愛滋病個案管理師管理技巧及其與感染者關係初探－以輔導感染者自我健康為例

Exploring How HIV/AIDS Case Managers Manage Clients and Their Professional Relationship:Take Guiding Clients’ Self-Care as an Example

潘柏翰(Bo-Han Pan)

指導教授 ： 陳端容

國立臺灣大學/公共衛生學院/健康政策與管理研究所/碩士(2015年)

https://doi.org/10.6342/NTU.2015.00911

摘要

背景：政府自1997年免費提供三合一高效能抗反轉錄病毒療法（highly active antiretroviral therapy，簡稱HAART，俗稱雞尾酒療法）讓愛滋病毒感染者（以下簡稱感染者）服用後，感染者在規律服藥的情形下，其平均餘命逐年增加，生活型態也與其他慢性病患者無異。近年來感染者面臨多樣且複雜的照顧與資源需求，也期望降低愛滋病毒合併梅毒或C型肝炎的傳染率，感染者的生活就成了公共衛生部門亟需關切與介入的對象。臺灣衛生福利部疾病管制署（以下簡稱疾管署）自2007年起實施愛滋病個案管理計畫（以下簡稱個管計畫），目前已有不少學術研究從結果面（如感染者的生理或健康狀態）來評估此計畫的成效。在此同時我們亦不能忽略個管師作為計畫中的能動者（agent）對感染者的影響。個管師如何從一開始與感染者建立關係，到後續輔導感染者的自我健康管理，都與個管師的技巧以及雙方間的專業關係息息相關。

目的：從微觀互動的層次來探索個管師與感染者互動時的策略或技巧，與既有行為理論中的哪些面向有所呼應。其次，了解雙方間關係的維繫除了理解專業關係如何影響感染者，也可知道該維繫怎麼樣的專業關係才有助於感染者的健康。

方法：本研究為針對個管計畫中個管師與感染者互動情形的探索型研究。我採取深度訪談法來收集研究資料，以滾雪球抽樣（snowball sampling）訪談了13位任職於北部地區愛滋病指定醫院或地方衛生局的愛滋病個管師，與10位居住在臺灣北部地區的感染者。訪談內容由研究者將錄音檔內容聽寫轉錄成逐字稿後，依據Strauss和Corbin（1997）提出的開放性譯碼（open coding）原則來分析資料。

結果：研究主要發現有：（1）個管師（特別是醫療院所）會運用大量的會談技巧來與感染者建立專業關係，初期建立專業關係時主要透過「噓寒問暖」、「開放式問句」、「反映式傾聽」與「建立框架」來獲取感染者的信任，並營造讓感染者願意訴說的環境。（2）在協助感染者行為改變與服用雞尾酒療法方面，個管師多著眼於強化感染者的認知。針對前者採取「利己觀」的立場，並以感染者的免疫或是疾病負擔作為訴求；服用雞尾酒療法則接近既有行為理論中的行為（學習）理論，藉由創造或形塑感染者的前因（antecedent）來讓感染者規律服藥（3）個管師與感染者間的專業關係會因為疾病的性質、藥物的發明等因素，使得專業關係的性質在時、空間、權力關係，以及信任程度面向較為彈性。（4）個管師與感染者間的專業關係會受到信任程度的影響而朝向親近或疏遠化發展。

結論：不論是哪一場域的個管師與感染者互動時都會運用大量的會談技巧，然而不同場域間的技巧純熟度有別，建議未來在個管師任職前應提供相關訓練。個管師在協助感染者提升服藥順從時的策略較為接近行為學習理論，不過感染者身體對藥物的感受或想法仍較少在共同討論藥物時獲得重視。雙方間的專業關係在性質與規範上會隨著互動情形與信任程度而彈性變化，特別是關係疏遠化時彰顯了個管師在個管計畫中的位置與重要性。

關鍵字

愛滋病個案管理計畫 ； 專業關係 ； 個案管理師 ； 會談技巧

並列摘要

Background: Since the highly active antiretroviral therapy (HAART, also known as ART: antiretroviral therapy) was introduced and freely provided for people living with HIV/AIDS (PLWH) by the government in 1997. People who take HAART on a regular basis have prolonged their life expectancy, and their lifestyles are similar to patients with other chronic diseases accordingly. Multiple and complex needs of care and resources of PLWH have been concerned and intervened by public health sector, along with the expectation of reducing transmission rates of HIV along with syphilis or hepatitis C virus.
The HIV Case Management Program (HIVCMP) has been launched by Centers for Disease Control in Taiwan since January 2007, many research has been done to assess effects of this program’s outcomes (such as physical or health status of PLWHs). Simultaneously, we cannot neglect HIV case managers as important agents in the program and their influence on PLWHs. How HIV case managers establish contact with and assist PLWHs’ self-care management is closely related to HIV case managers' skills and professional relationship.

Objectives: This study is to explore strategies or skills when HIV case managers interact with PLWHs, and to examine behavior theories corresponding to these strategies. Furthermore, understanding how HIV case managers establish contact with PLWHs helps us to comprehend how professional relationship influences PLWHs, and what kind of professional relationship is beneficial for PLWHs’ health.

Methods: This study was an exploratory study focusing on situations where HIV case managers and PLWHs interact. Data were collected by in-depth interviews. By means of snowball sampling, 13 case managers working in AIDS assigned hospitals and local health bureaus and 10 PLWHs living in Northern Taiwan were selected and interviewed. The sound-recording interview data were transcribed into verbatim draft and followed by open coding principle proposed by Strauss and Corbin (1997) to analyze data.

Results: The main findings of this study as follows: (1) HIV case managers (especially those who work in AIDS assigned hospitals) use a great amount of interview skills to establish professional relationship with PLWHs. The skills of “social conversation”, “open question”, “reflexive listening “, and “providing framework” are used to at the initial stage to earn PLWHs’ trust and create an environment where PLWHs are willing to make self-disclosure. (2) HIV case managers concentrate on strengthening PLWHs’ cognition when assisting PLWHs’ behavior change and use of HAART. In assisting PLWHs’ behavior change, case managers adopt an egoistic-oriented standpoint, along with PLWHs’ immunity or disease burden as argument. HIV case managers create or form PLWHs’ antecedents to help them take HAART, which is similar to behavioral learning perspectives. (3) Due to the characteristics of HIV, the invention and effects of HAART, the professional relationship between HIV case managers and PLWHs is flexible in time, space, power relationship and degree of trust. (4) The professional relationship between HIV case managers and PLWHs becomes more intimate or remote depending on degree of trust in their professional relationship.

Conclusion: HIV case managers use a great amount of interview skills in every field. However, the proficiency of skills varies within case managers in different field. Therefore, this research suggests that providing related training before working as a HIV case manager is crucial. The strategies that case managers use when assisting PLWHs’ use of HAART is similar to behavioral learning theory. However, the experience and ideas of PLWHs who take HAART receive less attention when case managers and PLWHs discuss about HAART. The property and norms of professional relationship between HIV case managers and PLWHs vary with interaction and degree of trust between them. When the professional relationship is remote, the importance and role of HIV case managers in the program is especially significant.

並列關鍵字

HIV case management program (HIVCMP) ； professional relationship ； HIV case manager ； interview skill

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