心理社會因素與臨床特徵對於心衰竭病人呼吸困難之影響

Abstract

前言：呼吸困難是心衰竭病人最為困擾的症狀之ㄧ，雖然心理社會因素也是導致呼吸困難的原因，然而多數的研究重點仍以臨床疾病特徵為主。為有效處理呼吸困難，應完整了解對於此一症狀所有的影響因子。 目的：了解生理社會因素對於臨床疾病特徵對呼吸困難效應之調節作用。由於文化差異對個體心理社會因素有重要影響，且缺乏相關研究，本研究另一目的為比較台灣與美國兩群體心衰竭病人心理社會因素效應對呼吸困難影響之差異。 方法：本研究共邀請193名心衰竭個案參與，含97名台灣人（平均年齡為66.2±12.1歲；76% 男性病人；28% 為NYHA功能性分級第III/IV級）與96名美國人（平均年齡為61.6 ± 11.7歲；74%男性病人；42%為NYHA功能性分級第III/IV級）。研究中以獨立t檢定或卡方檢定比較兩組個案基本資料、呼吸困難與心理社會因素（含焦慮、憂鬱、自覺控制感與自覺社會支持），以複回歸交互作用檢定心理社會因素的調節作用，最後再以LISREL檢定兩群體交互作用之差異。本研究以肺功能暨呼吸困難修正版量表(Modified Pulmonary Function Status and Dyspnea Questionnaire)測量心衰竭病人之呼吸困難，以簡要症狀量表(Brief Symptom Inventory)測量憂鬱及焦慮，以控制態度修正版(Revised Control Attitudes Scale)測量自覺控制感，以社會支持量表修正版(Perceived Social Support Scale- Revised)測量病人之自覺社會支持。 結果：雖然台灣與美國兩群體心衰竭病人的基本資料與鄰床疾病特徵有顯著差異，然其呼吸困難(11.36±13.76 / 12.17±13.57, p > .05)、憂鬱(0.57±0.70 / 0.58±0.75, p> .05)與焦慮狀況(0.48±0.60 / 0.59±0.68, p> .05)並無顯著差異，美國群體心衰竭病人比台灣群體有較佳自我控制感與自覺社會支持，但此二者在兩群體中分別為重要的預測因子，可以有效預測病人呼吸困難症狀。自覺社會支持為美國與台灣心衰竭病人之重要調節因子，兩群體的調節效應比較後無顯著差異(∆χ2=2.36/df=1, p>.05)。 結論：自覺控制感與社會支持對於心衰竭病人呼吸困難症狀有重要影響力，對此二者的關注將有助於改善心衰竭病人的呼吸困難。

Introduction: One of the most common and distressing symptoms of heart failure (HF) is dyspnea. Although psychosocial factors likely contribute to dyspnea, only clinical characteristics have been studied in HF. It is necessary to identify all factors influencing dyspnea so that effective symptom management interventions can be developed. Specific Aims: To determine whether psychosocial factors moderate the relationship between clinical characteristics and dyspnea. Because cultural diversity is increasingly prominent world-wide and not well explored, an additional aim of this study was to compare Taiwanese and American HF patients. Method: Two groups of HF patients were enrolled: 97 Taiwanese (mean age 66.2±12.1 yrs; 76% male; 28% NYHA III/IV) and 96 American (mean age 61.6 ± 11.7 yrs; 74% male; 42% NYHA III/IV). Dyspnea and psychosocial variables (i.e., depression, anxiety, perceived control, and perceived social support) were compared between the two groups. Dyspnea was measured using the Modified Pulmonary Function Status and Dyspnea Questionnaire, depression and anxiety using the Brief Symptom Inventory, perceived control using the revised Control Attitudes Scale, and perceived social support using the Perceived Social Support Scale- Revised. Multiple regression with interaction effect analysis and multi-sample LISREL analysis were used to test for a moderator effect and its difference across groups. Result: Dyspnea severity (11.36±13.76 Taiwanese, 12.17±13.57 American, p> .05), depression (0.57±0.70 Taiwanese, 0.58±0.75 American, p> .05), and anxiety (0.48±0.60 Taiwanese, 0.59±0.68 American, p> .05) in both groups were similar. Perceived control (47.59±6.86 Taiwanese, 54.01±6.57 American, p< .05) and perceived social support (44.16±7.72 Taiwanese, 68.32±14.69 American, p< .05) were rated better in Americans compared to Taiwanese HF patients. Perceived control and perceived social support were powerful predictors of dyspnea in both Taiwanese and American patients. Perceived social support moderated the relationship between clinical variables and dyspnea in both groups. The moderator effect between groups are invariant (∆χ2=2.36/df=1, p>.05). Conclusion: Perceived control and social support play substantial roles in the dyspnea symptom experience in patients with HF. Attention to perceived control and social support may improve HF patients’ symptom status.