健康相關生活品質模式之建立－子宮切除婦女為例之縱貫性研究

Abstract

子宮切除術的施行將會影響婦女的健康狀況。本研究的目的，期望能了解並建立子宮切除婦女之健康經驗的概念模式及其健康相關生活品質的迴歸模式。 本研究採用縱貫式三角交叉檢視法（triangulation methods），以質性研究方法來呈現出研究個案在其情境脈絡下，對自我健康經驗的內容與歷程，以建立出子宮切除婦女健康經驗的概念意義。同時以量性研究的設計，量化出研究個案健康相關生活品質在手術前、後的變化及其影響因素，以建立出子宮切除婦女健康相關生活品質的迴歸模式。質性資料共訪談22位研究對象，參與研究個案依照其所接受之術式，又可分成腹式子宮切除術及腹腔鏡輔助子宮全切除術兩組，每組各為11人。量性研究共收120位研究對象，其中有五人在病理檢驗結果，不符合研究對象的條件，因此最後進行資料分析的為115位，其中56位接受腹式子宮切除術，59位是接受腹腔鏡輔助子宮全切除術。質性訪談資料的分析是採用內容分析法，質性資料分析結果的信效度是採用Lincoln & Cuba (1985)提出之質性資料的嚴謹度四個標準。量性資料的分析則採用SPSS 11.0來做資料的描述性分析、因素分析及無母數分析。以SAS 8.2之廣義估計方程式(GEE method) 進行健康相關生活品質迴歸模式的建立。 子宮切除婦女健康的經驗歷程，經歸納後所得之主題為「從擁有到失去，由失去到整合回歸」。其歷程可分為四個階段從糾結混亂、忍受損傷、調整與改變到整合與認同的健康經驗。健康經驗內涵包含三個向度：身體機能運作、心理與情緒反應及人際關係與角色功能等，向度間會彼此相互影響。研究對象亦經由此三個向度的運作過程，而感知自我的健康狀況，過程中受醫療照護及社會及家庭情境因素的影響，最終會藉由自我心像，以呈現出當下對自我健康情況的態度與評價，為其接受子宮切除之健康經驗表達方式。 量性研究的結果，不同術式間研究對象在基本屬性、症狀嚴重度/困擾度及自我心像的評估間並無差異。術後研究對象在症狀嚴重度與困擾度均較術前降低，唯在術後三個月（開始回復其性生活時）性生活相關症狀嚴重度及困擾度皆大幅上升，術後六個月有微幅降低但仍較術前高。GEE所建立之健康相關生活品質預測模式中，生理功能健康構面（physical component summary, PCS）的解釋量平均約為0.65、心理功能健康構面（mental component summary, MCS）的釋量平均約為0.52。術式的影響僅侷限在術後一星期左右。PCS的變化：術後大幅變差至術後一個月時回升，但術後三個月又下降，待術後六個月有再回升但仍較術前差，此改變均具顯著差異。MCS的改變上：為術後大幅上升，但至術後三個月則較術前差，並有顯著差異。 總之，藉由質與量性之研究結果的相互輔助，使健康照護醫療團隊對子宮全切除婦女健康照護有更清楚的全貌，對未來子宮切除術的施行與照護能更符合婦女健康的需求，確實增進其健康相關生活品質。

A hysterectomy affects woman’s health. This study aims to develop a conceptual and a regression model of health related quality of life (HRQoL) before and after hysterectomy in premenopausal women with benign gynecological conditions. This prospective follow-up study adopted the triangulation methods; the qualitative and quantitative methods were used simultaneously, and were equally valuable. The recruited in the quantitative study were 120 women aged 31 t0 50, each of whom had undergone a hysterectomy in a medical center for non-malignant causes. Twenty-two women from the sample participated in both the quantitative and the qualitative study. The qualitative data were analyzed using the content analysis to gain insight into the participants’ situational experience of health and life course. Statistical computer program versions SPSS 11.0 and SAS 8.2 were applied to data analysis. The quantitative data were analyzed using descriptive statistics, nonparametric tests and the generalized estimating equation (GEE) method for modeling the marginal means of repeated responses. The theme of the women’s subjective health experiences is 「From productiveness to chaos, then piecing refigure together back wholeness」. This transitional process of health experiences in participants was divided into four phases: chaos and confusion, suffering and impairment, changes and adjusting, and integrating and identity. The domains of the health concept included physical function, psychological and emotional reaction and role identity in relation to others. Health related quality of life was measured by the MOS Short Form 36 (SF-36) questionnaire. The results of quantitative analysis showed that the influencing factors were age, marriage and employment status, the severity and distress of symptom perceived by participants, hemoglobin level before surgery, self-image, and the diagnosis by pathological findings. The variance of physical component summary (PCS) was explained 0.65, there was deterioration over six months after surgery no matter what kind hysterectomy was taken. The variance of mental component summary (MCS) was explained 0.52, there was improvement immediately after hysterectomy but declined three months after surgery. From the viewpoint of methodological triangulation, the most significant finding was that the qualitative approach provided an insight into the transitional pattern of HRQoL obtained by the quantitative approach, showing the crucial factors to be age, self image, and marriage related aspects of the women’s situational experiences of HRQoL before and after hysterectomy. Comprehensive knowledge and understanding of the concept of HRQoL and its influencing factors before and after hysterectomy among gynecological medical and nursing stuff is essential for their understanding of the HRQoL of these women, to provide them with accurate information at the pre- and post- surgical counseling, and for carrying out appropriate treatment and care.