臺灣博碩士論文加值系統

末期腎病盛行率高居不下，血液透析是病患首選治療方式，人數眾多加上醫療費用昂貴，於是醫療照護體系帶來龐大負擔。若透析初期病患能夠確實執行自我管理，將可減少合併症的發生，確保病患進入長期透析後的照護品質，因此本研究目的主要在了解透析初期病患健康識能、自我管理的現況；探討其相關性並分析自我管理之預測因子。
本研究採橫斷式相關性之研究設計，研究對象為於北部各等級醫療院所接受血液透析6個月內的病患，採立意取樣方式收案，以結構式問卷收集資料。總收案人數共271位，研究結果顯示，研究對象平均年齡為65.46歲；以男性與教育程度以小學以下(含)居多。整體自我管理總得分為49.97分（標準差為12.88），四個面向中以執行自我照顧活動得分為最高分，而伙伴關係得分最低；研究結果發現「教育程度、主要照顧者、機構等級」與整體自我管理有顯著差異；「年齡、症狀困擾程度」與整體自我管理呈現負相關；「自覺健康、健康識能、社會支持」與整體自我管理呈現正相關。在多元迴歸分析顯示「年齡」、「教育程度」、「健康識能」、「社會支持」等變項為自我管理的預測因子，整體解釋變異量為36%。
年齡大、教育程度低的病患為健康識能不足的族群，其自我管理行為也較差，健康識能與社會支持是自我管理重要的影響因素；而透析前接受個案管理比例偏低，因此初期透析病患之照護無法提前介入，故自我管理仍有待努力。未來照護低健康識能群體時，需針對個案之需求與特性，以病人為中心訂定照護計劃，善用社會支持網絡資源，協助病患落實自我管理。建議宜將健康識能評估納入例行照護工作中，更準確掌握病患的健康識能程度，提供適切照護服務，以確保初期透析病人之照護品質。

Abstract
The prevalence of end stage renal disease (ESRD) in Taiwan is higher than many other developed countries in the world. Hemodialysis is the most common kidney replacement treatmentfor ESRD patients. The huge medical expenditure in hemodialysis has been heavy burden in national health insurance system. Hemodialysis patients have well self-management that would decrease complications and increase long-term life quality. This study was conudected to investigate the health literacy and self-management levels of patients who just starting hemodialysis, and to analyze the predictive factors for self-management.
This is a cross-sectional correlation study. The subjects who received hemodialysis no more than six months were recruited from medical organizations with different medical levels in northern Taiwan by pueposive sampling. The data had been collected by structured questionnaire.
There were total recruited 271 patients in this study. The average age of all subjects was 65.46 years old. Most subjects were male and had education levels below primary school. Overall self-management score was 49.97 ± 12.88 points. The highest score appeared in self-care activities of the four aspects of self-managenent scale, and the lowest in partnerships. Education level, primary caregiver, and hospital level showed significant difference with overall self-management. Age and severity of symptoms showed negative correlation with overall self-management. Self-perceived health status, health literacy, and social support showed positive correlation with overall self-management. Multiple regression analysis showed that age, education, health literacy, and social support were the significant predictive factors for self-management. The explained sum of variation was 36%.
Health literacy and social support are major influencing factors of self-management. Patients who were older and have lower education levels have less health literacy, therefore they also had poor self-management. However, the percentage of chronic kidney disease patients attending health education project is too low to make early medical intervention. We should put more effort and set first priority in HD patients’ self-management improvement program. The assessment of health literacy should be included in routine care for hemodialysis patients. Health care providers have to provide adequate care according to patients’ health literacy levels. For patients with poor health literacy, a patient-centered care plan should be made according to individual need to improve self-management by using social support network resource. The results of this study may provide useful information to improve quality of care for patients with initial hemodialysis.

目錄
致謝………………………………………………………………………… ⅰ
中文摘要…………………………………………………………………… ⅲ
英文摘要…………………………………………………………………… ⅳ
目錄………………………………………………………………………… ⅵ
圖目錄……………………………………………………………………… ⅷ
表目錄……………………………………………………………………… ⅸ
第一章 緒論……………………………………………………………… 1
第一節 研究背景與現況…………………………………………… 1
第二節 研究動機與重要性………………………………………… 3
第三節 研究目的…………………………………………………… 6
第二章 文獻查證………………………………………………………… 7
第一節 血液透析病患常見照護問題……………………………… 7
第二節 自我管理概念與測量……………………………………… 10
第三節 健康識能概念與測量……………………………………… 13
第四節 健康識能與自我管理的關係……………………………… 19
第五節 透析初期病患與自我管理之相關因素…………………… 21
第三章 研究方法………………………………………………………… 25
第一節 研究設計…………………………………………………… 25
第二節 研究架構…………………………………………………… 26
第三節 研究假設…………………………………………………… 27
第四節 名詞定義…………………………………………………… 28
第五節 研究對象與場所…………………………………………… 29
第六節 研究工具及信效度………………………………………… 30
第七節 研究步驟與資料蒐集過程………………………………… 34
第八節 倫理考量…………………………………………………… 35
第九節 資料分析…………………………………………………… 36
第四章 研究結果………………………………………………………… 39
第一節 透析初期病患基本屬性、健康自覺、健康識能與社會支持
之概況…………………………………………………… 39
第二節 透析初期病患之社會人口學特性、健康自覺症狀、健康識
能、社會支持與自我管理的相關性……………………… 53
第三節 透析初期病患自我管理之預測因子……………………… 64
第五章 討論……………………………………………………………… 75
第一節 探討透析初期病患特性、健康識能、社會支持與自我管理
之概況……………………………………………………… 75
第二節 探討透析初期病患社會人口學特性、健康識能、社會支持
與自我管理之相關性……………………………………… 84
第三節 探討透析初期病患自我管理之預測因子………………… 89
第六章 結論、研究限制與建議…………………………………………… 93
第一節 研究結論…………………………………………………… 93
第二節 研究限制…………………………………………………… 95
第三節 研究建議…………………………………………………… 96
參考文獻…………………………………………………………………… 100
附錄一 症狀困擾與社會支持使用同意書……………………………… 119
附錄二 血液透析病友健康相關知能使用同意書……………………… 120
附錄三 血液透析病患自我管理量表使用同意書……………………… 121
附錄四 研究問卷………………………………………………………… 122
附錄五 人體試驗委員會同意臨床試驗證明書………………………… 132

圖目錄
圖3-2-1 研究架構………………………………………………………… 26
圖6-1-1 研究架構………………………………………………………… 94

表目錄
表2-2-1 健康識能測量工具彙總表……………………………………… 18
表3-9-1 描述性統計分析方法（一）……………………………………… 36
表3-9-2 描述性統計分析方法（二）……………………………………… 36
表3-9-3 推論性統計分析方法（一）……………………………………… 37
表3-9-4 推論性統計分析方法（二）……………………………………… 38
表4-1-1 透析初期病患社會人口學特性之次數分配表………………… 40
表4-1-2 透析初期病患症狀困擾程度得分情形………………………… 42
表4-1-3 透析初期病患自覺健康評量表得分情形……………………… 43
表4-1-4 透析初期病患健康識能正確率情形…………………………… 45
表4-1-5 透析初期病患健康識能各題答題正確率……………………… 46
表4-1-5 透析初期病患健康識能各題答題正確率(續)………………… 47
表4-1-6 透析初期病患社會支持得分情形……………………………… 49
表4-1-7 透析初期病患自我管理各次量表得分情形…………………… 50
表4-1-8 透析初期病患自我管理各題得分情形………………………… 52
表4-2-1 透析初期病患社會人口學特性、照護系統與自我管理之檢定
分析…………………………………………………………… 57
表4-2-1 透析初期病患社會人口學特性、照護系統與自我管理之檢定
分析(續)………………………………………………………… 58
表4-2-2 透析初期病患健康自覺症狀與自我管理相關分析(r)………… 59
表4-2-3 透析初期病患健康識能與自我管理相關分析(r)……………… 61
表4-2-4 透析初期病患社會支持與自我管理相關分析(r)……………… 63
表4-3-1 單變項線性迴歸探討透析初期病患自我管理之預測因子…… 68
表4-3-1 單變項線性迴歸探討透析初期病患自我管理之預測因子(續) 69
表4-3-2 影響自我管理因子共線性診斷分析表………………………… 71
表4-3-3 以多元線性迴歸探討透析初期病患自我管理之預測因子…… 73
表4-3-3 以多元線性迴歸探討透析初期病患自我管理之預測因子(續) 74

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