陳月枝臺灣大學：護理學研究所陳金彌Chen, Chin-MiChin-MiChen2007-11-272018-07-072007-11-272018-07-072007http://ntur.lib.ntu.edu.tw//handle/246246/55819復原力是探究青少年成功適應逆境的重要概念，但是目前研究很少比較青少年腦瘤存活者與健康青少年復原力之差異。本研究目的有三項：1.比較青少年腦瘤存活者與健康青少年的復原力之差異，以澄清青少年復原力的高低差異是受健康問題影響或是受腦瘤診斷的影響；2.將復原力視為危險因子與保護因子互動的結果，以檢驗青少年腦瘤存活者的復原力與情緒型健康問題、生活目的與社會支持之間的關係；3.將復原力視為正向適應的過程，以檢驗青少年腦瘤存活者的復原力在情緒型健康問題與生活適應之間所扮演的角色。本研究依據三個理論─生命發展理論、Frankl存在分析、Haase青少年復原力理論─以形成本研究的架構與研究假設。 本研究設計是橫斷式個案控制/配對研究，青少年腦瘤存活者的樣本是自某醫學中心以方便取樣方式獲得，選樣條件如下：1.現年13-18歲；2.已完成腦瘤治療，或經醫生診治不需治療而持續追蹤者；3.目前規律到校上課。而健康青少年的樣本是與青少年腦瘤存活者進行性別、就讀學校的類別與就學年級、居住地等配對後，隨機抽樣自國中、高中、高職學校而得。經收案醫院倫理委員會審定後， 並取得家長與青少年同意後，以郵寄結構式問卷收集個案資料。資料分析是以SPSS 12.0版及LISREL 8.8（學生版）統計軟體進行，包括描述性統計、推論性統計與路徑分析。 本研究收案時間自2006年11月至2007年4月，共收集60位青少年腦瘤存活者以及120位健康青少年的問卷資料。兩組青少年的平均年齡約15歲，63.3%是男性，55%是國中生。藉由統計分析與測試研究假說，本研究結果如下：1.在控制人口學變項後，兩組青少年的復原力沒有差異，情緒型健康問題都是兩組青少年復原力的危險因子。但對於青少年腦瘤存活者而言，其情緒型健康問題對於復原力的負向影響較健康青少年為大（Beta= -0.34, p < .05）。2.對青少年腦瘤存活者而言，只有情緒型健康問題會對復原力造成負面影響（Beta = 0.43, p < .01, R-square = .27），疾病史與基本資料都不是其復原力的危險因子。3.有情緒型健康問題的青少年腦瘤存活者，須經由家庭支持才能產生復原力（R-square = .57）。4.青少年腦瘤存活者的生活目的，可減少情緒型健康問題對其復原力的負面影響約達51.3%（R-square = .49）。5.透過路徑分析可知，醫療人員的支持能直接增強青少年腦瘤存活者的復原力，或是間接透過與家人支持並共同訂定生活目的後，其復原力才得以提升。6.青少年腦瘤存活者的復原力可減少情緒型健康問題對於其生活適應的負面影響約達48.7%（R-square = .56）。 本研究依據上述研究結果作出以下五點結論：1.造成青少年復原力產生差異的原因是情緒型健康問題而非單純受腦瘤診斷的影響。2.青少年腦瘤存活者的情緒型健康問題對復原力之危害，較健康青少年甚巨。3.不管是青少年腦瘤存活者或是健康青少年，其情緒型健康問題是復原力的危險因子。4.青少年腦瘤存活者的生活目的、家庭支持、醫療人員的支持都是其復原力的保護因子。5.青少年腦瘤存活者的復原力可調節情緒型健康問題對於其生活適應的負面影響。本研究結果也提供醫療人員能早期發現青少年腦瘤存活者的情緒型健康問題、加強其支持系統、實踐其生活目的，進而提升復原力且達到正向的生活適應。Background. Resilience is an important concept in the positive psychosocial adjustment of adolescents to adversity. However, few studies have compared differences in resilience and its influence among adolescent survivors of brain tumors (ASBT) with that among healthy adolescents. The researcher hypothesized that resilience is influenced by emotion-related health problems, purpose in life, and perceived social support. Purpose. The aims were 1) to clarify normative development and impact of illness in ASBT by comparing them to healthy adolescents in terms of resilience and the effect of types of health problems on resilience, 2) to test the relationship among resilience and influences on resilience in ASBT, when resilience is an outcome, and 3) to examine the effect of resilience on the relationships between emotion-related health problems and life adaptation in ASBT, when resilience is a process. Theory and Method. The theoretical framework was based on life-span developmental theory, Haase’s Adolescent Resilience Model, and Frankl’s existential analysis. This study used a cross-sectional, case-control design. Convenience sampling was used to recruit participants who were ASBT and 13 to 18 years old. Random sampling was used to recruit healthy adolescents matched with ASBT by school level, gender and living area. Data were collected by a structured questionnaire (a demographic questionnaire and 7 scales). Analysis. Four of the 7 scales were translated and back-translated from English to Mandarin according to principles of instrument translation. Descriptive statistics were used to illustrate the distribution of variables. T-test was used to analyze differences in group means for independent and dependent variables. Multiple regression was used to analyze the contribution of each predictor to explaining total variance in the ASBT group. Path analysis was used to identify the process of forming resilience in ASBT. Results. The study participants included 60 ASBT and 120 healthy adolescents. ASBT and healthy adolescents were on average 15.4 years (SD = 1.56) and 15.17 years (SD = 1.65), respectively. Participants in both groups were predominantly male (63.3%) and studying in junior high school (55%). The findings were as follows. 1) ASBT and healthy adolescents did not differ significantly in resilience. However, resilience was more strongly and negatively affected by emotion-related problems (Beta value = -0.34, p < .05) in ASBT than in healthy adolescents with emotion-related health problems. 2) Except for emotion-related problems, medical history and demographics were not risk factors for resilience in ASBT. The negative effect of emotion-related health problems on resilience (Beta = 0.43, p < .01) in ASBT accounted for 26.9% of the variance in resilience. 3) ASBT with emotion-related health problems didn’t develop their resilience until they perceived support family support (R-square = .57). 4) “Purpose in life” reduced the effect of emotion-related health problems on resilience up to 51.4% (R-square = .49). 5) Path analysis showed that health care providers’ support not only directly enhanced resilience in ASBT, but also indirectly nurtured their resilience by assisting them and their families to achieve purpose in life by themselves. 6) Regarding resilience as a process of life adaptation, resilience reduced the effect of emotion-related health problems on life adaptation up to 48.7% (R-square = .56). Conclusions. This study’s results can be summarized by five conclusions after considering limitations of the study. 1) Differences in resilience between ASBT and healthy adolescents were due to emotion-related health problems, not “having a brain tumor” only. 2) The impact of emotion-related health problems on resilience was more severe in ASBT than in healthy adolescents. 3) Emotion-related health problems were identified as a risk factor for resilience in both ASBT and in healthy adolescents. 4) Perceived family support, perceived support from health care providers, and purpose in life were identified as protectors of resilience in ASBT. 5) For ASBT, resilience mediated between emotion-related health problems and life adaptation. These results suggest that health care professionals could foster resilience in ASBT by screening them soon after diagnosis for emotion-related health problems, strengthening their family support system, and supporting their purpose in life.ABSTRACT (Mandarin Version)……….…………………......………..……………….…..i ABSTRACT (English Version)….…….…………….……........……………………….….iii LIST OF TABLES……………………………………………......…………..…………......x LIST OF FIGURES ……………………………………………..........………….………..xii CHAPTER I INTRODUCTION………………………………………………......…….…..1 Research Questions………………..…….....………………..….........………….…....…..4 Purposes………………..…….....………………............................…………….…....…..5 Significance of the Study………………..…….....………………..…………….…....…..5 Assumptions…..…………………………………………………………….…....….7 Theoretical Perspectives.....…………………………………………………..........…..….7 Life-span Developmental Theory…………………….....…………….……....…..….7 Adolescent Resilience Model.....…………………….…….....……….……....…..….8 Existential Analysis.....…………………………………….....….…………....…..…10 Summary…………………………………………………………………….…….….11 CHAPTER II REVIEW OF THE LITERATURE…………….………………….…….….12 Adolescent Development………………………………………......……….…….….12 Physical Development………………………………………………….…….….12 Psychosocial Development………………….……….....………………….…….….13 Childhood Brain Tumor……………………….....…………………………….…….….14 Incidence Rate…………………………………………………......……….…….….14 Classifications of Most Common Brain Tumors………......………………………..15 Types of Treatment.…………………..…………………….....………….……...….16 Impact of Having a Brain Tumor for Adolescent…….....…………………….……..….17 Physical Impact……………………..................................................…….……...….17 Psychosocial Impact…….....................................…………………….……...….18 Resilience in Adolescents ….……….……………………………..……….……….19 Definitions of Resilience………………........……………………………………….19 Attributes of Resilience………………………………............………………..…….20 Antecedents and Consequences of Resilience…………………….....………..…….21 Types of Resilience Research………..…………......……………………..…..…….22 Measurements of Resilience …………........………………………………………..22 Influences on Resilience ……………………………….……………….………………29 Health Problems……………………………..…………………………….......29 Perceived Social Support……........................…………..…………………………..30 Purpose in Life………………………….……………………..……………….……31 Demographic characteristics……........……………………..……………………….33 Effect of Resilience on Life Adaptation…….........……..…………………………….....34 Life Adaptation…………………….…………………..……..………………..……34 Resilience and Life Adaptation of ASBT…….………..……..………………..……35 Summary of Literature..…......................……...………..……………………….……... 36 Research Hypotheses.................……...………..……………….....……….……... 37 Theoretical Framework……………………………………………………….…...…38 Operational Definitions of Variables …….......…………………………………….…...40 Summary………………………………….....…………………….....…………..….….…41 CHAPTER III METHODOLOGY……..……….………………………….………….......46 Research Design………………………………….…………………..………………….46 Setting……….……………………………………………..……………...…..…...46 Sampling………………………………………………..…..………………………..47 Inclusion Criteria for ASBT……..………..………………………..………………..47 Inclusion Criteria for Healthy Adolescents…..…………………….………………..48 Sample Size……………..………..………………………..………………………..48 Ethical Consideration……………………………………………..………….…….........49 Data Collection Procedures……………………………………………………......49 Measurements………………………………………………..………………………53 Demographic Questionnaires……………………………………......………………54 Health Utilities Index Mark 2 (HUI 2) …………………………………………54 Life Purpose Questionnaire for Adolescents (LPQ-A) …………………………55 Perceived Social Support from Families (PSS-Fa) …………………..………56 Perceived Social Support from Friends (PSS-Fr) …………………..…………57 Perceived Social Support from Health care Professionals (PSS-Hc) …………57 Haase Adolescent Resilience in Illness Scale (HARIS) …………….….………58 Life Adaptation Scale (LAS) ……………………………………………………58 Psychometric Properties of Instruments Tested in the Study…………..…………....60 Strategies of Testing Psychometric Properties of Instruments…..........................60 Psychometric Properties of Instruments………………………………………....61 Differences between Two Versions of Instruments..........................................61 Reliability of Instruments in Mandarin Version.……......................……….....65 Validity of Instruments in Mandarin Version…………..………..….……......65 Data Analysis……………………………………………………..……….............68 Summary……..……………………………………………………..…………...........70 CHAPTER IV RESULTS…………………………………..……………………………...72 Description of Sample…………………………………………………….................72 Sample of Adolescent Survivors of Brain Tumors (ASBT)……….……....…..……73 Sample of Healthy Adolescents …………..……..……….……..………..…………75 Distributions of Scores for Each Instrument..……..………..…………………..............78 Group Differences in Resilience and Influences on Resilience…….........……..….........81 Influences on Resilience in ASBT Group…………..……..…………..………..............97 Effect of Resilience on Life Adaptation in ASBT Group……………..…………........115 Summary……..……………………………………………………..………….........121 CHAPTER V DISCUSSION……........................................................…………………..124 Emotion-related Health Problem as a Risk Factor of Resilience.......................…..124 Differences in Resilience……................................................………………..........…..125 Differences between ASBT and Healthy Adolescents…………………………125 Differences within ASBT Group……………………….……………………..128 Protectors of Resilience in ASBT................................................…………………..128 Perceived Social Supports as Protectors of Resilience….….............…………..129 Perceived Support from Family as a Protector of Resilience........................130 Perceived Support from Healthcare providers as a Protector of Resilience.......................................................................130 Purpose in Life as a Protector of Resilience……….............….....……..………….132 Resilience as a Protector of Life Adaptation in ASBT……..………………………133 Philosophy of Nursing Based on the Findings of the Study......................................134 Definitions of Major Concepts…………………….…………….……….....……..135 Diagram of Resilience in Adolescence Model (RIA Model)……...........................135 Propositions………………………………..…………………………………139 Nursing Meta-paradigm Based on the RIA-Model..……………………….………139 Summary……..………………………………………………………..………..........141 CHAPTER VI CONCLUSION……………………….…………………………………..142 Conclusions of the Study……………………….………………………………….142 Strengths of the Study………………………………………..…………………….143 Limitations and Recommendations for Further Studies…....……………………....144 Implications……………………………………………………………………….146 Nursing Practice Implications………………………………………………..146 Continuously Connecting with ASBT and Their Families…………..……..147 Identifying Etiologies of Emotion-related Health Problems………..….…..147 Improving Family Protectors of ASBT…………………………..…….…..148 Enhancing Peer Support Networks of ASBT…………………….….……..148 Nursing Education Implications………………………..………………………149 Learning to Work with Interdisciplinary Teams……….….……………….…..149 Learning to Work in Communities……………………….……………………149 Learning to Work with ASBT……………………………..………………...…150 Nursing Research Implications…………………………………………………….150 Constructing a Surveillance System………………………..………………….150 Testing the RIA Model………………….................…….…………………….151 Organizing Interdisciplinary Research Teams..........…………………...….151 REFERENCE……………………..……………………………………………........153 APPENDIX A Consent Forms.........................…….…..………..............……………..165 Appendix A.1 Consent Form for ASBT.........................................................................166 Appendix A.2 Descriptions of the Study Introduced to ASBT....................................167 Appendix A.3 Consent Form for Healthy Adolescents..................................................169 Appendix A.4 Descriptions of the Study Introduced to Healthy Adolescents................170 Appendix A.5 Institutional Review Board (IRB) Approvals..........................................172 APPENDIX B Methodological Considerations………………………………….…….174 Appendix B.1 Comparison of Methods for Data Collection………………..……175 Appendix B.2 Scoring on Health Utilities Index Mark 2 (HUI 2)……........…………..176 APPENDIX C Permit to Use Scales………..……….......……………………..……….177 Appendix C.1 Permission to Use the Life Purpose Questionnaire for Adolescents (LPQ-A).....................................................................178 Appendix C.2 Permission to Use the Perceived Social Support from Health Care Professionals (PSS-Hc).........................................179 Appendix C.3 Permission to Use the Haase Adolescent Resilience in Illness Scale (HARIS)...................................................................180 Appendix C.4 Permission to Use the Life Adaptation Scale (LAS)........................181 APPENDIX D Experts for Working on Instruments……..…………………………….182 Appendix D.1 Experts for Instruments Translation……………………………………183 Appendix D.2 Experts for Examining Content Validity………….……………………184 APPENDIX E The Results of Forward Translation and Back Translation of Instruments ……………….......................................……………..…185 APPENDIX F Pre-revision and Post-revision of Each Item in Instruments…..…….….192 APPENDIX G Exploratory Factor Analysis of Instruments………….………………..199 Appendix G.1 Factor Analysis of the Life Purpose Questionnaire for Adolescents (LPQ-A)..........................................................................200 Appendix G.2 Factor Analysis of the Life Adaptation Scale (LAS)……….………….201 Appendix G.3 Factor Analysis of the Haase Adolescent Resilience in Illness Scale (HARIS)……………………………………..…..202 Appendix G.4 Factor Analysis of the Perceived Social Support from Healthcare Providers (PSS-Hc)…………………………………..203 Appendix G.5 Factor Analysis of the Perceived Social Support from Families (PSS-Fa)………………………….…………………..…204 Appendix G.6 Factor Analysis of the Perceived Social Support from Friends (PSS-Fr)………………………………………………….205 Appendix G.7 Factor Analysis of the Perceived Social Support from Family and Friends……………………………………………….206 APPENDIX H Questionnaires..........................…….…..…......…............……………..207 APPENDIX I Time Line for This Study………….....……....……..……..…………….229 LIST OF TABLES 2.1 Attributes and Antecedents of Resilience…………..…...........…….………..…...25 2.2 Studies on Adolescent Resilience in Taiwan……….…........………….………....27 2.3 Comparison of Findings from the Researcher’s Qualitative Study and the HARIS.............................................................................................................28 3.1 Description of Instruments...…………..…………………………….....................59 3.2 Comparison of English and Mandarin Versions of Instruments….........................63 3.3 Differences in the Items of the PSS-Hc between Two Versions………...………..64 3.4 Reliability of Instruments……………..…………………….………....................67 3.5 Statistical Analysis.......................................................................................................71 4.1 Demographic Characteristic of Participants…………..…………………………76 4.2 Medical History of Adolescent Survivors of Brain Tumors……..………….……..77 4.3 Group Differences among Variables between ASBT and Healthy Adolescents….79 4.4 Effect of Brain Tumors on Resilience under Controlling Control Variables…..….83 4.5 Group Differences in Resilience by Health Problems between ASBT and Healthy Adolescents…………………………………………………………..…84 4.6 Differences in Resilience by Health Problems in ASBT………….........…….……..87 4.7 Differences in Resilience by Health Problems in Healthy Adolescents…...……..88 4.8 Comparison of Differences in Resilience among Three Groups.................................89 4.9 Effect of Types of Health Problems on Resilience in ASBT and in Healthy Adolescents…….......………………………………………………..…..91 4.10 Group Differences in the Effect of Emotion-related Health Problems on Resilience……........................................................................................…….......92 4.11 Risk Effects of Emotion-related Health Problems on Degree of Resilience........96 4.12 Correlations among Variables in ASBT Group……………………….………..98 4.13 Differences in Influence by Emotion-related Health Problems in ASBT group..………..................................................................................……..99 4.14 Influence of Emotion-related Health Problems on ASBT Responses to Selected Items of the HARIS …………………....……………………………101 4.15 Effect of Medical History on Relationship between Emotion-related Health Problems and Resilience………………….…………102 4.16 Comparison of Medical Histories for ASBT with Benign Tumor and Malignant Tumor……………………………….………………………104 4.17 Effect of Perceived Social Support on the Relationship between Emotion-related Health Problems and Resilience………..…………........………108 4.18 Perceived Types of Health Care Providers’ Support………………………….…..109 4.19 Advantages of Perceived Health Care Providers’ Support………....……………..110 4.20 Needs for Support from Health Care Providers………..……………….………....111 4.21 Effect of Purpose in Life on the Relationship between Emotion-related Health Problems and Resilience……………………....….....113 4.22 Effect of Resilience on the Relationship between Types of Health Problems and Life Adaptation……………….………………......….…….119 4.23 Hypotheses and Summary of Findings…….……..........................................…….123 LIST OF FIGURES 2.1 Theoretical Framework….............…….……….......................………….……....42 2.2 Theoretical Framework for Panel A: Effects of Brain Tumors and Health Problems on Resilience……...............…….………………….…....43 2.3 Theoretical Framework for Panel B: Influences on Resilience in ASBT....................44 2.4 Theoretical Framework for Panel C: Effects of Resilience on Life Adaptation among ASBT……......................................…………….……....45 3.1 Sampling Procedure……………………………………………………....……....52 4.1 Group Differences in Resilience among Three Groups..............................................90 4.2 Group Differences in the Effect of Emotion-related Health Problems on Resilience..........................................................................................................93 4.3.1 Effect of Health Problems on Resilience.............................................................94 4.3.2 Effect of Having a Brain Tumor on the Relationship between Emotion-related Health Problem and Resilience......................................................94 4.4 Group Difference in Emotion-related Health Problems between ASBT with Benign and Malignant Tumors………………………………………………105 4.5 Path Model............................................................................................................116 4.6 Decision Nodes of Resilience in ASBT……........…………...…………………117 4.7 Effect of Resilience on the Relationship Between Emotion-related Health Problems and Life Adaptation.................................................................120 5.1 Resilience in Adolescence Model (RIA-Model)..................................................1384647896 bytesapplication/pdfen-US青少年存活者兒童腦瘤復原力生活適應adolescentsurvivorschildhood brain tumorresiliencelife adaptationotherhttp://ntur.lib.ntu.edu.tw/bitstream/246246/55819/1/ntu-96-D92426004-1.pdf