<32382D3120BCBAC0CEB0A3C8A320B3EDB9AE2DC3D6C1BE2E687770>

Size: px
Start display at page:

Download "<32382D3120BCBAC0CEB0A3C8A320B3EDB9AE2DC3D6C1BE2E687770>"

Transcription

1 Korean Journal of Adult Nursing (Korean J Adult Nurs) Vol. 28 No. 1, 13-29, February 2016 ISSN (Print) / ISSN X (Online) 수면장애가있는중장년환자에게적용한비약물적중재의효과 : 메타분석 김지현 1 오복자 2 고려대학교간호대학대학원 1, 삼육대학교간호학과 2 Effects of Non-pharmacological Interventions on Primary Insomnia in Adults Aged 55 and Above: A Meta-analysis Kim, Ji Hyun 1 Oh, Pok Ja 2 1 Graduate School, College of Nursing, Korea University, Seoul 2 Department of Nursing, Sahmyook University, Seoul, Korea Purpose: This study was performed to evaluate the effects of non-pharmacological interventions on sleep disturbance amongst adults aged 55 and above. Methods: PubMed, Cochrane Library, EMBASE, CINAHL and several Korean databases were searched. The main search strategy combined terms including non-pharmacological interventions and presence of. Non-pharmacological interventions included cognitive behavioral therapy, auricular acupuncture, aromatherapy, and emotional freedom techniques. Methodological quality was assessed using Cochrane's Risk of Bias for randomized studies and Risk of Bias Assessment tool for non randomized studies. Data were analyzed by the RevMan 5.3 program of Cochrane Library. Results: Sixteen clinical trials met the inclusion criteria with a total of 962 participants. Non-pharmacological interventions was conducted for a mean of 5.5 weeks, 7.7 sessions, and an average of 70 minutes per session. The effects of non-pharmacological interventions on sleep quality (ES=-1.18), sleep efficiency (ES=-1.14), sleep onset latency (ES=-0.88), awakening time after sleep onset (ES=-0.87), and sleep belief (ES=-0.71) were significant, and their effect sizes were ranged from moderate to large. However, the effects on total sleep time and severity were not significant. Conclusion: The findings of the current study suggest that non-pharmacological interventions have a positive impact on attitudes and beliefs about sleep, sleep quality, sleep duration, and sleep efficiency. Therefore, the findings of the study provide an evidence to incorporate various non-pharmacological interventions into nursing practice to improve both sleep quality and quantity in patients with. Key Words: Sleep initiation and maintenance disorders, Intervention studies, Aged, Meta-analysis 서론 1. 연구의필요성수면은인간의기본적인생리적욕구로서생리적, 정신적 항상성을유지하는데절대적으로필요하며개인의안녕을전인적측면에서평가할수있는주요개념으로제시된다 [1]. 이러한수면은노령화와더불어깊은수면 (slow wave sleep) 이줄고빈번한각성으로인해수면효율성이저하되어주간에과도한졸리움이나기억력감퇴, 집중력저하를초래하고달 주요어 : 수면장애, 중재연구, 중장년, 메타분석 Corresponding author: Oh, Pok-Ja Department of Nursing, Sahmyook University, 815 Kongnung-dong, Hwarang-ro, Nowon-gu. Seoul 01795, Korea. Tel: , Fax: , ohpj@syu.ac.kr Received: Oct 1, 2015 / Revised: Jan 25, 2016 / Accepted: Feb 12, 2016 This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. c 2016 Korean Society of Adult Nursing Vol No. 1,

2 김지현 오복자 라진수면-각성양상은삶의질을저하시킨다 [2,3]. 또한노화과정에의한전반적인신체기능의쇠퇴와더블어수면장애는수면부족으로인한피로감, 불안정등으로낙상이나골절등의사고가능성을높여주요간호문제를초래할수있다 [4]. 이와같이수면이건강에중요한요소임에도불구하고불면증등의수면장애는나이가들면서당연히동반되는증상으로만인식하는경향이있어수면장애에대한관심이상대적으로적다. 따라서수면장애는치료를하지않는경우가많으며치료를하는경우에도약물치료가보편적이나약물은 REM 수면의억압, 약물과의상호작용, 남용가능성등의위험성이있고 [5], 장기복용시신체적 심리적의존성으로인해약물중단이어려울수있다. 또한대부분의불면증에서심리및행동요인이수면방해의요인으로작용하기때문에 [6], 만성불면증의효과적인관리를위해서는비약물요법을중심으로한접근이더욱강조된다. 이러한맥락에서최근에는단일중재법들을복합적으로적용하여최상의결과를유도하는대상자중심의통합적중재법이활발하게연구되고있다. 이러한통합중재법의요소로는인지행동중재, 수면위생교육및상담, 이완기술등의심리사회적중재법과음악요법, 빛치료, 침, 지압등대체보완요법이포함되어있다. 국내의경우그동안수행된선행연구들을살펴보면수면인식과수면양상, 수면에영향을미치는요인등서술적연구가대부분을차지하고있고최근학위논문을중심으로수면간호중재가시도되었다. 이들중재연구는대부분발마사지, 아로마테라피, 웃음치료및이압요법등보완대체요법이주를이루고있다 [7]. 한편국외의경우는수면중재연구가많이수행되었는데대부분인지행동중재 (Cognitive Behavioral Therapy-Insomnia, CBT-I) 가활발하게수행되었으며인지행동중재에는수면제한요법 (sleep restriction therapy), 이완요법, 수면위생교육 (sleep hygiene education) 및자극조절요법 (stimulus control therapy) 등으로구성된통합중재법으로이루어졌다. 그외광치료 (phototherapy) 와운동요법및요가등의다양한중재법이단독또는약물치료와병행하여활발하게시행되었다 [8]. 따라서국외의경우수면장애환자에게적용한중재연구에대한체계적고찰 [9,10] 이나메타분석연구 [11,12] 들이수행되었다. 그러나이들연구는인지행동중재에 [13] 국한되어통합적으로비약물적중재의효과를제시한연구는거의없고최근의수면중재연구를포함하고있지않다. 한편국내의경우는보완대체요법중심의수면중재에대한연구가증가되고있음에도불구하고이를통합하여중재연구의방향과효과분 석을제시한메타분석연구는전혀없는실정이다. 따라서본연구는현재까지국내외의불면증이나수면장애를가지고있는중장년을대상으로인지행동중재와보완대체요법을포괄하여비약물적중재에대한효과크기를체계적인방법으로개관하는메타분석연구를수행하고자한다. 이러한결과는고령화에따른수면장애의문제를관리하기위한비약물적중재의효과를제시하여수면모델의이론을강화시키고국내중재연구의방향을제시하며추후수면장애가있는환자의치료와간호실무를위한기초자료를제시할수있을것이다. 2. 연구목적본연구는수면장애가있는중장년환자에게적용한비약물적중재가수면에미치는효과크기를메타분석하는것으로목적은다음과같다. 검색과정을통해도출된비약물적중재연구의일반적특성을파악한다. 비약물적중재가수면의일차적결과 ( 총수면시간, 수면잠복기, 입면후각성시간, 수면효율성 ) 에미친효과크기를분석한다. 비약물적중재가수면의이차적결과 ( 불면증심각성, 수면의질, 수면에대한신념및태도, 수면의만족도 ) 에미친효과크기를분석한다. 연구방법 1. 연구설계본연구는 55세이상중장년환자의불면증을개선하기위한비약물적중재의효과를객관적으로규명하기위한메타분석연구이다. 2. 자료의선정기준자료의선정은 PRISMA (preferred reporting items for systematic reviews and meta-analyses) 의지침에따라수행되었다. 1) 연구참여자 (P) 는불면증이나수면장애가있는중장년환자, 2) 중재 (I) 는비약물적중재 ( 사회심리적중재, 상담, 교육, 인지행동, 이완, 명상, 보완대체요법등 ) 로수면장애를해결하기위해시도한모든방법을포함한다. 3) 대조군 (C) 은비약물적중재를받지않은자혹은위 (sham) 중재를받은자이다. 4) 14 Korean Journal of Adult Nursing

3 수면장애가있는중장년환자에게적용한비약물적중재의효과 : 메타분석 결과 (O) 는일차적결과변수로총수면시간, 수면잠복기, 입면후각성시간및수면효율성, 이차적결과변수로불면증의심각성, 수면의질, 수면에대한신념및태도를측정하였고, 5) 결과측정시점 (T) 은비약물적중재직후혹은추후추적기간모두포함, 6) 세팅 (S) 은입원및지역사회모두포함, 7) 연구설계 (SD) 는무작위대조연구 (Randomized controlled trial, [RCT]) 및비동등성대조연구 (Non-randomized controlled clinical trial, [Non-RCT]), 8) 실험군과대조군의효과크기를산출할수있도록평균값혹은표준편차가있으면서검정통계량값혹은신뢰구간이제시되어있는논문이다. 제외기준은 1) 약물적중재와비약물적중재를병합한연구이거나, 2) 기저질환 ( 의학적혹은정신질환등 ) 을동반한수면장애환자를대상으로한중재연구는제외하였다. 3. 자료검색및자료선정 1) 검색전략자료검색은 1차적으로 2014 년 12월에이루어졌고, 기관생명심의위원회의심의면제요청서의승인 (IRB No. SYUIRB ) 을받은후 2차적인자료검색및수집을 2015년 1월부터 2015년 5월까지수행하였다. 자료검색은메타분석문헌검색경험이있는연구자와연구보조자들에의해독립적으로이루어졌다. 검색에앞서검색식은수면장애가있는중장년환자 (P) 와비약물적중재 (I) 및연구설계를나타내는용어들을병합하여구성하였다. 먼저 MEDLINE 에서비약물적중재의통제어인 MeSH어를확인한후관련모든 MeSH어 9개 ("Social Support", "Behavior Therapy", "Cognitive Therapy", "Relaxation Therapy", "Meditation", "Imagery", "Directive Counseling", "Psychotherapy") 를포함하였다. 이후초록에서확인되는관련중심주제어포함한검색식을구성하였다. EMBASE에서는 EMTREE에서통제어 (controlled vocabulary) 를확인한후위와동일한방법으로이루어졌고, Cochrane Library CENTRAL 과 CINAHL에서는 MEDLINE에서확인된 MeSH 어를통해검색이이루어졌다. 국내의경우는 1) 수면장애 OR 불면증 AND 노인 OR 중장년 2) 심리사회적중재 OR 상담 OR 치료 OR 교육 OR 인지행동 OR 이완 OR 명상 OR 보완대체요법등을병합하여이루어졌다. 국내의자료검색은한국의학논문데이타베이스 (KMbase), 학술연구정보서비스 (RISS), 국회도서관 (Nanet), 한국학술정보 (KISS), 국가과학기술정보센타 (NDSL) 에서이루어졌고, 국외전자검색은핵심전자DB인 MEDLINE, EMBASE, Cochrane Library CENTRAL 및 CINAHL을통해이루어졌다. 또한포괄적인자료의검색을위해검색된논문의참고문헌과구글을통해자료검색을보완하였다. 자료검색은한국어와영어로제한하여이루어졌고, 검색은개별전자DB에서자료를제공하는년도부터 2015년 1월까지출판된자료로하였다. 2) 자료선정및자료추출국내외핵심전자DB를통해확인된관련논문은문헌관리 DB (reference management database [Refworks]) 에서중복자료를제거하였다. 논문의제목과초록을통해관련논문을 1차로확인하고, 이후선정기준에따라선정된논문의원문을검토하였다. 이과정에서 2명의연구자가독립적으로자료를검색하고선정하였으며, 최종선정된연구로부터저자및발표년도, 연구가수행된국가, 연구설계, 대상자특성 ( 연령, 대상자수 ), 중재특성 ( 중재명, 중재방법, 중재시간, 제공자 ) 및연구결과를추출하였다. 사전조사를통해자료추출의일치성을높이고자료가일치하지않을경우는원문을함께검토하여최종결정하였다. 3) 논문의질평가논문의방법론적질평가는 RCT를이용한순수실험연구는 The Cochrane Bias Method Group이개발한 7문항의 RoB (The Cochrane's Risk of Bias) 도구를, Non-RCT를이용한유사실험설계와원시실험설계는 NECA의체계적문헌고찰지침에서제시한 RoBANS (Risk of Bias Assessment tool for Non-randomized Studies) 도구를사용하였다 [14]. RoB 평가도구는 무작위배정유무, 배정순서은폐, 대상자및중재제공자맹검, 조사자맹검, 탈락률및관리, 선택적결과보고 및 그외비뚤림을높일수있는문제 등 7 문항으로구성되어있다. NECA의질평가도구는대상자비교가능성, 대조군선정, 교란변수, 중재 ( 노출 ) 측정, 결과평가눈가림, 결과평가, 불완전자료, 선택적결과보고등의 8문항으로구성되어있다. 질평가는각문항에대하여비뚤림위험낮음 (+), 불확실 (?), 높음 (-) 으로평가하도록되어있다. 4. 자료분석 1) 연구논문의일반적특성및중재방법연구논문의일반적특성과비약물적중재의특성은빈도, 백분율및평균으로분석하였다. Vol. 28 No. 1,

4 김지현 오복자 2) 비약물적중재의효과크기산출대상논문의중재에대한효과크기는 Cochrane Library의 RevMan 5.3 프로그램을활용하여산출하였다. 분석대상은동일한결과변수를제시한논문이 3편이상인경우에실시하였고, 하위그룹분석은 2편이상일때수행하였다. 자료입력시분석논문에서평균값이높아질수록실험중재의효과가있는경우는실험전평균값에서실험후의평균값을빼고, 평균값이낮아질수록실험중재의효과가있는경우는실험후평균값에서실험전의평균값을뺐다. 따라서효과크기의부호는 (-) 를나타낸것이중재의긍정적인변화를의미한다. 효과크기는동질성이확보되지않은경우개별연구들의대상자들간변동과각연구들간의이질성을고려하여가중치를재설정하는임의효과모형 (random effects model) 으로산출하였다 [14]. 대상연구들의동질성여부는 Cochrane의카이제곱검정과 I 2 검정을통하여확인하였고, I 2 값은이질성이없을때 0% 가되며, 25% 는낮은이질성, 50% 는중등도의이질성, 75% 이상인경우는이질성이큰것을의미한다 [15]. 자료입력시결과변수측정을사후에 2회이상실시한경우는평균값을포함하였고, 표준편차는 pooled standard deviation 공식으로산정하였다. 효과크기 (effect size: ES, 또는 d) 의통계적인의미는전체효과검정과 95% 신뢰구간 (CI) 으로판단하였고, 유의수준 5% 를기준으로하였다. 효과크기의해석은 Cohen (1988) 의효과해석기준에따라 ES=0.20 이상 ~0.50 미만은작은효과, ES=0.50 이상 ~0.80 미만은중간효과그리고 ES=0.80 이상은큰효과를의미한다 [16]. 3) 출판편향및효과크기에대한신뢰도검정출판편향 (publication bias) 을점검하기위해 funnel plot ( 깔때기그림 ) 을사용하였는데, funnel plot의 x축은각연구에서측정된처리효과를의미하고 Y축은해당연구의정밀성을나타내는척도 ( 표본수혹은표준오차 ) 를사용해산점도 (scatter plot) 를그린것이다. 출판편향은삼각형모양내에연구가골고루분포되어있으면출판편향이발생되지않은것으로해석하고, 통계적으로유의하지않은영역에서연구들이결측되어있으면출판편향이있다고본다 [17]. 또한출판편향의통계적유의성은분석논문이 10편이상일때 Egger s linear regression asymmetry test로확인하였다. 출판편향에대한신뢰도검증으로안전계수 (Fail-safe number, Nfs) 를산출하였고안전계수가 5N+10 이상이면메타분석에서산출된효과가신뢰도를가진것으로판정한다. 이는현재까지출판된연구의결과들로산출된효과크기가출판되지않은결 과들에의해효과크기가유의하지않게나타나는지를살펴보기위한것으로추가되는논문수 ( 안전계수 ) 가큰경우에는숨겨진논문수가많지않은것을의미한다 [18]. 연구결과 1. 자료선정국외자료의경우전자 DB에서논문제목과초록을통해총 2142편이검색되었고, 528편의중복자료가제외되고 1614편이되었다. 국내자료의경우는총 309편이검색되었고, Refworks 에서중복된자료를제외한후 140편이되었다. 국내외총 1754편중에서 55세이상불면증환자, 비약물적중재의사용, RCT연구와 Non-RCT 연구, 그리고효과크기를계산하기에충분한자료등 32편의연구를 1차로선정하였으며선정기준에적합하지않은 1722편은제외하였다. 1차선정된 32편의연구는원문을검토하였으며, 국외의경우는비약물중재가아닌서술연구 6편, 비약물적중재가아닌연구 5편, 평균값과표준편차가모두없는불충분한자료가있는연구 9 편등선정기준에적합하지않는연구 20편을제외하였다. 또한참고문헌을통한검색으로 4편의연구가추가되어최종국내연구 5편, 국외연구 11편총 16편이포함되었다 (Figure 1). 2. 비약물적중재연구의방법론적질평가질평가는 2명의연구자가 4편연구에대해 pilot test를실시한후별도로각문항에대하여비뚤림위험낮음 (+), 불확실 (?), 높음 (-) 으로평가한후일치여부를검토하고일치되지않은문항은원문을검토한후재평가하였다. Pilot test는먼저평가기준을설명하는평가틀에판단기준의이유를기술하면서평가하였다. 분석논문 16편중 12편의 RCT연구방법론적질평가는무작위는 5편의연구 (41.7%) 에서자세히기술되었으나 58.3% 는불확실한것으로판단되었으며배정순서은폐는 1편의연구 (8.3%) 만이비뚤림이낮은것으로판단되었다. 참가자및연구자의눈가림문항은 7편의 (43.7%) 의연구에서비뚤림이낮은것으로판단되었으며, 결과평가자눈가림문항또한 2편의 (16.7%) 의연구에서비뚤림이낮은것으로판단하였다. 탈락비뚤림은비뚤림낮음이 100% 로실험군과대조군의탈락률차이가 20% 이상은없는것으로판단하였다. 선택적결과보고는없었고, 기타비뚤림에서는비약물적중재에대한매뉴얼이나적용프로그램이있고, 중재제공 16 Korean Journal of Adult Nursing

5 수면장애가있는중장년환자에게적용한비약물적중재의효과 : 메타분석 Identification Total 2,451 studies identified Pubmed (n=151) EMbase (n=1203) Cochrane (n=374) CINAHL (n=414) Korean DB (n=309) 697 studies excluded for duplications English studies (n=528) Korean studies (n=169) Screening Eligibility 1,754 studies identified Pubmed (n=35) EMbase (n=1007) Cochrane (n=242) CINAHL (n=330) Korean DB (n=140) 32 studies initially reviewed English studies (n=27) Korean studies (n=5) 1,722 studies did not meet inclusion criteria Only older adults ( 55 years old) with primary Use an nonpharmacological intervention Use RCTs or non-rcts Enough data to calculate an effect size Hand search: 4 studies 20 Full-text studies excluded: English studies (n=20) Descriptive studies (n=6) Non-relevant interventions (n=5) Non-sufficient data (n=9) Included Total 16 studies selected for final inclusion English studies (n=11) Korean studies (n=5) Figure 1. Flow of studies included from database search. 자의전문성 ( 훈련유무 ) 으로판단하였는데비뚤림이낮은것 (91.7%) 으로판단되었다. Non-RCT는 RoBANS로평가하였는데 대상군비교가능성, 대조군선정, 교란변수, 중재 ( 노출 ) 측정, 결과평가눈가림, 결과평가, 불완전한자료, 선택적결과보고 등총 8개문항으로구성되었으며각항목에대해비뚤림위험이 낮음 으로평가되는경우에편향이없어문헌의질이높음을의미한다. 4편의 Non-RCT 논문의방법론적질평가에서 교란변수고려, 중재 ( 노출 ) 측정, 결과평가눈가림 항목은비뚤림낮음이각각 3편 (75%) 으로나타났으며 불완전한자료 와관련된항목은비뚤림낮음이 2편 (50%), 그외문항에서는 100% 비뚤림위험 이 낮음 으로평가되어적절하게보고된것으로나타났다. 3. 비약물적중재를적용한불면증중재연구의특성본연구에포함된불면증중재연구 16편의일반적인특성은다음과같다 (Table 1). 연구의출처는국내 5편 (31.3%), 국외 11편 (68.7%) 으로미국에서발표된연구가 7편, 캐나다 2편, 영국 1편, 오스트리아 1편순으로나타났다. 연구설계는 RCT 연구 12편 (75%), Non-RCT 연구 4편 (25%) 이었다. 연구대상자는일차불면증환자로평균나이는 69.79세로나타났다. Vol. 28 No. 1,

6 김지현 오복자 Table 1. Descriptive Summary of the Included Studies (N=16) Study Country Patient Design Mean age Sample size Name Format (setting) Intervention Provider Duration/ No. of session Min/ session Control group Outcomes (Scale) 1. Buysse et al (2011) USA Chronic and comorn comorbidities RCT Exp. (72.5) Cont. (70.8) Exp. (39) Cont. (40) BBTI (brief behavioral treatment for ) Individual (unclear) Nurse clinician 2 wks/ 2+2 telephone calls 45~ minute telephone calls later and after 1, 3 wks Information control (read publication s and 10-minute telephone calls) 1) Neuropsychiatric status - Depression (Hamilton Rating Scale for Depression) - Anxiety (Hamilton Anxiety Rating Scale) 2) Subjective sleep quality (PSQI / ESS) 3) Health related quality of life (SF-36) 4) sleep (The pittsburgh sleep diary) 5) Wrist actigraphy data 6) PSG 2. Haimov & Shatil (2013) USA Chronic RCT Exp. (73.2) Cont. (69.9) Exp. (34) Cont. (17) CogniFit (cognitive training program) Individual (home) Computerbased personalized 8 wks/ 24 20~30 Active control (software program, "Word and Paint") 1) Sleep quality - SOL, SE, TST, WASO, Actigraphy 2) Cognitive performance (AM, DA, DS, GC, GM, IN, NM, PL, RT, SH, SP, TE, VM, VP, VS, WM) 3. Hong (2008) Republic of Korea Elderly with Non- RCT Exp. (67.9) Cont. (70.7) Exp. (16) Cont. (16) Sleep management training (sleep hygiene & progressive muscle relaxation) Group (unclear) Researcher & assistants 4 wks/ Home-work No treatment 1) Sleep score 2) Sleep-satisfaction score (VAS) 3) Partial immune response (T3 (CD3), T4 (CD4), B cell (CD19)) 4. Irwin et al (2014) USA Chronic and primary RCT Exp. 1 (64.4) Exp. 2 (66.3) Cont. (66.4) Exp. 1 (50) Exp. 2 (48) Cont. (25) Exp. 1: CBT Exp. 2: TCC (tai chi chih) Group (unclear) Therapist 12 wks/ Sleep seminar education control 1) Patient reported outcomes of symptom severity and sleep quality - Sleep Quality, TST, SL, SE, WASO (PSQI/AIS/Sleep Diary/PSG) 2) Additional behavioral outcomes - Fatigue (MDFSI) - Sleepiness (ESS) - Depressive symptom (IDS-C) 3) CRP levels 5. Lee & Kwon (2009) Republic of Korea Elderly with sleep disorder Non- RCT Exp. (74.5) Cont. (69.4) Exp. (23) Cont. (20) Auriculotherapy Individual (community senior centers) Researcher & assistants 4 wks/ 4 Unclear No treatment 1) Sleep scale score 2) Sleep satisfaction 6. Lee (2011) Republic of Korea Institutionalize d elderly Non- RCT Exp. (74.1) Cont. (73.5) Exp. (20) Cont. (22) Aromatherapy hand massage program Individual (hospital) Researcher & assistants 2 wks/ No treatment 1) Anxiety scale 2) Depression scale 3) Sleep disturbance scale 4) Fatigue scale 18 Korean Journal of Adult Nursing

7 수면장애가있는중장년환자에게적용한비약물적중재의효과 : 메타분석 Table 1. Descriptive Summary of the Included Studies (Continued) (N=16) Study Country Patient Design Mean age 7. Lee (2013) Republic of Korea Elderly with RCT Exp. (79.67) Cont. (76.07) Sample size Exp. (15) Cont. (15) Name EFT-I (emotional freedom techniques) Format (setting) Group (hospital) Intervention Provider EFT instructor Duration/ No. of session Min/ session Control group 4 wks/ 8 60 Sleep hygiene education Outcomes (Scale) 1) Korean sleep scale 2) Sleep quality (PSQI) 3) Depression (GDS-K) 4) State-Trait Anxiety (STAI) 5) life satisfaction scale 8. Lichstein et al (2001) USA Late-life RCT Exp. 1 (68.11) Exp. 2 (67.92) Cont. (68.04) Exp. 1 (27) Exp. 2 (24) Cont. (23) Exp. 1: Relaxation Exp. 2: Sleep compression Individual (sleep disorders center) Therapists 6 wks/ 6 45 Usual care (placeboquasi desensitization) (Sleep Diary, PSG) 1) Sleep latency 2) Number of awakening 3) WASO 4) TST 5) SE 6) Sleep quality rating 7) Napping 8) REM (%) 9) Fatigue (FSS) 10) Insomnia impact (IIS) 11) Epwoth sleep (ESS) 12) Beliefs and attitude about sleep (BASS) 9. Lovato et al (2014) Austrailia Sleep maintanance RCT Exp. (86) Cont. (32) CBT-I Group (flinder university) Five trainee psychologists 4 wks/ 4 60 Waiting-list 1) Subjective sleep quality - WASO, SE, Number of awakenings, SOL, TST, Bedtime, Lights-out time, Sleep onset time, Final wake-up time, Out-of-bed time, Time in bed 2) Objective sleep quality - WASO, TST, SE (Actigraphy) 3) Reported severity of / Daytime functioning/confidence and beliefs about sleep - ISI/FFS, ESS, Daytime feeling and functioning scale/sleep self-efficacy, DBAS, sleep anticipatory anxiety 10. Morgan et al (2012) UK Insomnia RCT Exp. (67) Cont. (66.3) Exp. (98) Cont. (95) Self-help CBT Individual (home) Trained advisors Unclear (6 self-help booklets & low-cost telephone helpline) Unclear Treatment as usual Primary outcome 1) Sleep Quality (PSQI) Secondary outcome measures 1) Insomnia severity (ISI) 2) Subjective sleep efficiency (SE) 3) Fatigue (FSS) 4) Sleep medication use 11. Morin & Azrin (1988) Canada Geriatric (sleep-mainte nance ) RCT Exp. 1 (68.4) Exp. 2 (67.5) Cont. (67.4) Exp. 1 (9) Exp. 2 (9) Cont. (10) Behavioral cognitive treatment (Exp. 1: Stimulus control, Exp. 2: Imagery training) Group (unclear) Therapists 5 wks/ 6 60~75 Waiting-list (Sleep Diary) 1) Awakening duration 2) Awakening frequency 3) Sleep-onset latency 4) TST Vol. 28 No. 1,

8 김지현 오복자 Table 1. Descriptive Summary of the Included Studies (Continued) (N=16) Study Country Patient Design Mean age 12. Morin et al (1993) 13. Morin et al (1999) 14. Rybarczyk et al (2002) 15. Rybarczyk et al (2005) 16. Sok & Kim (2008) USA Late-life Canada Late-life USA Comorbid geriatric USA Comorbid Insomnia Republic of Korea Insomnia of Taeumin in elderly women Sample size RCT 67.1 Exp. 1 (12) Cont. (12) RCT Exp. 1 (64.4) Exp. 2 (64.1) Exp. 3 (65.2) Cont. (64.9) RCT Exp. 1 (66.5) Exp. 2 (65.6) Cont. (71.4) RCT Exp. (70.1) Cont. (67.7) Clinical psychologist or a postdoctoral fellow in clinical psychology Clinical geropsychologists Non- RCT Exp. 1 (18) Exp. 2 (17) Exp. 3 (19) Cont. (18) Exp. 1 (11) Exp. 2 (14) Cont. (13) Exp. (46) Cont. (46) 65 Exp. (28) Cont. (28) Format Name (setting) CBT Group (home) Exp. 1: CBT Exp. 2: PCT Exp. 3: CBT+PCT Exp. 1: CBT Exp. 2: Home based audio relaxation treatment (HART) Group (hospitaloutpatients) Group (unclear) CBT Group (medical offices and senior centers) Auricular acupuncture therapy Individual (home, community welfare center, senior citizen center) Intervention Provider Clinical psychologist Clinical psychologists Duration/ No. of session Min/ session Control group Outcomes (Scale) 8 wks/ unclear 90 Waiting-list 1) Sleep-onset latency 2) WASO 3) Early morning awakening 4) Total wake time 5) TST 6) SE 8wks/ 8 90 Waiting-list (Sleep diary, PSG) 1) WASO 2) SE 3) TST 6 wks/ 6 90 Treatment as usual 8wks/ Stress manageme nt and wellness Researcher 2 wks/ 4 Unclear Usual care (blood pressure) 1) Sleep log measures 2) Actigraphy 3) Sleep quality (PSQI) 4) Dysfunction beliefs and attitude (DBAS) 5) Geriatric depression scale (GDS) 6) BAI 7) Pain (SF-MPQ) 8) Life Satisfaction Index-Short Form 9) Quality of life (SF-36) 1) Sleep log 2) Sleep quality (PSQI) 3) SII 4) Dysfunction beliefs and attitude (DBAS) 5) POMS 6) Geriatric depression scale (GDS) 7) Quality of life (SF-36) 8) Sickness impact profile (SIP) 9) Pain (SF-MPQ) 10) TEQ 1) Sleep score 2) Self-reported satisfaction (Visual Analogue Scale) Exp.=experimental group; Cont.=control group; RCT=randomized controlled trials; Non-RCT=non-randomized controlled trial; PSQI=the pittsburgh sleep quality index; ESS=epworth sleepiness scale; SF-36=short form (36) health survey; PSG=polysomnography; SOL=sleep onset latency; SE=sleep efficiency; TST=total sleep time; WASO=wakefulness after sleep onset; NA=number of awakenings; AM=auditory memory; DA=divided attention; DS=avoiding distractions; GC=hand-eye co-ordination; GM=general memory; IN=inhibition; NM=naming; PL=planning; RT=response time; SH=shifting; SP=spatial perception; TE=time estimation; VM=visual working memory; VP=visual perception; VS=visual scanning; WM=working linguistic-auditory memory; VAS=visual analog scale; CBT=cognitive behavioral therapy; SL=sleep latency; AIS=athens scale; MDFSI=multidimensional fatigue severity index; IDS-C=inventory of depressive symptomatology-clinician rating scale; GDS-K=geriatric depression scale in Korea; STAI=state-trait anxiety inventory; FSS=fatigue severity scale; IIS= impact scale; BASS=belief and attitudes about sleep scale; ISI= severity inventory; FFS=flinders fatigue scale; DBAS=dysfunctional beliefs and attitudes about sleep scale; GDS=geriatric depression scale; BAI=beck anxiety inventory; SF-MPQ=short form mcgill pain questionnaire; SII=sleep impairment index; POMS=profile of mood states; SIP=sickness impact profile; ITEQ= treatment evaluation questionnaire. 20 Korean Journal of Adult Nursing

9 수면장애가있는중장년환자에게적용한비약물적중재의효과 : 메타분석 총연구참여자수는실험군 530명, 대조군 432명으로총 962 명이었으며, 실험군은평균 33.2명, 대조군평균 27명으로나타났다. 비약물적중재의종류는인지행동중재 (Cognitive Behavior Treatment, CBT) 로명명된중재가 9편 (56.3 %) 으로가장많았으며단순행동치료 (Brief Behavior Treatment, BBT) 1편, 인지치료1편, 귀자극요법 ( 이압요법 ) 1편, 향요법 1편, 감정자유기법, Emotional Freedom Techniques, EFT) 1편, 이완요법 1편으로조사되었다. 중재는개별중재 7편 (43.8 %), 그룹중재 9편 (56,3%) 로수행되었다. 비약물적중재의제공자는심리치료사 5편 (31.3%), 치료사 4편 (25.0%), 연구자 4편 (25.0%), 한의사및간호사인경우가각각 1편 (6.3%) 으로나타났다. 비약물적중재의적용주수는평균 5.5주, 적용횟수평균 7.7회, 1회평균중재시간 70분으로조사되었다. 결과변수는수면의일차적결과변수로총수면시간 10편, 수면잠복기 9편, 입면후각성시간 9편, 수면효율성 11편이측정되었다. 이차적결과변수로는수면의질 8편, 불면증심각성 3 편, 수면에대한비합리적신념및태도 4편, 수면만족도 4편으로나타났다. 측정도구는수면패턴을주관적으로기록한수면일지작성, 객관적측정도구인액티그라피 (actigraphy) 와수면다원검사로측정하였다. 4. 효과크기의추정 1) 비약물적중재가수면장애에미친효과크기비약물적중재의효과측정은일차결과변수와이차결과변수별로산출하였다. 일차적결과변수에는총수면시간, 수면잠복기, 입면후각성시간, 수면효율성이포함되고이차적결과는불면증의심각성, 수면의질, 수면에대한비합리적신념및태도, 수면만족도가포함된다. 종속변수별이질성이나타난경우는척도유형 ( 주관적척도 vs 객관적척도 ), 중재형태 ( 그룹별 vs 개인별 ), 대조군처치유형 (usual care vs attention control group) 및중재적용횟수 ( 평균 7회이상 vs 평균 7회미만 ) 에따른하위그룹분석 (subgroup analysis) 을실시하였는데분석대상연구가 2편이상일때실시하였다. (1) 비약물적중재효과크기의일차결과변수 1 비약물적중재가총수면시간에미친효과비약물적중재가총수면시간에미친효과를제시한연구는총 10편으로이질적인것으로나타나 (x 2 =40.77, p<.001; I 2 =78%) 임의효과모형으로효과크기를산출하였고하위그룹분석을통해이질성을탐색하였다. 이들연구에서비약물중재 의효과크기는통계적으로유의하지않았다 (p=.820). 안전계수 (Nfs) 는 25.2로나타났다. 척도유형별하위분석에서주관적척도인수면일기로총수면시간을측정한경우 (k=8, p=.790), 객관적인도구인액티그래피로측정한경우 (k=4, p=.32), 수면다원검사로측정한경우 (k=5, p=.670) 에서비약물적중재는통계적으로유의하지않았다. 2 비약물적중재가수면잠복기에미친효과비약물적중재가수면잠복기에미친효과를제시한연구는총 9편으로이질적인것으로나타나 (x 2 =107.26, p<.001; I 2 =93%) 임의효과모형으로효과크기를산출하였다. 이들연구에서효과크기는 (95% CI: -1.60, -0.16) 로통계적으로유의하였고 (p =.02), 안전계수 (Nfs) 는 30.6으로나타났다. 하위그룹분석을실시한결과척도유형별분석에서주관적척도인수면일기로수면잠복기를측정한경우효과크기 (95% CI: -1.87, -0.07) 로통계적으로유의하였으나 (k=7, p=.030, I 2 =94%), 액티그래피로측정한경우 (k=3, p=.10) 와수면다원검사로측정한경우 (k=4, p=.200) 는통계적으로유의하지않았다. 중재형태별하위그룹에서는, 수면일기의경우개인별중재보다는그룹중재가효과크기 (95% CI: -0.60, -0.05) 로통계적으로유의하였고 (p=.020, I 2 =25%) 이질성은낮았다. 중재적용횟수에따른분석에서는평균적용횟수 7회이상인경우효과크기 (95% CI: -0.70, -0.07) 로통계적으로유의하였으나 (k=3, p=.020, I 2 =21%), 7회미만인경우는이질성이높았고 (I 2 =95%) 통계적으로유의하지않았다 (p=.060). 출판편향은 funnel plot 상에서다소있는것으로나타났다 (Figure 2). 3 비약물적중재가입면후각성시간에미친효과비약물적중재가입면후각성시간에미친효과를제시한연구는총 9편으로이질적인것으로나타나 (x 2 =81.97, p<.001; I 2 =90%) 임의효과모형으로효과크기를산출하였다. 이들연구에서효과크기는 (95% CI: -1.49, -0.26) 로통계적으로유의하였고 (p =.005), 안전계수 (Nfs) 는 27로나타났다. 척도유형별하위그룹분석에서수면일기로수면잠복기를측정한경우효과크기 (95% CI: -1.67, -0.17) 로통계적으로유의하였으며 (k=7, p =.020), 액티그래피로측정한경우도효과크기 (95% CI: -1.90, -0.10) 로통계적으로유의하였으나 (k=4, p=.030), 수면다원검사로측정한경우는통계적으로유의하지않았다 (k=5, p =.100). 중재형태별하위그룹에서는수면일기의경우개인별중재보다는그룹중재가효과크기 (95% CI: -0.79, -0.29) 로통계적으로유의한것 (p<.001, I 2 =13%) 으로나타난반면액티그래피로측 Vol. 28 No. 1,

10 김지현 오복자 정한경우두그룹모두에서통계적으로유의하지않았다. 대조군처치유형에따른비약물적중재의효과크기는대조군에통상적돌봄만제공된그룹 (usual care) 이수면중재이외의다른중재를제공한경우 (attention control group) 보다효과크기 (95% CI: -0.91, -0.14) 로통계적으로유의한것으로나타났다 (p=.008, I 2 =42%). 중재적용횟수에따른분석에서평균적용횟수 7회이상인경우효과크기 (95% CI: -0.62, -0.10) 로통계적으로유의하였고동질하였다 (k=4, p=.006, I 2 =0%). 7회미만인경우는통계적으로유의하였으나 (p=.030) 이질성이높았다 (I 2 =94%). 출판편향은 funnel plot 상에서다소있는것으로나타났다 (Figure 3). 4 비약물적중재가수면효율성에미친효과수면효율은수면의연속성을측정하는가장좋은측정방법으로일반적으로침대에누워있는시간의비율에 100을곱한 2.1 Sleep onset latency 2.2 Wake after sleep onset (WASO) 2.3 Sleep efficiency Figure 2. Forest plot of effect size and 95% CI by non-pharmacological interventions on sleep onset latency, wake after sleep onset (WASO), and sleep efficiency. 22 Korean Journal of Adult Nursing

11 수면장애가있는중장년환자에게적용한비약물적중재의효과 : 메타분석 2.1 Sleep quality. 2.2 Sleep belief. Figure 3. Forest plot of effect size and 95% CI by non-pharmacological interventions on sleep quality and sleep belief. 값으로나타낸다. 비약물적중재가수면효율성에미친효과를제시한연구로는총 11편으로이질적인것으로나타나 (x 2 = p<.001; I 2 =90%) 임의효과모형으로효과크기를산출하였다. 이들연구에서효과크기는 (95% CI: -1.68, -0.60) 로통계적으로유의하였다 (p <.001). 출판편향을검정한 funnel plot에서출판편향이의심되었으나 Egger test결과출판편향은없는것으로나타났다 (p =.181). 안전계수 (Nfs) 는 51.7로나타났다. 척도유형별하위분석에서수면일기 (k= 8, p =.003) 는효과크기 (95% CI: -1.80, -0.54) 로통계적으로유의하였으며액티그래피 (k=4, p=.05) 와수면다원검사로측정한경우 (k=5, p=.090) 는통계적으로유의하지않았다. 중재형태별하위그룹에서는, 수면일기의경우개인별중재보다는그룹중재가효과크기 (95% CI: -1.04, -0.58) 로통계적으로유의한것으로나타난반면 (p<.001, I 2 =0%) 액티그래피로측정한경우두그룹모두에서통계적으로유의하지않았다. 대조군처치유형에따른비약물적중재의효과크기는대조군에통상적돌봄만제공된그룹 (usual care) 의경우효과크기 (95% CI: -1.00, -0.34) 로통계적으로유의한것 (p<.001, I 2 =54%) 으로나타났으며, 수면중재이외의다른중재를제공한경우에도통계적으로유의하였으나이질적인것으로 (I 2 =97%) 확인되어효과크기를제시하지않았다. 중재적용횟수에따른분석에서는평균적용횟수 7회이상인경우효과크기 (95% CI: -1.02, -0.50) 로통계적으로유의하였고동질하였다 (k=4, p<.001, I 2 =0%). 7회미만인경우는통계적으로유의하였으나 (p =.003) 이질성이높았다 (I 2 =94%). (2) 비약물적중재효과크기의이차결과변수 1 비약물적중재가불면증심각성에미친효과비약물적중재가불면증심각성에미친효과를제시한연구로는총 3편으로효과크기는통계적으로유의하지않았고 (p =.050), 이질적인것으로나타났다 (x 2 =23.86, p<.001; I 2 =92%). 2 비약물적중재가수면의질에미친효과비약물적중재가수면의질에미친효과를제시한연구로는총 8편으로이들연구는이질적인것으로나타나 (x 2 =127.56, p<.001; I 2 =95%) 임의효과모형으로효과크기를산출하였다. 이들연구에서효과크기는 (95% CI: -1.89, -0.47) 로통계적으로유의하였고 (p <.001), 안전계수 (Nfs) 는 39.2 로나타났다. 중재형태별하위그룹에서는, 그룹중재보다는개인중재가효과크기 (95% CI: ) 로통계적으로유의하였다 (p=.020). 대조군처치유형에따른비약물적 Vol. 28 No. 1,

12 김지현 오복자 중재의효과크기는이질적인것으로 (x 2 =20.96, p<.001; I 2 =86%) 확인되어효과크기를제시하지않았다. 척도유형별하위분석에서는 Pittsburgh 수면의질척도로측정한연구는총 6편이었으며효과크기 (95% CI: -2.48, -0.60) 로통계적으로유의하였다 (p =.001). 출판편향은 funnel plot 상에서통계적으로유의하지않은영역에서연구들이결측되어있어다소있는것으로나타났다. 3 비약물적중재가수면에대한비합리적신념및태도에미친효과비약물적중재가수면에대한비합리적신념및태도에미친효과를제시한연구로는총 4편으로동질하였다 (I 2 =10%). 이들연구의효과크기는 (95% CI: -0.98, -0.44) 로통계적으로유의하였고 (p<.001), 안전계수 (Nfs) 는 10.2 로나타났다. 척도유형별하위분석에서 DBAS (Dysfunctional Beliefs and Attitudes about Sleep) 로효과를제시한연구로는총 3 편으로효과크기 (95% CI: -1.08, -0.52) 는통계적으로유의하였다 (p<.001; I 2 =0%). 4 비약물적중재가수면만족도에미친효과비약물적중재가수면만족도에미친효과를제시한연구는총 4편으로통계적으로유의하였으나 (p<.001) 이질적인것으로 (I 2 =97%) 확인되어효과크기를제시하지않았다. 논의 1. 비약물적중재의특성과질평가본연구는불면증이나수면장애가있는 55세이상의중장년에게시행된비약물적중재와그효과를확인하여비약물적중재의근거기반의활성화와추후연구의방향을제시하고자시도하였다. 본연구에서비약물적중재의종류는인지행동중재가 9편으로가장많았으며그다음보완대체요법이 4편으로나타났다. 보완대체요법의경우는모두국내에서수행되어국외의수면중재와차이가있었으며경락기반치료기법과향요법을활용하였다. 실제본연구에서활용한보완대체요법은종류별 1~2편씩으로수행되었으므로추후비약물적중재로서수면중재에적용하여검증할필요가있다. 인지행동중재 (Cognitive Behavioral Therapy-Insomnia, CBT-I) 는인지치료와행동중재를통합한것으로수면위생교육, 자극조절및수면제한그리고이완기술등을포함하고있다. 이러한중재는보통 4~8주정도의치료기간을필요로하고있어최근 2 회정도수행하는단기인지행동중재 (Brief Behavioral Therapy-Insomnia, BBT-I) 가대두되었다 [9]. 선행연구에서비약물적중재종류별효과를제시한연구가없어비교하기는어려우나국외의수면중재에대한메타분석연구는행동치료가약물치료에비해좋은효과를보였다고보고한바있고 [19,20] 인지행동중재중자극조절요법과수면제한치료가가장효과적인행동치료개입이라고보고하였다 [21,22]. 본연구에서비약물적중재의적용주수는평균 5.5주, 적용횟수평균 7.7회, 1회평균중재시간 70분으로조사되어, 암환자대상의선행메타분석연구 [23] 에서일반심리사회적중재가평균 8.4주기간에평균 9.1회를적용하고 1회당평균 93.4 분으로수행된것에비해본연구의비약물적중재는단기에이루어져중장년층의수면장애환자에게적절한중재임을알수있다. 본연구에포함된비약물적중재연구들의방법론적인질평가에서전체적으로중정도이상으로나타나메타분석에포함시키기에적합하였다. 그러나결과평가자의눈가림문항에서자세히서술되어있지않아불확실로평가되었다. 대상자와중재자의눈가림은심리사회적중재의특성상대상자와중재자가중재를받는군인지아닌지를알기때문에중재의질평가에서제외하는연구가많은데 [24], 결과평가자의눈가림문항은중요하게평가하고있으므로추후연구에서는이에대한연구설계를보완할필요가있다. 또한무작위는되어있으나배정순서은폐항목에서도대부분의연구 (91.7%) 에서이루어지지않았다. 그러나심리사회적중재의질을담보하는중재매뉴얼유무와중재제공자의전문성 ( 훈련유무 ) 을분석한결과거의모든연구 (93.7%) 에서중재의구조화된체계성을볼수있었다. 2. 비약물적중재가수면장애에미친효과크기비약물적중재가수면의일차적결과변수에미친효과는수면효율성 (ES=-1.03), 수면잠복기 (ES=-.88), 입면후각성시간 (ES=-.87) 에유의한효과가있었는데이들효과크기는안전계수 27~51.7로안전계수산출근거인 5N+10 이상의기준에미치지는못하나본연구결과를의의없는것으로번복시키는데 27~52편의연구가요구되므로효과크기는신뢰할만한것으로나타났다. 그러나비약물적중재는총수면시간에는유의한효과가없었다. 이러한연구결과는인지행동중재가수면에미친효과에대해체계적고찰을수행한선행연구 [13] 에서인지행동중재가수면의질, 수면효율성과수면잠복기와불면증의심각성에유의한효과를나타냈으나입면후각성시 24 Korean Journal of Adult Nursing

13 수면장애가있는중장년환자에게적용한비약물적중재의효과 : 메타분석 간과총수면시간에유의하지않았다는결과와유사하다. 그러나불면증환자에게적용한인지행동중재의메타분석연구에서수면효율성, 수면잠복기, 입면후각성시간뿐아니라총수면시간에도유의한효과가있었다는보고와는차이가있다 [12]. 이상의결과는수면위생교육, 행동및인지치료, 자극조절요법, 수면제한요법및이완기술등의통합인지행동중재가수면증진에효과가있음을제시하고있다. 본연구에서도인지행동중재는비약물적중재의 56.2% 를차지하고있었으며통합인지행동중재를수행하였다. 본연구에서인지행동중재는인지치료와행동치료가통합된것으로단독인지치료나단독행동치료보다유의한효과가있는것으로나타나추후연구에서수면중재에통합된인지행동중재가좋을것으로사료된다. 본연구에서비록총수면시간에대한효과는유의하지않았으나수면의질이증가되었으므로추후수면증진에비약물적중재를활용할필요가있겠다. 본연구에서분석된수면잠복기와입면후각성시간의효과크기는 funnel plot상에서출판편향이다소있는것으로나타나효과크기가과대추정된결과일수있다. 이들변수는분석논문이 9편이어서실제출판편향유무를통계적으로검증할수없었는데추후이에대한연구가누적되어재분석할필요가있다. 비약물적중재가수면에미친구체적인효과를보면수면잠복기는 30분이내에잠들기가어려움이있는것을의미하는데본연구에서비약물적중재는수면잠복기를감소시키는것으로나타났다. 이는선행메타분석연구에서비약물적중재가수면잠복기에미치는효과크기를 0.88로보고한것과일치한다 [24]. 입면후각성시간은주어진수면기회시간중각성한시간을말하는데본연구결과는선행연구의효과크기.65보다큰것으로나타났다. 이러한결과는노인의경우수면장애는수면잠복기가길고 ( 잠들기가어렵고 ) 밤동안에깨거나깊이잠들지못하는입면후각성시간이길어지는것을호소하기때문에비약물적중재를통해이러한수면의문제를완화시키는것은근거기반의중재자료를제공한다고볼수있다. 또한비약물적중재는총수면시간에는유의한효과가없었으나수면의효율성은높이는것으로나타났다. 수면효율성은수면의연속성을측정하는가장좋은방법으로침대에누워있는시간에서실질적으로수면한시간을의미한다. 이러한결과는고령화와더불어델타파또는깊은수면이줄고, 침대에서보내는시간은많지만실질적인수면시간이감소되고있는 [26,27] 현실에서비약물적중재는수면의효율성을증진시키는의미있는것으로보인다. 척도유형별하위그룹분석에서주관적척도인수면일기로 수면잠복기를측정한경우는수면효율성, 수면잠복기및입면후각성시간에통계적으로유의하였으나객관적인도구인수면다원검사로측정한경우는통계적으로유의하지않았다. 이는 60세이상수면장애가있는성인을대상으로인지행동중재를실시한연구 [11] 에서도객관적인수면다원검사와주관적으로보고한수면일기의결과와차이가있었다는보고와도일치한다. 이러한결과는수면일기가개인이지각하는수면패턴을주관적으로기록하는것이지만수면문제에대한동기부여와자기모니터링을통해치료적인효과를갖는다는것을알수있다 [18]. 선행메타분석연구에도일차불면증환자대상으로인지행동중재를수행한후수면일기로관련변인들을측정한결과치료적효과가있다고보고하여본연구와일치한다 [12]. 한편수면다원검사를통한수면측정은뇌와신체활동을직접정량적으로평가하는객관적인방법이기는하나보통하룻밤동안뇌파, 근전도, 안구운동, 호흡운동, 심전도, 말초산소포화도등을측정하는센서를부착해서수면구조와수면패턴, 수면관련장애여부를파악하기때문에낯선환경에따른심리적요인등이변수로작용할수있다고생각된다. 실제로미국수면의학회에서도일반적인경우불면증환자에게수면다원검사를권고하지않으며초기진단이확실하지않거나치료에실패또는야간의이상행동을동반한급작스런각성이일어나는경우에만수면다원검사를시행할것을권고하고있다 [28]. 따라서수면다원검사는하룻밤이아닌사흘이상의모니터링기간을두어낮선환경에서의적응기간을두어심리적요인을배제한후그효과성을측정하는것이필요하리라생각된다. 본연구에서수면의연속성을객관적으로측정하는액티그래피의경우는입면후각성시간과수면효율성에서유의한효과가있는것으로나타났고초기평가, 치료순응도측정, 치료에따른변화평가등많은정보를제공하므로수면일기와함께수면의효과를측정하는데유용한도구로생각된다. 본연구에서중재유형 ( 그룹별 vs 개인별 ) 별하위그룹에서는, 개인별중재보다는그룹중재가통계적으로더유의한것으로나타났다. 이러한결과는수면중재의선행메타분석연구에서보고된결과가없어직접적인비교는어려우나최근메타분석연구에서인터넷을이용한자조프로그램의인지행동중재가수면증진에효과가있는것으로제시하여 [13] 개인별치료의효과를시사하고있다. 불면증은스트레스에대한신체화한긴장감 (somatized tension) 과초조감그리고잠들수없다는사실에대해지나치게걱정하는수면방해연상이되풀이되는경우가많으므로개별중재를통해환자를치료과정에 Vol. 28 No. 1,

14 김지현 오복자 적극적으로참여시키는것이중요하다. 따라서개인별치료와그룹치료를통합해서적용하는복합접근방법이적합할것으로보인다. 본연구에서비약물적중재가수면의이차적결과변수에미친효과는수면의질 (ES=-1.18) 과수면에대한비합리적신념및태도 (ES=-.71) 및만족도에유의한효과가있었고효과크기는큰것으로나타났다. 수면의질은깨어날때잘잤음을느끼는것으로노화로인한가장흔한수면의문제로제시되는데본연구결과비약물적중재는수면의질을향상시키는것으로나타났고안전계수가 39.2로본연구결과를의의없는것으로번복시키는데 39편의연구가요구되므로효과크기는신뢰할만하다고본다. 이는수면의질은수면잠복기와수면의효율성을포함하고있으므로 [29] 본연구결과의일차결과에서수면잠복기와수면의효율성이증진된것과동일한맥을형성한다고보인다. 특히수면의질이떨어지면기억력과집중력의저하및수면제복용과관련되고삶의질이저하되므로비약물적중재로인한수면의질향상은매우의미가있다. 본연구에서비약물적중재는수면에대한비합리적신념이나태도를변화시킨것으로제시되었다. 이는본연구에서활용된비약물적중재로서활용된인지행동중재가불면증환자의수면에도움이되지않는행동과잘못된수면관련믿음을교정한것과관련되는것으로보인다. 불면증환자는수면문제를악화시키는비합리적인신념이나태도를가지고있는경우가많은데본연구에서인지적개입을통해불면증환자의수면문제를악화시키는비합리적인신념이나태도를변화시켰다고보인다. 이러한신념이나태도의변화가수면의효율성을높이고수면잠복기를감소시키며수면의질을향상시킨것과관련되지않았는지생각된다. 이는선행연구에서도수면에대한생각을회피하려고노력하거나잠을의도적으로자려고노력하면할수록수면에대한걱정및각성이증가하게되고수면잠복기는더욱길어지게된다고보고하여 [30] 수면에대한신념및태도는수면중재에있어서중요한것으로보인다. 이러한수면에대한신념및태도는불면증의심각성에도유의한영향을미치므로이를변화시키는것이수면중재에서우선적으로고려해야할변수로보인다. 선행메타분석연구에서불면증환자에게적용한인지행동중재가수면에대한비합리적신념의정도와태도에큰변화를가져온것으로나타났다 [12]. 따라서수면과불면증에대한지식과행동적접근을통해대상자의수면에대한잘못된신념등을교정하고자기효능감을증진시킨것으로생각된다. 본연구에서수면만족도는보완대체요법이효과가있는것으로나타났으므로추 후비약물적중재로서수면중재에적용하여검증할필요가있다. 특히본연구에서비약물적중재는인지행동중재 (9편) 와보완대체요법 (4편) 으로대별되었는데보완대체요법의경우는보완대체요법이종류별 1~2편씩수행되어수면만족도이외의수면의효과에대해서는중재의종류별 ( 인지행동중재 vs 보완대체요법 ) 분석이어려웠다. 이상의분석결과는비약물적수면중재가중장년층의수면문제를해결하는데유용한것으로제시되었으나본연구의제한점은다음과같다. 첫째, 국외의경우는 DB를통해검색된연구만을선정하여학위논문을포함한회색논문이포함되지않았을가능성이있다. 둘째, 선택된연구의방법론적인질평가에서조사자의맹검은중요한측면인데대부분의연구에서불충분하게이루어졌다. 셋째, 국내연구의경우 Non-RCT 연구가대부분으로무작위화를수행하지않았을때중재의효과크기가과대평가되는경향이있다. 추후연구에서는 RCT 연구설계로효과를검증할필요가있다. 넷째, 본연구는보완대체요법을포함한비약물적중재가수면에미치는효과를분석하고자하였으나실제로분석에포함된대부분의연구는인지행동요법을적용한것이었다. 다섯째, 하위그룹분석을통하여이질성을탐색하였으나중재의특성상부분적으로동질성이확보되지않은상태에서결과를제시한점이있다. 결론및제언본연구는 2015년 1월까지발표된국내외의비약물적수면중재연구를대상으로효과를분석하고근거기반실무의기초자료와수면장애관리를위한중재방법의방향을제시하고자하였다. 본연구의분석대상논문은총 16편으로인지행동중재가대부분을차지하였고보완대체요법은총 4편에불과하였다. 보완대체요법의경우는경락기반치료기법과향요법을활용하였으며메타분석에서수면만족도에효과가있었으므로추후수면중재에비약물적중재로서적용하여검증할필요가있다. 인지행동중재는인지치료와행동중재를통합한것으로수면위생교육, 자극조절및수면제한그리고이완기술등을통합하여적용하였으며 4~8주간의인지행동중재와 2회정도의단기인지행동중재로나타났다. 본연구결과비약물적중재는총수면시간을연장시키지는않았으나수면에대한비합적인태도가수정되어수면중깨는시간이감소되고 ( 입면후각성시간 ), 누워서잠들기까지의시간이짧아지며 ( 수면잠복기 ), 실질적으로수면의질이좋아지는것으로나타났다. 또한중재횟수가 7회이상으로긴경우 26 Korean Journal of Adult Nursing

15 수면장애가있는중장년환자에게적용한비약물적중재의효과 : 메타분석 수면증진에효과가있는것으로나타났다. 전체적으로비약물적중재의효과크기는본연구결과를의의없는것으로번복시키는데 27~52편의연구가요구되므로신뢰할만한것으로나타났다. 메타분석결과비약물적수면중재는평균적용횟수 7.7회, 일회평균중재시간 70분으로이루어져중장년층의수면장애환자에게적절한중재임을알수있다. 그러나본연구분석에서 non-rct 연구가포함되어있어효과크기의의미를신중하게해석할필요가있다. 본연구결과를통해다음과같이제언하고자한다. 실무적인측면에서는불면증이나수면장애가있는대상자들에게비약물적중재프로그램을개발하고적용할필요가있다. 교육및연구적인측면에서는수면증진을위해보완대체요법을활용한비약물적중재효과를검증할필요가있다. REFERENCES 1. Kwon KH, Suh SR, Suh BD. Sleep patterns and factors influencing sleep in institutionalized elders and elders living at home. Journal of Korean Gerontological Nursing. 2010;12: Basta M, Chrousos GP, Vela-Bueno A, Vgontzas AN. Chronic and stress system. Sleep Medicine Clinics. 2007;2: Jun SS, Ha SJ. Sleep disorder experience in older patients with depression. Journal of Korean Academy of Nursing. 2014;44 (3): Glass J, Lanctot KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with : meta-analysis of risks and benefits. British Medical Journal. 2005;331 (11): Stepanski EJ. Hypnotics should not be considered for the initial treatment of chronic. Con. Journal of Clinical Sleep Medicine. 2005;1(2): Espie CA. Insomnia: conceptual issues in the development, persistence, and treatment of sleep disorder in adult. The Annual Review of Clinical Psychology. 2002;53: Koo YJ, Koh HJ. Analysis of intervention research about sleep of the elderly in Korea. Keimyung Journal of Nursing Science. 2009;13(1): Jaffe S, Patterson DR. Treating sleep problems in patients with burn injuries: practical considerations. Journal of Burn Care & Rehabilitation. 2004;25(3): Wang MY, Wang SY, Tsai PS. Cognitive behavioural therapy for primary : a systematic review. Journal of Advanced Nursing. 2005;50(5): De Niet GJ, Tiemens BG, Kloos MW, Hutschemaekers GJ. Review of systematic reviews about the efficacy of non-pharmacological interventions to improve sleep quality in. International Journal of Evidence-Based Healthcare. 2009;7(4): Montgomery P, Dennis JA. Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database of Systematic Reviews. 2003;1 CD Okajima I, Komada Y, Inoue Y. A meta-analysis on the treatment effectiveness of cognitive behavioral therapy for primary. Sleep and Biological Rhythms. 2011; 9(1): Cheng SK, Dizon J. Computerised cognitive behavioural therapy for : a systematic review and meta-analysis. Psychotherapy and Psychosomatics. 2012; 81(4): Kim SY, Park JE, Seo HJ, Seo HS, Song HJ, Shin CM, et al. NECA's guidance for undertaking systematic reviews and meta-analyses for intervention. Seoul: National Evidencebased Healthcare Collaborating Agency Higgins JP, Green S. (Eds). Cochrane handbook for systematic reviews of interventions, version [updated March 2011]. The Cochrane Collaboration, Available from: Cohen, J. Statistical power analysis for the behavioral sciences, 2nd ed. Hillsdale, NJ, Lawrence Erlbaum Associates Lee J. Meta-analysis, Journal of Korean Endocrine Society. 2008;23(6): Oh SS. Meta-analysis: theory and practice. Seoul, Konkuk University Press Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. Psychological and behavioral treatment of : update of the recent evidence ( ). Sleep. 2006; 29(11): Smith MT, Perlis ML, Park A, Smith MS, Pennington J, Giles DE, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent. The American Journal of Psychiatry. 2002;159: Harvey L, Inglis SJ, Espie CA. Insomnias reported use of CBT components and relationship to long-term clinical outcome. Behaviour Research and Therapy. 2002;40: Vincent N, Lionberg C. Treatment preference and patient satisfaction in chronic. Sleep. 2001:24: Oh PJ, Jang ES. Effects of psychosocial interventions on cortisol and immune parameters in patients with cancer: a meta- Vol. 28 No. 1,

16 김지현 오복자 analysis, Journal of Korean Academy of Nursing. 2014:44(4): Goedendrop MM, Gielissen MF, Verhagen CA, Bleijenberg G. Psychosocial interventions for reducing fatigue during cancer treatment in adults. The Cochrane Database of Systematic Reviews. 2009;1 CD Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for : a meta-analysis of treatment efficacy. The American Journal of Psychiatry. 1994;151(8): Sok SH, Kim KB. Effects of auricular acupuncture on in Korean elderly. Journal of Korean Academy of Nursing. 2005;35(6): Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. The American Journal of Medicine. 2006;119(6): Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic in adults. Journal of Clinical Sleep Medicine. 2008; 4: Kwon KH. The development of measurement tool of sleep quality of the elderly [dissertation]. Daegu, Kyungpook National University. 2009: Morin CM, Blais F, Savard J. Are changes in beliefs and attitudes about sleep related to sleep improvements in the treatment of? Behaviour Research and Therapy. 2002;40: Korean Journal of Adult Nursing

17 수면장애가있는중장년환자에게적용한비약물적중재의효과 : 메타분석 Appendix. Reviewed Paper List 1. Buysse DJ, Germain A, Moul DE, Franzen PL, Brar LK, Fletcher ME, et al. Efficacy of brief behavioral treatment for chronic in older adults. Archives of Internal Medicine. 2011;171(10): Haimov I, Shatil E. Cognitive training improves sleep quality and cognitive function among older adults with. PLOS ONE. 2013;8(4):e Hong SH. Effects of sleep management training on sleep and immune response in elderly [master s thesis]. Pochon: Pochon CHA University; p Irwin MR, Olmstead R, Carrillo C, Sadeghi N, Breen EC, Witarama, T et al. Cognitive behavioral therapy vs. Tai Chi for late life and inflammatory risk: a randomized controlled comparative efficacy trial. Sleep. 2014;37(9): Lee JO, Kwon YS. Effects of auriculotherapy on sleep disorders in the elderly. Journal of East-West Nursing Research. 2009;15(1): Lee SY. Effects of aromatherapy hand massage on anxiety, depression, sleep disturbance and fatigue of the institutionalized elderly. Journal of Korean Biological Nursing Science. 2011;13(1): Lee JH. A randomized control trial for the evaluation of the effects of EFT-Insomnia (EFT-I) for the elderly [master s thesis]. Seoul: Kyung-Hee University; p Lichstein KL, Riedel BW, Wilson NM, Lester KW, Aguillard RN. Relaxation and sleep compression for late-life : a placebo-controlled trial. Journal of Consulting and Clinical Psychology. 2001;69(2): Lovato N, Lack L, Wright H, Kennaway DJ. Evaluation of a brief treatment program of cognitive behavior therapy for in older adults. Sleep. 2014;37(1): Morgan K, Gregory P, Tomeny M, David BM, Gascoigne C. Self-help treatment for symptoms associated with chronic conditions in older adults: a randomized controlled trial. Journal of the American Geriatrics Society. 2012;60(10): Morin CM, Azrin NH. Behavioral and cognitive treatments of geriatric. Journal of Consulting and Clinical Psychology. 1988;56(5): Morin CM, Kowatch RA, Barry T, Walton E. Cognitive-behavior therapy for late-life. Journal of Consulting and Clinical Psychology. 1993;61(1): Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacological therapies for late-life : a randomized controlled trial. Journal of the American Medical Association. 1999;281(11): Rybarczyk B, Lopez M, Benson R, Alsten C, Stepanski E. Efficacy of two behavioral treatment programs for comorbid geriatric. Psychology and Aging. 2002;17(2): Rybarczyk B, Stepanski E, Fogg L, Lopez M, Barry P, Davis A. A placebo-controlled test of cognitive-behavioral therapy for comorbid in older adults. Journal of Consulting and Clinical Psychology. 2005;73(6): Sok SH, Kim KB. Applied effects of auricular acupuncture therapy on of taeumin in elderly women. Journal of East-West Nursing Research. 2008;14(2):1-7. Vol. 28 No. 1,

Rheu-suppl hwp

Rheu-suppl hwp Objective: This paper reviews the existing Korean medical and public health, and nursing academy articles on disease-specific and domain-specific quality of life, and provides recommendations for the universally

More information

<B0A3C3DFB0E828C0DBBEF7292E687770>

<B0A3C3DFB0E828C0DBBEF7292E687770> 초청연자특강 대구가톨릭의대의학통계학교실 Meta analysis ( 메타분석 ) 예1) The effect of interferon on development of hepatocellular carcinoma in patients with chronic hepatitis B virus infection?? -:> 1998.1 ~2007.12.31 / RCT(2),

More information

012임수진

012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar

More information

27 2, 17-31, , * ** ***,. K 1 2 2,.,,,.,.,.,,.,. :,,, : 2009/08/19 : 2009/09/09 : 2009/09/30 * 2007 ** *** ( :

27 2, 17-31, , * ** ***,. K 1 2 2,.,,,.,.,.,,.,. :,,, : 2009/08/19 : 2009/09/09 : 2009/09/30 * 2007 ** *** ( : 27 2, 17-31, 2009. -, * ** ***,. K 1 2 2,.,,,.,.,.,,.,. :,,, : 2009/08/19 : 2009/09/09 : 2009/09/30 * 2007 ** *** (: dminkim@cau.ac.kr) 18 한국교육문제연구제 27 권 2 호, 2009. Ⅰ. (,,, 2004). (,, 2006).,,, (Myrick,

More information

Lumbar spine

Lumbar spine Lumbar spine CT 32 111 DOI : 10.3831/KPI.2010.13.2.111 Lumbar Spine CT 32 Received : 10. 05. 23 Revised : 10. 06. 04 Accepted : 10. 06. 11 Key Words: Disc herniation, CT scan, Clinical analysis The Clinical

More information

A Study on the Relationships between Self-Differentiation and Adaptability Factors for Senior Dementia Patients Care Givers Department of Social Welfare, Seoul Welfare Graduate University Full-time Lecturer

More information

- iii - - i - - ii - - iii - 국문요약 종합병원남자간호사가지각하는조직공정성 사회정체성과 조직시민행동과의관계 - iv - - v - - 1 - - 2 - - 3 - - 4 - - 5 - - 6 - - 7 - - 8 - - 9 - - 10 - - 11 - - 12 - - 13 - - 14 - α α α α - 15 - α α α α α α

More information

<C7D1B1B9B1B3C0B0B0B3B9DFBFF85FC7D1B1B9B1B3C0B05F3430B1C733C8A35FC5EBC7D5BABB28C3D6C1BE292DC7A5C1F6C6F7C7D42E687770>

<C7D1B1B9B1B3C0B0B0B3B9DFBFF85FC7D1B1B9B1B3C0B05F3430B1C733C8A35FC5EBC7D5BABB28C3D6C1BE292DC7A5C1F6C6F7C7D42E687770> 기혼 여성이 사이버대학에서 상담을 전공하면서 겪는 경험 방기연 (고려사이버대학교 상담심리학과 부교수) * 요 약 본 연구는 기혼 여성의 사이버대학 상담전공 학과 입학에서 졸업까지의 경험을 이해하는 것을 목적으로 한 다. 이를 위해 연구참여자 10명을 대상으로 심층면접을 하고, 합의적 질적 분석 방법으로 분석하였다. 입학 전 에 연구참여자들은 고등교육의 기회를

More information

서론 34 2

서론 34 2 34 2 Journal of the Korean Society of Health Information and Health Statistics Volume 34, Number 2, 2009, pp. 165 176 165 진은희 A Study on Health related Action Rates of Dietary Guidelines and Pattern of

More information

노인정신의학회보14-1호

노인정신의학회보14-1호 제14권 1호 통권 제23호 www.kagp.or.kr 발행인 : 정인과 / 편집인 : 이동우 / 발행처 : 정인과 (152-703) 서울특별시 구로구 구로동 80번지 고려대학교 구로병원 정신과 / TEL : 02-818-6608 / FAX : 02-852-1937 발행일 : 2008년 4월 30일 / 제 작 : (주)엠엘커뮤니케이션 140-846 서울특별시

More information

Journal of Educational Innovation Research 2016, Vol. 26, No. 3, pp DOI: * Meta Analysis : T

Journal of Educational Innovation Research 2016, Vol. 26, No. 3, pp DOI:   * Meta Analysis : T Journal of Educational Innovation Research 2016, Vol. 26, No. 3, pp.289-314 DOI: http://dx.doi.org/10.21024/pnuedi.26.3.201612.289 * Meta Analysis : Trends and Effects of Art-Therapy with Clay Purpose:

More information

:,,.,. 456, 253 ( 89, 164 ), 203 ( 44, 159 ). Cronbach α= ,.,,..,,,.,. :,, ( )

:,,.,. 456, 253 ( 89, 164 ), 203 ( 44, 159 ). Cronbach α= ,.,,..,,,.,. :,, ( ) :,,.,. 456, 253 ( 89, 164 ), 203 ( 44, 159 ). Cronbach α=.83.91.,.,,..,,,.,. :,, (402-751) 253 E-mail : yspark@inha.ac.kr ..,.,.,. Bandura(1997),.,,,,., (,,, 2009), (,,,, 2014).?.,,,.. Bandura (1995) (Resiliency

More information

Journal of Educational Innovation Research 2017, Vol. 27, No. 1, pp DOI: * The

Journal of Educational Innovation Research 2017, Vol. 27, No. 1, pp DOI:   * The Journal of Educational Innovation Research 2017, Vol. 27, No. 1, pp.243-268 DOI: http://dx.doi.org/10.21024/pnuedi.27.1.201703.243 * - 2001 2015 - The Research Trends on Peer Counseling in Elementary and

More information

Journal of Educational Innovation Research 2016, Vol. 26, No. 2, pp DOI: * The Mediating Eff

Journal of Educational Innovation Research 2016, Vol. 26, No. 2, pp DOI:   * The Mediating Eff Journal of Educational Innovation Research 2016, Vol. 26, No. 2, pp.159-177 DOI: http://dx.doi.org/10.21024/pnuedi.26.2.201608.159 * The Mediating Effects of Self-esteem on the Relationship between Social

More information

A Study on Married Female Immigrants Life Style and Marriage Satisfaction in Terms of Preparing Their Old Age in Chungcheongnam-do Department of Gerontology, Hoseo University Doctoral Student : Hi Ran

More information

Journal of Educational Innovation Research 2019, Vol. 29, No. 2, pp DOI: 3 * Effects of 9th

Journal of Educational Innovation Research 2019, Vol. 29, No. 2, pp DOI:   3 * Effects of 9th Journal of Educational Innovation Research 2019, Vol. 29, No. 2, pp.357-378 DOI: http://dx.doi.org/10.21024/pnuedi.29.2.201906.357 3 * Effects of 9th Grade Students Participation in Career Curriculum Cluster

More information

<5BB0F8B0F8BFECC6ED5D20C3D6C1BEBAB8B0EDBCAD5F3132313628BFCF292E687770>

<5BB0F8B0F8BFECC6ED5D20C3D6C1BEBAB8B0EDBCAD5F3132313628BFCF292E687770> 전국우편지부 노동자의 노동환경과 건강실태 연구보고서 2013년 12월 공공운수노조 전국우편지부 / 한국노동안전보건연구소 사회진보연대 부설 노동자운동연구소 제 출 문 공공운수노조 전국우편지부가 한국노동안전보건연구소와 사회진보연대 부설 노동자운동연구소에 의뢰한 전국우편지부 노동자의 노동환경과 건강실태 연구보고서 의 결과로 본 보고서를 제출합니다. 2013년 12월

More information

DBPIA-NURIMEDIA

DBPIA-NURIMEDIA The e-business Studies Volume 17, Number 4, August, 30, 2016:319~332 Received: 2016/07/28, Accepted: 2016/08/28 Revised: 2016/08/27, Published: 2016/08/30 [ABSTRACT] This paper examined what determina

More information

歯1.PDF

歯1.PDF 200176 .,.,.,. 5... 1/2. /. / 2. . 293.33 (54.32%), 65.54(12.13%), / 53.80(9.96%), 25.60(4.74%), 5.22(0.97%). / 3 S (1997)14.59% (1971) 10%, (1977).5%~11.5%, (1986)

More information

歯5-2-13(전미희외).PDF

歯5-2-13(전미희외).PDF The Korean Journal of Counseling 2004, Vol. 5, No. 2, 423-434,. 4 5 18 9, 9.,,,,,.,,, t-.. :,,, (,, 1996),.,,. (, 2001),... 88 98 2000, 88 12.5%(250 )98 35.6%(712 )2.8 (,,, 2001) (Corresponding Author)

More information

- i - - ii - - iii - - iv - - v - - 1 - - 2 - - 3 - - 4 - - 5 - - 6 - - 7 - - 8 - - 9 - - 10 - - 11 - - 12 - - 13 - - 14 - - 15 - - 16 - - 17 - - 18 - - 19 - α α - 20 - α α α α α α - 21 - - 22 - - 23 -

More information

139~144 ¿À°ø¾àħ

139~144 ¿À°ø¾àħ 2 139 DOI : 10.3831/KPI.2010.13.2.139 2 Received : 10. 04. 08 Revised : 10. 04. 26 Two Case Report on Wrist Ganglion Treated with Scolopendrid Pharmacopuncture Accepted : 10. 05. 04 Key Words: Wrist Ganglion,

More information

한국성인에서초기황반변성질환과 연관된위험요인연구

한국성인에서초기황반변성질환과 연관된위험요인연구 한국성인에서초기황반변성질환과 연관된위험요인연구 한국성인에서초기황반변성질환과 연관된위험요인연구 - - i - - i - - ii - - iii - - iv - χ - v - - vi - - 1 - - 2 - - 3 - - 4 - 그림 1. 연구대상자선정도표 - 5 - - 6 - - 7 - - 8 - 그림 2. 연구의틀 χ - 9 - - 10 - - 11 -

More information

,......

,...... The Impact of Personal Traits, Family Characteristics, and Job Satisfaction on the Psychological Well-Being of Middle Aged Men from the Baby Boomer Generation Working in Large Corporations Department of

More information

<283732372D3733312920B4D9C3CAC1A120BCD2C7C1C6AEC4DCC5C3C6AEB7BBC1EEC0C720B3EBBEC8C0C720BDC3B7C2BAB8C1A4BFA120B4EBC7D120C0AFBFEBBCBA20C6F2B0A1283035292E687770>

<283732372D3733312920B4D9C3CAC1A120BCD2C7C1C6AEC4DCC5C3C6AEB7BBC1EEC0C720B3EBBEC8C0C720BDC3B7C2BAB8C1A4BFA120B4EBC7D120C0AFBFEBBCBA20C6F2B0A1283035292E687770> 대한안과학회지 제 49 권 제 5 호 2008 J Korean Ophthalmol Soc 49(5):727-731, 2008 DOI : 10.3341/jkos.2008.49.5.727 다초점 소프트콘택트렌즈의 노안의 시력보정에 대한 유용성 평가 김현경 1 김효명 2 정성근 1 가톨릭대학교 의과대학 성모병원 안과학교실 1, 고려대학교 의과대학 안암병원 안과학교실

More information

상담학연구 , , ,, ( ),.,., 15 19,, 30, (Corresponding Author): / Tel: /

상담학연구 , , ,, ( ),.,., 15 19,, 30, (Corresponding Author): / Tel: / . 2000 2015 30.., 30 100, 0.949.,, ( ),.,., 15 19,, 30, 2 3.. (Corresponding Author): / Tel: 054-284-3474 / E-mail: kikiki-2@daum.net (, 2009)... (Peterson & Seligman, 2004), (, 2011). Fitzgerald(1998),,,,,

More information

Journal of Educational Innovation Research 2018, Vol. 28, No. 3, pp DOI: The Effect of Caree

Journal of Educational Innovation Research 2018, Vol. 28, No. 3, pp DOI:   The Effect of Caree Journal of Educational Innovation Research 2018, Vol. 28, No. 3, pp.325-349 DOI: http://dx.doi.org/10.21024/pnuedi.28.3.201809.325 The Effect of Career Preparation Behavior Before and After Major Transitions

More information

- 최원희ㆍ 김명희: 중년후기 여성의 집단회상 경험과 효과에 대한 연구 - 에 직면하며 심리 사회적인 역할갈등, 고립, 위축, 상실 감 등을 경험하게 된다. 이 시기동안 위기에 잘 대처하 지 못하면 자신에 대하여 실망하며 두려움과 슬픔 등 을 겪으면서 자아존중감이 낮아

- 최원희ㆍ 김명희: 중년후기 여성의 집단회상 경험과 효과에 대한 연구 - 에 직면하며 심리 사회적인 역할갈등, 고립, 위축, 상실 감 등을 경험하게 된다. 이 시기동안 위기에 잘 대처하 지 못하면 자신에 대하여 실망하며 두려움과 슬픔 등 을 겪으면서 자아존중감이 낮아 한국모자보건학회지 제15권 제1 호(2011년 1 월) J Korean Soc Matern Child Health 2011;15(1):48-59 E 1) 중년후기 여성의 집단회상 경험과 효과에 대한 연구 최 원 희ㆍ김 명 희 1 경남대학교 간호학과, 부산대학교 간호대학 1 = Abstract = The Experience and Effects of Group

More information

Kor. J. Aesthet. Cosmetol., 및 자아존중감과 스트레스와도 밀접한 관계가 있고, 만족 정도 에 따라 전반적인 생활에도 영향을 미치므로 신체는 갈수록 개 인적, 사회적 차원에서 중요해지고 있다(안희진, 2010). 따라서 외모만족도는 개인의 신체는 타

Kor. J. Aesthet. Cosmetol., 및 자아존중감과 스트레스와도 밀접한 관계가 있고, 만족 정도 에 따라 전반적인 생활에도 영향을 미치므로 신체는 갈수록 개 인적, 사회적 차원에서 중요해지고 있다(안희진, 2010). 따라서 외모만족도는 개인의 신체는 타 RESEARCH ARTICLE Kor. J. Aesthet. Cosmetol., 20-40대 여성의 외모만족도가 미용관리태도에 미치는 영향 홍수남 1, 김효숙 2 * 1 건국대학교 뷰티사이언스디자인학과, 2 건국대학교 의상디자인과 Effects of Extrinsic Body Satisfaction on Beauty Management Behavior of

More information

1..

1.. Volume 12, Number 1, 6~16, Factors influencing consultation time and waiting time of ambulatory patients in a tertiary teaching hospital Jee-In Hwang College of Nursing Science, Kyung Hee University :

More information

- i - - ii - - iii - - iv - - v - - vi - - 1 - - 2 - - 3 - 1) 통계청고시제 2010-150 호 (2010.7.6 개정, 2011.1.1 시행 ) - 4 - 요양급여의적용기준및방법에관한세부사항에따른골밀도검사기준 (2007 년 11 월 1 일시행 ) - 5 - - 6 - - 7 - - 8 - - 9 - - 10 -

More information

(Exposure) Exposure (Exposure Assesment) EMF Unknown to mechanism Health Effect (Effect) Unknown to mechanism Behavior pattern (Micro- Environment) Re

(Exposure) Exposure (Exposure Assesment) EMF Unknown to mechanism Health Effect (Effect) Unknown to mechanism Behavior pattern (Micro- Environment) Re EMF Health Effect 2003 10 20 21-29 2-10 - - ( ) area spot measurement - - 1 (Exposure) Exposure (Exposure Assesment) EMF Unknown to mechanism Health Effect (Effect) Unknown to mechanism Behavior pattern

More information

386-390.hwp

386-390.hwp 386 HANYANG MEDICAL REVIEWS Vol. 29 No. 4, 2009 우리나라 미숙아의 통계와 의료비용 Statistics and Medical Cost of Preterm in Korea 윤혜선 을지대학교 노원을지병원 소아청소년과학교실 Hye Sun Yoon, M.D., Ph.D., Department of Pediatrics, Nowon

More information

DBPIA-NURIMEDIA

DBPIA-NURIMEDIA The e-business Studies Volume 17, Number 6, December, 30, 2016:3~20 Received: 2016/12/04, Accepted: 2016/12/27 Revised: 2016/12/27, Published: 2016/12/30 [ABSTRACT] This study aims to comprehensively analyze

More information

A 617

A 617 Special Issue Diabetic Retinopathy Won Ki Lee, M.D. Department of Ophthalmology The Catholic University of Korea College of Medicine Kangnam St. Mary s Hospital E mail : wklee@catholic.ac.kr Abstract R

More information

DBPIA-NURIMEDIA

DBPIA-NURIMEDIA The e-business Studies Volume 17, Number 6, December, 30, 2016:237~251 Received: 2016/11/20, Accepted: 2016/12/24 Revised: 2016/12/21, Published: 2016/12/30 [ABSTRACT] Recently, there is an increasing

More information

Journal of Educational Innovation Research 2017, Vol. 27, No. 2, pp DOI: * Review of Research

Journal of Educational Innovation Research 2017, Vol. 27, No. 2, pp DOI:   * Review of Research Journal of Educational Innovation Research 2017, Vol. 27, No. 2, pp.79-102 DOI: http://dx.doi.org/10.21024/pnuedi.27.2.201706.79 * Review of Research Trends on Curriculum for Students with Severe and multiple

More information

878 Yu Kim, Dongjae Kim 지막 용량수준까지도 멈춤 규칙이 만족되지 않아 시행이 종료되지 않는 경우에는 MTD의 추정이 불가 능하다는 단점이 있다. 최근 이 SM방법의 단점을 보완하기 위해 O Quigley 등 (1990)이 제안한 CRM(Continu

878 Yu Kim, Dongjae Kim 지막 용량수준까지도 멈춤 규칙이 만족되지 않아 시행이 종료되지 않는 경우에는 MTD의 추정이 불가 능하다는 단점이 있다. 최근 이 SM방법의 단점을 보완하기 위해 O Quigley 등 (1990)이 제안한 CRM(Continu 한 국 통 계 학 회 논 문 집 2012, 19권, 6호, 877 884 DOI: http://dx.doi.org/10.5351/ckss.2012.19.6.877 Maximum Tolerated Dose Estimation Applied Biased Coin Design in a Phase Ⅰ Clinical Trial Yu Kim a, Dongjae Kim

More information

Journal of Educational Innovation Research 2018, Vol. 28, No. 4, pp DOI: * A Research Trend

Journal of Educational Innovation Research 2018, Vol. 28, No. 4, pp DOI:   * A Research Trend Journal of Educational Innovation Research 2018, Vol. 28, No. 4, pp.295-318 DOI: http://dx.doi.org/10.21024/pnuedi.28.4.201812.295 * A Research Trend on the Studies related to Parents of Adults with Disabilities

More information

기관고유연구사업결과보고

기관고유연구사업결과보고 기관고유연구사업결과보고 작성요령 2001 ~ 2004 2005 ~ 2007 2008 ~ 2010 2001 ~ 2004 2005 ~ 2007 2008 ~ 2010 1 2/3 2 1 0 2 3 52 0 31 83 12 6 3 21 593 404 304 1,301 4 3 1 8 159 191 116 466 6 11 (`1: (1: 16 33 44 106

More information

Journal of Educational Innovation Research 2018, Vol. 28, No. 1, pp DOI: * A Analysis of

Journal of Educational Innovation Research 2018, Vol. 28, No. 1, pp DOI: * A Analysis of Journal of Educational Innovation Research 2018, Vol. 28, No. 1, pp.99-117 DOI: http://dx.doi.org/10.21024/pnuedi.28.1.201803.99 2015 * A Analysis of the Characters and Issues about the 2015 Revised Social

More information

Journal of Educational Innovation Research 2018, Vol. 28, No. 4, pp DOI: 3 * The Effect of H

Journal of Educational Innovation Research 2018, Vol. 28, No. 4, pp DOI:   3 * The Effect of H Journal of Educational Innovation Research 2018, Vol. 28, No. 4, pp.577-601 DOI: http://dx.doi.org/10.21024/pnuedi.28.4.201812.577 3 * The Effect of Home-based Activities Using Traditional Fairy Tales

More information

???? 1

???? 1 The Korean Journal of Applied Statistics (2014) 27(1), 13 20 DOI: http://dx.doi.org/10.5351/kjas.2014.27.1.013 Maximum Tolerated Dose Estimation by Stopping Rule and SM3 Design in a Phase I Clinical Trial

More information

03-서연옥.hwp

03-서연옥.hwp 농업생명과학연구 49(4) pp.31-37 Journal of Agriculture & Life Science 49(4) pp.31-37 Print ISSN 1598-5504 Online ISSN 2383-8272 http://dx.doi.org/10.14397/jals.2015.49.4.31 국가산림자원조사 자료를 적용한 충남지역 사유림경영율 추정 서연옥

More information

untitled

untitled Original Article Experiences of Unwed Mothers Choi, Yang-Ja 1) Kim, Kwuy-Bun 2) 1) Professor, Redcross College of Nursing, 2) Professor, Kyung Hee University, College of Nursing Science 1) 2) 1) 2) Purpose:

More information

조사연구 권 호 연구논문 한국노동패널조사자료의분석을위한패널가중치산출및사용방안사례연구 A Case Study on Construction and Use of Longitudinal Weights for Korea Labor Income Panel Survey 2)3) a

조사연구 권 호 연구논문 한국노동패널조사자료의분석을위한패널가중치산출및사용방안사례연구 A Case Study on Construction and Use of Longitudinal Weights for Korea Labor Income Panel Survey 2)3) a 조사연구 권 호 연구논문 한국노동패널조사자료의분석을위한패널가중치산출및사용방안사례연구 A Case Study on Construction and Use of Longitudinal Weights for Korea Labor Income Panel Survey 2)3) a) b) 조사연구 주제어 패널조사 횡단면가중치 종단면가중치 선형혼합모형 일반화선형혼 합모형

More information

.,,,,,,.,,,,.,,,,,, (, 2011)..,,, (, 2009)., (, 2000;, 1993;,,, 1994;, 1995), () 65, 4 51, (,, ). 33, 4 30, (, 201

.,,,,,,.,,,,.,,,,,, (, 2011)..,,, (, 2009)., (, 2000;, 1993;,,, 1994;, 1995), () 65, 4 51, (,, ). 33, 4 30, (, 201 4 21.,,,.,,. 1, 2, 3, 4.,,,,,,.,,,,., ( ). 60-66,,,,,.. (Corresponding Author): / / 303 Tel: 063-220-2495/ E-mail: ikkim@jj.ac.kr .,,,,,,.,,,,.,,,,,, (, 2011)..,,, (, 2009)., (, 2000;, 1993;,,, 1994;,

More information

상담학연구,, SPSS 21.0., t,.,,,..,.,.. (Corresponding Author): / / / Tel: /

상담학연구,, SPSS 21.0., t,.,,,..,.,.. (Corresponding Author): / / / Tel: / ,,. 164 -. SPSS 21.0., t,.,,,..,.,.. (Corresponding Author): / / 1 11 404 / Tel: 02-880-7636 / E-mail: dikimedu@snu.ac.kr ...,,, (, 2012),, (,,, 2012a, 2012b;,, 2011;, 2011;,, 2010). (, 2013;, 2012;, ;

More information

Kor. J. Aesthet. Cosmetol., 라이프스타일은 개인 생활에 있어 심리적 문화적 사회적 모든 측면의 생활방식과 차이 전체를 말한다. 이러한 라이프스 타일은 사람의 내재된 가치관이나 욕구, 행동 변화를 파악하여 소비행동과 심리를 추측할 수 있고, 개인의

Kor. J. Aesthet. Cosmetol., 라이프스타일은 개인 생활에 있어 심리적 문화적 사회적 모든 측면의 생활방식과 차이 전체를 말한다. 이러한 라이프스 타일은 사람의 내재된 가치관이나 욕구, 행동 변화를 파악하여 소비행동과 심리를 추측할 수 있고, 개인의 RESEARCH ARTICLE Kor. J. Aesthet. Cosmetol., 한국 중년 여성의 라이프스타일이 메이크업 추구이미지와 화장품 구매행동에 미치는 영향 주영주 1 *, 이순희 2 1 서경대학교대학원미용예술학과, 2 신성대학교 미용예술계열 The Effects of The Life Style for Korean Middle Aged Women on

More information

노인의학200303.PDF

노인의학200303.PDF Assisted Living 9,, ( ) ( ) 1. 6) 2. 5. 3. 1) 4. 2) 1) 6. : 2) 1) 3) 2) 4) 3) 5) 4) (1998) 21 2025 80 73.,. 1980..?,,.,.,, 130 ,,.,.,,,. (managed care),,,.,.,,,.,,,,.,.,,,,,.,..,. 131 1. 2010 - -,,,,,...,

More information

DBPIA-NURIMEDIA

DBPIA-NURIMEDIA e- 비즈니스연구 (The e-business Studies) Volume 17, Number 1, February, 28, 2016:pp. 293~316 ISSN 1229-9936 (Print), ISSN 2466-1716 (Online) 원고접수일심사 ( 수정 ) 게재확정일 2015. 12. 04 2015. 12. 24 2016. 02. 25 ABSTRACT

More information

Journal of Educational Innovation Research 2018, Vol. 28, No. 1, pp DOI: * A Study on the Pe

Journal of Educational Innovation Research 2018, Vol. 28, No. 1, pp DOI:   * A Study on the Pe Journal of Educational Innovation Research 2018, Vol. 28, No. 1, pp.405-425 DOI: http://dx.doi.org/10.21024/pnuedi.28.1.201803.405 * A Study on the Perceptions and Factors of Immigrant Background Youth

More information

Journal of Educational Innovation Research 2018, Vol. 28, No. 2, pp DOI: IPA * Analysis of Perc

Journal of Educational Innovation Research 2018, Vol. 28, No. 2, pp DOI:   IPA * Analysis of Perc Journal of Educational Innovation Research 2018, Vol. 28, No. 2, pp.45-72 DOI: http://dx.doi.org/10.21024/pnuedi.28.2.201806.45 IPA * Analysis of Perception and Needs on Teaching Competencies of Faculty

More information

Ⅲ Ⅲ Ⅰ Ⅰ Ⅰ α < < < < < χ χ Ⅰ Ⅱ Ⅲ Ⅰ Ⅲ Ⅰ Bagozzi, R., & Dholakia, U. (2002). Intentional Social Action in Virtual Communities. Journal of Interactive Marketing, 16(2), 2-21. Borkovec, T. D. (1976).

More information

,,,.,,,, (, 2013).,.,, (,, 2011). (, 2007;, 2008), (, 2005;,, 2007).,, (,, 2010;, 2010), (2012),,,.. (, 2011:,, 2012). (2007) 26%., (,,, 2011;, 2006;

,,,.,,,, (, 2013).,.,, (,, 2011). (, 2007;, 2008), (, 2005;,, 2007).,, (,, 2010;, 2010), (2012),,,.. (, 2011:,, 2012). (2007) 26%., (,,, 2011;, 2006; ,,.. 400,,,,,,.,,, -, -, -., 3.. :, Tel : 010-9540-0640, E-mail : sunney05@hanmail.net ,,,.,,,, (, 2013).,.,, (,, 2011). (, 2007;, 2008), (, 2005;,, 2007).,, (,, 2010;, 2010), (2012),,,.. (, 2011:,, 2012).

More information

-07-......

-07-...... A Depth Interview on Qualification, Role, and Professionalism of Infant/Toddler Teachers Department of Child & Family Studies, Kyung Hee University Associate Professor : Ahn, Sun Hee Department of Early

More information

Effects of baseball expertise and stimulus speeds on coincidence-anticipation timing accuracy of batting Jong-Hwa Lee, Seok-Jin Kim, & Seon-Jin Kim* Seoul National University [Purpose] [Methods] [Results]

More information

Àå¾Ö¿Í°í¿ë ³»Áö

Àå¾Ö¿Í°í¿ë ³»Áö Disability & Employment 55 Disability & Employment 56 57 Disability & Employment 58 59 Disability & Employment 60 61 Disability & Employment 62 63 Disability & Employment 64 65 Disability & Employment

More information

Abstract Background : Most hospitalized children will experience physical pain as well as psychological distress. Painful procedure can increase anxie

Abstract Background : Most hospitalized children will experience physical pain as well as psychological distress. Painful procedure can increase anxie Volume 12, Number 1, 92~102, An Intervention Study of Pain Reduction during IV Therapy in Hospitalized Children Myo-Jin Kim 1), Joung-Hae Bak 1), Won-Seok Seo 2) Mi-Young Kim 3), Sun-Kyoung Park 3), Jai-Soung

More information

<30312DC1A4BAB8C5EBBDC5C7E0C1A4B9D7C1A4C3A52DC1A4BFB5C3B62E687770>

<30312DC1A4BAB8C5EBBDC5C7E0C1A4B9D7C1A4C3A52DC1A4BFB5C3B62E687770> Journal of the Korea Institute of Information and Communication Engineering 한국정보통신학회논문지(J. Korea Inst. Inf. Commun. Eng.) Vol. 19, No. 2 : 258~264 Feb. 2015 ID3 알고리즘 기반의 귀납적 추론을 활용한 모바일 OS의 성공과 실패에 대한

More information

DBPIA-NURIMEDIA

DBPIA-NURIMEDIA The e-business Studies Volume 17, Number 6, December, 30, 2016:275~289 Received: 2016/12/02, Accepted: 2016/12/22 Revised: 2016/12/20, Published: 2016/12/30 [ABSTRACT] SNS is used in various fields. Although

More information

Jkcs022(89-113).hwp

Jkcs022(89-113).hwp 대한배뇨장애 및 요실금 학회지 J. Korean Continence Society 2004;8:89-113 Bristol Female Lower Urinary Tract Symptom 설문지의 한국어 번역 및 번역본의 언어 타당도 Seung-June Oh*, Hyung Geun Park*, Sung Hyun Paick, Won Hee Park and Myung-Soo

More information

특수교육논총 * ,,,,..,..,, 76.7%.,,,.,,.. * 1. **

특수교육논총 * ,,,,..,..,, 76.7%.,,,.,,.. * 1. ** 특수교육논총 *. 257..,,,,..,..,, 76.7%.,,,.,,.. * 1. ** (eun67@dankook.ac.kr) .,,,,,,,,,, (,, 2014)., (,, 2007)....,,,, (,, 2014).. (2003)...,,, (Baron-Cohen, O Riordan, Stone, Jone, & Plaisted, 1999; Hobson,

More information

54 한국교육문제연구제 27 권 2 호, I. 1.,,,,,,, (, 1998). 14.2% 16.2% (, ), OECD (, ) % (, )., 2, 3. 3

54 한국교육문제연구제 27 권 2 호, I. 1.,,,,,,, (, 1998). 14.2% 16.2% (, ), OECD (, ) % (, )., 2, 3. 3 27 2, 53-70, 2009. (Nursing Home) * ** (Nursing Home). 5 50 5 2 1,,,,, SPSS t.,,,,,,,. :,, : 2009/08/27 : 2009/09/24 : 2009/09/30 * ** (: hjkim@daelim.ac.kr) 54 한국교육문제연구제 27 권 2 호, 2009. I. 1.,,,,,,, (,

More information

γ

γ 경락경혈학회지 Vol.27, No.1, pp.87 106, 2010 Journal of Meridian & Acupoint Dept. of 1 Meridian & Acupoint, 3 Acupuncture & Moxibustion, College of Oriental Medicine, Daejeon University 2 Division of Clinical

More information

27 2, * ** 3, 3,. B ,.,,,. 3,.,,,,..,. :,, : 2009/09/03 : 2009/09/21 : 2009/09/30 * ICAD (Institute for Children Ability

27 2, * ** 3, 3,. B ,.,,,. 3,.,,,,..,. :,, : 2009/09/03 : 2009/09/21 : 2009/09/30 * ICAD (Institute for Children Ability 27 2, 71-90. 2009. 3 * ** 3, 3,. B 2003 4 2004 2.,.,,,. 3,.,,,,..,. :,, : 2009/09/03 : 2009/09/21 : 2009/09/30 * ICAD (Institute for Children Ability Development) ** ( : heyjun@gmail.com) 72 한국교육문제연구제

More information

(01) hwp

(01) hwp Journal of Life Science 2013 Vol. 23. No. 2. 157~166 ISSN (Print) 1225-9918 ISSN (Online) 2287-3406 DOI : http://dx.doi.org/10.5352/jls.2013.23.2.157 α μ δ κ 158 생명과학회지 2013, Vol. 23. No. 2 Journal of

More information

서론

서론 - i - - ii - - iii - - iv - - v - - vi - - 1 - - 2 - - 3 - - 4 - - 5 - - 6 - - 7 - - 8 - - 9 - - 10 - - 11 - - 12 - - 13 - - 14 - - 15 - - 16 - - 17 - - 18 - - 19 - - 20 - - 21 - - 22 - - 23 - - 24 - -

More information

상담학연구. 10,,., (CQR).,,,,,,.,,.,,,,. (Corresponding Author): / / 567 Tel: /

상담학연구. 10,,., (CQR).,,,,,,.,,.,,,,. (Corresponding Author): / / 567 Tel: / . 10,,., (CQR).,,,,,,.,,.,,,,. (Corresponding Author): / / 567 Tel: 063-270-2746 / E-mail : tgeunmi@jbnu.ac.kr . 2,... 2011 (, 2011), (, 2010),., (, 2004;, 2011). (,, 2006), (,, 2005; Yalom & Leszcz, 2005:

More information

., (, 2000;, 1993;,,, 1994), () 65, 4 51, (,, ). 33, 4 30, 23 3 (, ) () () 25, (),,,, (,,, 2015b). 1 5,

., (, 2000;, 1993;,,, 1994), () 65, 4 51, (,, ). 33, 4 30, 23 3 (, ) () () 25, (),,,, (,,, 2015b). 1 5, * 4.,, 3,,, 3,, -., 3, 12, 27, 20. 9,,,,,,,,. 6,,,,,. 5,,,,.. * (2016),. (Corresponding Author): / / 303 Tel: 063-225-4496 / E-mail: jnj1015@jj.ac.kr ., (, 2000;, 1993;,,, 1994), 2000. 2015 () 65, 4 51,

More information

( )Kju269.hwp

( )Kju269.hwp 만성세균성전립선염모델흰쥐에서 의항염효과 Anti-inflammatory Effect of Lycopene on Chronic Bacterial Prostatitis Rat Model Cho Hwan Yang, Dong Wan Sohn, Yong-Hyun Cho From the Department of Urology, The Catholic University

More information

untitled

untitled 대한마취과학회지 2008; 55: 190~6 Korean J Anesthesiol Vol. 55, No. 2, August, 2008 임상연구 대한민국의 마취통증의학 임상실습 현황 연세대학교 의과대학 마취통증의학교실 및 마취통증의학연구소 장동진ㆍ안소운ㆍ안지원ㆍ김종훈 The current status of anesthesiology clerkship in Korea

More information

Journal of Educational Innovation Research 2017, Vol. 27, No. 2, pp DOI: : Researc

Journal of Educational Innovation Research 2017, Vol. 27, No. 2, pp DOI:   : Researc Journal of Educational Innovation Research 2017, Vol. 27, No. 2, pp.251-273 DOI: http://dx.doi.org/10.21024/pnuedi.27.2.201706.251 : 1997 2005 Research Trend Analysis on the Korean Alternative Education

More information

12이문규

12이문규 Review on Conservative Treatment of Spinal Scoliosis Moon-kyu Lee, O.M.D., Gil-jae Lee, O.M.D., Yun-kyung Song, O.M.D., Hyung-ho Lim, O.M.D. Dept. of Oriental Rehabilitation Medicine College of Oriental

More information

상담학연구. 9., , 21..,,,,,,... (Corresponding Author): / / 154 Tel: /

상담학연구. 9., , 21..,,,,,,... (Corresponding Author): / / 154 Tel: / . 9., 235 69, 21..,,,,,,... (Corresponding Author): / / 154 Tel: 070-8620-3314 / E-mail: moonylmh@hanmail.net , (,,, ).,.. (Huppert et al., 2001; Luborsky, McLellan, Diguer, Woody, & Seligman, 1997; Crits-Christoph

More information

Journal of Educational Innovation Research 2017, Vol. 27, No. 4, pp DOI: * A Study on Teache

Journal of Educational Innovation Research 2017, Vol. 27, No. 4, pp DOI:   * A Study on Teache Journal of Educational Innovation Research 2017, Vol. 27, No. 4, pp.149-171 DOI: http://dx.doi.org/10.21024/pnuedi.27.4.201712.149 * A Study on Teachers and Parents Perceptions on the Introduction of Innovational

More information

278 경찰학연구제 12 권제 3 호 ( 통권제 31 호 )

278 경찰학연구제 12 권제 3 호 ( 통권제 31 호 ) 여성경찰관의직업윤리의식결정요인분석 * An Analysis of Determinantal Factors Influencing Professional Ethical Standards of South Korean Police Women 신문희 ** 이영민 *** Ⅰ. 서론 Ⅱ. 이론적배경 Ⅲ. 연구방법 Ⅳ. 연구결과 Ⅴ. 결론 Ⅰ. 서론 278 경찰학연구제 12

More information

-06-......,......

-06-......,...... Analysis of the Current Condition of Student Childcare Training in Korea: Student Childcare Training Centers, Guidance Teachers, Student Teachers and Student Childcare Training Fees Department of Childcare

More information

04조남훈

04조남훈 Received : 2011. 11. 16 Reviewed : 2011. 11. 25 Accpeted : 2011. 12. 5 A Case Report of Prescribing Yanghyeolgeopung-tang(yangxuequfeng-tang) to Two Patients with Cervical Disc Herniation and Headache

More information

Journal of Educational Innovation Research 2019, Vol. 29, No. 2, pp DOI: * The Effect of Paren

Journal of Educational Innovation Research 2019, Vol. 29, No. 2, pp DOI:   * The Effect of Paren Journal of Educational Innovation Research 2019, Vol. 29, No. 2, pp.95-116 DOI: http://dx.doi.org/10.21024/pnuedi.29.2.201906.95 * The Effect of Parent Education Program Using Action Learning on Family

More information

44-4대지.07이영희532~

44-4대지.07이영희532~ A Spatial Location Analysis of the First Shops of Foodservice Franchise in Seoul Metropolitan City Younghee Lee* 1 1 (R) 0 16 1 15 64 1 Abstract The foodservice franchise is preferred by the founders who

More information

http://www.kbc.go.kr/pds/2.html Abstract Exploring the Relationship Between the Traditional Media Use and the Internet Use Mee-Eun Kang This study examines the relationship between

More information

A Problem for Government STAGE 6: Policy Termination STAGE 1: Agenda Setting STAGE 5: Policy Change STAGE 2: Policy Formulation STAGE 4: Policy Evalua

A Problem for Government STAGE 6: Policy Termination STAGE 1: Agenda Setting STAGE 5: Policy Change STAGE 2: Policy Formulation STAGE 4: Policy Evalua A Problem for Government STAGE 6: Policy Termination STAGE 1: Agenda Setting STAGE 5: Policy Change STAGE 2: Policy Formulation STAGE 4: Policy Evaluation STAGE 3: Policy Implementation 6 Monitor Policy

More information

Analysis of teacher s perception and organization on physical education elective courses Chang-Wan Yu* Korea Institute of curriculum and evaluation [Purpose] [Methods] [Results] [Conclusions] Key words:

More information

THE JOURNAL OF KOREAN INSTITUTE OF ELECTROMAGNETIC ENGINEERING AND SCIENCE. vol. 29, no. 10, Oct ,,. 0.5 %.., cm mm FR4 (ε r =4.4)

THE JOURNAL OF KOREAN INSTITUTE OF ELECTROMAGNETIC ENGINEERING AND SCIENCE. vol. 29, no. 10, Oct ,,. 0.5 %.., cm mm FR4 (ε r =4.4) THE JOURNAL OF KOREAN INSTITUTE OF ELECTROMAGNETIC ENGINEERING AND SCIENCE. 2018 Oct.; 29(10), 799 804. http://dx.doi.org/10.5515/kjkiees.2018.29.10.799 ISSN 1226-3133 (Print) ISSN 2288-226X (Online) Method

More information

Journal of Educational Innovation Research 2018, Vol. 28, No. 3, pp DOI: * Strenghening the Cap

Journal of Educational Innovation Research 2018, Vol. 28, No. 3, pp DOI:   * Strenghening the Cap Journal of Educational Innovation Research 2018, Vol. 28, No. 3, pp.27-43 DOI: http://dx.doi.org/10.21024/pnuedi.28.3.201809.27 * Strenghening the Capacity of Cultural Arts Required in Special Education

More information

27 2, 1-16, * **,,,,. KS,,,., PC,.,,.,,. :,,, : 2009/08/12 : 2009/09/03 : 2009/09/30 * ** ( :

27 2, 1-16, * **,,,,. KS,,,., PC,.,,.,,. :,,, : 2009/08/12 : 2009/09/03 : 2009/09/30 * ** ( : 27 2, 1-16, 2009. * **,,,,. KS,,,., PC,.,,.,,. :,,, : 2009/08/12 : 2009/09/03 : 2009/09/30 * ** (: jjhkim@cau.ac.kr) 2 한국교육문제연구제 27 권 2 호, 2009 Ⅰ.,. 2008 3,536, 10 99.9% (, 2008). PC,, (, 2007). (, 2008),.,

More information

16(1)-3(국문)(p.40-45).fm

16(1)-3(국문)(p.40-45).fm w wz 16«1y Kor. J. Clin. Pharm., Vol. 16, No. 1. 2006 x w$btf3fqpsu'psn û w m w Department of Statistics, Chonnam National University Eunsik Park College of Natural Sciences, Chonnam National University

More information

차 례... 박영목 **.,... * **.,., ,,,.,,

차 례... 박영목 **.,... * **.,., ,,,.,, 차 례... 박영목 **.,... * 2010. **.,.,.... 1980.,,,.,,. 1980.. .... (Bereiter Scardamalia, 1987).. Hayes Flower(1980),,,..,,.....,,,... Hayes Flower 1980, Hayes 1996, Kellogg 1996, Hayes 2012. Hayes Flower

More information

Analysis of objective and error source of ski technical championship Jin Su Seok 1, Seoung ki Kang 1 *, Jae Hyung Lee 1, & Won Il Son 2 1 yong in Univ

Analysis of objective and error source of ski technical championship Jin Su Seok 1, Seoung ki Kang 1 *, Jae Hyung Lee 1, & Won Il Son 2 1 yong in Univ Analysis of objective and error source of ski technical championship Jin Su Seok 1, Seoung ki Kang 1 *, Jae Hyung Lee 1, & Won Il Son 2 1 yong in University & 2 Kang Won University [Purpose] [Methods]

More information

Abstract Musculoskeletal Symptoms and Related Factors for Nurses and Radiological Technologists Wearing a Lead Apron for Radiation Pro t e c t i o n Jung-Im Yoo, Jung-Wan Koo 1 ) Angio Unit, Team of Radiology,

More information

조사연구 aim of this study is to find main cause of the forecasting error and bias of telephone survey. We use the telephone survey paradata released by N

조사연구 aim of this study is to find main cause of the forecasting error and bias of telephone survey. We use the telephone survey paradata released by N 조사연구 권 호 DOI http://dx.doi.org/10.20997/sr.17.3.5 연구노트 2016 년국회의원선거전화여론조사정확성분석 Analysis of Accuracy of Telephone Survey for the 2016 National Assembly Elections 1)2) a) b) 주제어 선거여론조사 전화조사 예측오차 편향 대국회의원선거

More information

황지웅

황지웅 Comparison of Laparoscopy and Exploration in the Distal Pancreatectomy BACKGROUND: To determine the benefits of laparoscopic surgery compared with exploration, the clinical outcomes of open and laparoscopic

More information

<30392EB9DAB0A1B6F72CC1A4B3B2BFEE2E687770>

<30392EB9DAB0A1B6F72CC1A4B3B2BFEE2E687770> 한국심리학회지 : 상담 및 심리치료 The Korean Journal of Counseling and Psychotherapy 2008, Vol. 20 No. 1, 161-182 성폭력 상담에서 내담자들이 지각한 도움경험(Helpful Experience): 질적 분석 * 박 가 람 정 남 운 가톨릭대학교 본 연구는 성폭력 상담에서 내담자들이 지각하는 도움경험과

More information

(5차 편집).hwp

(5차 편집).hwp (215), 54(1), 17-3 211 STEAM,.. STEAM, STEAM, 5~6 11.,., 5~6...,. (, 21)., 29. (,, 212). 211 STEAM * :, E-mail: njkwon@hanmail.net http://dx.doi.org/1.15812/ter.54.1.2153.17 (215), 54(1), 17-3,. (Arts)

More information

歯14.양돈규.hwp

歯14.양돈규.hwp : The Korean Journal of Counseling and Psychotherapy 2003. Vol. 15, No. 3, 615-631. 1 2 3 1,410.,, ( ),., ( 69%),.,, ( ), ( ).,,.., ( ).,. :,,. :, (390-711) 21-1, : 043-649-1362 E-mail : ydk9498@hanmail.net

More information

달생산이 초산모 분만시간에 미치는 영향 Ⅰ. 서 론 Ⅱ. 연구대상 및 방법 達 은 23) 의 丹 溪 에 최초로 기 재된 처방으로, 에 복용하면 한 다하여 난산의 예방과 및, 등에 널리 활용되어 왔다. 達 은 이 毒 하고 는 甘 苦 하여 氣, 氣 寬,, 結 의 효능이 있

달생산이 초산모 분만시간에 미치는 영향 Ⅰ. 서 론 Ⅱ. 연구대상 및 방법 達 은 23) 의 丹 溪 에 최초로 기 재된 처방으로, 에 복용하면 한 다하여 난산의 예방과 및, 등에 널리 활용되어 왔다. 達 은 이 毒 하고 는 甘 苦 하여 氣, 氣 寬,, 結 의 효능이 있 대한한방부인과학회지 THE JOURNAL OF ORIENTAL OBSTETRICS & GYNECOLOGY VOL.17, NO.2 : 115-122 (2004) 달생산이 초산모 분만시간에 미치는 영향 * 북경한의원, ** 윤산부인과의원, *** 최은림산부인과의원, 상지대학교 한의과대학 부인과학교실 ****, 경희대학교 동서의학대학원 김성준 *****, 윤왕준

More information

歯제7권1호(최종편집).PDF

歯제7권1호(최종편집).PDF ********* (*, **, *** ).., 2002, 7, 1, 1-12. 2-5 80.,.,..,,... :,,. (naming).., (word finding), (lexical look- up), (lexical retrieval), (word recall) (Fried- Oken, 1987). (pause),,, (naming error) (Snyder

More information

Analyses the Contents of Points per a Game and the Difference among Weight Categories after the Revision of Greco-Roman Style Wrestling Rules Han-bong

Analyses the Contents of Points per a Game and the Difference among Weight Categories after the Revision of Greco-Roman Style Wrestling Rules Han-bong Analyses the Contents of Points per a Game and the Difference among Weight Categories after the Revision of Greco-Roman Style Wrestling Rules Han-bong An 1 & Kyoo-jeong Choi 2 * 1 Korea National Wrestling

More information

<353420B1C7B9CCB6F52DC1F5B0ADC7F6BDC7C0BB20C0CCBFEBC7D120BEC6B5BFB1B3C0B0C7C1B7CEB1D7B7A52E687770>

<353420B1C7B9CCB6F52DC1F5B0ADC7F6BDC7C0BB20C0CCBFEBC7D120BEC6B5BFB1B3C0B0C7C1B7CEB1D7B7A52E687770> Journal of the Korea Academia-Industrial cooperation Society Vol. 13, No. 2 pp. 866-871, 2012 http://dx.doi.org/10.5762/kais.2012.13.2.866 증강현실을 이용한 아동교육프로그램 모델제안 권미란 1*, 김정일 2 1 나사렛대학교 아동학과, 2 한세대학교 e-비즈니스학과

More information