中風相關職能治療知識適性教學與測驗系統之發展

Abstract

背景：職能治療知識 (occupational therapy knowledge, OTK)為對病人與家屬重要的職能治療 (occupational therapy, OT)相關知識。OTK不足可能導致病人與家屬不易與OT人員達成治療共識，不利病人於OT之參與度與治療成效。然而目前尚無適用於中風病人與家屬之完整OTK架構與衛教主題作為教材發展之依據，亦無相對應之OTK教材與OTK測驗，OT人員難以全面瞭解中風病人與家屬之OTK程度，亦難依其程度提供OTK適性衛教以提升其OTK程度。 目的：本研究目的有三：一、針對中風病人與家屬建立完整的OTK架構與OTK衛教主題。二、依據OTK衛教主題發展OTK教材與測驗。三、驗證OTK適性衛教之成效。 方法：本研究包含3個子研究。子研究一、建立OTK架構與衛教主題：以德菲法 (Delphi method)收集OT專家意見以發展OTK架構與衛教主題。子研究二、發展OTK教材與測驗：OTK教材部分：作者依據子研究一發展的OTK衛教主題撰寫OTK教材，而後請OT專家確認教材之完整性、重要性與是否符合現況，再請中風病人與家屬確認教材貼近其日常生活情境。最後由中風病人、家屬、國一學生、文本可讀性指標自動化分析系統分析教材可讀性 (readability)。OTK測驗部分：作者撰寫與OTK教材相對應之測驗後，請OT專家確認OTK測驗與教材之關聯程度（內容效度），再由國一學生閱讀OTK教材並接受測驗（可讀性）。子研究三、驗證OTK適性衛教成效：以單盲隨機控制試驗 (single blinded randomized controlled trial)比較二組中風病人與家屬分別於1週內接受約3次OTK適性衛教或中風知識衛教（對照組）之成效。於衛教前後，參與者皆接受OTK測驗。中風病人與參與者所照顧的中風病人於衛教後1週接受OT參與度後測，衛教後8週接受日常生活活動 (activity of daily living, ADL)後測。衛教成效以共變數分析 (analysis of covariance)控制前測分數進行分析。主要成效指標為OTK測驗分數與OT參與度。次要成效指標為ADL表現。 結果：子研究一：共8位專長與中風後復健相關的職能治療師參與。本研究發展之OTK架構與衛教主題皆有≧80%的OT專家認為對中風病人與家屬重要。OTK架構包含三個面向：核心價值、服務場所與相關法規。OTK衛教主題共38個。子研究二：作者共撰寫46份OTK教材（不同服務場所有相同衛教主題）。所有專家 (n=3)確認教材具內容效度，所有病人與家屬(n=40)認為教材內容符合中風者之日常生活情境，而病人、家屬與所有國一學生 (n=18)認為教材可讀性佳，文本可讀性自動化分析系統分析發現OTK教材適讀年齡為國小一至六年級。OTK測驗共包含26題選擇題與26題簡答題。專家確認測驗內容與教材內容具高度關聯，國一學生確認測驗內容容易閱讀。此外，國一學生OTK測驗分數於閱讀教材之後明顯提升（作答正確率由0%提升至約50%）。子研究三中，49位中風病人/家屬參與研究。結果發現OTK適性衛教組之OTK測驗分數顯著提升，與對照組相比具有大效應 (效應值partial η2 >0.48)。追蹤1週後，28人 (57.1%)流失。若以意向治療分析方式（intention to treat analysis），衛教後1週的OT參與度，二組內之分數皆無顯著提升，二組間比較具小效應 (partial η2=0.02-0.04)。若僅以完成追蹤的病人分析，OTK適性衛教組之OT參與度與對照組相比具有大效應 (partial η2=0.11-0.34)。於衛教後8週之ADL表現結果，不論以意向治療分析或以全程參與者之資料分析，當參與者為病人時，OTK組相較於對照組之分數提升具有大效應 (partial η2=0.14-0.41)。 結論：本研究建立一個完整的OTK架構與OTK衛教主題，並依據此架構與主題發展內容完整、符合中風情境與OT現況，並具有良好可讀性之OTK教材。OTK測驗為依據OTK教材撰寫，具備良好之內容效度與可讀性。中風病人與家屬接受OTK適性衛教後，OTK程度大幅提升，但OT參與度與ADL僅有少至中等程度的提升。由於本研究參與者流失率高，影響對衛教成效之推論。建議未來研究驗證OTK衛教成效時，需留意降低流失率以確認OTK衛教成效。

Background: Occupational therapy knowledge (OTK) refers to important knowledge about occupational therapy (OT) for clients and their families. However, there are few comprehensive OTK educational materials and corresponding OTK tests suitable for patients with stroke and their families. A lack of OTK educational materials and corresponding tests may lead to difficulties in providing OTK education tailored to patients and families’ OTK level and discrepancies in treatment goals among patients with stroke and their families and occupational therapists, which may hamper patients’ participation in OT and patients’ functional recovery. Purposes: There were three purposes of this study: (1) to develop an OTK framework and educational topics for patients with stroke and their families, (2) to develop OTK educational materials and corresponding OTK tests according to the OTK educational topics, (3) to investigate the effects of tailored OTK education. Methods: This study involved 3 sub-studies. Sub-study 1. Development of a comprehensive OTK framework and educational topics: Delphi methods were applied to collect OT experts’ opinions to develop the OTK framework and educational topics. Sub-study 2. Development of OTK educational materials and tests: the comprehensive OTK educational materials were developed in response to the topics in Sub-study 1. The appropriateness, the content related to life after stroke, and the readability were respectively confirmed by OT experts, patients with stroke and their families, and grade 7 students and analyzed with the Chinese Readability Index Explorer (CRIE). The OTK tests were developed corresponding to the materials. The relevance between materials and tests was confirmed by OT experts and grade 7 students. Sub-study 3. Investigation of effects of tailored OTK education: Patients with stroke and their families were enrolled and randomized into two health education groups: tailored OTK education and stroke knowledge (SK). Primary outcomes were the participants’ OTK test score and patients’ engagement in OT programs. Secondary outcome was the patients’ performance in activity of daily living (ADL). Results: Sub-study 1: The OTK framework contained three domains (core value of OT, places of OT service, and laws related to OT service), and a total of 38 OTK educational topics were developed. Sub-study 2: forty-six OTK educational materials were developed. The appropriateness of the content was determined by 3 OT experts, and relevance to life after stroke were determined by 40 patients with stroke or their families. The readability was determined by 18 grade 7 students and the CRIE (readable for students in grades 1 to 6). The OTK tests were developed to contain 56 items and were highly related to the OTK educational materials. The 18 grade 7 students determined the OTK tests to have good readability and had significant improvement in the accuracy rates of the OTK tests (from 0% to 50-70%). Sub-study 3: Forty-nine patients with stroke or their families participated and 31 of them (53.4%) were lost to follow up after 1 week. The OTK group showed a significantly greater improvement in OTK level than the SK group (large effect size, partial η2 >0.48), but small effect on OT engagement (partial η2=0.02-0.04). Furthermore, the OTK group showed greater improvement in ADL performance than the SK group (large effect, partial η2>0.14) when participants were patients. Conclusion: A comprehensive OTK framework, educational topics, educational materials and tests were established. After receiving tailored OTK education, the participants had large improvements in the scores of OTK test. However, the effects of tailored OTK education on patients’ OT engagement and ADL performance were limited. Further research investigating the effects of OTK education are suggested to decrease the number of patient's lost-to-follow-up to yield more convincing results.