| 摘要: | 背景: 父母育兒自我信心和母乳哺育信心會影響養育子女的行為，並與兒童重要健康指標密切相關，父母雙方在心理健康方面的表現對家庭福祉和親子關係皆會產生重要的影響。具體來說，從懷孕到產後其睡眠模式和憂鬱情緒的變化，對產婦在產後身體和情緒適應造成極大地影響。隨著科技的進步，運用數位科技為基礎的教育課程常納入為健康照護元素，作為幫助新手父母的可能策略之一。因此，探討父母育兒自我效能和心理健康及其相關因素，並發展有效的實證介入方案，乃是提供為人父母者的重要議題。
目的: 本論文的研究目的陳述如下:
研究一、探討父母育兒自我效能、母乳哺育自我效能與心理健康及其相關因素。
研究二、瞭解懷孕至產後婦女睡眠和憂鬱軌跡的變化模式及其相關因素。
研究三、探討運用數位科技為基礎的父母教育課程對育兒自我效能、社會支持及憂鬱之影響。
方法:
研究一、採橫斷性研究設計，以育有一歲以內之嬰幼兒母親及父親為招募對象，使用結構化問卷於2022年12月至2024年1月期間進行線上蒐集資料。問卷內容包含親職效能量表和母乳哺育自我效能量表-簡表，以評估父母親在養育子女及母乳哺育上的信心程度;並分別使用愛丁堡產後憂鬱量表、特質焦慮量表、以及匹茲堡睡眠品質量表，來評估心理健康症狀及睡眠品質，採用多元線性迴歸和線性混合模型進行資料分析。
研究二、本研究採二次資料分析，利用一項前瞻性世代研究?資料來源，該研究收集資料時間從懷孕中期至產後3個月，招募標準為懷孕24-28週且單胞胎之婦女，排除條件為患有妊娠併發症或慢性病之婦女。研究工具主要為愛丁堡產後憂鬱量表評估其憂鬱情形，睡眠品質則採用匹茲堡睡眠品質量表進行測量，並在五個時間點進行重複資料收集，分別為懷孕28週(時間一)和36週(時間二)、產後1週(時間三)、1個月(時間四)和3個月(時間五)，以結構式問卷進行資料收集，採用成長軌跡分析模型確定憂鬱和睡眠隨時間變化的模式，並使用多項式羅吉斯迴歸探索各軌跡的預測因子。
研究三、針對數位科技的育兒教育課程之隨機對照試驗之研究，以系統回顧暨統合分析進行探討，研究結果包含育兒自我效能(主要結果)、社會支持和憂鬱情形(次要結果)，檢索電子資料庫自建立之初至2022年9月以前相關文獻及出版物的參考文獻列表，進行次族群分析和統合迴歸模型以確定與育兒教育課程相關之重要因素，並使用考科藍誤差風險評估工具評讀納入文章之誤差風險。
結果:
研究一、本研究招募共計383名母親和120名父親，其中，57對為同一家庭之夫妻。母親平均年齡為32.8歲(SD = 4.9)，而父親的平均年齡稍長為34.9歲(SD = 5.1)。參與者多數擁有大學或更高學歷、母親多數是初產婦，23.5%的母親表示實行純母乳哺育，在家庭樣本中也發現相似的人口統計和健康變數之趨勢。在育兒自我效能方面，年紀較長(母親: β = 0.20；父親: β = 0.50)、教育程度愈高(母親: β = 3.58)、具小年齡嬰兒(父親: β = -0.50)、焦慮(母親:β = -0.38;父親: β = -0.25)、憂鬱(母親:β = -0.50)與育兒自我效能顯著相關(ps < 0.05)。在整體樣本分析，母乳哺育自我效能方面，具大年齡嬰兒(母親: β = 0.48)、育有2位子女(含)以上之父母(母親: β = 3.72；父親: β = 7.18)、具較高的社會支持(母親: β = 0.16；父親：β = 0.29)、且實行純母乳哺乳者(母親: β = 16.9；父親: β = 13.5)與較高的母乳哺育自我效能有顯著相關(ps < 0.05)。家庭樣本也顯示，焦慮和憂鬱與育兒自我效能(焦慮: β = -0.25；憂鬱: β = -0.65)和母乳哺育自我效能(焦慮: β = -0.46)之間具一致關聯。
研究二、本研究共計190名符合條件之婦女參與並簽署同意書，平均年齡為32.3 (SD = 4.1)歲，我們使用成長曲線分析模型識別出三種不同的睡眠軌跡：第一組「穩定好」(stable good, 18.4%)、第二組「持續增加差」(increasing poor, 48.9%)和第三組「穩定差」(stable poor, 32.6%); 我們也確定了憂鬱症狀的三種軌跡組：第一組「穩定低」(stable low, 36.3%)、第二組「穩定中度」(stable mild, 42.1%)和第三組「穩定高」(stable high, 21.6%)，且睡眠品質差和較高的憂鬱症狀會同時出現(co-occurrence)。研究發現，高度疲勞症狀(odds ratio, OR = 4.75, 95% CI = 1.29, 17.44)和低社會支持(OR = 2.23, 95% CI = 1.15, 4.32)，顯著預測睡眠和憂鬱的聯合軌跡。
研究三、根據標題和摘要篩選出6063篇文章，隨後選出131篇文章進行全文檢視。最後，總共納入7篇隨機對照實驗，包括1342名父母，其平均年齡為27.3至32.7歲。統合分析結果顯示，接受數位科技的育兒教育介入可顯著提高父母育兒自我效能(SMD = 1.06, 95% CI= 0.40, 1.71)和社會支持(SMD = 2.72, 95% CI = 0.38, 5.07)，並減輕產後3個月憂鬱症狀(SMD = -0.39, 95% CI = -0.73, -0.04)。來自經濟合作暨發展組織國家Organization for Economic Co-operation and Development (OECD)的父母(SMD = 1.98, 95% CI = 1.78, 2.19)、參加為期六週或更長時間之教育課程(SMD = 1.62, 95% CI = 1.18, 2.06)、提供面對面訓練(SMD = 1.88, 95% CI = 1.32, 2.44)及提供課程指導(SMD = 2.00, 95% CI = 1.78, 2.22)，皆能顯著提高父母的自我效能。
結論： 本論文提供了關於育兒自我效能及母乳哺育自我效能與心理健康之間關係的重要結果，包括睡眠和憂鬱軌跡，以及運用數位科技育兒教育介入對於父母育兒信心之影響。研究結果呈現，父母的心理健康狀況，包括憂鬱和焦慮程度，是為人父母在第一年之育兒自我效能和母乳哺育自我效能的最佳預測因子。此外，確定了母親從懷孕到產後三個月，睡眠和憂鬱軌跡之間具有同時出現(co-occurrence)的情況，懷孕期間母親的社會支持和疲勞症狀可以預測聯合軌跡。透過系統性回顧和統合分析，發現以數位科技為基礎之育兒教育介入可提供有效策略來提高父母的自我效能並改善心理健康。因此，有必要及時評估自我效能和心理健康狀況，醫療保健專業人員應將有效的數位科技育兒計畫納入對母親和父親的照護中，有助於促進家庭健康和嬰兒照護。
Background: Parents’ confidence in parenting and breastfeeding influences parenting practices and closely links to child health outcomes. The psychological health of parents contributes significantly to overall parental well-being and the parent-infant relationship. Specifically, changes in sleep patterns and depression from pregnancy to the postpartum period may greatly impact maternal physical and emotional adaptation after birth. With advancements in technology, digital-based educational interventions have been incorporated into healthcare as potential strategies to assist parents with young infants. Investigating parental self-efficacy and psychological health, along with their associated factors, and developing effective evidence-based strategies are health priorities for parents transitioning to parenthood.
Objectives: The objectives of this dissertation were as following:
Study 1: To investigate the self-efficacy in breastfeeding and parenting, as well as the psychological outcomes in mothers and fathers, focusing on the relationships and associated factors.
Study 2: To explore the maternal sleep and depression trajectories and associated factors from pregnancy to postpartum period.
Study 3: To examine the effectiveness of digital-based educational interventions on parental self-efficacy, support, and depression during the transition to parenthood.
Methods:
Study 1: A cross-sectional study of mothers and fathers with infants aged 0-12 months was conducted. A survey using online structured questionnaires was undertaken from December 2022 and January 2024. Parenting and breastfeeding self-efficacy were assessed using the Parenting Sense of Competency scale and the Breastfeeding Self-Efficacy Scale-Short Form, respectively. Psychological symptoms and sleep variables were assessed using the Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory, and the Pittsburgh Sleep Quality Index (PSQI), respectively. Multiple linear regression and linear mixed-effects models were performed.
Study 2: A secondary data analysis was conducted on a prospective cohort study that followed mothers from mid-pregnancy to three months postpartum. Inclusion criteria was mothers who was pregnant at 24 to 28 weeks with a singleton fetus. Mothers with obstetric complications or chronic conditions were excluded. Depression was measured using the EPDS, and sleep was assessed using the PSQI. Repeated data were collected as the following five time points- i.e. at 28 weeks pregnancy (Time 1) and 36 weeks pregnancy (Time 2), postpartum 1 week (Time 3), 1 month (Time 4), and 3 months (Time 5). Demographic and health variables were assessed using structured questionnaires. The patterns of changes in depression and sleep over time were identified using group-based trajectory modeling. The predictors for each trajectory were examined using multinomial logistic regression modeling.
Study 3: A systematic review and meta-analysis was conducted on randomized controlled trials of digital-based parenting educational programs. The studied outcomes were self-efficacy in parenting (primary outcome), social support, and depression (secondary outcome). Electronic databases and the reference list of publications were searched from their inception to September 2022. The effect of study outcomes was analyzed using a random-effects model. Subgroup analyses and a meta-regression model were performed to identify the important factors associated with the effective parenting program. The selected articles were assessed the risk of bias using the Cochrane risk-of-bias tool.
Result:
Study 1: A total of 383 mothers and 120 fathers were included in the study. Among them, 57 pairs of mothers and fathers were from the same family. The average age of mothers was 32.8 years (SD = 4.9), whereas fathers were slightly older, with a mean age of 34.9 years (SD = 5.1). Most participants had a college education or higher. Most mothers were primiparas, and 23.5% of mothers reported practicing exclusive breastfeeding. Similar demographic and health variable patterns were found in the family samples. For parenting self-efficacy, advanced age (mothers: β = 0.20; fathers: β = 0.50), education levels (mothers: β = 3.58), infant age (fathers: β = -0.50), anxiety (mothers: β = -0.38; fathers: β= -0.25), and depression (mothers: β = -0.50) were significantly associated with parenting self-efficacy (ps < 0.05). For breastfeeding self-efficacy, older infant age (mothers: β = 0.48), parents who were multiparas (mothers: β = 3.72; fathers: β = 7.18), received higher social support (mothers: β = 0.16; fathers: β = 0.29), and practiced exclusive breastfeeding for their infant (mothers: β = 16.9; fathers: β = 13.5) were significantly associated with higher scores in the total sample (ps < 0.05). The family samples also showed consistent associations between anxiety and depression with self-efficacy in parenting (anxiety: β = -0.25; depression: β = -0.65) and breastfeeding (anxiety: β = -0.46).
Study 2: A total of 190 women was followed up in a cohort study design and was included in this secondary data analysis. The average age of participants was 32.3 (SD = 4.1) years. The results of group-based trajectory modeling showed three distinctive trajectories of sleep: group 1 (stable good, 18.4%), group 2 (increasing poor, 48.9%), and group 3 (stable poor, 32.6%). We also identified three trajectory groups of depression: group 1 (stable low, 36.3%), group 2 (stable mild, 42.1%), and group 3 (stable high, 21.6%). A frequent co-occurrence pattern of poor sleep quality and elevated depressive symptoms was detected. Women with high fatigue symptoms (odds ratio, OR = 4.75, 95% CI = 1.29, 17.44) and lower social support (OR = 2.23, 95% CI = 1.15, 4.32) significantly predicted the joint trajectories of sleep quality and depressive symptoms.
Study 3: A total of 6063 articles titles and abstracts were identified and screened. Next, 131 articles were selected for further full-text screening. In total, seven randomized controlled trials were identified, and 1342 parents were included in this study. The included parents were with an average age ranged from 27.3 to 32.7 years. A meta-analysis revealed that parents who participated in digital-based educational interventions reported significantly improved parental self-efficacy (standardized mean difference, SMD = 1.06, 95% CI= 0.40, 1.71), higher level of social support (SMD = 2.72, 95% CI = 0.38, 5.07), and reduced depression at 3 months postpartum (SMD = -0.39, 95% CI = -0.73, -0.04). Parents from Organization for Economic Co-operation and Development (OECD) countries (SMD = 1.98, 95% CI = 1.78, 2.19), those who participated in an educational program for six weeks or longer (SMD = 1.62, 95% CI = 1.18, 2.06), those in programs that included an in-person orientation (SMD = 1.88, 95% CI = 1.32, 2.44), or those in programs that provided guidance (SMD = 2.00, 95% CI = 1.78, 2.22) had higher levels of parenting self-efficacy.
Conclusions:
This dissertation provides valuable insights into the relationship between parenting and breastfeeding self-efficacy and psychological well-being, including the trajectories of sleep and depression, and the impact of digital-based parenting educational interventions on the overall experience of new parents. The findings indicate that strong interconnections between parental self-efficacy and psychological health, including levels of depression and anxiety, are significant predictors of parenting and breastfeeding self-efficacy in the first year of parenthood. The distinctive co-occurrence patterns of sleep and depression trajectories in mothers were identified from pregnancy through three months postpartum. Maternal social support and fatigue symptoms during pregnancy can help predict these joint trajectories. From the systematic review and meta-analysis, digital-based parenting programs were found to offer effective strategies to increase parents' self-efficacy and improve their psychological well-being. Prompt assessment of self-efficacy and psychological health is warranted. Healthcare professionals should integrate effective digital parenting programs into care for mothers and fathers, as these are beneficial for optimal family health and infant care. |
