43卷4期

• Link 政策論壇 Policy Forum
• 兒童發展篩檢與評估Screening and assessment of child development
• 王亮人、周文君
  Liang-Jen Wang, Wen-Jiun Chiou
• 兒童發展篩檢、兒童發展評估
  screening of child development, assessment of child development
• 無none
  無none
• 327-328
• 10.6288/TJPH.202408_43(4).PF04

• Link 綜論 Review Article
• 人類乳突病毒基因篩檢自我取樣：子宮頸癌篩檢的新方式 Self-sampling for human papillomavirus genetic screening: a new method for cervical cancer screening
• 李佳純、張綺紋、黃淳霞、韓丹茹、張廷彰
  Chia-Chun Li, Chi-Wen Chang, Chun-Hsia Huang, Tan-Ju Han, Ting-Chang Chang
• 人類乳突病毒；自我取樣；子宮頸癌篩檢
  human papillomavirus; self-sampling; cervical cancer screening
• 子宮頸癌在台灣仍是女性常見的十大癌症之一，其主要原因為高危險性人類乳突病毒(HPV)的感染。為提升子宮頸癌的篩檢率，台灣政府為無法外出或六年以上未進行子宮頸抹片篩檢的女性提供了人類乳突病毒基因篩檢或病毒基因自我取樣的選項。然而，2021年全台灣36歲以上的女性中，仍有約278萬名在過去6年內未接受子宮頸癌篩檢。本文旨在比較子宮頸抹片與人類乳突病毒基因篩檢的差異，並介紹人類乳突病毒基因自我取樣這一新方法。研究顯示，人類乳突病毒基因篩檢的敏感度高於傳統抹片篩檢，且篩檢呈陰性的女性可以延長篩檢間隔，從而提高篩檢效率。自我取樣不僅具有高度一致性，敏感度也無明顯差異，同時為女性提供了更好的便利性和個人隱私的保護，有效減少尷尬和焦慮感。儘管少數女性可能在自我取樣後感到輕微不適，但多數女性更傾向於採用這種方法，顯示自我取樣未來可能成為台灣另一種受歡迎且有效的子宮頸癌篩檢新選擇。
  "Cervical cancer, one of the most common cancers among women in Taiwan, is primarily caused by high-risk human papillomavirus (HPV) infection. To improve cervical cancer screening rates, the Taiwanese government provides options for HPV DNA testing or self-sampling for women who are unable to visit a clinic or have not undergone a Pap smear in more than 6 years. However, in 2021, approximately 2.78 million women aged 36 years or older in Taiwan had not undergone cervical cancer screening in the preceding 6 years. This article compares Pap smear results with HPV DNA screening results and introduces a new method of HPV DNA self-sampling. Studies have indicated that HPV DNA screening is more sensitive than traditional Pap smears and that women with a negative result from such a screening can extend the screening interval, thereby improving screening efficiency. Self-sampling provides highly consistent results with comparable sensitivity (to Pap smears) while offering greater convenience and privacy protection for women, effectively reducing feelings of embarrassment and anxiety. Although a minority of women may experience slight discomfort after self-sampling, most women prefer this method, suggesting that self-sampling could become a popular and effective cervical cancer screening option in Taiwan in the future."
• 329-337
• 10.6288/TJPH.202408_43(4).113026

• Link 綜論 Review Article
• 家屬代理維生醫療決策之道德基礎、標準與決策形成模式：對台灣安寧緩和政策的反思 Moral grounds, standards, and decision-making models for surrogate life-sustaining treatment decisions by family members: a reflection on Taiwan's hospice and palliative care policy
• 莊宇真、陳端容
  Yu-Chen Juang, Duan-Rung Chen
• 家屬；代理決定；維生醫療
  family; surrogate decision; life-sustaining treatments
• 當老化或病情影響而無法為自己做醫療決定，需由他人代為進行，此即醫療上之代理決策。維生醫療抉擇是生命最後一哩路上，關涉個人尊嚴與生活品質之重要決策。鑒於預立醫療相關文件(預立安寧緩和醫療暨維生醫療抉擇意願書、預立醫療決定書)之簽署率偏低，當無決定能力病人需進行維生醫療抉擇時，仍以家屬代理決策最為常見。本文回顧其他國家關於家屬代理決策之道德基礎、標準與決策形成模式之相關文獻，藉以檢視我國現行規範，並對相關安寧緩和政策與未來研究提出建議。
  Individuals experiencing old age or advanced-stage diseases may be insufficiently lucid and thus require surrogate decision-makers. The decision to use life-sustaining technologies is a crucial one for such individuals because prolonged life may lead to suffering in some cases, implicating the individual's ability to die with dignity. When it comes to making life-sustaining medical decisions for incapacitated patients, in practice, family members often function as surrogate decision-makers in Taiwan because of the low uptake of written documents about advance care plans, including "The Letter of Intent for the Choice of Hospice Palliative Care and Life-Sustaining Treatment" and "Advance Decisions." This article reviews the literature, mainly on studies outside of Taiwan, on the moral grounds, standards, and decision-making models for life-sustaining treatment decisions made by family members. This article also examines Taiwan's current regulations, offering suggestions for researchers and policymakers.
• 338-350
• 10.6288/TJPH.202408_43(4).113028

• Link 綜論 Review Article
• 愛滋風險入罪化之公衛與人權省思－國外實證回顧與台灣法院判決分析 Reflections on public health and human rights in HIV criminalization: empirical review and analysis of court judgments in Taiwan
• 林欣柔
  Shin-Rou Lin
• 愛滋病毒；刑法；傳播；暴露；揭露
  HIV; criminal law; transmission; exposure; disclosure
• 世界各國以刑事手段處罰知悉自己為感染者而暴露或傳播愛滋病毒者，期望讓感染者向其性伴侶揭露感染狀況並放棄風險行為，或促進採行保護措施，最終減少傳播。台灣自1990年制定愛滋防治專法即處罰透過性行為或共用針頭傳播愛滋病毒者，三十多年來除增加處罰未遂行為，更加重刑度至與重傷罪相當，但此類傳播愛滋刑法究為防疫助力或阻力，亟待評估。本研究於PubMed搜尋英文文獻，收集探討傳播愛滋刑法對公衛影響之實證文獻，並利用司法院裁判書查詢系統，收集涉及37名被告之26件傳播愛滋罪地方法院判決，評估現行「人類免疫缺乏病毒傳染防治及感染者權益保障條例」第21條傳播愛滋罪對整體防疫之效益或負面影響。結果顯示，根據國際實證資料，刑罰對改變風險行為之影響不顯著，未能產生預期的嚇阻風險行為防疫效益;雖無充分證據顯示傳播愛滋刑法妨礙檢測意願，但健康照護者擔憂照護可近性、感染者擔憂汙名化可能對愛滋照護產生負面影響;台灣傳播愛滋罪高比例用於訴追及處罰未遂行為，包括幾近零風險行為，主觀上不以傳染故意為要件，而以知悉感染狀況為已足，法院以僅能證明檢體病毒基因相似性的比對分析鑑定結果做為被告致傳染於被害人之證據，量刑上有刑度過高疑慮。政策制定者應思考愛滋風險入罪化之防疫效益，評估採行非刑罰之防治手段。
  Countries around the world have enacted HIV-specific statutes that criminalize undisclosed exposure to HIV as a method for preventing and treating the disease. These policies presume that the punishment may encourage people to disclose their infection status to their sexual partners and forgo risky behaviors or increase protective measures, ultimately reducing HIV transmission. When the HIV/AIDS prevention and control law was passed in 1990, Taiwan enacted an HIV-specific statute to criminalize nondisclosure transmission of HIV through sexual intercourse or sharing needles. In the past three decades, the policy scope was extended to attempted acts even if the virus is not transmitted, and longer sentences were adopted, equivalent to sentences for aggravated assault. However, little is known whether such harsh criminal laws are effective HIV prevention methods or have potential negative impacts. This study searched for empirical studies discussing the effects of HIV criminal laws on public health from PubMed and collected twenty-six district court judgments involving 37 defendants charged with criminal HIV transmission from the Judicial Yuan Judgment Court Decisions Inquiry database. Empirical studies show that criminal HIV laws have an insignificant effect on changing risky behavior, failing to produce the expected epidemic prevention benefits of deterring risky behaviors. Although evidence is insufficient to demonstrate that criminal HIV laws hinder the willingness to test, health caregivers are worried about the accessibility of care. Some worry that the care of patients with HIV may still be impeded by stigma. A disturbing proportion of court cases in Taiwan have involved prosecution and punishment of attempted behaviors, including almost zero-risk behaviors. The intention to infect is not considered, while knowledge of the infection status is deemed sufficient. Phylogenetic analysis—the study of the genetic relatedness between HIV strains—has been adopted by courts as evidence to prove that HIV transmission occurred directly between the defendant and the witness. The severity of the sentences is also concerning. Policymakers should consider the benefits of criminalizing public health risks and evaluate the use of noncriminal prevention and control measures.
• 351-370
• 10.6288/TJPH.202408_43(4).113031

• Link 原著 Original Article
• 戒癮動機中的處遇準備與家庭支持的關聯性：針對社區處遇中物質使用者的分析 Relationship between motivational readiness and family support: an examination of clients with substance use disorder in community-based treatment
• 韓意慈、張祺、朱群芳
  Yih-Tsu Hahn, Chi Chang, Doris C. Chu
• 物質使用；復元；家庭支持；性別；處遇準備
  substance use; recovery; social support; gender; treatment readiness
• 目標：相較於司法處遇帶來的外在戒癮動機，社區處遇能否有益於內在戒癮動機，國內研究相對有限。本研究目的為探討動機中的處遇準備與家人支持的關聯性。方法：本研究以全台灣13所民間戒癮處遇社區的150位入住者為對象，包含130位男性與20位女性，其中有94人具有更生人身分。本研究應用自陳式家庭支持網絡及功能問卷、戒癮動機問卷進行測量。本文將家人社會支持功能區分為情緒支持、實質支持與資訊支持;戒癮動機以處遇準備為主要探討問題。結果：研究發現家人支持總分與動機之處遇準備呈現正相關(r=.204， p<0.05);家人之情緒支持與處遇準備(r=.212， p<0.05)呈現正相關;在控制相關變項後，僅性別、家人戒癮協助、家人支持總分對於處遇準備具有統計顯著。結論：未來政策考量提供家庭支持服務時，應重視家庭關係改善的內涵，更加重視情感性的支持功能，並關注性別差異對於成癮者處遇準備的影響;實務上若能關注增進成癮者處遇準備的相關服務，將可能提升其處遇動機，裨益於整體處遇結果。
  Objectives: Current policies emphasize diverse interventions for individuals struggling with illicit drug addiction, highlighting the pivotal role of individual motivations. However, limited research and discussion have been conducted on this topic in Taiwan. Methods: This study targeted 150 residents, comprising 130 men and 20 women, with 94 having a criminal history, from 13 private addiction treatment centers across Taiwan. Self-reporting measures were employed, namely the Social Support Network and Function Questionnaire, Addiction Motivation Questionnaire, and Treatment Readiness. Family social support was categorized into emotional, instrumental, and informational support, with the primary focus being on treatment readiness in addiction motivation. Results: The study found a positive correlation between total family support scores and treatment readiness motivation (r = .204, p < .05). Emotional support from family was also positively correlated with treatment readiness (r = .212, p < .05). After controlling for the relevant variables, only gender, family addiction assistance, and total family support showed statistical significance in relation to treatment readiness. Conclusions: Future policies emphasizing family support services should prioritize the reconstruction of family relationships, particularly focusing on emotional support. Additionally, attention should be given to the influence of gender differences on the treatment readiness of individuals with addiction, thus enhancing the overall treatment outcomes.
• 371-382
• 10.6288/TJPH.202408_43(4).113016

• Link 評論 Commentary
• 評論：戒癮動機中的處遇準備與家庭支持的關聯性：針對社區處遇中物質使用者的分析 Commentary: relationship between motivational readiness and family support: an examination of clients with substance use disorder in community-based treatment
• 李俊宏
  Chun-Hung Lee
• 無none
  無none
• 無none
  無none
• 383
• 10.6288/TJPH.202408_43(4).11301601

• Link 作者回覆 Authors' response to commentary
• 作者回覆：戒癮動機中的處遇準備與家庭支持的關聯性：針對社區處遇中物質使用者的分析 Authorsʼ response to commentary: relationship between motivational readiness and family support: an examination of clients with substance use disorder in community-based treatment
• 韓意慈、張祺、朱群芳
  Yih-Tsu Hahn, Chi Chang, Doris C. Chu
• 無none
  無none
• 無none
  無none
• 384-385
• 10.6288/TJPH.202408_43(4).11301602

• Link 原著 Original Article
• 戒除抑或減害：台灣藥愛防治專業人員之處遇經驗與觀點 Abstinence versus harm reduction: experiences and perspectives of chemsex service providers in Taiwan
• 李佳霖、黃宣穎、衛漢庭、王聲昌
  Chia-Lin Li, Hsuan-Ying Huang, Han-Ting Wei, Sheng-Chang Wang
• 戒除；減害；物質使用；男性間性行為者；藥愛
  abstinence; harm reduction; substance use; men who have sex with men; chemsex
• 目標：本文旨在探討藥愛防治專業人員之處遇取向觀點及可能影響因素。方法：經立意取樣招募17位具有藥愛防治經驗的專業人員進行深度訪談，調查其專業訓練習得之處遇取向，及其執業場域和工作經驗對該取向的影響。結果：受訪者的處遇取向可分為戒除、減害，以及介於兩者之間這三類。受訪之精神科醫師與臨床心理師多數傾向支持戒除，其依據理由為：腦科學實證、重建社會適應，及施用成癮物質的刑責。減害傾向的受訪者之專業背景較多元，主要在民間機構從事性健康與愛滋防治，其主張為：停用成癮物質非唯一目標、重視個案參與復元的動機，並提供務實協助。實務上，半數戒除取向的受訪者調整為「在戒除與減害之間」或減害取向，只有一名減害取向的受訪者往兩種取向之間調整。處遇調整的考量有：以個案需求為中心以及如何落實處遇。結論：專業人員面對藥愛議題時須以個案為中心，並體察法規、社會與照護系統對於藥愛處遇近用的障礙，從而開發友善、支持的處遇方案。
  "Objectives: This study explored the perspectives of chemsex service providers and the factors influencing their treatment approaches. Methods: Through purposive sampling, this study interviewed 17 experienced chemsex service providers to examine approaches acquired during training and how practice settings and experiences influence approach. Results: Participants were categorized into three groups on the basis of their treatment approach: abstinence, harm reduction, and an approach situated between the aforementioned two approaches. Most participants supported abstinence, basing their approach on evidence-based neuroscience, social reintegration needs, and the legal ramifications of substance use. Participants favoring the harm reduction approach were from diverse professional backgrounds, primarily working in nongovernmental organizations focused on sexual health and HIV prevention. They argued against a sole focus on abstinence, prioritizing the client’s motivation and participation and providing pragmatic assistance. In practice, half of those in the abstinence group adapt their methods to incorporate more flexibility or to align with the harm reduction approach. By contrast, only one participant from the harm reduction group modified their stance. Shifts in approach generally reflect an emphasis on client needs and the effective implementation of treatment plans. Conclusions: Chemsex service providers must embrace client-centered approaches and recognize the barriers to care imposed by legal regulations, social contexts, and the health-care system and develop supportive and inclusive treatment strategies."
• 386-400
• 10.6288/TJPH.202408_43(4).113027

• Link 原著 Original Article
• 建構能力導向訓練計畫之評估架構—修正式德菲法研究 Developing an evaluation framework for competency-based training programs using a modified Delphi method
• 郭淑卿、陳建宇、周致丞、陳麗玉、李宜恭、蕭政廷、邱欣怡
  Shu-Liu Guo, Chien-Yu Chen, Fremen Chihchen Chou, Li-Yu Chen, Yi-Kung Lee, Cheng-Ting Hsiao, Hsin-Yi Chiu
• 計畫評估；邏輯模型；勝任能力導向醫學教育；修正式德菲法
  program evaluation; logic model; competency-based medical education
• 目標：在台灣發展「能力導向訓練計畫之評估架構」以利能力導向醫學教育之實踐。方法：本研究團隊依據「美國畢業後醫學教育評鑑委員會」訓練計畫指引，並參考國內112年度醫院評鑑及教學醫院評鑑基準、衛福部住院醫師審議委員會評鑑、衛福部二年期醫師畢業後一般醫學訓練計畫等文件，並採用邏輯模型來發展「能力導向訓練計畫之評估架構」之初稿。本研究團隊利用修正式德菲法，蒐集國內23位醫學教育專家之建議。每次調查後，針對各項指標的適切性和一致性進行分析，並依專家意見修正和調整指標內容。結果：能力導向訓練計畫之評估架構之發展涵蓋：計畫書排版與格式、訓練目標與架構、教學師資、教學資源、臨床學習環境、醫學與專業能力訓練方式、全人照護能力訓練方式、考評機制與反映管道、輔導與補強機制和其他等十構面56項細項指標。結論：本研究建構能力導向訓練計畫之評估架構，並透過多機構專家形成共識，此評估架構之分享，旨在協助機構內的計畫評估，以利於能力導向醫學教育之推展與實踐。
  Objectives: This study developed an evaluation framework for competency-based training programs to support the implementation of competency-based medical education (CBME) in Taiwan. Methods: Our research team used the logic model to draft an evaluation framework for training programs that align with the Accreditation Council for Graduate Medical Education's Program Director Guide to Common Program Requirements in the United States. In addition, we referenced various documents, including the 112th-year hospital and teaching hospital accreditation standards in Taiwan, evaluations from the Ministry of Health and Welfare's Residency Review Committee, and guidelines from the Ministry of Health and Welfare's General Medical Training Program for Physicians after graduation. This study collected opinions from 23 domestic medical education experts by using the modified Delphi method. After each survey, the appropriateness and consistency of each indicator were evaluated. These indicators were then revised and refined in accordance with feedback from the expert panelists. Results: The evaluation framework for competency-based training programs comprises the following 10 dimensions including a total of 56 indicators: "Project Proposal Layout and Format," "Training Objectives and Framework," "Faculty," "Educational Resources," "Clinical Learning Environment," "Medical and Professional Skills Training Approaches," "Holistic Care Training Approaches," "Assessment and Feedback Channels," "Counseling and Remediation Pathways," and "Others." Conclusions: The study developed an evaluation framework for competency-based training programs, reaching a consensus with expert panelists from various institutions. This evaluation framework can enhance program evaluations within institutions, thereby facilitating the advancement and implementation of CBME.
• 401-414
• 10.6288/TJPH.202408_43(4).113012