第二型糖尿病個案情緒困擾、社會支持及自我照顧行為對糖化血色素及生活品質影響之模式建構:縱貫性研究

糖尿病已成為全世界公共衛生政策中重要的議題，而如何達到好的HbA1C控制與生活品質，為照護上的重點。過去研究少採用縱貫性研究探討影響糖尿病患HbA1C與生活品質的社會心理因素及其路徑。本研究目的探討基線社會人口特質、情緒困擾、社會支持、六個月後自我照顧行為等因子對一年後HbA1C及生活品質之影響徑路。採縱貫性研究，以方便取樣於南部四家糖尿病專科診所及一家醫學中心之內分泌新陳代謝科門診共收案576人。收案條件為經醫師確立診斷為第二型糖尿病且罹病一年以上者，年齡20-80歲，識字意識清楚可與人溝通。排除條件為有認知障礙、語言無法溝通、不識字或精神疾病無法完整回答問卷內容者以及妊娠糖尿病患者。以自我填寫問卷分別在基線測量「社會人口變項」、「情緒困擾」以及「社會支持」，並於六個月後測量「自我照顧行為」，一年後再收集「生活品質」及由病歷收集HbA1C。統計方法包含頻率、百分比、平均值等描述性統計之外，並以驗證性因素分析檢定各量表的建構效度。最後以結構化方程模型 (Structural Equation Modeling, SEM)檢定，以瞭解所收集的資料是否支持假設的「人口特質、情緒困擾、社會支持、及六個月後自我照顧行為之模式對一年後HbA1C及生活品質影響模式」。經四次模式修正後獲得一個資料支持的模式，其指標為χ2 值,142.606(df＝51, p＜.001)，配適度指標為.939，調整後之配適度指標為.907，增值配適度指標為.911，非規範適配度指標為.883，比較配適度指標為.910，近似均方根誤差為.069。此模式發現: 1.人口特質中的罹病年數對六個月後的自我照顧行為(β= .214, t= 3.787, p<.001) 有顯著性正向直接效果。 2.社會支持對六個月後的自我照顧行為(ß= .292, t= 5.059, p<.001) 有顯著性正向直接效果，且會經由六個月後的自我照顧行為對一年後之生活品質(ß= .176, t= -2.049, p= .040)有顯著性負向間接效果。 3.社會支持對情緒困擾(β= -.259, t= -5.234, p< .001) 有顯著性負向直接效果，且社會支持會經由情緒困擾對一年後的生活品質(β= .176, t= 11.899, p<. 001) 有顯著性正向間接效果。 4.情緒困擾對一年後的生活品質(β= -.447, t= -7.939, p< .001) 有顯著性負向的直接效果，且會經由一年後的生活品質對一年後之HbA1C(ß= .093, t= 7.911, p< .001)有顯著性正向間接效果。 5.六個月後的自我照顧行為對一年後的生活品質(β= .205, t=3.366, p= .001) 有正向顯著的直接效果，且會經由一年後的生活品質對一年後之HbA1C(ß= .043, t= -1.986, p= .046)有顯著性負向間接效果。本研究建議未來仍須以不同的樣本檢測，以瞭解最後接受的模式在其他樣本的適用性。本研究結果可提供健康專業人員擬定改善HbA1C及生活品質介入策略的參考。

關鍵字

第二型糖尿病個案；情緒困擾；社會支持；自我照顧行為；糖化血色素；生活品質

並列摘要

Type 2 diabetes mellitus (T2DM) is a public health issue worldwide. Simultaneous achievement of the targets of both a good level of HbA1C and quality of life is key to diabetes care. Although there are complex inter-relationships between the psychosocial factors that affect diabetes care, few studies have employed longitudinal design to delineate the pathways between psychosocial factors, HbA1C and quality of life. The purpose of this study was to develop a pathway model to investigate the effects of personal demographic characteristics, social support, diabetes-related distress and self-care behaviors on quality of life and HbA1C in patients with T2DM using a structural equation modeling (SEM) procedure. In this longitudinal study, a total of 576 adults with T2DM were recruited from four endocrinology clinics and an outpatient clinic of a medical center in Southern Taiwan. The criteria for selecting the participants were those aged 20-80 years with an adequate level of literacy who had been diagnosed with T2DM for more than one year, and who had no communication problems. Patients with gestational diabetes mellitus, those with cognitive disorders, those with language barriers, illiterate subjects and those suffering mental illness, all of which may result in patients being unable to complete the questionnaire by themselves, were excluded from this study. Self -reported questionnaires were used to collect related to personal demographic characteristics, diabetes-related distress and social support at baseline. Self -care behaviors was collected at 6 months later. Quality of life and HbA1C were collected at 1 year later. Data are presented using descriptive statistics, including frequencies, percentages, and means. All scales were assessed in terms of their content validity and test-retest reliability. Confirmatory factor analysis was used to test the validity of each scale. The hypothesis of the model was tested by SEM using Amos 18.0 software. After a series of SEM analyses, a parsimonious and best-fit model was identified. The fit indices were χ2 = 142.606, df ＝ 51, p < .001, goodness of fit index = 939, adjusted goodness of fit Index = .907, incremental fit index = .911, non-normed fit index = .883, comparative fit index = .910, root mean square error of approximation = .069. The model indicated: 1.Duration of disease (β = .214, t = 3.787, p < .001) has a significant direct positive effect on self-care behaviors 6 months later. 2.Baseline social support has a significant direct positive effect (β =.292, t = 5.059, p < .001) on self-care behaviors 6 months later, and through self-care behaviors 6 months later has a significant negative indirect effect on quality of life one year later (β = .176, t = 2.049, p = .040). 3.Baseline social support has a significant direct negative effect (ß = −.259, t = −5.234, p < .001) on baseline diabetes-related distress, and through diabetes-related distress has a significant positive indirect effect on quality of life one year later (ß = .176, t = 11.889, p < .001). 4.Baseline diabetes-related distress has a significant direct negative effect (ß = −.447, t = −7.939, p < .001) on quality of life one year later, and through quality of life one year later has a significant negative indirect effect on HbA1C one year later (β = .093, t = 7.911, p < .001). 5.Self-care behaviors at 6 months later have a significant direct positive effect (β = .205, t = 3.366, p =.001) on quality of life one year later, and through quality of life one year later have a significant negative indirect effect on HbA1C one year later (ß = .043, t = −1.986, p = .046). These results delineated the pathways between social support, diabetes-related distress, self-care behaviors, HbA1C and quality of life in patients with T2DM. The model proposed in this study should be tested further in different populations in the future. The findings could be utilized to design intervention programs to improve HbA1C control and quality of life.

並列關鍵字

Patients with Type 2 Diabetes ； Social Support ； Diabetes Related Distress ； Self-Care Behaviors ； Quality of Life ； HbA1C

參考文獻

Cosansu, G., & Erdogan, S. (2014). Influence of psychosocial factors on self-care behaviors and glycemic control in Turkish patients with type 2 diabetes mellitus. Journal of Transcultural Nursing, 25(1), 51-59. doi:10.1177/1043659613504112

de Vries, L., van der Heijden, A. A., van 't Riet, E., Baan, C. A., Kostense, P. J., Rijken, M., . . . Nijpels, G. (2014). Peer support to decrease diabetes-related distress in patients with type 2 diabetes mellitus: design of a randomised controlled trial. BMC Endocrine Disorders, 14, 21. doi:10.1186/1472-6823-14-21

Hortensius, J., Kars, M. C., Wierenga, W. S., Kleefstra, N., Bilo, H. J., & van der Bijl, J. J. (2012). Perspectives of patients with type 1 or insulin-treated type 2 diabetes on self-monitoring of blood glucose: a qualitative study. BMC Public Health, 12, 167. doi: 10.1186/1471-2458-12-167

Hsu, C. C., Chang, H. Y., Huang, M. C., Hwang, S. J., Yang, Y. C., Lee, Y. S., . . . Tai, T. Y. (2012). HbA1C variability is associated with microalbuminuria development in type 2 diabetes: a 7-year prospective cohort study. Diabetologia, 55(12), 3163-3172. doi: 10.1007/s00125-012-2700-4

Polonsky, W. H., Fisher, L., Schikman, C. H., Hinnen, D. A., Parkin, C. G., Jelsovsky, Z., . . . Wagner, R. S. (2011). Structured self-monitoring of blood glucose significantly reduces A1C levels in poorly controlled, noninsulin-treated type 2 diabetes: results from the Structured Testing Program study. Diabetes Care, 34(2), 262-267. doi: 10.2337/dc10-1732

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第二型糖尿病個案情緒困擾、社會支持及自我照顧行為對糖化血色素及生活品質影響之模式建構:縱貫性研究

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