父母自主性支持、自我效能及自我管理對第一型糖尿病青少年糖化血色素的影響：縱貫性研究

The influence of parental autonomy support, self-efficacy, and self-management on glycosylated haemoglobin in adolescents with type 1 diabetes mellitus: A longitudinal study

徐少慧(Shao-Hui Shu)

指導教授 ： 王瑞霞

高雄醫學大學/護理學院/護理學系博士班/博士(2019年)

摘要

理想糖化血色素(haemoglobin, HbA1c)控制是維持第一型糖尿病（type 1 diabetes mellitus, T1DM）青少年身心健康的重要照護與議題。為了解父母自主性支持、自我效能與自我管理對T1DM青少年HbA1c的影響，本研究目的在建構基線父母自主性支持、自我效能與自我管理影響第六個月父母自主性支持、自我效能、自我管理及HbA1c的路徑模式，所得結果提供臨床T1DM青少年糖尿病照護及相關衛教介入方案參考。
本研究是半年期之縱貫性研究，研究期間從2016年4月至2017年2月以方便取樣在北部一醫學中心兒童代謝科門診共收案229位10-19歲符合收案條件之T1DM青少年。研究工具為結構式問卷，內容含社會人口學變項、第一型糖尿病青少年自我管理、自我效能及父母自主性支持量表，以及由病歷收集HbA1c。統計方法包括頻率、百分比、平均數等描述性統計分析，以及驗證性因素分析檢定各量表的建構效度，最後以結構方程取向之路徑分析模式（SEM approach）檢定所收集的資料是否支持本研究之假設模式。
經一次模式修正後，得本研究所收集資料支持的路徑模式「父母自主性支持、自我效能對T1DM青少年HbA1c的影響」，其指標為χ2= 37.942（df=11, p < .0001）、χ2/df = 3.449、CFI= 0.970、GFI= 0.957、AGFI= 0.891、NFI= 0.959、IFI= 0.970、RMSEA= 0.104。此模式資料顯示：
1. 基線父母自主性支持、自我效能及自我管理正相關性，則第六個月父母自主性支持、自我效能及自我管理也是正相關性。
2. 基線自主性支持對基線自我效能（β= 0.44）、基線自我效能對基線自我管理（β= 0.64）、基線自主性支持對基線自我管理（β= 0.24）、第六個月自主性支持對第六個月自我效能（β= 0.41）、第六個月自我效能對第六個月自我管理（β=0.64）、第六個月自主性支持對第六個月自我管理（β= 0.22）、基線父母自主性支持對第六個月自主性支持（β= 0.61）、基線自我效能對第六個月自我效能（β=0.42）、基線自我管理對第六個月自我管理（β= 0.17）有直接顯著正向影響（p < .001）；以及第六個月自我管理對第六個月的HbA1c（β= -0.29）有直接顯著負向影響（p < .001）。
3. 本研究「父母自主性支持、自我效能與自我管理對T1DM青少年HbA1c的影響」路徑模式可被支持；在基線自主性支持與第六個月的HbA1c間，有五個有效的間接路徑，間接影響效果值β= -0.012∼-0.046（p < .05）。五個路徑分別是（1）基線自主性支持會直接正向影響基線自我效能（β= 0.44, p < .001），並透過基線與第六個月自我管理對第六個月的HbA1c產生間接負向作用（β= -0.014, p < .05）；（2）基線自主性支持會直接正向影響基線自我管理（β= 0.61, p < .001），並透過第六個月自我管理對第六個月的HbA1c產生間接負向作用（β= -0.012, p < .05）；（3）基線自主性支持會直接正向影響基線自我效能（β= 0.44, p < .001），並透過第六個月自我效能、第六個月自我管理對第六個月的HbA1c產生間接負向作用（β= -0.034, p < .05）；（4）基線自主性支持會直接正向影響第六個月自主性支持（β= 0.61, p < .001），並透過第六個月自我效能及自我管理對第六個月的HbA1c產生間接負向作用（β= -0.046, p < .05）；（5）基線自主性支持會直接正向影響第六個月自主性支持（β= 0.61, p < .001），並透過第六個月自我管理對第六個月的HbA1c產生間接負向作用（β= -0.040, p < .05）。
4. 第6個月父母自主支持與第6個月的HbA1c間有二個有效的間接路徑，分別是第6個月父母自主支持會直接影響第6個月自我效能（β= 0.41, p < .001），並透過第6個月的自我管理，間接影響第6個月的HbA1c (β= -0.076, p < .05)，以及第6個月父母自主支持會直接影響第6個月自我管理，間接影響第6個月HbA1c (β= -0.064, p < .05)。
本研究建構了父母自主性支持、自我效能、自我管理和T1DM青少年HbA1c之路徑模式。建議未來研究增加不同收案來源，以了解此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照護方案，改善T1DM青少年HbA1c的控制成效。

關鍵字

第一型糖尿病青少年 ； 糖化血色素 ； 父母自主性支持 ； 自我效能 ； 自我管理

並列摘要

Optimal glycosylated hemoglobin (HbA1c) control is key to the physical and mental health care of adolescents with type 1 diabetes mellitus (T1DM), but also an important issue for health providers. To understand the impact of T1DM adolescents' parental support, self-efficacy and self-management on HbA1c, the purpose of this study was to construct baseline parental autonomy support, self-efficacy and self-management effects in the sixth month of parental autonomy support, self-efficacy, self-management and HbA1c. Path mode, the results provide reference for clinical T1DM juvenile diabetes care and related interventional programs.
Six-month longitudinal research from April 2016 to February 2017 with convenient sampling is used as our research method. The participants are 10〜19-year-old T1DM adolescents from one medical center in the North of Taiwan. All participants completed structured questionnaires regarding demographic information, self-management of T1DM for adolescent scale, self-efficacy for self-management, diabetes-specific parental autonomy support for adolescents. And HbA1c levels form medical records were collected.
Descriptive statistical analysis were used to describe all variables. Three questionnaires were examined by content validities, construct validities, Cronbach’s αand, test-retest reliabilities. The hypothesis of a model was examined by SEM approach analysis. The fit indices of final model were the chi-squared (χ2) = 37.942, degrees of freedom (df) = 11 (p<.0001), χ2 / df = 3.449, comparative fit index (CFI) = 0.970, goodness of fit index (GFI) = 0.957, adjusted goodness of fit index (AGFI) = 0.891, normed fit index (NFI) = 0.959, incremental fit index (IFI) = 0.970, and root mean square error of approximation (RMSEA) = 0.104.
The path mode, “the influence of parental autonomy support, self-efficacy, and self-management on HbA1c in adolescents with T1DM”, indicated:
1. Baseline significant positive correlations between parental autonomy support, self-efficacy, and self-management can predict that the 6th month parental autonomy support, self-efficacy, and self-management are also significant positively correlated.
2. The significantly direct and positive effect (p < .001) among variables are baseline parental autonomy support effect on baseline self-efficacy (β= 0.44), baseline self-efficacy effect on baseline self-management (β= 0.64), baseline parental autonomy support effect on baseline self-management (β= 0.24), the 6th month parental autonomy support effect on the 6th month self-efficacy (β= 0.41), the 6th month self-efficacy effect on the 6th month self-management (β= 0.64), the 6th month parental autonomy support effect on the 6th month self-management (β= 0.22), baseline parental autonomy support effect on the 6th month parental autonomy support (β=0.61), baseline self-efficacy effect on the 6th month self-efficacy (β=0.42) and baseline self-management effect on T2 self-management(β=0.17). And the 6th month self-management had a significantly direct and negative effect on the 6th month HbA1c (β= -0.29, p<.001).
3. In the study, the path mode “the influence of parental autonomy support, self-efficacy, and self-management on HbA1c in adolescents with T1DM” was supported. And there are five effective indirect paths between baseline parental autonomy support and the 6th month HbA1c (β= -0.012 ~ -0.046, p < .05). They are (1) baseline parental autonomy support has a significant direct positive effect on baseline self-efficacy (β=0.44, p < .001), and through baseline and the 6th month self-management has a significant negative indirect effect on the 6th month HbA1c (β= -0.014, p < .05); (2) baseline parental autonomy support has a significant direct positive effect on baseline self-management (β=0.61, p < .001), and through the 6t month self-management has a significant negative indirect effect on the 6th month HbA1c (β= -0.012, p < .05); (3) baseline parental autonomy support has a significant direct positive effect on baseline self-efficacy (β= 0.44, p < .001), and through the 6th month self-efficacy and self-management has a significant negative indirect effect on the 6th month HbA1c (β= -0.034, p < .05); (4) baseline parental autonomy support has a significant direct positive effect on the 6th month parental autonomy support (β= 0.61, p < .001), and through the 6th month self-efficacy and self-management has a significant negative indirect effect on the 6th month HbA1c (β= -0.046, p < .05) ; (5)baseline parental autonomy support has a significant direct positive effect on the 6th month parental autonomy support (β= 0.61, p < .001), and through the 6th month self-management has a significant negative indirect effect on the 6th month HbA1c (β= -0.040, p < .05).
4. Two effective indirect paths between the 6th month parental autonomy support and the 6th month HbA1c. There are (1) the 6th parental autonomy support has a significant direct positive effect on the 6th month self-efficacy（β= 0.41, p < .001）, and through the 6th self-management has a significant negative indirect effect on the 6th month HbA1c (β= -0.076, p < .05); (2) the 6th parental autonomy support through the 6th self-management has a significant negative indirect effect on the 6th month HbA1c (β= -0.064, p < .05).
These results delineated the pathways between parental autonomy support, self-efficacy, self-management and HbA1c in adolescents with T1DM. This model should be tested further in different populations in the future to understand the applicability of this model to others. The theoretical basis findings could be utilized to develop interventional programs to improve HbA1c control for adolescents with T1DM.

並列關鍵字

adolescents with type 1 diabetes mellitus ； glycosylated haemoglobin ； parental autonomy support ； self-efficacy ； self-management

參考文獻

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參考資料