30卷6期

• Link 綜論 Review Article
• 台灣社會政治環境變遷、防治策略與登革熱流行及未來展望The Relationships among Socio-political/Environmental Changes, Prevention and Control Strategies, and Epidemics of Dengue Fever in Taiwan-Future Prospects
• 董宗華、蔡坤憲、金傳蓬、黃彥彰、金傳春
  Tsung-Hua Tung, Kun-Hsien Tsai, Chwan-Pong King, Scott Yan-Jang Huang, Chwan-Chuen King
• 登革熱 ； 環境變遷 ； 防治策略 ； 傳染病偵測 ； 全球衛生
  Dengue ; Environment change ; Control Strategies ; Infectious Diseases Surveillance ; Global Health
• 台灣登革流行史，自南洋戰爭、戒嚴、環境整治至今日防疫，恰是台灣社會變遷最速期。而交通發展、都市化加速疾病傳播效率，政治民主化與媒體致防治困難，消費型態改變增病媒蚊滋生處，尤其全球氣候變遷更對病媒蚊生長與傳播影響深遠。本文以大尺度社會與政治變遷為背景溯析與登革流行相關的外在變化，進而由組織架構更替、登革偵測系統、防治作為與全球氣候變遷的面向，嘗試探索其對流行的影響。中央／地方政府、基層衛生人員與民眾合作無間為台灣登革防治成功的重要關鍵。因選舉年基層動員及空窗期而無暇防疫，致使2002、2006及2010年平均本土病例數較往年為高[平均±標準差：1526.3±928.1（在2002、2006、2010的三選舉年）] vs 156.9±181.6[在非選舉年（1999～2001、2003～2005、2007～2009）, p＝0.004）]。台灣近年在偵測系統與實驗診斷有長足的進步，是目前登革防治的最大優勢，但基層公共衛生功能與防疫人才流失為兩大隱憂，尤其過去與民眾關係最密切的里長及衛生所防疫功能漸失。全球暖化後，登革防治為全球衛生的重要議題，因此系統化跨年檢討台灣登革流行，期能鑑往知來，對未來全球登革防治盡棉薄之力。（台灣衛誌2011；30（6）：517－532）
  The history of dengue epidemics in Taiwan has spanned World War II, martial law, and environmental remediation. We are currently in a period of rapid social change with an emphasis on disease prevention. Urbanization and mass-transportation systems have facilitated viral transmission, while democratization, mass media, changing patterns of consumption, and global climate change have all created more difficulties in prevention and control. The aim of this article was to retrospectively examine the relationship between epidemics of dengue/dengue hemorrhagic fever and ”external changes,” and to explore important factors (organizational structure, surveillance systems and global/regional climate change) that may have had an impact on Taiwan's dengue epidemics. Collaborations among central/local government, public health professionals, and cooperative residents have been the key to success in prevention and control of dengue. The mean number of cases in the years of city-mayor elections (2002, 2006, and 2010) was significantly higher than in those years without an election (1526.3 ± 928.1 vs 156.9 ± 181.6, p = 0.004). This was possibly due to grassroots mobilization and the lack of effective implementation during the transition period. The major strengths in the control of dengue in Taiwan are advancements in the surveillance system and in laboratory diagnosis, however, the diminishing function of local public health agencies and the loss of infectious disease experts are two important problems. The assistance provided by district leaders and officials at local health centers that are closest to residents have gradually gone. Dengue is an important issue in global health in an era of global warming. Our systematic examination of the micro- and macro- factors in the success and failure of prevention and control of dengue over three decades will hopefully be helpful in the global control of dengue. (Taiwan J Public Health. 2011;30(6):517-532)
• 517 - 532
• 10.6288/TJPH2011-30-06-01

• Link 原著 Original Article
• 台灣地區高樓可得性與跳樓自殺之相關The Correlation between Availability of High-rise Buildings and Suicide by Jumping in Taiwan
• 紀玉臨、周孟嫻、謝雨生
  Yu-Lin Chi, Meng-Sian Jhou, Yeu-Sheng Hsieh
• 跳樓自殺 ； 方法可得性 ； 探索式空間資料分析 ； 多層次分析
  Suicide by Jumping ; Availability of Methods ; Exploratory Spatial Data Analysis ; Multilevel Analysis
• 無
  Objectives: The aim of this study was to explore the spatial patterns of suicide by jumping in Taiwan and to examine the effects of the availability of high-rise buildings on suicide completers' propensity to jump from heights. Methods: Data on all completed suicides during the period 1994-2007 (n=50,705) were derived from the cause of death database provided by the Department of Health, Executive Yuan, Taiwan. The proportion of high-rise building at the township-level (n=358) came from the 2000 census of population and housing. Exploratory spatial data analysis methods were used to investigate the spatial patterns of proportions of suicide by jumping and high-rise buildings. Multilevel logistic regressions were employed to assess the association between the township-level availability of high-rise buildings and the individual's choice of suicide methods. Results: The proportion of suicide by jumping showed a significant spatial dependence (Moran's I=0.551, p<0.001). Hot spots were detected in Keelung-Taipei-Taoyuan, Taichung, and Kaohsiung metropolitan areas. Such a spatial pattern coincided with the proportion of high-rise buildings. Results from multilevel models indicated that 10% of the variance in the choice of suicide methods was between townships. After controlling for gender, age, marital status, occupational status, season, period, social fragmentation, economic deprivation, and level of urbanization, we found that the deceased who lived in a township with a greater availability of tall buildings had a significantly higher likelihood of committing suicide by jumping. Conclusions: Since there are significant township-level differences in the proportions of suicide by jumping, community suicide intervention strategies should take these spatial variations into account. Programs to prevent suicide by jumping should be targeted to areas with more high-rise buildings. (Taiwan J Public Health. 2011;30(6):533-546)
• 533 - 546
• 10.6288/TJPH2011-30-06-02

• Link 評論 Commentary
• 評論：台灣地區高樓可得性與跳樓自殺之相關Commentary: The Correlation between Availability of High-rise Buildings and Suicide by Jumping in Taiwan
• 溫在弘
  Tzai-Hung Wen
• 無
  none
• 無
  none
• 547 - 547
• 10.6288/TJPH2011-30-06-03

• Link 評論 Commentary
• 作者回覆：台灣地區高樓可得性與跳樓自殺之相關Response: The Correlation between Availability of High-rise Buildings and Suicide by Jumping in Taiwan
• 紀玉臨、周孟嫻、謝雨生
  Yu-Lin Chi, Meng-Sian Jhou, Yeu-Sheng Hsieh
• 無
  none
• 無
  none
• 548 - 548
• 10.6288/TJPH2011-30-06-04

• Link 原著 Original Article
• 服用雞尾酒療法之愛滋病毒感染者其慢性病盛行率與發生率之探討The Incidence and Prevalence of Chronic Diseases among HIV-Infected Patients on Highly Active Antiretroviral Therapy (HAART)
• 林咏臻、楊靖慧、黃彥芳、賴安琪
  Yung-Jen Lin, Chin-Hui Yang, Yen-Fang Huang, An-Chi Lai
• 人類免疫缺乏病毒 ； 雞尾酒療法 ； 糖尿病 ； 高血壓 ； 高血脂
  HIV ; highly active antiretroviral therapy ; diabetes ; hypertension ; hyperlipidemia
• 無
  Objectives: Although highly active antiretroviral therapy (HAART) can effectively improve immunity, reduce morbidity and mortality, and prolong the life-span of patients infected with human immunodeficiency virus (HIV), it may also increase the risk of chronic diseases and subsequent medical costs. To understand the risks of HAART, the aim of this research was investigate the incidence and prevalence of chronic diseases such as diabetes, hypertension and hyperlipidemia, and to determine the differences between those HIV infected patients with and without HAART regimens. Methods: A prospective observational study was conducted among 1,724 patients diagnosed with HIV infections before 2000 in order to estimate the prevalence and risk of chronic diseases in 2010 for patients, and between those patients with and without HAART regimens. Furthermore, patients completed an interviewer-administered questionnaire to investigate the incidence of chronic diseases. Results: A total of 1,344 patients survived until 2010. In 2010, the prevalence rates among all patients were 7.5% for diabetes, 11.5% for hypertension, and 29.1% for hyperlipidemia. Among the 85.3% of patients who had taken HAART, there were higher prevalence rates for chronic diseases (diabetes: 7.8%>2.2%, hypertension: 11.8% >4.4%, hyperlipidemia: 30.1% >4.4%, p<.001) than for those patients without HAART regimens. After adjustment for age and gender, patients with HAART regimens have significantly higher ORs then did those without HAART regimens (diabetes: 17.8, hypertension: 13.6, hyperlipidemia: 44.2, p<.001). The incidence of diabetes among HIV infected patients was 6.2 cases per 1000 person-years. It was 6.6 cases per 1000 person-years for hypertension, and 28.5 cases per 1000 person-years for hyperlipidemia. Conclusions: The prevalence rates for chronic diseases among HIV-infected patients with HAART were higher than those of patients without HAART regimens. (Taiwan J Public Health. 2011;30(6):549-557)
• 549 - 557
• 10.6288/TJPH2011-30-06-05

• Link 原著 Original Article
• 比較不同地理可近性分析方法於評估台灣各鄉鎮每萬人口西醫師數之差異Comparisons of Different Methods of Geographical Accessibility in Evaluating Township-level Physician-to-Population Ratios in Taiwan
• 章殷超、溫在弘、賴美淑
  Yin-Chao Chang, Tzai-Hung Wen, Mei-Shu Lai
• 醫師人口比 ； 地理可近性 ； 地理修正醫師人口比 ； 地理資訊系統 ； 二階段浮動可近區位法
  physician-to-population ratio ; geographic accessibility ; geographically modified physician-to-population ratio ; geographic information system ; Two-step floating catchment area method
• 目標：適當的資源評估，將影響資源配置的合理性。以往以行政區域每萬人口醫療資源作為評估醫療資源配置的依據之一，由於地理資訊系統能夠掌握複雜的空間變異與差異，本研究旨在比較不同的地理概念所呈現的地理可近性對醫療資源評估的影響。方法：本研究應用「二階段浮動可近區位法」的分析方法，提出兩種具備距離特質的地理可近性評估模式，以2007年台灣本島各鄉鎮的每萬人口西醫師數為例，比較衛生署「現行評估法」與本研究的模式評估結果之差異。結果：本研究的兩種模式與衛生署「現行評估法」的比較結果，其分布差異大且相關度不高（相關係數各為0.38及0.57）。在進行西醫師資源缺乏鄉鎮的判定部分，與健保局判定的結果一致性並不理想（kappa=0.141～0.231）。此外，「新模式」與「現行評估法」之比值在空間單元面積最大組（面積大於112平方公里）有最多的鄉鎮介於0.8－1.25之間，而同組中有最多的鄉鎮評估順位下降大於50名；以鄉鎮人口加總至較大的縣市或區域時，其差異程度降低。結論：本研究顯示具距離特質的地理可近性模式對於評估鄉鎮層次的醫師資源有重大的影響，若未詳加考量將可能導致醫療資源補助的錯置。（台灣衛誌2011；30（6）：558－572）
  Objectives: An appropriate evaluation of the supply of and demand for physician resources is important for the allocation of medical resource. The current evaluation practice, the townshiplevel physician-to-population ratio, cannot capture the characteristics of cross-district movements of the population. The purpose of this study was to use a geographic information system to capture spatial variations in order to compare different methods of spatial accessibility in the evaluation of physician resources. Methods: This study proposed a geographically modified physician-topopulation ratio by using a two-step floating catchment area method which incorporated two different distance-decay functions to evaluate physician resources in Taiwan. These methods were also compared with current evaluation practices. Results: Results from the catchment area method that incorporated two distance-decay functions were different from the current evaluation practice of township level ratios (correlation coefficients were 0.37 and 0.58). The areas of physician shortage identified by these two methods were also different from current evaluation practices (kappa = 0.141-0.231); however, the differences among these methods decreased when township-level population and physician data were aggregated at the county or regional levels. Conclusions: Our significant findings showed that township-level resource allocations could be misplaced if cross-township accessibility were not incorporated in the evaluation models. (Taiwan J Public Health. 2011;30(6):558-572)
• 558 - 572
• 10.6288/TJPH2011-30-06-06

• Link 原著 Original Article
• 探索勞工健康信念與噪音暴露防護行為之關聯Exploring Various Health Beliefs Concerning Hearing Loss and Noise Prevention Among Workers in Relation to their Personal protective behavior
• 黃郁凱、黃俊豪
  Yu-Kai Huang, Jiun-Hau Huang
• 健康信念模式 ； 噪音 ； 聽力損失 ； 勞工
  Health Belief Model ; noise ; hearing loss ; worker
• 目標：探索勞工是否會因為健康信念差異而對於噪音預防個人防護用具的使用有所不同。方法：利用問卷調查的方式，收集34位作業環境有噪音暴露且患有二級聽力損失的勞工做為研究對象，參考健康信念模式，分析勞工健康信念與噪音預防個人防護用具使用之關係。結果：勞工之健康信念中，噪音暴露預防行為的自覺障礙性較高者，其噪音預防個人防護用具的使用意願以及過往實際使用頻率顯著較低；噪音暴露預防行為之自我效能較高者，其使用意願以及過往實際使用頻率顯著較高。此外，因噪音暴露導致聽力損失的自覺嚴重性、噪音暴露預防行為的自覺利益性較高者，使用意願顯著較高。然而，接收資訊之行動線索與勞工過往實際使用頻率並無顯著相關。結論：勞工之健康信念及其對於噪音預防個人防護用具的使用意願有顯著關聯。未來若欲提升現行職業衛生安全教育效果，可參考本研究之結果，改變勞工的健康信念。（台灣衛誌2011；30（6）：573－581）
  Objectives: The objectives of this study were to explore various health beliefs concerning hearing loss and noise prevention, and to examine the relationship of those beliefs with personal protective behavior. Methods: Based on the Health Belief Model as its theoretical framework, this study gathered information with a self-administered questionnaire from a total of 34 workers who had occupational noise exposure and hearing loss. Statistical analyses, including Fisher's exact test, Wilcoxon rank sum test, and the chi-square test, were performed to examine the associations between workers' health beliefs and their personal protective behavior. Results: Perceived barriers were found to be associated with both decreased intention to adopt and decreased actual practice of personal protective behavior. By contrast, greater self-efficacy was associated with an increase in both the intention to adopt and the actual practice of personal protective behavior. Perceived benefits and perceived severity also increased the intention to adopt personal protective behavior; however, cues to action were not significantly associated with increased practice of personal protective behavior. Conclusions: Our findings indicated that workers' health beliefs regarding noise were significantly associated with their personal protective behavior. Accordingly, in order to improve the effectiveness of occupational health education, future programs about noise and hearing loss prevention should consider putting more emphasis on modifying related health beliefs among workers. (Taiwan J Public Health. 2011;30(6):573-581)
• 573 - 581
• 10.6288/TJPH2011-30-06-07

• Link 實務 Public Health Practice
• 民眾溝通特質與策略對醫師滿意與信任的影響The Impact of Personal Communication Characteristics and Strategies for Dialogue on Patients' Satisfaction with and Trust in Physicians
• 洪小涵、邱玉蟬
  Hsiao-Han Hung, Yu-Chan Chiu
• 網路 ； 溝通特質 ； 溝通策略 ； 滿意 ； 信任
  Internet ; communication characteristics ; communication strategy ; satisfaction ; trust
• 目標：網際網路逐漸成為提供病人醫療資訊的重要角色。本研究探討民眾的溝通特質、提問網路資訊策略與感知醫師回應等因素，對醫師滿意與信任的影響。方法：本研究使用網路問卷搜集資料，張貼連結於14個網站，13個個人部落格及寄送電子郵件，共回收231份有效問卷。結果：本研究發現（1）感受到醫師正向回應的人，對醫師比較滿意。（2）個人溝通特質隸屬傾向高（個人希望被所屬團體接納程度愈高者）、採取直接列出資料提問、感受到醫師正向回應的人，對醫師比較信任。結論：民眾溝通特質、提問策略與感知醫師回應，會影響民眾在與醫師討論網路資訊後，對醫師的滿意與信任。建議醫學教育訓練內容應教導醫師如何引導民眾說出資訊來源，提出問題，減少被動的民眾對醫師回應感到不滿意的可能性，促進良好的醫病關係。（台灣衛誌2011；30（6）：582－593）
  Objectives: The Internet has become a major source of health information for the public. This study examined how people's personal communication characteristics, strategies for asking questions, and perceived physician responses influenced their satisfaction with and trust in physicians. Methods: This study used an online survey (N=231). The survey link was posted on 14 cancer support group sites, 13 personal blogs, and also sent out by e-mails. Results: The results showed that (1) People who .perceived more positive feedback from a physician were more likely to have higher satisfaction with physicians. (2) Subordinate communication characteristics and printed information were also associated with greater trust. Conclusions: People's communication characteristics, strategies, and perceived physician feedback had an impact on their satisfaction with and trust in physicians. This study suggests that medical education should improve the physician's ability to provide patients with an opportunity to participate in the discussion in the clinic so as to enhance the physician-patient relationship. (Taiwan J Public Health. 2011;30(6):582-593)
• 582 - 593
• 10.6288/TJPH2011-30-06-08

• Link 實務 Public Health Practice
• 台灣小型醫院防火安全等級評價模式Ranking Evaluation and Analysis of Fire Safety for Small-Scale Hospitals in Taiwan
• 曾偉文、張文成、潘國雄
  Wei-Wen Tseng, Wen-Cheng Chang, Kuo-Hsiung Pan
• 小型醫院 ； 防火安全 ； 評價模式
  small-scale hospitals ; fire safety ; evaluation model
• 目標：針對99床以下小型醫院防火安全進行評價模式開發與試用。方法：藉由案例分析了解小型醫院防火安全問題，初步研擬出我國小型醫院防火安全評價內容，再由模糊德爾非法專家問卷取得評價主、次指標因子，依指標因子再分別進行層級分析法（A.H.P.）專家問卷取得權重，並以25家小型醫院做實證調查分析。結果：以醫療衛生、建管及消防各角度，所研擬之小型醫院防火安全評價項目指標內容，可針對既有小型醫院防火安全之良窳，做出客觀有效的等級評價。結論：提出模式運用、限制及未來改善方向；運用防火安全評價，可將小型醫院予以初步安全分級，就安全評價較低之小型醫院火災風險現況，做為優先予以輔導改善的目標。（台灣衛誌2011；30（6）：594－603）
  Objectives: The aim of this study was to develop a fire safety evaluation model for small-scale hospitals (fewer than 99 beds) in Taiwan and to execute a trial survey. Methods: An evaluation model was developed by means of an analysis of small hospital fire safety problems through case studies. A preliminarily proposal of fire safety evaluation criteria was developed before using the fuzzy Delphi method to obtain primary/secondary index factors which were then evaluated by experts by means of questionnaires. These were then weighted separately by using the Analytical Hierarchy Process. Twenty five small-scale hospitals were the focus of this new model of empirical survey and analysis. Results: The fire safety status of small-scale hospitals can be classified clearly and fairly with an objective and effective evaluation model that meets the criteria of health authorities, building controls, and the fire service. Discussions: Model applications, limitations, and directions for improvement in the near future have been proposed. A comprehensive survey using this model is necessary in order to identify priorities in fire safety for health authorities. (Taiwan J Public Health. 2011;30(6):594-603)
• 594 - 603
• 10.6288/TJPH2011-30-06-09

• Link 實務 Public Health Practice
• 台灣毒品防制政策成效未能彰顯之成因探究The Primary Factors that Affect the Efficacy of Drug Prevention Policies in Taiwan
• 詹中原、陳泉錫
  Chung-Yuang Jan, Chuan-His Chen
• 減害 ； 美沙酮 ； 毒癮者 ； 毒品危害防制中心 ； 再犯率
  Harm reduction ; methadone ; drug offenders ; drug prevention center ; recidivism rate
• 目標：台灣自1993年宣布向毒品宣戰以來，歷經十餘年之施行，毒品犯人數與再犯率並未減緩，反出現增加之趨勢。足見毒品防制政策有全面檢視問題癥結，重新調整執行策略之必要。方法：本文從國家治理及出監毒癮者需求兩個面向分別進行研究。經由深度訪談具實務經驗之矯正機關、毒品防制中心主管，並對7,596名即將出監之毒品犯進行社會適應需求問卷調查，分析歸納影響防制政策成效不顯的主要成因癥結。結果：影響現行毒品防制成效不彰最具關鍵的三項問題為：1.缺少常設之國家級專責機關2.中途處遇機制缺乏3.部會間防制作業程序不一，防治資訊未能整合。在出監藥癮者需求方面，本研究發現出監藥癮者社會適應最大障礙在於找不到工作及避不開毒友的勸誘。結論：毒品防制最待改善之三項關鍵問題與建議可作為政府規劃毒品防制資源投入方向之重要參考。59%出監藥癮者有工作需求，只是不易被社會接受且又躲不開毒友的勸誘終致棄守而再犯，甚值政府重視，並速採對策因應。（台灣衛誌2011；30（6）：604－616）
  Objectives: The Taiwan government has waged war on drugs since 1993; however, after more than 10 years of enforcement, the number of drug offenders continues to increase steadily and the recidivism rate remains high, thereby demonstrating a need to review current drug policies. Methods: This study adopted a multi-method research approach by interviewing the directors of correctional institutions and the managers of drug prevention centers, and conducting a questionnaire survey of 7,596 drug addicts nearing the end of their prison sentences. Results: The three most critical issues affecting the efficacy of drug abuse prevention in Taiwan are: (1) lack of a permanent responsible government department; (2) lack of midway treatment mechanisms; and (3) a lack of integration among drug prevention agencies. On the demand side, 59 % of drug users require a job but have difficulty being accepted by employers; thus results in a high rate of recidivism. This study determined that the biggest obstacles for drug addicts to surmount after leaving prison are the difficulties in securing employment and avoiding temptation from drug-using friends. Conclusions: These three critical issues and the actions suggested in response to them are worth the attention of the government. (Taiwan J Public Health. 2011;30(6):604-616)
• 604 - 616
• 10.6288/TJPH2011-30-06-10