【作者】 张彩虹；

【导师】 何国平；

【作者基本信息】 中南大学 ， 护理学， 2009， 博士

【摘要】 目的1.编制一套适用于我国慢性阻塞性肺疾病(COPD)患者的自我管理量表,对该量表进行条目分析和信、效度检验。2.探讨影响COPD患者自我管理的主要因素。方法1.以Bandura的社会认知理论、自我效能理论及自我决定理论作为编制量表的基本理论框架,以对症状管理、日常生活管理、情绪管理、信息管理和自我效能所下操作定义为基础,广泛查阅文献,参考国外已经开发的慢性病自我管理行为及自我效能测评量表,通过专家咨询及访谈,形成初始问卷。采用探索性因子分析发展COPD患者自我管理量表的初步理论结构,再用验证性因子分析证明理论结构的合理性和正确性。选用重测信度、内部一致性信度、分半信度、概化系数检验量表的信度;效度检验主要包括内容效度、结构效度和效标效度。2.以多阶段分层整群抽样的方式抽取湖南省3个地区9家医院的COPD患者作为调查对象。使用抑郁自评量表、社会支持量表、COPD患者生活质量调查表及自编的COPD患者自我管理量表对其进行调查。采用多分类Logistic回归分析、Pearson相关分析、路径分析对数据进行统计分析。结果1.通过项目分析和初步的因子分析,确定COPD患者自我管理量表由5个维度51个条目组成。2.信度检验:(1)重测信度:各分量表重测信度系数分别在0.72～0.87之间,总量表的信度系数为0.87;(2)分半信度:各分量表分半信度(经Spearman-Brown公式校正)系数在0.80～0.86之间,总量表为0.92;(3)Cronbach’sα系数:各分量表α系数在0.82～0.87之间,总量表为0.92;(4)分量表的一致性:各条目与分量表间的相关系数在0.45～0.85之间,各分量表间相关系数为0.36～0.64,各分量表与总量表的相关系数为0.81～0.92;(5)概化研究:结果显示各分量表概化系数Ep~2为0.8174～0.9196,可靠性指数Φ为0.8005～0.9027,由样本平均数估计总体平均数的误差变异分量,即σ~2(Xpi)为0.0086～0.0597;全量表概化系数Ep~2为0.9196,可靠性指数Φ为0.9027,由样本平均数估计总体平均数的误差变异分量,即σ~2(Xpi)为0.0047。3.效度检验:(1)内容效度:量表经该领域9位专家对条目内容进行评估,计算内容效度指数为0.90。(2)结构效度:采用探索性因子分析抽取5个一阶因子,其方差累积贡献率为46.20%;再抽取一个二阶因子,解释方差62.88%;验证性因子分析结果表明一阶五因子模型、二阶一因子模型的x~2/df值均＜5,RMSEA≤0.08,GFI、AGFI、TLI、CFI均＞0.9,IFI、IFI、NFI等值均＞0.85,各项拟合指标均显示拟合良好。(3)效标效度:COPD患者自我管理量表与慢性病自我管理行为量表总分相关系数为0.61,与慢性病自我效能量表总分相关系数为0.66,与FEVl占预计值%的相关系数为-0.55,均具有统计学意义(P＜0.01)。COPD门诊、住院患者自我管理得分差异比较结果显示,COPD门诊患者除因子4(信息管理)的得分与住院患者因子4的得分比较差异无统计学意义(P＞0.05),其他各因子得分及总分与住院患者得分相比,差异均具有统计学意义(P＜0.05)。在不同等级医院就诊的COPD患者自我管理量表各因子得分及总分差异均具有统计学意义(P＜0.05),其中在三级医院就诊的COPD患者的得分高于在二级医院就诊患者的得分,在二级医院就诊患者的得分高于在一级医院就诊患者的得分。4.多分类Logistic回归分析结果显示,与低自我管理水平有关的影响因素为小学、初中文化水平、家庭人均月收入少于500元、医疗费用全部自费、病程少于5年,其OR值分别为3.362、2.546、3.621、5.974、4.437;与中等自我管理水平有关的影响因素为高中或中专学历、家庭人均月收入在501～1500元、医疗费用部分报销、病程在16年以上,其OR值分别为1.272、2.728、2.917、1.569、1.999;对两者皆有影响的因素为男性,其OR值分别为1.795和1.819。5.Pearson相关分析结果显示,COPD患者自我管理得分与生活质量得分、社会支持得分、抑郁得分有相关性,相关系数分别为0.49、0.67、0.69。6.路径分析结果显示,生活质量对自我管理有直接影响;抑郁对自我管理的影响通过两重路径进行,一是通过与生活质量的协同作用以间接方式进行,二是对COPD患者的自我管理直接造成影响;社会支持通过三重路径对COPD患者的自我管理产生影响,一是通过生活质量对自我管理有间接影响,二是通过抑郁对自我管理有间接影响,三是对自我管理直接造成影响。结论1.编制的COPD患者自我管理量表有较理想的信度和效度。量表的稳定性、可靠性较高,效度检验结果均较为合理,各项指标均达到了测量学的要求。2.影响COPD患者自我管理的社会人口学因素有性别、文化程度、家庭收入、付费方式、病程。生活质量、社会支持、抑郁与COPD患者自我管理呈线性相关,并分别对其产生直接或间接影响。更多还原

【Abstract】 Objective1 .To develop self-management scale (SMS) for Chinese patients with chronic obstructive pulmonary disease (COPD) and analyze the psychometric properties of this scale.2. To discuss the influential factors of self-management for patients with COPD.Methods1. The SMS was developed based on the Social-Cognitive Theory, Self-Efficacy Theory, Self-Determination Theory and the definitions of symptom management, daily life management, emotion management, information management and self-efficacy. Related literature had been extensively reviewed, related instruments developed domestic and abroad already had been consulted, and suggestions from experts had been considered before the initial questionnaire formed. Exploratory factor analysis (EFA) was used to develop the intra-structure of the scale and confirmatory factor analysis (CFA) was used to evaluate that. The reliability analysis included the test-retest reliability, Cronbach’sαcoefficient, split-half reliability, and the generalizability analysis. The validity analysis included content validity, construct validity and criterion-related validity.2. The multistage stratified cluster sampling method was used to obtain the sample in Hunan Province, and the participants of 9 hospitals in 3 cities were recruited to participate in this investigation. Self-rating depression scale(SDS), social support rating scale(SSRS), quality of life scale(QOLS) for patients with COPD and self-management scale(SMS) for patients with COPD were used together to collect the data, and multinomial logistic regression analysis, correlation analysis, path analysis were employed.Results1. Item reduction and scale construction were carried out using principal component and the final scale comprised 5 dimensions grouping 51 items.2.The results of reliability were as follows: (1) the range of test-retest reliability coefficient were 0.72 to 0.87, the test-retest reliability coefficient of the total score was 0.87; (2)The range of split-half reliability coefficient (corrected by Spearman-Brown Formula) were 0.80 to 0.86, the split-half reliability coefficient of total score was 0.92; (3) Cronbach’sαcoefficient, which is an index of internal consistency reliability, ranged from 0.82 to 0.87, the Cronbach’s a coefficient of total score was 0.92; (4) The correlation coefficient between each item and sub-scale ranged from 0.45 to 0.85, the correlation coefficient between subscales ranged from 0.36 to 0.64 and the correlation coefficient between subscale and total scale ranged from 0.81 to 0.92; (5) The generalizability analysis showed that the generalizability coefficient Ep~2, reliability indexΦ, error varianceσ~2 (Xpi) were ranged from 0.8174 to 0.9196, 0.8005 to 0.9027, 0.0086 to 0.0597 respectively for subscale, and was 0.9196, 0.9027 and 0.0047 for total scale.3. The results of validity were as follows: (1) the content validity index was 0.90; (2) First-order five factors were extracted using EFA, which accounted for 46.20% of the accumulated variance; second-order 1 factor extracted which accounted for 62.88%. CFA were conducted to assess the measurement of factor structure of the scale, the results showed that the first-order 5 factors model and second-order 1 factor model were fitted well. The two model’s index ofχ~2 /df were lower than 5, the index of RMSEA were lower than 0.08, the index of GFI, AGFI, TLI, CFI were upper than 0.9, the index of IFI, IFI, NFI were upper than 0.85; (3) Criterion-related validity study indicated that the correlation between the total scores of SMS and the full scores of chronic disease self-management behavior scale were 0.61. The correlation between the total scores of SMS and the full scores of chronic disease self-efficacy scale were 0.66.The correlation between the total score of SMS and FEV1 percent of predicted normal were -0.55(P<0.01).There was statistical significance between the score of SMS for outpatients and inpatients with COPD, except the score of factor 4 (information management). There was statistical significance among the score of SMS for patients with COPD in different ranked hospitals (P<0.01). The score of SMS for patients with COPD was higher in top-ranked hospitals than in other one.4. The results of multinomial logistic regression analysis showed that the influential factors of participants with lower self-management levels were educational level of primary school and junior high school, family income lower than 500 RMB per month, uninsured group, duration lower than 5 years and their OR were 3.362, 2.546, 3.621, 5.974 and 4.437 respectively. The influential factors of participants with middle self-management levels were educational level of diploma, family income between 501-1500 RMB per month, medical insurance group, duration upper than 16 years and their OR were 1.272, 2.728, 1.569, 2.917 and 1.999 respectively. The influential factors of participants with lower and middle self-management levels were the gender of male, their OR were 1.795, 1.819 respectively.5. The results of Pearson correlation analysis showed that there were correlations among the score of self-management(SM), quality of life(QOL), social support(SS) and depression. Their coefficient correlation were 0.49, 0.67, 0.69 respectively.6. The results of path analysis showed that QOL had direct effect on SM. Depression affected SM directly and collaborated with QOL indirectly. SS had direct effect on SM and had indirect effect on SM through QOL and depression.Conclusion1. Psychometric properties analyses showed that the SMS for patients with COPD achieved good to excellent levels of internal consistency, test-retest reliability, and content validity, construct validity, criterion-related validity.2. The SM of patients with COPD are influenced by gender, education levels, family income, payment manner of medical care and duration. There are liner correlation among QOL, SS, depression and SM for patients with COPD. The QOL has direct on SM for patients with COPD. SS and depression has direct and indirect effect on SM for patients with COPD respectively.更多还原