運用計畫行為理論於醫病共享決策輔助工具中，探討第二型糖尿病病人使用筆針型降血糖藥之行為意圖

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Title:	運用計畫行為理論於醫病共享決策輔助工具中，探討第二型糖尿病病人使用筆針型降血糖藥之行為意圖 Developing Type 2 Diabetic Patient Decision Aids for Taking Injection Medicine Based on Theory of Planned Behavior
Authors:	許舒涵 SUHAN, HSU
Contributors:	藥學系臨床藥學碩士在職專班唐功培王莉萱
Keywords:	第二型糖尿病;筆針型降血糖藥;醫病共享決策;決策輔助工具;計畫行為理論 Type 2 diabetes;Injection medicine;Shared decision making (SDM);Patient decision aid (PDA);Theory of Planned Behavior(TPB)
Date:	2021-07-07
Issue Date:	2022-04-16 17:23:37 (UTC+8)
Abstract:	研究背景全世界第二型糖尿病人口持續增加，而台灣亦是如此，此現象已成為公衛及醫療體系的挑戰。目前「糖尿病自我管理教育和支持」(Diabetes Self-Management Education and Support, DSMES)已成為糖尿病照顧之主流，而醫病共享決策(Shared decision making, SDM)為應用於DSMES之照護手法之一。有臨床試驗研究指出，提早使用胰島素對於糖尿病病患有較好的整體癒後，然而台灣筆針劑型降血糖藥物使用率遠不及歐美，這可能是台灣糖尿病病人治療指標糖化血色素未達標的原因之一。因此本研究以醫病共享決策應用於第二型糖尿病病人對筆針劑型降血糖藥物選擇。此外，本研究同時應用計畫行為理論(Theory of Planned Behavior，TPB)了解病人對於使用筆針型降血糖藥的行為意圖，將來可依據此結果，進一步設計介入方案，提供糖尿病病人最適當的藥品治療，進而提升第二型糖尿病病患整體照護成效。研究方法本研究以TPB作為概念框架，使用醫病共享決策之決策輔助工具(Patient decision aid, PDA)開發流程，開發出一個全新PDA，此PDA經α測試後定稿。β測試以準實驗設計(Quasi-Experimental Design)方式中兩組前後測 (before-and-after study of two group) 研究設計進行，將收案病人依是否使用SDM介入分為兩組進行研究。主要研究目的為確認PDA的信效度及TPB的假設驗證。將PDA中所列題目執行項目分析、信度分析、建構效度分析，以確保PDA符合信效度的要求，再利用驗證性因素分析與路徑分析驗證TPB研究假設中，態度、主觀規範、行為知覺控制對行為意圖的影響。次要研究目的為研究SDM介入的成效，以獨立樣本t檢定評估SDM介入組是否有較高的決策結果、後測知識成績，以及滿意度。研究結果主要研究結果，PDA中題目幾乎都符合項目分析標準，信度指標α係數皆>0.7，建構效度分析將題目分為3個構面，符合TPB理論，且每個構面都至少保留2個以上的題目。驗證性因素分析整體模型適配度指標為RMSEA 0.053、 χ2/df 1.699、CFI 0.981、TLI 0.973、GFI 0.959、AGFI 0.93、SRMR 0.0558，顯示其適配度良好。收斂效度雖然部分未達標，但區別效度良好；路徑分析結果顯示，態度與知覺控制對於行為意圖有正相關的直接效果，其效果分別為0.432與0.258。次要研究結果在校正人口學變項後，實驗組之決策結果分數、後測知識成績與滿意度皆分別較控制組高出0.598，0.892與1.918分。結論本研究發展的PDA內容信效度良好，TPB部分的結果顯示，對於筆針型降血糖藥的態度以及行為知覺控制，會正向顯著的影響第二型糖尿病病人使用筆針型降血糖藥的行為意圖。因此在SDM過程出現負向的態度，包含害怕針頭、疼痛及藥品副作用等情況時，醫療人員可透過衛教改變病人的態度。對於消除其行為知覺控制構面上的問題，可加強病人的正確用藥知識教育與筆針操作教學等，以增加病人對於使用筆針的信心，進而提升病人的行為知覺控制能力。 Background The number of patients with type 2 diabetes has been growing in Taiwan and worldwide. The phenomenon has become a challenge for public health and health system. Nowadays, Diabetes Self-Management Education and Support (DSMES) is the mainstream of diabetes care, and Shared Decision Making (SDM) is one of the methods used in DSMES. Some studies indicate that early use of insulin improves the entire outcome of diabetes, while the usage rate of insulin in Taiwan is still far behind in Europe and America. It might indicate that the low usage rate of injection medicine can be one of the reasons why blood sugar of diabetics is still out of control. Therefore, this study applied SDM in the scenario of the choice of injection medicine for type 2 diabetes patients. In addition, this study practiced the Theory of Planned Behaviour (TPB) in SDM at the same time to understand the patient’s intentions to use injection medicine. The result can be the basis on designing the intervention programs for the next step in the future, which will offer the most appropriate drug use for each patients with type 2 diabetes to promote the overall care effectiveness of type 2 diabetes. Methods The conceptual model of this study was based on TPB. This study developed a whole new patient decision aid (PDA) by PDA development process. PDA set the tone after the α test. The β test was designed by before-and-after study of two group research design in the Quasi-experimental design, separating the patients into two groups according to whether to use SDM intervention or not. The main purpose of this study was to confirm the reliability and validity of the PDA and test the hypotheses of TPB. It conducted the item analysis, reliability studies, construct validity analysis to ensure the request of reliability and validity in PDA questions , then utilizing confirmatory factor analysis and pathway analysis to confirm the influence on intention by attitude (AT), subjective norm (SN), and perceived behavioral control (PBC) in the TPB hypotheses testament. The secondary purpose was to study the intervention effectiveness of SDM by using independent sample t-test to research whether the intervention group had the higher decision score, post-knowledge grade, and satisfaction. Results The main results of the study showed that most of the questions in PDA met the standard of the item analysis, all cronbach’s α > 0.7, and the findings of construct validity made all the questions into 3 constructs that fit TPB, and every construct had at least 2 questions remained. The fit indices of model by confirmatory factor analysis were RMSEA 0.053, χ^2/df 1.699, CFI 0.981, TLI 0.973, GFI 0.959, AGFI 0.93 and SRMR 0.0558. It showed goodness of fit. Although some constructs did not meet the criteria of convergent validity, discriminant validity in all constructs was good. The results of pathway analysis showed attitude and perceived behavioral control were positively correlated with the intention to use injection medicine. The path coefficients were 0.432 and 0.258, separately. The secondary outcome showed that after the covariates adjusted, decision score and post-knowledge grade, satisfaction of intervention group were 0.598, 0.892 and 1.918 point higher than control group each, respectively. Conclusion This study developed a PDA with good reliability and validity. The TPB part of this study showed that the attitude and perceived behavioral control toward injection medicine would have positively and significantly impacts on patients’ intentions to use injection medicine. Therefore, when a patient shows negative attitude such as fear of needles, pain, adverse effects, and other situations during SDM, physicians shall devote on altering the patients’ attitude through patient education. As to eliminate the obstacles on perceived behavioral control for patients, enhancing their proper medication usage knowledges education, the skill with injection devices, and other abilities might increase their confidence in the use of injection medicine, and thereby promote their perceived behavioral control.
Description:	碩士指導教授：王莉萱指導教授：唐功培委員：許怡欣委員：李仁愛委員：林淑娟
Data Type:	thesis
Appears in Collections:	[School of Pharmacy] Dissertation/Thesis

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