中华流行病学杂志  2023, Vol. 44 Issue (3): 477-485   PDF    
http://dx.doi.org/10.3760/cma.j.cn112338-20220728-00669
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文章信息

高雪蕾, 张景华, 杨漾, 曹振波.
Gao Xuelei, Zhang Jinghua, Yang Yang, Cao Zhenbo
大学生久坐行为/屏幕时间与心理健康的Meta分析
Sedentary behavior, screen time and mental health of college students: a Meta-analysis
中华流行病学杂志, 2023, 44(3): 477-485
Chinese Journal of Epidemiology, 2023, 44(3): 477-485
http://dx.doi.org/10.3760/cma.j.cn112338-20220728-00669

文章历史

收稿日期: 2022-07-28
大学生久坐行为/屏幕时间与心理健康的Meta分析
高雪蕾1 , 张景华2 , 杨漾3 , 曹振波2,3     
1. 上海理工大学体育教学部, 上海 200093;
2. 上海体育学院运动健康学院, 上海 200438;
3. 上海市学生体质健康研究中心, 上海 200438
摘要: 目的 系统梳理久坐行为/屏幕时间与大学生心理健康影响的相关文献,旨在探讨大学生久坐行为/屏幕时间与心理健康之间的关系,为促进大学生心理健康发展提供理论依据。方法 在PubMed、Embase、Cochrane Library、中国知网、维普数据库和万方数据知识服务平台进行检索,截止日期为2022年7月14日,研究久坐行为/屏幕时间与大学生心理健康研究相关文献。由一名研究者按照拟订方案对纳入的文献进行数据提取并进行质量评分,再由另一名研究者进行复核;对符合纳入标准的文献进行系统综述,并根据文献可提取数据的情况,采用Stata 14.2软件进行Meta分析。结果 共有36篇文献符合纳入标准,包括35篇观察性研究和1篇干预性研究。对久坐行为(4篇)、屏幕时间(9篇)与大学生抑郁、屏幕时间与大学生焦虑(4篇)进行Meta分析,对其他研究进行系统综述。久坐行为与大学生抑郁的Meta分析结果显示,较长的久坐时长增加了大学生抑郁风险(OR=1.07,95%CI:1.05~1.10)。亚组分析显示,未校正混杂因素模型中,较长的久坐时长与抑郁不存在相关性(OR=1.74,95%CI:0.93~3.25),但校正混杂因素后两者之间呈正相关(OR=2.15,95%CI:1.18~3.90)。屏幕时间与大学生抑郁的Meta分析结果显示,较长的屏幕时间与抑郁呈显著正相关(OR=1.03,95%CI:1.02~1.05)。亚组分析结果显示,未校正混杂因素模型和校正混杂因素模型中,较长的屏幕时间与抑郁均呈显著正相关(OR=1.27,95%CI:1.13~1.42;OR=1.45,95%CI:1.18~1.79)。久坐行为与大学生焦虑的Meta分析显示,较长的屏幕时间与较高的焦虑风险呈正相关(OR=1.44,95%CI:1.31~1.58)。亚组分析结果显示,原始模型和校正混杂因素模型中,较长屏幕时间与焦虑呈正相关(OR=1.47,95%CI:1.31~1.65;OR=1.38,95%CI:1.17~1.62)。对不符合Meta分析的文献综述发现,久坐行为/屏幕时间与大学生压力和其他心理健康具有显著相关性。结论 久坐行为或屏幕时间与大学生心理健康呈显著负相关,特别是对大学生抑郁和焦虑情绪具有显著影响,且该影响可能存在学习日和休息日差异。
关键词: 大学生    久坐行为    屏幕时间    心理健康    Meta分析    
Sedentary behavior, screen time and mental health of college students: a Meta-analysis
Gao Xuelei1 , Zhang Jinghua2 , Yang Yang3 , Cao Zhenbo2,3     
1. Physical Education Department, University of Shanghai for Science and Technology, Shanghai 200093, China;
2. School of Exercise and Health, Shanghai University of Sport, Shanghai 200438, China;
3. Shanghai Research Centre for Physical Fitness and Health of Children and Adolescents, Shanghai 200438, China
Abstract: Objective To evaluate the effects of sedentary behavior/screen time on mental health of college students by Meta-analysis based on the results of literature retrieval and provide theoretical basis for the improvement of college students' mental health. Methods The original research literatures about sedentary behavior (including screen time) and college students' mental health published as of 14 July 2022 were retrieved from PubMed, Embase, Cochrane Library, CNKI, VIP and Wanfang data. Data were extracted from the included studies and scored by one author in accordance with the proposed programme, and quality score was reviewed by another author. The literature that met the inclusion criteria was systematically reviewed and Meta-analysis was carried out by software Stata 14.2 based on the data from the literatures. Results A total of 36 studies met the inclusion criteria, including 35 observational studies and 1 interventional study. There are 4 papers about the effects of sedentary behavior and 9 papers about the effects of screening time on depression in college students and 4 papers about the effects of sedentary behavior/screening time on anxiety in college students were used for a Meta-analysis, and the other studies were also analyzed. The Meta-analysis on the effects of sedentary behavior on depression in college students showed that there was a significant positive correlation between higher level sedentary behavior and increased risk for depression (OR=1.07, 95%CI: 1.05-1.10). Subgroup analysis indicated that there was no significant correlation between higher level sedentary behavior and depression (OR=1.74, 95%CI: 0.93-3.25) in the unadjusted confounding factor model, but there was significance positive correlation after adjusting confounding factors (OR=2.15, 95%CI: 1.18-3.90). Meta-analysis on the effects of screen time on depression in college students showed that longer screen time were significantly positively correlated with higher depression level (OR=1.03, 95%CI: 1.02-1.05). The results of subgroup analysis showed that in both unadjusted confounding factor model and adjusted confounding factor model, longer screen time was significantly positively correlated with depression (OR=1.27, 95%CI: 1.13-1.42; OR=1.45, 95%CI: 1.18-1.79), respectively. Meta-analysis on the effects of sedentary behavior on anxiety showed that longer screen time was significantly positively correlated with increased anxiety risk (OR=1.44, 95%CI: 1.31-1.58). The results of subgroup analysis showed that in both unadjusted confounding factor model and adjusted confounding factor model, there was a significant positive correlation between longer screen time and anxiety (OR=1.47, 95%CI: 1.31-1.65; OR=1.38, 95%CI: 1.17-1.62). The analysis for the literatures which were not eligible for Meta-analysis found that sedentary behavior/screen time was significantly associated with stress and other mental health in college students. Conclusions Sedentary behavior or screen time is significantly negatively correlated with college students' mental health, in particular, resulting in depression and anxiety. These effects might be be different between weekdays and weekend days.
Key words: College students    Sedentary behavior    Screen time    Mental health    Meta-analysis    

不同于普通成年人,大学生是社会存在的特殊群体,处于青春期和成年期的重要过渡时期,其心理健康直接影响进入社会的生活和工作。大学生抑郁、焦虑、压力等心理疾患高发[1-5]。已有研究显示,大学生群体抑郁症患病率为10.3%~84.5%,平均发病率为30.6%[6]。也有研究显示,抑郁发病或具有抑郁症状的比例为9.3%~55.9%,平均为27.2%[7]。近年来,由于新型冠状病毒感染疫情暴发,大学生抑郁、焦虑等心理健康问题尤甚[8-9]。心理健康状况不佳可能会影响社会心理发展、增加药物滥用、降低学习成绩,进而导致步入社会后的失业和生活质量的降低[10-11]。此外,大学生的压力、焦虑和抑郁对自杀率有直接影响[12]。因此,心理健康问题在大学校园中日益受到关注,亟需研究其影响因素加以预防和干预。

久坐行为包括看电视、使用电脑工作或躺着玩手机[13]。过去10年电子设备在大学生中广泛流行,大大增加其久坐行为或屏幕时间[14]。一项纳入119篇研究的Meta分析结果显示,大学生久坐时长为7.29 h/d,而基于加速度计运动传感器的客观调查数据更是高达10.70 h/d,远超过其他群体,并且在近10年内呈现增加趋势[14]。使用电脑、学习/上课、玩手机是三大久坐行为,其中基于电脑的久坐行为时间均值为8.04 h/d[14]。可见,视屏行为是常见的久坐行为[15]。新型冠状病毒感染流行期间,很多高校实行封闭式管理,教学工作转移至线上,更是导致大学生久坐行为/屏幕时间激增。

久坐行为与心血管疾病[16-18]、糖脂代谢[19]、心理健康问题[20-21]以及学习成绩密切相关。一项队列研究发现,每周久坐时长 > 42.0 h的大学毕业生患心理障碍的风险比每周久坐时长 < 10.5 h的大学毕业生高31%[22]。但澳大利亚的一项研究发现,久坐行为与心理健康相关的生活质量无关[23]。多项Meta分析和系统综述发现,久坐行为或屏幕时间与心理健康呈负相关[24-26],但这些研究主要涉及成年人、老年人和儿童青少年。本研究将总久坐行为和屏幕时间加以区分,旨在分别探讨总久坐行为/屏幕时间与大学生心理健康(抑郁、焦虑和压力等)的关系。

资料与方法

1. 文献来源及检索:本研究遵循了系统评价和Meta分析的首选报告项目指南标准[27]。利用中国知网、维普数据库、万方数据知识服务平台、PubMed、Embase和Cochrane Library数据库,以中文(久坐OR坐OR静态行为OR屏幕时间OR媒体)AND(心理健康OR焦虑OR抑郁OR情绪OR内向OR社交恐惧OR惊恐障碍)AND大学生和英文关键词(sedentary OR sitting OR screen time OR media)AND(mental health OR anxiety OR anxious OR depress OR emotional OR internalizing OR social phobia OR panic disorder)AND(college student OR university student),搜索至2022年7月14日的相关文献。

2. 文献筛选:依次通过查重,标题、摘要筛选,然后提取全文进行评估。此外,追踪筛查出文献的参考文献以补充电子文献库检索遗漏文献。纳入标准:①公开发表的中英文全文文献;②以久坐行为或屏幕时间为自变量,大学生心理健康相关指标为因变量的文献。排除标准:①相同数据来源的重复分析研究(仅纳入质量最高的1篇文献);②数据不完整、质量不高的文献。

3. 统计学分析:若文献数量达不到Meta分析要求,则仅进行系统综述。采用Stata 14.2软件进行Meta分析。其中将低久坐行为水平或屏幕时间与心理健康指标的比值比(odds ratio,OR),采用四格表法转换为高久坐行为水平或屏幕时间与心理健康指标的OR值,应用Woolf法计算OR值的95%CI[28]

若各研究具有同质性时(I2≤50%,P≥0.10)使用固定效应模型。异质性时(I2 > 50%,P < 0.10)通过Meta回归、亚组分析、敏感性分析以及发表偏倚来判断异质性来源,找不到明确原因时,采用随机效应模型。由于影响大学生心理健康的因素较多,进行了是否校正混杂因素的亚组分析。采用森林图分析久坐行为/屏幕时间对大学生心理健康的影响。采用Egger检验评价研究的发表偏倚风险;通过影响分析检测Meta分析的敏感性。以P < 0.05为差异有统计学意义。

结果

1. 文献筛选:通过系统检索,共检索到5 393篇文献,通过检索相关参考文献获得3篇。查重、阅读标题、摘要和全文后,最终纳入36篇进行分析[1-3, 5, 20-21, 29-58](图 1),其中13篇符合Meta分析条件,另外23篇进行系统综述分析。

注:a文献有交叉 图 1 文献筛选流程

2. 文献基本特征:1篇为干预性研究[58]。35篇观察性研究[1-3, 5, 20-21, 29-57],25篇研究久坐行为/屏幕时间与抑郁的关系,17篇研究久坐行为/屏幕时间与焦虑的关系,7篇研究久坐行为/屏幕时间与压力的关系,10篇研究久坐行为/屏幕时间与其他心理健康指标的关系。其中5篇涉及医学专业大学生[38, 40, 46, 48, 53],2篇涉及体育类专业大学生[47, 52],1篇涉及医学生和体育生[45]和1篇涉及医学生和非医学生[55],27篇并未明确大学生专业。

3. 抑郁:对10篇[1, 3, 20-21, 31, 34, 36, 40, 52, 55]文献进行Meta分析,其中久坐行为4篇[3, 36, 52, 55](n=29 643),屏幕时间9篇[1, 20-21, 31, 34, 40, 49, 52, 55](n=15 219)。因各研究间存在异质性(I2=98.3%,I2=84.5%,P < 0.001),采用随机效应模型分析。Meta分析结果显示,较长的久坐时长与抑郁呈正相关(OR=1.07,95%CI:1.05~1.10),见图 2。亚组分析结果显示,未校正混杂因素模型中,较长的久坐时长与抑郁不存在相关性(OR=1.74,95%CI:0.93~3.25),但校正混杂因素后两者之间呈正相关(OR=2.15,95%CI:1.18~3.90)。

图 2 久坐时长/屏幕时间与大学生抑郁的关系

Meta分析结果显示,较长的屏幕时间与较严重的抑郁呈正相关(OR=1.03,95%CI:1.02~1.05)。亚组分析结果显示,原始模型和校正混杂因素模型中,较长的屏幕时间与抑郁呈正相关(OR=1.27,95%CI:1.13~1.42;OR=1.45,95%CI:1.18~1.79)。见图 2

未纳入Meta分析的久坐行为和屏幕时间研究结果也支持Meta分析结果 [2, 5, 29-30, 41-42, 44-45, 48, 50-51, 53, 56]。且Lee和Kim[5]的研究显示,无论大学生总的久坐时间还是学习日和休息日久坐时长均与抑郁呈正相关。但李倩倩等[39]的研究显示视频时长与大学生抑郁无关联。

4. 焦虑:符合Meta分析要求的文献共5篇[20-21, 33-34, 36],其中久坐行为1篇[36],屏幕时间4篇[20-21, 33-34],受试者共41 636名。屏幕时间与焦虑关系的各研究间不存在异质性(I2=18.5%,P=0.257),采用固定效应模型分析。Meta分析结果显示,较长的屏幕时间与较严重的焦虑呈正相关(OR=1.44,95%CI:1.31~1.58)。亚组分析结果显示,原始模型和校正混杂因素模型中,较长的屏幕时间与焦虑均呈正相关(OR=1.47,95%CI:1.31~1.65;OR=1.38,95%CI:1.17~1.62)。见图 3

图 3 屏幕时间与大学生焦虑的关系

未纳入Meta分析的研究结果显示,久坐行为与大学生焦虑呈正相关[5, 29, 36, 44-47, 50]。对不同焦虑类型进行分析发现,久坐行为与状态焦虑无相关性;休息日中高久坐行为水平与特质焦虑呈正相关,但增加校正中高强度身体活动水平后,二者之间无相关性[35]。Lee等[53]的研究显示,美国护理学院大学生久坐行为与焦虑无相关性。未纳入Meta分析的屏幕时间研究也发现与久坐行为类似的结果[35, 47, 56]。但鲍丙刚等[40]对我国合肥市某医科大学学生屏幕时间对心理影响的调查发现,学习日和周末屏幕时间 > 2 h/d对焦虑症状检出率和焦虑得分均无明显影响。

5. 压力:久坐行为或屏幕时间与压力的研究数量较少,故不进行Meta分析。一些研究发现,久坐行为和屏幕时间与大学生感知压力呈显著正相关[5, 37, 48]。Lee等[53]的研究显示,只有在校正社会人口学等混杂因素后,美国护理学院大学生久坐行为与压力呈正相关。研究发现,久坐行为和屏幕时间与压力之间的关系存在学习日与休息日差异,学习日久坐行为与感知压力无相关性,但休息日高久坐行为水平与感知压力呈正相关[35, 38];而屏幕时间则相反,只有学习日屏幕时间与大学生感知压力和焦虑呈正相关[35, 38]

6. 其他心理健康指标:研究也发现久坐行为与大学生自杀意愿[36]、心理障碍[43]、注意力问题[54]、紧张和愤怒[32]和人际关系敏感[29]之间存在关联,但孟加拉国大学生较高久坐行为水平与心理困扰之间无相关性[57]。研究发现,屏幕时间与大学生精神病理症状风险[20-21]、心理亚健康[40]和视频依赖[29]之间存在相关性,但与注意力不集中、胡思乱想、情绪兴奋之间无显著相关[29]

7. 发表偏倚和异质性分析:久坐行为和屏幕时间与大学生抑郁关系存在发表偏倚的可能性较大,Meta分析结果不稳健,发表偏倚可能是其异质性来源。Meta回归分析发现,发表年份、样本量、国家地区可能是其异质性来源(P < 0.001),见表 12。屏幕时间与大学生焦虑关系的Meta分析发表偏倚可能性较小,不是其异质性来源。

表 1 久坐行为与抑郁关系的Meta回归分析
表 2 屏幕时间与抑郁关系的Meta回归分析

8. 敏感性分析:在久坐行为和屏幕时间与大学生抑郁关系研究中,其中剔除Tashiro等[55]的研究再合并改变了原结果,因此该研究可能是异质性来源。久坐行为/屏幕时间与大学生焦虑的各研究之间的异质性不大。

讨论

由本研究结果可知,久坐行为或屏幕时间与大学生心理健康呈负相关,较长久坐时长或屏幕时间对大学生心理健康具有不利影响。与已有研究结果一致[59]。一项儿童青少年屏幕时间与抑郁风险关系的Meta分析还发现,屏幕时间与抑郁呈非线性剂量反应关系[24]。但鲍丙刚等[40]的研究结果显示,学习日屏幕时间显著增加了大学生抑郁得分,但周末屏幕时间无显著影响。产生这一结果的原因可能是大学生学习日屏幕时间主要用于学习,而周末屏幕时间主要用于娱乐所导致的。但赵越等[31]的研究结果显示,无论学习日还是休息日的屏幕时间均与大学生抑郁筛选量表得分呈正相关。休息日屏幕时间≥2 h/d与抑郁的OR值(OR=0.11,95%CI:0.80~1.37)出现错误,这可能是两项研究结果不一致的原因。Zhou等[52]的研究发现,与作业时间 < 1 h/d相比,大学生作业时间≥1 h/d显著降低了抑郁风险,但与 < 1.43 h/d休闲性屏幕时间相比,≥1.43 h/d显著增加了大学生抑郁风险。可见,久坐行为内容对大学生心理健康的影响亦不同。由于久坐行为的具体内容多样,既包括学习等精神高度集中的活动形式,也包括演奏或练习乐器、做手工或艺术创作等活动,未来研究需要细分久坐行为具体内容,进而探讨不同久坐行为内容对大学生心理健康的影响及其机制。

本研究结果显示,较长的屏幕时间与大学生焦虑呈显著正相关,与一项纳入13项观察性研究的系统综述和Meta分析[25]和1项为期15个月的纵向调查[56]结果一致。而一项纳入9篇研究的系统综述发现,屏幕时间、看电视时间、电脑使用与焦虑风险之间的关系并不一致[26],表明久坐行为/屏幕时间与焦虑之间的关系可能受久坐行为/屏幕时间的具体行为内容的影响[5]。但鲍丙刚等[40]的研究结果显示,无论学习日还是周末屏幕时间对焦虑无显著影响,这可能是由于该研究中屏幕时间 > 2 h/d的时间切点较低,引起焦虑所需屏幕时间阈值可能更高。

一项为期1年的前瞻性研究发现,身体活动不足时,久坐行为与大学生心理困扰呈显著正相关[57],但身体活动充足时,长时间的久坐行为与大学生心理困扰无相关性。可见身体活动可以在一定程度上抵消了久坐行为对心理健康的危害。干预性研究发现,6 h久坐行为干预对大学生紧张焦虑、抑郁沮丧无显著性影响[58]。但一项随机对照试验发现,身体活跃的成年人增加久坐行为时间1周就能导致抑郁得分显著增加,并且恢复身体活动量1周后,抑郁得分显著降低[60]。因此,久坐行为对心理健康影响可能是一个累积的过程。

本研究存在局限性。①纳入的文献仅有1篇为干预性研究[58]。本研究纳入Meta分析研究数量较少,结果和系统综述结果一致,仍需未来更多相关研究验证。②纳入文献的久坐行为或屏幕时间数据的采集均采用问卷调查的方式进行。③纳入文献中久坐行为时间划分并未统一,并且时间跨度较大(> 2 h/d[2] vs. ≥13 h/d[35])。心理健康评价量表并未统一,而不同量表对心理健康问题检出并不一致,可能存在测量偏倚。这些都可能混淆久坐行为/屏幕时间对大学生心理健康的影响。网上学习、娱乐及浏览新闻等屏幕内容不同可能对大学生心理健康的影响也不同,但其具体影响需要进一步研究探讨。④小样本量研究(< 500人)13篇(35.14%),这可能限制了久坐行为/屏幕时间与大学生心理健康关系的统计效力。⑤大部分研究并未校正人口学、社会等相关混杂因素(58.33%),这也将可能混淆其相关关系。但在纳入的校正混杂因素的文献中亦发现久坐行为/屏幕时间均与大学生心理健康呈显著相关性[3, 5, 20-21, 31, 33, 36, 38, 49, 53]。⑥文献检索仅限于中英文,由于语言和文化的差异,可能会导致结果偏差。

综上所述,久坐行为/屏幕时间与大学生心理健康呈显著负相关,特别是对大学生抑郁和焦虑情绪具有显著影响,且该影响可能存在学习日和休息日差异。久坐行为或屏幕时间的具体内容对大学生心理健康影响尚需未来设计更完善的研究进一步探讨。

利益冲突  所有作者声明无利益冲突

作者贡献声明  高雪蕾:论文构思及设计、检索文献、文献质量评价、数据提取、整理及分析、论文撰写;张景华:文献质量评价、数据提取、整理及分析、论文修改;杨漾:文献质量评价、论文修改;曹振波:论文构思及设计、研究指导、论文修改

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