심장이식 수혜자의 이식 후 사회적지지, 우울 및 건강상태

다국어 초록 (Multilingual Abstract)

As the number of heart transplantation cases and post-transplant survival rates have been increased, health care providers' interests in recipients' post-transplant experiences such as depression, quality of life, or adjustment after heart transplant have been increased as well. For smooth recovery and return to their previous status, following instructions of the post-transplant management is crucial. Social support is known to be very important in buffering the impact of stress from the post-transplant adjustment and in boosting the coping of the recipients.
This study was a descriptive correlational study to investigate the recipients' perceived social support in terms of resource and degree of support, depression, and health status following heart transplantation. Also, this study explored the level of post-transplant depression and health status according to the social support they perceived. Subjects were recruited from the heart transplant center of the S National University Hospital in Seoul. Those recipients who understand the purpose of this study and agree to participate were 32. Data collection was done from 28 June, 2011 to 30 September, 2011. Three survey questionnaires measuring social support, depression, and health status were used along with questions of sociodemographic background and health behaviors. Each recipient's disease-related information was obtained by electronic medical records by researcher. Data analysis was done by SPSS WIN 12.0 program and findings of this study are summarized as below.

1) Participants' mean age was 52.97±12.97, ranging from 19 to 74 years old while their average age at the time of heart transplantation was 47.44±13.40. Of 32 recipients, 29 were men and most of them were married (84.4%). The most common primary care giver they reported was their spouse (71.9%). Elapsed time after transplantation was 68.44 months on average which varies from 17 years, the longest, to 4 months, the shortest. Majority of the recipients' pre-transplant diagnosis was cardiomyopathy with ejection fraction (EF), 18.47±5.63% on average. Post-transplant EF was improved to 63.25±7.57%. According to the New York Heart Association, most of them (96.9%) who were categorized into Class 3 or 4 were improved to Class 1 without symptoms (75%) or class 2 after transplantation.
2) Regarding the perceived social support, mean score was 101.72±15.39 (possible range of 25 to 125) which is high overall. Out of four subgroups of social support, emotional support and evaluative support were the highest. Number of resource persons they have was 5.22±3.45 on average. When weights were applied to the resource persons according to how they are important and meaningful to the recipients, spouse was ranked first, followed by doctors, son, mother, friend, father and nurses. Differences in their perceived social support by sociodemographic background, health behaviors, and disease-related characteristics were not statistically significant.
3) Mean score of depression they experienced now was 13.63±7.46 that indicates mild depression. Health status they perceived was 89.44±17.77 on average. Those who are employed reported better health status than the unemployed (t=-1.998, p=.055). Differences in depression and health status by sociodemographic backgrounds, health behaviors, or disease-related characteristics were not statistically significant.
4) Although differences in perceived social support, depression, and health status by the number of resource person are not significant, those recipients whose resource persons are six or more were less depressed and reported better health status than those with less than six.
5) Perceived social support were not correlated with depression or health status. However, inverse correlation between depression and health status was statistically significant (r=-.605, p=.00). In other words, the less the depression, the better the health status.

Since the subject recruitment was done at only one hospital, sample size of this study was small and elapsed time after transplantation were varied. Therefore, generalization of this study findings are limited and suggestions for the future studies include types and level of social support they needed in different phases following heart transplantation with larger sample size. it was important to note that even with the high degree of social support they perceived, they still presented mild depression at 68 months on average after the transplant although indicators of post-transplantation physical health status including the NYHA class and EF, were surprisingly improved. Thus, health care providers need to develop effective programs for heart transplant recipients.

국문 초록 (Abstract)

심장이식은 치유가 불가능한 말기 심장질환 환자들이 마지막으로 선택하는 유일한 치료방법으로 고려되어, 확장성 심근병증 환자가 주종을 이루었던 과거와는 달리 최근에는 관상동맥 질환 및 타 질환으로 인한 말기 심부전 환자가 점차 증가함에 따라 심장이식의 사례도 증가하고 있다. 심장이식수술의 사례와 이식 후 생존율이 점차로 증가함에 따라 수혜자들이 경험하는 스트레스와 그에 따른 대처 및 이식 후 삶에 대한 관심도 증가하였는데 이는 수혜자들이 경험하는 스트레스는 우울 등의 정신적 건강상태에 영향을 미치고 있기 때문이라고 할 수 있다. 심장이식수술 후의 원만한 회복과 복귀를 위해서는 환자 자신이 수행해야 하는 건강관리도 중요하지만 이런 환자를 돕는 사회적지지도 매우 중요하다고 보고되고 있다. 사회적지지는 수혜자가 이식 후에 경험하는 스트레스 원에 대한 부적절한 반응을 감소시킬 수 있을 것이고 나아가 수혜자의 신체·정신적 건강상태를 회복시키는데 기여할 수 있기에, 이식 후의 삶에 적응하는데 있어서 중요하게 고려되어야 한다.
본 연구는 말기 심장질환으로 심장을 이식 받은 수혜자가 인식하는 사회적지지원과 지지정도를 확인하고 이식 후 경험하는 우울 및 건강상태를 파악하며, 사회적지지에 따른 우울 및 건강상태를 확인하고자 시행된 서술적 상관관계 연구이다. 연구대상자는 서울시 소재 S대학병원 장기이식센터에서 심장이식 수술을 받은 전수를 대상자로 하였으나, 수술 후 최소 3개월이 경과한 자들 중에 본 연구의 목적을 이해하고 연구 참여에 동의한 자는 총 32명이었다. 자료수집 기간은 2011년 6월 28일부터 2011년 9월 30일까지이다. 연구도구는 총 88문항으로 대상자가 작성하는 일반적 특성 및 건강관련 특성 15문항, 사회적지지의 정도를 측정하기 위한 25문항, 우울의 정도를 측정하기 위한 21문항, 건강상태를 측정하기 위한 12문항과 전자의무기록을 토대로 연구자가 작성하는 질병관련 특성 15문항으로 구성되어있다.
수집된 자료는 SPSS WIN 12.0 통계프로그램을 사용하여 분석하였고, 각각의 사항에 대해 빈도, 백분율, 평균, 표준편차, t-test, Mann-Whitney, Kruskal-Wallis, Pearson's correlation coefficient를 이용하여 분석하였다.
본 연구의 결과는 다음과 같다.

1) 수혜자의 평균연령은 52.97±12.97세로 연령분포는 19세부터 74세였고, 이식 당시에는 18세에서 74세로 평균연령은 47.44±13.40세였다. 총 32명 중 29명이 남자로 대부분이 기혼자(84.4%)였으며 이식 후 대상자를 돌본 1차 간호제공자도 배우자(71.9%)가 가장 많았다. 이식 후 최단 4개월에서 최장 17년 이상 경과한 평균 68.44±75.55 개월이 지난 상태였다. 수혜자의 59.4%가 심근병증으로 이식을 받았고, 수술 전 초음파 상의 심장박출률은 평균 18.47±5.63%였으나 수술 후에는 평균 63.25±7.57%로 향상되었다. 또한 뉴욕심장협회의 등급분류에 따르면 수술 전에는 대부분(96.9%)이 중증인 3등급과 4등급에 속하였지만 이식 후에는 75%가 증상이 없는 1등급으로 향상되었다.
2) 수혜자가 보고한 사회적지지는 평균 101.72±15.39점(25점에서 125점의 가능범위)으로 본 연구에 참여한 수혜자들이 인식한 사회적지지는 높게 나타났다. 하위영역에서는 정서적지지와 평가적지지가 가장 높았고 물질적지지, 정보적지지가 그 다음이었다. 수혜자가 표시한 자신에게 도움을 주는 사회적지지원의 수는 최소 2명에서 최대 16명으로 평균 5.22±3.45명이었다. 이들에게 중요하고 의미 있게 인식하는 제공원에게 가중치를 적용하였을 때 가장 많이 보고된 제공원은 배우자로, 그 뒤를 이어 의사, 아들, 어머니, 친구, 아버지, 간호사의 순으로 나타났는데 이들 7가지 관계 중 가족이 4, 의료진이 2, 포함되어 있었다.
또한 일반적 특성과 생활습관 및 질병관련 특성에 따른 사회적지지의 차이는 통계적으로 유의하지 않았으나, 운동을 규칙적으로 하지 않는 자들이 인식하는 사회적지지가 운동을 규칙적으로 하는 자들보다 유의하게 더 높았다(t=2.831, p=.008).
3) 수혜자가 인식하는 우울의 정도는 평균 13.63±7.46점으로 경증(mild)에 해당하는 14점에 근접하였다. 이들이 인식하는 건강상태는 평균 89.44±17.77점으로 무직자보다 직업이 있는 자들의 건강상태가 더 높았다(t= -1.998, p=.055).
일반적 특성과 생활습관 및 질병관련 특성에 따른 우울과 건강상태의 차이는 통계적으로 유의하지 않았다.
4) 사회적지지의 정도에 따른 우울과 건강상태의 차이는 통계적으로 유의하지 않았지만, 도움을 요청할 수 있는 사회적지지원의 수가 6명이상인 경우 6명 미만의 경우보다 우울점수는 더 낮고 건강상태 점수는 더 높게 나타났다.
5) 사회적지지와 우울 및 건강상태의 관계를 살펴보면, 사회적지지는 우울이나 건강상태와는 유의한 상관관계가 없었지만 우울과 건강상태 간에는 유의한 역상관관계(r=-.605, p=.000)가 있었다. 즉, 우울정도가 낮을수록 건강상태가 좋은 것으로 보고되었다.

본 연구의 대상자 모집이 대학병원 한 곳에서만 이뤄졌기에 대상자 수가 적었고, 이들의 이식 후 경과 기간도 다양하였기 때문에 결과분석과 적용에 제한이 있었지만, 심장이식 수혜자가 인식하는 사회적지지의 정도와 의미 있는 제공원의 종류 및 적절한 제공원의 수를 조사한 것은 의미가 있었다. 즉, 이식 후 크게 향상한 객관적인 신체·생리적 건강지표만 아니라 이들의 회복과 복귀에 요구되는 사회적지지에 대한 이들의 주관적인 인식에 대한 이해를 더하였다. 사회적지지 정도가 높았음에도 불구하고 경미하거나 경한 우울을 보고한 자의 건강상태가 높지 않았음에 주목할 필요가 있다. 이들 연구결과를 토대로, 이식 후 효과적인 관리를 위한 중재 프로그램의 개발과 연구가 수행되어야 하겠다.

목차 (Table of Contents)

• 논문개요 ····························································································ⅰ
• Ⅰ. 서론 ···························································································· 1
• 1. 연구의 필요성 ············································································ 1
• 2. 연구의 목적 ················································································ 3
• 3. 용어 정의 ···················································································· 3
• Ⅱ. 문헌고찰 ··················································································· 6
• 1. 심장이식 수혜자의 사회적지지 ·············································· 6
• 1) 의료진에 의한 지지 ································································· 8
• 2) 가족에 의한 지지 ····································································· 8
• 3) 자조집단에 의한 지지 ···························································· 9
• 2. 심장이식 수혜자의 우울 ······················································· 10
• 3. 심장이식 수혜자의 건강상태 ··············································· 11
• 4. 심장이식 수혜자의 사회적지지, 우울, 건강상태의 관계 ·· 12
• Ⅲ. 연구방법 ················································································ 13
• 1. 연구설계 ·················································································· 13
• 2. 연구대상 ················································································· 13
• 1) 연구대상 선정 기준 ······························································ 13
• 2) 연구대상 제외 기준 ······························································ 13
• 3. 연구도구 ················································································ 14
• 1) 사회적지지 측정도구 ·························································· 14
• 2) 우울 측정도구 ······································································ 14
• 3) 건강상태 측정도구 ······························································ 15
• 4) 일반적 특성 질문지 ···························································· 15
• 4. 자료수집 기간 및 방법 ························································ 17
• 5. 자료분석 방법 ······································································ 17
• 6. 윤리적 고려 ········································································· 18
• 7. 연구의 제한점 ·······································································18
• Ⅳ. 연구결과 ············································································· 19
• 1. 심장이식 수혜자의 일반적 특성 ······································· 19
• 1) 수혜자의 인구사회학적 특성 ··········································· 19
• 2) 수혜자의 생활습관 ····························································· 21
• 3) 수혜자의 질병관련 특성 ···················································· 22
• 2. 심장이식 수혜자가 인식하는 사회적지지원과 지지정도 ·· 25
• 1) 수혜자의 사회적지지원 ····················································· 25
• 2) 수혜자가 인식하는 사회적지지의 지지정도 ·················· 25
• 3) 사회적지지의 하위영역 ····················································· 26
• 3. 심장이식 수혜자의 우울 및 건강상태 ······························27
• 1) 수혜자의 우울 ···································································· 27
• 2) 수혜자의 건강상태 ···························································· 27
• 4. 심장이식 수혜자의 일반적 특성에 따른 사회적지지, 우울,
• 건강상태 ············································································· 28
• 1) 인구사회학적 특성에 따른 사회적지지, 우울, 건강상태 ··· 28
• 2) 생활습관과 질병관련 특성에 따른 사회적지지, 우울,
• 건강상태 ··············································································· 31
• 5. 심장이식 수혜자의 사회적지지 특성에 따른 우울 및
• 건강상태 ················································································· 34
• 1) 사회적지지의 지지정도에 따른 우울 및 건강상태 ·········· 34
• 2) 수혜자가 인식하는 사회적지지원에 따른 우울 및
• 건강상태 ················································································ 34
• 6. 심장이식 수혜자의 사회적지지, 우울, 건강상태의 관계 ··· 35
• Ⅴ. 논의 ························································································ 37
• 1. 심장이식 수혜자의 일반적 특성 ··········································· 37
• 2. 심장이식 수혜자가 인식하는 사회적지지원과 지지정도 ··· 39
• 3. 심장이식 수혜자가 인식하는 우울과 건강상태··················· 42
• 1) 수혜자의 우울 ········································································ 42
• 2) 수혜자의 건강상태 ································································ 43
• 4. 심장이식 수혜자가 인식하는 사회적지지원과 지지정도에
• 따른 우울 및 건강상태 ························································ 44
• 5. 심장이식 수혜자의 사회적지지, 우울, 건강상태의 관계 ··· 46
• Ⅵ. 결론 및 제언 ·········································································· 47
• 1. 결론 ·························································································· 47
• 2. 제언 ·························································································· 49
• 참고문헌 ······················································································· 50
• 부록 1 임상시험 심의위원회 심의결과통보서 ························ 56
• 부록 2 피험자동의서 및 설문지 ················································ 58
• 부록 3 사회적지지의 지지별 문항분류 ···································· 74
• Abstract ························································································ 75