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研究生:陳蓓蒂
研究生(外文):CHEN, PEI-TI
論文名稱:以健康信念模式為基礎的介入措施對改善心房纖維顫動病人抗凝劑服藥信守程度之成效
論文名稱(外文):The Effect of a Health Belief Model-Based Intervention on Adherence to Anticoagulation Therapy in Patients with Atrial Fibrillation
指導教授:王采芷王采芷引用關係
指導教授(外文):WANG, TASE-JYY
口試委員:謝敏雄王桂芸廖玟君劉介宇
口試委員(外文):HSIEH, MING-HSIUNGWANG, KWUA-YUNLAIO, WEN-CHUNLIU, CHIEH-YU
口試日期:2017-06-19
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:2017
畢業學年度:105
語文別:中文
論文頁數:254
中文關鍵詞:心房纖維顫動抗凝劑治療服藥信守健康信念模式
外文關鍵詞:atrial fibrillationanticoagulant therapymedications adherencehealth belief model
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心房纖維顫動病人低程度的抗凝劑服藥信守行為會增加中風或異常出血的危險,近年來新型口服抗凝劑(new oral anticoagulants, NOACs)的使用日益普遍,國內少有研究探討抗凝劑服藥信守程度之影響因素及比較warfarin與NOACs服藥信守程度之差異,因此本研究探討影響心房纖維顫動病人抗凝劑服藥信守程度因素,並進而發展相關介入措施以提升病人抗凝劑服藥信守行為。
本系列研究包括兩個子研究。研究一、採描述相關性研究設計以探討心房纖維顫動病人之抗凝劑服藥信守程度及其影響因素。以診斷心房纖維顫動並接受抗凝劑治療之病人為研究對象,採方便取樣,於北部兩所教學醫院之心臟內科門診進行收案,以自填式問卷進行資料收集,問卷內容包括基本資料(人口學與疾病特性資料)、抗凝劑用藥、憂鬱、心房纖維顫動知識、抗凝劑治療知識、抗凝劑治療專業支持、抗凝劑治療信念、服藥自我效能與服藥信守程度。共有151位符合選樣條件的病人參與本研究,平均年齡為71.98歲(SD = 8.61)、男性居多(62.9%)
;抗凝劑用藥種類以NOACs居多(64.9%)、warfarin較少(35.1%)。研究對象在返診及藥物信守程度量表平均得分為8.83分(SD = 1.87) ;8項藥物信守程度量表平均得分為6.64分(SD = 1.65),其中以高度信守程度的人數最多(n = 69, 45.7%),其次為中度信守程度(n = 47, 31.1%)與低度信守程度(n = 35, 23.2%)。皮爾森相關分析結果顯示返診及藥物信守程度與INR(r = -.32, p = .029)、抗凝劑副作用數(r = .18, p = .031)、自覺抗凝劑治療障礙(r = .40, p = .000),以及抗凝劑服藥自我效能(r = -.56, p = .000)呈顯著相關。而8項藥物信守程度與職業狀況(F = 3.10, p = .048)、INR(r = .38, p = .009)、抗凝劑副作用數(r = -.29, p = .000)、症狀困擾程度(r = -.26, p = .002)、自覺抗凝劑治療障礙(r = -.45, p < .001)、抗凝劑服藥自我效能(r = .47, p < .001),以及憂鬱(r = -.20, p = .012)呈顯著相關。多元線性迴歸分析結果顯示抗凝劑副作用數、自覺抗凝劑治療障礙、抗凝劑服藥自我效能可解釋返診及藥物信守程度之35.5%變異量(F = 20.13, p < .001);職業狀況、抗凝劑副作用數、自覺抗凝劑治療障礙及抗凝劑服藥自我效能可預測解釋8項藥物信守程度之36.6%變異量(F = 11.80, p < .001)。心房纖維顫動病人之抗凝劑服藥信守程度屬高度信守程度;抗凝劑服藥信守程度之重要預測因子有職業狀況、抗凝劑副作用數、自覺抗凝劑治療障礙、與抗凝劑服藥自我效能;但服用warfarin與NOACs於服藥信守程度則無顯著差異。
研究二、採重複測量之隨機分派臨床實驗的研究設計,探討以健康信念模式為基礎的介入措施對提升心房纖維顫動病人抗凝劑治療知識、專業支持、治療信念、服藥自我效能與服藥信守程度之成效。以診斷心房纖維顫動並接受抗凝劑治療之病人為研究對象,採配額取樣,自研究一的研究對象中進行招募,兩所醫院各招募60位,於前測問卷填答後,分層隨機分派至實驗組及控制組。實驗組接受以健康信念模式為基礎的介入性措施,於前測完成後一週內在門診進行60分鐘護理指導,以及於第3週、第7週、第11週、第15週、第19週與第23週共6次,每次約15分鐘的電話追蹤介入,以瞭解抗凝劑服藥信守程度情形及確認返診時間。控制組接受醫院常規藥物衛教,並於前測完成後一週內在門診進行10分鐘護理指導,提供控制組心律不整病人生活保健知識,並於第3週、第7週、第11週、第15週、第19週與第23週共6次,每次約10分鐘的電話追蹤,以關心生活保健狀態及確認返診時間。兩組研究對象均於前測(T1)、第12週(T2)與第24週(T3)於回診時進行問卷填答。問卷內容同研究一。共94位符合選樣條件的病人參與本研究,實驗組49位、控制組45位,平均年齡71.38歲(55至93歲),其中73位(65.8 %)為男性,兩組研究對象在人口學與疾病特性、抗凝劑用藥之各成效變項均具同質性。以廣義估計方程式分析各變項由前測經第12週至第24週隨時間改變的組間差異,研究結果顯示實驗組第12週的warfarin治療知識比控制組的前測知識佳(β = 1.63, p < .001)、實驗組第24週的warfarin治療知識比控制組的前測知識佳(β = 1.56, p = .004);實驗組第12週的NOACs治療知識比控制組的前測知識佳(β = 2.14, p < .001)、實驗組第24週的NOACs治療知識比控制組的前測知識佳(β = 1.89, p < .001)。研究結果支持抗凝劑服藥介入措施顯著提升心房纖維顫動病人抗凝劑治療知識。可於臨床實務持續推廣、應用於服用抗凝劑之心房纖維顫動病人。
Adherence to anticoagulation is commonly low among patients with atrial fibrillation, which increases the risk of stroke and abnormal bleeding. In recent years, the use of new oral anticoagulants, NOACs, is increasingly popular; however, studies exploring factors associated with anticoagulants adherence as well as studies comparing the adherence of Warfarin with NOACs are quite few in Taiwan. Thus, this study aims to evaluate factors affecting anticoagulants adherence in patients with atrial fibrillation and furthermore develop related interventions to improve patient adherence to anticoagulation therapy.
This program of study includes two studies. In the first study, a descriptive correlational design was used to explore adherence to the anticoagulation medication prescription and its related factors in patients with atrial fibrillation. A convenience sample of 151 adults who were treated with anticoagulants for atrial fibrillation were recruited from two teaching hospitals in northern Taiwan. Data were collected by using self-administered questionnaires, including questions on demographics, anticoagulation medication, depression, knowledge of atrial fibrillation, knowledge of anticoagulation treatment, professional support for anticoagulation treatment, belief of anticoagulation treatment, medication self-efficacy, and medication adherence. The mean age of study participants was 71.98 years (SD = 8.61), and the majority of the study participants were males (62.9 %). As to the type of anticoagulation medication, NOACs were used more than warfarin (64.9% and 35.1%). The mean score of Adherence to Refills and Medications Scale (ARMS) is 8.83 (SD = 1.87). The mean score of Eight-Item Morisky Medication Adherence Scale (MMAS-8) is 6.64 (SD = 1.65). Of the 151 participants, 69 (45.7%), 47 (31.1%), 35 (23.2%) were in the high, medium, and low adherence groups, respectively. The results of Pearson correlation analyses showed that adherence to refills and medications significantly correlated with INR (r = -.32, p = .029), anticoagulants side effects (r = .18, p = .031), barriers to anticoagulants self-monitoring (r = .40, p = .000) and anticoagulation medication self-efficacy (r = -.56, p = .000). The adherence as indicted by Eight-Item Morisky Medication Adherence Scale significantly correlated with employment status(F = 3.10, p = .048), INR (r = .38, p = .009), anticoagulants side effects (r = -.29, p = .000), the degree of symptom distress (r = -.26, p = .002), barriers to anticoagulants self-monitoring(r = -.45, p < .001), anticoagulation medication self-efficacy (r = .47, p < .001), and depression (r = -.20, p = .012). Results of multiple linear regression analyses showed that anticoagulants side effects, barriers to anticoagulants self-monitoring and anticoagulation medication self-efficacy explained 35.5% of the variance in adherence to refills and medications (F = 20.13, p < .001). Employment status, anticoagulants side effects, barriers to anticoagulants self-monitoring and anticoagulation medication self-efficacy can predictably explain the 36.6% of the variance in the score of the Eight-Item Morisky Medication Adherence (F = 11.80, p < .001).
Among Our study found that Patients with atrial fibrillation reported higher adherence to anticoagulation therapies. The important predictors of anticoagulation therapy adherence include employment status, anticoagulants side effects, barriers to anticoagulants self-monitoring, and medication self-efficacy. However, there was no significant difference between adherence to taking warfarin and NOACs.
In the second study, an experimental design with repeated measurements were conducted to evaluate the effects of health belief model based anticoagulation therapy self-management program on improving the anticoagulant therapy knowledge, professional support, health belief, self-efficacy, and medication adherence among patients treated with anticoagulants for atrial fibrillation. A quota sample of 94 participants with atrial fibrillation were recruited and randomly assigned to either the experimental (n = 49) or the control group (n = 45). Patients in the experimental group received the health belief model based anticoagulation therapy self-management program, including 60-minute individual instructions and six 15-minute telephone follow-up interventions. Patients in the control group got the regular medication education, 10-minute individual instruction for health knowledge and six 10-minute telephone follow-up as care interventions. Patients in both groups answered the study questionnaires at pre-test (T1), week 12 (T2), and week 24 (T3). The mean age of the participants was 71.38 years (range: 55 to 93). The majority of the study participants were males (n = 73, 65.8%). The demographics, disease characteristics and anticoagulation medication outcome variables at baseline were balance between the two study groups. Generalized estimating equations showed significant group by time interaction effects on warfarin treatment knowledge and NOACs treatment knowledge. The warfarin treatment knowledge of the intervention group at week 12 was 1.63 higher than it of the control group at baseline (p < .001); the warfarin treatment knowledge of the intervention group at week 24 was 1.56 higher than it of the control group at baseline (p = .004). The NOACs treatment knowledge of the intervention group at week 12 was 2.14 higher than (p < .001) it of the control group at baseline; the NOACs treatment knowledge of the intervention group at week 24 was 1.89 higher than (p < .001) it of the control group at baseline. Results of the study support the effects of health belief model based anticoagulation therapy self-management program on improving knowledge of anticoagulation treatment among patients with atrial fibrillation. This intervention can be used to enhance anticoagulation therapy knowledge among adults with atrial fibrillation.
目  次
中文摘要 ……………………………………………………………………i
英文摘要 ……………………………………………………………………iv
目 次 ……………………………………………………………………vii
表 次 ……………………………………………………………………xi
圖 次 ……………………………………………………………………xiii
前 言 ……………………………………………………………………1
研究一、心房纖維顫動病人之抗凝劑服藥信守程度及其影響因素探討
第一章 緒論
第一節 研究背景與動機 …………………………………………………2
第二節 研究目的 …………………………………………………………4
第三節 研究問題與假設 …………………………………………………4
第二章 文獻探討
第一節 心房纖維顫動之流行病學 ………………………………………5
第二節 心房纖維顫動之診斷與治療 ……………………………………6
第三節 心房纖維顫動之中風風險評估…………………………………7
第四節 心房纖維顫動之抗凝劑治療 ……………………………………9
第五節 服藥信守性 ………………………………………………………11
第六節 心房纖維顫動病人抗凝劑服藥信守程度及其影響因素………18
第七節 研究架構與名詞界定 …………………………………………… 20
第三章 研究方法
第一節 研究設計 …………………………………………………………25
第二節 研究場所與對象 …………………………………………………25
第三節 研究工具 …………………………………………………………26
第四節 研究步驟與流程 …………………………………………………33
第五節 資料分析方法 ……………………………………………………33
第六節 研究對象權益保護 ………………………………………………34
第四章 研究結果
第一節 人口學特性、疾病特性與抗凝劑用藥 …………………………36
第二節 症狀困擾程度、心房纖維顫動知識、抗凝劑治療知識、抗凝劑治療專業支持、抗凝劑治療信念、抗凝劑服藥自我效能及憂鬱……………………………………………40
第三節 抗凝劑服藥信守程度 ……………………………………………51
第四節 各研究變項與抗凝劑服藥信守程度之相關性 …………………52
第五節 抗凝劑服藥信守程度之預測因子 ………………………………57
第五章 討論
第一節 人口學特性、疾病特性與抗凝劑用藥 …………………………60
第二節 症狀困擾程度、心房纖維顫動知識、抗凝劑治療知識、抗凝劑治療專業支持、抗凝劑治療信念、抗凝劑服藥自我效能、憂鬱與服藥信守程度 …………………………………………………61
第三節 影響抗凝劑服藥信守程度之因素 ………………………………64
第四節 抗凝劑服藥信守程度之預測因子 ………………………………65
第五節 研究限制 …………………………………………………………66
第六章 結論與建議
第一節 結論 ………………………………………………………………69
第二節 建議 ………………………………………………………………70
研究二、以健康信念模式為基礎的介入措施對提升心房纖維顫動病人抗凝劑治療知識、專業支持、治療信念、服藥自我效能與服藥信守程度之成效
第一章 緒論
第一節 研究背景與動機 …………………………………………………72
第二節 研究目的 …………………………………………………………74
第三節 研究假設 …………………………………………………………74
第二章 文獻探討
第一節 心房纖維顫動病人抗凝劑服藥信守程度 ………………………75
第二節 提升抗凝劑服藥信守程度之介入性研究 ………………………77
第三節 健康信念模式 ……………………………………………………80
第四節 研究架構與名詞界定 ……………………………………………86
第三章 研究方法
第一節 研究設計 …………………………………………………………88
第二節 研究場所與對象 …………………………………………………89
第三節 介入措施 …………………………………………………………90
第四節 研究工具 …………………………………………………………94
第五節 研究步驟與流程 …………………………………………………94
第六節 資料分析方法 ……………………………………………………98
第七節 研究對象權益保護 ………………………………………………99
第四章 研究結果
第一節 人口學特性、疾病特性與抗凝劑用藥之組間同質性 ………… 101
第二節 介入措施對提升心房纖維顫動知識與抗凝劑治療知識之成效…………108
第三節 介入措施對提升抗凝劑治療專業支持之成效 …………………114
第四節 介入措施對提升抗凝劑治療信念之成效 ………………………114
第五節 介入措施對提升抗凝劑服藥自我效能之成效 …………………122
第六節 介入措施對提升抗凝劑服藥信守程度之成效 …………………125
第五章 討論
第一節 人口學特性、疾病特性與抗凝劑用藥之組間同質性 ………… 130
第二節 介入措施執行情形 ………………………………………………130
第三節 措施對提升心房纖維顫動知識與抗凝劑治療知識之成效 ……131
第四節 措施對提升抗凝劑治療專業支持之成效 ………………………133
第五節 措施對提升抗凝劑治療信念之成效 ……………………………134
第六節 措施對提升抗凝劑服藥自我效能之成效 ………………………134
第七節 措施對提升抗凝劑服藥信守程度之成效 ………………………135
第八節 研究限制 …………………………………………………………136
第六章 結論與建議
第一節 結論 ………………………………………………………………139
第二節 建議 ………………………………………………………………140
參考文獻
中文部份 …………………………………………………………………143
英文部分 …………………………………………………………………145
附錄
附錄一 研究一之樣本數估計 ………………………………………… 161
附錄二 研究二之樣本數估計 ………………………………………… 162
附錄三 抗凝劑服藥介入措施專家效度審查……………………………163
附錄四 抗凝劑服藥介入措施專家效度審查修正前後對照表………… 196
附錄五 介入措施專家效度審查之專家名單及評分結果………………208
附錄六 抗凝劑服藥介入措施教案………………………………………209
附錄七 心房纖維顫動衛教單張………………………………………… 218
附錄八 抗凝劑(warfarin)治療衛教單張 ………………………………220
附錄九 抗凝劑(NOACs)治療衛教單張…………………………………222
附錄十 抗凝劑服藥自我紀錄卡………………………………………… 223
附錄十一 受訪者知情同意書 ………………………………………… 224
附錄十二 基本資料………………………………………………………228
附錄十三 心房纖維顫動嚴重度量表……………………………………230
附錄十四 心房纖維顫動知識量表……………………………………… 235
附錄十五 抗凝劑(warfarin)治療知識量表 ……………………………237
附錄十六 抗凝劑(NOACs)治療知識量表………………………………240
附錄十七 抗凝劑治療服務滿意度量表…………………………………243
附錄十八 抗凝劑信念問卷………………………………………………244
附錄十九 適當藥物使用之自我效能量表………………………………246
附錄二十 返診及藥物信守程度量表……………………………………247
附錄二十一 8項藥物信守程度量表……………………………………248
附錄二十二 電話追蹤紀錄表…………………………………………… 249
附錄二十三 研究倫理委員會通過證明函………………………………250
附錄二十四 Morisky 8項藥物信守程度量表授權使用同意書 ………254
表  次
研究一、心房纖維顫動病人之抗凝劑服藥信守程度及其影響因素探討
表2-1 CHADS2 與CHA2DS2-VASC中風風險因子 …………………… 8
表2-2 CHADS2 與CHA2DS2-VASC總分與每年中風機率 ……………9
表2-3 HAS-BLED出血風險評估 ………………………………………11
表2-4 信守程度測量之方法學及其優缺點……………………………… 16
表2-5 心房纖維顫動病人抗凝劑服藥信守程度之影響因素……………20
表4-1 研究對象的人口學與疾病特性……………………………………38
表4-2 研究對象的抗凝劑用藥情形………………………………………39
表4-3 研究對象在各研究變項得分情形…………………………………40
表4-4 研究對象在症狀困擾程度量表中各題得分情形………………… 41
表4-5 研究對象在健康照護使用情形……………………………………42
表4-6 研究對象的疾病負荷情形…………………………………………43
表4-7 研究對象回答心房纖維顫動知識量表各題之正確率……………44
表4-8 研究對象回答warfarin治療知識量表各題之正確率……………45
表4-9 研究對象回答NOACs治療知識量表各題之正確率…………… 46
表4-10 抗凝劑治療服務滿意度量表各題得分情形………………………47
表4-11 研究對象在自覺中風罹患性與嚴重性、自覺抗凝劑治療利益各題得分情形…………48
表4-12 研究對象在自覺抗凝劑治療障礙的分布情形……………………48
表4-13 研究對象在自覺抗凝劑治療障礙各題得分情形………………… 49
表4-14 研究對象在適當藥物使用之自我效能量表各題得分情形………50
表4-15 研究對象在憂鬱量表各題得分情形………………………………51
表4-16 研究對象在返診及藥物信守程度量表各題得分情形……………52
表4-17 研究對象在8項藥物信守程度量表各題得分情形……………… 52
表4-18 人口學、疾病特性及抗凝劑用藥與抗凝劑服藥信守程度之關係…………54
表4-19 各研究變項與抗凝劑服藥信守程度之相關性……………………57
表4-20 返診及藥物信守程度重要預測因子之迴歸係數摘要表…………59
表4-21 8項藥物信守程度重要預測因子之迴歸係數摘要表……………59
研究二、以健康信念模式為基礎的介入措施對提升心房纖維顫動病人抗凝劑治療知識、專業支持、治療信念、服藥自我效能與服藥信守程度之成效
表2-1 健康信念模式之構面與可行策略…………………………………84
表3-1 研究對象隨機分派情形 …………………………………………89
表3-2 以健康信念模式為基礎之抗凝劑服藥介入措施………………… 93
表3-3 研究二各問卷施測時間與資料收集之內容………………………96
表4-1 研究對象人口學與疾病特性之組間比較…………………………105
表4-2 研究對象健康照護使用情形於前測之組間比較………………… 106
表4-3 研究對象疾病負荷於前測之組間比較……………………………107
表4-4 研究對象抗凝劑用藥於前測之組間比較…………………………108
表4-5 研究對象心房纖維顫動知識與抗凝劑治療知識於各時間點之組間比較 …………………………………110
表4-6 研究對象心房纖維顫動知識與抗凝劑治療知識隨時間變化之組間比較 …………………………………111
表4-7 研究對象抗凝劑治療專業支持與抗凝劑治療信念於各時間點之組間比較………………………………116
表4-8 研究對象抗凝劑治療專業支持隨時間變化之組間比較…………117
表4-9 研究對象抗凝劑治療信念隨時間變化之組間比較………………118
表4-10 研究對象抗凝劑服藥自我效能於各時間點之組間比較…………122
表4-11 研究對象抗凝劑服藥自我效能隨時間變化之組間比較…………123
表4-12 研究對象抗凝劑服藥信守程度於各時間點之組間比較…………126
表4-13 研究對象抗凝劑服藥信守程度隨時間變化之組間比較…………127
表4-14 研究對象8項藥物信守程度分布情形於各時間點之組間比較…128
圖  次
研究一、心房纖維顫動病人之抗凝劑服藥信守程度及其影響因素探討
圖2-1 心房纖維顫動病人抗凝劑服藥信守程度之影響因素 ……………21
研究二、以健康信念模式為基礎的介入措施對提升心房纖維顫動病人抗凝劑治療知識、專業支持、治療信念、服藥自我效能與服藥信守程度之成效
圖2-1 健康信念模式 ……………………………………………………… 85
圖2-2 抗凝劑服藥介入措施對提升心房纖維顫動病人之心房纖維顫動與抗凝劑治療知識、治療信念、服藥信守程度之研究架構………87
圖3-2 研究二之資料收集流程 ……………………………………………97
圖4-1 介入研究收案流程圖 ………………………………………………104
圖4-2 兩組研究對象的心房纖維顫動知識隨時間變化趨勢圖 …………112
圖4-3 兩組研究對象的抗凝劑治療知識隨時間變化趨勢圖 ……………113
圖4-4 兩組研究對象的抗凝劑治療專業支持隨時間變化趨勢圖 ………119
圖4-5 兩組研究對象的抗凝劑治療信念隨時間變化趨勢圖 ……………120
圖4-6 兩組研究對象的抗凝劑服藥自我效能隨時間變化趨勢圖 ………124
圖4-7 兩組研究對象的抗凝劑服藥信守程度隨時間變化趨勢圖 ………129

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