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研究生:蔡麗雲
研究生(外文):Li-Yun Tsai
論文名稱:台灣地區婦癌存活者害怕癌症復發、疾病詮釋、自我調整與生活品質相關之質量性研究
論文名稱(外文):The Qualitative and Quantitative Study of Fear Cancer Recurrence, Illness Representations, and Self-regulation associated with Life of Quality for Gynecology Cancer Survivors in Taiwan
指導教授:蔡秀鸞蔡秀鸞引用關係
指導教授(外文):Shiow-Luan Tsay
口試委員:梁淑媛賴裕和林寬佳王功亮
口試委員(外文):Shu-Yuan LiangYeur-Hur LaiKuan-Chia LinKung-Liahng Wang
口試日期:2014-01-03
學位類別:博士
校院名稱:國立臺北護理健康大學
系所名稱:護理研究所
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:2014
畢業學年度:102
語文別:中文
論文頁數:261
中文關鍵詞:婦癌存活者害怕癌症復發疾病詮釋自我調整生活品質二階段最小平法
外文關鍵詞:gynecologic cancer survivorfear of cancer recurrenceillness representationsself regulationquality of lifetwo stage least square
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現今婦癌存活超過急性存活期的機率增加,甚至多數可達到永久存活階段,但卻需要面對治療多樣性所引發的器官毒性副作用、害怕復發、轉移、身體心像,家庭及親密關係的改變等問題,且家庭照顧者的角色負擔依舊存在,故婦癌存活者往往較其他癌症病人承受更大身心壓力與適應問題,協助婦癌存活者維持良好的生活品質極為重要。本研究目的是以質性研究探討台灣婦癌存活者的生活經驗,並翻譯合宜且適合本土化之害怕癌症復發與自我調整量表,再以量性研究探討婦癌存活者之害怕癌症復發、疾病詮釋、自我調整與生活品質的相關性。
研究設計分二部份,第一部份採現象學研究方法,以立意取樣訪談23位婦癌存活者,瞭解罹癌之生活經驗。第二部份採量性研究法,透過臨床照護經驗及系統性文獻查證,提出影響婦癌存活者生活品質之假說加以驗證,採橫斷性研究設計,透過門診由主治醫師轉介個案,於北部一家醫學中心門診進行問卷填寫或訪談,共回收287份有效問卷。本研究有興趣於中介變項之評估,以期使研究結果能有助於介入措施之研擬與規劃,然而許多解釋變數和依變數均存在有內生變數偏差(endogeneity bias)的問題,故本研究採以二階段最小平方法(two-stage least square, 2SLS)來進行本文之直接與間接效果評估,以確保係數估計之不偏性和一致性。研究工具包括害怕癌症復發量表、疾病詮釋量表、自我調整量表,以及台灣中文版生活品質核心量表「EORTC QLQ -C30」搭配婦癌種類,加上子宮頸癌「EORTC QLQ-CX24」、子宮內膜癌「EORTC QLQ-EN24」、卵巢癌「EORTC QLQ-OV28」等三種特定婦癌疾病/問題嚴重程度之生活品質量表。
研究結果,第一部份婦癌存活者之生活經驗,共歸類出三個主題與六個次主題,三個主題為:活在罹癌與復發間的內心糾結,罹癌歷程的詮釋與調整,經歷冗長過程找到想要的生活方式。六個次主題為:反覆探索罹癌原因與治療,面對癌症復發的擔憂,瀰漫在起伏不定的身心困擾,激勵自己轉念,經歷長期的存活過程,看見身心靈及社會的力量。第二部份婦癌存活者生活品質相關因素探討,共測試人口學特性、疾病相關因素、害怕癌症復發、疾病詮釋、自我調整與生活品質等六個概念,結果顯示年齡50歲以下、曾參加病友團體、疾病嚴重度嚴重、睡眠狀況差,則愈害怕癌症復發;年齡50歲以下、有工作、教育程度專科以上、曾參加病友團體、家人支持度沒被支持、治療方式手術加上化學治療或手術加上放射線及化學治療、疾病嚴重度嚴重、健康狀況差、睡眠狀況差,則疾病詮釋愈負向;年齡50歲以下、家人支持度沒被支持、疾病嚴重度嚴重、健康狀況差、睡眠狀況差,則生活品質愈差。此外,愈害怕癌症復發、自我調整愈差,則生活品質愈差;疾病詮釋愈負向、自我調整愈差,則生活品質愈差。再者,年齡直接影響害怕癌症復發,並透過自我調整之中介效能正向影響生活品質。年齡、健康狀況、睡眠狀況及自我調整直接影響疾病詮釋,並透過自我調整之中介效能正向影響生活品質。最後,自我調整、疾病詮釋、健康狀況差vs好及健康狀況普通vs好等四個因素可解釋整體健康生活品質39%變異量。
本研究結果可提升醫護人員瞭解婦癌存活者的生活品質,以及害怕癌症復發與疾病詮釋對婦癌存活者生活品質之影響,並讓醫護人員瞭解影響婦癌存活者生活品質的負向影響與正向助力,未來提供照護不只關注婦癌存活者治療期的問題,更應結合社會可用的資源幫助婦癌存活者長期身心適應,並能提供多面向的照護措施,包括將存活者的教育朝向系列性設計,除一般性的症狀問題管理之外,亦應加入自我與人際關係、壓力調適或情緒支持的課程,幫助婦癌存活者發展個人的調適策略與支持系統,並能鼓勵每位婦癌存活者參與不同型式的病友團體或運用病友團體的資源,最後期待整合癌症存活者之全面性照護納入腫瘤個案管理模式、腫瘤護理照會或腫瘤諮詢門診的規劃做考量。
Background: Nowadays the probability of gynecologic cancer patients survived through the acute period is increasing; even more, a majority of gynecologic cancer survivors reach the permanent survival phase. However, gynecologic cancer survivors are confronted with problems, which are cause by the diversity of cancer treatment, such as organ toxic side effects, fear of recurrence and metastasis, changes in body image, and changes in family and intimate relationship. Furthermore, the burden of playing family caregiver role is continuing; hence gynecologic cancer survivors usually withstand greater physical and mental stress and adaptation issues than other types of cancer survivors. Therefore, assisting gynecologic cancer survivors to maintain quality of life is important to healthcare professionals. The purpose of this research was to explore life experience of gynecologic cancer survivors in Taiwan using qualitative method, and to conduct Chinese translation and adaptation of appropriate measurement scales suited for localization in assessing fear of cancer recurrence and self regulation, in addition to explore associations among fear of cancer recurrence, illness representations, self regulation, and quality of life using quantitative method.
Methods: The research was consisted of two parts. In the first part, phenomenology was used to analyze interview contents collected from purposive sampling of gynecologic cancer survivors in order to gain an understanding of life experience and meanings of being gynecologic cancer survivor. In the second part, quantitative approach was used to establish and validate hypotheses and models if quality of life of gynecologic cancer survivor could be influenced by factors uncovered from clinical care experiences and systematic literature reviews. A cross-sectional design was adopted in the second part. Subjects were recruited to complete questionnaires or interviews from one clinic of a medical center in the northern Taiwan and were with attending physicians’ referral. The research was interesting in evaluating the effects of intermediary factors and the research findings were expecting to be applicable clinically to the development and planning of patient care intervention. However, the existence of endogeneity bias among explanatory and dependent factors was problematic. In resort, the two-stage least square (2SLS) method was employed in direct and indirect effectiveness assessment in order to ensure estimation of coefficients be unbiased and consistent. Research tools included Fear of Cancer Recurrence Questionnaires, Illness Representations Questionnaires, Self-Regulation Questionnaires, Chinese version of EORTC QLQ-C30 with gynecologic cancer category, and three cancer specific scales, EORTC QLQ-CX24, EORTC QLQ-EN24, and EORTC QLQ-OV28. These tools had obtained the permission of usage from original authors for present study and were translated and validated into Chinese by present research.
Results: The results of the research came in two portions. In the first portion, 23 gynecologic cancer survivors completed the interviews in the qualitative study. Life experience of gynecologic cancer survivors were identified and categorized into three phenomenological themes, which included ‘inner tangle of living with cancer and recurrence’, ‘interpretation and adjustment of cancer treatment’, and ‘long passage of finding the desired life style’ and six subthemes, which included ‘repeatedly exploring the reason of cancer and treatment’, ‘facing the fear of cancer recurrence’, ‘filled with fluctuating physical and mental distress’, ‘motivating oneself to switch mind’, ‘experiencing the process of long-term survival’, and ‘realizing the strength of society, body and mind’. In the second portion, 287 valid questionnaires were collected for statistics analysis. Data were designed into six conceptual categories: demographic characteristics, disease-related factors, fear of cancer recurrence, illness representations, self adjustment, and quality of life. The results indicated that: fear of cancer recurrence was positively associated with the combined effects of age (<50), participation of patient support groups, high illness severity, and bad sleep quality; illness representations was positively associated with the combined effects of age (<50), employment, education level (higher than college), participation of patient support groups, without family support, treatment method (surgery plus chemotherapy or surgery plus radiotherapy and chemotherapy), high illness severity, bad health condition, and bad sleep quality; quality of life was positively associated with the combined effects of age (<50), without family support, high illness severity, bad health condition, and bad sleep quality; more fear of cancer recurrence as well as bad self regulation implied low in quality of life; worse illness representations as well as bad self regulation implied low in quality of life; fear of cancer recurrence was directly affected by age; illness representations was directly affected by age, health condition, quality of sleep, and self regulation; however, self regulation acting as an intermediary had positive effect on quality of life; 39% of total variance in overall quality of life was explained by the combined variances of self regulation, illness representations, health condition (bad vs. good), and health condition (average vs. good).
Conclusions: The present research could help healthcare professionals understand the life quality of gynecologic cancer survivors and the negative effects imposed by fear of cancer recurrence and illness representations on quality of life among gynecologic cancer survivors. Future care providers should not only concern about problems during treatment period but should also combine with social resources to help gynecologic cancer survivors dealing with long-term psychological adjustment and to provide multi-facet care measures. For instance, the design of survivor education for gynecologic cancer survivors should orient toward a system that could accommodate teachings on the management of self and interpersonal relationship and the resource access of stress coping or emotional supports in addition to the general symptoms management. Care providers should help gynecologic cancer survivors to develop personal coping strategies and support system and should encourage gynecologic cancer survivors to participate in patient support groups or to utilize available social resources. Finally, the integration of comprehensive care for gynecologic cancer survivors was recommended to be considered while planning for oncology case management, oncology nursing care or cancer counseling clinic.

目 次
中文摘要 ………………………………………………………………… Ⅰ
英文摘要 ………………………………………………………………… Ⅲ
目次 ……………………………………………………………………… Ⅶ
表次 ……………………………………………………………………… Ⅹ
圖次 ……………………………………………………………………… ⅩII
第一章 緒論
第一節 研究背景與動機 ………………………………………………… 2
第二節 問題陳述 ………………………………………………………… 4
第三節 研究的重要性與目的 …………………………………………… 6
第四節 研究問題 ………………………………………………………… 8
第五節 名詞定義 ………………………………………………………… 9
第二章 文獻查證
第一節 婦癌存活者的定義、治療方式與身心衝擊 …………………. 11
一、婦癌存活者的定義 ….……………………………………..... 11
二、婦癌之疾病特性與治療方式 …..………………………………… 13
三、婦癌存活者之身心衝擊 ………………………………………… 18
第二節 婦癌存活者害怕癌症復發之概念與相關研究 ………………… 21
一、害怕癌症復發的定義與概念 …………..………………………… 21
二、害怕癌症復發之測量工具 ………………………………………… 22
三、影響婦癌存活者害怕癌症復發之相關研究 …………………… 25
第三節 婦癌存活者疾病詮釋之概念與相關研究 ……………………… 28
ㄧ、疾病詮釋的定義與概念 ……………………………………………..28
二、疾病詮釋之測量工具 …………………………………………….. 30
三、影響婦癌存活者疾病詮釋之相關研究 ………………………... 32
第四節 婦癌存活者自我調整之概念與相關研究 …………………... 35
ㄧ、自我調整的定義與概念 …….……………………………………. 35
二、自我調整之測量工具 …………………………………………….. 36
三、影響婦癌存活者自我調整之相關研究 ………………………….. 37
第五節 婦癌存活者生活品質之概念與相關研究 ……………………… 39
ㄧ、生活品質的定義與概念 ………………………………………….. 39
二、婦癌存活者之生活品質測量工具 ……………………………….. 41
三、影響婦癌存活者生活品質之相關研究 ………………………….. 47
第三章 研究方法
第一節 婦癌存活者生活經驗之質性研究 ……………………………… 61
一、研究參與者 ……………………………………………………….. 61
二、測量工具 ………………………………………………………….. 61
三、倫理考量 ………………………………………………………….. 62
四、研究資料之收集 ………………………………………………….. 62
五、資料分析方法 …………………………………………………….. 63
六、研究嚴謹度 ……………………………………………………….. 65
第二節 婦癌存活者疾病詮釋、害怕癌症復發、自我調整與生活品質
關係之量性研究 ………………………………………………..65
一、研究架構 ……..…………………………………………………… 66
二、研究假說 ………..………………………………………………… 66
三、研究參與者 ……………………………………………………….. 67
四、研究樣本數 ……………………………………………………….. 67
五、測量工具 ………………………………………………………….. 68
六、量表之信效度檢測 …………..……………………………….… 77
七、倫理考量 ………………………………………………………….. 78
八、研究資料之收集 ………………………………………………….. 78
九、資料整理與分析 ………………………………………………….. 79
第四章 研究結果
第一節 質性研究之結果 ………………………………………………… 83
一、主題一活在罹癌與復發間的內心糾結 ………………………….. 86
二、主題二罹癌歷程的詮釋與調整 ………………………………….. 101
三、主題三經歷冗長過程找到想要的生活方式 …………………….. 115
第二節 研究工具信效度檢定結果 …………………………………….. 136
第三節 量性研究之結果 ………………………………………………… 145
一、婦癌存活者人口學特性、疾病相關因素、害怕癌症復發、疾病詮釋
、自我調整、生活品質之描述性分析 …………................ 146
二、人口學特性、疾病相關因素對害怕癌症復發、疾病詮釋與生活品質
之影響 …………………………………………………………….......163
三、害怕癌症復發、疾病詮釋、自我調整與生活品質之相關分析與中介
效果 ……………………………………………………………........189
四、預測生活品質的因素 …………………………………………… 198
第五章 討論
第一節 婦癌存活者害怕癌症復發的相關因素 …………………….. 205
第二節 婦癌存活者疾病詮釋的相關因素 ………………………….. 209
第三節 婦癌存活者害怕癌症復發、疾病詮釋、自我調整與生活品質的
關係及中介效果 ………………………………………………........211
第四節 婦癌存活者生活品質的相關因素 ……………………………..214
第六章 結論與建議
第一節 結論 ……………………………………………………..…… 223
第二節 實務運用 …………………………………………………….. 226
第三節 限制與建議 ………………………………………………….. 229
參考文獻
中文部份 ………………………………………………………………… 231
英文部份 ………………………………………………………………… 233
附錄
附錄一 人體試驗委員會通過證明 …………………………………… 248
附錄二 質量性研究受試者同意書 …………………………………… 252
附錄三 害怕癌症復發量表原作者同意函 …………………………… 256
附錄四 自我調整量表原作者同意函 ………………………………. 258

表 次
表 1 Revise FCR questionnaires .................................... 24
表 2 Previous studies of adult cancer patients’
illness perceptions in relation to distress and
quality of life…………………………………........................34
表 3 癌症病人常用之生活品質量表 …………………………… 44
表 4 EORTC量表信效度之相關研究 …………………………… 46
表 5 婦癌存活者與健康婦女生活品質差異之研究結果 ……… 50
表 6 台灣中文版生活品質核心量表內容「EORTC QLQ-C30」 74
表 7 台灣中文版子宮頸癌量表內容「EORTC QLQ-Cx24」 … 74
表 8 台灣中文版子宮內膜量表內容「EORTC QLQ-EN24」 … 75
表 9 台灣中文版卵巢癌量表內容「EORTC QLQ-OV28」 …… 75
表 10 質性研究個案基本資料 …………………………………… 84
表 11 婦癌存活者生活經驗之主題單元總表 .............. 85
表 12 婦癌存活者自我調整量表適配度檢定之參數估計 ….. 138
表 13 研究工具信度檢定 ……………………………………….. 144
表 14 研究對象之基本資料分佈狀況 ………………………….. 148
表 15 研究對象之害怕癌症復發量表得分情形 ……………….. 149
表 16 研究對象之疾病詮釋量表得分情形 …………………….. 150
表 17 研究對象認為罹癌原因 ………………………………….. 152
表 18 研究對象之自我調整量表得分情形 …………………….. 153
表 19 研究對象之生活品質量表得分情形 …………………….. 155
表 20 研究對象之生活品質量表單題得分情形 ……………….. 156
表 21 子宮頸癌病人之EORTC QLQ-Cx24量表得分情形 ….. 158
表 22 子宮內膜癌病人之ORTC QLQ-EN24量表得分情形 ……. 160
表 23 卵巢癌病之EORTC QLQ-OV28量表得分情形 ……….. 162
表 24 研究對象基本資料與害怕癌症復發之差異性分析 …….. 164
表 25 研究對象基本資料與疾病詮釋之差異性分析 ………….. 167
表 26 研究對象基本資料與生活品質量表-整體健康生活品質題
組之差異性分析 ………………………………..................169
表 27 研究對象基本資料與生活品質量表-身體功能題組之差異
性分析 ............................................171
表 28 研究對象基本資料與生活品質量表-角色功能題組之差異
性分析 ............................................173
表 29 研究對象基本資料與生活品質量表-認知功能題組之差異
性分析 .............................................175
表 30 研究對象基本資料與生活品質量表-情緒功能題組之差異
性分析 .............................................177
表 31 研究對象基本資料與生活品質量表-社會功能題組之差異
性分析 .............................................179
表 32 研究對象基本資料與生活品質量表-症狀題組之差異性分析 182
表 33 究對象基本資料與生活品質量表-單項問題之差異性分析 …185
表 34 研究對象害怕癌症復發與自我調整之相關分析 ……………189
表 35 研究對象害怕癌症復發與生活品質之相關分析 ……………190
表 36 研究對象疾病詮釋與自我調整之相關分析 …………………191
表 37 研究對象疾病詮釋與生活品質之相關分析 …………………191
表 38 研究對象自我調整與生活品質之相關分析 …………………192
表 39 工具變項對害怕癌症復發直接效果之迴歸分析 ……………194
表 40 中介變項對害怕癌症影響生活品質間接效果之迴歸分析 …194
表 41 工具變項對疾病詮釋直接效果之迴歸分析 …………………196
表 42 中介變項對疾病詮釋影響生活品質間接效果之迴歸分析 …196
表 43 研究對象生活品質(整體健康生活品質)之多元迴歸預測分析 199
表 44 研究對象生活品質(身體功能)之多元迴歸預測分析 …………200
表 45 研究對象生活品質(角色功能)之多元迴歸預測分析 …………200
表 46 研究對象生活品質(認知功能)之多元迴歸預測分析 ………201
表 47 研究對象生活品質(情緒功能)之多元迴歸預測分析 ………201
表 48 研究對象生活品質(社會功能)之多元迴歸預測分析 ………202
表 49 研究對象生活品質(疲倦)之多元迴歸預測分析 ……………203
表 50 研究對象生活品質(疼痛)之多元迴歸預測分析 ………… 203

圖 次
圖 1 Proposed model for the "seasons of survivorship" ...............................................13
圖 2 影響婦癌存活者害怕癌症復發、病詮釋發、自我調整與生活
品質關係之研究架構 …………………………………………............66
圖 3 婦癌存活者害怕癌症復發量表一級標準化係數測量模式路徑圖 ..............................................137
圖 4 婦癌存活者自我調整量表一級標準化係數測量模式路徑 …139
圖 5 婦癌存活者自我調整量表一級標準化係數測量模式路徑圖
(修正模式) …………………………………………...............140
圖 6 控制工具變數害怕癌症復發對婦癌存活者生活品質影響模式
(2SLS分析) ……………………………………………………….........195
圖 7 控制工具變數疾病詮釋對婦癌存活者生活品質影響模式
(2SLS分析) ………………………………………………………..........197






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