胰島素治療的第二型糖尿病患者血糖控制不佳之阻礙因素：一個質性探索

Barriers of poorly controlled patients with type 2 diabetes using insulin therapy: A qualitative study

莊雅婷(Ya-Ting Chuang)

指導教授 ： 彭秀玲

中山醫學大學/醫學科技學院/心理學系暨臨床心理學系/碩士(2019年)

https://doi.org/10.6834/CSMU201900163

摘要

研究背景與目的：第二型糖尿病患者的血糖控制是當今醫療與患者本身關注的議題，即使用降血糖效果最好的胰島素注射治療，血糖卻依舊無法穩定控制。過去研究多以量化的方法探索血糖控制與生理心理社會因素的關係，忽略文化、心理社會對血糖控制的影響。因此，本研究以質性角度深入探索台灣第二型糖尿病患者使用胰島素治療後，血糖控制不佳的各種因素。
研究方法：本研究以中區某醫學中心的病人為對象，從質性訪談的角度，分別以焦點團體訪談與個別深度訪談進行兩階段的資料收集。首先是3次焦點團體訪談法（男：12，女：23，共35名患者，平均年齡63歲），依循紮根理論的概念進行資料分析後，再從團體參與者中找出經驗相異且有潛力進一步說明的8位成員進行個別深度訪談，以便彌補兩種方法上的缺點，並使資料飽足，以呈現糖尿病患者的真實經驗。
研究結果：本研究發現國內第二型糖尿病患者進行胰島素治療後血糖控制不佳的因素主要有：一、知識的窒礙難行。二、生活習慣難以改變。三、難以棄之不顧的文化習俗。四、低血糖與其他不適的威脅。五、無立即性的血糖變化與併發症。六、難以調節的負面情緒。七、缺乏支持與共同奮戰的戰友。可見，不同文化的確透過習俗對血糖控制有影響，知識運用、改變的抗拒、情緒狀態、危機感等心理社會因素亦是血糖控制的阻礙與挑戰。
結論：本研究發現患者追求血糖良好控制的過程中，經歷不少內、外在掙扎與抵抗。一旦掙扎與抵抗失敗，將成為血糖控制的重要阻礙。建議未來的衛教內容可針對不同的阻礙因素做調整，例如：如何面對危機感、在生活落實知識的應用、如何處理負面情緒、如何抗衡文化壓力、提供家屬支持與諮詢的機會等等，以增進血糖控制的效果。

關鍵字

第二型糖尿病 ； 胰島素治療 ； 血糖控制 ； 質性研究 ； 焦點團體訪談 ； 個別深度訪談

並列摘要

Background: Glycemic control in patients with type II diabetes mellitus(T2DM) is a concerned field within the medical profession and T2DM patients. Even insulin injection therapy is the best strategy for glycemic control, the patient’s blood glucose still cannot keep stable. Previous studies usually used quantitative method to explore the correlation between glycemic control and biopsychosocial factors instead of the influences of psychosocial factors and cultural issues. Therefore, the present study aims to explore the factors, which may influence poor glycemic control in patients with T2DM who are using insulin injection.
Method: The qualitative approach was applied in the study, including focused group interviews and in-depth interview. Patients with T2DM were recruited from one of the hospitals in the central of Taiwan. Firstly, we had focused group interviews with 35 patients whose average age is 63 (12 males and 23 females). Secondly, data were analyzed based on grounded theory. Thirdly, 8 members with the potential to further probe by an individual in-depth interview for probing more about the experience of glycemic controlling to have data satiation and investigate the experiences of diabetic patients comprehensively.
Results: Results showed that 7 main factors are leading to poor glycemic control among T2DM patients who were treated by insulin injection therapy. (1) Difficult in executing the treatment plan; (2) Hardly to change the living habits. (3) Hard to get rid of cultures and customs. (4) No hypoglycemia and other physical discomforts. (5) No immediate glycemic change or complications. (6) Negative emotions that are difficult to adjust. (7) Lack of supportive and comrades to facing difficulties. As mention above, cultures differences have an indeed impact on blood glucose due to their customs. Besides, psychosocial factors including knowledge application, resistance mindset of changing, mood state, sense of crisis, etc., are also the challenges and obstacles for keeping blood glucose in a steady state.
Conclusions: T2DM patients have been experienced in many internal and external factors while struggling to keep the blood glucose levels in a long time. Once they give up for fighting the struggling, blood glucose levels would be out of control. Therefore, it is recommended that the content of health education can be adjusted based on the above obstacles so that the effect on glycemic control can be improved for T2DM patients. Here is some advice to the medical practice: improve the sense of crisis, regulate negative mood, contend with cultural pressure, and the application of knowledge and a consult chance for the family.

並列關鍵字

Type II diabetes mellitus(T2DM) ； insulin injection ； glycemic control ； qualitative research ； focused group interview ； in-depth interview

參考文獻

Krass, I., Schieback, P., & Dhippayom, T. (2015). Adherence to diabetes medication: a systematic review. Diabet Med, 32(6), 725-737. doi: 10.1111/dme.12651

ADA. (2018). standards of medical care in diabetes-2018. Diabetes Care, 41, S55-S64.

Ahmad, N. S., Islahudin, F., & Paraidathathu, T. (2014). Factors associated with good glycemic control among patients with type 2 diabetes mellitus. J Diabetes Investig, 5(5), 563-569. doi: 10.1111/jdi.12175

Al Sayah, F., & Williams, B. (2012). An integrated model of health literacy using diabetes as an exemplar. Canadian Journal of Diabetes, 36(1), 27-31.

Anderson, R. M., & Robins, L. S. (1998). How do we know? Reflections on qualitative research in diabetes. Diabetes Care, 21(9), 1387.