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  • 學位論文

癌症病人使用止痛藥物遵從性之影響因子-中介以及調節效應之測試

Analgesics Adherence In Cancer Patients: Test of the Mediation And Moderation Effect

指導教授 : 林佳靜

摘要


論文摘要 論文名稱:癌症病人使用止痛藥物遵從性之影響因子-中介以及調節效應之測試 研究所名稱:臺北醫學大學護理學研究所 研究生姓名:周碧玲 畢業時間:九十九學年度第二學期 指導教授:林佳靜教授 本研究以癌症病人對止痛藥物的遵從性作為主要的結果變項,系列探討相關的障礙因素、研擬介入性研究措施促進病人對止痛處置滿意度、並發展中文版病人對醫師滿意度量表,且同時瞭解癌症病人對醫師滿意度之預測因子;以及具體測試病人對醫師滿意度於止痛藥物遵從性之影響,並瞭解其影響機轉。總計四個主要的子計畫,包括: 一、中文簡短版止痛藥障礙因子問卷之發展與量表之信效度測試。 本研究以橫斷性研究設計,調查臺灣北部兩間醫學中心183名癌症居家病人。經由量表精簡、因素分析以及前趨測試的過程完成中文簡短版止痛藥障礙因子問卷。此問卷具有良好的內部一致性以及再測信度。同時此問卷精簡後的九個題項仍符合原始量表的兩大構面;此問卷具有良好的建構效度、效標關連效度、以及已知群體效度,可在臨床上三到五分鐘便能施測完成,是一個具有臨床可近性以及有效的評估工具,能運用於篩檢癌症病人對於使用止痛藥物的可能顧慮。 二、 測試疼痛教育對改善癌症病人於醫護人員對疼痛處置滿意度之成效,以及對藥物遵從行為之影響─中介效應之驗證。 本研究採實驗性、長期追蹤研究,以北部兩間醫學中心61位門診癌症病人對象,進行為期一個月的疼痛教育措施,並於介入後兩週、後四週測試其對醫療人員對於疼痛處置滿意度之成效,同時測試對藥物遵從性之中介效應。在實驗組病人的介入成果發現,於介入後二週以及四週能顯著增進病人對醫師以及護理人員對疼痛處置之滿意度,然而對照組則無此效果。此外,病人對疼痛處置之滿意度為一個顯著之中介因子,存在於對止痛藥物使用之障礙以及服藥遵從行為間。本研究結果證實促進病人對疼痛處置滿意度也能顯著提升病人對藥物的遵從行為,因此除了以改善止痛藥物的相關介入措施來改善對藥物遵從行為外,亦對促進病人的遵從行為具有重要的影響。 三、發展臺灣版醫師門診滿意度問卷與量表之信效度測試。 本研究目的為發展中文版醫師門診滿意度問卷,同時進行信效度之檢驗。本研究以210名癌症門診病人為對象,於臺灣南部一間醫學中心以及區域醫院進行資料收集。本研究經回覆翻譯以及專家效度之認可外,同時使用探索性因素分析以及驗證性因素分析建立臺灣版的量表。第一階段的探索性因素分析以及驗證性因素分析主要是為了決定量表的題項,經由第一階段前趨測試以及臺灣癌症病人的實際施測結果,修正為十五題,計有四大構面。以信度分析檢定問卷之信度其內在一致性(Croncach’ α)為0.76,30名個案兩週後至一個月的再測信度為0.73(p=0.000),顯示本問卷具有良好之內在一致性與穩定的再測信度。經由第二階段的驗證性因素分析結果,臺灣版的醫師門診滿意度問卷符合原始問卷的四大構面,並可解釋60.87%的變異量。經由第二階段的驗證性因素分析結果顯示,整體模式為顯著,且每個子題均能反應四個構面,代表此量表具有良好之收斂以及區辨效度,此外量表和病人對醫師之信任度也具有良好的效標關連效度。 四、 瞭解病人對醫師之滿意度與癌症病人服用止痛藥物的障礙因子、癌症病人服用止痛藥物遵從性之相關性─中介效應以及調節機轉之測試。 本研究目的為調查癌症病人對醫師之滿意度,瞭解預測影響病人對醫師滿意度之相關影響因子,同時測試其在止痛藥物障礙因子與服藥遵從性間的中介效應以及調節效應。本研究以194名癌症門診病人為對象,於臺灣南部一間醫學中心以及區域醫院進行資料收集。研究結果發現病人對醫師之滿意度平均分數為 5.29(SD=0.49) ,最低的平均分為4.07,最高的平均分為 6.53。在次量表分數上的表現,分數最高的構面為“心理的舒適(Psychological comfort)”,平均分數為 5.93(SD=0.51);而最低的構面為“遵循的意圖(Adherence Intention) ”其平均分為4.47(SD=1.06)。能顯著預測病人對醫師之滿意度之變項為病人對醫師的信任(p=0.000) ,解釋力可達30%(p<0.001)。Sobel檢定其並不是一顯著的中介因子 (Sobel test=0.53, p=0.60)。然而,病人對醫師之滿意度與對止痛藥障礙因子的交互作用項具有顯著意義,其B值為1.68(Odds ratio=5.35)(p<0.01),代表病人因對藥物的障礙因素愈高,低度遵從組發生率會有愈高的現象,因病人對醫師滿意度的影響,而產生了弱化的調節效果。本研究結果具體證實病人對疼痛處置滿意度以及對醫師滿意度於藥物遵從行為間扮演顯著之中介因子與調節因子,於未來的疼痛處置計畫加強對醫療人員疼痛處置之滿意度,以及對醫師的整體滿意度可能可具體提升疼痛控制之成果。

並列摘要


Abstract Title of Dissertation: To Verify Related Factors on Analgesics Adherence in Cancer Patients-Test of its Mediation and Moderation Effect Institution: Graduate Institute of Nursing, Taipei Medical University Author: Pi Ling Chou Dissertation directed by: Chia Clin Lin, Professor The dissertation included four studies, mention as follows: Study-1 Purpose: This paper is a report of the development and psychometric properties of the short version of the Barriers Questionnaire-Taiwan form (S-BQT). Design: This study employed a descriptive design. Setting: A convenience sample was recruited from oncology clinics at two medical centers in Taiwan. Participants: One hundred and eighty-three (N = 183) patients receiving analgesics for cancer pain participated in the study. Methods: Instruments included the Barriers Questionnaire-Taiwan form (BQT), the Taiwanese version of the Morisky Medication Adherence Measure-Taiwan form (MMAM-T).The ratio of analgesic usage was computed over a two-week period. Results: To develop the S-BQT, we used reliability analysis to extract nine items from nine subscales. Internal consistency of the S-BQT was indicated by a Cronbach’s alphas score of 0.86. Test-retest reliability was assessed as 0.83 over a two-week interval. Factor analysis revealed two factor structures. Criterion-related validity was examined by correlating the S-BQT score, and MMAM-T score, and the ratio of analgesic use. Known group validity was examined by comparing the S-BQT scores of patients with hesitancy to report pain and take analgesics vs. patients demonstrating no such hesitancy in the previous week. Known group validity was also established by comparing the S-BQT scores among patients with low, moderate, and high adherence to the usage of medication. Conclusions: The S-BQT shows excellent reliability and validity. The use of this instrument can help to improve communication between patients and clinicians regarding the use of analgesics in the management of pain. Study-2 Purpose: The purpose of this study was (1) to evaluate the effectiveness of a pain education program to increase the satisfaction of cancer patients with regard to pain management; and (2) to examine how patient satisfaction with pain management mediates the barriers to using analgesics and analgesics adherence. Design: This study used an experimental and longitudinal design. Methods: A total of 61 patient–family pairs (N = 122) were randomly assigned to either experimental or control groups. The instruments included the American Pain Society outcome questionnaire, the Barriers Questionnaire-Taiwan form, self-reporting evaluations of analgesic adherence, and the Pain Education Booklet. The experimental group (n = 31) participated in a pain education program, while those in the control group (n = 30) did not. The two groups were compared using Generalized Estimation Equations after the second and fourth weeks. A Sobel test was used to examine the mediating relationships among patient satisfaction with pain management, barriers to using analgesics, and analgesic adherence. Results: In the experimental group showed a significant improvement in the level of satisfaction they felt for physicians and nurses regarding the pain management. For those in the experimental group, satisfaction with pain management was a significant mediator between barriers to using analgesics and analgesic adherence. Conclusions: This research provides evidence supporting the effectiveness of a pain-education program for patients and their family members in increasing patient satisfaction with regard to the management of cancer pain. Study-3 Purpose: This paper is a report of the development and psychometric properties of the Medical Interview Satisfaction Scale (MISS-21). Design: This study employed a descriptive design. Setting: A convenience sample was recruited from oncology clinics at one medical centers and one local hospital in South Taiwan. Participants: two hundred and ten (N = 210) cancer patients participated in the study. Methods: Instruments included the Medical Interview Satisfaction Scale (MISS-21), Interpersonal Physician Trust Scale-Chinese version (IPTS-C) and patient demographic sheet. Results: To develop the MISS Taiwan Version (MISS-T). Internal consistency of the S-BQT was indicated by a Cronbach’s alphas score of 0.76. Test-retest reliability was assessed as 0.73 over a two to four weeks interval. Comfirmatory factor analysis revealed four factor structures. The factor analysis extraction explained 60.87% total variance. Criterion-related validity was examined by correlating IPTS-C score. Conclusions: The MISS-T shows very good reliability and validity. The use of this instrument can help to improve satisfaction between patients and physicians regarding the communication in the treatment process. Study-4 Purpose: The purpose of this study was (1) To investigate the predictors related to the satisfaction toward physicians; and (2) to examine patient satisfaction toward physicians is an significant factor between barriers of analgesics and analgesics adherence- test its mediation and moderation effect. Methods: A correctional and descriptive design was used in this study. A convenience and consecutive sample was recruited from outpatient oncology clinics at one medical centers and one local hospital in South Taiwan. One hundred and sixty (N = 194) outpatients receiving analgesics for cancer pain participated in the study. Instruments included the Medical Interview Satisfaction Scale-21-Chinese Version(MISS-21-C), the Barriers Questionnaire-Taiwan form (BQT), the Taiwanese version of the Morisky Medication Adherence Measure-Taiwan form (MMAM-T), Interpersonal Physician Trust Scale-Chinese version (IPTS-C) and Karnofsky performance Status (KPS). The Sobel test within SAS and multiple hierarchical regression analysis within SPSS 16.0 to test if patients’ to examine the mediated and moderates effects with dichotomous outcomes of patients’ satisfaction towards physicians between the barriers to analgesics and the patients’ adherence to analgesics. Results: The variables that can significantly predict the effects of patient satisfaction towards physicians are patients’ pain intensity, social support, and patient’s trust in physicians, variance is 40%. The results of this study show that patients’ satisfaction towards physicians is one of the key moderator between patients’ barriers to analgesics and patients’ adherence. Conclusions: Cancer patients’ satisfaction towards physicians may moderate the effect of adherence to analgesics, namely once the patients’ satisfaction towards physicians is high the patients’ adherence to analgesics will be significantly increased.

參考文獻


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