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研究生:周昀臻
研究生(外文):Yun-Jen Chou
論文名稱:以復原力模式為基礎之預防性身心復健計畫於改善初診斷結直腸癌患者身心症狀困擾與生活品質之成效
論文名稱(外文):Effect of a Resilience Model-Based Physical and Psychological Prehabilitation Program in Reducing Physical and Psychological Distress and Improving Quality of Life in Patients with Newly Diagnosed Colorectal Cancer
指導教授:孫秀卿孫秀卿引用關係
指導教授(外文):Shiow-Ching Shun
口試委員:曹昭懿杜裕康李芸湘邱怡欣
口試委員(外文):Jau-Yih TsauoYu-Kang TuYun-Hsiang LeeYi-Hsing Chiu
口試日期:2020-07-02
學位類別:博士
校院名稱:國立臺灣大學
系所名稱:護理學研究所
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:2020
畢業學年度:108
語文別:中文
論文頁數:129
中文關鍵詞:結直腸癌復原力癌症預防性復健身心症狀困擾生活品質
外文關鍵詞:colorectal cancerresiliencecancer prehabilitationphysical distresspsychological distressquality of life
DOI:10.6342/NTU202001359
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背景:結直腸癌自2006年起成為我國發生人數最多的癌症,且隨著國人飲食、生活及工作型態的改變,新診斷的人數持續攀升,約26%~90%的患者會經歷疾病或治療帶來的身體及心理症狀困擾,最常見的包括:疲倦、症狀困擾、憂鬱、擔心復發等。雖然過去已經證實癌症預防性復健(Cancer prehabilitation)措施,及提升個體的復原力可以有效改善癌症患者接受首次治療後的恢復狀況,及其面對人生衝擊事件時能有較好的適應能力。然而,過去研究的族群多著重於兒童、青少年及癌症存活期患者,運用復原力模式於初確診結直腸癌患者的早期介入研究仍屬缺乏。因此,本研究分為兩階段進行,用以探討結直腸癌患者的復原力之現況,及發展與測試以復原力理論為基礎之身心照護計畫介入措施對於改善復原力、身心症狀困擾,及生活品質之成效。
目的:第一階段探討診斷五年內之結直腸癌患者的復原力之現況,及其與身心困擾之相關性,並做為第二階段衛教教材之參考,第二階段以疾病復原力模式(The Resilience in Illness Model)為基礎進行兩階段之研究,以瞭解台灣結直腸癌患者疾病復原力之保護及破壞因子,並進一步發展與測試以復原力模式為基礎之癌症預防性身心復健計畫於改善初診斷結直腸癌患者之身心症狀困擾與生活品質之成效。
方法:第一階段透過橫斷面研究設計,以結構式問卷收集資料,於台北2家醫學中心之大腸直腸外科及腫瘤醫學科門診收案,針對診斷五年內之結直腸癌患者資料進行收集,探討結直腸癌患者之復原力狀況及其與保護和破壞因子之關係,並做為發展第二階段以疾病復原力模式為基礎的照護計畫之教材參考,資料分析採描述性統計、皮爾森積差相關、結構方程模式,以了解復原力之相關因素及測試本研究提出之結直腸癌復原力模式。第二階段採隨機對照試驗,於台北某醫學中心之大腸直腸外科及腫瘤醫學科門診收案,選取初診斷為第Ι至第Ⅲ期結直腸癌並即將安排入院開刀之患者為研究對象,實驗組之個案接受以復原力模式為基礎之照護計畫課程,介入時間為期12週,期間共接受5次(確診當日、住院當日、術後出院前、出院後第1次返診、出院後第2次返診),依據每次課程設計,每次進行約15~50分鐘的面對面課程,及每週的電訪或Line追蹤,課程內容以疾病復原力模式為架構,透過提升個案復原力之保護因子,和降低復原力的破壞因子協助提升個案之復原力;控制組則採常規照護。成效監測為問卷之評量,測量時間點共4次:確診當日(T0)、術後第1個月(T1)、術後第2個月(T2)、術後第6個月(T3)。資料採廣義估計方程式(generalized estimating equations)分析二組間改善身心症狀、擔心復發與生活品質之成效差異。
研究結果:第一階段共收案416人,平均年齡為62.42歲。整體個案具有中度復原力、輕度的症狀嚴重度與輕度疲倦困擾、及較好的自我效能與靈性安適感。經結構方程模式分析,研究結果僅發現保護因子可預測復原力(β = .746, 95%; BC-CI: .884~1.493),但破壞因子未達統計上之顯著差異(β = -.067; 95% BC-CI: -.273~.062),且此模型之模式配適度欠佳(CFI=0.864; RMSEA=0.142; SRMR=0.166)。第二階段共收案64人,實驗及控制組平均年齡分別為57.97歲及61.84歲。經Student’s test及卡方檢定進行兩組之人口學、病特性差異性,及各量表T0分數的檢定,兩組均無達統計上的顯著差異。分析結果顯示預防性身心復健介入措施於兩組的T1及T2之擔心復發達顯著差異,與T0相比,實驗組於T1(β=-3.396; p=.018)及T2(β=-3.145; p=.037)時比控制組在擔心復發的部分顯著獲得改善,但於T3時未達統計上之顯著差異。除此,兩組於T1的靈性安適感達顯著差異,與T0相比,實驗組於T1時比控制組在靈性安適感的部分獲得顯著提升(β=4.770; p=.033)。然而,預防性身心復健介入措施對於復原力、症狀嚴重度、疲倦、憂鬱,及健康相關的生活品質皆未達統計上之顯著差異。
結論:於結直腸癌復原力模型中,僅保護因子可預測復原力,破壞因子無法預測復原力,未來仍需更多研究證實此階段的研究結果。此外,以復原力模式為基礎的預防性身心復健介入措施可有效降低擔心復發,及提升靈性安適感。
Background: Colorectal cancer (CRC) has the highest cancer incidence rate and is the third highest cause of cancer-related death in Taiwan. Symptom distress, fatigue, depression, and fear of cancer recurrence are the most distress in patients with CRC receiving active treatment. Evidence has revealed that people who accept cancer prehabilitation program and with better resilience can successfully recover, adapt and rebound from suffering. However, there is no study that focuses on the issue among cancer prehabilitation, resilience, physical and psychological distresses in CRC patients.
Purpose: In the first phase, the aim was to explore the resilience and its related factors in CRC survivors by cross-sectional design, and develop a resilience model-based care plan. In the second phase, the purpose was to examine the effect of a resilience model-based physical and psychological cancer prehabilitation program in reducing symptom severity, fatigue, fear of cancer recurrence, depression and improving health-related quality of life (QOL) and spiritual well-being in newly diagnosed CRC patients.
Methods: In the first phase, the subjects were recruited from oncology and surgery clinics at two medical centers in Taipei. A structural questionnaire was used to evaluate a proposed Resilience Model for patients with CRC. The data were analyzed using descriptive statistics, Pearson’s correlation, and Structural equation modeling (SEM). In the second phase, a randomized control trial was used. The subjects who are newly diagnosed were recruited from a medical center in Taipei. Participants in the experimental group received the 12-week care plan with 5 times face-to-face intervention and weekly phone call follow-up to increase the protective factors and decrease the risk factors of resilience. Subjects in control group received usual care. A set of questionnaires was used to assess the effect of the 12-week resilience model-based care plan. The questionnaire were obtained prior to surgery (T0) and at one month (T1), two months (T2) and six months (T3) after surgery. Generalized estimating equations were used to evaluate for a statistically significant group x time interactions.
Results: In the first phase, 416 patients were recruited. In overall, patients have moderate resilience, mild level of symptom severity, mild level of fatigue, good self-efficacy, and good spiritual well-being. The proposed model resulted in a poor fit (CFI= .86; RMSEA = .14; SRMR = .16). While the protective factors were significant predictor of resilience (β = .746, 95% bias-corrected CI: .884 to 1.493), the risk factors were not significant (β = -.067, 95% BC-CI: -.273 to .062). In the second phase, 64 patients were recruited. The mean age of the experimental and control groups were 57.97 and 61.84, respectively. And, no differences in demographic, clinical characteristics, and all measurment outcomes at T0 were found between the two group. In addition, the resilience model-based physical and psychological prehabilitation programs were efficacious for reducing fear of cancer recurrence at T1 (β=-3.396; p=.018) and T2 (β=-3.145; p=.037) as well as increasing spiritual well-being at T1 (β=4.770; p=.033).
Conclusions: The protective factors can predict resilience; however, the risk factors can not predict resilience. Further resilience-related studies are needed in the future. In addition, the resilience model-based physical and psychological prehabilitation programs was demonstrated to decrease fear of cancer recurrence and improve spiritual well-being in newly diagnosed CRC patients.
目錄
口試委員審定書 i
誌謝 ii
中文摘要 iii
英文摘要 v
第一章 緒論 1
第一節 研究動機與重要性 1
第二節 研究目的 4
第三節 研究問題 5
第二章 文獻查證 6
第一節 結直腸癌的治療及照護 6
第二節 結直腸癌患者的身心困擾 9
第三節 癌症預防性復健 15
第四節 復原力 17
第五節 結直腸癌患者與生活品質 29
第六節 結直腸癌與身心困擾介入措施與成效 36
第三章 研究方法 46
第一節 研究假設 46
第二節 研究架構 47
第三節 名詞解釋及操作型定義 49
第四節 研究設計 51
第五節 研究場所及對象 58
第六節 研究工具 59
第七節 資料處理及分析 64
第四章 研究結果 68
第一節 診斷五年內結直腸癌患者之人口學與疾病特性 68
第二節 保護因子、破壞因子與復原力之現況及相關性 71
第三節 結直腸癌之復原力模型 75
第四節 初診斷結直腸癌患者之人口學與疾病特性 78
第五節 實驗組執行預防性身心復健介入措施之遵從性 82
第六節 復原力之變化情形 84
第七節 身心困擾之變化情形 86
第八節 生活品質之變化情形 92
第八節 預防性身心復健介入措施之成效 94
第五章 討論 99
第一節 結直腸癌之復原力模型 99
第二節 預防性身心復健介入措施之遵從性 101
第三節 預防性身心復健介入措施於復原力及身心症狀困擾之成效 103
第四節 預防性身心復健介入措施於生活品質之成效 105
第六章 結論與建議 106
第一節 結論 106
第二節 研究限制 107
第三節 建議 108
參考文獻 110
附錄一 流行病學研究中心憂鬱量表使用同意函 125
附錄二 癌症復發害怕量表使用同意函 126
附錄三 復原力量表使用同意函 127
附錄四 FACT-G7量表使用同意函 128
附錄五 FACIT-Sp-12量表使用同意函 129

表目錄
表1 復原力量表的比較 28
表2 常見癌症生活品質量表的比較 34
表3 結直腸癌與身體活動介入措施與成效之系統性文獻回顧整理 39
表4 研究設計 52
表5 以復原力理論為基礎之照護計畫課程內容 54
表6 第一階段研究問題與統計分析表 66
表7 第二階段研究問題與統計分析表 67
表8 診斷五年內結直腸癌患者之人口學特性 69
表9 診斷五年內結直腸癌患者之疾病特性 70
表10 身心症狀困擾、自我效能與靈性安適感 72
表11 復原力 73
表12 身心症狀困擾、自我效能、靈性安適感與復原力之相關 74
表13 結直腸癌復原力模式分析結果 77
表14 初診斷結直腸癌患者之人口學特性 80
表15 初診斷結直腸癌患者之疾病特性 81
表16 實驗組執行介入措施之遵從性 83
表17 復原力量表分數變化情形 85
表18 身體症狀困擾分數變化情形 88
表19 實驗組個案常見症狀之變化情形 89
表20 控制組個案常見症狀之變化情形 90
表21 心理症狀困擾分數變化情形 91
表22 生活品質分數變化情形 93
表23 介入措施於改善復原力及身體症狀困擾之成效 95
表24 介入措施於改善心理症狀困擾之成效 96
表25 介入措施於改善生活品質之成效 97
表26 介入措施於改善靈性安適感之成效 98

圖目錄
圖1、復原力歷程模式 19
圖2、疾病復原力模式 23
圖3、第一階段研究架構圖 47
圖4、第二階段研究架構圖 48
圖5、結直腸癌復原力模式分析結果 76
圖6、收案流程圖 79
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