臺灣住院與社區慢性病獨居老人之健康照護需求與需求滿意度之探討與工具之發展

Exploring Health Needs, Needs Satisfaction and Instrument Development for the Single-living Elders with Chronic Disease in Hospital and Community Settings

史曉寧(Shaw-Nin Shih)

指導教授 ： 蔡仁貞

共同指導教授 ： 施富金

臺北醫學大學/醫學院/醫學科學研究所/博士(2010年)

https://doi.org/10.6831/TMU.2010.00145

摘要

目前國內尚未有整體性住院心臟病與社區慢性病獨居老人健康照護需求與需求滿足度工具之建立與信效度測試，故本研究主要目的如下: (1)探討住院心臟病獨居老人健康照護需求與工具發展; (2)分析社區慢性病獨居老人健康照護需求及需求滿足度之探討與工具發展。本研究採取合併使用質量綜合法（Between-method）研究設計，分三階段進行，第一階段為質性方法，以半結構式導引之深度訪談及觀察個案來蒐集資料，運用質性內容分析法分析個案健康照護需求，並探討不同健康照護需求間之相關性；第二階段為工具設計及信效度檢定；第三階段為量性方法，運用描述性(平均值、標準偏差、個案人數、與百分比)與皮爾森相關性等統計分析法，分析個案健康照護需求與需求滿足度百分比及健康照護需求與需求滿足度之相關性。
研究結果分下列三部份加以說明，第一部份為住院心臟病之獨居老人健康照護需求，共訪談34位個案，其健康照護需求包括五大類，分別為:實質性、心理與靈性、資訊性、醫療性、和參與決定權需求。另外社區慢性病獨居老人健康照護需求，共訪談44位慢性病獨居老人，其健康照護需求包括下列三類:實質性、心理與靈性、和資訊性需求。
本研究結果第二部份為住院心臟病與社區慢性病獨居老人健康照護需求及需求滿足度，為工具之設計和信效度測定。共訪談54位個案。在健康照護需求工具方面，內在一致性信度Cronbach‘s α值均為0.7以上，除參予決定權需求，Cronbach‘s α值為0.67；評分者信度方面達到99%。在關聯同時效度方面，以Barthel ADL index與本工具之日常生活協助之實質性需求有顯著負相關(γ = -0.40, p < 0.05)。另外教育程度與資訊性需求亦有顯著正相關(γ = 0.29, p < 0.05)。內容效度指標(content validity index, CVI)(Lynn, 1986)均大於0.80以上。另以五位個案進行測試，皆表示此量表可以呈現其健康需求，且簡單易懂，顯示此量表有令人滿足之表面效度。
另外社區慢性病獨居老人健康照護需求及需求滿足度工具，共訪談110位個案，除心靈性需求為0.66，內在一致性Cronbach’s α均為0.7以上，。評分者信度方面達到99%， 再測信度於2週內再測一次，有顯著相關(r = 0.983, p = 0.001)。
同時關聯效度分別以生理健康狀況(黃、蘇，2000)、心理社會狀況(林等人，1999)、和社會支持(Norbeck et al., 1981, Sarason et al., 1983)，三項量表分別與健康照護需求與需求滿足度量表進行相關性分析，整體健康照護需求與生理健康狀況有顯著相關(r = 0.32, p = 0.009)。整體健康照護需求與生理健康狀況有顯著相關(r = 0.32, p = 0.009)。整體需求滿足度與社會支持(r = 0.33, p = 0.007)有顯著相關，心靈性需求與生理健康狀況(r = 0.35, p = 0.003)、和心理社會狀況(r = 0.32, p = 0.008)有顯著相關，且實質性需求與生理健康狀況亦有顯著相關(r = 0.24, p =0.048)。內容效度分析方面，內容效度指標大於0.78以上。表面效度方面，五位個案皆表示此量表可呈現其健康需求，且簡單易懂，顯示此量表有令人滿足之表面效度。
本研究結果第三部份為分析量性資料，共訪談54位住院心臟病與110位社區慢性病獨居老人。在住院心臟病之個案，其健康照護需求種類分別為資訊性(n = 54, 100%)、參與決定權(n = 52, 96%)、實質性(n = 47, 87%)、醫療性(n = 46, 85%)和心理與靈性(n = 36, 67%)。在個案不同種類健康照護需求之相關性，本研究發現個案在不舒服時需要心理支持，分別與資訊性（γ = 0.39, p = 0.005）、手術或檢查時之實質性（γ = 0.46, p = 0.001）、和醫療協助（γ = 0.47, p = 0.001）有顯著相關。另外日常生活之實質性需求分別與手術或檢查時之實質性需求（γ = 0.33, p = 0.005）、出入院之實質性需求（γ = 0.37, p = 0.05）、和醫療需求（γ = 0.34, p =0.005）有顯著相關。社區慢性病獨居老人健康照護需求百分比，分別為心理與靈性(n = 90, 81.2%)、實質性(n = 80 , 72.7%)、和資訊性(n = 70, 63.6%)。需求滿足度人數與百分比分別為實質性(n = 50 , 45.5%)、心理與靈性(n = 50, 45.5%)和資訊性(n = 60, 54.5%)。其整體健康照護需求與整體需求滿足度有顯著負相關(r = -0.22, p < 0.05)。
本研究建立兩種本土化此特殊族群之健康照護需求工具，包括住院心臟病獨居及社區慢性病獨居老人，可有效評估獨居老人健康需求高，但滿足度低之健康照護需求，以提供醫療照護單位提高其健康照護滿足度。

關鍵字

心臟病 ； 慢性病 ； 獨居老人 ； 健康照護需求 ； 需求滿足度

並列摘要

Until now, there has been no reliable instrument for health professionals to comprehensively assess health care related needs and needs satisfaction for Taiwan’s single-living elders (TSLE) with cardiovascular disease in hospital and with chronic disease in community. Therefore, the objectives of this study were to explore health care related needs or needs satisfaction for TSLE with cardiovascular disease in hospital and chronic disease in community. Moreover, the researcher developed a culturally sensitive Health Care Need Instrument (HCNI) in hospital and Health Care Needs and Needs Satisfaction Instrument (HCNNSI) in community, and examined the relationships between their health care related needs and needs satisfaction. The between method triangulation design was used for exploring the health care related needs or needs satisfaction, and developing HCNI and HCNNSI.
There were three phases in research design and results of this study. The first phase was a purposive sampling in hospital (n = 34) and in community (n = 44) by the explorative qualitative method. The first phase explored the health care related needs including the instrumental, psycho-spiritual, informational, medical, and participating decision-making aspect with cardiovascular disease for TSLE in hospital. The health care related needs and needs satisfaction with chronic disease for TSLE in community were instrumental, psycho-spiritual, and informational aspects.
The second phase developed the HCNI and HCNNSI and established its reliability and validity. For the internal consistency, the total HCNI sub-scales of Cronbach's α were above 0.7 except the participation in decision-making (0.67). Inter-rater reliability ranged from 0.99. In concurrent validity, the Barthel index was a significant negative correlation with subjects' tangible needs for help with ADLs during their hospitalization transition(r = -0.40, p < 0.05). Moreover, a strong correlation between educational level and the need for health-related information as well as a significant difference in need when educational levels were compared(r = -0.29, p < 0.05). The CVI (Content validity Index) scores were above 0.80. The face validity of the HNI was also tested and confirmed with the help of five patients with cardiovascular disease which established its readability and appropriateness.
In terms of internal consistency in HCNNSI, the Cronbach's α for health care related needs and needs satisfaction subscales in community were above 0.7 except psycho-spiritual needs was 0.66. The range of inter-rater reliability was 99%. The test-retest reliabilities for health needs and need satisfaction were significantly correlated respectively. In concurrent validity, a significant correlation was demonstrated between the overall health needs and physical health condition (r = 0 .32, p < 0.01). Moreover, significant correlations were also demonstrated for overall health need satisfaction and social support (r = 0.33, p < 0 .001). The overall health need satisfaction was significant different from the frequency of children’s visits (F = 3.30, p < 0.05). Educational level of the informants was also significantly different from their informational health needs (F = 10.51, p < 0.01). The mean CVI was 0.78. In face validity, five single-living older patients with chronic disease provided opinions concerning the readability and appropriateness of each item.
The final phase implemented the instrument in a cohort study with cardiovascular disease in hospital (n = 54) and chronic disease in community (n = 110), and explored the health care related needs in both setting and needs satisfaction in community for TSLE. In HCNI, the health care related needs were the informational (n = 54, 100%), participating decision-making (n = 52, 96%), instrumental (n = 47, 87%), medical (n = 46, 85%), and psycho-spiritual (n = 36, 67%) aspects with cardiovascular disease for TSLE in hospital. While examining the relationship among different types of health needs, psychological needs during periods of discomfort were found to have a significant positive correlation with informational needs (r = 0.39, p = 0.005), with tangible needs after surgery, with the invasive examination period (r = 0.46, p = 0.001), and with the need for medical support (r = 0.47, p < 0.001). Moreover, the need for tangible help in maintaining activity of daily livings in hospital had a significant positive correlation with help during the post invasive examination or surgery period (r = 0.33, p = 0.005). In addition, this need also correlated positive significantly with other tangible needs for help in managing admissions and discharge procedures (r = 0.37, p < 0.05), and the need for medical support (r = 0.34, p = 0.005)。
In HCNNSI, the health care related needs were psycho-spiritual (n = 90, 81.2%) instrumental (n = 50, 45.5%), and the informational (n = 70, 63.6%) aspects with chronic disease for TSLE in community. In addition, the needs in satisfaction were instrumental (n = 50, 45.5%), psycho-spiritual (n = 50, 45.5%), and the informational (n = 60, 54.5%) aspects with chronic disease for TSLE in community. Moreover, the overall health care related needs have negative relationship with needs satisfaction (r = -0.22, p < 0.05)。
The researcher developed a culturally HCNI in hospital and HCNNSI in community. Moreover, the health care provider can use these instruments to detect complex health needs of this particular population earlier and more accurately in order to promote their satisfaction in the health care related needs.

並列關鍵字

cardiovascular disease ； chronic disease ； single-living elder ； health care related needs ； needs satisfaction

參考文獻

江慧珠、劉雪娥、黃秋錦（1995）•影響接受可活動性腹膜透析病人需要之因素探討•護理研究，3 (2)，106-107。

吳燕惠、許淑蓮 (2002)•冠狀動脈繞道手術病人之健康照護需求。台灣醫學會•6(3)，288-304。

林月春、李怡娟、許秀月、萬育維、郭英調、盧志輝 (1999) •屏東地區居家脊椎損傷者的自我概念及其相關因素之探討•護理研究，7(1), 51-64。

邱啟潤、郭素娥、陳惠珠（1994）•高雄市有慢性健康問題的老人利用社區醫療資源情形之探討•高雄醫學科學雜誌，10(10)， 583-591。

馬維芬、施富金（1999）•照顧邊緣性人格特質患者之經驗對精神科護理人員的影響•高雄醫學科學雜誌，15(6），372-381。