Health behavior models and relevant influencing factors related to medication adherence
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摘要: 依从性是指患者(或个体)在服药、饮食调整及生活方式改变等方面, 其行为与卫生保健服务提供者专业建议的契合程度。依从性对个体健康和治疗效果具有重大意义。本研究对服药依从性相关的健康行为理论模型及其作用原理进行了综述。同时基于WHO提出的依从性5个维度, 系统总结了影响服药依从性的社会经济、医疗保健系统、疾病、治疗、患者特征等多层面因素, 为提高患者服药依从性、改善预后提供参考依据。Abstract: Adherence is defined as the extent to which a patient′s or individual′s behavior aligns with the professional recommendation of the healthcare provider regarding medication, dietary modifications, and lifestyle alterations. Adherence is important to a patient′s or individual′s health status and treatment outcome. We summarized health behavior models of medication adherence and underlying principles. Furthermore, we systematically reviewed the relevant influencing factors regarding socio-economic status, the healthcare system, diseases, treatments, and patient characteristics that would affect patients′ medication adherence, based on the five dimensions of adherence proposed by the World Health Organization. Findings in this study would provide scientific evidence to improve patients′ medication adherence and prognosis outcomes.
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表 1 依从性研究中常见健康行为理论模型的比较
Table 1. Comparisons of health behavior models of medication adherence: summarizing the strengths, limitations, and application areas of each model
健康行为理论模型 优势 局限性 应用领域 计划行为理论 强调个体对行为的意向在预测行为中的关键作用。包含主观规范和知觉行为控制两个重要的社会心理因素, 使得模型更全面。在多个健康行为领域得到了广泛验证, 具有较高的预测力和解释力。 忽视了情绪、情感等非理性因素在行为决策中的作用。在某些复杂行为或长期行为的预测上可能不够准确。 药物依从性运动依从性饮食依从性术后康复依从性手部卫生依从性 信息-动机-行为技巧理论 整合信息、动机和行为技巧3个关键要素, 提供了一个全面的行为改变框架强调信息在行为改变中的重要性。适用于多种健康促进和疾病预防项目。 在某些情况下, 可能难以准确测量和评估信息、动机和行为技巧的水平。忽略了社会环境和文化因素对行为的影响。 药物依从性饮食依从性运动依从性暴露前预防依从性筛查依从性自我监测依从性 健康信念模型 强调个体对健康行为后果的信念对行为的影响。为健康教育和健康促进项目提供了有效的干预设计框架。 可能过于简化个体对健康行为的决策过程。较少考虑社会网络和社会支持对行为的影响。 药物依从性持续气道正压通气依从性暴露前预防依从性生活方式依从性 保护动机理论 强调威胁评估和应对评估在行为决策中的作用, 有助于理解个体在面临健康风险时的心理过程。提供了具体的干预策略, 如增强恐惧诉求、提高自我效能等。 过度强调恐惧诉求可能引发个体的焦虑或逃避行为。在某些情况下, 可能低估了其他非理性因素(如习惯、价值观等)对行为的影响。 手部卫生依从性康复依从性新冠前预防依从性饮食依从性疫苗接种依从性 社会网络与社会支持理论 强调社会网络和社会支持在行为改变中的重要作用, 有助于理解行为的社会影响因素。提供了多种干预策略, 如增强社会联系、提供情感支持等。 在某些情况下, 可能难以准确测量和评估社会网络和社会支持的质量。忽略了个人因素(如动机、信念等)在行为决策中的作用。 暴露前预防依从性药物依从性医疗保健依从性 社会认知理论 承认认知因素在激励和使人们采取行动和改变其行为方面的作用。社会认知理论为设计旨在提高自我效能的干预措施提供了框架。 可能忽略了情感和动机的概念。社会认知理论包含多个概念和变量可能增加研究的复杂性。 手部卫生依从性药物依从性运动依从性 社会生态学模型 强调个体、人际、社区、组织、政策等多个层面因素对行为的影响, 提供了一个全面的分析框架。可以指导多层次、多维度的干预策略。 在实际操作中, 可能难以准确测量和评估各个层面因素的影响程度。模型较为复杂, 需要综合考虑多个因素, 可能导致研究和分析的复杂性增加 药物依从性筛查依从性运动依从性暴露前预防依从性 实施性研究综合框架 了解干预在多个环境中有效、在哪里有效以及为什么有效。提供了多维度、多层次的评估框架, 能够全面、系统地分析影响干预实施过程中的各种因素。适用于卫生服务提供背景下的实施有效性评估, 同时也适用于其他领域, 如教育、企业管理等。 作为一个框架而非理论模型, 其理论深度可能较浅。其设计和应用基于一定的假设和前提条件。在实际应用中需要根据具体情况进行灵活调整和应用。 实施低成本电子依从性检测仪的有效性非药物性精神错乱预防方案依从性干预HPV疫苗接种依从性实施电子监护仪改善结核病患者依从性提高对HPV阳性妇女分类的依从性城市医院环境中眼科就诊依从性 
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表 2 服药依从性的影响因素维度、各维度具体的影响因素以及用于探讨该维度影响因素的健康行为理论模型
Table 2. Influencing-factor dimension of medication adherence, specific influencing factors of this dimension, and health behavior models utilized to explore influencing factors of this dimension
服药依从性的影响因素维度 该维度上具体的影响因素 用于探讨该维度影响因素的健康行为理论模型 社会经济因素维度 患者的经济状况、社会地位、受教育程度、家庭功能、社会支持网络, 以及生活环境等, 这些社会人口和经济变量可共同作用于患者的服药行为。 社会生态学模型社会认知理论社会网络与社会支持理论实施性研究综合框架 医疗保健系统因素维度 医疗资源的分配、医疗服务的可及性、社区支持和自我管理建设能力以及医患关系的质量等都会影响患者的服药依从性[33]。如医疗系统能够提供便捷、高效的服务, 并且医生与患者之间建立良好的信任关系, 患者的服药依从性往往会更高[34]。 社会生态学模型社会认知理论社会网络与社会支持理论实施性研究综合框架 疾病相关因素维度 症状的严重程度、残疾程度(涉及身体、心理、社会和职业多个方面)、疾病的进展速度和恢复程度、并发症, 以及有效治疗的可获得性等, 都会对患者的风险认知、后续治疗重要性感知及患者对依从性的优先级产生深远影响。 信息-动机-行为模型保护动机理论社会认知理论 治疗相关因素维度 医疗方案的复杂性、治疗持续时间的长短、以往治疗失败的经历、治疗方案的频繁变动、药物的有益效果及不良反应的即时表现, 以及患者在处理这些问题时能够获得的医疗支持等, 都会直接影响患者的服药行为[35]。 信息-动机-行为模型保护动机理论社会网络与社会支持理论社会认知理论实施性研究综合框架 患者相关因素维度 资源、知识、态度、信念、感知和期望等与患者相关的因素均会显著影响服药依从性[36]。其中, 疾病管理和治疗知识的缺乏、疾病风险认知不足、对药物不良反应和治疗结果的担忧、对药物依赖的恐惧、对治疗效果的负面看法或误解、对诊断的不信任、对医疗提供者的失望等心理和情感因素, 均可能动摇患者的治疗信念和自我效能[37]。此外, 动力不足、对治疗需求感知不足、对复杂治疗方案的焦虑、疾病耻辱感、低治疗期望值以及心理社会压力和遗忘等, 也会进一步影响患者的服药行为[38]。 计划行为理论信息-动机-行为模型健康信念模型社会认知理论社会生态学模型实施性研究综合框架
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