引用本文

方嘉列, 陳婉莉, 王靜雅, 趙杰, 王繼偉, 邵春海. 基于健康信念模型（HBM）的社區(qū)冠心病患者遵醫(yī)行為影響因素的橫斷面研究[J]. 復(fù)旦學(xué)報(bào)醫(yī)學(xué)版, 2020, 47(3): 378-384, 391.

FANG Jia-lie, CHEN Wan-li, WANG Jing-ya, ZHAO Jie, WANG Ji-wei, SHAO Chun-hai. Factors associated with medication adherence in community patients with coronary artery disease based on health belief model(HBM): a cross-sectional study[J]. Fudan University Journal of Medical Sciences, 2020, 47(3): 378-384, 391.

基于健康信念模型（HBM）的社區(qū)冠心病患者遵醫(yī)行為影響因素的橫斷面研究

, 陳婉莉2 , 王靜雅2 , 趙杰2 , 王繼偉2 , 邵春海3,4     

1. 上海市靜安區(qū)疾病預(yù)防控制中心 上海 200072;
2. 復(fù)旦大學(xué)公共衛(wèi)生學(xué)院-國(guó)家衛(wèi)生計(jì)生委衛(wèi)生技術(shù)評(píng)估重點(diǎn)實(shí)驗(yàn)室 上海 200032;
3. 復(fù)旦大學(xué)附屬華山醫(yī)院營(yíng)養(yǎng)科 上海 200040;
4. 復(fù)旦大學(xué)附屬上海市第五人民醫(yī)院營(yíng)養(yǎng)科 上海 200240

收稿日期：2019-07-01；網(wǎng)絡(luò)首發(fā)時(shí)間: 2020-05-27 13:49:36

基金項(xiàng)目：上海市靜安區(qū)科委醫(yī)學(xué)科研課題（2016MS15）

摘要：目的 以健康信念模型（health belief model，HBM）為理論基礎(chǔ)，探索影響冠心病患者遵醫(yī)行為的影響因素。方法 采用橫斷面調(diào)查研究，對(duì)上海市靜安區(qū)189例社區(qū)冠心病患者進(jìn)行問(wèn)卷調(diào)查。調(diào)查內(nèi)容包括人口社會(huì)學(xué)特征、冠心病患病情況、健康信念模型維度（疾病易感性、疾病嚴(yán)重性、行為益處、行為障礙和自我效能）；通過(guò)Morisky量表評(píng)價(jià)服藥依從性和健康促進(jìn)生活方式量表Ⅱ（health promoting lifestyle profile Ⅱ，HPLP-Ⅱ）評(píng)價(jià)健康生活方式的依從性。采用t檢驗(yàn)和F檢驗(yàn)分析人口學(xué)特征對(duì)健康促進(jìn)生活方式和遵醫(yī)服藥行為的影響。采用Pearson相關(guān)分析和多元線性回歸分析健康信念模型各維度與健康促進(jìn)生活方式和遵醫(yī)服藥行為之間的關(guān)系。結(jié)果 189例患者中，男性占38.6%，女性占61.4%，137例大于60歲。健康信念模型各維度與健康促進(jìn)生活方式各維度及遵醫(yī)服藥行為均成顯著正相關(guān)，r值為0.173~0.734。多元線性回歸分析結(jié)果顯示：感知障礙（β=0.190，P=0.021）對(duì)健康責(zé)任的影響有統(tǒng)計(jì)學(xué)意義（R2=0.073，P=0.016），感知易感性（β=0.134，P=0.008）對(duì)身體活動(dòng)的影響有統(tǒng)計(jì)學(xué)意義（R2=0.274，P＜0.001），感知嚴(yán)重性（β=0.221，P=0.005）和感知益處（β=0.100，P=0.008）對(duì)精神成長(zhǎng)的影響有統(tǒng)計(jì)學(xué)意義（R2=0.423，P＜0.001），感知益處（β=0.181，P=0.026）對(duì)壓力管理的影響有統(tǒng)計(jì)學(xué)意義（R2=0.302，P＜0.001）；感知易感性（β=0.689，P=0.027）、感知嚴(yán)重性（β=0.580，P=0.003）、感知障礙（β=0.689，P=0.002）和自我效能（β=0.417，P=0.023）對(duì)遵醫(yī)服藥行為的影響有統(tǒng)計(jì)學(xué)意義（R2=0.645，P＜0.001）。結(jié)論 健康信念模型中各維度對(duì)冠心病患者的遵醫(yī)服藥行為和健康促進(jìn)生活方式有影響，可以通過(guò)提升患者的健康信念，增強(qiáng)冠心病患者遵醫(yī)服藥行為和健康生活方式的依從性。

關(guān)鍵詞：冠心病    遵醫(yī)服藥行為    健康促進(jìn)生活方式    健康信念模型（HBM）    

Factors associated with medication adherence in community patients with coronary artery disease based on health belief model(HBM): a cross-sectional study

FANG Jia-lie1 , CHEN Wan-li2 , WANG Jing-ya2 , ZHAO Jie2 , WANG Ji-wei2 , SHAO Chun-hai3,4     

1. Jing'an District Center for Disease Control and Prevention, Shanghai 200072, China;
2. Key Lab of Health Technology Assessment of National Health Commission-School of Public Health, Fudan University, Shanghai 200032, China;
3. Department of Nutrition, Huashan Hospital, Fudan University, Shanghai 200040, China;
4. Department of Nutrition, Shanghai Fifth People's Hospital, Fudan University, Shanghai 200240, China

Foundation item: This work was supported by the Medical Research Project of Shanghai Jing'an District Science and Technology Commission (2016MS15)

Abstract: Objective To explore factors affecting medication adherence in patients with coronary artery disease (CAD) based on Health Belief Model (HBM). Methods This community register-based, cross-sectional study consisted of individuals diagnosed with CAD in Jing'an District of Shanghai (n=189).The data were obtained through face-to-face interviews using a questionnaire covering sociodemographic characteristics, CAD status, HBM variables, Health-Promoting Lifestyle Profile Ⅱ (HPLP-Ⅱ), and the 8-item Morisky Medication Adherence Scales (MMAS-8).The independent two-sample t-test and F-test were used to analyze the influence of demographic characteristics on health-promoting lifestyle and medication adherence.Pearson's correlations were used to analyze associations among variables.Multiple linear regression models were used to evaluate effects of HBM variables on adherence to medication behavior, and health-promoting lifestyles. Results Among the 189 patients, 38.6% were males and 61.4% were females, 137 cases were over 60 years old. There were significant positive correlations between the HBM variables, adherence to health promoting lifestyles and medication behavior. The value of the correlation coefficient varies from 0.173 to 0.734. Multiple linear regression analysis suggested that the perceived barriers (β=0.190, P=0.021) on health responsibility (R2=0.073, P=0.016), the perceived susceptibility (β=0.134, P=0.008) on physical activity (R2=0.274, P < 0.001), the perceived severity (β=0.221, P=0.005) and the perceived benefits (β=0.100, P=0.008) on mental growth (R2=0.423, P < 0.001), the perceived benefit (β=0.181, P=0.026) on stress management (R2=0.302, P < 0.001), were significant impact factors, respectively.Additionally, the perceived susceptibility (β=0.689, P=0.027), perceived severity (β=0.580, P=0.003), perceived impairment (β=0.689, P=0.002), and self-efficacy (β=0.417, P=0.023) had a statistically significant effects on medication behavior (R2=0.645, P < 0.001). Conclusion The HBM provides a useful framework for investigating predictors of medication adherence in patients with CAD.Future intervention to improve medication adherence should focus on changing the health beliefs among patients with CAD.

Key words: coronary artery disease    medication adherence    health-promoting lifestyles    health belief model(HBM)    

2017年發(fā)布的《中國(guó)心血管病報(bào)告》推算，我國(guó)心血管疾病現(xiàn)患人數(shù)2.9億，其中冠心病1 100萬(wàn)[1]。隨著人們生活方式、飲食習(xí)慣、工作方式的改變及遺傳因素的影響，我國(guó)冠心病的發(fā)病率逐漸上升，而發(fā)病年齡逐漸下降[2-3]。冠心病反復(fù)發(fā)作嚴(yán)重影響患者生活質(zhì)量，給個(gè)人、家庭及社會(huì)帶來(lái)沉重的經(jīng)濟(jì)負(fù)擔(dān)[4]。此外，冠心病還具有遷延不愈及治療周期長(zhǎng)的特點(diǎn), 故多數(shù)患者依從性差，預(yù)后轉(zhuǎn)歸不佳[5], 而依從性不佳對(duì)健康有許多不利影響[6-7]。一項(xiàng)針對(duì)3萬(wàn)多名急性心肌梗死幸存者的縱向觀察研究中發(fā)現(xiàn)，急性心肌梗死后第一年對(duì)他汀類藥物的依從性差，死亡風(fēng)險(xiǎn)增加25%[8]。此外，有研究顯示采取健康的生活方式與中年女性冠狀動(dòng)脈事件發(fā)生率降低[9]和女性冠心病死亡風(fēng)險(xiǎn)降低有關(guān)[10]。因此，遵從醫(yī)務(wù)人員的建議堅(jiān)持服藥、改變生活方式對(duì)冠心病的二級(jí)預(yù)防至關(guān)重要[11]。提高冠心病患者的服藥依從性、促進(jìn)冠心病患者采取健康生活方式可以改善患者的預(yù)后和康復(fù)。

健康信念模型(health belief model, HBM)是考慮個(gè)人因素對(duì)行為方式影響的重要理論之一，強(qiáng)調(diào)個(gè)人對(duì)某一問(wèn)題的態(tài)度和信念，以及對(duì)采取預(yù)防行為的利益和障礙評(píng)估后可能導(dǎo)致特定的行為[12]。健康信念模型通常包括5個(gè)維度，分別為感知易感性、感知嚴(yán)重性、感知益處、感知障礙和自我效能。感知易感性描述了人們?cè)谀承┣闆r下知道他獲得負(fù)面健康結(jié)果的風(fēng)險(xiǎn)的主觀信念；感知嚴(yán)重性是指?jìng)€(gè)人對(duì)潛在危害的主觀認(rèn)知；感知益處是指對(duì)采取預(yù)防行為的好處的認(rèn)知；感知障礙包括參與特定行為的主觀困難；自我效能指人對(duì)自己是否能夠成功地進(jìn)行某一行為的主觀判斷。健康信念模型廣泛應(yīng)用于解釋與健康有關(guān)的行為的改變，如飲食、身體活動(dòng)以及高血壓、糖尿病患者的治療依從性，并指導(dǎo)健康行為干預(yù)[13-15]，但較少用于解釋中國(guó)冠心病患者的遵醫(yī)服藥行為和健康生活方式。因此，本研究旨在以健康信念模型為理論基礎(chǔ)，了解健康信念模型各維度對(duì)冠心病患者遵醫(yī)行為的影響，為改善冠心病患者的遵醫(yī)服藥行為和健康生活方式提供干預(yù)靶點(diǎn)。本研究中的遵醫(yī)行為包括遵醫(yī)服藥行為和采取健康生活方式兩方面。

資料和方法

研究對(duì)象  2018年6月至9月，我們通過(guò)上海市靜安區(qū)市民電子健康檔案平臺(tái)篩選調(diào)查對(duì)象，采用簡(jiǎn)單隨機(jī)法選擇200名經(jīng)區(qū)級(jí)以上醫(yī)院確診、且在社區(qū)衛(wèi)生服務(wù)中心定期隨診的冠心病患者進(jìn)行調(diào)查。入選標(biāo)準(zhǔn)參考Honda等[16]的研究，符合以下情況之一的冠心病患者：冠狀動(dòng)脈造影至少有1支病變狹窄程度≥50%；穩(wěn)定型心絞痛(stable angina, SA)；不穩(wěn)定型心絞痛(unstable angina, USA)；陳舊心肌梗死(old myocardial infarction, OMI)；急性心肌梗死(acute myocardial infarction, AMI)；經(jīng)皮冠狀動(dòng)脈介入(percutaneous coronary intervention, PCI)術(shù)后；外科冠狀動(dòng)脈搭橋(coronary artery bypass graft, CABG)術(shù)后；缺血性心肌病等。其他必須標(biāo)準(zhǔn)為18~70歲；具有讀寫(xiě)和認(rèn)知能力；無(wú)其他嚴(yán)重疾病。使用樣本量計(jì)算公式$n = frac{{{rm{z}}_{{mathit{α }}/2}^2pleft( {1 - p} right)}}{{{{rmgek000m}^2}}}$，取α=0.05，d=0.15p。冠心病患者的服藥依從率為52.9%[17]，據(jù)此計(jì)算樣本量為153，考慮20%的無(wú)應(yīng)答率，將樣本量擴(kuò)大至184，取整數(shù)200。本次研究共調(diào)查200例患者，回收問(wèn)卷189份，回收率為94.5%，均為有效問(wèn)卷。由靜安區(qū)社區(qū)衛(wèi)生服務(wù)中心的醫(yī)師對(duì)調(diào)查對(duì)象進(jìn)行問(wèn)卷調(diào)查，調(diào)查前統(tǒng)一對(duì)調(diào)查員進(jìn)行培訓(xùn)。調(diào)查問(wèn)卷當(dāng)場(chǎng)回收。

調(diào)查問(wèn)卷  健康信念模型問(wèn)卷根據(jù)健康信念模型[18]自行編制而成，共15個(gè)條目，包括疾病的感知易感性、感知嚴(yán)重性、感知效益、感知障礙和自我效能等維度。采用5分Likert量表計(jì)分，分?jǐn)?shù)越高表明健康信念越好。本研究中健康信念模型問(wèn)卷的Cronbach's α為0.945，各維度的內(nèi)部一致性系數(shù)為0.675~0.917，信度良好。

健康促進(jìn)生活方式量表Ⅱ（health-promoting lifestyle profile Ⅱ，HPLP-Ⅱ）[19]共包含52個(gè)項(xiàng)目，6個(gè)維度（健康責(zé)任、身體活動(dòng)、營(yíng)養(yǎng)、精神成長(zhǎng)、人際關(guān)系和壓力管理）。所有項(xiàng)目都按照4分Likert量表（1分：從不；2分：有時(shí)；3分：經(jīng)常；4分：總是）計(jì)分。健康促進(jìn)生活方式和各維度的得分使用52項(xiàng)和每個(gè)子量表（8項(xiàng)或9項(xiàng)）的平均得分來(lái)計(jì)算，分?jǐn)?shù)越高表示健康行為水平越高。中文版HPLP-Ⅱ在國(guó)內(nèi)廣泛使用，具有良好的信效度[20-21]，本研究中量表的Cronbach's α為0.964，各維度內(nèi)部一致性系數(shù)為0.806~0.906，信度良好。

遵醫(yī)服藥行為量表（Morisky Medication Adherence Scales，MMAS-8）[22]是使用最廣的用于測(cè)定遵醫(yī)服藥行為的自評(píng)問(wèn)卷，共有8個(gè)條目，得分越高表明遵醫(yī)服藥行為越好。該量表中文版用于中國(guó)心血管疾病患者具有良好的信效度[23]。

統(tǒng)計(jì)學(xué)處理  統(tǒng)計(jì)軟件使用SPSS 22.0。對(duì)調(diào)查對(duì)象的基本情況進(jìn)行描述性分析，計(jì)數(shù)資料用例數(shù)和百分?jǐn)?shù)（%）表示，計(jì)量資料用x±s表示。采用t檢驗(yàn)和F檢驗(yàn)分析人口學(xué)特征對(duì)健康促進(jìn)生活方式和遵醫(yī)服藥行為的影響。采用Pearson相關(guān)分析和多元線性回歸分析健康信念模型、健康促進(jìn)生活方式和遵醫(yī)服藥行為之間的關(guān)系。所有統(tǒng)計(jì)學(xué)檢驗(yàn)均為雙側(cè)檢驗(yàn)，以P＜0.05為差異有統(tǒng)計(jì)學(xué)意義。

結(jié)果

調(diào)查對(duì)象基本情況  被調(diào)查者平均年齡為（64.04±9.93）歲，其中60歲及以下52人（27.5%）；60歲以上137人（72.5%）。男性73名（38.6%）、女性116名（61.4%）；被調(diào)查者月經(jīng)濟(jì)收入以3 000~4 000元為主（50.8%）。具體見(jiàn)表 1。

表 1 社區(qū)冠心病患者基本情況Tab 1 Basic situation of the community patients with coronary artery disease

Basic Features Number Composition ratio（%） Age（y）  ≤60 52 27.5  ＞60 137 72.5 Gender  Male 73 38.6  Female 116 61.4 Marital status  Married 168 88.9  Othersa 21 11.1 Educational levels  Junior high school and below 86 45.5  High school and so onb 92 48.7  Undergraduate and above 11 5.8 Employment status  Ill retirement or retirement 157 83.1  Other 32 16.9 Monthly income（yuan）  ≤3 000 36 19.0  3 000-4 000 96 50.8  ＞4 000 57 30.2 Average monthly household income（yuan）  ≤3 000 25 13.2  3 000-6 000 103 54.5  ＞6 000 61 32.3aIncluding unmarried, divorced, widowed, separated and unmarried cohabitation; bIncluding secondary professional technical school, technical school, junior college and vocational high school.

人口學(xué)特征對(duì)健康促進(jìn)生活方式和遵醫(yī)服藥行為的影響  t檢驗(yàn)和F檢驗(yàn)分析結(jié)果顯示，健康促進(jìn)生活方式和遵醫(yī)服藥行為在人口學(xué)特征上的差異均無(wú)統(tǒng)計(jì)學(xué)意義（表 2）。性別、年齡、婚姻狀況、受教育程度和個(gè)人月收入等情況不會(huì)對(duì)健康促進(jìn)生活方式和遵醫(yī)服藥行為產(chǎn)生影響。

表 2 健康促進(jìn)生活方式和遵醫(yī)服藥行為在不同人口學(xué)特征社區(qū)冠心病患者中的分布Tab 2 Distributions of health promotion lifestyle and medication adherence in community patients with coronary artery disease and different sociodemographic characteristics

Index Health responsibility Physical activity Nutritional status Mental growth Interpersonal relationship Stress management Medication adherence Age（y）  ≤60 2.43±0.49 2.20±0.62 2.64±0.52 2.60±0.73 2.62±0.52 2.31±0.46 5.37±2.23  ＞60 2.42±0.46 2.36±0.62 2.74±0.54 0.61±0.63 0.65±0.49 2.40±0.49 5.36±1.99  t 0.159 -1.496 -1.142 -0.100 -0.394 -1.132 0.018  P 0.874 0.136 0.255 0.920 0.694 0.259 0.986 Gender  Male 2.45±0.47 2.31±0.64 2.67±0.54 2.63±0.65 2.67±0.51 2.39±0.48 5.49±2.06  Female 2.40±0.47 2.32±0.61 2.73±0.54 2.59±0.67 2.63±0.49 2.37±0.49 5.28±2.06  t 0.745 -0.103 -0.736 0.320 0.544 0.319 0.700  P 0.457 0.918 0.463 0.749 0.587 0.750 0.485 Marital status  Married 2.44±0.47 2.34±0.60 2.72±0.51 2.62±0.63 2.66±0.48 2.39±0.48 5.36±2.06  Othersa 2.29±0.39 2.05±0.77 2.58±0.66 2.47±0.92 2.53±0.64 2.30±0.57 5.18±2.07  t 1.415 1.658 0.905 0.715 0.909 0.825 0.389  P 0.159 0.111 0.375 0.482 0.373 0.410 0.698 Educational levels  Junior high school and below l 2.36±0.42 2.32±0.61 2.67±0.52 2.57±0.67 2.58±0.47 2.37±0.47 5.20±2.07  High school and so onb 2.47±0.51 2.28±0.63 2.74±0.55 2.61±0.66 2.69±0.50 2.37±0.49 5.48±2.00 Undergraduate and above 2.43±0.45 2.57±0.68 2.72±0.58 2.87±0.64 2.79±0.62 2.52±0.51 5.55±2.38  F 1.199 1.054 0.354 0.988 1.604 0.510 0.465  P 0.304 0.351 0.703 0.374 0.204 0.601 0.629 Monthly income（yuan）  ≤3 000 2.45±0.42 2.28±0.64 2.72±0.54 2.56±0.68 2.63±0.44 2.39±0.49 4.97±2.06  3 000-4 000 2.37±0.48 2.27±0.64 2.68±0.54 2.56±0.70 2.58±0.52 2.35±0.53 5.59±1.98  ＞4 000 2.47±0.47 2.40±0.60 2.73±0.52 2.69±0.58 2.74±0.47 2.42±0.40 5.19±2.05  F 0.990 0.763 0.214 0.812 1.872 0.456 1.436  P 0.374 0.468 0.807 0.446 0.157 0.634 0.240aIncluding unmarried, divorced, widowed, separated and unmarried cohabitation; bIncluding Secondary professional technical school, technical school, junior college, vocational high school.

健康信念模型與健康促進(jìn)生活方式和遵醫(yī)服藥行為的相關(guān)性  健康信念模型各維度與健康促進(jìn)生活方式各維度及遵醫(yī)服藥行為均成顯著正相關(guān)，相關(guān)系數(shù)范圍為0.173~0.734（表 3）。健康促進(jìn)生活方式和遵醫(yī)服藥行為的得分隨健康信念模型得分升高而升高。

表 3 社區(qū)冠心病患者健康信念模型、健康促進(jìn)生活方式和遵醫(yī)服藥行為的相關(guān)分析Tab 3 Correlation analysis of health belief model, health promotion lifestyle and medication behavior in community patients with coronary artery disease

Index x±s Cronbach's α 1 2 3 4 5 6 7 8 9 10 11 1.The perceived susceptibility 3.34±0.53 0.818 1 2.The perceived severity 3.45±0.76 0.903 0.741(1) 1 3.The perceived benefits 3.21±0.75 0.917 0.780(1) 0.703(1) 1 4.The perceived barriers 3.13±0.65 0.675 0.643(1) 0.567(1) 0.765(1) 1 5.Self-efficacy 2.90±0.76 0.726 0.665(1) 0.632(1) 0.715(1) 0.641(1) 1 6.Health responsibility 2.42±0.47 0.827 0.177(2) 0.133 0.206(1) 0.268(1) 0.173(2) 1 7.Physical activity 2.31±0.62 0.875 0.501(1) 0.446(1) 0.467(1) 0.363(1) 0.348(1) 0.600(1) 1 8.Nutritional status 2.71±0.54 0.824 0.415(1) 0.408(1) 0.414(1) 0.390(1) 0.355(1) 0.678(1) 0.756(1) 1 9.Mental growth 2.61±0.66 0.906 0.569(1) 0.568(1) 0.604(1) 0.518(1) 0.432(1) 0.552(1) 0.699(1) 0.742(1) 1 10.Interpersonal relationship 2.64±0.50 0.844 0.431(1) 0.439(1) 0.468(1) 0.410(1) 0.361(1) 0.629(1) 0.573(1) 0.733(1) 0.845(1) 1 11.Stress management 2.38±0.48 0.806 0.484(1) 0.425(1) 0.530(1) 0.467(1) 0.426(1) 0.663(1) 0.778(1) 0.757(1) 0.815(1) 0.739(1) 1(1)Correlation is significant when the confidence (double test) is 0.01；(2)Correlation is significant when the confidence (double test) is 0.05.

健康信念模型對(duì)健康促進(jìn)生活方式和遵醫(yī)服藥行為的影響  以健康促進(jìn)生活方式各維度及遵醫(yī)服藥行為為因變量，健康信念模型各維度為自變量進(jìn)行多元線性回歸分析，結(jié)果顯示:感知障礙（β=0.190，P=0.021）對(duì)健康責(zé)任的影響有統(tǒng)計(jì)學(xué)意義，感知易感性（β=0.134，P=0.008）對(duì)身體活動(dòng)的影響有統(tǒng)計(jì)學(xué)意義，感知嚴(yán)重性（β=0.221，P=0.005）和感知益處（β=0.100，P=0.008）對(duì)精神成長(zhǎng)的影響有統(tǒng)計(jì)學(xué)意義，感知益處（β=0.181，P=0.026）對(duì)壓力管理的影響有統(tǒng)計(jì)學(xué)意義；感知易感性（β=0.689，P=0.027）、感知嚴(yán)重性（β=0.580，P=0.003）、感知障礙（β=0.689，P=0.002）和自我效能（β=0.417，P=0.023）對(duì)遵醫(yī)服藥行為的影響有統(tǒng)計(jì)學(xué)意義（表 4）。

表 4 社區(qū)冠心病患者健康信念模型、健康促進(jìn)生活方式和遵醫(yī)服藥行為的多元線性回歸分析Tab 4 Multiple linear regression analysis of health belief model, health promotion lifestyle and medication behavior in community patients with coronary artery disease

Dependent variable Independent variable B value Standard error β value t value P R2 F value P Health responsibility The perceived susceptibility 0.030 0.113 0.034 0.268 0.789 0.073 2.874 0.016 The perceived severity -0.034 0.070 -0.054 -0.483 0.630 The perceived benefits 0.005 0.089 0.009 0.060 0.952 The perceived barriers 0.190 0.082 0.263 2.325 0.021 Self-efficacy 0.006 0.067 0.010 0.091 0.928 Physical activity The perceived susceptibility 0.357 0.134 0.302 2.666 0.008 0.274 13.827 ＜0.001 The perceived severity 0.112 0.082 0.136 1.361 0.175 The perceived benefits 0.162 0.106 0.196 1.530 0.128 The perceived barriers -0.012 0.097 -0.012 -0.124 0.901 Self-efficacy -0.058 0.079 -0.070 -0.731 0.465 Nutritional status The perceived susceptibility 0.133 0.120 0.131 1.114 0.267 0.215 10.030 ＜0.001 The perceived severity 0.119 0.074 0.168 1.619 0.107 The perceived benefits 0.047 0.094 0.066 0.500 0.618 The perceived barriers 0.123 0.087 0.148 1.416 0.158 Self-efficacy 0.014 0.070 0.019 0.194 0.846 Mental growth The perceived susceptibility 0.180 0.127 0.143 1.418 0.158 0.423 26.781 ＜0.001 The perceived severity 0.221 0.078 0.253 2.841 0.005 The perceived benefits 0.267 0.100 0.305 2.677 0.008 The perceived barriers 0.131 0.092 0.128 1.428 0.155 Self-efficacy -0.107 0.075 -0.123 -1.438 0.152 Interpersonal relationship The perceived susceptibility 0.067 0.108 0.071 0.618 0.538 0.250 12.172 ＜0.001 The perceived severity 0.127 0.067 0.193 1.902 0.059 The perceived benefits 0.141 0.085 0.215 1.651 0.100 The perceived barriers 0.086 0.078 0.112 1.098 0.274 Self-efficacy -0.022 0.064 -0.033 -0.342 0.733 Stress management The perceived susceptibility 0.126 0.102 0.137 1.236 0.218 0.302 15.824 ＜0.001 The perceived severity 0.023 0.063 0.036 0.368 0.713 The perceived benefits 0.181 0.081 0.281 2.243 0.026 The perceived barriers 0.091 0.074 0.121 1.230 0.220 Self-efficacy 0.022 0.060 0.034 0.360 0.720 Medication adherence The perceived susceptibility 0.689 0.310 0.177 2.225 0.027 0.645 66.587 ＜0.001 The perceived severity 0.580 0.191 0.213 3.044 0.003 The perceived benefits 0.461 0.245 0.169 1.883 0.061 The perceived barriers 0.689 0.224 0.217 3.082 0.002 Self-efficacy 0.417 0.182 0.154 2.290 0.023

討論

本研究通過(guò)對(duì)冠心病患者健康促進(jìn)生活方式及遵醫(yī)服藥行為的調(diào)查，評(píng)估了健康信念模型各維度對(duì)冠心病患者遵醫(yī)行為的影響。多元回歸分析結(jié)果表明健康信念模型中感知易感性、感知嚴(yán)重性、感知障礙和自我效能是遵醫(yī)服藥行為的影響因素；感知障礙是健康責(zé)任的影響因素，感知易感性是身體活動(dòng)的影響因素，感知嚴(yán)重性和感知益處是精神成長(zhǎng)的影響因素，感知益處是壓力管理的影響因素。

患者對(duì)健康促進(jìn)生活方式和遵醫(yī)服藥行為的依從性不受性別、年齡、婚姻狀況、受教育程度和個(gè)人月收入等因素的影響。也有研究表明年齡、受教育程度、個(gè)人月收入等是冠心病患者健康促進(jìn)生活方式的影響因素[24-25]。Kulkarni等[26]對(duì)1 326名冠心病患者的調(diào)查結(jié)果顯示，性別、受教育程度和婚姻狀況是遵醫(yī)服藥行為的影響因素，男性、受教育程度較高和已婚的患者依從性更好。本研究結(jié)果與其他類似研究結(jié)果有差異，提示我們應(yīng)關(guān)注人口社會(huì)學(xué)因素以外的其他可干預(yù)變量對(duì)健康促進(jìn)生活方式和遵醫(yī)服藥行為的影響。

感知易感性和感知嚴(yán)重性是患者對(duì)自己所患疾病的認(rèn)識(shí)，患有相同疾病的患者可能對(duì)其病情有不同的認(rèn)識(shí)[27]，從而導(dǎo)致治療依從性的不同。冠心病患者意識(shí)到疾病對(duì)健康的嚴(yán)重危害，或認(rèn)為自己發(fā)生心梗的可能性較高時(shí)，更傾向于聽(tīng)從醫(yī)師的建議，服藥的依從性更高，也更注重健康的生活方式。自我效能是慢性病患者的廣泛健康行為的已知預(yù)測(cè)因子，包括藥物依從性[28]。自我效能較高、感知障礙較少的個(gè)體更易遵從醫(yī)師的建議服藥。當(dāng)患者具有高度的自信心和毅力時(shí)，就可以在長(zhǎng)期的治療中堅(jiān)持下來(lái)，從而達(dá)到自我期望的結(jié)果。

健康責(zé)任是指?jìng)€(gè)人對(duì)自己的健康狀況有積極的責(zé)任感，包括關(guān)注自己的健康，了解如何保持健康以及如何尋求專業(yè)的幫助[19]。感知障礙是健康責(zé)任的影響因素，感知障礙越少，個(gè)人的健康責(zé)任越高。冠心病患者若主觀上認(rèn)為困難少，可增強(qiáng)其對(duì)自身健康負(fù)責(zé)的信心，從而愿意在日常生活中關(guān)注自身健康。感知易感性是身體活動(dòng)的正向影響因素。要發(fā)生行為改變，人們必須感受到當(dāng)前行為模式的威脅，并認(rèn)為通過(guò)改變可以獲得有益的結(jié)果，也要有能力進(jìn)行改變[29]。冠心病患者基于對(duì)疾病的認(rèn)識(shí)及目前身體狀況判斷自己容易發(fā)生或再次發(fā)生心梗，會(huì)促使患者遵從醫(yī)師建議的生活方式，從而增加身體活動(dòng)。感知益處對(duì)精神成長(zhǎng)和壓力管理有正向影響。冠心病患者在日常生活中需要面對(duì)疾病帶來(lái)的壓力，如焦慮、抑郁、身體活動(dòng)受限，以及疾病帶來(lái)的經(jīng)濟(jì)壓力等問(wèn)題，當(dāng)患者感知采取健康生活方式和遵醫(yī)服藥行為對(duì)于自己的病情有幫助時(shí)，可以增加個(gè)人對(duì)疾病的控制感，有助于患者的精神成長(zhǎng)和壓力管理。

健康信念模型對(duì)遵醫(yī)服藥行為和健康促進(jìn)生活方式有積極影響，健康信念得分越高, 患者對(duì)健康促進(jìn)生活方式和遵醫(yī)服藥行為的依從性越好。這表明進(jìn)行健康教育，使患者意識(shí)到冠心病的嚴(yán)重性以及改變生活方式對(duì)健康的益處，可以改善服藥依從性，增加身體活動(dòng)。健康的生活方式不僅是適量的身體活動(dòng)，還包括均衡的營(yíng)養(yǎng)、良好的人際關(guān)系等，因此生活方式的改變還需要外部支持，如家人、朋友的支持、周邊環(huán)境的改善等。沒(méi)有任何單一的方法能有效改善患者的依從性[30]，提高冠心病患者的遵醫(yī)行為不僅要醫(yī)師的幫助，還需要家人和社會(huì)的支持。

本研究還存在一些局限性：（1）本次調(diào)查中拒絕參加調(diào)查者11人，其中男性8人、女性3人，可能導(dǎo)致無(wú)應(yīng)答偏倚。（2）本次研究樣本量較少，無(wú)法按疾病類型進(jìn)行亞組分析，疾病類型可能與冠心病患者遵醫(yī)行為有密切關(guān)系，未來(lái)可進(jìn)行進(jìn)一步研究。（3）本研究為橫斷面研究，無(wú)法確定健康信念和遵醫(yī)行為的因果關(guān)系，需進(jìn)行干預(yù)研究以驗(yàn)證兩者之間的關(guān)系。

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