DOI: 10.4046/trd.2010.69.6.434 ISSN: 1738-3536(Print)/2005-6184(Online) Tuberc Respir Dis 2010;69:434-441 CopyrightC2010. The Korean Academy of Tuberculosis and Respiratory Diseases. All rights reserved. 만성폐쇄성폐질환자가족의보호부담에관한연구 Original Article 1 이화여자대학교사회복지전문대학원, 2 한림대학교성심병원사회사업팀, 3 한림대학교성심병원호흡기 - 알레르기내과, 4 한림대학교춘천성심병원호흡기 - 알레르기내과, 5 한림대학교의과대학춘천성심병원사회사업팀김정화 1, 김은경 2, 박선형 2, 이경애 2, 황용일 3, 김은지 3, 장승훈 3, 박성훈 3, 이창률 4, 이명구 4, 이지연 5, 김동규 3, 정기석 3 Burden of COPD among Family Caregivers Jeong Hwa Kim, M.S.W. 1, Eun Kyung Kim, M.S.W. 2, Sun Hyung Park, M.S.W. 2, Kyung Ae Lee, M.S.W. 2, Yong Il Hwang, M.D. 3, Eun Ji Kim, M.D. 3, Seung Hun Jang, M.D. 3, Sung Hoon Park, M.D. 3, Chang Youl Lee, M.D. 4, Myung Goo Lee, M.D. 4, Ji Yeon Lee, M.S.W. 5, Dong-Gyu Kim, M.D. 3, Ki-Suck Jung, M.D. 3 1 Graduate School of Social Welfare, Ewha Womans University, Seoul, 2 Department of Social Work, and 3 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, 4 Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, and 5 Department of Social Work, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea Background: Chronic obstructive pulmonary disease (COPD) is a major health problem resulting in significant burden for patients and families. However, family caregivers burden has not been well recognized. The objectives of this study were to evaluate the level of caregivers burden and to explore the related factors based on family, patient, and social support factors. Methods: A face-to-face interview with 86 family caregivers who had been taking care of COPD patients was conducted. The participants answered a self-administered questionnaire. The questionnaire included the level of family caregivers burden, health status and the relationship within the family, functional limitation of patients perceived by family caregivers and the social support. Results: The level of caregivers burden among participants was considerably high. Risk factors for caregivers burden included low educational level of family caregivers, low family income, hours of caregiving, and functional limitation of the patients. Protective factors for caregivers burden were good relationship within the family and support from other family members or friends. Conclusion: It is proved that family caregivers are facing significant burden in taking care of COPD patients. To reduce family caregivers burden, it is necessary to address socioeconomic status of the family and to provide various community resources including financial support and nursing services. Key Words: Pulmonary Disease, Chronic Obstructive; Family Nursing; Cost of Illness 서 Address for correspondence: Ki-Suck Jung, M.D. Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, 896, Pyeongan-dong, Dongan-gu, Anyang 431-070, Korea Phone: 82-31-380-3717, Fax: 82-31-380-3973 E-mail: pulmoks@hallym.ac.kr Received: Sep. 2, 2010 Accepted: Oct. 12, 2010 론 만성폐쇄성폐질환 (Chronic Obstructive Pulmonary Disease, COPD) 은 2020년 3대사망원인으로예측될정도로여러가지중요한사망원인중전세계적으로유일하게유병률이증가하고있는질환이다 1. 이에 COPD는사회 경제적부담이높은전세계적인공공건강문제로지적되고있다 2. COPD 의중증도가심해짐에따라독립적인생활에심각한영향을주기때문에 3,4 환자가일상생활을유지하기위해서는가족의돌봄이필수적이다. 따라서 COPD 는환자와상호관계에있는가족구성원에게도영향을미치게된다. COPD 환자를돌보는가족은환자에대한장기적인돌봄요구로인해신체적, 경제적, 사회적, 정서적인 434
Tuberculosis and Respiratory Diseases Vol. 69. No. 6, Dec. 2010 Figure 1. Study model. 어려움, 즉보호부담을경험할것으로예상된다. 실제 COPD 환자가족들은 41.0 53.3% 가우울증상을경험하는것으로알려져있고 5,6, Bergs 7 는 COPD 환자의아내를 숨겨진환자 (hidden patient) 라고명명하면서아내는기존역할에서환자돌봄역할이추가되면서우울, 분노, 만성피로, 에너지감소, 경제적스트레스를경험한다고보고하였다. 이러한가족의신체적, 정신적상태는다시환자의치료와재활에영향을미치기때문에가족의총체적인보호부담을살펴보는것은매우중요하다. 치매, 뇌졸중, 정신분열증등과같은만성병환자의보호부담은주로가족의인구사회학적및돌봄의특성, 환자의건강상태, 사회적지지와관련이있다 8. 돌봄시간, 환자의신체적의존성, 가족의부정적건강상태, 경제적어려움등의요인은보호부담을높이며사회적지지, 원만한가족관계등은보호부담을낮추는것으로알려져있다 9-11. 하지만 COPD 환자가족들에대해서는보호부담을실증적으로분석한연구가드물며, 국내에서는전무한상황이다. COPD 환자가족들의보호부담의정도와가족보호부담과관련된요인들은무엇인지에대한분석은 COPD 환자가족의보호부담감소뿐만아니라환자의통합적치료전략을세우는데기초자료를제공할수있을것이다. 이에본연구에서는 COPD 환자가족들의보호부담수준을알아보고, 보호부담과가족요인, 환자요인, 사회적지지요인사이의관련성을살펴보고자하였다 (Figure 1). 대상및방법 1. 연구대상본연구는 2006년 10월 1일부터 2007년 6월 30일까지 경기지역소재 1개대학병원호흡기-알레르기내과에서입원혹은외래치료를받고있는 COPD 환자의가족보호자 86명을대상으로이루어졌다. 2. 연구방법 COPD 환자의진료를담당한의사의의뢰에의해사회복지사가 COPD 환자의가족보호자를 1 : 1면담형식으로설문조사를진행하였다. COPD의정의는 Global Initiative for Chronic Obstructive Lung Disease (GOLD) 진료지침에의한기준을적용하였다. 설문지구성은다음과같은측정도구로구성되었으며설문조사는약 30분씩소요되었다. 1) 가족보호부담가족보호부담은 CBI (Caregiver Burden Inventory) 12 와 BI (Burden Interview) 13 척도를수정, 번역한 36문항으로측정하였고각문항은 5점척도로구성되었다. 18개문항은주관적보호부담이고, 18개문항은객관적보호부담을측정하기위한문항이다. 주관적보호부담은환자를돌보는과정에서가족들이느끼는감정, 태도, 정서등을말하며, 객관적보호부담은도움을주는다른가족의수, 돌봄에소요되는시간, 돌봄활동등과같은시간적, 신체적제약등을말한다. 점수범위는 0 144점으로, 0 36점은경한부담, 37 72 점은중간부담, 73 108점은심한부담, 109 144점은매우심한부담을나타낸다. 2) 가족의건강상태가족의건강상태평가는 Cornell Medical Index 14 를수정, 번역한 69개문항으로측정하였다. 이척도에는감각기계, 호흡기계, 소화기계, 근골격계, 신경계와비뇨기계관련증상에대한문항들이포함되며, 점수범위는 0 138 435
JH Kim et al: Burden of caregiver for COPD 점이고점수가높을수록건강상태가양호한것을말한다. 3) 가족관계가족관계의측정은가족환경척도 (family environment scale) 15 중가족관계하위영역에해당하는 27개문항을사용하였다. 이가족관계하위영역에서는가족구성원의응집, 감정표현, 갈등이없는정도를측정한다. 각문항에대해 예 (1점), 아니오 (0점) 로계산하였다. 점수범위는 0 27 점이며점수가높을수록가족관계가긍정적임을나타낸다. 4) 환자의기능제한본연구에서보호자가인식한환자의기능제한정도는기능제한측정도구 (functional limitation battery) 13개문항중국내상황에맞지않은 2개문항을제외하고번역한 11개문항을사용하여측정하였다 16,17. 총 6개영역 ( 자가간호활동, 이동성, 경등도의걷기, 중등도의걷기, 격렬한활동, 역할제한 ) 으로구성되어있다. 본척도의점수는 예 (1점), 아니오 (0점) 으로계산하였다. 점수범위는 0 11점이며점수가높을수록일상생활에서기능제한인식정도가높음을의미한다. 5) 사회적지지사회적지지정도는가족및친구로부터의지지정도와의료진에게받고있는지지정도를나누어서측정하였고각각의설문은 19문항으로구성되었다 8. 각문항은 전혀아니다 (0점) 에서 매우그렇다 (4점) 의 5점척도로, 점수범위는각각 0 76점이며점수가높을수록지지정도가높음을의미한다. 3. 자료분석방법수집된자료는 SPSS version 17.0 (SPSS Inc., Chicago, IL, USA) 을이용하여분석을실시하였다. 먼저가족및환자의인구학적특성과가족보호부담의정도를알아보기위해서기술분석을하였다. 또한환자요인, 가족요인, 사회적지지요인과가족보호부담간의관련성을파악하기위해서비연속변수의경우평균차이검증인 t-test 와 ANOVA 분석을하였고, 연속변수의경우피어슨의상관계수 (Pearson's correlation coefficient: r) 를산출하는상관관계분석을하였다. 결과 1. 가족의인구학적및돌봄특성응답자총 86명중남성이 21명 (24.4%), 여성이 65명 (75.6%) 으로약 80% 가여성이었다. 응답자의평균연령은 51.5±14.9세이며, 교육수준은초졸이하 22명 (25.5%), 중졸 12명 (14.0%), 고졸 33명 (38.4%), 대졸 19명 (22.1%) 이었다. 주부를포함한무직이 56명 (65.1%) 으로직업이있는경우 (30명) 보다많았다. 환자가족의월평균수입은 100만원이하 31명 (36.0%), 101 300만원 34명 (39.6%), 301만원이상이 21명 (24.4%) 으로나타났다. 가족의돌봄특성으로환자와의관계는배우자 (39명) 와자녀 (34명) 가가장많았고, 환자의보호를 1차적으로책임지는주보호 Table 1. Demographic characteristics of family caregivers No. (%) Sex Male 21 (24.4) Female 65 (75.6) Age group, yr 40 23 (26.7) 41 60 34 (39.5) 61 80 29 (33.8) Education level No education 7 (8.1) Elementary school 15 (17.4) Middle school 12 (14.0) High school 33 (38.4) University 19 (22.1) Occupation Yes 30 (34.9) No 56 (65.1) Income, KRW/month 1,000,000 31 (36.0) 1,010,000 3,000,000 34 (39.6) 3,010,000 21 (24.4) Relation with patient Spouse 39 (45.3) Child 34 (39.5) Daughter-in-law 9 (10.5) Grandchild 4 (4.7) Primary caregiver Yes 65 (75.6) No 21 (24.4) Average hours of caregiving per day 6 34 (39.5) 7 12 15 (17.4) 13 18 10 (11.6) 19 27 (31.4) Share of care responsibility Yes 49 (57.0) No 37 (43.0) Total 86 (100) 436
Tuberculosis and Respiratory Diseases Vol. 69. No. 6, Dec. 2010 자가전체가족보호자의 75.6% 였다. 일일평균환자보호시간은 6시간이하가 34명 (39.5%) 으로가장많았으나, 하루종일돌보는경우가 27명 (31.4%) 으로두번째로많았다. 환자보호를교대할수있는가족이있다는응답자는 49명 (57.0%), 없다는응답자는 37명 (43.0%) 으로나타났다 (Table 1). 2. 환자의인구학적및임상적특성총 86명의 COPD 환자중남성이 71명 (82.6%) 으로대다수를차지하였으며, 환자의평균연령은 71.3±9.7세였다. 설문당시입원치료중인환자는 43명 (50.0%) 으로외래치료중인환자와동일한비율이었다. 환자의흡연상태를보면당시흡연중이었던환자는 13명 (15.2%), 금연한환자는 63명 (73.3%), 흡연한적이없는환자는 10명 (11.5%) 으로나타났다. GOLD 병기기준으로분류하였을때경증 7명 (8.1%), 중등증 31명 (36.0%), 중증 29명 (33.7%), 고도중증 19명 (22.2%) 이었다 (Table 2). 32.5±12.0점이었고, 객관적보호부담은 34.3±12.6점으로객관적보호부담이약간높았다 (Figure 2). 4. 가족, 환자및사회적지지요인의분석가족의평균건강상태는 113.5±21.8점 ( 범위, 0 138) 으로건강상태가좋은편으로나타났다. 가족관계는평균 12.7±3.8점으로 27개문항중절반정도인평균약 13개문항에서긍정적인가족관계라고응답하였다. 가족이인식하는환자의일상생활기능제한정도는 7.3±3.2 점으로 11개의일상생활기능제한영역중평균적으로약 7개의영역에서기능제한이있는것으로나타났다. 사회적지지요인은가족및친구들의지지는 47.4±14.8 점, 의료진의지지는 41.0±13.2점으로, 전반적으로 COPD가족들은중간보다약간높은사회적지지를받고있었으며가족및 3. 가족보호부담 COPD 환자가족의보호부담은평균 66.8±23.4 점으로중간정도의부담범위로나타났다. 주관적보호부담은 Table 2. Demographic and clinical characteristics of COPD patients N (%) Sex Male 71 (82.6) Female 15 (17.4) Age group, yr 40-41 60 13 (15.2) 61 80 58 (67.4) 81 15 (17.4) Smoking status Current smoker 13 (15.2) Ex-smoker 63 (73.3) Never smoker 10 (11.5) COPD stage Mild (GOLD 1) 7 (8.1) Moderate (GOLD 2) 31 (36.0) Severe (GOLD 3) 29 (33.7) Very severe (GOLD 4) 19 (22.2) Total 86 (100) COPD: chronic obstructive pulmonary disease; GOLD: global initiative for chronic obstructive lung disease. Figure 2. The level of family caregivers burden. Table 3. Data of family health stage, family relationship, patient functional limitation and social support Mean±SD Range Family factor Stage of health* 113.5±21.8 0 138 Family relationship 12.7±3.8 0 27 Patient factor Functional limitation 7.3±3.2 0 11 Social support factor Family & friends support 47.4±14.8 0 76 Doctors support 41.0±13.2 *Higher scores indicate higher stage of health, Higher scores indicate more positive family relationship, Higher scores indicate a greater number of functional limitation symptoms, Higher scores indicate receiving greater social support. SD: standard deviation. 437
JH Kim et al: Burden of caregiver for COPD 친구들의지지점수가의료진의지지점수보다약간높았다 (Table 3). 5. 가족의인구학적및돌봄특성에따른보호부담 (Table 4) 가족의성별과연령에따라서가족이느끼는보호부담의차이는없었다. 교육수준에따라서는보호부담의차이가있었는데 (p=0.003), 특히중졸이하학력의응답자들이고졸이상의응답자들보다보호부담을더느끼고있었다. 또한, 직업이없는경우직업이있는경우보다보호부담을더느끼고있었다 (p=0.002). 가족의소득에따라서도보호부담의차이가있었는데, 가구월평균소득이 100만원이하인가족의경우보호부담평균이 80.1점, 100 300만원의경우 61.6점, 300만원보다많은경우 55.7점으로소득이적은가족집단의보호부담이더컸다 (p<0.001). 소득에따른주관적및객관적보호부담의차이또한이와유사하게나타났다. 가족의환자돌봄특성과관련하여, 아들이나다른가족구성원이환자를돌볼때보다배우자가돌볼때보호부담이다소높게나타났으나통계적으로유의하지는않았다. 환자의보호를 1차적으로책임지는주보호자는보조적보호자에비해보호부담을통계적으로유의하게더높게인식하는것으로나타났다 (p<0.05). 환자돌봄시간에따라서도보호부담의차이가유의하여 (p<0.001), 환자를 6시간이하로돌보는가족에비해 6시간이상돌보는가족의보호부담이높았고, 환자를온종일돌볼때보호부담평균점수가가장높게나타났다. 환자를교대로간병해줄수있는가족구성원이있는지여부에따라서는보호부담의차이가유의하지않았다. 6. 환자의인구학적및임상적특성에따른보호부담 (Table 5) 환자의성별, 연령, 흡연상태, COPD 병기에따라전체, 주관적및객관적보호부담평균차이가통계적으로유의하지않아, 이환자요인들과보호부담은관련이없는것으로나타났다. 입원치료환자에비해외래환자가족의객관적보호부담만이통계적으로유의하게약간높게나타났다 (p=0.049). 7. 가족, 환자, 사회적지지요인과보호부담간의상관관계 (Table 6) 가족의건강상태와보호부담은주관적및객관적보호 Table 4. Family caregivers burden according to various indices Total Subjective Objective burden burden burden Sex Male 69.3 33.9 35.5 Female 59.1 28.2 30.9 Age group 40 61.0 28.4 32.6 41 60 65.9 32.9 33.0 61 80 72.5 35.2 37.3 Education level No education 68.7* 31.7* 11.8 Elementary school 79.3* 39.4* 9.3 Middle school 80.7* 40.1* 12.5 High school 63.3* 30.5* 13.6 University 53.7* 25.9* 10.1 Occupation Yes 72.1* 35.2* 37.0* No 56.9* 27.5* 29.4* Income, KRW/month 1,000,000 80.1 39.3 40.8* 1,000,000 3,010,000 61.6 29.6 32.0* 3,010,000 55.7 27.1 38.6* Relationship with patient Spouse 72.3 35.8 36.5 Child 63.2 29.6 33.6 Others 60.0 30.2 29.8 Primary caregiver Yes 70.0 34.1 35.8 No 57.1 27.4 29.8 Average hours of caregiving per day 6 52.5 25.8 26.7 7 12 68.7 33.2 35.7 13 18 72.8 34.7 38.1 All day long 81.5 39.7 41.8 Share of care responsibility Yes 71.0 35.1 35.9 No 63.7 30.5 33.1 Values are presented as mean unless stated otherwise. t-test was performed for sex, occupation, share of responsibility (one-way). ANOVA was performed for age group, education level, income level, relationship with patient, and average hours of caregiving per day. *p<0.01, p<0.05, p<0.001. 부담모두에서음의상관관계로가족의건강상태가나쁠수록주관적및객관적보호부담이높아지는것으로나타났다 (p<0.001). 가족관계또한보호부담과음의상관관계가있었는데, 객관적보호부담보다 (r=-0.41) 주관적 438
Tuberculosis and Respiratory Diseases Vol. 69. No. 6, Dec. 2010 Table 5. Family caregivers burden according to the COPD patients status Total Subjective Objective burden burden burden Sex Male 67.1 32.9 34.2 Female 65.6 30.7 34.9 Age group 41 60 71.8 34.9 36.9 61 80 65.8 32.2 33.6 81 66.8 31.5 34.8 Treatment type Inpatient 70.1 33.1 37.0* Outpatient 63.5 31.9 31.7* Smoking status Current smoker 62.7 30.3 32.4 Ex-smoker 66.3 32.3 34.0 Never smoker 78.1 37.6 40.5 COPD stage Mild (GOLD 1) 65.0 30.6 34.4 Moderate (GOLD 2) 60.2 29.1 31.1 Severe (GOLD 3) 72.2 35.8 36.5 Very severe (GOLD 4) 70.2 33.8 36.4 Values are presented as means unless stated otherwise. t-test was performed for sex, treatment type (one-way). ANOVA was performed for age group, smoking status, and COPD stage. COPD: chronic obstructive pulmonary disease; GOLD: Global Initiative for Chronic Obstructive Lung Disease. *p<0.05. 보호부담 (r=-0.26) 과더높은상관관계를보였다. 환자요인중환자의일상생활제한인식정도와가족의보호부담은높은양의상관관계를갖는것으로나타났다 (r= 0.47). 즉환자가일상생활에서기능제한이많다고가족이인식할수록가족의보호부담이높았다. 사회적지지요인중친구및타가족구성원의지지는전체보호부담및주관적보호부담과음의상관관계가있어친구및가족구성원의지지를높게인식할수록보호부담이낮은것으로나타났다. 그러나의료진의지지는보호부담과유의한상관관계가나타나지않았다. 고 본연구에서 COPD 환자가족의보호부담은평균 66.38 점으로중간정도의보호부담이있는것으로나타났다. 동일척도를사용한뇌졸중환자가족의보호부담이 73.38 찰 Table 6. Correlation between family caregivers burden and factors of family, patient and social support Total Subjective Objective burden burden burden Family factor Health status -0.69* -0.66* -0.65* Family relationship -0.35-0.41* -0.26 Patient factor Functional limitation 0.47* 0.36 0.53* Social support factor Family & friends support -0.30-0.38* -0.19 Doctors support -0.06-0.09-0.03 Values are correlation coefficient (r). *p<0.001, p<0.01, p<0.05. 점인것과 9 비교할때 COPD 환자가족은뇌졸중환자가족과거의유사한수준의보호부담을인식하고있는것으로볼수있다. 본연구에서주관적보호부담은평균 32.5 점이고객관적보호부담은평균 34.3점으로나와 COPD 환자의가족들은객관적보호부담을다소높게인식하고있었다. 이는 COPD 환자가족들이환자돌봄으로인한부정적인정서보다는사생활및여가시간의감소나실제적소득의감소를더크게느꼈다고볼수있다. 주관적보호부담이낮게나타나는것은가족원의환자돌봄을당연하게여기는한국의문화적특성으로가족들이자신의불안혹은우울한감정등을잘드러내지않는것으로생각된다 8,18,19. 저자들은또한 COPD 환자가족의보호부담과관련성이있을것으로예상되는변수들을가족, 환자, 사회적지지의 3가지요인으로구분하여살펴보았다. 가족요인에서는먼저가족의인구학적특성중교육수준, 직업유무, 소득수준에따라보호부담에통계적으로유의한차이가있었다. 즉, 가족보호자의교육수준이낮으며직업이없고소득수준이낮은경우보호부담을더크게느낀것으로나타났다. 소득이낮을수록사망률등의건강관련지표들이나쁘게나타나고주관적인건강수준은더욱낮은것으로알려져있다 20,21. COPD 에서도심리사회경제적자원이취약한저소득층은더욱더많은어려움을경험하며이는높은보호부담으로작용했을것으로보인다. 돌봄특성에서는주보호자이고하루중환자를돌보는시간이긴가족일수록보호부담이큰것으로나타났다. 이런결과는보호부담감이큰 COPD 환자의가족집단이통계적으로유의하게환자를더장시간돌보는것으로보 439
JH Kim et al: Burden of caregiver for COPD 고한기존의연구 6 결과와일치한다. 간병을교대할수있는가족의유무는환자를돌보는시간을줄여주고심리적불안감을감소시킬수있다는점에서주관적및객관적보호부담에서모두중요한변수로보고된바있다 9. 그러나본연구에서는환자돌봄을교대할다른가족유무에따른보호부담은통계적인차이가없는것으로나타났는데, 이는간병을교대할가족이있다고하더라도교대가족의역할이미미한경우객관적및주관적으로크게도움이되지않는다고인식하였다고해석해볼수있다. 이에향후연구에서는간병을교대할가족이있는경우그가족구성원의환자돌봄시간이나역할정도를분석할필요가있겠다. 또한가족의건강상태가나쁘고가족관계가좋지않을수록보호부담이증가되었다. 가족의건강상태가보호부담과관계된중요한변수로작용한다는점은가족또한신체적질병이있거나피로, 수면부족등으로건강상태가불편한경우높은보호부담을인지한다고한기존의연구들을 9,18,22 통해서도확인할수있다. 또한가족관계가긍정적일수록가족의보호부담이낮게나타났는데, 긍정적가족관계는가족의응집력이높고의사소통을활발히하며갈등이낮은것을의미한다. 이는좋은가족관계의부재가보호부담으로연결된다는 Bulger 등 23 의보고와일치되며만성정신질환가족연구들 11,24 에서긍정적가족기능이환자와가족의삶의질을높인다는결과들과도연관된다. 환자요인에서는환자의일상생활기능제한정도가가족의객관적및주관적보호부담모두와관련이있는것으로나타났다. 이결과는보호부담척도를개발한 Zarit 등 25 이보호자의부담은환자장애의심각성과매우강하게연관되어있다고한보고와일치한다. COPD 중증도는가족의보호부담과관련이없는것으로나타났는데, Takata 등 6 도 COPD 환자의 FEV 1 수치와가족의보호부담간에통계적으로유의한관련성이없다고밝혀 COPD 환자질환의심각성을나타내는지표인 COPD 중증도나 FEV 1 수치가가족들의환자보호부담과는직결되지않음을알수있다. 그러나본연구및 Takata 등 6 의연구모두 100명미만의소규모표본연구로보다결과를일반화할수있는대규모무작위표본연구를통한후속검증이필요하겠다. 사회적지지요인에서는가족과친구의지지만이전체보호부담및주관적보호부담과유의한음의상관이있었고, 의료진의지지는보호부담모두와유의한상관관계가없었다. 사회적지지는 Lazarus 와 Folkman 26 의스트레스및대처모델에따라환자의간병과같은스트레스상황에 대한대처자원으로지속적으로검증되어왔다. 본연구결과도이러한사회적지지의긍정적역할을일부지지하였으나, 의료진의지지는가족의보호부담과관련성이없다고나타난점이특이할만하다. 의료진의지지는보호부담과음의상관관계가있다는연구 8,9 와관계가없다고한연구 18 가혼재해있다. 또한보호부담이높은가족이의료진의지지에대한요구가높아보호부담이낮은가족보다실제의료진의지지를더많이받았다는보고들도 6,27 있어, 향후의료진의지지와보호부담간에는단순상관관계보다는보호부담이발생한후에도의료진의지지가보호부담을낮추는지에대한조절및완화효과에대한검증이필요하겠다. 본연구는 COPD 환자가족에대한국내의실증적연구가전무한상태에서가족의보호부담수준과그관련요인을탐색한점에서의미가있는연구이지만몇가지제한점을가진다. 먼저, 본연구는 COPD 환자가족대상다른연구들 5,6 보다는표본수가많은편이나소규모표본연구로전체 COPD 환자가족의특성을충분히반영하였다고보기어렵다. 향후에는가능한대규모표본연구결과들이축적되어야겠다. 또한, 향후연구에서는환자요인에서환자의유병기간및다양한질병의중증도측정들을포함한분석을실시하여환자요인과보호부담간의관련성을추가적으로살펴볼필요가있다. 세번째로본연구에서는국내첫연구로 COPD 가족의보호부담관련요인들을중심으로살펴보았는데, 후속연구에서는관련요인들간의상대적영향력을검증하거나선후영향관계를밝혀가족의보호부담감소를위한보다구체적인전략을세워나가야할것이다. 결론적으로 COPD 환자가족은중간정도의보호부담을느끼고있었으며이러한보호부담은가족의교육수준, 직업유무, 소득수준, 주보호자여부, 돌봄시간, 건강상태, 가족관계, 환자의일상생활기능제한정도, 가족및친구의지지와관련이있었다. COPD 환자보호자의보호부담감소를위해서는팀협력을통한환자가족의사회경제적상태, 가족관계, 돌봄특성, 사회적지지에대한사정및평가가필요하다. 스트레스감소및가족관계향상을위한상담과가족및친구등비공식적지지체계의활성화프로그램이주관적보호부담을낮출수있는방안이될수있을것으로생각되며객관적보호부담을낮추기위해서는환자의치료비지원및환자의제한된일상생활기능을원조할수있는지역사회자원과의연결이필요할것이다. 440
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