【作者】 李莹；

【导师】 吴辉；

【作者基本信息】 中国医科大学 ， 卫生事业管理学， 2022， 博士

【副题名】基于三阶段交叉滞后模型的建立

【摘要】 目的:近年来,虽然有关大学生问题性智能手机使用(PSU)的文献频繁报告了问题性智能手机使用与焦虑、抑郁、冲动性和睡眠质量间的相关关系。但截止目前,这些因素和大学生问题性智能手机使用存在多大程度的相关尚无定论。因此,我们首先开展了一项Meta分析通过定量合并前人的研究结果以期得到各变量间确切的相关系数,为今后的研究提供循证依据,增加统计学效能,提高研究结论的可靠性。其次,随着研究人员对问题性智能手机使用研究热度的迅速提高,研究人员发现大学生抑郁倾向与问题性智能手机使用之间不仅有直接关系,还存在间接效应(中介效应或调节效应)。本研究基于机体-情感-认知-执行模型(I-PACE Model)理论模型及前人研究,将探讨大学生人群中错失恐惧症(FoMO)、思维反刍等心理特质因素是否可作为中介因子间接影响抑郁倾向与问题性智能手机使用之间的关系,此外,我们还探讨了自我效能的调节的中介作用。最后,为了验证抑郁症状、FoMO和思维反刍与PSU这些研究变量间的因果关系,我们开展了纵向队列研究,进一步研究了上述四个主要研究变量与睡眠时间、自我控制双系统维度、社交恐惧和人际关系间因果关系,为今后问题性智能手机使用与个人特性、心理健康之间关系研究提供可靠的证据。研究方法:1.系统综述和Meta分析通过采用Pub Med、Embase、考克兰图书馆、万方数据库、CNKI数据库、维普数据库和中国生物医学文献数据库(CBM)检索相关文献。检索日期限定为自各数据库建库起至2020年8月1日。PSU与焦虑、抑郁、冲动性和睡眠质量之间的Pearson相关系数的合并采用R语言“meta”程序包。2.我们依托中国医科大学开展了一项横断面研究,2021年5月(第一轮)采用方便抽样方法选取医学生进行线上调查(问卷星平台)。调查内容包括一般资料、智能手机成瘾量表、流调用抑郁自评量表、思维反刍量表、错失恐惧量表和一般自我效能感量表。连续性变量根据资料的分布类型可以表达为均数(标准差)或中位数(四分位间距),并适当采用Student t检验、方差分析或者非参数Wilcoxon秩和检验进行组间比较;分类变量采用频数和构成比进行描述性分析,并采用χ~2检验进行组间比较的检验。本研究的主要数据处理分析软件采用SPSS 22.0。采用R软件绘制两两变量间Pearson相关矩阵热点图。FoMO、思维反刍、自我效能的中介作用、调节作用和调节的中介作用则采PROCESS v4.0。同时,若调节效应存在统计学意义时,则下一步要进行简单斜率检验,并作简单斜率分析图。结构方程模型路径图采用IBM SPSS AMOS插件实现。3.在横断面研究基础上,每间隔三个月随访调查一次大学生心理健康与行为成瘾量表,共进行了3次阶段的问卷调查(学期期中、开学和寒假)。采用AMOS插件对不同时间点大学生抑郁症状-FoMO-PSU以及抑郁症状-思维反刍-PSU三者之间的三元交叉滞后回归模型进行路径分析。为保证同一因果关系在3个时间点下的路径系数(回归系数)具有一致性,运行模型之前先进行路径系数等值设定,以保证研究结果的可解释性。结果:1.经筛选,Meta分析共纳入40个研究,共涉及33650名大学生。我们发现PSU与焦虑、抑郁、冲动性和睡眠质量之间存在弱到中等强度相关(焦虑:合并r=0.39,95%CI=0.34-0.45,P<0.001,I~2=84.9%;抑郁:合并r=0.36,95%CI=0.32-0.40,P<0.001,I~2=84.2%;冲动性:合并r=0.38,95%CI=0.28-0.47,P<0.001,I~2=94.7%;睡眠质量:合并r=0.28,95%CI=0.22-0.33,P<0.001,I~2=85.6%)。亚组分析结果显示不同亚组间的合并相关系数存在一定的差异。敏感性分析提示我们的结果比较稳定可靠。2.横断面研究中PSU总平均分为35.43±8.16分,患病率高达70.58%(1154/1635)。抑郁症状、FoMO、思维反刍两两变量间都呈正相关,与PSU也呈正相关关系(r=0.382、0.262、0.382,P<0.01);相反,自我效能与抑郁症状、FoMO、思维反刍和PSU严重程度呈负相关(r分别为-0.331、-0.055、-0.260和-0.277;P<0.05)。在大学生群体中,FoMO在抑郁症状与PSU关系中起到部分中介作用,中介效应占总效应的15.07%。自我效能感调节了FoMO在抑郁症状与PSU关系的中介作用。思维反刍在抑郁症状与PSU关系中起到部分中介作用,中介效应占总效应的15.5%。自我效能对抑郁和PSU关系起调节作用。3.只有321名研究对象完成了全部3次追踪调查。结果显示,大学生抑郁症状、FoMO、思维反刍和PSU之间在T1、T2和T3不同时间段下两两相关且呈正相关,并有统计学意义。纵向交叉滞后回归模型显示,大学生抑郁症状与PSU之间存在双向因果关系,抑郁症状水平越高,越容易引发PSU发生,反之亦然。大学生抑郁症状与FoMO也存在互为因果关系,抑郁症状水平越高,越易发生FoMO。此外,抑郁症状可以预测思维反刍,反之不成立。本研究未发现FoMO与PSU之间存在正向或负向的预测作用。结论:Meta分析发现PSU行为与焦虑、抑郁、冲动性和睡眠质量存在弱到中等强度的正相关关系。这提示有PSU行为的大学生更容易存在焦虑、抑郁、冲动性和睡眠质量不佳等问题。大学生的抑郁症状是PSU的发生风险的独立预测因素;错失恐惧和思维反刍与大学生抑郁和PSU行为的发生均存在正向相关关系;且起到了中介效应作用,即伴有抑郁倾向的大学生可通过错失恐惧和思维反刍的恶化而进一步导致PSU行为的发生;自我效能调节了错失恐惧在大学生抑郁症状-PSU关系间的中介效应。自我效能直接调节了抑郁症状-PSU之间的关系,而不能调节思维反刍的中介作用。生命早期是机体思想和行为形成和发育的关键时期,可塑性较强,应该以青少年和青年早期作为干预的重点窗口期,关注心理健康状况和PSU行为的发生发展过程,通过提升积极心理因素-自我效能作为提高防御智能PSU的干预手段之一,为政府、学校和家庭治理PSU提供实证经验。更多还原

【Abstract】 Objective:Firstly,problematic smartphone usage(PSU)is frequently reported tobe correlated with anxiety,depression,stress,impulsivity,and sleep quality among college students.However,to date,there is no consensus on the extent to which those factors are correlated with PSU among college students.We thus performed a meta-analysis to quantitatively synthesizethe previous findings.Secondly,with the rapid increase of researchers’interest in mobile phone addiction research,researchers have found that there is not only a direct relationship between college students’depression tendency and PSU,but also an indirect effect(mediating effect or moderating effect).Therefore,based on the theoretical model of the Interaction of Person-Affect-Cognition-Execution(I-PACE model)and previous studies,we would explorethat whether psychological factors such as fear of missing out(FoMO)and rumination in college students could be used as mediators to indirectly affect the relationship between depression tendency and PSU,as well as the moderated mediation effectof gender and self-efficacy.To determine the causal relationships between study variables such as depressive symptoms,FoMO,and rumination,and PSU,we further conducted a cohort study.Additionally,the causal relationships between these four main research variables and sleep duration,dual-system dimension of self-control,social fear,and interpersonal relationships were also examined so as to provide solid evidence for future research on the relationships between PSU,personal characteristics,and mental health.Methods:A systematic review and meta-analysis was conducted by searching Pub Med,Embase,Cochrane Library,Wanfang,CNKI,VIP,and CBM databases from inception to August 1,2020.Pooled Pearson’s correlation coefficients between MPA and anxiety,depression,impulsivity,and sleep quality were calculated by R software using randomeffects model.Second,we carried out a cross-sectional study based on China Medical University on May 2021(the first round).Medical students were recruited through an online survey platform(Wenjuanxing platform)using the convenience sampling strategy.A total of 1837 study subjects were enrolled.After the exclusion of 202 study subjects who aged over 24 years old and did not complete the questionnaires.Finally,1635subjects met the inclusion criteria(572 males and 1063 females),and the effective response rate was 89.0%.The average age of the study subjects was 20.65±1.70 years.The survey contents included basic information,short version of the Smartphone Addiction Scale(SAS-SV),Center for Epidemiological Survey Depression Scale(CES-D),Ruminative Responses Scale(RRS),Fear of Missing Out Scale(FoMOs),and the General Self-Efficacy Scale(GSES).Continuous variables can be expressed as mean(standard deviation)or median(interquartile range)depending on the distribution of the data.The comparisons between groups were conducted using Student’st test,analysis of variance(ANOVA),or Wilcoxon rank sum testasappropriate.Categorical variables were depicted as frequencies and percentages.And the Chi-square tests was used to examinethe differences between groups.Data analyses were mainly conducted using SPSS software version 22.0.Pearson’s correlation matrix heat map was drawn using R software.The mediating,moderating,and moderated mediating effect of FoMO,RRS,and self-efficacy were analyzed by PROCESS v4.0.Meanwhile,if the moderating effect is statistically significant,a simple slope test was then subsequently conducted.The structural equation model was conducted using SPSS AMOS.On the basis of the cross-sectional study,the Mental Health and Behavioral Addiction Scale of College Students was followed up with an interval of three months.In total,college students were investigated at three timepoints(mid-semester,beginning of school and winter vacation).The AMOS plug-in was used to analyze the path analysis of the ternary cross-lag regression models between the depressive symptoms-FoMO-PSU and the depressive symptoms-rumination-PSU of college students at different timepoints.To ensure the consistency of the path coefficients(regression coefficients)of the same causal relationship under the three timepoints,the path coefficients were first set to be equivalent,and then the cross-lag regression models were estimated.Results:1.Inour meta-analysis,forty studies involving a total of 33,650 college students were identified.Weak-to-moderate positive correlations were found between PSU and anxiety,depression,impulsivity and sleep quality(anxiety:summary r=0.39,95%CI=0.34-0.45,P<0.001,I~2=84.9%;depression:summary r=0.36,95%CI=0.32-0.40,P<0.001,I~2=84.2%;impulsivity:summary r=0.38,95%CI=0.28-0.47,P<0.001,I~2=94.7%;sleep quality:summary r=0.28,95%CI=0.22-0.33,P<0.001,I~2=85.6%).The pooled correlations revealed some discrepancies when stratified by some moderators.The robustness of our findings was further confirmed by sensitivity analyses.2.The overall average SAS-SV score was 35.43±8.16 points.The prevalence of PSU was 70.58%(1154/1635).Depressive symptoms,FoMO,and RRS were all positively correlated with each other.They were also positively correlated with PSU(r=0.382,0.262,0.382,P<0.01).Conversely,self-efficacy was inversely associated with depressive symptoms,FoMO,rumination,and PSU severity(r=-0.331,-0.055,-0.260,and-0.277,respectively;P<0.05).FoMO played a partial mediating role in the relationship between depressive symptoms and PSU among college students and the mediating effect accounted for 15.07%of the total effect.Self-efficacy moderated the mediating role of FoMO in the relationship between depressive symptoms and PSU.Rumination played a partial mediating role in the relationship between depressive symptoms and PSU,and the mediating effect accounted for 15.5%of the total effect.Self-efficacy moderates the relationship between depression and PSU.However,the moderated mediating effect of RSS on the relationship betweend epression and PSU wasinsignificant.3.Totally,321 groups of subjects completed all three follow-up surveys.Our findings suggested that the depressive symptoms,FoMO,rumination and PSU of college students were positively correlated at T1,T2,and T3.The longitudinal cross-lagged regression model showed that there was a bidirectional causal relationship between depressive symptoms and PSU in college students.There was also a causal relationship between depressive symptoms and FoMO in college students.The higher the level of depressive symptoms,the more likely to have FoMO.In addition,depressive symptoms predicted rumination,but no predictive effect was found in the opposite direction.However,no mutual predictive effect was found between FoMO and PSU.Conclusion:The meta-analysis suggested that college students with PSU were more likely to develop high levels of anxiety,depression,and impulsivity and suffer from poor sleep quality.The depressive symptoms are independent influencing factors for PSU among college students.FoMO and RSS play a mediating role in the depression-PSU relationship.That is to say,college students with higher level of depressive symptoms are more susceptible to RSS.Self-efficacy moderates the mediating effect of FoMO on the relationship between depression symptoms and PSU in college students.Self-efficacy directly moderated the depression-PSU relationship,but could not the moderated the mediating effect of RRS.Established evidence showed that early life is a critical period for the formation and development of the body’s thoughts and behaviors.Adolescence and early youth are important periods for the development of mental health and PSU.Enforcing positive psychological factors(self-efficacy)might help college students fight against PSU.Our studies provided empirical experience for the government,schools,and families to manage PSU.更多还原