影響第二型糖尿病患自我血糖監測之相關因素探討

Factors affecting self-monitoring of blood glucose in patient with type 2 diabetes.

郭雨菁(Yu-Ching Kuo)

指導教授 ： 陳美美

長榮大學/健康科學學院/醫務管理學系(所)/碩士(2013年)

https://doi.org/10.6833/CJCU.2013.00129

摘要

背景動機 近年糖尿病人口數持續上升，對國民健康造成威脅，也對社會的醫療支出造成負擔。糖尿病屬慢性疾病，需要長期的醫病配合，以飲食控制、規律運動和藥物來控制病情。依據治療指引，病情控制良好的糖尿病患其糖化血色素應在7以下。但是2004年的統計發現，30.8%的病患糖化血色素介於8.0%-9.4%之間，34.7%的病患≥9.5%。這顯示大部分的糖尿病患未能有效控制血糖。糖尿病患若能利用血糖機來自我血糖監測，進而調整生活習慣，才有可能達到控制血糖的目標。但是依據研究，僅有30%的糖尿病患會使用血糖機。如能了解糖尿病患使用或不使用血糖機的原因，將有助於擬定自我血糖監測的推廣計畫，達到有效血糖控制的目標。
研究目的 探討第二型非使用胰島素之成人糖尿病患會或不會自我血糖監測的原因。
研究方法 以健康信念模式結合IMB model和社會支持理論形成本研究之理論基礎。研究架構包括人口屬性、自覺罹患性、自覺嚴重度、情感性支持、工具性支持、資訊性支持、自覺行動利益、自覺行動障礙、行為技巧等九個構面。採橫斷面問卷調查，在2012年7-10月訪談第二型非使用胰島素之成人糖尿病患，共收集有效問卷304份。受訪對象來自隨機抽樣之三家門診糖尿病患超過10,000名之醫學中心及區域醫院。資料經整理後以SPSS18.0進行樣本基本特性描述，並使用T檢定、卡方檢定、因素分析、複線性迴歸及羅吉斯迴歸進行統計分析。
研究結果
304位受訪者中，有47.4%的患者使用血糖機。有使用血糖機比未使用血糖機者年齡較小(t=6.20，df=281.26，p<0.0005)；罹患糖尿病之病程較短(t=5.9，df=301.17，p<0.0005)；教育程度上高中以上畢業或肄業、國中畢業或肄業之患者比例較高(χ2=44.87，df=3，p<0.0005)；飲食照顧者為自己和配偶的比例較高(χ2=6.98，df=2，p=0.030)；有工作的比例較高(χ2=28.30，df=1，p<0.0005)；收入15000-79999元之比例較高(χ2=39.2，df=3，p<0.0005)；併發症發生種類上，有使用血糖機者併發症數量較少(t=-5.057，df=302，p<0.0005)。
受訪者自覺罹患性分數較未使用血糖機者高(t=12.97，df=294.16，p<0.0005)；自覺嚴重度分數較未使用血糖機者高；情感性支持分數較未使用血糖機者高(t=14.19，df=274.44，p<0.0005)，而情感性支持來源較多(t=10.65，df=270.35，p<0.0005)；工具性支持分數較未使用血糖機者高，而工具性支持來源較多(t=14.59，df=282.37，p<0.0005)；資訊性支持分數較未使用血糖機者高(t=12.01，df=278.97，p<0.0005)，而資訊性支持來源較多(t=9.8，df=258.72，p<0.0005)；自覺行動利益分數較未使用血糖機高(t=11.69，df=302.00，p<0.0005)；自覺行動障礙較未使用血糖機低(t=-11.84，df=247.93，p<0.0005)；行為技巧也較未使用血糖機者高(t=10.11，df=286.03，p<0.0005)。
有使用血糖機者認為在家監測血糖最自在，在工作場比較不自在；若監測血糖遇到困難時容易找得到人詢問，而且當耗材用盡時，購買也很方便；醫護人員也確實會充分告知監測血糖的頻率及時間。
羅吉斯迴歸分析中，提高自我血糖監測機率之因素為高自覺罹患性(β=1.247，S.E=0.602，Z=2.072，p=0.038)；高自覺嚴重度(β=1.686，S.E=0.579，Z=2.913，p=0.004)；高工具性支持(β=1.661，S.E=0.764，Z=2.173，p=0.030)；高資訊性支持(β=1.349，S.E=0.584，Z=2.309，p=0.021)。
結論與建議
研究發現，其他條件不變的情況下，自覺罹患性、自覺嚴重度、工具性支持與資訊性支持高的組別會增加使用血糖機的機率；有一部份的情感性支持可能被工具性支持所解釋。而依據研究架構，人口學變項可能會被自覺罹患性、自覺嚴重度、工具性支持、資訊性支持構面所解釋。
自覺罹患性與自覺嚴重度高的組別，通常會在意罹患併發症的機率與嚴重性。建議可以讓患者多一些罹患併發症後之情境的試想，讓患者想要保持身體健康，進而對行為改變有所幫助。工具性支持及資訊性支持發現有使用血糖機者有較多人給予自己控制血糖實質幫助且自主搜尋資訊的能力也較強，而有使用血糖機者支持來源也較多。建議去了解患者周遭可以有哪些人可以協助患者，並提供患者教材或衛教單張以幫助增加工具與資訊性支持之來源。另外也要特別注意患者資訊的來源及內容，以免讓患者想要控制血糖的本意因為用錯了方法而效果不彰或病情惡化。若因此提高自覺罹患性、自覺嚴重度、工具性支持及資訊性支持，會增加使用血糖機之機會。

關鍵字

第二型糖尿病患 ； 血糖監測 ； 健康信念模式 ； IMB模式 ； 社會支持理論

並列摘要

Background: The number of diabetic patients has increased continuously in recent years, causing a great threat to the health of Taiwanese citizens as well as a huge burden to the society’s medical expenses. Diabetes is a chronicle disease and to manage its condition requires patients’ long-term cooperation with doctors’ instructions regarding diet, regular exercises and medications. According to the treatment guidelines, when their condition is stable, diabetic patients’ HbA1c value should be below 7. However, based on the statistics from 2004, 30.8% of diabetic patients presented an HbA1c value between 8.0% and 9.4%, while 34.7% of patients above 9.5%, suggesting that most diabetic patients failed to control their blood glucose level effectively. Only when diabetic patients learn to monitor their blood glucose level using a glucose meter and to adjust their lifestyle accordingly can patients successfully manage their blood glucose level. Yet, studies have showed that only 30% of diabetic patients have used a blood glucose meter. By exploring reasons why patients choose to use or not use a glucose meter, promotional projects can be designed to encourage patients to monitor their blood glucose and therefore, to help them successfully maintain a stable blood glucose level.

Research Objective: To explore reasons why non-insulin using adult patients of type-two diabetes choose to monitor or not their blood glucose level.

Research Methodology: The theoretical framework of this study combines the health beliefs model together with the information-motivation-behavioral (IBM) skills model and the social support theory. The research structure includes nine aspects of demographic information, perceived susceptibility, perceived severity, social companionship, instrumental support, informational support, perceived benefits, perceived barriers and behavioral skills. The researcher adopted a cross-sectional questionnaire to interview non-insulin using adult patients of type-two diabetes between July and October in 2012. A total of 304 copies of valid questionnaires were collected. The samples were randomly recruited from three medical centers or regional hospitals where more than 10,000 diabetic patients received out-patient services. The collected data was processed using SPSS 18.0. Besides of descriptive statistics, a T-test, chi-square test, factor analysis, multiple linear regression analysis and logistic regression were conducted.

Research Results
Among 304 respondents, 47.4% of them had the habit of using a glucose meter. Compared to patients who did not use a glucose meter, patients who did were averagely younger (t=6.20, df=281.26, p<0.0005) and had a shorter course of disease (t=5.9, df=301.17, p<0.0005). The majority of them possessed an educational degree of high school or middle school (χ2=44.87, df=3, p<0.0005) and their diet was mostly taken care of by themselves or their spouses (χ2=6.98, df=2, p=0.030). Also, more of them had a job (χ2=28.30, df=1, p<0.0005), while most of whose monthly salary was between 15000 and 79999 NTD (χ2=39.2, df=3, p<0.0005). In terms of complications, patients who used a glucose meter experienced fewer complications (t=-5.057, df=302, p<0.0005).
Compared to patients who did not use a glucose meter, patients who did had a higher score in perceived susceptibility (t=12.97, df=294.16, p<0.0005), perceived severity, social companionship (t=14.19, df=274.44, p<0.0005), instrumental support, informational support (t=12.01, df=278.97, p<0.0005), perceived benefits (t=11.69, df=302.00, p<0.0005), and behavioral skills (t=10.11, df=286.03, p<0.0005). Also, this group of patients had more sources of social companionship (t=10.65, df=270.35, p<0.0005), instrumental support (t=14.59, df=282.37, p<0.0005) and informational support (t=9.8，df=258.72，p<0.0005). On the other hand, their score in perceived barriers was lower than patients who did not use a glucose meter (t=-11.84, df=247.93, p<0.0005).
Patients who used a glucose meter considered it most convenient to measure their glucose level at home and less inconvenient at workplaces. They felt that it was easy to seek someone’s help when they experienced difficulties measuring their blood glucose level and to purchase necessary supplies when running out. In addition, they had been fully informed by medical personnel of the frequency and the time to measure their blood glucose level.
The logistic regression analysis showed that factors associated with improving patients’ likelihood of measuring their blood glucose level included high perceived susceptibility (β=1.247, S.E=0.602, Z=2.072, p=0.038), high perceived severity (β=1.686, S.E=0.579, Z=2.913, p=0.004), high instrumental support (β=1.661, S.E=0.764, Z=2.173, p=0.030) and high informational support (β=1.349, S.E=0.584, Z=2.309, p=0.021).

Conclusion and Suggestions
The study shows that, when other factors controlled, patients with higher perceived susceptibility, higher perceived severity, higher instrumental support, and higher informational support are more likely to use a blood glucose meter, while instrumental support can account partially for social companionship. Based on the research structure, the demographic variables may be explained by perceived susceptibility, perceived severity, instrumental support and informational support.
Patients with a higher score in perceived susceptibility and perceived severity are usually more concerned about the possibility and severity of complications, so it is recommended to teach patients to imagine the situation of suffering from some complications so as to encourage them to maintain healthy and furthermore, to change their behaviors. In terms of instrumental and informational support, patients who use a glucose meter often receive more help from others regarding blood glucose control and have a stronger ability of searching for important information on their own as well as more sources of support. Thus, it is suggested to discover more relevant individuals or groups that can assist patients and provide them with educational materials or leaflets, so that patients would have more sources of instrumental and informational support. On the other hand, it is important to scrutinize the sources and content of the information in order to prevent patients’ willingness to measure their glucose level being compromised and their condition worsened due to inappropriate information. When patients’ perceived susceptibility, perceived severity, instrumental support and informational support are improved, they are more likely to use a blood glucose meter.

並列關鍵字

Type 2 diabetic patients ； self-monitoring of blood glucose ； health beliefs model ； IMB Model ； social support

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