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標題: | 影響愛滋感染者服藥意願之因素初探:質性研究 An Exploratory Study of Factors Influencing the Decision to Start Antiretroviral Treatment Among People with HIV/AIDS: A Qualitative Study |
作者: | Kai-Ping Hu 胡凱評 |
指導教授: | 張書森 |
關鍵字: | 愛滋,感染者,服藥意願,自覺健康,醫病關係, AIDS,HIV positive,willingness to take drugs,self-perceived health,doctor-patient relationship, |
出版年 : | 2016 |
學位: | 碩士 |
摘要: | 背景:根據衛生福利部疾病管制局截至2016年6月之統計,全台灣已知的累積愛滋感染者共有32,237名,存活人數(含發病者)計有26,898人,而每年約新增2000例感染者,存活感染者中約有近五千多名未接受治療,佔總感染人數之二至三成,因此,如何提升治療人數為防治愛滋病之重要議題。既有流行病學文獻指出,儘早服用抗逆轉錄病毒藥物,能夠有效降低愛滋感染者體內的病毒量,提升免疫力,與改善整體健康和生活品質;另外,穩定接受治療、且血中無法測得病毒的愛滋感染者,與沒有治療者相較下,傳染性大幅降低。2015年世界衛生組織(World Health Organization,WHO)公布最新的愛滋感染者治療指引,其中最重大的改變,便是將成人的建議治療範圍放寬:前版指引為感染者體內之CD4+細胞數量小於500cells/μL才建議接受治療,新版更改為「所有的感染者」都應接受治療(即不論其CD4+細胞數目之高低),對於感染者的服藥決策將造成重大影響。
近年來,聯合國愛滋病組織(UNAIDS)提出目標希望在2020年達到「90-90-90」,即90%感染者知道自己病況、90%知道病況者服用藥物、90%服用藥物者成功抑制病毒量,符合「以治療作為預防(TasP)」的原則。過去國外針對感染者服藥因素之研究,曾指出若干重要因素,如經濟、個人因素、藥物與醫療信念、日常計畫,以及人際關係等,經濟因素尤為關鍵。然而,台灣過去相關研究主要著重於服藥遵從性,甚少將影響開始服藥的因素作為主題。同時,由於台灣全面補助抗逆轉錄病毒藥物的政策,免除了經濟障礙,也讓感染者的主要考量因素,必定有別於國外研究結果。 目的:瞭解台灣愛滋感染者在確認感染後,接受或拒絕服用藥物治療之影響因素。 方法:本研究為探索感染者決定服藥與否之因素的質性研究。採深度訪談方法收集資料,以滾雪球與公開招募方式訪談21位愛滋感染者,3位醫療服務人員。感染者條件為:20歲以上、愛滋感染確診者;相關醫療人員則為20歲以上、曾照護愛滋感染者之醫療人員,包括感染科醫師與個案管理師。研究者將訪談內容錄音檔轉錄成逐字稿後,依據Strauss 和Corbin(1997)提出的開放性譯碼(open coding)原則來分析資料。 結果:影響感染者服藥意願之因素可劃分為三個層次,分別為個體、人際,與環境結構層次。同時,這些因素又會因生命歷程而改變,亦即為時間軸的面向。在三個層次當中,主要的影響因素分別是:(1)自覺健康(個體層次):感染者以其對身體健康與感染狀態之知覺、感受,或是生物性替代指標(CD4+細胞數量)來判斷自身健康狀態,當自認為健康良好狀態,或是不願接受自身感染狀態時,會有較大的傾向決定不接受服藥治療;(2)隱私問題(人際層次):多數感染者會盡量避免感染事實曝光,而抗愛滋藥物的外觀、每天固定服藥的舉動,以及就醫所留下的服藥紀錄,皆可能暴露感染身份,因此感染者會以此為考量拒絕接受治療;(3)醫療環境(環境結構層次):外在環境所帶來的醫療經驗,將會進而影響其服藥意願;良好友善的醫療環境與醫病關係,會使感染者對於醫療人員產生更多的信任,並進而與之討論自身狀況,而協商出適合感染者的治療方案;反之若為負面經驗,則會促使感染者對醫療體系產生排斥,進而不願就診與接受治療。 結論:本研究透過深度訪談,發掘影響台灣愛滋感染者服藥意願的主要因素,包括自覺健康、隱私問題、與醫病關係等;國外研究中所強調的經濟因素只影響少數弱勢受訪者的服藥意願。在防治策略上,可建立暢通的資訊管道、對愛滋友善的社會風氣、良好的醫病關係,並幫助弱勢感染者有更穩定的生活,以期感染者能更周全、真實、與具體地瞭解自身的健康狀態、病毒對健康造成的影響,以及藥物治療的效益與可能副作用。這些策略可望減少感染者接受藥物治療的阻礙,使其有較高意願決定接受治療。 Background: According to Centers for Disease Control, a total of 32,237 human immunodeficiency virus (HIV)-positive cumulative cases have been reported in Taiwan as of June 2016, and the number of live patients (including those with Acquired Immune Deficiency Syndrome [AIDS]) is 26,898, while there are about 2,000 new cases every year. Among live patients approximately 5,000 did not receive treatment, accounting for around 20-30% of all live patients. To increase the number of HIV-positive patients who receive treatment is therefore an important issue. According to epidemiological literature, the early use of antiretroviral drugs can effectively reduce the amount of HIV virus in the body, enhance patient immunity and significantly contribute to health and better quality of life. In addition, comparing with those who do not receive treatment, the infectious ability of HIV-positive patients who receive stable treatment and have non-detectable level of virus amount reduce significantly. In 2015, the World Health Organization (WHO) released the latest guidelines on the treatment of HIV/AIDS. The most vital change is to loosen the recommended therapeutic range for adults. The original criterion was that antiretroviral treatment was recommended for patients with a level of CD4+ cells less than 500 cells/μL, and this was changed to “all HIV-positive patients should be treated (regardless of the level of CD4+ cells)”. This change would nevertheless significantly impact on decision-making about receiving treatment among patients. In recent years, the Joint United Nations Program on HIV and AIDS (UNAIDS) announced it goal to achieve “90-90-90” by 2020. That means by 2020, 90% of all people living with HIV will know their HIV status; 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy; and 90% of all people receiving antiretroviral therapy will have viral suppression, to conform to the principle of “Treatment as prevention (TasP)”. Past international research on the factors influencing the decision to receive antiretroviral treatment has pointed out the importance of several factors, such as economic factors, individual factors, drug and medical beliefs, daily plans, and interpersonal relationships. Especially, the economic factors are shown to be particularly critical. In Taiwan, related previous studies have mainly focused on medication adherence rather than to decision to receive and initiate treatment. At the same time, the Taiwanese government has implemented the policy of comprehensive subsidy of the anti-retroviral drugs, which would not only eliminate the economic barriers to receiving treatment but also make different considerations among HIV-positive patients regarding receiving treatment from those shown in international research results. Object: The aim of this study was to understand factors influencing the decision to receive or refuse antiretroviral treatment among patients with HIV in Taiwan. Methods: We conducted a qualitative study to explore the factors influencing HIV-positive patients’ decision to receive or refuse antiretroviral treatment. By using in-depth interview method to collect data, we interviewed 21 HIV-positive patients and three medical professionals with snowball sampling and open recruitment. The inclusion criteria for HIV-positive patients included an age of 20 years or older and a confirmed diagnosis of HIV infection; those for medical professionals (infectious disease specialists or specialized case managers of HIV-positive patients) included an age of 20 years or older and past experiences of providing care for HIV-positive patients. The interviews were transcribed into verbatim transcripts and analyzed according to the open coding principle proposed by Strauss and Corbin (1997). Result: Factors that affect the patients’ willingness to receive treatment could be assigned into three levels, i.e. individual, interpersonal, and environmental / structural levels. These factors would also evolve and change over the life course, namely an additional time dimension. At each of three levels, the most important factors were: (1) self-perceived health (individual level): patients judged their own health status according to their perception, feeling, or biologic substitute index (CD4+ cell number). When patients considered themselves healthy or in good health condition, or they tended to deny or ignore their own infection status, they would tend to decide not to receive treatment; (2) privacy protection issue (interpersonal level): most patients made efforts to hide their infection from being exposed to other people. However, the possession of antiretroviral medications, taking the medications in front of others, and the medical records are likely to expose their infection status. Therefore, they would refuse to receive treatment as a result of this concern; (3) medical service environment (environmental / structural level): experiences of interacting with medical professionals would impact on patients’ decision to receive treatment. Positive experiences, friendly environment, and good doctor–patient relationship would result in more trust in health care providers and allow them opportunities to discuss their concerns with health care providers; the process would then contribute to agreed and appropriate treatment plans for patients. On the contrary, negative experiences will lead to rejection toward health care system, loss of follow-up, and treatment refusal. Conclusion: In this study we conducted in-depth interviews to identify major factors influencing the decision to receive antiretroviral treatment among HIV-positive patients in Taiwan and found the importance of self-perceived health, privacy concerns, and doctor-patient relationship. The economic factors that were emphasized in the international research had an impact only among a small number of disadvantaged patients. Regarding prevention and control strategies, we can strive to develop channels for unimpeded dissemination of information, an HIV friendly social atmosphere, good doctor-patient relationships, and adequate support for patients with a deprived socioeconomic condition, with an aim to help patients to develop a more comprehensive understanding into their health status based on unbiased information, the true impact of the virus on their health, and the benefits and and potential side effects of the treatment. It is expected that these strategies could reduce the barriers and enhance the willingness of receiving antiretroviral treatment among HIV-positive patients. |
URI: | http://tdr.lib.ntu.edu.tw/jspui/handle/123456789/7826 |
DOI: | 10.6342/NTU201603667 |
全文授權: | 同意授權(全球公開) |
顯示於系所單位: | 健康政策與管理研究所 |
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