25卷4期

• Link 綜論 Review Article
• 綜論氣象變化對心血管、呼吸道及腸胃道之健康衝擊The Impact of Weather Conditions on Cardiovascular, Respiratory, and Gastroenteric Health
• 王玉純、宋鴻樟
  Yu-Chun Wang, Fung-Chang Sung
• 心血管 ； 呼吸道 ； 腸胃病 ； 氣象
  cardiovascular disease ; gastrointestinal disease ; respiratory disease ; weather
• 全球暖化和地區氣候變化的健康影響在近年廣受注意。本文回顧氣象變化和心血管、呼吸道及腸胃道疾病之間的相關性文獻，並進一步探討未來研究方向。目前證實極端氣候變化具有健康衝擊，對心血管疾病的風險高於呼吸道及其他疾病，尤其是在熱浪及寒流期間。熱浪對健康影響較冷氣候立即，而寒冷則有較長的影響期間。長期淫雨或暴雨導致飲水不淨，增加腸胃道疾病的風險，已開發國家亦不例外。年齡、性別、社經狀態、地區氣候等為影響氣象變化對健康衝擊評估之相關因子，年長者尤為敏感。氣象對疾病發生的生物機制、氣象與大氣環境交互作用，對疾病的影響以及氣象、健康參數及模式的選擇等，對所有的風險估計而言均有一定的影響，這其中錯綜複雜的相關性仍待許多研究去探討，和疾病相關的氣候因子的防預之道亦為公共衛生關切的課題。
  The health effect of global warming and regional climate changes has attracted considerable attention in recent years. This article reviews the recent publications on the associations between weather conditions and cardiovascular, respiratory, and gastrointestinal diseases. Temperature change has a stronger association with the risk of cardiovascular and respiratory diseases than gastrointestinal diseases, particularly during extreme conditions such as heat waves and cold spells, which may lead to significant excess mortality. The health impact is immediate from a heat wave because of the shorter latency effect, while cold whether may have a health impact that is persists over a longer period of time. Individuals with cardiovascular disease are more sensitive to low temperatures than those with respiratory disease. Gastroenteritis occurs when clean water is unavailable, as a result of prolonged rainfall or unusually heavy precipitation. Such heavy rainfall during storms has an increased effect on gastrointestinal disorders, even with populations ill developed nations. Age, gender, socioeconomic status, and regional climate are modifiers with respect to the health impact of weather. The elderly are particularly sensitive to changes in temperature. The interaction among air pollution, biological mechanisms, socioeconomic status, and health care availability associated with the health impact of weather changes is not completely known. It would thus be useful to estimate how these factors influence the health risks associated with various whether conditions and in different geographic areas. Prevention strategies associated with these variations are additional issues of public health importance.
• 256 - 265
• 10.6288/TJPH2006-25-04-02

• Link 原著 Original Article
• 役男發生重度憂鬱症之相關因子探討Factors Associated with the Occurrence of Major Depression among Men Serving Military Obligations
• 張國榮、陳端容、蔡孟岳、馮煥光
  Kuo-Jung Chang, Duan-Rung Chen, Meng-Yueh Tsai, Huan-Kwang Ferng
• 役男 ； 重度憂鬱症 ； 支持度 ； 壓力源 ； 因應方式
  solider ; major depression ; support ; stressor ; coping
• 目標：國內目前仍實施國民義務服役制度，役男進入軍隊後，生活情境發生明顯改變，當個人心理調適機轉無法適應環境改變，易誘發重度憂鬱症的發生。本研究旨在瞭解役男重度憂鬱症發病之危險因子。方法：以個案對照組方式進行結構式面對面問卷調查。先選取155位被醫師診斷為「重度憂鬱症」之住院役男為個案組，再同時選取246位沒有「重度憂鬱症」之役男為對照組，自變項為役男之社經背景、社會支持、主要壓力源及壓力因應方式等變項。結果：誘發役男「重度憂鬱症」的顯著影響因子為入伍前工作狀況、父親管教方式、家人具憂鬱症病史、下部隊時間、支持者、軍中壓力、家庭壓力、積極因應、及消極因應等。結論：役男容易發生「重度憂鬱症」同時受到個人、家庭和軍隊的影響，本研究發現的各項因子值得進一步探討，也可作為預防役男發生重度憂鬱症之介入計畫的參考。
  Objective: Major depression, the most serious form of depression, has recently become a widely discussed issue with respect to soldiers in national service. The current study was undertaken to determine the risk factors for major depression among enlisted men. Methods: One hundred fifty-five soldiers treated ill psychiatric inpatient settings for major depression and 246 soldiers without a diagnosis of major depression were each administered a questionnaire in which the presence of major depression was the dependent variable measured, and social background, social support, stressors, and coping skills served as the independent variables. We thus analyzed the influence of all independent variables on the incidence of major depression to ascertain the associated risk factors. Results: Using various regression models, the variables shown to significantly affect the incidence of major depression were job status before recruitment, father's style of discipline, personal psychiatric history, family psychiatric history, the time elapsed after the completion of new recruit basic training, support from family and friends, military stress, family stress, positive coping skills, and negative coping skills. Conclusions: The characteristics of soldiers at increased risk for major depression included: unemployment before recruitment, a father with a dominant style of discipline, the presence of psychiatric illness before recruitment, the presence of psychiatric illnesses in family members, completion of new recruit basic training within three months, lack of support from family and friends, increased perception of military stress, heightened family stress, lack of positive coping skills, and increased negative coping skills.
• 266 - 273
• 10.6288/TJPH2006-25-04-03

• Link 原著 Original Article
• 大臺北地區成癮物質使用調查A Survey on Substance Abuse in the Greater Taipei Area
• 劉淑芬、李品珠、呂孟穎、蔡文瑛、李志恒
  Shu-Fen Liu, Ping-Chu Lee, Ming-Ing Lu, Wen-Ing Tsay, Jih-Heng Li
• 調查 ； 盛行率 ； 非法藥物 ； 成癮物質使用
  survey ; prevalence ; illicit drug ; substance abuse
• 目標：探究臺灣北部地區一般民眾成癮物質使用（包括菸、酒、檳榔與非法藥物）狀況。方法：以臺北縣、市12歲以上一般民眾為母體，採多階段分層系統抽樣，共選取3,301人為本研究樣本，並以結構式問卷派員至個案家中面訪，總計完成1,984份問卷，完訪率601%。結果：臺北縣、市12歲以上居民的菸、酒、檳榔與非法藥物濫用盛行率為：28.9%、47.3%、13.3%、1.6%。首次使用菸、檳榔、非法藥物年齡為：19歲、19.5歲、20歲。使用非法藥物種類前三名為：「安非他命」、「大麻」、「強力膠」。非法藥物濫用者菸、酒、檳榔使用比例皆高於非藥物濫用者，而使用菸、檳榔者其藥物濫用的風險顯著高於不使用者。另未婚、有收入及教育程度低者其藥物濫用之風險亦顯著高於已婚、沒有收入及教育程度高者。結論：本研究顯示，與酒相比較，菸、檳榔的使用與非法藥物之間有更顯著的關聯性，另各成癮物質個案首次使用原因皆為好奇，未來應對民眾加強宣導入門物質對非法用藥的影響以及非法用藥危險因子，共同防制成癮物質的使用。
  Objectives: The purpose of this study was to investigate the lifetime prevalence of substance abuse in the general population of the Greater Taipei area. Methods: Of 3,301 persons 12 years of age or older who were randomly selected from the study area according to a multistage stratified systematic sampling design, 1,984 (60.1%) persons were successfully interviewed at home with the use of a structured questionnaire. Data on substances use and sociodemographic status were collected. Results: The prevalence rates of tobacco, alcohol, areca quid, and illicit drug use were 28.9%, 47.3%, 13.3%, and 1.6%, respectively. The ages of the first-time users of tobacco, areca quid, and illicit drugs were 19, 19.5, and 20 years, respectively. The major illicit drugs were amphetamine, marijuana, and glue (inhalant) in order of abuse prevalence. The rates of tobacco, alcohol, and areca quid use were higher in illicit drug abusers than in nonabusers. The users of tobacco and areca quid had a higher risk of illicit drug abuse than did the nonusers. In addition, the risk of illicit drug abuse was significantly higher ill the subjects who were unmarried, had an income, and had low education levels than in those who were married, had no income, and had high education levels. Conclusion: This study showed that tobacco and areca quid use is more strongly correlated with illicit drug use than is drinking. Because curiosity is the major cause of first-time substance abuse, it is imperative to prevent substance abuse by educating the public on the dangers of gateway drugs and the risk factors associated with the abuse of illicit drugs.
• 274 - 282
• 10.6288/TJPH2006-25-04-04

• Link 原著 Original Article
• 實施“前胎剖腹產之陰道生產”論病例計酬對醫師執行剖腹產後自然產之影響Impact of Case Payment on Physicians Practicing Vaginal Birth after Cesarean Section
• 蔡雅慧、黃國哲、 宋永魁
  Ya-Hui Tsai, Kuo-Cherh Huang, Yung-Kuei Soong
• 前胎剖腹產之陰道生產 ； 論病例計酬
  vaginal birth after cesarean section ; case payment
• 無
  Objectives: To reduce the cesarean delivery rate, Taiwan's Bureau of National Health Insurance (BNHI) introduced the ”Vaginal Birth after Cesarean Section” (VBAC) case payment program on April 1, 2003. The purpose of the current study was to determine the impact of case payment on physicians practicing VBAC. Methods: The data used in the study were derived from the health care system in Taiwan, including four of the system's hospitals, 30 obstetric attendings, and 2,246 gravidas with a previous cesarean section delivery under the attending physician's care. A paired t-test was used to analyze the VBAC rate before and after the introduction of the VBAC case payment initiative. Logistic regression analysis was then performed to determine the relationship between VBAC case payment and the likelihood of physicians practicing VBAC, controlling for related variables, such as previous cesarean section delivery of the sample gravidas. Results: After implementation of VBAC case payments, the VBAC rates at the sampled hospitals increased 6.06% (p<0.001). Logistic regression analysis showed that implementation of VBAC case payments and major clinical diagnoses were significant predictors of physicians practicing VBAC. Conclusions: The results of the current study indicate that after implementation of the VBAC case payment initiative, physicians demonstrated an increased tendency to offer VBAC. Thus, financial incentives exert an impact on a physician's practice behavior.
• 283 - 292
• 10.6288/TJPH2006-25-04-05

• Link 原著 Original Article
• 病患與醫師間良好關係是否會增強其對醫院的忠誠度呢？Does a Good patient-physician Relationship Enhance Patient Loyalty to a Hospital?
• 翁瑞宏、黃靖媛、黃金安
  Rhay-Hung Weng, Ching-Yuan Huang, Jin-An Huang
• 病患忠誠度 ； 關係品質 ； 關係行銷 ； 醫病關係
  Patient loyalty ; Relationship quality ; Relationship marketing ; Patient-physician relationship
• 目標：探討病患與醫師間良好關係品質對其醫院忠誠度的影響路徑，本研究推導出三項假設，共包含兩條透過病患之醫院關係品質與醫師忠誠度的中介性路徑，以及一條病患之醫師關係品質對其醫院忠誠度的直接性路徑。方法：以問卷調查的方式，針對三家醫院的門診病患進行實地的訪員問卷調查，總計共收到339份有效問卷。在統計分析方法方面，則採用結構方程模式，針對本研究所提出的研究模型進行驗證。結果：本研究模型具良好的測量信度與建構效度，且整體模式的配適度亦相當良好。統計分析結果發現，病患與醫師間關係品質除了會直接負向影響其對於醫院的忠誠外，另會透過兩項因素（病患之醫院關係品質、病患之醫師忠誠度）的中介來正向影響其對醫院之忠誠度，而整體影響的總效果為0.66。結論：整體看來，病患與醫師間良好的關係品質不僅會增進病患對於該名醫師的忠誠度，亦會提升病患對該醫師所屬醫院之忠誠度。
  Objectives: The purpose of the current study was to explore the impact that patient-physician relationships have on patients' loyalty to hospitals. We hypothesized that the quality of the patient-physician relationship has a direct link with a patient's loyalty to a hospital, as well as an indirect links via the quality of the patient-hospital relationship and a patient's loyalty to their physician. Methods: Self-administered questionnaires were used to collect all data. The sample consisted of 339 ambulatory patients from three regional hospitals in Taiwan. A structural equation model was used to validate the research model. Results: The measure reliability, construct validity, and model fitness of the research model were satisfactory. In addition to having a direct negative influence, two factors (i.e., the quality of the patient-hospital relationship and a patient's loyalty to their physician) positively effected the impact of the quality of the patient-physician relationship on a patient's loyalty to a hospital. The total effect of the quality of the patient-physician relationship was 0.66. Conclusions: Overall, the quality of the patient-physician relationship not only enhanced patient loyalty to their physician, but strengthened a patient's loyalty to a hospital.
• 293 - 302
• 10.6288/TJPH2006-25-04-06

• Link 實務 Public Health Practice
• 簡易視力篩檢表用於65歲以上老人之信度與效度評估Assessment of the Validity and Reliability of the Simplified Visual Acuity Chart When Administered to Adults 65 Years of Age and Older
• 張雪會、劉靜芸、黃茜莉、程景煜、李中一
  Hsueh-Hui Chang, Jing-Yun Liu, Chie-Li Huang, Ching-Yu Cheng, Chung-Yi Li
• 老人 ； 篩檢 ； 視力清楚 ； 效度 ； 信度
  elderly ; screening ; visual acuity ; validity ; relability
• 目標：對於大規模視力篩檢而言，簡易視力篩檢表因攜帶方便、施測容易而有其使用上的優勢。本研究利用簡易視力篩檢表和傳統E字視力表針對一65歲以上老人樣本進行視力測驗，以評估簡易視力篩檢表的效度與信度。方法：2005年3月初開始收案，針對收案期間首次前來衛生所之65歲以上老人，徵詢其參與研究之意願，獲得新竹縣兩衛生所共38名門診病人，研究樣本同時接受簡易視力篩檢表及E字視力表之檢查（黃金標準），間隔一週後，再回衛生所接受簡易視力篩檢表之複測。計算正確率、敏感度與特異性作為效度指標，另外計算Kappa係數以評估信度。結果：根據簡易視力篩檢表測驗的結果，研究樣本左眼、右眼、與雙眼視力小於0.5之比例分別為52.6%、50.0%、與42.1%，其相對應之正確率分別為0.82、0.84與0.82；敏感度為1.00、0.93與0.91：特異度則是為0.72、0.78與0.78。兩次利用簡易視力篩檢表測驗的結果，左眼、右眼與雙眼的一致性Kappa係數分別為0.79、0.74與0.73。結論：簡易視力篩檢表有不錯的再測信度，但利用簡易視力篩檢表針對老人進行視力篩檢所獲得的視力障礙盛行率將高於E字視力表檢查的結果。
  Objective: An enormous potential exists for use of the Simplified Visual Acuity Card (SVAC) in conducting mass eye screening because it can be easily utilized in the field. The purpose of the current study was to compare the SVAC with Snellen's chart in a sample of adults >65 years of age. Methods: Thirty-eight elderly adults attending one of two Hsin-Chu County primary health centers in March 2005 volunteered to participate in the study. The SVAC and Snellen's chart were simultaneously administered to the participants, and the SVAC was administered again one week later. The accuracy, sensitivity, specificity, and Kappa coefficient of the SVAC were calculated to assess SVAC validity and reliability. Results: Based on SVAC testing, the prevalence of visual acuity in the study population was determined to be 52.6%, 50.0%, and 42.1% for the left eye, right eye, and both eyes, respectively, consistent with corresponding accuracy rates of 0.82, 0.84, and 0.82, sensitivities of 1.00, 0.93, and 0.91, and specificities of 0.72, 0.78, and 0.78. On the basis of the SVAC test-retest data, the Kappa coefficient was estimated to be 0.79, 0.74, and 0.73 for the left eye, right eye, and both eyes, respectively. Conclusions: The test-retest reliability for the SVAC was satisfactory; however, the prevalence of visual impairment estimated using the SVAC in elderly adults was higher than when tested with Snellen's chart.
• 303 - 309
• 10.6288/TJPH2006-25-04-07

• Link 實務 Public Health Practice
• 大陸湖北省荊州區醫療機構安全注射調查An Investigation of Safe Injection Practices of Health Facilities in Jingzhou District, Hubei, China
• 嚴有望、張光萍、張安強、陳愚、關勇、敖紅平
  You-Wang Yan, Guang-Ping Zhang, An-Qiang Zhang, Yu Chen, Yong Guan, Hong-Ping Ao
• 醫療機構 ； 安全注射 ； 調查
  Health care facility ; Safe injection ; Investigation
• 目標：瞭解荊州區各級醫療機構安全注射現況和醫護人員的安全注射知識，提供衛生行政部門制定安全注射管理措施之依據。方法：以4家區直醫院和用分層隨機抽樣方法抽出的6家鎮衛生院、14家村衛生室和14家社區衛生服務站為樣本，通過抽查2004年病歷和門診處方、現場觀察、問卷調查醫護人員等方法，瞭解病人的注射情況、注射品質、及醫護人員的安全注射知識。結果：查住院病歷1,452份，注射率為99.86%，平均每人注射10.92針次，抗生素注射率為48.40%，靜脈注射為主要途徑(64%)。查門診處方5,655張，注射率52.38%，區直醫院最高(64.41%)，以靜脈注射抗生素和抗病毒藥為主。現場觀察不安全注射率為16.00%，不必要注射率為55.43%。調查118名醫護人員，知道不安全注射能傳播愛滋病毒、B和C型肝炎病毒的比率分別為94.92%，88.98%和59.32%。結論：荊州區醫療機構的安全注射仍存在很多問題，加強醫護人員的安全注射知識和技能培訓，強化管理措施是非常必要的。
  Objectives: This survey was conducted to assess the status of safe injection practices and professional knowledge of health workers at all levels of the health care system in Jingzhou District, Hubei Province, and to provide useful science data to formulate feasible, standardized injection safety practices. Methods: Four district hospitals, 6 health centers, 14 village clinics, and 14 community health stations were selected by stratified random sampling. Quantitative data were collected from medical records in 2004, observation of injection practices, and interviews with nurses and doctors. Results: Of the 1452 medical records sampled, 1450 (99.86%) identified patients who had received an average of 10.92 injections. The most frequently injected substances were antibiotics (48.40%), and most of the injections were given intravenously (63.35%). Of the 5655 outpatient prescriptions dispensed, 52.38% were for substances requiring injection. The highest rate of injection (64.41%) occurred in district hospitals. Most antibiotics and antiviral drugs were injected intravenously. Field observation found that 16.00% of injections were unsafe and 55.43% were unnecessary. Interviews of 118 professional employees revealed that 94.92%, 88.98%, and 59.32%, knew HIV, HBV, and HCV can be transmitted by injection, respectively. Conclusions: The quality of injection practices has been improved in the medical facilities in Jingzhou District. However, all health workers should receive continuing training to increase their theoretical and practical knowledge of safe injection.
• 310 - 314
• 10.6288/TJPH2006-25-04-08

• Link 實務 Public Health Practice
• 某教學醫院室內空氣之微生物The Microorganisms of Indoor Air in a Teaching Hospital
• 黃麗玲、毛義方、陳美蓮、黃建財
  Li-Ling Huang, I-Fang Mao, Mei-Lien Chen, Chien-Tsai Huang
• 醫院 ； 安德森一階生物氣膠採樣器 ； 細菌 ； 黴菌
  hospital ; one-stage Andersen microbial particle sizing sampler ; bacteria ; fungi
• 無
  Objectives: The purpose of this study was to determine the level and species of air microorganisms in a teaching hospital so that improvements in air quality could be made. Methods: A one-stage Andersen microbial particle sizing sampler was used to sample the air at five units ill this hospital. On the basis of these results, consecutive sampling and analyses were conducted at one of the locations where the highest microbial levels were found. Results: The levels of air bacteria in the respiratory care ward were comparatively high: daytime levels exceeded the low bacteria standard of 200 cfu/m^3, and the peak level of 934 cfu/m^3 occurred between 1300 and 1500 h. Total bacterial counts correlated positively with relative humidity and the level of carbon dioxide (P<0.01). Coagulase-negative Staphylococci (31.3%) and Staphylococcus aureus (18.8%) were commonly detected in the air of the respiratory care ward, and the dominant fungi species detected were Penicillium (16.7%) and Aspergillus (12.5%). Conclusions: The findings suggest that this teaching hospital should periodically monitor the air for microorganisms. High-efficiency particulate air filters should be used ill areas where those susceptible to infections exist. Appropriate relative humidity levels should be maintained, and the gate-control feature of the ventilation system should be activated to prevent airborne nosocomial infections.
• 315 - 322
• 10.6288/TJPH2006-25-04-09