医患关系：依恋理论与糖尿病治疗依从性
The patient-provider relationship: attachment theory and adherence to treatment in diabetes.
作者信息
Ciechanowski P S, Katon W J, Russo J E, Walker E A
机构信息
Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, USA.
出版信息
Am J Psychiatry. 2001 Jan;158(1):29-35. doi: 10.1176/appi.ajp.158.1.29.
OBJECTIVE
Lack of adherence to diabetic self-management regimens is associated with a high risk of diabetes complications. Previous research has shown that the quality of the patient-provider relationship is associated with adherence to diabetes treatment. This study attempts to improve understanding of both patient and provider factors involved in lack of adherence to treatment in diabetic patients by using the conceptual model of attachment theory.
METHOD
Instruments that assessed attachment, treatment adherence, depression, diabetes severity, patient-provider communication, and demographic data were administered to 367 patients with type 1 and 2 diabetes in a health maintenance organization primary care setting. Glucose control, medical comorbidity, and adherence to medications and clinic appointments were determined from automated data. Analyses of covariance were used to determine if attachment style and quality of patient-provider communication were associated with adherence to treatment.
RESULTS
Patients who exhibited dismissing attachment had significantly worse glucose control than patients with preoccupied or secure attachment. An interaction between attachment and communication quality was significantly associated with glycosylated hemoglobin (Hb A(1c)) levels. Among the patients with a dismissing attachment style, there was a significant difference in glycosylated hemoglobin levels between those who rated their patient-provider communication as poor (mean=8.50%, SD=1.55%) and those who rated this communication as good (mean=7.49%, SD=1. 33%). Among all patients who were taking oral hypoglycemics, adherence to medications and glucose monitoring was significantly worse in patients who exhibited dismissing attachment and rated their patient-provider communication as poor.
CONCLUSIONS
Dismissing attachment in the setting of poor patient-provider communication is associated with poorer treatment adherence in patients with diabetes.
目的
不坚持糖尿病自我管理方案与糖尿病并发症的高风险相关。先前的研究表明，患者与医护人员之间的关系质量与糖尿病治疗的依从性相关。本研究试图通过使用依恋理论的概念模型，增进对糖尿病患者治疗依从性差所涉及的患者和医护人员因素的理解。
方法
在一个健康维护组织的初级保健机构中，对367例1型和2型糖尿病患者使用评估依恋、治疗依从性、抑郁、糖尿病严重程度、患者与医护人员沟通情况以及人口统计学数据的工具。通过自动数据确定血糖控制情况、合并症以及药物和门诊预约的依从性。采用协方差分析来确定依恋风格和患者与医护人员沟通质量是否与治疗依从性相关。
结果
表现出漠视型依恋的患者血糖控制明显比表现出专注型或安全型依恋的患者差。依恋与沟通质量之间的相互作用与糖化血红蛋白（Hb A1c）水平显著相关。在表现出漠视型依恋风格的患者中，将患者与医护人员沟通评价为差的患者（平均值 = 8.50%，标准差 = 1.55%）与评价为好的患者（平均值 = 7.49%，标准差 = 1.33%）之间糖化血红蛋白水平存在显著差异。在所有服用口服降糖药的患者中，表现出漠视型依恋且将患者与医护人员沟通评价为差的患者，其药物依从性和血糖监测情况明显更差。
结论
在患者与医护人员沟通不良的情况下，漠视型依恋与糖尿病患者较差的治疗依从性相关。
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