29卷6期

• Link 原著 Original Article
• 新世紀美國公共衛生教育改革之經驗與啟示Millennium Education Reform in Public Health: US Experiences and Lessons for Taiwan
• 吳文琪、陳紫郎、陳為堅、江東亮
  Wen-Chi Wu, Ted TL Chen, Wei-Jen Chen, Tung-Liang Chiang
• 公共衛生 ； 教育改革 ； 專業性 ； 美國經驗
  public health ; education reform ; professionalism ; American experience
• 二十一世紀開始，世界各國即面臨全球環境變遷帶來嚴峻的公共衛生挑戰，台灣亦不例外。公共衛生教育萌芽於美國，至今雖然仍執世界之牛耳，美國公共衛生教育為了迎接新世紀挑戰，自1980年代後期以來即不斷進行改革。本文旨在回顧美國公共衛生教育的歷史沿革以及新世紀改革的目標與策略，做為台灣的借鏡。在分析美國經驗之後，我們建議台灣公共衛生教育改革可以從檢討公共衛生教育任務著手，改革內容包括：建立評鑑機制、改善課程規劃、強調實務訓練，以及舉辦公共衛生核心能力考試。
  Since the start of the twenty-first century, changes in the global environment have been accompanied by major public health challenges throughout the world, and Taiwan is no exception. Education for Public health began in the United States, and is still the best in the world; however, to meet the new challenges, the United States has undergone major education reforms in public health since the late 1980s. This paper reviewed the historical development of education for public health in the United States as well as the objectives and strategies for millennium education reform in public health. Based on the American experience, we suggested that reforms in Taiwan start with re-identification of the education mission for public health and the scope of education reform. This would include establishment of an accreditation system, redesign of curriculum, development of a practicum and practical training, and an examination of the core competencies in public health.
• 477 - 486
• 10.6288/TJPH2010-29-06-01

• Link 原著 Original Article
• 醫院策略執行對醫師同理心之影響：跨層次分析The Effect of Hospital Strategy Implementation on Physicians' Empathy: A cross-level Analysis
• 汪秀玲、關皚麗、黃俊英
  Hsiu-Ling Wang, Aij-Lie Kwan, Jun-Ying Huang
• 策略執行 ； 同理心 ； 系絡變項 ； 跨層次研究 ； 層級線性模型
  strategy implementation ; empathy ; contextual variable ; cross-level research ; hierarchical linear modeling
• 無
  Objectives: This study explored the contextual effects of a perceived emphasis on cost and revenue on physicians' empathy in hospitals participating in the global budget program. Methods: We selected 84 teaching hospitals and surveyed 1, 280 physicians with structured questionnaires. A total of 441 usable questionnaires from 51 hospitals were returned. This represented response rates of 60.71 percent for the hospitals and 34.45 percent for the physicians. We conducted hierarchical linear modeling using individual physician-evaluated empathy as the outcome variable. The perceptions of strategic implementation at the physician level were aggregated at the hospital level to serve as a contextual variable. We also included rank, ownership and religious type as hospital-level variables. Results: The strategy of revenue-generation led to increases in physicians' compassionate care and perspective taking (?=0.249, 0.150, p<.05), but unit management's emphases on cost containment did not significantly reduce physicians' empathy (?=-0.054~-0.109, p>.05). The contextual effects of hospital rank (medical centers vs. regional hospital) on physicians’ compassionate care (?=0.20, p<.05) as well as ownership (public vs. private) on physicians’ perspective taking (?=0.208, p<.05) showed significant differences, although the contextual effects of religious type were not significant (?=0.019~0.202, p>.05). Physician age positively influenced physician empathy in compassionate care (?=0.070, p<.05); however, data revealed no significant differences among medical specialties (?=-0.057~0.051, p>.05). The individual-level factors explained 26.77%~32.93% of within-hospital variance on empathy and hospital-level factors explained 45.49%~59.33% of between-hospital variance. Conclusions: Results indicated that organization context could shape the physicians' empathy, while the impact of personal characteristics should not be ignored.
• 487 - 502
• 10.6288/TJPH2010-29-06-02

• Link 原著 Original Article
• 評論：醫院策略執行對醫師同理心之影響：跨層次分析Commentary: The Effect of Hospital Strategy Implementation on Physicians' Empathy: A cross-level Analysis
• 魏中仁、邱瓊萱
  Zhong-Ren Wei, Chiung-Hsuan Chiu
• 無
  none
• 無
  none
• 503 - 504
• 10.6288/TJPH2010-29-06-03

• Link 原著 Original Article
• 作者回覆：醫院策略執行對醫師同理心之影響：跨層次分析 Response: The Effect of Hospital Strategy Implementation on Physicians' Empathy: A cross-level Analysis
• 汪秀玲、關皚麗、黃俊英
  Hsiu-Ling Wang, Aij-Lie Kwan, Jun-Ying Huang
• 無
  none
• 無
  none
• 504 - 504
• 10.6288/TJPH2010-29-06-04

• Link 原著 Original Article
• 影響處方箋釋出系統的資訊採用與醫藥分業之關鍵因素分析Factors Influencing the Adoption of the Release of Prescription Information System and the Separation of Drug Prescribing and Dispensing
• 宋佩貞、古政元、謝文淮、陳富豪、場瑛碧
  Pei-Chen Sung, Cheng-Yuan Ku, Wen-Huai Hsieh, Fu-Howe Chen, Ying-Pi Yang
• 醫藥分業 ； 處方箋釋出資訊系統 ； 資訊系統成功模式 ； 社會連帶
  Separation of Drug Prescribing and Dispensing ; Release of Prescription Information System ; Information System Success Model ; Social Ties
• 目標：本研究以醫師與藥師之觀點，探討影響採用處方箋釋出系統的關鍵因素。方法：以資訊系統成功模式為理論基礎，並結合社會連帶觀點來建構研究模式，而研究對象為參與行政院衛生署處方箋釋出資訊平台推廣計畫之醫師與藥師，透過問春收集資料並以複迴歸方法進行分析。結果：（一）系統品質是影響醫藥師系統使用的關鍵：（二）系統開發人員的服務品質不影響醫藥師系統使用與使用者滿意：（三）處方箋釋出資訊系統的資訊品質不影響醫藥師使用者滿意：（四）影響醫師使用者滿意的是系統品質，而影響藥師使用者滿意的是系統使用：（五）互動關係與信任對系統使用、使用者滿意有直接的影響。結論：醫藥師對系統使用與使用滿意度會影響淨效益，而系統品質是醫藥師決定系統採用與否的關鍵因素。除了系統特性之外，人際互動也會影響系統使用與滿意度，因此在系統建置過程中應更加强互動，以提高醫藥師的系統使用與使用滿意度。
  Objectives: The aim of this study was to understand the critical factors influencing the adoption of the Release of Prescription Information System (RPIS) from the perspectives of physicians and pharmacists based on the Information System Success Model and Social Ties. Methods: A survey was conducted to identify those factors that affected the adoption of the RPIS. Subjects were physicians and pharmacists who joined the RPIS project. Multiple regression analysis was used to investigate the factors which were most influential in the adoption of the system. Results: System quality was the key factor influencing system use; service quality did not influence system use and user satisfaction; information quality did not influence user satisfaction; system quality influenced user satisfaction from the physicians’ perspective and system use influenced user satisfaction from the pharmacists’ perspective; rapport and trust had a significant and positive influence on system use and user satisfaction. Conclusions: Both system use and user satisfaction influenced net benefits. Physicians and pharmacists were most concerned about system quality. In addition to system characteristics, the interaction affected system use and user satisfaction. System developers should have more interaction with physicians and pharmacists during system implementation in order to improve system use and user satisfaction.
• 505 - 517
• 10.6288/TJPH2010-29-06-05

• Link 原著 Original Article
• 嚴重外傷存活病患的失能影響因素Factors Associated with Disability after Major Trauma
• 李卓倫、 陳瑞杰、陳文意、梁亞文、陳慈純
  Jwo-Leun Lee, Ray Jade Chen, Wen-Yi Chen, Yia-Wun Liang, Tzu-Chun Chen
• 外傷 ； 照護品質 ； 失能 ； 危險因子 ； 外傷登錄
  Trauma ; Medical care quality ; Disability ; Risk factor ; Trauma registry
• 目標：外傷照護的終極目標是讓病患恢復到受傷之前的功能，本研究藉由嚴重外傷病患的失能結果與相關因素的分析，提供部分臨床治療準則與制訂政策的參考依據。方法：分析2005年7月l日至2008年6月30日中部某醫學中心嚴重外傷存活病患(ISS≧16)1，036人，其中失能病患318人，以多變項邏輯斯迴歸分析失能的因素，包括性別、年齡、到院方式、到院時昏迷指數、血壓、每分鐘呼吸次數、以及受傷機轉、傷害嚴重度、是否有過去病史、治療過程是否有手術、是否有併發症。結果：年齡每增加1歲，失能勝算增加11%，失能機率增加0.002；女性與男性病患的失能勝算比153（信賴區間1.11-2.12)，女性失能機率比男性高出0085；到院時昏迷指數(GCS)小於13分的失能勝算比237（信賴區間1.68-3.35），失能機率增加0.178；治療過程曾手術的病患失能勝算比3.97（信賴區間2.80-5.61），失能機率增加0.260；有併發症者的失能勝算比2.86（信賴區間1.97-4.15），失能機率增加0.227。結論：初期治療決策的適當性與臨床醫療的照護品質顯著影響嚴重外傷病患的治療結果，適當的醫療決策包括依據生命徵象與昏迷指數，做為院前緊急救護和到院後檢傷分類的標準，並且以受傷部位和嚴重度，來決定是否啓動跨科別的外傷小組，進入重大外傷處置流程；臨床照護品質主要則為降低併發症的發生。
  Objectives: The ultimate goal of trauma care is to restore patients to the level of health they enjoyed before injury. This study analyzed the risk factors for physical dysfunction after trauma care. Methods: A Trauma Registry dataset for July 2005 to June 2008, based at a medical center in central Taiwan, was used to analyze the factors related to disability after major trauma by the use of logistic regression models. Results: The probability of disability was increased by several factors: each additional year of age by 0.002 (OR=1.01; CI:1.00-1.02), being female by 0.085 (OR=1.53; CI:1.11-2.12), having a Glasgow Coma Score less than 13 by 0.178 (OR=2.37; CI:1.68-3.35), and an operation or complications during trauma care by 0.260 (OR=3.97; CI:2.80-5.61) and 0.227 (OR=2.86; CI:1.97-4.15), respectively. Conclusions: Evidence from this study supports making appropriate decisions during the initial phase of care. An appropriate decision to activate the cross-specialty trauma team according to risk factors and reducing complications are the most important guidelines for the optimal care of major trauma patients. When properly applied, the trauma registry system is helpful for quality control and the development of quality improvement programs in hospitals.
• 518 - 527
• 10.6288/TJPH2010-29-06-06

• Link 原著 Original Article
• 台灣新竹市女性性工作者持續使用保險套的盛行率和預測因子Prevalence of and Predictors for Consistent Condom Use among Female Sex Workers in Hsinchu City, Taiwan
• 徐玉珍、韓文蕙、李中一、何秀玉
  Yu-Chen Hsu, Wen-Hui Han, Chung-Yi Li, Hsiu-Yu Ho
• 預測因子 ； 保險套使用 ； 性工作者 ； 盛行率
  predictors ; condom use ; sex workers ; prevalence
• 目標：本研究目的在於探討台灣新竹市女性性工作者持續使用保險套的盛行率和預測因子。方法：於2006年七月至十月間，利用橫斷式調查研究法，取得155名新竹市女性性工作者問春資料，再以描述性統計、卡方檢定或費雪爾正確概率檢定和邏輯斯迴歸分析該等研究資料。結果：本研究參與者中有63%有持續使用保險套的行為；傾向持續使用保險套者分別是：少喝酒者、知道使用保險套好處者、對於保險套使用覺得不會減少做愛情趣者，或有正確保險套使用技巧者；進一步複邏輯斯回歸分析顯示：「良好的保險套使用技巧」以及「不覺得使用保險套會降低樂趣」兩因素與「持續使用保險套」有顯著的正相關性。結論：本研究發現女性性工作者持續使用保險套行為的盛行率應該要進一步被提昇；而本研究的數據發現是否能外推至本國其他城市也需要進一步被驗證。作者也建議應針對此特定族群進行保險套使用技巧之教育介入。
  Objectives: The aims of the study were to explore the prevalence of and predictors for consistent condom use (CCU) among female sex workers (FSWs) in Hsinchu City, Taiwan. Methods: Between July and October 2006, a cross-sectional survey was conducted with 155 FSWs. Descriptive analyses, Chi-square or Fisher's exact tests, and logistic regression analysis were used to analyze the data. Results: CCU was reported by 63% of the study participants. Those who consumed less alcohol, knew the benefits of condom use, perceived no reduction in pleasure with condom use, or had good condom use skills tended to be consistent condom users. Further multiple logistic regression analysis revealed that good condom use skills (OR 14.80; CI 2.85-76.91; p=0.001) and the perception that there was no reduction in pleasure with condom use (OR 7.41; CI 1.14-48.24; p=0.036) were significantly and positively associated with CCU. Conclusions: The prevalence of CCU needs to be enhanced among FSWs. Whether the findings from the participating city can be generalized to other cities of the nation requires further investigation. We also suggest educating FSWs in good condom use skills.
• 528 - 537
• 10.6288/TJPH2010-29-06-07

• Link 原著 Original Article
• 反毒資源線上博物館使用現況與資源可用性分析Analyses of the Trends in Use of and Satisfaction with the Online Museum of anti-drug Resources
• 林素真
  Sue-Jen Lin
• 反毒宣導 ； 反毒資源線上博物館 ； 資源可用性 ； 網站使用滿意度
  anti-drug promotion ; Online Museum of Anti-drug Resources ; information resourcefulness ; website user satisfaction
• 目標：瞭解(1)反毒資源線上博物館的使用現況及(2)網站的資源可用性與使用者對網站的滿意度間的關聯性。方法：本研究(1)利用查詢過程記錄分析的技術以研判反毒資源線上博物館網站二年的使用趨勢及造訪者的行為；(2)以線上問卷調查的方式評估網站的使用是否能解決使用者的資訊問題及其與網站滿意度的關係。結果：(1)網站的使用量以平日較高而東暑假期間較低；其使用情形與上班（上課）族的作息相仿；有超過一半的使用者在網站停留不到3分鐘。最常被瀏覽、進入率及離開率最高的網頁皆為flash首頁；(2)網站的使用滿意度由使用者所要解決的問題或達成的目的是否能在反毒資源線上博物館網站後獲得解決及達成目的來決定。結論：為增加反毒資源線上博物館網站的使用流量及使用滿意度，反毒資源線上博物館網站在設計上不應全站使用flash架設、要加強搜尋功能、應充實網站內容及加強網站宣傳。
  Objectives: This study investigated the browsing trends for the Online Museum of Anti-drug Resources (OMAR) and the relationship between website information and website user satisfaction. Methods: This study employed weblog analysis techniques to gauge the browsing trends of OMAR users for two years and to track website visitors' behaviors. It then used online questionnaires to determine if users' problems were solved by visiting OMAR and if they were satisfied with website use. Results: The website was visited most often during weekdays and used less during summer and winter vacations. The use pattern of OMAR was similar to the daily routine of white collar workers and students. Over half of the users stayed on OMAR for fewer than 3 minutes. The web page which was visited most often was the flash homepage. Website user satisfaction was determined by whether the user’s problems were solved and goals achieved after visiting OMAR. Conclusions: To attract more visitors to OMAR and to improve user satisfaction with OMAR, flash applications for the design and infrastructure of OMAR should not be added, but the functions of its search engine enhanced, its content enriched and diversified, and the website promoted instead.
• 538 - 550
• 10.6288/TJPH2010-29-06-08

• Link 原著 Original Article
• 職場社會心理危害調查監測制度之國際概況An International Overview of National Surveys for Psychosocial Hazards at Work
• 王佳雯、 鄭雅文、李論昇、 徐儆暉
  Chia-Wen Wang, Ya-Wen Cheng, Yu-Sheng Lee, Jin-Huei Hsu
• 職場社會心理危害 ； 國際比較 ； 調查研究
  psychosocial hazards at work ; international comparison ; survey research
• 目標：隨著勞動市場的轉變，職場社會心理危害已成為西方工業先進國家職場安全健康定期監測的主題之一。本研究探討國際與台灣職場社會心理危害之調查監測制度，並比較監測指標之項目與內容。方法：比較歐盟、加拿大、英國、丹麥、芬蘭與台灣之職場社會心理危害調查監測制度，以其網頁公布之資料與相關學術論文或出版報告作為分析材料。國際制度之選取依據為：網頁上有公開的英文資訊，包括調查監測名稱、研究設計、調查對象、樣本大小、問卷內容、測量方式、調查時問與頻率等。結果：各國職場社會心理危害調查之監測指標主要包括：僱用契約、薪資狀態、工作保障性、升遷機會與訓練、工作控制、工作負荷、工時、輪班、夜班工作、組織正義、家庭與工作衝突等；台灣納入監測指標則較為有限。結論：我們建議台灣職場社會心理危害調查監測之範圍可充實以下面向：在就業狀態方面，應納入契約類型、薪資狀態、就業保障子指標並予以精確化；在工作內容與特質方面，可考慮擴充工作負荷之測量內容，另外超時工作之類型與是否額外給薪，亦可納入考量；在職場社會與組織特質方面，除了組織正義之外，亦可考慮國際上普遍被監測的家庭與工作衝突、職場暴力、騷擾、霸凌等題項。
  Objectives: Due to dramatic changes in the labor market, psychosocial hazards at work have become increasingly important and have been included in national surveys about occupational safety and health in most developed countries. This study was designed to explore survey methods and questionnaire items from selected countries and to compare them with those used in Taiwan. Methods: Survey questionnaires from the European Union, Canada, the United Kingdom, Denmark and Finland were studied. These surveys were selected based on the availability of the following information in English: title of survey, research design, survey subjects, sample size, the full questionnaire, measurements, survey time and frequency. Results: Major dimensions for the assessment of psychosocial work hazards included: work contract, salary status, employment security, career prospects and opportunities for future development, job control, job demands, working hours, shift work, night work, organizational justice, and family-work conflict. In contrast, only a limited number of these factors have been assessed in national surveys in Taiwan. Conclusions: We suggest that surveys in Taiwan could be further improved by adopting validated measures for work contracts, salary status and employment security, expanding the scope of the measures of job demands, and including measures for overtime work with or without pay, family-work conflicts, violence, harassment and bullying.
• 551 - 560
• 10.6288/TJPH2010-29-06-09

• Link 原著 Original Article
• 我國職業傷病通報制度之現況與問題Reporting Systems for Occupational Injuries and Diseases in Taiwan: Conditions and Problems
• 鍾佩樺、鄭雅文
  Pei-Hua Chung, Ya-Wen Cheng
• 職業傷病 ； 通報 ； 政策
  occupational injuries and diseases ; reporting ; policy
• 目標：職業傷病的通報機制乃是現代化國家勞動保護制度中不可或缺的一環，其目的在於早期發現職場中異常的健康問題並早期介入。本研究探討我國職業傷病通報制度現況與實務操作層面之問題。方法：本研究採文獻回顧、政府統計資料分析，與7位相關人士（包括政府行政部門主管、事業單位代表、職業醫學部門醫護人員、勞工安全衛生實務工作者、勞工代表子）之深度訪談，並舉辦一次專家座談會，徵詢數位職業醫學專家、政府勞工安全衛生主管、勞工團體代表與其他學者專家之意見。結果：我國職業傷病通報制度設計混亂，主要的問題包括：通報機制多元但互相之問缺乏連結、醫護工作者缺乏充分的通報誘因、通報數據的品質缺乏有效稽核；勞委會於2007年重新建置的「職業傷病通報系統」目前缺乏法源強制力、被通報的職業傷病個案及事業單位是否被告知尚無強制機制、該通報也未與勞動檢查或職災補償體系作連結，此外，該通報系統以年度計畫案方式由勞委會委託醫學中心辦理，易造成通報業務的不穩定。結論：本研究指出我國職業傷病通報制度之問題，並提出改善建議。
  Objectives: Reporting systems for occupational injuries and diseases are essential for early detection and intervention in work-site health problems. This study investigated the designs and functions of current reporting systems in Taiwan in order to identify the problems with them. Methods: The existing literature and official statistics were reviewed. This was followed by in- depth interviews with 7 stakeholders, including labor representatives, managers of enterprises, governmental officials, occupational physicians and occupational health representatives of enterprises. A conference was also held to solicit the opinions of government officials, senior occupational physicians, labor representatives and researchers. Results: Many problems exist in the current reporting systems in Taiwan. These include poor coordination among different reporting systems, a lack of sufficient incentives for health care professionals to implement reporting, and poor quality control of the reported data. The reporting system recently established by the Council of Labor Affairs also has several problems such as a lack of enforcement power and the fact that reporting systems are not linked to the systems of labor inspection or workers’ compensation. It also lacks stable financial and administrative resources. Conclusions: Several problems were identified and recommendations for reform were proposed.
• 561 - 574
• 10.6288/TJPH2010-29-06-10

• Link 原著 Original Article
• 禽流感疫情爆發情境下醫院之抗疫能力模擬分析－以署立專責醫院為例Simulation Analysis of a Hospital's anti-avian Flu Saturation Capability in Various Outbreak Scenarios
• 王貴民、惠霖、 陳心慧、許貴婷
  Kuei-Min Wang, Lin Hui, Sin-Huei Chen, Gui-Ting Xu
• 模擬 ； 負壓病房 ； 等候時間 ； 情境 ； 瓶頸
  simulation ; NPIR ; waiting time ; scenario ; bottleneck
• 目標：2003年嚴重急性呼吸道症侯群(SARS)所帶來嚴重衝擊，驚醒國人，政府隨之擬訂流感大流行作戰等計畫，建立抗疫能量，以因應可能發生之流感疫情。本研究目標係針對禽流感疫情爆發時專責醫院之設計能量達成抗疫任務程度進行分析。方法：依與專責醫院訪談結果建立概念性模型，發展醫院抗疫系統模擬模型。結果：以醫院能力可持續作業之時間長度（日）為量測指標，針對政府設計專責醫院之現有資源，融入衛生署應用之疫情情境進行模擬分析。疫情情境有四種設定：推估狀況、最小疫情、可能實況與最壞狀況；模擬出之醫院抗疫作業飽和能量分別為9、1、1、1日。醫療瓶頸出現於疫病篩檢站與負壓病房。結論：指定專責抗疫醫院之現況設計與整備難以因應前述四種情境之能量需求。疫病篩檢站與負壓病房之不足，形成醫療作業嚴重瓶頸，另衍生出大量轉院之病患之管理議題。
  Objective: Since 2003, SARS has been a major problem in Taiwan and the government has started to develop and issue anti-avian flu plans in order to respond to probable epidemic situations in the future. The objective of this paper was to analyze the saturation capability of the government owned anti-avian flu hospital in four avian flu outbreak scenarios including estimated, least impact, most likely and worst case. Methods: A Conceptual Model (CM) was built and validated with support from the medical staff of the collaborating hospital. Based on the CM, a system simulation model was developed to obtain the Measure Of Effectiveness (MOE) from simulating the interactions of patients and the medical process in the hospital. Results: the hospital’s saturation capability (days) in terms of the given scenarios was 9, 1, 1, 1. Conclusions: The design of the government owned hospital is incapable of dealing with the given outbreak scenarios. Bottlenecks in the medical process are easily built up at the Plague station and in Negative Pressure Isolation Rooms (NPIR) which are equipped with only 53 beds. Another issue observed during simulation was the management of huge lines of patients waiting to be transferred after the hospital was saturated.
• 575 - 582
• 10.6288/TJPH2010-29-06-11