以資訊-動機-行為技能模型探討第二型糖尿病人服藥順從性之影響因素

Abstract

研究背景與重要性:第二型糖尿病的高盛行率及其衍生的潛在併發症，使得其控制變得至關重要。雖然藥物在第二型糖尿病的治療過程中扮演關鍵的角色，仍有許多人難以依照醫師處方服用藥物。現有研究指出諸多因素皆可能影響病人的服藥行為，卻沒有公認一致的準則讓醫療專業人員識別服藥順從性不佳的病人，而提供相對應的服務以增進病人的服藥行為。應用行為理論以了解病人服藥行為，可以系統性地去探索影響病人服藥順從性不佳的原因，進而提供臨床健康照護介入措施之基礎，以提升病人服藥順從性。 研究目的：本研究使用資訊-動機-行為技能模型，(1) 檢驗影響第二型糖尿病病人 服藥順從性的因素;(2) 加入糖化血色素作為臨床療效指標來延伸研究模型，探 索影響服藥順從性與糖化血色素的可能因素。 研究方法：本橫斷性研究以資訊-動機-行為技能模型作為理論基礎，檢驗影響服藥順從性的因素。於 2023 年 9 月至 2024 年 5 月期間在五間社區藥局以自填式問卷進行資料收集。符合條件的受試者為能理解繁體中文並被診斷為第二型糖尿病 的 18 歲以上成年人，且至少服用一種口服糖尿病藥品。研究問卷內容共 46 題，除人口統計學與臨床資訊(8 題)外，還評估受試者的電子健康素養(8 題)、藥品信念(10 題)、自我效能(8 題)和服藥順從性(12 題)。本研究問卷約需 10-15 分鐘內即可完成，糖化血色素和用藥複雜度將透過全民健康保險雲端藥歷系統記錄獲得，本研究中服藥順從性行為可分為服藥和領藥兩部分。以路徑分析探索影響服藥和領藥行為的人口統計學和心理社會因素之潛在路徑，並透過模型修正指數進行較佳模型適配性評估和調整。 研究結果：本研究共招募 273 名受試者，平均年齡為 67.72 歲，其中 52.01%為女性。糖化血色素與病人自述的用藥行為呈負相關(β = -0.198, p < 0.001)。此外，年齡較大(β = 0.138, p = 0.025)、教育程度較低(β = 0.139, p = 0.020)、注射藥品較少(β = 0.136, p = 0.038)、對藥品的擔憂較低(β = 0.165, p = 0.003)、自我效能較好(β = 0.257, p < 0.001)的病人較可能按時服用糖尿病藥品。結果也顯示透過自我效能的中介效果，較高電子健康素養（間接效應，β = 0.045, p = 0.010）、對藥品的擔憂較低（間接效應，β = 0.079, p = 0.001）以及對藥品必要性的信念較高（間接效應，β = 0.032, p = 0.047）與較佳的病人的服藥行為相關。在領藥行為的結果方面，按時領藥的受試者(β = 0.120, p = 0.028)和第二型糖尿病用藥服雜度較低的受試者(β = 0.395, p < 0.001)更有可能擁有較低的糖化血色素。此外，年齡較大的成年人(β = 0.180, p = 0.008)傾向於按照處方建議領取他們的糖尿病藥品。 結論：未來的糖尿病介入措施應聚焦病人自我效能的增強，根據不同電子健康素養的族群設計適合的資訊，減少他們對藥品的擔憂，並同時強調持續用藥的重要性。此外，在設計健康照護介入措施時，還須考慮目標族群文化差異與病人基本特質。

Background Managing type 2 diabetes mellitus (T2DM) is crucial, which can lead to serious complications if not handled properly, yet many individuals struggle with adhering to their prescribed treatments. Incorporating the behavioral theory models into studies offers researchers a structured framework for assessing health behaviors, provides insights into behaviors, and facilitates the development of tailored interventions to improve medication adherence. Despite extensive studies globally, no universal standard for enhancing medication adherence among patients with T2DM has been proposed, underlying a significant gap in diabetes management. Objectives This study aimed to address two objectives: (1) to examine the factors influencing medication adherence among patients with T2DM using the Information-Motivation- Behavioral skills (IMB) model, and (2) to identify key factors of medication adherence and link the model to A1C levels. Methods This cross-sectional study adopted the IMB model to examine factors influencing medication adherence. A 46-item questionnaire was administered face-to-face at five community pharmacies from September 2023 to May 2024. Eligible participants were adults who understood Traditional Chinese, were diagnosed with T2DM, and were taking at least one oral diabetes medication. In addition to collecting demographic and clinical information (8 items), we measured participants’ eHealth literacy (8 items), belief in medicines (10 items), self-efficacy (8 items), and medication adherence (12 items). Completing the questionnaire took approximately 10-15 minutes. The A1C level and medication regimen complexity index (MRCI) were obtained from the National Health Insurance PharmaCloud System. Medication adherence was divided into medication-taking and medication-refill. Path analysis was conducted to explore potential pathways linking demographics and psychosocial factors relevant to medication-taking and refill. Model fit indices were evaluated, and modification indices were applied to adjust the preferred models. Results Two hundred and seventy-three participants were recruited for the study, with an average age of 67.72 years and 52.01% being females. The A1C level was negatively associated with self-reported adherence to medication-taking behavior (β = -0.198, p < 0.001). Besides, individuals with older age (β = 0.138, p = 0.025), lower educational levels (β = 0.139, p = 0.020), fewer injectable medications (β = 0.136, p = 0.038), fewer concerns about medications (β = 0.165, p = 0.003), and better self-efficacy (β = 0.257, p < 0.001) were more likely to adhere to their diabetes medications. Medication-taking behavior was also improved in individuals with higher eHealth literacy (indirect effects, β = 0.045, p = 0.010), fewer concerns about medications (indirect effects, β = 0.079, p = 0.001), and stronger beliefs in medication necessity (indirect effects, β = 0.032, p = 0.047) through enhanced self-efficacy. Regarding medication-refill behaviors, participants who refilled their prescription less on schedule (β = 0.120, p = 0.028) and had a higher T2DM MRCI (β = 0.395, p < 0.001) tended to have higher A1C levels. Moreover, older adults (β = 0.180, p = 0.008) were apt to refill their diabetes medications as recommended. Conclusion The study identified the potential factors, based on the IMB model, influencing medication-taking and refill behaviors, highlighting the importance of medication-taking in managing T2DM. As a result, future diabetes interventions should prioritize enhancing patients’ self-efficacy, addressing eHealth literacy, alleviating concerns about medications while underlining the importance of adhering to medications. Additionally, it is also crucial to consider cultural adaptations and differences in patients’ baseline characteristics when developing tailored interventions.