【作者】 唐红英；

【导师】 朱京慈；

【作者基本信息】 第三军医大学 ， 护理学， 2011， 博士

【摘要】 我国现有2亿高血压患者,且每年新增加1千万人。高血压是心脑血管病最主要的危险因素,目前心脑血管病已经成为中国首位死因,心脑血管病的发生和死亡,半数以上与高血压有关,因此控制高血压是防治心脑血管病的关键。高血压的发病率高而控制率低已成一个全球性的难题,其中患者对治疗的依从性差是导致血压控制率低的最主要原因,而患者对降压治疗的态度与信念是影响依从性行为的重要原因。准确有效评估患者对降压治疗的态度与信念及依从性行为,有助于开展有针对性的个体化干预,提高患者对治疗的依从性。高血压治疗包括药物及非药物治疗(即治疗性生活方式改善)。既往研究中常用一些慢性病量表对高血压服药依从性进行评估,针对性不强,且对生活方式的评估极少。目前国内外尚缺乏可同时评估高血压服药及非药物治疗依从性的评价量表,也没有高血压治疗相关态度与信念评价量表。由于缺乏信效度较好的测量工具,致使研究结果的可信度及结论的可比性受限,影响了研究结果的推广应用,不利于高血压的治疗和管理。本研究针对高血压依从性及认知评估测量工具的不足,按照规范的量表开发流程,首次构建高血压治疗依从性量表及高血压治疗态度和信念评价量表,并进行信效度评价;分析影响依从性行为及态度与信念的相关因素,为确定干预的重点对象、制定有针对性的个体化干预措施提供参考依据;建立量表的常模标准并初步探讨其合理的划界分,为高血压治疗依从性及认知评估提供有效的测量工具和参照标准,以进一步规范高血压管理,提高血压控制率。研究一高血压治疗依从性量表(TASHP)的系列研究第一部分TASHP量表的编制与信效度评价一、目的编制高血压治疗依从性评价量表(Therapeutic Adherence Scale for Hypertensive Patients,TASHP),并进行信效度评价。二、方法第一阶段,通过文献研究及对16例高血压患者和10名心脑血管疾病专家的访谈结果发展条目池。经过9名心脑血管疾病医护专家及2名心理学专家对条目进行两轮筛选与评定,在30例患者中进行预调查后再次调整修正,建立TASHP(预试)量表,含28个条目;第二阶段,采用TASHP(预试)量表对404例高血压患者进行横断面调查,其中105例同时填答中文版Morisky服药依从性问卷。采用项目分析、相关分析、探索性因素分析、校标关联效度、内部一致性Cronbachα系数和重测信度等进行信效度评价,共删除3个条目,保留25个条目。第三阶段,以第二阶段形成的量表结构为基础,在594例高血压患者中进行验证性因素分析,以进一步修订完善量表,形成高血压治疗依从性评价正式量表。三、结果TASHP量表最后含25个条目,由以下四个维度组成:遵医服药行为(5个条目)、不良服药行为(8个条目)、日常生活管理行为(10个条目)、烟酒嗜好管理行为(2个条目)。各条目在其公因子的负荷值为0.486~0.890。各因子与总分的相关系数为0.421~0.736(P<0.01);各因子之间的相关相关系数为0.123~0.356(P<0.01);量表总的Cronbachα系数为0.862,4个因子的Cronbachα系数为0.827~0. 894。总量表的重测信度系数为0.958,各因子重测信度系数为0.791~0.939。采用Likert 5级评分法,从“没有或极少时间”到“全部时间”,分别赋值1~5分,反向题则反向计分(5~1分),总分25~125分。评估患者最近一月的高血压治疗依从性,得分越高表示依从性越好。四、结论研制的高血压治疗依从性量表(TASHP)具有较好的信度与效度,可以作为高血压患者依从性的有效测量工具。第二部分高血压患者治疗依从性行为特点及影响因素的研究一、目的了解重庆市高血压患者治疗依从性水平及影响因素,为确定干预的重点对象、制定有针对性的个体化干预措施提供参考依据。二、方法采用分层随机抽样方法,以高血压治疗依从性量表(TASHP)及基本情况调查表为调查工具,对1120例高血压患者进行横断面调查。分析不同性别、年龄等人口社会学因素,以及高血压病程、有无高血压并发症/合并症等疾病相关因素对高血压患者治疗依从性的影响。三、结果经单因素分析,高血压患者治疗依从性行为在以下几个方面存在显著差异性:即性别(女性>男性)、年龄(年长者>年轻者)、文化程度(文化程度高者>低者)、工作状况(离退休>未就业>城镇在职者>务农者)、家庭经济收入(收入高者>低者)、服降压药时间(时间长者>短者)、医疗费用支付方式(全公费>城镇医保>全自费>新农合)、高血压并发症/合并症(有>无)、高血压伴发症状(无>有)、家庭自测血压(家庭自测血压频率高者>低者)、血压控制是否达标(达标者>未达标者)、自评降压效果(效果好者>差者)、自评健康状况(健康好者>差者)、居住城乡(城镇>农村)等14个因素。多元逐步回归分析结果显示,影响高血压患者治疗依从性因素从大到小依次为:家庭自测血压、血压控制是否达标、性别、居住地、自评降压药效果、服降压药时间、患者自评健康状况、高血压并发症/合并症、家庭人均月收入。标准化回归方程式为:高血压治疗依从性=0.140×家庭自测血压-0.160×血压控制是否达标-0.184×性别+0.062×居住地+0.068×自评降压药效果+0.090×服降压药时间+0.092×患者自评健康状况+0.070×高血压并发症/合并症+0.071×家庭人均月收入。四、结论高血压治疗依从性主要受家庭自测血压、血压控制是否达标、性别、居住地、自评降压药效果、服降压药时间、患者自评健康状况、高血压并发症/合并症、家庭人均月收入等影响,根据这些特点,可以在高血压管理中筛选重点干预的对象。第三部分TASHP量表重庆市常模的建立一、目的建立高血压治疗依从性量表的重庆市常模,并制订依从性分级标准,以期为临床合理判断患者的依从性提供参照标准。二、方法结合论文研究一第二部分的统计分析结果,高血压治疗依从性量表总分及各因子分在不同性别、年龄、文化程度、工作状况、服降压药时间、居住地等组间均存在显著差异,因此本研究分别建立高血压治疗依从性的总体常模、性别常模、年龄常模、文化程度常模、工作状况常模、服降压药时间常模、城乡常模。采用的常模形式为粗分、标准分Z分数和T分数。以高血压控制情况为依据,采用ROC曲线分析对高血压治疗依从性量表的划界分进行初步探讨。找出尤登指数最大即敏感度和特异度均较好的切点作为划界分。三、结果1.分别建立了高血压治疗依从性量表总分及各因子分的原始粗分常模、标准Z分数及T分数常模:即总体常模、性别常模、年龄常模、文化程度常模、工作状况常模、城乡常模、服药时间常模。2.以T分51分(原始分95分)为划界分,将高血压治疗依从性划分为高低两组,其敏感性为61.9%,特异性为58.7%。四、结论建立了重庆市高血压治疗依从性量表的常模,并制订了依从性分级判断标准,为临床评估高血压患者依从性提供了参照标准。研究二高血压治疗态度与信念评价量表(ATRABS)的系列研究第一部分ATRABS量表的编制与信效度评价一、目的研制高血压治疗态度与信念评价量表(Antihypertensive Therapy Related Attitudes and Beliefs Scale, ATRABS),并进行信效度评价,以期为有效识别高血压患者的错误认知,采取有针对性的、个体化的健康教育等认知疗法干预提供依据及量化评估工具。二、方法同研究一第一部分。三、结果ATRABS量表最后保留21个条目,由4个维度组成:服药治疗态度与信念(7个条目)、治疗性生活方式态度与信念(7个条目)、持续治疗困扰顾虑(3个条目)、坚持治疗态度与信念(4个条目)。各条目在其因子的负荷值为0.468~0.846。各因子之间的相关系数为0.160~0.302(P<0.01),各因子与总分的相关系数为0.513~0.802(P<0.01)。量表总的Cronbachα系数为0.804,4个因子的Cronbachα系数为0.639~0. 841总量表的重测信度系数为0.922,各因子重测信度系数为0.859~0.936。ATRABS量表采用Likert 5级评分法,从“完全同意、同意、说不准、不同意、完全不同意”,分别赋值1~5分,反向题则反向计分(5~1分),总分21~105分,得分越高表示患者对治疗越持有正性的态度与信念。四、结论研制的高血压治疗态度与信念量表(ATRABS)经信效度检验及验证性因素分析,表明具有较好的信度和效度,可以作为高血压患者认知评估及干预的测量工具。第二部分高血压患者治疗态度与信念的特点及影响因素的研究一、目的了解重庆市高血压患者对降压治疗所持态度与信念,并分析其影响因素,为开展健康教育、制定有针对性的个体化干预措施提供依据。二、方法同研究一第二部分。三、结果经单因素分析,高血压患者治疗态度与信念在以下几个方面存在差异性,即年龄(年长者>年轻者)、婚姻(已婚>未婚及其他>丧偶)、文化程度(文化程度高者>低者)、工作状况(城镇在职>离退休人员>未就业>务农者)、家庭经济收入(经济收入高者>低者)、医疗费用支付方式(全公费>城镇医保>全自费>新农合)、血压控制是否达标(达标者>未达标者)、有无并发症/合并症者(有>无)、家庭自测血压频率(家庭自测血压频率高者>低者)、服降压药时间(时间长者>短者)、有无高血压相关症状(无>有)、自评降压药效果(效果好者>差者)、自评健康状况(健康好者>差者)、居住城乡(城镇>农村)等。多元逐步回归分析显示,影响高血压患者治疗态度与信念的因素从大到小依次为:家庭自测血压、居住地、自评健康状况、自评降压效果、家庭人均月收入、血压控制是否达标、服降压药时间。标准化回归方程式为:高血压治疗态度与信念=0.180×家庭自测血压+0.097×居住地+0.115×自评健康状况+0.080×自评降压药效果+0.101×家庭人均月收入-0.085×血压控制是否达标+0.080×服降压药时间。四、结论高血压患者治疗态度与信念主要受家庭自测血压、居住地、自评健康状况、自评降压效果、家庭人均月收入、血压控制是否达标、服降压药时间等影响。在针对不同特征高血压人群制定个体化认知干预措施时,应将居住农村、经济收入低、服降压药时间短、自评降压药效果差及健康差、不/偶尔进行家庭自测血压的患者作为干预的重点对象。第三部分ATRABS量表重庆市常模的建立一、目的建立高血压治疗态度与信念量表的重庆市常模,并制订分级标准,为临床合理判断患者对降压治疗的态度与信念提供参照标准。二、方法结合研究二第二部分的统计分析结果,高血压治疗依从性量表总分及各因子分在不同年龄、文化程度、工作状况、服降压药时间、居住地的高血压患者治疗态度与信念均存在显著差异,故分别建立了高血压治疗态度与信念的总体常模、年龄常模、文化程度常模、工作状况常模、服降压药时间常模、城乡常模。采用的常模形式为粗分、标准分Z分数和T分数。划界分的选取方法同第三部分。三、结果1.分别建立了高血压治疗态度与信念的总分及各因子分的原始粗分常模、标准Z分数及T分数常模:即总体常模、年龄常模、文化程度常模、工作状况常模、服降压药时间常模、城乡常模。2.以T分49分(原始分70分)为划界分,将高血压治疗态度与信念划分为高低两组,其敏感性为66.1%,特异性为49.2%。四、结论建立了重庆市高血压治疗态度与信念量表的常模,并制订了分级判断标准,为临床评估高血压患者的态度与信念提供了参照标准,更多还原

【Abstract】 In China, there are 200 million hypertensive patients, with the trend of increasing 10 million patients per year. Hypertension is the main risk factor in cardio-cerebrovascular disease, which has been the leading death cause in China. As more than half of the occurrence and death of patients with cardio-cerebrovascular disease are related with hypertension, controlling hypertension is the key point to prevent and treat the cardio-cerebrovascular disease. Hypertension has characteristics of high incidence rate and low control rate, which has become a worldwide problem. The poor therapeutic adherence to antihypertensive treatment is the main factor leading to the low blood pressure (BP) control rate which is affected by the attitude and beliefs in controlling hypertension. To efficiently evaluate patients’antihypertensive treatment related attitude and beliefs helps to perform the specific individual intervention and increase their therapeutic adherence.Antihypertensive treatment is consisted of medication treatment and non-medication treatment. In the previous study, the universal scales were used to evaluate the therapeutic adherence for hypertensive patients, which were not specific and almost not involving of the evaluation of lifestyle modification. At present, there is no generally-accepted therapeutic adherence scale for hypertensive patients at home and abroad, and no suitable scale for evaluation of attitude and briefs related to antihypertensive treatment. Because of being lack of good measurement tool, the reliability coefficient of research result and comparability of conclusion is limited, which affects the application of the research result and the treatment and management of hypertension.In our research, aiming at the drawback in the measurement tools in measuring therapeutic adherence and antihypertensive cognition, we initially established a therapeutic adherence scale and an antihypertensive therapy related attitudes and beliefs scale for hypertensive patients. We also analyzed the related factors affecting the adherence and attitude and beliefs, so as to determine the specific tailored intervention. In addition, we established the norm of the scales and primarily discussed its rational cutoff score, which provided effective measurement tools and reference criteria for evaluating hypertensive patients so as to further specify the management of hypertension and improve the BP control rate.Part 1 A series study on the therapeutic adherence scale for hypertensive patients1 Development of a new therapeutic adherence scale for hypertensive patients (TASHP) and evaluation of its reliability and validityObjectiveTo construct a new therapeutic adherence scale for hypertensive patients and evaluate its reliability and validity.MethodsFirst stage: the original item pool was formulated through literature review and in-depth interview. Following the two-turn selection and evaluation by 9 cardio-cerebrovascular professors and 2 psychological experts, then being modified after investigating 30 patients, we developed therapeutic adherence pre-scale for hypertensive patients (TASHP) (including 28 items). Second stage: we used TASHP pre-scale to perform cross-sectional study in 404 hypertensive patients, 105 of whom were finished the Morisky Medication Adherence Scale (MMAS). Meanwhile, item analysis, correlation analysis, exploratory factor analysis, criterion-related validity, internal consistency Cronbachαcoefficient and test-retest reliability were used to evaluate the reliability and validity of the scale, resulting in deleting 3 items and preserving 25 items. Third stage: based on the scale structure formed during the second stage, confirmatory factor analysis were performed in 594 hypertensive patients, so as to further revise and consummate the scale, and form the standard therapeutic adherence scale.ResultsTASHP included 25 items, which was consisted of the following dimensions: behavior of medication adherence (5 items), behavior of medication non-adherence (8 items), behavior of daily life management (10 items), behavior of smoking and drinking management (2 items). The loading value of each item in the common factor was 0.486~0.890. The coefficient correlation between each factor and total score was 0.421~0.736 ( P < 0.01 ) ; the coefficient correlation between each dimension was 0.123~0.356(P<0.01); the total Cronbachαcoefficient of the scale was 0.862 and the Cronbachαcoefficient of each dimension was 0.827~0.894. The test-retest reliability coefficient of the total scale was 0.958 and the test-retest reliability coefficient of each dimension was 0.791~0.939.Likert 5–grade scoring was applied, 1~5 scores were given from the“no time or few time”to“full time”, inverse question was scored reversely, and the total score was 25~125. Patients’adherence to antihypertensive therapy during the recent month was evaluated, with higher score indicating better adherence.ConclusionThe TASHP scale showed good reliability and validity, which can be used as an efficient adherence measurement tool for hypertensive patients.2 Behaviors characteristics of therapeutic adherence in hypertensive patients and its influencing factorsObjectiveTo investigate the therapeutic adherence level in hypertensive patients and its influencing factors, so as to provide reference for determining focal objects of intervention and instituting specific individual intervention measures in Chongqing. Methods Totally 1120 hypertensive patients were performed cross-sectional study with the way of stratified random sampling, and investigated with TASHP scale and basic status questionnaire. Sociodemographic factors such as gender, age, etc. and disease related factors including hypertension course, hypertension-related complications were analyzed for investigating its effect on the therapeutic adherence in hypertensive patients.ResultsBy single factor analysis, significant difference in the therapeutic adherence of hypertensive patients was observed in the following aspects, including 14 factors: gender(female >male), age(elder>younger), education level(higher educated people> lower educated people), work status(retired people> unemployed people>urban worker>farmers), family income (higher-income people > lower-income people), course of administration antihypertensive medications(longer course > shorter course) , payment of medical cost(public expenses > urban medical insurance > private expense > new-style rural cooperative medical insurance), hypertension-related complications(people with hypertension-related complications> people without hypertension-related complications ), concomitant symptom of hypertension( people without complications > people with complications), home blood pressure monitoring (higher-frequent HBPM people > lower-frequent HBPM people), BP controlling status (normal BP people > abnormal BP people), self-evaluated effect of antihypertensive treatment (better effect > poor effect), self-evaluated health status (healthy > unhealthy)and residential status (urban people > countryside people ).The standard regression equation was as follows: therapeutic adherence to hypertension=0.140×(HBPM) -0.160×(BP controlling status) -0.184×(gender)+0.062×(residential status) +0.068×(self-evaluated the effect antihypertensive treatment) +0.090×(course of administration antihypertensive medications) +0.092×(self-evaluated health status) +0.070×(hypertension-related complications) +0.071×(family income).ConclusionThe therapeutic adherence in hypertensive patients was mainly affected by HBPM, BP controlling status, gender, residential status, self-evaluated effect of antihypertensive treatment , course of administration antihypertensive medications, self-evaluated health status , hypertension complications, concomitant symptom of hypertension, and family income, etc. With this result, emphasized intervention objects can be selected for the management of hypertension3 Establishment of the norm of the TASHP scale in ChongqingObjectiveTo establish the norm of the TASHP scale in Chongqing and make a grade range so as to provide useful information for evaluation the level of adherence in hypertensive patients. MethodsThe statistical analysis results showed that there was significant difference in the total score of therapeutic adherence scale and score of each dimension in the aspects of gender, age, education level, work status, course of administration antihypertensive medications, residential status. Therefore, in our research, integrated norm, gender norm, age norm, education norm, work status norm, course of administration antihypertensive medications norm, residential status norm were established. The norm was showed in conversion table with raw score, standard Z score, and T score.Based on the relationship with BP control, we primarily discussed the cutpoint score of the TASHP scale by ROC (receiver operator characteristic curve) analysis method. The maximal Youden’s index was used to choose cutoff score, which had better sensitivity and specificity.ResultsThe raw score norm, standard Z score norm, and T score norm were respectively established in the total score of the TASHP scale and score of each dimension. The norms were involving of integrated norm, gender norm, age norm, education norm, work status norm, course of administration antihypertensive medications norm, residential status norm.The T 51 score point in norm was chosen as cutoff score, and the antihypertension therapeutic adherence was divided into high score group and low score group, with the sensitivity and specificity of 61.9% and 58.7%, respectively.ConclusionThe norm of TASHP scale has been established in Chongqing, and the level of adherence grading standard was made, so that the TASHP scale can provide useful information for evaluation patients’adherence in clinical settings.Part 2 A series study on the antihypertensive therapy related attitudes and beliefs scale1 Development of antihypertensive therapy related attitudes and beliefs scale and evaluation of its reliability and validityObjectiveTo develop an antihypertensive therapy related attitudes and beliefs scale (ATRABS) and evaluate its reliability and validity, so as to identify the incorrect cognition about antihypertensive therapy and provide reference for tailored behavioral/educational intervention for BP control.MethodsThe same as the Part 1.1ResultsATRABS was consisted of 21 items and 4 dimensions: attitude and beliefs of antihypertensive pharmacotherapy (7 items), attitude and beliefs of modification lifestyle (7 items), anxiety of persistent antihypertensive treatment (3 items), attitude and beliefs of persistent antihypertensive treatment (4 items). The loading value of each item in each factor was 0.468~0.846. The coefficient correlation of each dimension was 0.160~0.302 (P< 0.01), the coefficient correlation between each dimension and total score was 0.513~0.802 (P<0.01). The total Cronbachαcoefficient of the scale was 0.804, the total Cronbachαcoefficient of 4 dimensions was 0.639~0. 841. The test-retest reliability coefficient of the total scale was 0.922 and each dimension was 0.859~0.936.Likert 5-grade score method was applied in ATRABS, with 5 grades of“completely agree”,“agree”,“unsure”,“not agree”and“completely disagree”, respectively, which was given 1~5 scores respectively. The reversed question was scored reversely (5~1 scores), with total score of being 21~105. And higher score indicated more positive attitude and beliefs in antihypertensive treatment.ConclusionThe new-formed ATRABS scale was tested with reliability and validity and analyzed with confirmatory factor, indicating adequate reliability and validity, which could be used as measurement tool of evaluation and intervention of hypertensive patients.2 Characteristics of antihypertensive therapy related attitudes and beliefs and its influencing factorsObjectiveTo investigate the attitude and beliefs about antihypertensive treatment in hypertensive patients and analyze the influencing factors, so as to provide reference for carrying out health education and make specific intervention.MethodsThe same as the Part 1.2ResultsBy single factor analysis, significant difference in the therapeutic adherence of hypertensive patients was observed in the following aspects, including 14 factors: age(elder>younger), marriage status (married > unmarried >widowed), education level(higher educated people> lower educated people), work status(urban worker >retired people > unemployed people>farmers), family income (higher-income people > lower-income people), payment of medical cost(public expenses > urban medical insurance > private expense > new-style rural cooperative medical insurance ), BP controlling status ( normal BP people > abnormal BP people ), concomitant symptom of hypertension( people without complications > people with complications), home blood pressure monitoring (higher-frequent HBPM people > lower-frequent HBPM people), course of administration antihypertensive medications(longer course > shorter course) , hypertension-related complications(people with hypertension-related complications > people without hypertension-related complications ), self-evaluated effect of antihypertensive treatment (better effect > poor effect), self-evaluated health status (healthy > unhealthy )and residential status( urban people > countryside people ).Multiple stepwise regression analysis showed the factors influencing antihypertensive therapy related attitudes and beliefs from high to low , which was HBPM, residential status, self-evaluated health status, self-evaluated effect of antihypertensive treatment, family income, BP control status, course of administration antihypertensive medications. The standard regression equation was as follows: antihypertensive therapy related attitude and beliefs=0.180×(HBPM) +0.097×(residential status) +0.115×(self-evaluated health status)+0.080×(self-evaluated effect of antihypertensive treatment) +0.101×(family income) -0.085×(BP control status), +0.080×(course of administration antihypertensive medications).ConclusionThe antihypertensive therapy related attitudes and beliefs were mainly affected by factors of HBPM, residential status, self-evaluated health status, self-evaluated effect of antihypertensive treatment, family income, BP control status, course of administration antihypertensive medications. While formulating individual intervention measures for hypertensive patients involving countryside residents, poor income family, short course of administration antihypertensive medications, poor self-evaluated health status, poor self-evaluated effect of antihypertensive treatment, seldom-used HBPM should paid more attention for intervention.3 Establishment of the norm of ATRABS scale for hypertensive patients in ChongqingObjectiveTo establish the norm of ATRABS scale for hypertensive patients in Chongqing and make a grade range, so as to provide reference standard for estimating patients’attitude and beliefs in antihypertensive treatment.MethodsThe statistical analysis results showed that there was remarkable difference in the total score of ATRABS scale and score of each dimension in the aspects of age, education level, work status, course of administration antihypertensive medications, residential status. Therefore, in this research, integrated norm, age norm, education norm, work status norm, course of administration antihypertensive medications norm, residential status norm were established. The norm was showed in conversion table with raw score, standard Z score, and T score.The cutoff score was selected with the same method in the part.1.3ResultsThe original score norm, standard Z score, and T score norm were respectively established in the total score of ATRABS scale and score of each dimension. The norms were involving of integrated norm, age norm, education norm, work status norm, course of administration antihypertensive medications norm, residential status norm.The T 49 score point in norm was chosen as the cutoff score, and the antihypertensive therapy related attitudes and beliefs was divided into high score group and low score group, with the sensitivity and specificity of 66.1% and 49.2 %, respectively.ConclusionThe norm of ATRABS scale has been established in Chongqing and grading criteria has been made, providing reference for evaluating hypertensive patients’attitude and beliefs in clinical settings.更多还原