범이론 모형을 적용한 고혈압환자 약물순응 중재 프로그램 개발 및 적용 효과

Abstract

본 연구는 고혈압환자 중 약물 비순응자의 약물순응도를 증진시키기 위해 범이론 모형을 이용한 약물순응 중재 프로그램을 개발하고 적용하여 그 효과를 검증하기 위해 수행되었다. 범이론 모형을 이용한 약물순응 중재 프로그램을 개발하기 위해 S시에 소재한 일개구 보건소에 등록된 고혈압환자 중 2010년 7월 1일부터 7월 30일까지 내소한 323명의 고혈압환자를 대상으로 예비조사를 실시하였다. 중재 프로그램은 범이론 모형의 주요개념인 약물순응 변화과정, 의사결정 균형, 자기효능감을 고려하여 8회로 구성된 프로그램을 개발하였다. 개발된 중재 프로그램의 효과를 검증하기 위해 2010년 8월 16일부터 11월 5일까지 12주동안 S시에 소재한 일개구 보건소에 등록된 고혈압환자 중 약물순응 변화단계를 파악한 후 변화단계가 계획전단계, 계획단계, 준비단계에 있는 자로 실험군 53명, 대조군 55명, 총 108명을 대상으로 비동등성 대조군 전후실험설계를 이용한 유사실험 연구를 수행하였다. 범이론 모형을 이용한 약물순응 중재 프로그램은 약물순응행위 변화단계별로 개별대면교육 4회와 전화교육 4회로 구성하였으며, 실험군은 약물순응행위 변화단계에 따른 교육 자료를 통해 중재 프로그램을 제공하였고, 대조군은 교육 자료만 전달하였다. 중재 프로그램의 효과는 약물순응 변화단계, 변화과정, 의사결정 균형, 자기효능감, 약물순응도, 혈압을 측정하였으며, 약물순응 실천정도와 변화단계는 2주마다 조사하였다. 또 중재 프로그램 제공 후에도 실험효과가 지속적으로 유지되는지 검증하기 위해 중재 종료 4주후에 사후조사를 실시하였다. 수집된 자료는 SPSS 17.0 프로그램을 이용하여 실수와 백분율, 평균과 표준편차, X2-test, t-test, 그리고 Repeated measures ANOVA로 분석하였다. 본 연구의 가설검증 결과는 다음과 같다. 1. “실험군과 대조군의 약물순응행위 변화단계는 차이가 있을 것이다.”는 실험·대조군간의 약물순응행위 변화단계가 중재 5주부터 유의한 차이를 나타내기 시작하여(χ2=15.606, p=<.001), 중재 후 4주까지 통계적으로 유의한 차이를 보였고(χ2=52.917, p=<.001), 중재 후 실험군의 실행단계의 비율이 중재 5주18.9%, 중재 후 1주 62.3%, 중재 후 4주 71.7%로, 대조군 보다 높아 가설1은 지지되었다. 2. “실험군과 대조군의 약물순응 변화과정(인지적 변화과정, 행위적 변화과정)에는 차이가 있을 것이다.”는 인지변화과정은 중재 전·후와 실험·대조군 간의 교호작용에서 유의한 차이를 보였으며(F=13.528, p<.001), 행위변화과정은 실험·대조군 간(F=6.884, p=.010), 중재 전·후와 실험·대조군 간의 교호작용(F=10.808, p<.001)에서 유의한 차이를 보여 가설2는 지지되었다. 3. “실험군과 대조군의 의사결정 균형에는 차이가 있을 것이다.”는 의사결정 균형 중 약물순응 이익은 실험·대조군 간(F=4.886, p=<.001), 중재 전·후와 실험·대조군 간의 교호작용(F=5.569, p=.012), 약물순응 손실은 중재 전·후와 실험·대조군 간의 교호작용(F=15.661, p=<.001)에서 통계적으로 유의한 차이를 보여 가설3은 지지되었다. 4. “실험군과 대조군의 자기효능감에는 차이가 있을 것이다.”는 자기효능감은 중재 전·후와 실험·대조군 간의 교호작용에서 통계적으로 유의한 차이를 보여 가설4는 지지되었다. 5. “실험군과 대조군의 약물순응도는 차이가 있을 것이다.”는 약물순응도는 실험·대조군 간(F=43.966, p<.001), 중재 전·후와 실험·대조군 간의 교호작용(F=51.442, p<.001)에서 통계적으로 유의한 차이를 보였다. 약물순응도 하위변인 중 정확한 시간은 실험·대조군 간(F=34.083, p<.001), 중재 전·후와 실험· 대조군 간의 교호작용(F=8.704, p<.001), 정확한 횟수는 실험·대조군 간(F=4.099, p=.050), 중재 전·후와 실험·대조군 간의 교호작용(F=3.972, p=.010)에서 통계적으로 유의한 차이를 보였으나 정확한 용량에서는 유의한 차이를 보이지 않아 가설5는 일부 지지되었다. 6. “실험군과 대조군의 혈압에는 차이가 있을 것이다.”는 수축기혈압, 이완기혈압 모두 실험·대조군 간, 중재 전·후와 실험·대조군 간의 교호작용에서 통계적으로 유의한 차이를 보이지 않아 가설6은 지지되지 않았다. 이상과 같이 범이론 모형을 이용한 약물순응 중재 프로그램에 참여한 실험군은 대조군보다 약물순응 변화단계, 변화과정, 의사결정 균형, 자기효능감, 약물순응도가 유의하게 향상되었고, 약물순응행위 변화단계가 실행 및 유지단계로 이행되었음을 알 수 있다. 범이론 모형을 이용한 약물순응 중재프로그램은 고혈압환자에게 약물순응을 촉진시켰으므로 건강증진을 위한 중재방법으로 실무에서 유용하게 활용될 수 있을 것으로 기대된다. ;The purpose of this studywas to increase the medication adherence of hypertensive patients by developing and operating a medication adherence intervention program based on the Transtheoretical Model (TTM), and verifying its effectiveness. The development of the program involved a preliminary examination of 323 hypertensive patients, who were registered at a district health center in city S and visited the center from July 1, 2010 to July 30, 2010. The medication adherence intervention program consisted of eight sessions in consideration of the main components of the TTM processes of change, decisional balance, and self-efficacy. In order to verify the program’s effectiveness, a similar experiment was conducted using a nonequivalent control group, pre- and post-test design. The program was conducted on a total of 108 hypertensive patients, who were registered at a district health center in city S and visited the center during the 12 weeks from August 16, 2010 to November 5, 2010. The patients were in the stages of precontemplation, contemplation or preparation, and were divided into an experimental group of 53 patients and a control group of 55 patients after their adherence levels were measured with medication adherence tools. The TTM medication adherence intervention program consisted of 4 face-to-face education sessions and 4 telephone education sessions depending on the stages of change in medication adherence behavior. Members of the experimental group participated in an intervention program and were given educational materials based on the stages of medication adherence behavior, while the control group members were only given educational materials. The effectiveness of the intervention program was measured by stages of change, processes of change, decisional balance, self-efficacy, levels of medication adherence and blood pressure. The degree of participation and the current stage of medication adherence were measured every two weeks. To verify whether or not the effect of the experiment lasted even after the intervention program, a follow-up examination was conducted 4 weeks after the end of the intervention. The collected data were analyzed, using the IBM program SPSS 17.0, in terms of real numbers, percentages, averages, standard deviations, X2-tests, t-tests, and repeated measures ANOVA. The results of the hypotheses tested in this study are as follows. Hypothesis 1 predicted that there would be astatistically significant difference between the experimental group and control group in stages of their changing medication adherence behavior. The findings began to indicate a meaningful difference in the fifth week of medication intervention (χ2=15.606, p=<.001), displaying a statistically significant difference through to the fourth week following the intervention (χ2=52.917, p=<.001) and the proportion of the experiment group in the action stage was in the ascending order of the fifth week of the intervention period (18.9%), the first week (62.3%) then the fourth week (71.7%) after the intervention, which was higher in comparison to the control group’s results for after the intervention. Therefore, the results supported the hypothesis. Hypothesis 2 predicted that there would be a statistically significant difference between the experimental group and control group in the processes of change (involving cognitive and behavioral activities) related to medication adherence. The cognitive process of change showed a significant difference in the interaction between the research groups (experimental and control) and stages in the week before and after, and four weeks after the intervention (F=13,528, p<.001). The behavioral process of change showed a significant difference between groups (F=6,884, p<.001) and in the interaction between the research groups and stages (F=10.808, p<.001) in the week before and after, and four weeks after the intervention. Therefore, the results supported the hypothesis. Hypothesis 3 predicted that there would be astatistically significant difference between the experimental group and control group in decisional balance. Of the decisional balance, the benefits of medication adherence showed a statistically significant difference between groups (F=4,886, p<.001) and in the interaction between the research groups and stages (F=5,569, p<.012) in the week before and after, and four weeks after the intervention. The losses showed a statistically significant difference in interaction between the research groups and stages (F=15,661, p<.001) in the week before and after, and four weeks after the intervention. Therefore,the results supported the hypothesis. Hypothesis 4 predicted that there would be a statistically significant difference between the experimental groupand control group in self-efficacy. Self-efficacy showed a statistically significant difference in the interaction between the research groups and stages in the week before and after, and four weeks after the intervention, thus supporting the hypothesis. Hypothesis 5 predicted that there would be astatistically significant difference between the experimental group and control group in degrees of medication adherence. Adherence to medication schedules showed a statistically significant difference between groups (F=34,083, p<.001) and in the interaction between the research groups and stages (beforeand after the intervention) (F=8,704, p<.001) in the week before and after, and four weeks after the intervention. Adherence to frequency of dosage showed a statistically significant difference between groups (F=4,099, p<.050) and in the interaction between research groups and stages (F=3,792, p<.010) in the week before and after, and four weeks after the intervention. However, there was no significant difference in the adherence to the dosage amount, thus lending only partial support to the hypothesis. Hypothesis 6 predicted that there would be astatistically significant difference between the experimental group and control group in blood pressure levels. Neither systolic blood pressure nor diastolic blood pressure showed a statistically significant difference between groups and in the interaction between the research groups and stages in the week before and after, and four weeks after the intervention. Therefore,the hypothesis was not supported. As noted above, there was a significant improvementin the experimental group participants in the TTM medication adherence intervention program, compared to theircontrol group counterparts, in terms of stages of changes for medication adherence, processes of change, decisional balance, self-efficacy and levels of medication adherence. The findings also suggested that participation in the program led to stages of action and maintenance. Given that this intervention program motivated and stimulated hypertensive patients to adhere to the prescribed medications, the TTM medication adherence intervention program is expected to be an effective and practical intervention method for health improvement.