摘 要

病人的自我效能一直被視為影響健康的重要因子，本研究的目的在探討血液透析病人的社會人口學特性、臨床檢驗值、自我效能、自我照護與生活品質間的相關性。研究對象及方法：採橫斷式相關性之研究設計，以三家血液透析中心，年齡大於18 歲的個案為研究對象，共收案43 位，男生27 人，女生16 人；平均年齡為54.35 歲，透析年數平均7.53年，多數個案都有慢性病。研究工具採一份結構試問卷，包括基本資料、生活品質量表（KDQOL-SFTM）、自我效能量表、自我照護量表。並於透析前後收集個案之臨床檢驗數據，檢驗鉀、鈣、肌酸酐等生化數值。

研究結果發現：
一、 病人的年齡與自我效能、生活品質及自我照護是呈現負相關性(p<0.01)，表示年齡越大則自我效能、生活品質及自我照護量表的平均分數越低。
二、 病人的透析月數的長短與自我效能、生活品質及自我照護量表的比較，則無相關性。
三、 教育程度及腎臟疾病指標是預測病人的自我效能、生活品質及自我照護的重要因子。
　　本研究證實血液透析病人的治療結果與自我效能之間具有顯著相關，建議健保局在制定醫療政策時少有是從病人的立場去思考，未來健保的財務問題是需要由健保局、醫療機構、病人之間的關係是去思考解決的，而全民健保制度是否能持續運作也是三方的共同責任。因此開始建立一個完整的血液透析病人的資料庫，長期追蹤病人的治療結果及相關臨床資料，是未來健保政策推動的重要的參考資料。


關鍵辭：血液透析、生活品質、自我效能

ABSTRACT

Introduction:
Population of end-stage renal disease with subsequent renal replacement therapy patients is growing annually. Recently, quality of life (QOL) among chronic hemodialysis (HD) patients becomes an important parameter of the treatment adequacy and deserves various clinical investigations, especially cost-effectiveness relation under government insurance coverage. HD patients can have impaired daily functioning because of their primary kidney disease and comorbid conditions. Self-efficacy of patient-oriented point of view can be of great value in the evaluation of treatment outcome and dialysis course. The aim of this study was to analyze the association between independent clinical, laboratory, dialysis factors and self-efficacy of the QOL in HD treatment outcome.
Materials and Methods
There were 43 patients (27 men and 16 women, aged 54.35 ± 13.00 years old) undergoing long-term maintenance thrice weekly HD therapy recruited in this study. Patients answered the Kidney Disease Quality of Life questionnaire (KDQOL-SF™) which includes the SF-36 (8 dimensions/36 items): physical functioning (10 items), role limitations caused by physical problems (4 items), role limitations caused by emotional problems (3 items), pain (2 items), general health perceptions (5 items), social functioning (2 items), emotional well-being (5 items), energy/fatigue (4 items), and 1 item about health status compared to one year ago; kidney-disease-targeted items (11dimensions/43 items); symptom/problem list (12 items), effects of kidney disease (8 items), burden of kidney disease (4 items), cognitive function (3 items), quality of social interaction(3 items), sexual function(2 items), sleep(4 items), social support(2 items), work status (2 items), overall health rating( 1 item scored separately), patient satisfaction(1 item), and dialysis staff encouragement (2 items). Self-efficacy scoring system developed locally which is divided into two dimensions; self-awareness (11 items), and self-care (5 items) also added in the questionnaire. Clinical data including dialysis treatment type and co-morbidity (cardiovascular diseases, chronic obstructive lung disease, peripheral vascular disease, diabetes mellitus, cerebrovascular disease, liver disease, hypertension, visual deficit, ambulation deficit, and cancer) were recorded and analyzed. Laboratory parameters including electrolytes, HD efficiency data (e.g.: Kt/V, nPCR, URR), albumin and creatinine were also analyzed. The impact of various factors on KDQOL-SF™ was estimated by multivariate analysis using SPSS® 10.0 depending on variables'' characteristics. Cox’s regression analysis for relative laboratory and clinical outcome also performed. The tests were two-tailed and P<0.05 was considered to indicate statistical significance.

Results:
KDQOL–SF™ questionnaire scores obtained from the HD patients is significantly (P< 0.001) lower as comparing with the scores obtained from the normal control in Taiwanese population. Except for the mean dialysis age 7.53 ± 5.75 years is not statistically significant to the self efficacy and health care, or the KDQOL scores. Patients with older age had lower KDQOL coefficients’ scores

Conclusion:.
The methods used to evaluate the quality of life questionnaires in nephrology are not adequate and impractical as compared with the normal population ones. Among these, the role of assessment of health-related quality of life by the application of generic and specific measures that are used to examine which dimensions or areas of life of the patients are impaired and need to receive an appropriate intervention. Additional problems are the wrong choice of questionnaire or problems with its utilization. The KDQOL–SF™ has many advantages compared to other instruments e.g. it has been tested in several populations with kidney disease, it has both general and specific modules to access chronic kidney disease, it has questions about the sexual area and professional rehabilitation, and it can be self-applied or applied by the interviewer. Self efficacy and health care added in KDQOL–SF™ as a whole to investigate the exact quality of patients on regular hemodialysis proved to be a effective tool not only in predicting the outcome of dialysis patients, but the cost-effectiveness among medical intervention needed. From this study, it is obvious that the older the patients’ age, the less scores he will acquire. However, patients undergoing dialysis did not have lower scores with longer dialysis years. This implied that an intensive bedside assistance and continuous workup with quality survey monitoring will further profit the patients on dialysis, no matter how long they were on dialysis. As expected, the best correlation between KDQOL–SF™ and laboratory data was electrolytes, nutritional status and HD efficiency. Overall, greater dose of HD on high-flux membranes, sufficiently correction of serum electrolytes toward normal value and adequate social and emotional interaction with HD patients can also reflect better outcome.

Key words: hemodialysis,quality of life, self efficacy

目錄
書名頁 i
論文口試委員審定書 ii
授權書 iii
中文摘要 iv
英文摘要 v
誌謝 viii
目錄 ix
表目錄 xi
圖目錄 xiii
第一章　　緒論 1
第一節 研究動機及重要性 1
第二節 研究目的 3
第二章 文獻探討與評析 5
第一節 血液透析的概念及定義 5
第二節 生活品質的概念及定義 6
第三節 血液透析病人生活品質的研究 11
第四節 影響血液透析病人生活品質之相關因素 17
第五節 自我效能的概念及定義 22
第六節 自我照護的概念及定義 23
第三章 研究架構與假設 25
第一節 研究架構 25
第二節 名詞定義 26
第三節 研究假設 27
第四章 研究方法及過程 29
第一節 研究對象 29
第二節 研究工具 29
第三節 資料收集過程 32
第四節 資料分析與方法 33
第五章 研究結果 35
第一節 研究對象之基本資料 35
第二節 研究對象之生活品質統計結果 38
第三節 研究對象之疾病特性統計結果 43
第四節 研究對象之自我效能及自我照護 48
第五節 生活品質之相關因素 50
一、KDQOL-SFTM生活品質量表各範疇之相關性 50
二、社會人口學特性在生活品質範疇之間關係 53
三、臨床檢驗值與生活品質範疇之關係 57
四、自我效能與生活品質範疇之關係 59
五、自我效能與自我照護之關係 60
　第六節 研究架構驗證及研究假說討論 62
第七節 實證架構研究討論 69
一、教育程度、腎臟疾病指標對生活品質及自我照護的影響 71
二、教育程度、腎臟疾病指標、自我效能對生活品質及自我照護的影響 74
三、分析結果 78
第六章 結論及建議 79
第一節 結論 79
第二節 建議 81
第二節 研究限制 86
參考文獻 87
附錄 92
附錄一：血液透析病人對治療結果之自我效能評估問卷 93
附錄二：生活品質量計分表 110

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