合作式團隊模式之家庭訪視介入對動作遲緩嬰幼兒之療效

Abstract

背景與目的：動作發展遲緩的嬰幼兒除動作功能受限外，各發展領域及日常活動參與皆可能受限，家庭環境被認為是上述問題的重要影響因素，因此對動作發展遲緩的嬰幼兒採到宅並有家長參與之合作式專業團隊的介入是世界潮流，然其療效尚無實證。本研究於偏遠地區組成一個由大學小兒物理治療研究單位及當地早療中心之早期介入研究團隊，以探討合作式專業團隊介入對動作發展遲緩嬰幼兒於日常參與、動作功能、家庭環境品質、親職知識、及親職壓力之成效。此外，亦分析此合作式專業團隊介入之成本效果（cost effectiveness）。方法：雙盲隨機設計，從台東個案管理中心徵召24名6至33個月動作遲緩嬰幼兒，根據年齡與動作嚴重度分層後隨機分配至合作式家庭訪視組（合作組）或例行家庭訪視組（例行組）。兩組皆在三個月內接受五次家庭訪視介入，介入前後由一位不知兒童分組狀況之施測者進行施測。成效評量工具包括：「兒童生活功能評估量表」（Pediatric Evaluation of Disability Inventory; PEDI）、「皮巴迪動作量表第二版」（Peabody Developmental Motor Scales 2nd Edition, PDMS Ⅱ）、「家庭環境評量表」（Disability-Adapted Infant/Toddler version of Home Observation for Measurement of the Environment, DA-IT-HOME）、「嬰兒發展知識量表」（Knowledge of Infant Development Inventory, KIDI）、「親職壓力指標」（Parenting Stress Index-Short Form, PSI-SF）。合作組接受合作式專業團隊的家庭訪視介入，此合作式專業團隊包括活動設計者、社工及主要誘發者。由活動設計者根據評估結果，以「國際功能分類模式」（ICF model）分析嬰幼兒功能、障礙和環境之間的動態關係，並設定嬰幼兒介入的功能目標及家庭目標。此外，依據家庭日常作息及功能目標並參考卡羅萊納課程設計2至3個功能性活動，根據家庭目標提供主要照顧者有關兒童發展和親職的知識以及親職的技巧，經團隊會議後，由主要誘發者到宅提供介入。例行組接受社工提供之一般家庭訪視介入，內容為社福資源的整合及家庭的情緒支持。三個月後，以混合設計二因子分析方法（two-way mixed ANOVA），比較兩組在日常參與、動作功能、家庭環境品質、親職知識和親職壓力之改變，顯著水準α設為0.05，單尾檢定。在成本效果分析部分，以增加成本效果比（incremental cost-effectiveness ratio, ICER）計算，兩組相較，每增加效果一分，需增加之花費。結果：合作組及例行組個案平均年齡為20個月，平均動作年齡為12個月，主要照顧者之教育程度大多為高中或高中以下（占各組之100%及75%），且大多為低社經家庭（占各組之100%及83%）。經三個月介入後，合作組嬰幼兒較例行組在移動參與（Mobility domain of PEDI）有顯著的增加（p=.01），在家庭環境品質（DA-IT-HOME）與親職壓力（PSI-SF）亦有顯著改善（p<.0001, p=.028）。其他生活參與、基本動作功能及親職知識方面所有兒童在三個月皆有進步，但兩組無顯著交互效果（interaction effects）。經濟效果評估結果，合作式專業團隊介入在動作參與（Mobility domain of PEDI）的成效分析，量尺分數每增加一分，需多花費新台幣2880元。在家庭生活環境品質（DA-IT-HOME）及親職壓力（PSI-SF）的成效分析，合作組較例行組有較佳之成本效果。討論與結論：此結果支持合作式專業團隊於家庭訪視介入可增進偏遠地區動作遲緩嬰幼兒參與日常生活移動，提升家庭環境品質，並減輕主要照顧者之親職壓力。合作式專業團隊提供主要照顧者於家中進行達成其療育目標之功能性的日常活動、鼓勵主要照顧者參與，及建議家庭環境的安排，可增加動作遲緩嬰幼兒參與日常移動，並提升主要照顧者對嬰幼兒之正向的反應及給予適當的環境刺激，進而減少主要照顧者之壓力。此外，合作式專業團隊介入相較單一專業的一般家庭訪視介入有較佳之成本效果，每增加兒童移動參與分數1分，其費用相當於健保5次物理治療給付。建議未來研究可進一步探究其長期效果。

Background and Purpose: Infants and toddlers with motor delays (MD) not only had limitations in motor activities but also showed deficits in other developmental areas and daily participation. Home environment is considered as an important influencing factor for these limitations and deficits. It is an international trend to apply collaborative team into home visiting service with parental participation for infants and toddlers with MD. However, the effectiveness was not proved yet. This study investigated the effects of a collaborative home visiting program, which was the cooperation between a university pediatric physical therapy program and a local institute on (1) daily participation；(2) motor function；(3) quality of home environment；(4) parental knowledge；(5) parental stress for infants and toddlers with motor delays in rural area. In addition, we would analyze the cost effectiveness of the collaborative home visiting program. Methods: This study was conducted as a double-blind randomized control trial. 24 infants and toddlers aged 6 to 33 months and with MD were enrolled from Early Intervention Referral and Management Center in Taitung County. They were stratified according to age and motor severity and then were assigned to either a collaborative home visiting group (collaborative group) or a routine home visiting group (routine group) randomly. Both groups received five-time home-visiting services in three months. A tester who was masked with the group assignment performed the pre- and post-intervention assessments. The outcome measures included Pediatric Evaluation of Disability Inventory (PEDI), Peabody Developmental Motor Scales 2nd Edition (PDMS Ⅱ), Disability-Adapted Infant/Toddler version of Home Observation for Measurement of the Environment (DA-IT-HOME), Knowledge of Infant Development Inventory (KIDI), and Parenting Stress Index-Short Form (PSI-SF). The collaborative group received a collaborative home-visiting program. The collaborative team members comprised a program designer, a social worker and a main facilitator. The program designer analyzed the relationship among functioning, disability and contextual factors of each child and family based on ICF model and to set primary functional goals for child and family. In addition, 2 to 3 functional programs which were frequent occurrence in the family’s daily routine were designed according to Carolina curriculum. Parental programs that referred to family goals included parenting knowledge of child’s development and skills for the main caregivers. After team discussion, the main facilitator provided with direct intervention and instruction during each home visiting. For routine group, they received regular home visiting program which were social resource provision and emotional support for family. After three months, the changes of the daily participation, motor function, quality of home environment, parental knowledge, and parental stress were analyzed by using two-way mixed ANOVA. The significant level α was set as 0.05 with one tailed test. In cost analysis, the incremental cost-effectiveness ratio (ICER) was used to calculate the incremental cost in order to increase one point of score in collaborative home visiting compared with routine home visiting. Results: The mean corrected age of the collaborative group and routine group was 20 months and the mean motor age was 12 months. Education level of main caregivers was mostly senior high school or lower in the collaborative group or routine group (100% and 75% respectively) and most families were low socioeconomic status (100% and 83% respectively). After three months, infants and toddlers in collaborative group showed significantly improvement in Mobility scaled scores of PEDI (p=.01), total scores of DA-IT-HOME (p<.0001) and total scores of PSI-SF (p=.028) than those in routine group. In other outcomes as other scales of PEDI, percentage scores of PDMS-2, and accuracy percentages of KIDI, the whole group showed improvement without significant group and time interaction. In cost analysis, the collaborative home visiting program could increase one scaled score in Mobility domain of PEDI with the incremental cost of 2,880 NTD within 3 months. For DA-IT-HOME and PSI-SF, the collaborative home visiting program definitely demonstrated better cost effectiveness than routine home visiting program. Discussion and Conclusion: The findings in this study supported the effectiveness of collaborative home visiting on improvement of mobility participation, quality of home environment and parental stress alleviation for infants and toddlers with motor delays in rural area. The collaborative home visiting program, which provided with functional programs in daily routine, encouraged the engagement of main caregivers and suggested the arrangement of home environment could lead to increase participation of daily mobility for young children, positive responsivity and adequate stimulation in home environment for main caregivers and reduced the parenting stress furthermore. From the ICER analysis, the collaborative home visiting needed to increase the cost of an amount equal to the expenditure of 5-time physical therapy in the National Health Insurance to increase one scaled score in mobility participation for a child. The long term effects of collaborative home visiting for infants and toddlers with motor delays needs further studies.