乳癌病人疾病控制感與生活品質的關係 －初探壓力因應的中介效果

The Relationship between Perceived Control over Illness and Quality of Life among Patients with Breast Cancer: Exploring the Mediating Effect of Coping

洪家暐(Hung Chia-Wei)

指導教授 ： 吳治勳

國立政治大學/理學院/心理學系/碩士(2020年)

https://doi.org/10.6814/NCCU202000844

摘要

緒論：控制感對人而言有著重要的適應性意義。乳癌患者自診斷到治療期間，一方面受到疾病經歷影響而威脅其原有的控制感，一方面亦主動建構對於疾病的控制感。對於乳癌患者而言，疾病控制感除了與身心適應具有關聯性之外，疾病控制感亦可能影響病人使用的因應策略。疾病控制感可依據疾病覺知分為個人控制感與治療控制感，過去研究認為這兩類疾病控制感對個人後續因應之影響可能有所不同。本研究將以台灣乳癌病人為對象，探討疾病控制感（個人控制感與治療控制感）、因應型態及病人生活品質的關係。
研究方法：本研究以台灣北部某醫學中心之乳癌病人為對象，利用短版疾病覺知量表（Brief Illness Perception Questionnaire）、短版因應量表（Brief COPE）及台灣簡明版世界衛生組織生活品質問卷（WHOQoL）作為測量工具，於病人手術後一個月時評估其疾病覺知之個人控制感與治療控制感、因應策略及生活品質，並於術後六個月再次評估因應型態及生活品質。以路徑分析檢驗包含不同時間點變項之三個模型，探討因應型態是否可中介疾病控制感與生活品質之間的關係。模型一以術後一個月之疾病控制感、因應型態及生活品質；模型二以術後一個月之疾病控制感與因應型態，及術後六個月之生活品質；模型三以術後一個月之疾病控制感，及術後六個月之因應型態與生活品質，進行路徑分析。
研究結果：本研究術後一個月與六個月皆參與者共76人，平均年齡為53.42歲（SD = 10.40）。路徑分析之參數預測結果顯示(1)疾病控制感與生活品質的關係中，個人控制感無法直接預測生活品質；而術後一個月之治療控制感可負向預測術後六個月之心理、社會、環境的生活品質；(2)疾病控制感與因應型態的關係中，術後一個月的個人控制感可正向預測術後六個月的問題取向因應；術後一個月之治療控制感可正向預測術後六個月之逃避因應；(3)因應型態與生活品質的關係中，術後一個月之問題取向因應可正向預測術後一個月之心理、社會、環境生活品質；術後一個月之情緒取向因應可正向預測術後一個月之環境生活品質，術後一個月之情緒取向因應可正向預測術後六個月之社會、環境生活品質，術後六個月之情緒取向因應可正向預測術後六個月的生理、心理、社會及環境生活品質；術後一個月之逃避因應可負向預測術後一個月、六個月的生理、心理、社會及環境生活品質，術後六個月之逃避因應可負向預測術後六個月之生理、心理、社會及環境生活品質。各中介模式的結果顯示(1)個人控制感經由因應型態正向影響生活品質之三個中介模式的間接效果皆達顯著，模式一影響生理、心理、社會、環境之生活品質，模式二、模式三影響心理、環境生活品質，(2)治療控制感影響生活品質的模式一、二中介模式不成立，而模式三成立；模式二治療控制感不經由因應型態直接負向影響心理、社會、環境生活品質，模式三治療控制感經由因應型態負向影響生理、心理、社會、環境生活品質。
討論與結論：(1)因應型態確可視為疾病控制感與生活品質的中介變項。個人控制感無法直接預測生活品質，可經由因應型態而正向影響生活品質；治療控制感可負向直接預測生活品質，亦可經由因應型態負向影響生活品質。個人控制可能反映病人的效能感，協助病人減少逃避因應或增加問題取向因應以正向影響生活品質；治療控制感可能反映病人認知逃避的因應策略或是非醫療之內外在資源不足的危險因子，隨著治療進程，逐漸負向影響後續的生活品質。(2)問題取向因應可正向預測同時之生活品質，雖統計上僅接近顯著，然亦提供部分中介模型的間接效果，此預測效果隨著治療進程逐漸減少；情緒取向因應無法中介疾病控制感與生活品質的關係，但具有單獨預測生活品質的能力，隨著治療進程，情緒取向因應的重要性則逐漸增加；逃避因應可單獨預測生活品質，亦提供大部分中介模型的間接效果，顯示逃避因應對於乳癌病人適應的重要性。未來研究建議(1)納入更大量樣本，或可進一步討論個人控制感與治療控制感的交互影響；(2)收集疾病特性的資料，進一步理解不同疾病特性之族群，其疾病控制感、因應型態、生活品質關係；(3)蒐集更多時間點的追蹤研究，可更細緻了解不同時間點疾病控制感與因應型態變化，及其對於生活品質的影響。

關鍵字

乳癌 ； 疾病覺知 ； 疾病控制感 ； 因應 ； 生活品質 ； 中介

並列摘要

Background: Perceived control was crucial to adaptation meaning. Breast cancer patients’ “sense of control” could be affected by the cancer diagnosis, but they could otherwise actively construct the representation of perceived control over illness. Perceived control over illness was associated with the well-being of the patients and influenced the patients’ coping strategies. The Common Sense Model distinguished perceived control over illness into “personal control” and “treatment control.” Past studies indicated that either kind of perceived control over illness could influence the coping strategies differently. This study aimed to examine the relationship among perceived control over illness (includes personal control and treatment control), coping, and quality of life among patients with breast cancer.
Methods: Breast cancer patients were recruited from a medical center in northern Taiwan. Two items of the Brief Illness Perception Questionnaire were used to measure personal control and treatment control of illness representation at 1-month post-surgery. The Brief COPE and WHOQOL-Taiwan Brief versions were applied to measure coping strategies and quality of life (QoL) of patients with breast cancer at 1-month (t1) and 6-month (t2) post-surgery. Three path analysis models were used to explore whether coping mediates the relationship between perceived control over illness and QoL at different times. All variables used in Model 1 were measured at 1-month post-surgery (t1); Model 2 used perceived control over illness(t1) and coping(t1) to predict QoL at 6-month post-surgery (t2); Model 3 used perceived control over illness(t1) to predict coping(t2) and QoL(t2) .
Results: A total of seventy-six women with breast cancer participated in the study and completed both interviews at t1 and t2. The mean age of the participants was 53.42 (SD = 10.40). The path analysis results of parameter estimations showed (1) Personal control couldn’t predict the QoL, and treatment control (t1) could negatively predict psychological, social, and environmental QoL (t2). (2) Personal control (t1) could positively predict problem-focused coping (t2), and treatment control (t1) could positively predict avoidance coping (t2). (3) Problem-focused coping (t1) could positively predict psychological, social, and environmental aspects of quality of life (t1). Emotion-focused (t1) could positively predict environmental QoL (t1), and social and environmental QoL (t2). Emotion-focused coping (t2) could positively predict physical, psychological, social, and environmental QoL (t2). Avoidance coping (t1) could negatively predict all four aspects of QoL at both t1 and t2. Avoidance coping (t2) could also negatively predict all four aspects of QoL at t2. The mediation model results showed (1) the indirect effects in the relationship between personal control and QoL were significant in all three models. Personal control had significant positive effects on all four aspects of QoL in Model 1. It had significant positive effects on psychological and environmental QoL in Model 2, and 3. (2) The indirect effects in the relationship between treatment control and QoL were only significant in Model 3. Treatment control had significant negative direct effects on psychological, social, and environmental QoL, but the indirect effects through the copings were insignificant in Model 2. Treatment control had significant negative effects on all four aspects of QoL via the mediation of avoidance coping in Model 3.
Discussion and conclusion: (1) Coping was supported as a mediator of the relationship between perceived control over illness and quality of life. Personal control could not predict the QoL directly, but could positively influence the QoL through coping. Treatment control could negatively predict the QoL directly and indirectly via coping. Personal control might reflect patients’ efficacy. Thus, assisting patients to reduce avoidance coping or promote problem-focused coping could have positively influenced the QoL. Treatment control might serve as a cognitive strategy of avoidance coping and might also reflect the risk of insufficient internal and external resources other than medical resources. As the treatment proceeds, the negative influences of treatment control on QoL might increase gradually. (2) Problem-focused coping had marginal positive prediction to the QoL at the same time, and provided a partial indirect effect as mediator. However, its effect decreases as the treatment progress. Emotion-focused coping couldn’t mediate the relationship between perceived control over illness and QoL but could predict the QoL directly. As the treatment progresses, the importance of emotion-focused coping gradually increased. Avoidance coping had the most significant effects on predicting QoL directly and indirectly. It revealed the importance of avoidance coping for the adaption of breast cancer patients. Suggesting future studies to (1) discuss the interaction of personal control and treatment control with larger sample size, (2) explore the relationship between perceived control, coping and QoL in different disease population, and (3)explore the change of perceived control over illness and coping in different time point and their impact on the QoL by more follow-up time points.

並列關鍵字

Breast cancer ； Illness representation ； Perceived control over illness ； Coping ； Quality of life ； Mediation

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