教育介入對台灣婦女乳房自我檢查成效探討：三角交叉檢視

Abstract

研究背景：乳癌威脅台灣婦女的健康。雖然政府從2004年起，針對50-69歲婦女提供每兩年一次的免費乳房攝影，但仍舊鼓勵成年婦女每個月做乳房自我檢查。迄今，乳房自我檢查的功效尚未明確，其可能原因與自我檢查技巧的教導方式或評值的重點有關；甚至，對於婦女參加乳房自我檢查訓練的決策動機，至今仍然缺乏瞭解。 研究目的：本研究主要目的有三；第一，驗證ㄧ以社區為基礎的創新性教育介入方案，對於提昇婦女乳房自我檢查的頻率、精確度及乳房腫塊偵測能力的效果。第二，探索健康信念模式 (health belief model) 作為理論架構，對於台灣婦女乳房自我檢查行為的解釋效用。第三，描述婦女對於參與乳房自我檢查訓練的決策動機與類型。 研究方法：採隨機分派介入性研究設計，以三角交叉檢視方式，連結量性與質性兩種研究方法。資料來自問卷調查、直接觀察、深度訪談及日誌等，收集時機包括起點的前測及介入後第四個月的後測追蹤資料。介入方案的內容包括三部份，如乳癌及乳房自我檢查的相關知識、檢查技巧的訓練及提醒與增強等內容措施。參加婦女共計203位，年齡介於27-50歲；其中有66位參與者接受個別或焦點團體的訪談，共完成31篇逐字稿。 研究發現：本研究發現大部分婦女在訓練前並無規律性乳房自我檢查，其檢查技術的正確性也低。接受訓練後根據統計，顯示介入對於乳房自我檢查的能力及態度均有顯著作用。但，健康信念模式對於介入後四個月，婦女檢查能力改變的解釋力有限，其中只有自我效能 (self-efficacy) 對於檢查精確度 (proficiency) 具有真正解釋力；然而，自我效能與其他如檢查頻率、敏感度或陽性預測值 (positive predictive value) 間的關聯，經證實均屬假關係。另外，從質性資料分析顯示，婦女參加乳房自我檢查訓練是一有目的的行動，而獲得自我安全感的滿足是主要的學習動機；從婦女訪談中所建構出的動機階梯模型，可以描寫台灣婦女學習乳房自我檢查的動機類型，而這些婦女的決策動機亦符合Maslow提出的人類基本需要階級說。 研究貢獻：本研究證實此教育介入對台灣婦女是ㄧ具有可行性的訓練方案；本研究在適量樣本的婦女中，顯示婦女訓練後能學習到具有精確度、敏感度及正確度的乳房自我檢查技巧，且能有適量的執行頻率。另外，本研究的發現對乳房自我檢查知識的建構有貢獻，其中所提供的研究發現不侷限於認知行為的線性資料，同時採取較深入的方式來探討乳房自我檢查的行為，從中也發掘並彰顯出社會環境對於婦女行為的重要影響。基於，健康專業人員必須對於婦女自我照顧需要的過程有較多的理解，才有可能提供婦女真正有意義的服務，因此，本研究的這些發現將有助於健康專業人員，應用於協助婦女在乳房自我保健上的努力，使其獲得最大的功效。

BACKGROUND: Breast cancer is a major threat to the health among Taiwanese women. The Taiwanese Government has provided free mammography biannually to women between the ages of 50 and 69 years since 2004. Women are also encouraged to do BSE every month. However, its effectiveness has not been unequivocally established. The possible reasons for this concern include the varied methods used to teach BSE techniques as well as differing evaluations of the methods. Furthermore, there is little understanding how do women decided whether attending BSE training? PURPOSE: The aims of this study were three fold: First, to examine the effects of an innovative community-wide BSE instructional program (also known MCp) on increased BSE attitudes and competency (such as practice and accuracy); Second, to explore the utility of Health Belief Model as a theoretical framework for explaining the BSE behaviors of Taiwanese women; and, Third, to explore and to illustrate the patterns of how women made the decisions of learning BSE. METHODS: A randomized prospective study, combining of quantitative and qualitative data collected by direct observation and interaction with the participants. Measurement conducted at baseline and at 4-month follow-ups. The instruction will consist of a three-part BSE intervention program, including provided information about breast cancer and BSE, enhanced BSE competence and provided reminders. Participants were 203 women aged 50 or less from community setting to complete the measurement. We performed thematic analysis of 31 interviews that were previously conducted in similar participants. FINDINGS: Whereas most of the participants did not practice BSE regularly and accurately in the pre-training period, the statistical results of this study strongly support the hypothesis that the intervention would positively and significantly affect BSE competency and health beliefs. Furthermore, the present study revealed that a limited utility of HBM as a theoretical framework for explaining the BSE competency of Taiwanese women at 4-months after treatment, but the self-efficacy was a significantly positive predictor to BSE proficiency. Contradictory, there was a spurious relationship between the self-efficacy on frequency, sensitivity and positive predictive value. Our findings indicated that women participated BSE training was a purposive action, which the safety needs provided the principal motivation. Furthermore, a ladder motivation model was constructed to explain these participants’ motivation for entering the BSE training. The participants’ decision motivation supported the Abraham Maslow’s hierarchy of needs. CONTRIBUTION: This study demonstrated the feasibility of a program for teaching proficient BSE to Taiwanese women. It revealed that a sizeable sample of these women could learn to perform BSE to high quantitative standards of sensitivity, proficiency and having continued to practice it at acceptable frequencies. Moreover, this study contributes to current knowledge about BSE in several ways. It provides an alternative perspective to the linear cognitive-behavioral approaches to in depth explore BSE practice, highlighting the importance of the social environment and shared understanding among women. It is important for health professionals to assist women in their breast self-care efforts. With more understanding of processes that underpin their self-care needs, primary care professionals are better placed to provide meaningful services to this population of women.