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研究生:陳綱華
研究生(外文):Kang-Hua
論文名稱:發展與建構慢性阻塞性肺疾患自我管理量表與模式
論文名稱(外文):Development and Construction of a Self-Management Scale and Model for Patients with Chronic Obstructive Pulmonary Disease
指導教授:李選教授
學位類別:博士
校院名稱:中山醫學大學
系所名稱:醫學研究所
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2010
畢業學年度:98
語文別:中文
論文頁數:254
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研究背景與目的:慢性阻塞性肺疾病目前在全世界許多國家,是主要引起殘障與死亡的慢性疾病之ㄧ;隨著人口老化與抽菸人口增加,世界衛生組織預測到2030年,慢性阻塞性肺疾病將成為世界第三大死因。在現今醫療體系提倡以病人為中心的理念下,研究者以Bandura社會認知理論、Bourbeau等人行為改變因果模式為理論架構,目的要了解慢性阻塞性肺疾患日常生活中的疾病自我管理行為,建構慢性阻塞性肺疾患疾病自我管理模式,未來發展疾病自我管理計畫,提昇病人生活品質。
研究方法:本研究採方法三角交叉法,以質性研究了解慢性阻塞性肺疾患日常生活中疾病自我管理行為、影響因素及行為成果,並發展自我效能與自我管理行為量表;以量性研究驗證工具信、效度,建構自我管理模式。質性研究在北台灣某醫學中心之胸腔科病房、門診與呼吸治療室進行,自2004年4月、2006年11月至2007年4月,及2008年8月間,共訪談19位樣本,以Miles和Huberman的交互作用模式分析資料。量性研究在胸腔科門診進行,自2007年10月至2008年7月,共收集212份有效問卷,採用SPSS 15.0進行描述性統計分析、項目分析、探索式因素分析,以AMOS模組進行驗證式因素分析、結構方程式分析。
研究結果:質性研究結果發現,在尋求症狀穩定的過程中,病人會受到外在環境、疾病認知與情緒因素的影響,使用不同且多樣性的自我管理行為處理疾病與緩解症狀;無論疾病嚴重程度如何,樣本自我管理行為共五類,包括:症狀處理、活動和運動執行、環境控制、心理調適、生活保健。量性研究結果顯示,疾病知識與自我管理行為量表之信、效度未能達到滿意水準,自我管理模式之整體模式適配度指標:χ2/df 1.514、RMSEA 0.049,理論模式與資料間的適配度尚可接受,各變項中自我效能對自我管理行為的影響最大,直接影響係數0.641(p<0.01),自我管理行為對生活品質的直接影響係數0.315(p<0.01)。
結論與建議:慢性阻塞性肺疾患是自己生活的專家,他們將個人經驗、智慧與醫療人員教導的知識,整合至疾病自我管理行為;同時,藉由自我管理模式的建立,了解影響慢性阻塞性肺疾患自我管理行為與生活品質的因素包括:診斷時間、疾病知識、憂鬱、社會支持與自我效能。研究結果建議,醫療專業人員應發展以實證為基礎之自我管理計畫,並藉由自我管理教育之落實、定期電話追蹤與召開病友討論會,增強病人自我效能。


Background and Purpose: Chronic obstructive pulmonary disease (COPD) is a major cause of chronic morbidity and mortality throughout the world. The World Health Organization projects that, by 2030, COPD will be the third leading cause of death worldwide. These increases are in response to a longer life expectancy, coupled with an increasing number of individuals who smoke. A patient-centered perspective calls for this study. Based on Bandura’s social cognitive theory and Bourbeau’s et al. causal model of behavior change, the purpose of this study was to explore the self-management behaviors and to construct self-management model as means to develop self-management program and enhance quality of life for patients with COPD.
Methods: This study adopted the methodological triangulation. The qualitative study was to understand the self-management behaviors, antecedent factors, consequences of behaviors, and development scale of self-management behavior. The quantitative study was to verify the reliability and validity of instruments and to construct the self-management model.
A purposive sample of 19 men was invited to participate in the study. To better understand the behaviors of patients under different conditions, participants were drawn from different settings: including a thoracic ward, outpatient department, and the respiratory therapy room in a medical center in Northern Taiwan. Data were collected from April 2004, November 2006 ~ April 2007 to August 2008. Miles and Huberman’s interactive model was used to analyze the data. The quantitative study was conducted in the outpatient department from October 2007 to July 2008. The participants were a purposive sample of 212 participants who had COPD. Data from the questionnaire for each participant were entered into the Statistical Package for the Social Sciences (SPSS), version 15.0, for analysis of descriptive statistics, item analysis, and exploratory factor analysis. The SPSS module of analysis of moment structure (AMOS) used for confirmatory factor analysis and structure equation model (SEM) analysis.
Results: The participants chose the self-management behaviors that suited them to avoid any condition which might induce symptoms and to maintain stable physical functions and daily living conditions. Also, the participants would be affected by environmental factors, disease cognition, and affective factors. No matter what the level of severity, five themes of disease management behaviors were identified: symptom management, activity and exercise implementation, environmental control, emotional adaptation and maintaining a healthy lifestyle.
The results of quantitative study indicate that instruments of disease knowledge, and self-management didn’t demonstrate good internal consistency reliability and construct validity. The overall model fit of self-management was fair fit, χ2/df 1.514, RMSEA 0.049. Self-management behavior was directly influenced by self-efficacy (ß=.641). Quality of life was directly influenced by self-management behavior (ß=.315).
Conclusion and Suggestion: Participants are experts on their lives and, as such, they adopt appropriate disease control behaviors, based on their experience, wisdom, and knowledge that teach by healthcare professionals as well as integrate the illness and its symptoms into their lives. Factors associated with self-management including the average duration of illness, disease knowledge, depression, social support, and self-efficacy. The results suggest that healthcare professionals should develop an evidence-based program for self-management for COPD patients that incorporates strategies to enhance patient’s self-efficacy of self-management behavior.


目錄
頁數
謝誌‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥i
中文摘要‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ ii
英文摘要‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ iv
目錄‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥vii
附錄‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ x
圖目錄‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ xi
表目錄‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ xii

第一章 緒論
第一節 研究背景與重要性‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥1
第二節 研究假設‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥6
第三節 研究問題‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥6
第四節 名詞解釋‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥6
第二章 文獻查証
第一節 理論架構‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥9
一、 社會認知理論‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥9
二、 行為改變因果模式‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 12
三、 研究概念架構‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 14
第二節 慢性阻塞性肺部疾病之概念與相關研究‥‥‥‥‥‥‥‥‥‥ 15
第三節 慢性阻塞性肺疾患自我管理定義‥‥‥‥‥‥‥‥‥‥‥‥‥ 19
第四節 慢性阻塞性肺疾患自我管理行為‥‥‥‥‥‥‥‥‥‥‥‥‥ 23
第五節 慢性阻塞性肺疾患自我管理行為的影響因素‥‥‥‥‥‥‥‥ 26
一、 自我效能‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 26
二、 情緒狀態‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 28
三、 社會支持‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 29
四、 疾病認知‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 31
第六節 慢性阻塞性肺疾患自我管理成果與生活品質‥‥‥‥‥‥‥‥ 35
一、 慢性阻塞性肺疾患自我管理成果‥‥‥‥‥‥‥‥‥‥‥‥‥ 35
二、 慢性阻塞性肺疾患生活品質‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 39
第三章 研究方法
第一節 三角交叉研究法‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥42
第二節 質性研究—慢性阻塞性肺疾患疾病自我管理行為‥‥‥‥‥‥‥45
一、 研究目的與問題‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 45
二、 研究方法‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 45
(一) 研究場所與對象‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 45
(二) 研究工具‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 46
(三) 研究工具之信效度‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 48
(四) 研究倫理‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 50
(五) 資料分析‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 50
第三節 量性研究—慢性阻塞性肺疾患自我管理量表發展與模式結構‥‥55
一、研究目的與問題‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 55
二、量性研究概念架構‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 56
三、研究方法‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 57
(一) 研究對象‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 57
(二) 研究步驟‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 58
(三) 量表發展‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 59
(四) 研究工具‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 64
(五) 研究倫理‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 70
(六) 資料分析‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 70
第四章 研究結果
第一節 質性研究--慢性阻塞性肺疾患疾病自我管理行為‥‥‥‥‥‥‥73
一、研究對象之基本資料‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥ 73
二、慢性阻塞性肺疾患疾病自我管理行為‥‥‥‥‥‥‥‥‥‥‥ 76
三、慢性阻塞性肺疾患自我管理行為影響因素‥‥‥‥‥‥‥‥‥ 97
四、慢性阻塞性肺疾患自我管理成果‥‥‥‥‥‥‥‥‥‥‥‥‥106
第二節 量性研究—慢性阻塞性肺疾患自我管理量表發展與模式建構‥ 109
一、研究對象之基本資料‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥109
二、自我管理行為、自我效能與疾病知識量表之項目分析‥‥‥‥114
(一) 自我管理行為量表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥115
(二) 自我效能量表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥115
(三) 疾病知識量表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥120
三、疾病知識量表之因素分析‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥123
四、自我管理行為、自我效能與疾病知識量表之信度分析結果‥‥126
(一) 自我管理行為量表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥126
(二) 自我效能量表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥127
(三) 疾病知識量表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥127
五、自我管理行為與自我效能量表之建構效度分析結果‥‥‥‥‥128
(一) 自我管理行為量表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥128
(二) 自我效能量表‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥135
六、研究工具之描述性分析‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥138
(一) 自我管理行為‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥138
(二) 自我效能‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥140
(三) 疾病知識‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥141
(四) 憂鬱‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥143
(五) 社會支持‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥144
(六) 生活品質‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥147
七、慢性阻塞性肺疾患自我管理模式‥‥‥‥‥‥‥‥‥‥‥‥‥148
(一) 樣本資料常態分佈檢驗‥‥‥‥‥‥‥‥‥‥‥‥‥‥148
(二) 社會支持、疾病知識與憂鬱之測量結構評估‥‥‥‥‥151
(三) 自我管理模式之評估‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥161
第五章 討論
第一節 質性研究—慢性阻塞性肺疾患疾病自我管理行為‥‥‥‥‥‥ 165
一、慢性阻塞性肺疾患疾病自我管理行為‥‥‥‥‥‥‥‥‥‥‥165
二、慢性阻塞性肺疾患自我管理的影響因素‥‥‥‥‥‥‥‥‥‥171
第二節 量性研究—慢性阻塞性肺疾患自我管理量表發展與模式建構‥ 174
一、慢性阻塞性肺疾患之自我管理行為‥‥‥‥‥‥‥‥‥‥‥‥174
二、慢性阻塞性肺疾患之自我效能‥‥‥‥‥‥‥‥‥‥‥‥‥‥176
三、慢性阻塞性肺疾患之疾病知識‥‥‥‥‥‥‥‥‥‥‥‥‥‥178
四、慢性阻塞性肺疾患之憂鬱‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥183
五、慢性阻塞性肺疾患之社會支持‥‥‥‥‥‥‥‥‥‥‥‥‥‥185
六、慢性阻塞性肺疾患之生活品質‥‥‥‥‥‥‥‥‥‥‥‥‥‥187
七、慢性阻塞性肺疾患之疾病自我管理模式‥‥‥‥‥‥‥‥‥‥189
第六章 結論
第一節 慢性阻塞性肺疾患疾病自我管理行為‥‥‥‥‥‥‥‥‥‥‥193
第三節 慢性阻塞性肺疾患自我管理量表發展與模式建構‥‥‥‥‥‥194
一、慢性阻塞性肺疾患自我管理行為與量表信、效度‥‥‥‥‥‥194
二、慢性阻塞性肺疾患自我效能與量表信、效度‥‥‥‥‥‥‥‥194
三、慢性阻塞性肺疾患疾病知識與量表信、效度‥‥‥‥‥‥‥‥194
四、慢性阻塞性肺疾患憂鬱‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥195
五、慢性阻塞性肺疾患社會支持‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥195
六、慢性阻塞性肺疾患生活品質‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥195
七、慢性阻塞性肺疾患疾病自我管理模式‥‥‥‥‥‥‥‥‥‥‥195
第七章 研究限制與建議
第一節 限制‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥197
一、研究設計的限制‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥197
二、樣本特性的限制‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥197
三、研究工具的限制‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥198
四、資料品質的限制‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥198
第二節 建議‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥200
一、護理實務的建議‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥200
二、護理研究的建議‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥202
三、護理教育的建議‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥203
四、護理專業的建議‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥204
五、醫療政策的建議‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥204

中文參考資料‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥‥206
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