Original Article 한국기초간호학회 Journal of Korean Biological Nursing Science 2018;20(4): pissn eissn

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1 Original Article 한국기초간호학회 Journal of Korean Biological Nursing Science 2018;20(4): pissn eissn 혈액투석환자의우울과삶의질에서질병인식의통제효과 김시숙 1 류은정 2 1 경민대학교간호학과, 2 중앙대학교간호학과 Control Effect of Illness Perception on Depression and Quality of Life in Patients with Hemodialysis: Using Structural Equation Modeling Kim, Sisook 1 Ryu, Eunjung 2 1 Department of Nursing, Kyung-Min University, Uijeongbu; 2 Department of Nursing, Chung-Ang University, Seoul, Korea Purpose: This study aimed to evaluate the effect of illness perception on depression and quality of life in patients with hemodialysis. Methods: This is a cross-sectional study using structural equation modeling. Depression, quality of life and cognitive and emotional illness perceptions were measured by the Center for Epidemiologic Studies Depression-10 (CESD-10), Short Form-36 version 2 (SF- 36v2), and Brief Illness Perception Questionnaire (BIPQ) in 272 hemodialysis patients. Results: Prevalence of depression was 76.1%, and higher in female patients on hemodialysis. Cognitive illness perception had effect on depression and quality of life, while emotional illness perception had effect only on depression. Quality of life was explained 69.6% through depression (β = -.74, t = -8.17) and cognitive illness perceptions (β=.21, t= 3.06), while depression was explained 40.5% through cognitive (β= -.34, t= -5.99) and emotional (β=.59, t= 9.37) illness perceptions. Conclusion: In the inevitable choice of dialysis, illness perception could decrease depression and improve quality of life in hemodialysis patients. Key Words: Illness perception; Depression; Quality of life; Hemodialysis; Structural equation modeling 국문주요어 : 질병인식, 우울, 삶의질, 혈액투석, 구조모형 서론 1. 연구의필요성혈액투석환자에서우울의정도는외래에서치료를받는우울증환자와유사한수준으로혈액투석환자의나이, 성별, 합병증, 사회경제적상태등은우울및낮은삶의질수준과관련된다 [1,2]. 혈액투석환자는건강과생명을유지하기위해선택한투석과치료로 인하여음식을마음대로먹을수없는것, 투석을계속받아야하는것, 사회활동을잘할수없는것, 미래의삶에확신이없는것등질병특이적인측면에서사회 심리적인스트레스와우울이높다 [3]. 이러한혈액투석환자의우울은신체활동이나자아존중감저하, 수면장애와관련되며삶의질수준을감소시킬뿐만아니라사망률을높이는것으로보고된다 [4,5]. 혈액투석환자의우울을감소시키기위하여아로마요법이나음 Corresponding author: Rye, Eunjung Department of Nursing, Chung-Ang University, 84 Heukuk-ro, Dongjak-gu, Seoul 06974, Korea Tel: Fax: go2ryu@cau.ac.kr * 본논문은제1저자의박사학위논문에서수집한자료일부를사용함. * This article is a condensed form of the first author s doctoral thesis from Chung-Ang University. Received: August 15, 2018 Revised: October 30, 2018 Accepted: October 30, 2018 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 221

2 222 김시숙 류은정 악요법, 유머중재프로그램등이시도되었으나 [6] 대부분단편적이었으며조작이복잡하고효과가제한적이었다. 최근 10년동안혈액투석환자의삶의질에큰변화가없었다는점을고려할때 [7], 우울을감소시키고삶의질을개선하기위한교육과중재의방향은새로운관점과전환이필요하다. 이에본연구는혈액투석환자의우울과삶의질을개선하기위한접근으로인간의사고와환경사이의상호작용에중점을두는인지사회적인관점에서질병인식의역할에주목하고자한다. 인식이란기억과경험을통합하여현상을이해하는개인혹은집단특유의관점 [8] 으로질병인식은질병에대한개인의믿음이나기대, 해석을의미하며인지적측면과감정적측면으로구분된다 [9]. Leventhal 등 [9] 에의하면인지적질병인식은증상이나병명에대한명명 (identity), 질병이예상되는기간 (timeline), 질병에대한원인 (cause), 질병으로인하여삶에미치는결과 (consequence), 질병에대한치료와개인의통제력 (controllability) 으로통합되고, 감정적질병인식은불안, 두려움, 디스트레스와같은부정적인감정과반응으로나타난다. 이러한질병인식은개인적이고주관적인관점이지만질병에따라다양하게나타나며질병인식을재구성하는프로그램을통해당뇨나고혈압환자와같은만성질환자의치료이행및건강행동을증진할수있다 [10]. 혈액투석환자의질병인식은약물복용이나수분조절과같은건강행동뿐만아니라우울및삶의질과도관련된다 [11]. 치료나자신의행동이질병을통제하고상태를호전시킬수있다고믿는질병에대한통제력인식은혈액투석환자의우울과음의상관관계가있으며 [12], 분노, 불안, 귀찮음으로경험되는부정적인감정적질병인식은아무런계획이나행동을하지않는결과를초래하며삶의질과는음의상관관계가있다 [13]. 혈액투석환자와같이완치될수없는질병을가진환자의경우사건의심각성을긍정적시각에서가볍게다루거나상황의상대성을강조하는인식의변화와대처는우울을감소시키고삶의질을개선하기위한효과적인전략이될수있기때문이다 [14]. 질병인식은심리학이나정신신체의학에서만성질환자의건강행동을증진하기위한개념으로적용되어왔다 [9,11]. 또한혈액투석환자의우울과삶의질관계에서인지요법을이용한연구나질병인식의효과에관한논의는충분하지않으며 [6] 통제력이나감정과같은질병인식의하위요소와관련된연구들 [12-14] 이대부분이다. 따라서본연구는구조방정식모형을이용하여혈액투석환자의우울과삶의질관계에서질병인식의효과를동시적으로파악하고검증함으로써질병인식을이용한간호중재개발에기초자료를제공하고자한다. 2. 연구목적본연구의목적은혈액투석환자의우울이삶의질에미치는영향을확인하고, 우울과삶의질의관계에서질병인식이미치는효과를평가하는것이다. 구체적인연구목표는다음과같다. 1) 혈액투석환자의일반적인특성에따른우울의차이를파악한다. 2) 혈액투석환자의우울과삶의질관계를설명하는가설적모형을검증한다. 3) 혈액투석환자의우울과삶의질관계에서질병인식의통제효과를검증한다. 연구방법 1. 연구설계본연구는혈액투석환자의우울과삶의질에서질병인식이미치는영향을규명하기위하여가설적모형을구축하고모형과실제자료간의적합성을평가하는구조방정식모형을이용한횡단적서술조사연구이다. 2. 연구대상본연구의대상자는지역사회에거주하며 3개월이상정기적으로혈액투석을받는자로의사소통이가능한 19세이상성인환자를포함했다. 입원중이거나정신과적병력이있는경우는제외했다. 구조방정식에서표본크기는최대우도추정법을기준으로 200 개이상이요구되지만 개이상증가할수록적합도지수는완만하게증가하거나오히려감소한다 [15]. 잠재변수와관찰변수의비율및잠재변수간상관관계의최소효과를고려했을때 [16] 본연구에참여한 272명은적절한표본크기로판단된다. 3. 연구도구 1) 우울우울은 Center for Epidemiologic Studies Depression (CES-D) 을축약하여 Andresen 등 [17] 이개발한 Center for Epidemiologic Studies Depression-10 (CESD-10) 으로측정하였다. CESD-10은지난한주간경험에대한우울증상의정도를 0점 ( 극히드물다, 1일이하 ), 1점 ( 가끔, 1-2일 ), 2점 ( 종종, 2-3일 ), 3점 ( 대부분, 5일이상 ) 의 4점 Likert 척도로측정하며점수가높을수록우울증의정도가심한것을의미한다. 총점은 0-30점의범위이며임상적우울증을나타내는절단점은 10점이유용하다고보고되었다 [17]. CESD-10 의 Cronbach s α는국내일반인을대상으로우울을측정한 Kim과 Kim [18] 의연구에서.84 였으며본연구에서.89이었다.

3 혈액투석환자의우울과삶의질에서질병인식의통제효과 223 2) 삶의질삶의질은 Quality Metric Incorporated의 Short Form-36 version 2 (SF-36v2) 로측정하였다. SF-36v2은신체적기능, 신체적역할제한, 통증, 일반건강, 감정적역할제한, 정신건강, 사회적기능, 활력의 8개영역을 3-6점 Likert 척도로측정하며표준화를통해 0-100점으로변환할수있다. 8개영역은요인분석을통해신체적건강과정신적건강으로나뉘며점수가높을수록해당영역의삶의질이높은것을의미한다 [19]. 신체적건강영역과정신적건강영역의 Cronbach s α는국내일반인을대상으로삶의질을측정한 Kim 등 [20] 의연구에서 와 이었으며본연구에서.86과.68이었다. 3) 질병인식질병인식은 Illness Perception Questionnaire Revised (IPQ-R) 를축약하여 Broadbent 등 [21] 이개발한 Brief Illness Perception Questionnaire (Brief IPQ) 로측정하였다. Brief IPQ에서인지적질병인식은질병에대한명명, 기간, 결과, 치료통제, 개인통제에대한인식을, 감정적질병인식은질병에대한감정과걱정을 10점 Likert 척도로측정하며점수가높을수록해당영역의인식이높다는것을의미한다. 총점은 0-80점의범위이며인지적질병인식과감정적질병인식의 Cronbach s α는국내결핵환자를대상으로질병인식을측정한 Min 등 [22] 의연구에서 와 이었으며본연구에서.68과.78이었다. 4. 자료수집본연구의자료는 2017년 1월 1일부터 3월 31일사이에수집되었으며총참여자는 272명으로방문조사 143명, 인터넷조사 129명이참여하였다. 혈액투석실방문조사는세개종합병원과한개의원을선정하여편의표출하였다. 참여자는연구자가제공하는태블릿 PC를이용하여자기보고식설문에대한답을직접입력했으며, 직접입력이어려운경우에는연구자가문항을읽어주고대상자의응답을대신입력했다. 인터넷을이용한자료조사는국내두개의혈액투석환우온라인카페의관리자에게자료수집에대한허락을받은후각카페게시판에연구참여모집공고와웹기반설문링크를게시하여대상자의자발적인참여로자료수집하였다. 5. 분석방법수집된자료는 SPSS 21.0과 AMOS 21.0을사용하여분석하였다. 대상자의일반적인특성및임상적특성에따른우울의차이는교차분석을실시하였다. 본연구의가설적모형에사용된측정변수의왜도의절대값은 2보다작고첨도의절대값은 5보다작았으므로정 규분포의가정을충족하였다 [23]. 측정변수간의상관관계는 Pearson correlation coefficient 로분석하였으며측정변수간의상관관계계수는모두.85 이하였으므로다중공선성의문제는없었다 [24]. 측정도구의신뢰도는 Cronbach s α로검증하였으며일반적으로.7 이상의값이만족할만하지만, 사람을대상으로하는사회과학연구에서.65까지수용가능할수있다는 Vaske 등 [25] 의연구를참고하였다. 확인적요인분석과구조방정식모형의적합도검증은최대우도법을사용하였다. 확인적요인분석에서우울과삶의질개념이일관성있게측정되었는가를판단하기위하여집중타당성을검증하였고우울과삶의질개념이서로독립된구성개념으로측정했는가를판단하기위하여판별타당성을검증하였다. 집중타당성과판별타당성검증은선행연구의이론적배경이나가설을근거로지표를비교해야하며낮은요인부하량의관측변수를임의로제거할경우구성개념에대한본래의미가달라질수있으므로주의해야한다 [26]. 모형의적합도의평가는 χ 2 /df, goodness of fit index (GFI), root mean square residual (RMR), root mean square error of approximation (RMSEA), normal fit index (NFI), comparative fit index (CFI), adjusted goodness of fix index (AGFI) 를이용하였다. χ 2 /df는 3 이하면수용할만하고 RMR은.05 이하, RMSEA는.08 이하면양호하며 GFI, AGFI, NFI, CFI는.9 이상이면양호하다고판단할수있다 [26]. 유의성은회귀계수, t값, p값을이용하였고, 변수에대한설명력은다중상관자승을이용하였다. 직간접효과와총효과의통계적유의성을검증하기위하여 bootstrapping 방법을이용하였다. 6. 윤리적고려본연구의자료수집에앞서연구자가소속된대학의생명윤리위원회의승인을받아기준에따라수행되었다 (IRB HRSB K). 참여자에게는연구의목적과익명성, 참여이후에도철회가능함을설명하였고서면으로동의서를받았다. 연구결과 1. 일반적특성에따른우울의차이본연구대상자 272명중남성은 162 명 (59.6%), 여성은 110명 (40.4%) 이었다 (Table 1). 평균연령은 ± 15.51세로 50대미만이 105명 (38.5%) 으로가장많았고, 교육수준은대학졸업이상이 106명 (39.0%) 과고등학교졸업 96명 (35.3%) 이대부분이었다. 혈액투석기간은 5년이하가 194명 (71.3%) 으로가장많았고 85.3% (232명 ) 에해당되는환

4 224 김시숙 류은정 자는신장이식의과거력이없었다. 본연구참여자의 207명 (76.1%) 에서우울증상이있는것으로나타났으며성별 (χ 2 = 5.76, p =.010) 과의료기관 (χ 2 = 7.24, p =.027) 에따라유의한차이가있었다. 2. 우울과삶의질의확인적요인분석과구조방정식모형의적합도검증확인적요인분석의집중타당성검증에서표준화된요인부하량 λ 값 (β) 은모두유의했다 (Table 2). 확인적요인분석의판별타당성검증에서우울과삶의질상관계수는 -.76이고제곱값은.58로삶의질의평균분산추출.78보다작았으나우울의평균분산추출.53보다큰값이었다 (Table 3). 반면우울과삶의질상관계수와표준오차 를이용한범위로우울과삶의질은판별타당성이있는것으로나타났다 [26]. 확인적요인분석의전반적인적합도는양호했다 (χ 2 /df = 4.80, RMR=.06, RMSEA =.12, GFI =.86, AGFI =.79, NFI =.86, CFI =.89). 우울과삶의질구조방정식모형역시모든경로는유의했으며전반적인적합도는양호했다 (χ 2 /df = 2.96, RMR=.04, RMSEA =.09, GFI =.92, AGFI=.87, NFI=.92, CFI=.95). 3. 우울과삶의질관계에서질병인식의통제효과우울과삶의질모형에서통제변수로서질병인식을추가했을때, 대부분의적합도는양호했으며 (χ 2 /df = 2.57, RMR=.04, RMSEA =.08, Table 1. Depression Difference according to General Characteristics of Participants (N = 272) Characteristics Categories Total CESD< 10 CESD 10 n (%) χ2 p Gender Age (year) Education Medical institutions Hemodialysis period (year) Kidney transplantation Male Female Mean± SD < Middle school High school College Tertiary hospital General hospital Private clinic No Yes 162 (59.6) 110 (40.4) 55.28± (38.5) 63 (23.2) 44 (16.2) 60 (22.1) 70 (25.7) 96 (35.3) 106 (39.0) 70 (25.7) 141 (51.9) 61 (22.4) 194 (71.3) 60 (22.1) 18 (6.6) 232 (85.3) 40 (14.7) 47 (72.3) 18 (27.7) 24 (35.9) 20 (31.3) 11 (17.2) 10 (15.6) 18 (27.7) 16 (24.6) 31 (47.7) 25 (38.5) 28 (43.1) 12 (18.4) 45 (69.3) 14 (21.5) 6 (9.2) 53 (81.5) 12 (18.5) 115 (55.6) 92 (44.4) 81 (39.1) 43 (20.8) 33 (15.9) 50 (24.2) 52 (25.1) 80 (38.6) 75 (36.3) 45 (21.7) 113 (54.6) 49 (23.7) 149 (72.0) 46 (22.2) 12 (5.8) 179 (86.5) 28 (13.5) CESD = Center for epidemiologic studies depression; SD = Standard deviation. Table 2. Convergent Validity of Depression and Quality of Life in Confirmed Factor Analysis Latent variables Measured variables B S.E. t p λ (β) AVE CR Cronbach s α Depression Item Item < Item < Item < Item < Item < Item < Item < Item < Item < Quality of life Physical health Mental health < AVE= Average variance extracted; CR= Construct reliability.

혈액투석환자의우울과삶의질에서질병인식의통제효과 225 GFI =.91, AGFI =.87, NFI =.91, CFI =.94) 감정적질병인식에서삶의 질로향하는경로를제외한나머지경로는유의한것으로나타났 다 (Figure 1; Table 4). 우울은인지적질병인식과감정적질병인식에 의해 40.5% 의설명력을나타냈고, 삶의질은우울, 인지적인식에의 해 69.

5 혈액투석환자의우울과삶의질에서질병인식의통제효과 225 GFI =.91, AGFI =.87, NFI =.91, CFI =.94) 감정적질병인식에서삶의 질로향하는경로를제외한나머지경로는유의한것으로나타났 다 (Figure 1; Table 4). 우울은인지적질병인식과감정적질병인식에 의해 40.5% 의설명력을나타냈고, 삶의질은우울, 인지적인식에의 해 69.6% 의설명력을나타냈다. 매개효과분석에서인지적질병인식 은삶의질에대한직접효과 (β =.18, p =.010) 와우울을통한간접효 과 (β =.24, p <.001) 및총효과 (β =.42, p =.020) 모두유의했다. 논의 본연구결과혈액투석환자에서우울이삶에미치는영향을확 Table 3. Correlation and Discriminant Validity of Depression and Quality of Life in Confirmed Factor Analysis Depression Quality of life 2 AVE Depression 1.53 Quality of life AVE = Average variance extracted. 인하고, 우울과삶의질관계에서질병인식의효과를평가할수있었다. 본연구에참여한혈액투석환자의우울유병률은 76.1% 로 Park 등 [2] 의연구에서국내혈액투석환자의우울의유병률 31.9% 와비교했을때매우높은수준이었다. 반면 Palmer 등 [27] 의메타분석에서혈액투석환자의우울유병률은 1.4% 부터 94.9% 까지다양했으며잠재적인우울유병률에대한중재의필요성이우선강조되기도했다. Song 등 [28] 의연구에서혈액투석환자의 3.8% 만이우울증상이전혀없었으며우울의유병률은 47.6% 이었으나이들중 15% 는우울증상으로인하여자살생각의경험이있었다. 본연구모형의잠재변수로서우울과삶의질은음의상관관계가높았고, 우울은삶의질에부정적인영향을미치는것으로나타났다. 따라서혈액투석환자의우울증상에대한사정과함께우울을감소시키기위한교육과중재는동시에계속되어야한다. 추가적으로본연구에서여자혈액투석환자의우울증상은남자보다더높게나타났는데이는선행연구와일치하는결과이다 [2,27,28]. Park 등 [2] 의연구에서혈액투석을받는국내여성의정신적삶의질은서구와비교했을때낮은수준이었는데, 어머니와여성의역할이강요되는 Figure 1. The final model in this study. Table 4. Estimates of Pathways and Explanatory Powers in Final Model Dependent Variables Independent Variables B S.E. t p λ (β) SMC (%) Depression Quality of Life Cognitive illness perception Emotional illness perception Depression Cognitive illness perception Emotional illness perception <.001 <.001 < S.E. = Standard errors; SMC= Squared multiple correlations.

6 226 김시숙 류은정 한국의가부장적인사회문화적환경을고려했을때혈액투석환자의우울에대한사정과중재에서성별에따른차이를고려할필요가있다. 혈액투석환자의질병인식은우울및삶의질과관련된다는보고는계속되고있다 [11]. 본연구결과인지적질병인식은우울을감소시키고삶의질을증가시키는효과가있으며, 감정적질병인식은우울을증가시키는효과가있었다. 이와유사하게 Cha와 Lee [12] 의연구에서도질병에대해치료할수있고통제할수있다고인식할수록우울은감소하고삶의질수준은증가하였다. Timmers 등 [29] 의연구역시질병에대한통제인식은삶의질에긍정적인영향을미쳤으며질병에대한감정적인식은삶의질에부정적인영향을미치는것으로나타났다. 투석에대한선택이불가피한상황속에서혈액투석환자는정규적인투석및치료이행과함께엄격한식이요법이요구되며이로인한갈등과부정적인감정을해결하기위한노력또한필요하다. 질병인식은혈액투석환자의변화된삶에서우선순위와표준을재조정하고다양한갈등과감정을해결하기위하여고려될수있다 [9]. 본연구를통하여질병인식은혈액투석환자의우울과삶의질에직접적인영향을미치는다양한통제변수중하나로서차지하는역할이적지않다는의미로해석될수있었다. 따라서질병인식을적용하여혈액투석환자의우울을감소시키고삶의질을개선하기위한노력을시도해볼수있다. 예를들어혈액투석환자의치료이행이나약물복용에대한교육을할때, 만성적인질병기간이나질병통제감과같은인지적질병인식을증가시키고부정적인감정인식을감소시키는내용을포함한다면혈액투석환자의우울을감소시키고삶의질을증진하는효과를더할수있을것이다. 본연구에서인지적인식은삶의질에대한직접적인효과와우울을매개로간접효과모두유의했으나감정적인식은우울에대해직접효과만유의했다. 그이유는선행연구 [9] 에따라본연구에서의질병인식은인지적인관점과감정적인관점으로구분되었으나, 질병인식의하위영역들은항상일관된군집을형성하는것이아니며질병특성에따라관련된방식으로설명될수있기때문이다 [30]. 따라서감정적인식은우울에만영향을미치며삶의질에는유의한영향이없는가에관한논의는질병인식의하위속성을어떻게구분할것인가에관한연구가선행될필요가있으므로본연구의제한점이라할수있다. 한편우편과이메일을통해자료수집을한선행연구 [12,14] 를참고하여방문조사와인터넷조사를병용하였으나자료수집의방법에따른대상자의차이를고려하지못하였으므로연구결과의일반화에는신중할필요가있다. 결론및제언 본연구는혈액투석환자의우울과삶의질관계에서질병인식이 미치는영향을확인하였다. 인지적질병인식은우울을감소시키고 삶의질을증가시키는직접효과가있었으며, 우울을통해삶의질 에영향을미치는매개효과가있었다. 감정적질병인식은우울을증 가시키는효과가있었으나우울을통한매개효과는확인할수없었 다. 질병인식은환자자신의경험인식과상태에집중하는인지적인 요인으로아직까지질병인식의영향력에대한연구는충분하지않 았기에본연구는우울과삶의질의관계에서질병인식을통제변수 로사용하였다. 추후에는다양한대상자와관련된질병인식효과 를확인할수있는반복연구를제언한다. 또한혈액투석환자의우 울과삶의질을개선하기위하여질병인식을이용한교육과중재를 개발할것을제언한다. CONFLICT OF INTEREST The authors declared no conflict of interest. REFERENCES 1. Kim JW, Shin SE, Kim HK, Jang EY, Jung G, Lee KS. The comparison study of quality of life between hemodialysis patients and depressive or anxious psychiatric patients. Korean Journal of Psychosomatic Medicine. 2003;11(2): Park H, Yoon H, Son M, Jung E, Joo K, Chin H, et al. Depression and health-related quality of life in maintenance hemodialysis patients. Clinical Nephrology. 2010;73(5): Kim S, Yang J. Factors influencing the stress of patients on hemodialysis. The Journal of Korean Academic Society of Nursing Education. 2015;21(3): Park Y, Lee H. The levels of physical activity and its relationships with depression, health-related quality of life, sleep disturbance, and physiological indicators in hemodialysis patients. The Journal of Korean Academic Society of Adult Nursing. 2015;27(6): Perl J, Karaboyas A, Morgenstern H, Sen A, Rayner HC, Vanholder RC, et al. Association between changes in quality of life and mortality in hemodialysis patients: Results from the DOPPS. Nephrology Dialysis Transplantation. 2016;32(3): Kim CG, Cho MK. Effects on depression intervention programs of hemodialysis patients in Korea: Meta-analysis. Journal of the Korean Data Analysis Society. 2012;14(5): Gabbay E, Meyer KB, Griffith JL, Richardson MM, Miskulin DC. Temporal trends in health-related quality of life among hemodialysis patients in the United States. Clinical Journal of the American Society of Nephrology. 2010;5(2): McDonald SM. Perception: A concept analysis. International Journal of Nursing

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