- 學位論文
長照機構老年住民的活動與參與研究暨中文版活動參與量表的發展與驗證
Study of Activity and Participation Performance among the Elderly Residents in Long-Term Care Facilities and Validation of a Chinese Version of the PaArticular Scales
摘要
第一階段 背景及研究目的 世界老年人口比率和數量的急劇增加，使得失能和健康狀態下降的趨勢變得益加嚴重。如果延長的生命中卻一直伴隨着嚴重的健康衰退，就會對老年人和社會產生許多的負面影響。本研究旨在探討在國際健康功能與身心障礙分類（International Classification of Functioning, Disability, and Health, ICF）架構下，影響長照機構中老年住民的個人因素、環境因素、身體功能與結構和活動與參與對生活品質的影響。 方法 採橫斷性問卷調查設計，對個案進行結構式問卷調查和測量之研究。收案地點為中台灣長期照顧機構，估計樣本需求數為大於200人。由研究者於2016年9月至2017年2月透過方便取樣方式在長照機構經所有參與者同意並由研究者親自指導參與者完成調查問卷，應用多元環境評估量表（MEAP）、貝克憂鬱量表第二版（Beck Depression Inventory-II）、簡短身體功能量表（SPPB）、簡易智能狀態量表（MMSE）、世界衛生組織障礙評估手冊2.0 ̵ 36題版（WHODAS 2.0 36-item version）、 簡明版生活品質量表（WHOQOL - BREF）問卷收集資料，並應用描述性統計、皮爾森卡方檢定、相關係數、多元迴歸混合設計中的共變數模型和階層迴歸分析進行資料的分析。 結果 共計210位參與者完成問卷，並進行統計分析。個人因素、環境因素、身體功能與結構和活動與參與分別解釋了生活品質變化的 35.9%、18.5%、25.2% 和 52.1%。10個變項的階層回歸模型分析共解釋了生活品質總變異的 84.3%。 結論 研究結果顯示，活動與參與對老年長期照護機構居民的生活品質顯示出很高的解釋力。儘管影響老年人口的活動與參與因素仍未得到充分探索，但是無疑的是一個重要的議題。本探索性研究使用國際功能、殘疾和健康分類作為概念架構，顯示對生活品質更深入理解的一個方向。最後，此研究藉由揭露長照機構老年住民健康與失能的主要影響因子，協助相關專業人員選擇更好的介入措施和更有效率的資源挹注。 第二階段 背景及研究目的 關節攣縮是老年長照機構中常見的個人狀況，且可能導致活動侷限和參與受限。因此，相關的介入計劃應該涉及活動與參與相關方面，介入成效也應該藉由活動與參與的評估作為改善與否或程度的依據。然而，目前尚無以此為目的的以患者為中心的活動與參與心理計量的結果測量工具。關節攣縮活動參與量表（PaArticular Scales）是一個新的結果測量標準，用於老年照護中量化關節攣縮對個人活動與參與的影響。本研究目的是發展關節攣縮活動參與量表中文版並評估其心理計量特性，詳細評估再測信度、客觀性、內部一致性信度和效標效度。 方法 採橫斷面研究設計。5位專家（護理師、醫師、物理和職能治療師）參加了共識會議。擬招募175-350名護理之家或老年復健機構中64歲以上經醫生、護理師或物理和職能治療師評估確認患有嚴重關節攣縮的老年居民參加研究。藉由翻譯、審查、反覆翻譯、專家小組評估和預試五個階段產生出中文版關節攣縮活動參與量表。採用α = .01，中度效果量（r = .30），統計檢定力（power）為.90的双尾相關性檢定力分析，估算後合理樣本數為180位以上。因比，擬以簡單隨機取樣方式取得足夠樣本數。中文版關節攣縮活動參與量表信度分析方面，則依題項內、題項和全部題項間、次量表和全部量表之間依序進行相關性的分析。效度分析方面，則以最大變異轉軸法的原則，應用探索性因素分析、題項和次量表間相關性分析和效標效度分析以確認出中文版關節攣縮活動參與量表的效度。 結果 本研究參與者共計243人。中文版關節攣縮活動參與量表具有良好的信度，Cronbach α係數為 .975，平均得分為28.98（SD = 17.34）。由24道題項組成的活動次量表（Activities scale）的Cronbach α係數為 .973，平均得分為18.68（SD = 13.51）。由11道題項組成的參與次量表（Participation scale）的Cronbach α係數為 .938，平均得分為10.30（SD = 5.85）。表示兩個次量表同具優異的（excellent）內部一致性。探索性因素分析（exploratory factor analysis, EFA）發現活動次量表（Activity subscale）有三個主要因素，參與次量表（Participation subscale）只有一個主要因素（特徵值 > 1），活動次量表和參與次量表可以解釋總量表分別為75.18% 和 62.83%。次量表與總量表相關性分析顯示，活動次量表和參與次量表的 Pearson 相關係數分別為 .881和 .843。活動次量表（Activity subscale）與世界衛生組織障礙評估手冊2.0 ̵ 36 items和簡明版世界衛生組織生活品質問卷間的皮爾森積動差相關係數（Pearson’s product-moment correlation）分別為 .722和 -.502；參與次量表（Participation subscale）與世界衛生組織障礙評估手冊2.0 ̵ 36 items和簡明版世界衛生組織生活品質問卷間的相關係數分別為 .742和 -.580，皆達顯著且高的相關。 結論 研究結果顯示，中文版關節攣縮活動參與量表具有良好的內部一致性、信度和效度。中文版關節攣縮活動參與量表是衡量關節攣縮長者活動與參與的一個可靠（reliable）和有效的（valid）工具。不僅可以作為一個良好的結果測量（outcome measure）工具，且能在臨床上提供測量活動與參與的另一種較為簡便的工具選擇。然而，必須在未來的研究中進一步測試其適用性和普遍性，建議未來研究能朝擴大樣本數及施用在不同的臨床領域中的方向探討。
並列摘要
Part one Background and Purposes The proportion and amount of elderly in the world has increased. The downward trend of disability and health status becomes more serious. If the increasing longevity associated with serious health decline, it will have a negative impact on the elderly and social. The main purpose of the present study was to investigate the relationship among body functions, body structures, personal factors and environmental factors affecting older adults’ quality of life, activities and participation in long-term care facilitie, in ICF framework. Methods This study used a questionnaire-based cross-sectional design. A structured questionnaire was adopted as the research tool. Selective sampling was used to recruit through seven long-term care facilities in Central Taiwan. Approximately 222 participants were required. The data collection period of this study spanned from October to December 2016. The following convenience sample method was used. The researchers guided participants completed the questionnaire. A structured questionnaire was adopted as the research tool. The questionnaire was included MEAP (Multiphasic Environmental Assessment Procedure), Beck Depression Inventory, SPPB (Short Physical Performance Battery), MMSE (Mini-mental State Examination), WHODAS 2.0 ̵ 36 items (WHO Disability Assessment Schedule 2.0 ̵ 36 items version) and WHOQOL- BREF (WHO Quality of Life - BREF). A description, Pearson Chi-square test, Correlation Coefficient and Regression were used in the statistical analysis. Finally, it is desirable to expose the main influencing factor by older adults’ health and disability in long-term care facilities and assist relevant professionals choose a better and more efficient interventions to inject resources. Results All participants (n = 210) completed the questionnaire and performed statistical analysis. Personal factors, environmental factors, body function and structures, and activity and participation explained 35.9%, 18.5%, 25.2%, and 52.1% of the variability in quality of life, respectively. The hierarchical model included 10 variables and explained 84.3% of the total variability in quality of life. Conclusions The results of this study suggest that activity and participation showed high explanatory power for the quality of life of older long-term care facility residents. The influence of activity and participation in the older population is an important issue, although these factors remain relatively unexplored. This exploratory study used the International Classification of Functioning, Disability and Health as a conceptual framework to provide a more sophisticated understanding of quality of life. Part two Background and Purposes Joint contractures are common complications of elderly residents in long-term care facilities, causing activity limitations and participation restrictions and affecting quality of life (QOL). Therefore, evaluation scales for activity and participation by elderly residents are particularly important. However, in the Chinese-speaking region, there is currently no patient-centred and robust psychological outcome measurement scale for joint contractures. A Chinese version of the PaArticular Scales can fill that gap. The development of a Chinese version of the PaArticular Scales not only can provide a new measurement standard for the relevant medical professionals but can also quantify the effect of joint contractures on the activity and participation of elderly residents in long-term care facilities. Furthermore, the simplicity of measurement can also be considered. The purpose of this study was to develop a Chinese version of the PaArticular Scales and evaluate the psychometric characteristics. The test-retest reliability, objectivity, internal consistency reliability and criterion validity were evaluated in detail. Methods This study used a cross-sectional study design. Five experts (nurses, physicians, and physical and occupational therapists) participated in a consensus meeting. A total of 175-350 people living in long-term care facilities over 64 years old with severe joint contractures (as confirmed by doctors, nurses or physical and occupational therapists) were enrolled in this study. The Chinese version of the PaArticular Scales of joint contractures was generated through 5 stages: translation, review, back-translation, panel of specialists and pretest. A total sample size calculated by G * Power corresponds within the given two-tailed tests with α = .01, medium effect size correlation coefficient ρ = .30, and power = 0.90 indicated that the reasonable sample size should be 157. A simple random sampling method was used to obtain a sufficient sample size. For the reliability analysis of the Chinese version of the PaArticular Scales of joint contractures, the correlation analysis was conducted in the following order: within-item, between item-to-total, and subscale-to-total. For validity analysis, using varimax rotation, exploratory factor analysis (EFA), correlation analysis between items and subscales, and criterion-related validity analysis were performed to confirm the validity of the Chinese version of the PaArticular Scales of joint contractures. Results There were 243 participants in this study. The Chinese version of the PaArticular Scales had excellent reliability, with a Cronbach α coefficient of .975, with an average score of 28.98 (standard deviation (SD) = 17.34). For the Activities subscale, which consisted of 24 items, the Cronbach’s α was .973, with an average score of 18.68 (standard deviation (SD) = 13.51). For the Participation subscale, which consisted of 11 items, the Cronbach’s α was .938, with an average score of 10.30 (SD = 5.85). This meant that both subscales had excellent internal consistency. EFA showed that there were 3 main factors in the Activity subscale and only one major factor in the Participation subscale (eigenvalue > 1) that explained 75.18% and 62.83 % of the total variance in the Activity subscale and Participation subscale, respectively. The subscale-to-total scale correlation analysis showed Pearson correlation coefficients of .881 for the Activity subscale and .843 for the Participation subscale. The correlation coefficients between the Activity subscale and the WHODAS 2.0 ̵36 items and WHOQOL-BREF were .722 and -.502, respectively, and the correlation coefficients between the Participation subscale and the WHODAS 2.0 ̵36 items and WHOQOL-BREF were .742 and -.580, respectively; all the coefficients were significant and highly correlated. Conclusions This study found that the Chinese version of the PaArticular Scales had excellent internal consistency, reliability and validity. The Chinese version of the PaArticular Scales is a reliable and valid tool for measuring the activity and participation of elderly residents with joint contractures. Not only can it be used as a good sound outcome measure tool, but it can also provide another simple tool for measuring activity and participation in clinical practice. However, the Chinese version must be further tested for applicability and generalizability in future studies, preferably with a larger sample and in different clinical domains.
參考文獻
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