秀林鄉社區肺結核患者疾病觀、服藥行為與在地服藥督促介入探索研究

An Exploration of Indigenous Disease Conceptions, Treatment Adherence, and Localized Treatment Monitoring Intervention among Community Tuberculosis Patients in Hsiu-lin Township

吳思儀(Szu-Yi Wu)

指導教授 ： 丁志音

國立臺灣大學/公共衛生學院/衛生政策與管理研究所/碩士(2005年)

https://doi.org/10.6342/NTU.2005.02548

摘要

自1985年以降，肺結核有再度盛行的趨勢，尤其是對於結核桿菌抗藥性的擔憂，使得患者的服藥行為成為全球性學術研究以及政策介入的重點。台灣地區自民國八十六年起於山地鄉推行DOTS --「都治」計畫，以設置觀察員的方式，督促患者規律服藥。除了推動「都治」計畫，國內學術研究以及實務報告中，亦持續找尋能夠增進整體完治率以及個人無法規律服藥的原因。
本研究自民國九十三年七月至九十四年五月，於秀林鄉中以深度訪談法針對社區患者的服藥行為以及「在地服藥督促者」的介入內涵進行探索研究。研究結果分為三部分：第一部分以疾病起因、嚴重性以及治癒信念來描述地區患者的疾病觀；第二部分則藉著對肺結核患者生活世界的瞭解，顯現出服藥與生活、疾病解釋、身體狀況的交織互動情形，亦即當社區患者處於社會結構的中低下階層，從事短期不穩定的勞動工作、無經濟來源、飲酒的生活方式(於高密度頻率的人際互動中出現)、多重疾病複合的情況之下，自發性規律服藥的困難。
第三部分以患者、一個新增的在地督促服藥角色 -- 公服員，及地段公共衛生護士三方觀點的對照，發現在地的服藥督促者能夠改變非規律服藥者的服藥型態，使得社區患者能夠完成治療。
最後，本研究透過整體性的觀看社區患者的服藥行為脈絡，引用「Syndemic」 -- 「疾苦糾結互應」。此概念是指兩個以上，聯合、具交互作用，不斷自我增強的事件，經整體累積加乘，形成了一個群體共通且特別盛行的集結現象。
透過這個新概念與詞彙的使用，能夠替代過往以生物醫學的疾病分類方式為主的觀點，並且，就以針對一個社區或群體的介入設計而言，亦能從「Syndemic」的視角，擬訂出以「人」為中心，具有多層次關切且貼近生活的計畫內涵。建議未來研究繼續以此概念擴展，讓公共衛生能夠透過對於社會文化現象與疾病間的糾結認識，認識「大眾健康」的系統脈絡。
而就肺結核的防治而言，建議以設置永續性的在地服藥督促者，來執行「都治」計畫，促使患者規律服藥完成治療。

關鍵字

肺結核 ； 秀林鄉肺結核患者 ； 疾病觀 ； 服藥行為 ； 疾苦糾結互應 ； 都治計畫

並列摘要

Tuberculosis is a grave threat to global health, especially the emergence of TB strains resistant to multiple drugs. In response to this concern, it is most important to deal with the barriers of “adherence to treatment”. In Taiwan, DOTS (directly observed treatment, short-course) was intervened in mountains aboriginal townships in 1997. Moreover, we continue seeking the barriers of medicine taking default.
Mainly through in-depth interviewing community TB patients and local treatment observers, this research was conducted from July 2004 to May 2005 in Hsiu-lin township, Hualien County in an attempt to explore the pattern of “treatment adherence” among patients and the nature and implementation of local DOTS intervention. Three major results were derived from this ethnographic study. First, the indigenous conceptions of illness, including etiology, severity, and belief in the curability of disease, was delineated. Second, the interweaving of the daily life, illness concepts, and health status were presented. It was less likely for a patient to actively commit himself in regular drug taking if the patient was a member of lower socio-economic class, having unstable jobs and therefore without regular source of income, engaging in a lifestyle characterized by heavy drinking, and afflicted with multiple chronic disorders. Third, by articulating and comparing the perspectives of patients, public health nurses and local observers, it was able to present the accomplishment of the local observers in improving treatment adherence.
The concept of “syndemic” was used to explain the entwined phenomenon -- two or more afflictions, interacting synergistically, contributing to excess burden of disease in a population. This concept not only points out an explicit orientation of research and prevention approach, but also makes“public health”close to the context of everyday life.
Finally, it is suggested that the“local treatment observer” should be officially and permanently integrated into the system of TB prevention and control to provide sustainable and cultural sensitive services to TB patients, especially in remote areas.

並列關鍵字

Tuberculosis ； indigenous people ； disease concept ； treatment adherence ； DOTS

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