 3 Regression results of trust on physical HRQoL adjusting for outcome variable at Time 141
TABLE 4 Regression results of trust on mental HRQoL42
TABLE 5 Regression results of trust on mental HRQoL adjusting for outcome variable at Time 143
TABLE 6 Regression results of trust on HbA1C45
TABLE 7 Regression results of trust on HbA1C adjusting for outcome variable at Time 146
TABLE 8 Regression results of trust on fasting blood sugar47
TABLE 9 Regression results of trust on fasting blood sugar adjusting for outcome variable at Time 148
TABLE 10 Regression results of trust on blood lipid and BMI49
TABLE 11 Regression results of trust on self-efficacy50
TABLE 12 Regression results of trust on outcome expectations51
TABLE 13 Regression results of trust on general adherence53
TABLE 14 Regression results of trust on adherence to medication and exercise recommendations54
TABLE 15 Regression results of trust on adherence to diet recommendations55
TABLE 16 Model fit indexes and curve parameters for unconditional latent growth curves of physical HRQoL under various functional forms63
TABLE 17 Hierarchical regressions examining the effect of trust on adherence (Hypothesis 2a,2b) 70
TABLE 18 Test of the indirect effects through the bootstrapping method71
TABLE 19 Hierarchical regressions examining the effect of adherence on objective health outcomes (Hypothesis 3)72
TABLE 20 Hierarchical regressions examining the effect of trust on self-rated health (Hypothesis 4)73
TABLE 21 Hierarchical regression results with self-efficacy, outcome expectations, and adherence as the dependent variables (N = 393-462)77
TABLE 22 Hierarchical regression results with self-efficacy and outcome expectations as the dependent variables (N = 296)78
TABLE 23 Mediated moderation results for self-efficacy and outcome expectations across levels of decisional preference and information preference82
LIST OF FIGURES
FIGURE 1 Theoretical framework25
FIGURE 2 Research framework34
FIGURE 3 Trend in mean value of physical HRQoL60
FIGURE 4 Trend in mean value of mental HRQoL61
FIGURE 5 Trend in mean value of HbA1C62
FIGURE 6 Conditional univariate latent curve model of physical HRQoL with five exogenous variables64
FIGURE 7 Conditional univariate latent curve model of mental HRQoL with five exogenous variables65
FIGURE 8 Conditional univariate latent curve model of HbA1C with five exogenous variables66
FIGURE 9 Interaction among patient trust, decisional preference, and informational preference in predicting Time 3 self-efficacy79
FIGURE 10 Standardized parameter estimates for the hypothesized model - 1 (N = 296) 85
FIGURE 11 Standardized parameter estimates for the hypothesized model - 2 (N = 296) 86
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