張媚 副教授臺灣大學:護理學研究所劉苑菁Liu, Yuan-ChingYuan-ChingLiu2010-05-052018-07-072010-05-052018-07-072008U0001-2907200810402800http://ntur.lib.ntu.edu.tw//handle/246246/180383本研究之主要目的在於運用Ajzen 所提出的計劃行為理論（Theory oflanned Behavior）來探討糖尿病健康促進機構醫師在未來半年內，針對經衛教指導、積極飲食與運動控制及服用兩種口服抗糖尿病藥物達最大劑量，且A1C仍≧7.5%的第2型糖尿病人，其選擇抗糖尿病藥物之行為意向。研究對象為任職於136家糖尿病健康促進機構且診治門診糖尿病人的醫師。研究工具的設計乃根據開放式問卷的填答及電話訪問的結果，篩選出顯著信念而編制成結構式問卷，再運用郵寄問卷的方式進行資料收集，共計回收有效問卷214份，分佈於92家機構，回收率為43.8%。研究分別測量研究對象對選擇胰島素及口服抗糖尿病藥物在態度、主觀規範、自覺行為控制及行為意向的得分，再經過兩者得分相減，得到差別的分數，以瞭解研究對象在各變項的偏好，有別於該理論一般只針對一種行為選擇的作法，結果指出：（1）差別態度、差別主觀規範、差別自覺行為控制三個變項可以解釋研究對象選擇抗糖尿病藥物之差別行為意向整體變異量的24%，其中以差別態度對差別行為意向的影響力最大，其次分別為差別主觀規範及差別自覺行為控制；（2）在差別態度方面，45.8%的研究對象對這類病人開立胰島素抱持較正向的態度，其中較多數的研究對象認為開立胰島素較口服抗糖尿病藥物，來得適當及效果好。亦有37.4%的研究對象對這類病人開立口服抗糖尿病藥物抱持較正向的態度，其中較多數的研究對象認為開立口服藥較胰島素，來得不麻煩及安全；（3）在差別主觀規範方面，42.1%的研究對象覺得大多數的重要參考對象認為他較應該開立胰島素，僅有12.6%的研究對象覺得大多數的重要參考對象認為他較應該開立口服抗糖尿病藥物，而另有45.3%的研究對象覺得大多數的重要參考對象對他開立此兩種藥物的贊成程度是相同的；（4）在差別自覺行為控制方面，75.7%的研究對象認為開立口服抗糖尿病藥物的自主程度高於開立胰島素，其中較多數的研究對象認為對開立口服藥而言，較有把握、自身對治療意見的影響力較大、阻礙因素較少及較容易克服阻礙；（5）研究對象對於選擇抗糖尿病藥物之處方行為的差別態度、差別主觀規範與其構成要素之交乘積和間呈現正相關，差別自覺行為控制則與其構成信念亦呈現正相關，皆符合計劃行為理論的假設；（6）為進一步瞭解處方行為意向不同者在各信念間的差異，依照研究對象選擇抗糖尿病藥物之差別行為意向，剔除中立意見者73位，區分為胰島素及第三種口服抗糖尿病藥物取向組，兩組比較發現：1.差別行為信念方面：胰島素取向組較第三種口服抗糖尿病藥物取向組更認同胰島素較口服藥能有效控制血糖、降低罹患糖尿病併發症的風險、延緩β細胞功能惡化、降低口服藥物交互作用、改善胰島素阻抗性、彈性調整藥物劑量及改善病人的生活品質。2.差別規範信念方面：雖然兩組皆覺得醫院、新陳代謝科醫師、糖尿病相關學會、糖尿病衛教人員及實證研究等重要參考對象比較支持研究對象開立胰島素，但以胰島素取向組感受到的贊成程度較為強烈。兩組皆覺得病人較支持研究對象開立口服抗糖尿病藥物，但以第三種口服抗糖尿病藥物取向組感受到的贊成程度較為強烈。3.差別控制信念方面：胰島素取向組較同意這類病人出現糖尿病併發症比較會促使其改用或增加胰島素而非口服藥；（7）研究對象之社會人口學變項與其選擇抗糖尿病藥物的差別行為意向沒有顯著相關性；（8）本研究對象在未來半年內，對這類病人開立抗糖尿病藥物的選擇意向，傾向開立胰島素者佔57.0 %，傾向開立第三種口服抗糖尿病藥物者則佔32.7 %於以上研究結果，歸納出結論：計劃行為理論之主要變項--態度、主觀規範及自覺行為控制，能預測研究對象之處方抗糖尿病藥物之行為意向。其中以態度及主觀規範，較具影響力；處方行為意向不同組在態度、主觀規範及自覺行為控制之構成信念方面亦有顯著差異。最後，根據研究結果，提供建議供醫療及教育相關機構參考。The purpose of this study was to explore the physicians’ intentions to choose antidiabetic agents in the next six months by applying the Ajzen’s theory of planned behavior. A clinical vignette was designed to elicit physicians’ opinions: for type 2 diabetic patients who have had hygiene education and guidance, active diet and exercise control, and taking the maximum dosage for two oral antidiabetic agents, whose A1C is still ≧7.5%, to determine the intention for choosing antidiabetic agents. The sample population was selected from the physicians who take care of ambulatory diabetic patients in the 136 Institutions of Diabetes Health Promotion. The design of research instrument was based on the results of an open-ended questionnaire and telephone interviews from the sample population, and then to elicit salient beliefs. According to salient beliefs, the structured questionnaire was developed, and then structured questionnaires were mailed to collect data. The total number of valid questionnaires was 214, distributed to 92 institutions, and the overall valid response rate was 43.8%. n the study, attitude, subjective norm, perceived behavioral control, and behavioral intention were measured to get scores about choosing insulin and OAD by respondents respectively. Then, two scores were subtracted, creating a differential score which presented the views of respondents. This method was different from the traditional method of the theory, which was generally applied to explain one-choice behavior. The results show: (1) All three of the constructs in the theory—differential attitude, differential subjective norm, and differential perceived behavioral control could effectively explain 24% of variance of the differential intention to prescribe antidiabetic agents . Of which, differential attitude have the greatest influence for differential intention, followed by differential subjective norm and differential perceived behavioral control;（2）Regarding differential attitude, 45.8% of respondents had a more positive attitude toward prescribing insulin than OAD, because most of them believed prescribing insulin was more appropriate and effective. But 37.4% of respondents also had a more positive attitude toward prescribing OAD than insulin, most of them believed prescribing OAD was less inconvenient and more safer; (3)Regarding differential subjective norm, 42.1% of respondents felt most of the important referents expected he/she should prescribe insulin. Only 12.6% of respondents felt most of the important referents expected he/she should prescribe OAD. Besides, 45.3% of respondents felt most of the important referents agreed no matter what kind of drugs was prescribed by them; (4)Regarding differential perceived behavioral control, 75.7% of respondents believed the autonomy of prescribing OAD was higher than that for insulin, of which more respondents believed that in prescribing OAD, they were more confident, had more influence over treatment opinion, fewer obstacles, and such obstacles was easier to overcome; (5)The differential attitude of respondents toward prescribing intention was positively related to the sum of the product of differential behavioral beliefs multiplied by outcome evaluations（Σ（b1-b2）ii‧ei). The differential subjective norm of respondents toward prescribing intention was positively related to the sum of the product of differential normative beliefs multiplied by motivations to comply(Σ（nb1-nb2）i‧mc). The differential perceived behavioral control of respondents toward prescribing intention was also positively related to the sum of the product of differential control beliefs (Σ（cb1-cb2）i). These results were also consistent with the theory of planned behavior; (6)According to differential behavioral intention, excluding the 73 neutrals, respondents were divided into insulin-oriented and OAD-oriented group. There were significant differences in differential beliefs between these tow groups. For instance: 1.Regarding differential behavioral beliefs, the insulin-oriented group was more likely to agree insulin was more effective, could decrease the risk of diabetes-related complications, delay the failure of βcell function, decrease the interaction of oral agents, improve insulin resistance, adjust the dosage flexibly, and improve patients’ quality of life. 2.Regarding differential normative beliefs, though both groups felt important referents, ex: hospitals, metabolism specialists, diabetes-related institutions, diabetes educators, and evidenced-based research, support them to prescribe insulin, the insulin-oriented group felt stronger support than the OAD-oriented group. Both groups felt patients support them to prescribe OAD, but the OAD-oriented group felt stronger support than insulin-oriented group. 3.Regarding differential control beliefs, the insulin-oriented group was more likely to agree the occurred-complications would get them to prescribe insulin; (7)The social demographic variables were not correlated with the differential intention to prescribe antidiabetic agents; In addition, (8) In choice intention, 57.0% of respondents intended to choose insulin, and 32.7% intended to choose the 3rd OAD in the next six months.ccording to above results, the conclusion was made: all three of the constructs in the theory — attitude, subjective norm, perceived behavioral control, made significant contributions to predict respondents’ intentions to prescribe antidiabetic agents. Among them, attitude and subjective norm were the main effective variables; For the group with different intentions in prescriptions, there were also significant differences in belief composites that are assumed to determine attitude, subjective norm, and perceived behavioral control. In addition, based on the results, the researcher proposed suggestions to health care and educational institutions.口試委員會審定書…………………………………………….….….…........................i謝………………………………………………………………….….........................ii文摘要…………………………………………………………………......................iii文摘要….……………………………………………………….….…........................v一章 緒論 1一節 研究動機與重要性 1二節 研究目的 4二章 文獻查證 6一節 第2型糖尿病簡介 6二節 第2型糖尿病人之醫療處置 7三節 與第2型糖尿病人接受抗糖尿病藥物治療相關之議題 9四節 計劃行為理論 16五節 影響醫師處方行為的相關因素之探討 29六節 糖尿病照護人員對第2型糖尿病人使用胰島素治療之態度與行為意向之探討 30三章 研究設計 33一節 研究架構 33二節 名詞界定 34三節 研究假設 37四章 研究方法 39一節 研究對象 39二節 研究工具 39三節 研究步驟 47四節 資料處理 48五章 研究結果 53一節 研究對象的背景資料 53二節 對血糖控制不佳之第2型糖尿病人選擇抗糖尿病藥物之行為意向及其影響因素 56三節 差別態度、差別主觀規範、差別自覺行為控制與構成要素之關係.....60四節 不同行為意向者在各概念上的差異 72五節 其他發現 76六章 討論 79一節 對血糖控制不佳之第2型糖尿病人選擇抗糖尿病藥物之行為意向及其影響因素 79二節 差別態度、差別主觀規範、差別自覺行為控制與構成要素之關係........83三節 不同行為意向者在各信念之差異比較 84七章 結論與建議 86一節 結論 86二節 建議 87三節 研究限制 88考文獻 89錄一 研究對象對開立胰島素及口服抗糖尿病藥物在各變項之得分分佈及平均值 96錄二 開放式問卷內容 104錄三 正式施測問卷 106表目錄2- 1第2型糖尿病人高血糖的處理原則 112- 2理性行動理論與計劃行為理論架構 172- 3理性行動理論解釋選擇性行為之研究架構 213- 1研究架構 336- 1計劃行為理論中各變項間的關係圖 802- 1 ADA、AACE及中華民國糖尿病學會建議的血糖控制目標 92- 2探討健康照護人員促進個案健康行為的相關研究 274- 1預試問卷分量表內部一致性信度分析 434- 2正式施測各分量表內部一致性信度分析 484- 3變項計分方式與意義 494- 4研究假設之統計方法 525- 1社會人口學變項分佈 555- 2對病人選擇抗糖尿病藥物的選擇意向之描述性統計 565- 3對病人選擇抗糖尿病藥物的差別行為意向之描述性統計 575- 4選擇抗糖尿病藥物之選擇意向與差別行為意向之相關矩陣 575- 5差別態度、差別主觀規範、差別自覺行為控制與差別行為意向之相關矩陣 585- 6選擇抗糖尿病藥物之差別行為意向的複迴歸分析（強迫進入法） 585- 7選擇抗糖尿病藥物之差別行為意向與社會人口學變項的單因子變異數分析 595- 8研究對象對選擇抗糖尿病藥物的差別態度之得分分佈及平均值 615- 9研究對象對選擇抗糖尿病藥物的差別行為信念之得分分佈及平均值 625- 10研究對象對選擇抗糖尿病藥物的結果評價之得分分佈及平均值 635- 11態度與ΣBi‧Ei之相關矩陣 655- 12研究對象對選擇抗糖尿病藥物的差別主觀規範之得分分佈及平均值 665- 13研究對象對選擇抗糖尿病藥物的差別規範信念之得分分佈及平均值 675- 14研究對象對選擇抗糖尿病藥物的依從動機之得分分佈及平均值 685- 15差別主觀規範與Σ（NB1－NB2）j‧MCj之相關矩陣 695- 16研究對象對選擇抗糖尿病藥物的差別自覺行為控制之得分分佈及平均值 705- 17研究對象對選擇抗糖尿病藥物的差別控制信念之得分分佈及平均值 715- 18差別自覺行為控制與Σ（CB1－CB2)k之相關矩陣 725- 19胰島素/第三種口服抗糖尿病藥物取向組在各概念Wilk''s lambda分析 725- 20胰島素/第三種口服抗糖尿病藥物取向組在差別行為信念的變異數分析 735- 21胰島素/第三種口服抗糖尿病取向組在差別規範信念的變異數分析 745- 22胰島素/第三種口服抗糖尿病取向組在差別控制信念的變異數分析 755- 23對開立胰島素之直接測量變項、間接測量變項及行為意向的相關矩陣 775- 24對開立胰島素之行為意向的複迴歸分析（直接測量變項） 775- 25對開立口服抗糖尿病藥物之直接測量變項、間接測量變項及行為意向的相關矩陣 785- 26對開立口服抗糖尿病藥物之行為意向的複迴歸分析（直接測量變項） 78application/pdf1331743 bytesapplication/pdfen-US計劃行為理論處方行為意向抗糖尿病藥物態度主觀規範自覺行為控制Theory of planned behaviorprescribing intentionsantidiabetic agentsattitudesubjective normperceived behavioral control[SDGs]SDG3http://ntur.lib.ntu.edu.tw/bitstream/246246/180383/1/ntu-97-R94426030-1.pdf