病人所感受的醫師跨文化能力與醫療依從性的關係

Abstract

背景： 因為醫療的全球化及文化的多元性已是現代醫學的趨勢，醫師跨文化的能力(Cultural Competence)成為當前醫師必須具備的重要能力，希望藉由醫師的跨文化溝通能力的培養，以減少不同族群間的健康分歧。 目的： 試圖了解金山地區的慢性病患所感受到醫師跨文化的能力(Cultural Competence)如何，並探討病人所感受的醫師跨文化能力會不會影響病人的醫療從性(Adherence)，藉此釐清不同疾病種類下，病人感受的醫師跨文化能力與健康成效間的關係。 研究方法： 研究對象為台大醫院金山分院家醫科門診慢性病患，採立意取樣，使用「消費者對醫療服務提供者評價調查計畫(CAHPS®)文化能力項目集」問卷作為病人感受之醫師跨文化能力評估工具，翻譯為中文後，利用探索性因素分析(Exploratory factor analysis)分析問卷至構面效度，Cronbach's alpha計算內部一致性信度(Internal consistency reliability)，並利用雙相變項及多變項分析，了解影響病人感受之醫師跨文化能力各構面的因素。醫療依從性的評估則利用藥物持有率（Medication Possession Ratio, MPR），計算過去一年中，金山家醫科門診慢性病患領取處方的總天數所佔的比例，作為連續變項代表病人的醫療依從性，並利用多變項線性迴歸，在控制各項干擾因子後，不同疾病診斷下，病人所感受之醫師跨文化能力之各構面與醫療依從性的關係。 結果： 收案200例，因填答不完整及門診追蹤不滿一年，僅158例接受分析。「消費者對醫療服務提供者評價調查計畫(CAHPS®)文化能力項目集」原問卷包含八個層面，因本次收案之個案並未包含外籍病患，因此將語言翻譯服務層面排除後，剩下的七個層面做探索式因素分析，最終得到五個有意義之新構面，分別為：1.醫病溝通-良好互信2.共享醫療決策3.醫病溝通-關懷4.平等的醫療5.醫病溝通-健康提升（Kaiser-Meyer-Olkin Measure of Sampling Adequacy：0.729, p-value:<0.001,Total Variance Explained Cumulative percentage:73.67%）。內部一致性信度Cronbach’s alpha分別是0.824、0.962、0.602、0.840、0.842，總內部一致性信度為0.786。影響高血壓病人感受醫師跨文化能力的因素包括：年齡、宗教信仰、教育程度、性別、月收入、出生地、母親國籍、父親民族、病人自覺疾病嚴重度及慣用語言；影響糖尿病病患感受醫師跨文化能力的因素包括：信仰佛教、教育程度、婚姻狀態、保險種類及月收入。多變項線性迴歸分析發現，高血壓病患所感受的醫師跨文化能力與醫療依從性並無顯著相關性，而糖尿病病患所感受之平等的醫療構面，與較好的醫療依從性相關(B=1.413，p=0.026，Adjusted R-square:0.13)，在以上兩個多變項分析中，高血壓及糖尿病病患的自覺疾病嚴重度皆與病人之醫療依從性有正向關係（B=50.504，p=0.012及B=103.67，p=0.004）。 結論： 糖尿病病患所感受之平等的醫療跨文化能力構面確實與醫療依從性有正向關係，但其他醫師跨文化構面在兩類疾病中皆未達統計顯著性，日後應就不同疾病及不同跨文化能力之構面分別探討。

Background: Cultural competence is an essential ability for health providers to reduce health disparities between different cultural groups. Because of globalization of health care and cultural diversity of the modern world, cultural competence become more important. Aim: To explore relationships between patient-perceived cultural competence and medication adherence in patients with chronic disease at the family medicine outpatient clinics of National Taiwan University Hospital Jinshan branch. To establish correlations between confounder factors and patient-perceived cultural competence in Jinshan area. Method: The data were collected between May 2018 and June 2018 at the family medicine clinics of National Taiwan University Hospital Jinshan branch. Patients with hypertension(HTN), diabetes mellitus(DM), hyperlipidemia and gout were included, and at least one-year follow-up at Jinshan hospital was required. The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Cultural Competence (CC) Item Set was adopted to evaluate patient-perceived health provider cultural competence. Exploratory factor analysis was conducted to examine the construct validity, and internal consistency reliability of Chinese version of CAHPS® CC item set. Medication adherence was measured using Medication Possession Ratio (MPR). Relationships between confounder factors and patient-perceived health provider cultural competence, and relationships between patient-perceived health provider cultural competence and medication adherence were analyzed with multivariate linear regression. Result: 200 participants were enrolled and 158 participants were analyzed. Five factors were extracted to evaluate patient-perceived health provider cultural competence. These five main factors include: 1) Doctor communication-positive behaviors and trust, 2) Share decision making, 3) Doctor communication-concerned behaviors, 4) Equitable treatment, 5) Doctor communication-health promotion (Kaiser-Meyer-Olkin Measure of Sampling Adequacy: 0.729, p-value:< .001, Total Variance Explained Cumulative percentage: 73.67%). The Cronbach’s alpha of these five factors were 0.824, 0.962, 0.602, 0.840 and 0.842, the total Cronbach’s alpha was 0.786. The factors correlated with patient- perceived health provider cultural competence of HTN patients included age, religion, education, gender, income, birth place, language, mother’s nation, father’s ethnicity and patient-perceived disease severity. The factors correlated with patient-perceived health provider cultural competence of DM patients included religion, education, marital status, insurance type and income. The full model multivariate regression revealed no significant correlation between patient-perceived health provider cultural competence and medication adherence in HTN patients group, but positive effect was found between equitable treatment and medication adherence in DM patients group (B=1.413, p=0.026, Adjusted R-square: 0.13). In addition, patient-perceived disease severity had positive effect on medication adherence in both groups (B=50.504, p=0.012 in HTN group; B=103.67, p=0.004 in DM group). Conclusion: The patient equitable treatment of perceived health provider cultural competence had positive effect on medication adherence in DM patient group, but there was no significant correlation between patient-perceived health provider cultural competence in other factors and different diseases. Further study should include closer examination of these issues separately.