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研究生:何巧琳
研究生(外文):Ciao-Lin Ho
論文名稱:兒童近視防治實證與實踐
論文名稱(外文):Empirical evidence and Practice on Prevention and Treatment of Myopia in Children
指導教授:劉影梅劉影梅引用關係
指導教授(外文):Yiing Mei Liou
學位類別:博士
校院名稱:國立陽明大學
系所名稱:護理學系
學門:醫藥衛生學門
學類:護理學類
論文種類:學術論文
論文出版年:2019
畢業學年度:107
語文別:中文
論文頁數:268
中文關鍵詞:兒童青少年近視生活經驗眼睛保健
外文關鍵詞:childadolescentsmyopialife experienceeye care
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目的
本研究旨在從兒童照護者觀點出發,由他們的近視防治(5部分:電子產品管理、視力篩檢、視力複檢與診斷、Atropine治療與戶外活動管理)經驗中,逐步釐清當時的情境脈絡、想法與促進及障礙脈絡,如何交互形塑近視防治實踐?並完成三篇與文獻查證及結果相關之英文期刊論文撰述,子研究一近視幼童散瞳在治療過程中之照護者經驗,子研究二探討兒童與照護者遭逢近視診治經驗:質性整合分析,子研究三戶外活動策略對兒童近視防治成效之系統性文獻查證暨整合分析。
方法
主論文係採質性研究深度訪談法,以半結構訪談問題引導台灣北、中、南與東四個區域60名兒童照護人員(父母、幼兒園老師與護理師),陳述幼兒近視防治經驗,以半結構訪談問題深入訪談瞭解近視防治(電子產品管理、視力篩檢、視力複檢與診斷、Atropine治療與戶外活動管理)實施的情境,從近視防治小系統至大系統逐步瞭解近視防治策略施行障礙與促進因素。逐字稿聽打後,接著再將面談資料以信件或電子郵件的方式寄送給受訪者確認,進行訪談資料的相互驗證,以及訪談資料的編碼。接著研究者進行逐字稿與題目相對應。並從中尋找關鍵概念,再彙整為次主題與主題。
子研究一採用質性訪談,對台灣北部、中部、南部和東部四個地區的60名兒童照護者(父母,幼兒園教師和護士)進行訪談。子研究二通過英文和中文數據庫之系統性文獻查證,涵蓋時期為1960年至2018年,9項研究包括在質性綜合分析中。子研究三為系統性回顧與整合分析,用於評估室外光線暴露對近視的影響。
結果
主論文部分
1. 電子產品管理障礙因素:家庭不同調;阿公阿嬤愛孫子;不同性別角色導致育兒觀念差異;雙薪家庭忙碌;習慣已養成難改變;與滑世代嚴重衝擊眼健康。促進因素包含:嚴格限制使用;合理約法規則;時間管理辦法;活動發展與家長陪伴。
2. 視力篩檢障礙因素:幼兒成熟度可能影響視力檢查效度;檢查環境影響幼兒配合及篩檢流程不一與質量不足。
3. 在幼童視力複檢與診斷議題上:我們先釐清複檢前後兒童照護者如何溝通協商。再揭示家長在初診斷時反應各式負向情緒經驗:緊張嚇到感受;伴隨診斷經驗有許多情緒軌跡有許多情緒反應;需要多次診視才能確診造成家長的憂心焦慮;懷疑伴隨診斷與治療抉擇。最後呈現在視力複檢轉介障礙因素為視力複檢與診斷處理流程不一;家長不帶孩子去複檢的原因多元;僞陽性偽陰性引發家長、醫師、護理師與老師間的衝突;診治流程不一;學校護理師反覆陳述目前缺乏近視個案管理與追蹤機制;學校護理師表達家長需要更多近視相關訊息。
4. Atropine治療障礙與促進因素:本研究以兒童,父母,學校,醫院和社會四個維度探討Atropine治療障礙與促進因素。在兒童層面:障礙因素是父母在療效跟孩子的抱怨中掙扎,而促進因素是兒童從副作用的克服變遷到生活實踐。在父母層面:障礙因素包括父母表示忽視近視不需要特殊治療,藥到病除觀念;促進因素是接受醫師意見進行 Atropine治療,近視度數升降讓父母對atropine治療效果產生認同。在學校層面,障礙因素包括學校沒有為近視治療創造有效的環境;促進因素是老師幫助父母在學校幫學生服藥;護理師扮演案件管理的角色,以促進和追蹤atropine的護理計劃。在醫院和社會層面,障礙因素是缺乏個人化友善的醫療服務;促進因素是醫生作為導航;從重要的其他人那裡學習模型是堅持決定因素。
5. 戶外活動障礙因素:戶外活動質量不足,缺乏活動空間與軟硬體設備,與對於戶外活動防治近視機制不知其所以然。促進因素包含:活動軟硬體支持環境營造,幼兒園課程活動能朝戶外活動連結發展,與提升戶外活動知識、行為與習慣。
子研究部分
子研究一為主論文第4項研究之英文期刊寫作。子研究二研究結果呈現四個主題:1. 被未矯正的近視遮蔽了兒童學習發展,產生了負向情緒;2. 漫長迷惘的求醫之路;3. 戴眼鏡的污名化與重現光明間的掙扎;4. 家長由疏忽進化到與近視共存的生活智慧。子研究三共納入13篇研究,包括橫斷面、世代和介入等類型研究。15081名4-14歲兒童研究數據進行整合分析,結果顯示戶外光照暴露顯著降低了近視發生率/盛行率(優勢比[OR] = 0.85, 95%信賴區間[CI]: 0.80-0.91,p <0.00001; I2 = 90%)、球面等效屈光不正(SER)0.15D /年(CI: 0.09-0.27,p <0.0001)、眼軸增長0.08mm /年(CI: -0.14 ~ -0.02,p = 0.02)。根據匯總的總體結果,室外光線照射介入措施的好處包括三個近視指標數據減少:亞洲兒童的近視發生率減少50%,SER增長減少32.9%,眼軸增長率減少24.9%。每日戶外光照120分鐘以上是最有效的介入措施,每週介入時間與所有三個指標呈現劑量-反應關係。亞組比較部分,與世代研究和橫斷面研究相比,介入研究顯示室外光照射帶來的更大益處,介入研究中有近視者在SER和眼軸增長方面比沒有近視者獲益更多。
結論:
本研究以兒童照護者之視角,將問題意識連接到近視防治實證策略與實踐的間隙,植基於中國文化與近視防治的策略脈絡,深入訪查學校與家庭與訪談。以瞭解兒童照護者在協作幼童電子產品管理、視力篩檢、視力複檢與追蹤與Atropine治療、戶外活動管理等近視防治照護軌跡上所面臨的障礙與促進因素。實證知識策略與實踐之間存有隔閡。兒童、家庭、學校、醫院社區與健康政策等各環節的脈絡,皆會影響到近視防治實踐。
在漫長迷惘診治經驗中,引領期盼醫護人員給予最新實證指引與支持,本研究結果有助於臨床醫護人員在面對這些家庭更佳理解他們的問題、情緒經驗、促進及障礙因素,能及早透過對話協助啟發,由疏忽變遷到護眼行為生活實踐之家庭韌力。惟有透過各系統間不斷的介入、討論與相互合作。才能形成強健行動網絡,共同營造台灣近視防治環境。
OBJECTIVE
The purpose of this study is to clarify the context and facilitators of, as well as barriers to, myopia prevention and treatment from the perspective of child caregivers. From their point of view, this study explores myopia prevention and treatment strategies interactively based on child caregivers’ experiences of 5 items: electronic product management, outdoor activities, visual screening, visual re-examination and diagnosis, and atropine treatment. Three English journal articles were finished based on the results and literature review, including 1. Context of Atropine Adherence in Preschool Children with Early-Onset Myopia: A Qualitative Study (Sub-study 1); 2. Breaking the Perplexity to Reproduce Light - Experience of Corrected Myopia on Children and Adolescents: A meta-synthesis on qualitative research (Sub-Study 2); and 3. Dose–Response Relationship of Outdoor Exposure and Myopia Indicators: A Systematic Review and Meta-Analysis of Various Research Methods (Sub-study 3).
METHODS
In main dissertation, qualitative in-depth interviews for Chinese papers were conducted to guide 60 caregivers (parents, teachers, and nurses) of urban and rural children from the northern, central, southern, and eastern parts of Taiwan in presenting their experiences in the prevention and treatment of myopia. The objective of the interviews was to determine the context of the implementation of myopia prevention and control strategies and to gradually identify the barriers to and causes of failure for the implementation of myopia prevention and control strategies in small to larger myopia prevention systems. After the drafting of a verbatim, the interview data were coded and sent to respondents by letter or e-mail for them to confirm the content. The researcher then transcribed the interviews in a verbatim corresponding to the subject, identified the key concepts from them, and aggregated the concepts into subthemes and themes.
Sub-study 1 used interviews with qualitative interviews to interview 60 caregivers (parents, kindergarten teachers and nurses) in four areas of North, Central, South and East Taiwan. In sub-study 2, a systematic literature search identified through English and Chinese databases, covering the period was between 1960 and 2018, and nine studies included in quantitative synthesis. Sub-study 3 was a systematic review and meta-analysis to evaluate the effects of outdoor light exposure on myopia.
RESULTS
Main dissertation
1. The barriers to the implementation of electronic product management included different types of attitudes from the family members, children being spoiled by their grandparents, different parenting concepts from gender roles, a busy double-income family situation, difficulty to change bad habits, and slippery generations to impact eye health. Facilitators to the implementation of electronic product management included strict restrictions of the use of electronic products, reasonable rules and regulations, the application of time management methods, activity development, and parental companionship.
2. The barriers to visual screening included affecting the validity of the visual examination on children's maturity, the screening environment interference with children's cooperation, the difference in screening processes and their insufficient quality.
3. The barriers to visual re-examination referral were the difference in processes of visual re-examination and diagnoses, parents' unwillingness to take their children for re-examination, conflicts caused by false positive and false negative results, divergent processes of diagnosis and treatment strategies, lack of follow-up, case management, and tracking mechanism, and caregivers' lack of attention to myopia-induced problems and to prevention and treatment awareness.
4. This study explores the barriers and facilitators for the four dimensions involved in atropine treatment namely children, parents, schools, and hospitals & society. At the child level, the barrier was parents struggling with curative effects and children's complaints; the facilitator was that the side effects could be overcome by learning life practices. At the parental level, barriers included the action parents neglect of myopia and do not need special treatment, expectation to get rid of the disease immediately. The facilitators were acceptance of the physician's opinion on atropine treatment and parents’ agreement with atropine treatment by improve of the myopia. At the school level, the barrier was the fact that the school did not create an effective environment for myopia treatment; the facilitators were the teachers are obedient to the students in school and the nurses play a case management role in promoting and tracking the effectiveness of atropine. At the hospital and social level, the barrier was the lack of personalized and friendly medical services. The facilitators were that doctor as a navigation, and model learning from significant others is an adherence determinant.
5. The barriers to outdoor activities were the inadequate quality of the outdoor activities, a lack of space to conduct the activities or of hardware and software equipment, ignorance of the mechanism of myopia prevention and treatment through outdoor activities. The facilitators included the construction of software and hardware, kindergarten curriculum activities toward outdoor activities, and the enhancement of knowledge, behavior, and habits regarding outdoor activities.
Sub-study
In sub-study 1 is the English journal writing for the fourth study in main dissertation.
In sub-study 2, this study found four meta-syntheses included uncorrected myopia obscured learning development and caused negative emotions; the long confusing way to seek medical treatment; struggling with stigma of wearing glasses and the reproducing vision; and parents evolved from negligence to life wisdom that coexists with myopia.
In sub-study 3, according to research data from 13 studies of 15,081 children aged 4-14 at baseline, outdoor light exposure significantly reduced myopia incidence/prevalence (odds ratio [OR] = 0.85, 95% confidence interval [CI]: 0.80–0.91, p < 0.00001; I2 = 90%), spherical equivalent refractive error (SER) by 0.15 D/year (0.09–0.27, p < 0.0001), and axial elongation by 0.08 mm/year (−0.14 to −0.02, p = 0.02). The benefits of outdoor light exposure intervention, according to pooled overall results, included decreases in three myopia indicators: 50% in myopia incidence, 32.9% in SER, and 24.9% in axial elongation for individuals in Asia. Daily outdoor light exposure of more than 120 min was the most effective intervention, and weekly intervention time exhibited a dose–response relationship with all three indicators. Subgroup comparisons revealed that interventional studies report greater benefits from outdoor light exposure compared with cohort and cross-sectional studies, and individuals with myopia in intervention studies experienced slightly greater benefits than individuals without, in terms of SER and axial elongation.
CONCLUSIONS
This study links the problem to the gap between empirical strategies and real practices in myopia prevention and treatment from the perspective of child caregivers and based on the cultural context as evidenced through in-depth interviews conducted with schools and families. To understand the barriers and facilitators encountered by child caregivers when dealing with children's electronic product management, outdoor activities, visual screening, visual re-examination and tracking, and atropine treatment in the context of myopia prevention and treatment. There is a gap between empirical strategies and practices. Health policies from children, their families, schools, hospitals and society affect the practice of myopia prevention and treatment.
To avoid a long and confusing experience during the diagnosis and treatment of myopia, we recommend that medical staff provide the latest empirical guidance and most support possible to patients. The results of this study will help clinical staff understand better the problems and emotional experience that families undergo, overcome the barriers, and understand the facilitators when dealing with these families. This study should also inspire dialogue between medical staff and families as early as possible in the diagnosis process, from negligence to eye-care behavior life. The continuous intervention, discussion, and cooperation between the various levels formed a robust mobile network and created a myopia prevention and control environment in Taiwan.
目錄
頁碼
誌謝……………………………………………………………………………………i
中文摘要……………………….………………………………………………………iii
英文摘要…………………………..…………………………………………………vii
目錄…………………………….……………………………………………………xi
圖目錄…………………………………………..……………………………………xiii
表目錄…………………………………..……………………………………………xiv
第一章 緒論…………………………………………………………………………… 1
第一節 研究重要性……………………………………………………………… 1
第二節 研究動機 ………………………………………..……………………27
第三節 研究目的與問題……………..……………………..…………………31
第二章 文獻查證……………………………………..………………………………35
第一節 兒童近視防治概念分析………………………….……………………35
第二節 實證近視防治策略………………………….…………………………45
第三節 兒童近視診治經驗………………………….…………………………84
第三章 研究方法……………………………………………………………………..94
第一節 研究設計與實施………..………………………….……………………94
第二節 研究對象…………………………………….…………………………96
第三節 研究工具與資料收集……………………….…………………………98
第四節 研究嚴謹度………………..……………………….…………………101
第五節 研究倫理考量……………………………….………………………101
第六節 期刊發表形式結果呈現…….……………….………………………101
第四章 研究結果……………………………………………………………………102
第一節 參與者基本資料…………………..…………………………………102
第二節 電子產品管理障礙與促進因素…..…………………………………107
第三節 視力篩檢障礙與促進因素…………..………………………………113
第四節 幼童視力複檢與診斷之障礙與促進因素…………………………116
第五節 Atropine 治療障礙與促進因素………………………………………125
第六節 幼童戶外活動管理障礙與促進因素…………………………………138
第五章 討論……………………………………………………………..…….……145
第一節 電子產品管理障礙與促進因素…….…………………………………145
第二節 視力篩檢障礙與促進因素…………..………………………………147
第三節 幼童視力複檢與診斷之障礙與促進因素…………………………149
第四節 Atropine 治療障礙與促進因素………………………………………151
第五節 幼童戶外活動管理障礙與促進因素…………………………………153
第六章 結論、建議與研究限制………………………………………………………155
第一節 結論……………………………………………………………………155
第二節 臨床實踐與相關教育建議…………………..………………………159
第三節 研究限制與未來研究建議………………………..…………………166
中文參考文獻………………………………………………………………………168
英文參考文獻………………………………………………..………………………173
附錄一 陽明大學人體試驗同意證明書…………………….……………………191
附錄二 陽明大學人體試驗展延證明書……………………….…………………192
附錄三 陽明大學人體試驗結案證明書…………………………………………193
附錄四 近視幼童散瞳在治療過程中之照護者經驗….…………………………194
附錄五 兒童與照護者遭逢近視的診治經驗:質性整合分析……………………221
附錄六 戶外活動策略對兒童近視防治成效之系統性文獻查證暨整合分析…242

圖目錄
頁碼
第一章 緒論
圖1-1 2000年-預估2050年全球近視與高度近視人數……………………….….3
圖1-2 2000年-預估2050年全球近視盛行率……………..……………..………..4
圖1-3 台灣兒童自1983-2017年近視盛行率…………..…………….…………..5
圖1-4 台灣兒童2017年近視盛行率增加差異比較圖…………………..………5
圖1-5 台灣兒童自1986-2017年高度近視盛行率……………………….………5
圖1-6 世界各地3至6歲學童近視的發生率分佈圖…………………...………15
圖1-7 世界各地3至6歲學童近視的發生率曲線圖……………………..……16
圖1-8 世界各地7至12歲學童近視的發生率分佈圖…………………………17
圖1-9 世界各地7至12歲學童近視的發生率曲線圖…………………………18
圖1-10 世界各地13至15歲學童近視的發生率分佈圖………………………19
圖1-11 世界各地13至15歲學童近視的發生率曲線圖………………….……20
圖1-12論文研究構想圖.………………….……………………………………..28
第二章 文獻查證
圖2-1 Rodgers 演化概念發展過程…………………………...…………………36
圖2-2 電子產品使用與近視發生的森林樹….….…….…………………………51
圖2-3 研究工具敏感性與特異性整合分析結果圖..………...…………………54
圖2-4 診斷工具風險比率…….………….…………………...…………………55
圖2-5 研究品質分析成果…..………………….…………......…………………60
圖2-6 近視矯正方法網路分析圖...………...………………...…………………63
圖2-7 文獻檢索和研究選擇的流程圖..……………………...…………………69
圖2-8 介入研究的偏倚風險總結..………….…….………………….…………71
圖2-9 介入研究的偏倚風險表.….……….…….…………………………..……71
圖2-10 近視發生率和盛行率的整合分析結果…..…………...…….……………76
圖2-11 介入後減少SER的整合分析結果…………………...…………………77
圖2-12 介入後減少眼軸增長的整合分析結果.……………...…………………78
圖2-13 近視發生率/盛行率的減少率與學校的室外時間之間的劑量反應效應…………………………………………..……………………………...79
圖2-14 SER減少率與學校戶外時間之間的劑量反應效應….…………….……80
圖2-15 眼軸增長率和在校室外時間縮短比例之間的劑量-反應效應…………80
第四章 戶外活動策略對兒童近視防治成效之系統性文獻查證暨整合分析
圖4-1 台灣北、中、南、東幼稚園訪談幼稚園分區圖…………………………107

表目錄
頁碼
第一章 緒論
表1-1 台灣地區兒童近視起始年………………………….……………………6
表1-2 世界各地3至6歲學童近視的發生率…………………………...………9
表1-3 世界各地7至12歲學童近視的發生率………………….….…………11
表1-4 世界各地13至15歲學童近視的發生率……………………....……….13
表1-5 我國歷年防治近視策略.………….………………………………………25
第二章 文獻查證
表2-1 近視防治行為前因整理表 ………………………………………….….40
表2-2 系統性文獻查證電子產品使用與近視發生風險評估……….…………48
表2-3 以QUADAS-2文獻質量評估(N = 3)……………………..……………53
表2-4 幼兒篩檢與屈光檢測比較納入文獻………………………..…………54
表2-5 研究工具敏感性整合分析結果1………………………………….….54
表2-6 研究工具特異性整合分析結果2…………………..……….…………55
表2-7 矯正方法系統性文獻查證結果整理……………………..……………62
表2-8 各式矯正方法比較統計分析表………………………..……………64
表2-9 各式矯正方法次序……………………………………………….….….64
表2-10 評估橫斷面研究的質量…..………………………...……….……………70
表2-11 評估世代研究的質量……………….…………………..……………70
表2-12 近視整合分析中包括的研究數據…..………………………....…………72
表2-13 戶外暴露後對近視發展的影響:介入組與對照組(近視組和非近視組)的比較…………………………………………………………………75
第三章 戶外活動策略對兒童近視防治成效之系統性文獻查證暨整合分析
表3-1 質性訪談資料分析表………………………………………….………..102
第四章 兒童與照護者遭逢近視診治經驗:質性整合分析
表4-1 訪談幼稚園鄉鎮市區分層整理表………………………………….…108
表4-2 家長訪談名單…………………………………………..…….…………109
表4-3 幼稚園老師近視防治經驗名單……………………..……………109
表4-4 學校衛生護理人員近視防治經驗名單………………………..………110
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