臺灣博碩士論文加值系統

青少年的生活型態中「速食」、「外食」、「晚睡」及「不運動之宅男與宅女」逐日增加中，代謝症候群的盛行率也有日益嚴重之趨勢。過去研究發現，青少女以不正確的過份節食方式控制體重、從事身體活動的比率低及因體型被嘲笑之比率比青少男嚴重。然而鮮少針對青少女提供合宜的防治策略。探討青少女面對代謝症候群危險因子的生活經驗，進而設計貼近年輕人生活的E化健康管理平台，促進落實健康生活型態的護理介入措施，實有其必要性。本研究分三個階段進行，研究目的及結果分述如下：
第一階段採質性研究之紮根理論研究法（grounded theory），以建立台灣青少
女代謝症候群高危險群生活經驗的描述性理論。深入訪談20位年齡介於16-20
歲之代謝症候群高危險群青少女，所分析之類屬為：「對抗肥胖的掙扎糾結」為
整個過程的核心類屬，其引導整個減重生活歷程。「肥胖是恥辱」為此過程之先
驅條件，包含次類屬「被嘲笑」、「被責備」、「被霸凌」及「缺少青少女的吸引力」，
一旦青少女感受到肥胖是一種恥辱時，即進入「對抗肥胖的掙扎糾結」過程中。
在此過程中，體重過重青少女會有以下四個互動行為類屬：嘗試節食撇步、自我
放縱、面對弱點及展開新生活。青少女徘徊在選擇健康新生活或恢復以前生活飲
食習慣的掙扎中。最後，有些青少女在獲得支持激勵下，逐漸控制體重。然而，
有些人受不了誘惑或壓力，重回過去生活型態，體重又逐日上升，而再次陷入對
抗肥胖的惡性循環中。而其E化健康管理需求部分，資料採內容分析法，將青少
女代謝症候群高危險群的E化健康管理平台需求歸納為五大主軸：網頁介面具吸
引力且便於操作、可信的資訊與資源、個人化量身訂做的健康訊息、同儕支持及
自我監測與學習。
第二階段為研究工具之發展與信效度建構，依第一階段質性研究的結果及文獻查證，與跨領域專業合作建構完成「青少女代謝症候群E化健康管理平台」。其主要架構包括：健康自我認知-「開始作戰」、健康狀態自我監測-填寫體重及腰圍，監測曲線變化、飲食日誌及運動日誌、「超級比一比」、參與討論或瀏覽討論區-「心情加油站」、「問專家」、「hate 油發洩室」、「Faccebook粉絲團」、健康生活型態指導與諮詢-「主題專區」、「好站相連」、「電子書下載」、提示系統-透過email、MSN、Facebook、Line及電話連繫藉以監督及激勵，以及「集點A好康」。此E化健康管理平台具有良好之信效度(專家效度：content validity index during 0.973-0.991，使用者評鑑內容效度：content validity index =1.00，以及重測信度：Intra-Class Correlation during 0.805-0.957) 。
第三階段採縱貫性、重覆測試準實驗法設計，探討青少女代謝症候群高危險
群E化健康管理介入措施的追蹤成效，以及建立青少女代謝症候群高危險群之健
康管理模式。選取台灣北部某兩校同質性較高的學校進行收案。參與此介入性研
究的個案總數共有137名青少女，實驗組共62人；控制組共75人。實驗組接受由研究者透過E化健康管理平台介入之健康管理與諮詢，控制組為一般校園之健康教育。實驗期間為期一年。兩組在追蹤成效之四次施測時間點為:介入前，介入後3個月、6個月、12個月，兩組分別進行收集以下資料:身體活動情形、飲食行為特性，健康促進生活型態及代謝症候群檢測(腰圍、空腹血糖、總膽固醇、三酸甘油酯、高密度脂蛋白及血壓)。本研究介入一年實驗組流失率為14.5%，控制組流失率為4%。資料以SPSS 18.0建檔後進行統計，以描述性統計、卡方檢定、t考驗、廣義估計模式（Generalized Estimating Equation, GEE）進行資料分析。研究結果發現：介入3個月後，實驗組相較於控制組，有效改善代謝症候群危險因子（β=-0.436,p =.004），包括：身體質量指數、腰圍、高密度脂蛋白、收縮壓及舒張壓等。有效改善飲食行為特性及提升健康促進生活型態（β=11.514,p =.005）。且這些成效皆持續至第6個月並達統計上顯著差異。在第6個月增加出現之介入成效為:空腹血糖之下降(β=-7.174，p <.001)與運動時間之增強(β=0.256，p=.030)。在介入12個月後兩組相較，實驗組的代謝症候群危險因子仍有持續改善成效(包括：身體質量指數、腰圍、高密度脂蛋白、收縮壓、舒張壓及空腹血糖)，然而飲食行為特性中低熱量攝食技巧與高熱量攝取頻率中則未呈現顯著差異。此外，兩組的總膽固醇與三酸甘油酯在三次後測中皆未呈現顯著差異。在代謝症候群逆轉上，實驗組於前測時有9人符合代謝症候群判定標準，經3個月介入後有7人逆轉成功，介入12個月後僅剩一人符合代謝症候群判定；反觀控制組不降反升，3個月後測時由7人變為8人符合判定標準，12個月後更增加為10人。兩組代謝症候群危險因子改變情形達統計上顯著差異（χ2=5.479, p=.024）。登錄飲食運動日誌次數與代謝症候群危險因子改變、身體質量指數、腰圍及三酸甘油酯改變呈顯著負相關，與高密度脂蛋白改變呈顯著正相關；網站互動次數與代謝症候群危險因子改變、腰圍改變、收縮壓改變及三酸甘油酯改變呈顯著負相關。
綜合以上研究發現，E化健康管理平台介入可有效降低身體質量指數、腰圍、收縮壓、舒張壓、空腹血糖及提升高密度脂蛋白，並可有效改善飲食行為特性及提升健康促進生活型態。介入前期，健康提供者必須透過研究對象熟悉的網路語言，以非教條式的關心方式，發揮建立信任者的角色，與之建立信任關係，此乃決定介入成功與否的重要關鍵。而研究中也發現逆轉代謝症候群的黃金時期為介入前三個月，在此黃金期必須使研究對象能有所成效，方能建立信心持續努力下去。過程中當青少女面臨「對抗肥胖的掙扎」時須不斷提供激勵與支持，使其結束徘徊糾結而朝向展開健康新生活。此外，網站也需時時推陳出新並舉辦活動，才能吸引使用者持續上網應用，進而影響改變成效。建議未來可多推廣此E化健康照護模式，利用網際網路不限時空的便捷，提供年輕族群最契合的自我健康管理，透過瞭解飲食與運動的雙向溝通與正確知識傳遞，培養正確之生活習慣來逆轉疾病，並促進其人格及學業成績都有正向發展。

“Fast food,” “eating out,” “sleeping late,” and “lack of exercise” are lifestyles that are becoming increasingly common for adolescents. Additionally, the prevalence of metabolic syndrome is increasing. Previous studies have shown that adolescent girls are inclined to adopt extreme and unhealthy methods for weight control. Compared with adolescent boys, the proportion of adolescent girls who rarely exercise or have been teased about their figures is substantially high. However, few preventive health strategies have been proposed for adolescent girls. Understanding the subjective life experiences among adolescent girls with high risks of metabolic syndrome is necessary; enable the design of an e-health management platform that is customized to the lifestyles of young adults, and to promote nursing intervention that facilitate healthy lifestyles. This study was conducted in 3 stages, and the research purposes and results are provided in the following paragraphs.

In the first stage, the qualitative approach and grounded theory were adopted to generate a descriptive theory regarding the life experiences of Taiwanese adolescent girls who are at high risk for metabolic syndrome. In-depth interviews were conducted with 20 adolescent girls with high risk of metabolic syndrome who were aged 16-20 years. The “struggle against fat” was the core theme for describing and guiding the process of weight loss among overweight adolescent girls. During this process, “Obesity as a stigma” was identified as the antecedent condition that included subcategories -being teased, being blamed, being bullied and lack of girls’ attractiveness. The overweight adolescent girls struggled between keeping on practicing new lifestyle and resuming previous lifestyle during trying weight loss process. This process was categorized as “try dieting tips”, “self-sabotage”, “confronting weakness”, and “adhere to a new life”. During this process, some girls would confront self-weakness to practice new healthy lifestyle such as stop consuming snacks and sweetened beverages, exercising daily, not using eating as a means to combat stress. They adhere to a new life by perceiving peer or family support, using incentive slogans and sharing experiences. Finally, these girls kept on maintaining their new lifestyle and reduced their body weight gradually. However, some girls would self-sabotage by eating too much again in response to the pressure of life or allure. Therefore, some girls would resume their previous lifestyle and regaining their body weight by entering into a vicious cycle of combating fat by try dieting tips and self-sabotage. Content analysis was adopted to process the data regarding e-health management platform requirements. The e-health management platform that was designed for these adolescent girls at high risk of metabolic syndrome required 5 major functions: an attractive and user-friendly website interface, access to reliable information and resources, provision of tailored health information, access to peer support, and self-monitoring and learning tools.

The second stage involved developing a research tool and establishing validity and reliability. Moreover, the e-health management platform that was designed for adolescent girls at risk for metabolic syndrome was constructed based on a literature review, the qualitative results obtained during the first stage of the study, and interdisciplinary professional cooperation. The platform framework incorporates the following primary components: self-awareness of health (i.e., Start the Fight), self-monitoring of health status (i.e., recording weight and waist circumference measurements and monitoring changes in data trends); food and exercise diary maintenance; food intake compared with exercise involvement; participation in discussions or browsing forums (e.g., “Emotional Recharge Zone,” “What the Experts Say,” “Hate Fat Venting Room,” and the “Facebook fan page”); healthy lifestyle guidance and counseling (e.g., main topic area, links to recommended websites, and e-book downloads); reminder systems, which facilitated accountability and encouragement through e-mail, MSN, Facebook, Line, and the telephone; and finally, a token system of earning points in exchange for prizes. This e-health management platform is reliable and valid (expert validity: content validity index = 0.973 – 0.991; user-evaluated content validity: content validity index = 1.00; and test-retest reliability: intra-class correlation = 0.805 – 0.957).

The third stage of platform development incorporated the longitudinal approach and repeated testing using a quasi-experimental design to evaluate the follow-up outcomes of the e-heath management platform intervention for adolescent girls with high risk of metabolic syndrome. In addition, a health management model was devised for the participants. Research data were collected from 2 schools with high homogeneity in Northern Taiwan. Overall, 137 adolescent girls participated in this intervention study. The experimental group consisted of 62 participants and the control group consisted of 75 participants. The experimental group received health management support and counseling that were conducted by the researchers through the e-health management platform, whereas the control group received the typical health education provided in schools. The experiment period was 1 year. Follow-up outcome data were collected 4 times for both groups. The collection times were as follows: before the intervention began, 3 months after the intervention began, 6 months after the intervention began, and 12 months after the intervention began. The following data were gathered regarding the 2 groups: physical activity, dietary behavior characteristics, adolescent health promotion scale, and measurement data of metabolic syndrome risk factors (i.e., waist circumference, fasting blood glucose, total cholesterol, triglycerides, high-density lipoprotein [HDL], and blood pressure). The data attrition rate measured during the year was 14.5% for the experimental group and 4% for the control group. SPSS version 18.0 software was used to compile and analyze the research data. Descriptive statistics, the chi-squared test, Student t test, and generalized estimating equations were used during analysis. The results showed that 3 months after the intervention began, the experimental group demonstrated significant improvements (β = -0.436, p = .004) compared with the results of the control group. Improvements were exhibited in the following risk factors for metabolic syndrome: the body mass index (BMI), waist circumference measurements, HDL levels, and systolic and diastolic blood pressure results. Both dietary behavior characteristics and adolescent health promotion scale improved (β = 11.514, p = .005). In addition, these outcomes remained statically significant 6 months after the intervention began. Six months after the intervention began, the following intervention outcomes were observed: a decline in fasting blood glucose levels (β = -7.174, p < .001) and an increase in time spent exercising (β = 0.256, p = .030). Twelve months after the intervention began, the risk factors for metabolic syndrome continued to improve (i.e., decreasing BMI, waist circumference measurements, HDL levels, lowered systolic and diastolic blood pressure, and reduced fasting blood glucose levels). However, no significant differences were observed regarding several of the dietary behavior characteristics, such as low caloric intake habits and high caloric intake frequencies. Moreover, the results obtained from the 3 posttests concerning the total cholesterol and triglyceride levels did not exhibit a significant difference between the two groups. Regarding metabolic syndrome reversal, 9 participants in the experimental group were diagnosed with metabolic syndrome during the pretest. Three months after the intervention began, metabolic syndrome was successfully reversed in 7 of the 9 participants. Only 1 participant continued to exhibit risks of metabolic syndrome after 12 months. Conversely, the number of participants who were diagnosed with metabolic syndrome increased in the control group. The posttests administered in the third month of intervention showed that the number in this group increased from 7 to 8. Twelve months after the intervention began, the number rose to 10. In both groups, the changes in risk factors for metabolic syndrome were significantly different (χ2 = 20.56, p < .001). The frequency of using the food and exercise diaries was negatively correlated to changes in the risk factors for metabolic syndrome (i.e., BMI and waist circumference measurements and triglyceride levels), but was positively correlated to changes in HDL levels. The frequency of using the website was negatively correlated to changes in the risk factors for metabolic syndrome (i.e., waist circumference measurements and systolic blood pressure and triglyceride levels).

The results showed that the intervention provided through the e-health management platform effectively lowered the measurements of BMI, waist circumference, systolic and diastolic blood pressure, and fasting blood glucose levels, and increased HDL levels. Therefore, both dietary behavior characteristics and the results of the adolescent health promotion scale were effectively improved. In the early stage of the intervention, healthcare providers might need to adopt the Internet communication styles that are common among the participants. The care provided must be non-doctrinal to facilitate building rapport between the providers and users. Such communication is the key to successful intervention. This study also found that the first 3 months of intervention were the golden period for reversing metabolic syndrome. Interventions must be effective for users during this period to enable users to grow in confidence and continue their effort. Continual encouragement and support must be provided for adolescent girls who are struggling with obesity. A new healthy lifestyle can begin only if this weight struggle is ameliorated. In addition, websites providing such intervention must be updated constantly and provide novel events that will attract users to use the website functions, thereby facilitating lifestyle habit changes. This study suggests that the proposed e-health model be promoted and implemented. By using the Internet, which is not bound by time and space, this model is the most effective self-health management method for young people. Through the propagation of accurate information and bidirectional communication between care providers and users regarding diet and exercise, healthy lifestyle habits can be established to reverse diseases such as metabolic syndrome. Furthermore, the resulting healthy lifestyle habits contribute to the positive development of the personal character and academic performance of users.

目 次

中文摘要 …………………………………………………………………………… i
英文摘要……………………………………………………………………………. iv
目次 ………………………………………………………………………………… ix
表次 ………………………………………………………………………………… xii
圖次 ………………………………………………………………………………… xiv
第一章 緒論
第一節 研究背景、動機及重要性………………………………………………… 1
第二節 研究目的 ………………………………………………………………… 5
第三節 研究問題 ………………………………………………………………… 5
第四節 研究假設 ………………………………………………………………… 6
第五節 名詞界定 ………………………………………………………………… 6
第二章 文獻探討
第一節 代謝症候群的知識演進 ………………………………………………… 9
第二節 青少年代謝症候群的相關概念 ………………………………………… 11
第三節 以系統性文獻回顧探討E化健康管理對青少年體重控制成效 ……… 21
第四節 E化健康管理網路平台應用的理論策略 ……………………………… 30
第五節 研究架構 ………………………………………………………………… 38
第三章 研究方法
第一節 研究設計 ………………………………………………………………… 39
第二節 研究對象、取樣方法與招募過程………………………………………… 40
第三節 研究工具 ………………………………………………………………… 42
第四節 研究步驟 ………………………………………………………………… 63
第五節 資料分析 ………………………………………………………………… 69
第四章 研究結果
第一節 青少女代謝症候群高危險群之生活經驗及E化健康管理設計需求 … 70
第二節 青少女代謝症候群eHMP的信效度建構 ……………………………… 80
第三節 青少女代謝症候群高危險群eHMP介入措施的追蹤成效 …………… 88
一、研究對象基本資料、前測成效變項描述分析及同質性檢測 ………… 88
二、代謝症候群危險因子、身體活動、飲食行為特性及健康促進生活型態
於四次施測的分布情形…………………………………………………… 95
三、eHMP介入對代謝症候群指標、身體活動狀況、飲食行為特性及健康
促進生活型態之影響……………………………………………………… 104
四、實驗組eHMP使用情形與代謝症候群危險因子改變之相關性探討…… 127
第五章 討論
第一節 跨領域eHMP的建構與融合 …………………………………………… 134
第二節 eHMP介入措施對研究對象代謝症候群危險因子成效的探討………… 139
第三節 eHMP介入措施對研究對象身體活動狀況、飲食行為特性及健康促進
生活型態的成效探討 ………………………………………………… 143
第四節 實驗組eHMP介入措施的網站使用情形與逆轉代謝症候群的相關性... 148
第五節 實驗組接受eHMP介入措施的主觀經驗及評值 ……………………… 150
第六章 結論、研究限制與建議
第一節 青少女代謝症候群高危險群的生活經驗及eHMP設計需求 ………… 155
第二節 青少女代謝症候群eHMP的信效度建構 ……………………………… 156
第三節 青少女代謝症候群高危險群E化健康管理介入措施的追蹤成效 …… 157
第四節 研究建議 ………………………………………………………………… 158
第五節 研究限制 ………………………………………………………………… 160
參考文獻
中文部分 ………………………………………………………………………… 162
外文部分 ………………………………………………………………………… 167
附錄
附錄一 國立臺北護理健康大學研究倫理審查通知書 ……………………… 181
附錄二 同意臨床試驗計畫證明書 …………………………………………… 182
附錄三　問卷（訪談）調查受試者同意書 …………………………………… 183
附錄四 臨床試驗受試者同意書 ……………………………………………… 185
附錄五 臨床營養師量身訂做的每日飲食建議量 …………………………… 188
附錄六 家庭社經地位等級分類法……………………………………………… 190
附錄七 青少年健康促進生活型態量表授權使用同意書 …………………… 191
附錄八 專家效度名單…………………………………………………………… 192
附錄九 青少女代謝症候群高危險群健康成效追蹤之問卷調查……………… 193

中文部分
大英百科公司（2004）．大英簡明百科．台北：遠流。
尤水菊、李金泉、楊瑞珍（2010）．體重控制介入對於代謝症候群防治之成效初探：以某國中為例．學校衛生護理雜誌，21，78-90。
王助順（2008）．臺灣某大學新生代謝症候群指標與其健康促進生活型態相關性之探討．未發表的碩士論文，台南：國立成功大學護理研究所。
尤嫣嫣（2002）．大學生體型及其身體意象相關因素之研究－以中原大學新生為例．未發表的博士論文．台北：臺灣師範大學健康促進與衛生教育學系。
台灣營養學會臨床營養委員會（2006）．臨床營養工作手冊．臺北：行政院衛生署。
行政院社會福利推動委員會青少年事務促進專案小組（2008，7月23日）．青少年政策白皮書綱領．取自
http://ey.cbi.gov.tw/internet/main/doc/doc_detail.aspx?uid=381&docid=1513
行政院衛生署國民健康局（2007）．代謝症候群防治工作手冊．台中：五南。
行政院衛生署國民健康局（2007，1月18日）．成人（20歲以上）代謝症候群
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