32卷1期

• Link 公衛今與昔 Public Health Now and Then
• 美國海軍第二研究所與台灣公共衛生NAMRU-2 and Taiwan Public Health
• 李孟智
  Meng-Chih Lee
• 無
  none
• 無
  none
• 1-5
• 10.6288/TJPH2013-32-01-01

• Link 綜論 Review Article
• 從學理及行政執行面探討保險對象補充保險費課徵之問題A Review of the National Health Insurance Act's Supplementary Premium
• 韓幸紋
  Hsing-Wen Han
• 公平性 ； 中立性 ； 充足性 ； 穩定性 ； 節約性
  equity ; neutrality ; adequacy ; stability ; compliance
• 為提高健保保費負擔公平性，擴大計費基礎，2011年健保法修正案新增保險對象補充保險費，於2013年開始實施。保險對象之高頒獎金、兼職所得、執行業務收入、股利所得、利息所得及租金收入等所得項目，採就源扣繳方式課徵2%補充保險費。本文先就學理上討論補充保險費課徵方式是否符合健保財源籌措基本原則，從公平性、中立性、充足性、穩定性、節約性等五個面向分析，並由行政執行面列出未來補充保險費課徵時難以執行之處。本文希冀透過不同角度剖析課徵補充保險費可能問題，並提出相關建議，供主管機關未來擬定政策之參考。
  In 2011, an Amendment to the ”National Health Insurance Act” added a new supplementary premium by expanding the calculation base for employees. This is to be implemented on January 1, 2013. This approach will also reinforce the ability-to-pay principle and enlarge the premium base. An insured person will have to pay 2 percent of extra income, including that from interest, professional practice income, rent, stock dividends and bonuses exceeding the equivalent of four months' wages, as their supplementary premium for NHI. This study investigated the problems associated with this supplementary premium based on considerations of equity, neutrality, adequacy, stability, compliance and the administrative aspects, and provides suggestions for improvement.
• 6-17
• 10.6288/TJPH2013-32-01-02

• Link 原著 Original Article
• 健保居家照護使用者急診醫療利用Emergency Department Utilization by National Health Insurance Home-care Recipients
• 吳姿璇、謝碧晴、李中一、蘇慧芳
  Tzu-Hsuan Wu, Pi-Ching Hsieh, Chung-Yi Li, Hui-Fang Su
• 居家照護 ； 急診醫療利用 ； 發生密度 ； Andersen醫療利用模式 ； 全民健保資料庫
  home care ; emergency department utilization ; incidence density ; Andersen health care utilization model ; National Health Insurance Research Database (NHIRD)
• 目標：參考Andersen第一階段醫療服務利用行為模式，探討台灣地區健保居家照護使用者之急診醫療利用情形，以及預測急診就醫罹病發生之影響因素。方法：採回溯性世代追蹤研究設計，資料來源為國衛院發行之全民健康保險資料庫1999至2008年「居家照護特殊需求檔」，研究對象為2000至2008年居家照護新收案個案102,680人；使用卜瓦松迴歸模式預測影響急診就醫全病因與主要系統疾病病因別之罹病發生因素。結果：居家照護使用者急診就醫以循環系統疾病發生密度最高（441.41人次/10^3人年）。研究樣本以男性、65歲以上者、投保所在地於東區分局和大都會區、第二至四類居家護理資源耗用群、具有重大傷病和長期呼吸持依賴者，共存疾病指數3分以上、具有腫瘤、糖尿病與充血性心衰竭合併症者，其急診就醫全病因罹病風險較高。結論：研究發現健保居家照護使用者常因循環、呼吸、泌尿生殖系統等疾病而到急診就醫，特別是循環與泌尿生殖系統疾病，年長者之急診就醫相對風險倍增，值得居家照護提供者進一步檢視其照護需求。
  Objectives: With reference to Phase I of Andersen's Behavioral Model of Health Services Utilization, the researcher investigated emergency department utilization by home-care service recipients with National Health Insurance (NHI) in Taiwan, and examined the predictive factors affecting the risks of morbidity from emergency department utilization. Methods: This design was a retrospective cohort study. Data came from the ”home care specific file” in the National Health Insurance Research Database between 1999 and 2008. The subjects were 102,680 newly NHI homecare service users between 2000 and 2008. The Poisson regression model was used to predict the factors affecting emergency department utilization, morbidity from all causes, and major system classifications. Results: The NHI home-care service users experienced the highest incidence of circulatory system diseases (441.41/10^3 person-year). This study showed that a higher relative risk ratio for emergency department utilization and morbidity from all causes were found in male users, those aged 65 and older, those living in urban areas, Resources Utilization Group Category 2-4 home care consumers, major illness/injury and long-term respiratory dependent cases, cases with a Charlson Comorbidity Index score of 3 and above, and cases with tumors, diabetes and congestive heart failure complications. Conclusions: Based on the findings of this study, the top three reasons for emergency department utilization by home-care service recipients were diseases of the circulatory, respiratory, and urinary/reproductive systems. The adjusted relative risk of emergency department utilization increased dramatically among elders, especially for diseases of the circulatory and urinary/reproductive systems. Health care providers should pay close attention to the care needs of home-care service recipients.
• 18 - 30
• 10.6288/TJPH2013-32-01-03

• Link 原著 Original Article
• 台灣女同志之指險套使用盛行率與相關因素探討Prevalence and Associated Factors of Findom Use among Women Who have Sex with Women in Taiwan
• 梁曉藍、黃俊豪
  Hio-Lam Leung, Jiun-Hau Huang
• 女同志 ； 性健康 ； 指險套 ； 性傳染病 ； 性別平等
  women who have sex with women (WSW) ; sexual health ; Findome ; sexually transmitted infection(STIs) ; gender equality
• 目標：探討台灣女同志在最近一年內進行陰道指交時使用指險套之盛行率，及其使用之相關因素，以提供實證資料作為女同志性健康之衛生教育介入參考。方法：以現居台灣、年滿18歲以上、最近一年內曾與女性進行陰道指交之女同志為研究對象，利用網路問卷的方式，於各大女同志BBS網站進行量性資料收集，有效樣本為397位。結果：本研究發現，僅18.9%女同志在過去一年進行陰道指交時會使用指險套。平均每月收入超過四萬元、過去一年曾在陰道指交行為上有多重女性性伴侶、認為指險套會降低快感、認為其使用很麻煩及對其購買管道不熟悉者，較不可能在過去一年陰道指交時使用指險套；而對於性傳染病自覺罹患性高者，則較可能在過去一年陰道指交時使用指險套。此外，10.8%（43位）女同志曾罹患性傳染病，其中以細菌性陰道炎之盛行率最高（5.3%）。在曾罹患性傳染病之女同志中，44.2%未曾與男性發生過性行為。結論：過去台灣女同志常被認為是性病的低危險群，因此其性健康亦較常被忽視。然而本研究結果顯示，即使從未與男性發生性行為之女同志，仍有罹患性傳染病之風險。再者，女同志之性行為非常多元，其與男同志以及異性戀之性行為亦有差異。在政府大力倡導性別平等之趨勢下，不應忽視性少數族群的健康，並宜儘速制訂相關政策，以促進健康上的性別平等。
  Objectives: To explore the prevalence of and factors associated with Findom use during vaginal fingering in the previous year among women who have sex with women (WSW) in Taiwan, and to provide empirical data that help inform future educational interventions to improve the sexual health of WSW. Methods: Self-administered survey data from 397 WSW were collected via the Bulletin Board System in several forums frequented by most Taiwanese WSW. WSW who were living in Taiwan and at least 18 years old at the time of the survey, and who had vaginal fingering in previous year, were included in the present study. Results: Only 18.9% of the study participants reported Findom use during vaginal fingering in the previous year. Those who had a monthly income of more than NT$40.000, who had multiple female vaginal fingering partners in the previous year, who believed that Findom use would reduce sexual pleasure and was inconvenient, and who were unfamiliar with its venue for purchase, were less likely to have reported fandom use. Those who perceived greater susceptibility to sexually transmitted infections (STIs) were more likely to have reported Findom use. Forty-three participants (10.8%) had contracted STIs, and bacterial vaginosis was the most common STI, with a prevalence estimate of 5.3%. Of those who had contracted STIs, 44.2% never had sex with men. Conclusions: WSW in Taiwan have often been regarded as a low-risk group for STIs, and hence, their sexual health has often been neglected; however, findings of this study showed that even WSW who never had sex with men were still at risk for STIs. In addition, the sexual practices among WSW are diverse and different from those among gays and heterosexuals. Therefore, as the Taiwan government strives for gender equality, the health of sexual minorities should not be ignored, and related policies are urgently needed to promote gender equality in health.
• 31 - 41
• 10.6288/TJPH2013-32-01-04

• Link 原著 Original Article
• 台灣老人營養狀況與認知衰退之關聯性探討The Impact of Nutritional Status on Cognitive Decline in Elderly Taiwanese
• 黃純甄、蔡仲弘
  Chuen J. Huang, Alan C. Tsai
• 認知風險 ； 營養狀況 ； 老年人
  cognitive decline ; nutritional status ; elderly
• 無
  Objectives: To investigate the association of nutritional status and cognitive status and to identify a possible causal role of nutritional status in the future risk of cognitive decline in older Taiwanese. Methods: The study analyzed the 1999 and 2003 datasets of the ”Survey of Health and Living Status of the Elderly in Taiwan”. Subjects were interviewed, face-to-face, with a structured questionnaire. The Mini Nutritional Assessment (MNA) was used to rate nutritional status and the Short Portable Mental Status Questionnaire (SPMSQ)?was used to rate cognitive status. This cross-sectional study included 2,672 elderly at baseline while the longitudinal analysis included the 1895 subject who survived in 2003, less those who had severe cognitive impairment at baseline and those who failed to complete the 2003 interview. Both models controlled for socio-demographic factors, lifestyle, food intake, and health and medical conditions. Results: In regression models that controlled for possible confounders, cross-sectional analysis showed a significant association between nutritional status and cognitive status (OR=2.07, 95% CI=1.57-2.75, p<0.001); whereas the longitudinal analysis showed that poor nutrition was associated with a 43% increase (1.43, 1.01-2.04, p=0.049) in cognitive decline four years later. Conclusions: Results suggest that nutritional status can affect subsequent cognitive function. It is therefore important for the elderly to pay greater attention to their nutritional status in order to reduce the risk of the age-related cognitive decline. The MNA can predict functional decline as well as rate the nutritional status of the elderly.
• 42 - 51
• 10.6288/TJPH2013-32-01-05

• Link 原著 Original Article
• 退休對心理健康之影響—以鎮定安眠藥之使用為指標The Effects of Retirement on Mental Health as Measured by the Use of Hypnotic Drugs
• 孟欣宏、吳春樺、林文德
  Shin-Hung Meng, Chun-Hua Wu, Wen-Der Lin
• 退休 ； 心理健康 ； 鎮靜安眠藥物 ； 傾向分數法
  retirement ; mental health ; hypnotic drugs ; propensity score
• 目標：探討退休者與未退休者在退休者之退休日期前後鎮靜安眠藥使用之變化情形，以瞭解退休對心理健康的影響。方法：本研究利用1999年至2009年之健康保險承保歸人檔資料（LHID2005），分析50-64歲之退休與未退休年者在退休者之退休日期前三年及後六年的鎮靜安眠樂每年定義日劑量（defined daily doses, DDDs）之用量差異。藉由傾向分數配對法（propensity score, PS），依其退休前鎮靜安眠藥利用量分為高、低利用兩組，分別以1 : 1的方式配對產生對照之未退休樣本。最後以無母數的中位數比較方法，分別分析高利利用組的退休與未退休者間用藥量的差異。結果：配對前，高、低利用組分別有16,518人及14,322人，配對後，兩組分別有3,057個配對及3,282個配對，合計6,339組配對，共12,678個樣本。未配對前，退休者的鎮靜安眠藥用量均顯著高於未退休者，但配到後，兩者的用藥型態並沒有顯著差異。結論：退休者的鎮靜安眠藥用量在退休前後數年均顯著高於同年齡的未退休者，顯示退休者可能有較大的心理健康問題而使用較多的鎮靜安眠藥，而退休本身並無法改善其心理健康而減少鎮靜安眠藥的用量。
  Objectives: We investigated the impact of retirement on mental health by examining hypnotic drug use 3 years before and 6 years after retirement for retirees compared with non-retirees. Methods: We designed a retrospective cohort study to explore the association between retirement and hypnotic drug use. The data in this study were retrieved from Taiwan's 2005 Longitudinal Health Insurance Data set which contained 1 million representative samples. The hypnotic drug dosages were obtained from prescription information contained in ambulatory care claims for both retirees and non-retirees between the ages of 50 and 64. We classified the retired people into high-and low-user groups according to the dosages used before retirement. A greedy match based on propensity score (PS) for retirement was used to select comparable samples from those who were not retired. Wilcoxon's rank sum test and signed-rank test were used respectively to examine the difference in hypnotic drug use between retirees and non-retirees year by year before and after PS matching. Results: There were 3,282 and 3,057 pairs in the high- and low-user groups, respectively. Before PS matching, the annual hypnotic dosage for the retired was significantly higher than that for the non-retired samples in both groups; however, after PS matching, the annual dosage for retirees and non-retirees in both groups did not differ significantly. Conclusions: Retirees have more mental health problems as measured by the use of hypnotic drugs. Retirement per se had no positive impact on mental health.
• 52 - 61
• 10.6288/TJPH2013-32-01-06

• Link 原著 Original Article
• 拒菸廣告的恐懼訴求對年輕族群的說服效果：調控焦點與訊息框架之影響The Persuasive Effect of an Appeal to Fear in Anti-tobacco Advertisements: The Influences of Self-regulation and Message Framing in Young Adults
• 汪志堅、楊運秀、李明倩
  Chih-Chien Wang, Yun-Hsiou Yang, Ming-Chian Lee
• 拒菸廣告 ； 恐懼訴求 ； 調控焦點 ； 訊息框架
  anti-tobacco advertisement ; fear appeal ; self-regulatory ; message framing
• 目標：本論文探討恐懼訴求是否有助於提升拒菸廣告的說服效果，以及調控焦點、訊息框架對於恐懼訴求所產生說服效果的影響。方法：本論文共進行二次實證研究，研究一將閱聽人的調控焦點納入考慮，探討恐懼訴求的說服效果是否受閱聽人的調控焦點所影響，受訪者被隨機指派觀看恐懼或非恐懼訴求的拒菸廣告，並被詢問其對於廣告的態度與對於抽菸的態度，以比較恐懼與非恐懼訴求的廣告效果。研究二則將訊息框架對於恐懼訴求的影響納入考慮，採2（恐懼與非恐懼訴求）*2（正面與負面訊息框架）實驗設計，以了解調控焦點、恐懼訴求與訊息框架對於拒菸廣告效果的影響。結果：恐懼廣告的知覺效能及行為意圖高於非恐懼廣告，調控焦點有干擾恐懼訴求對於廣告態度及行為意圖的效果，且訊息框架會干擾拒菸廣告中恐懼訴求的說服效果。結論：經二次實證研究，本論文發現恐懼訴求在某些狀況下，確實能提升說服效果，但調控焦點會干擾恐懼訴求對於拒菸廣告態度行為意圖的影響，而訊息框架的配適性也會對恐懼訴求產生的廣告效果產生影響。
  Objectives: An appeal to fear may attract an audience's attention to anti-smoking advertisements that reveal tobacco to be harmful and lead to Chronic Obstructive Pulmonary Disease. Two empirical studies investigated the persuasive effects of advertisements with appeals to fear and the moderating effect of a self-regulatory focus. Methods: In Study 1. a paper-and-pencil questionnaire survey of 172 subjects was used to compare the persuasive effects of anti-tobacco ads with and without appeals to fear, and to examine the moderating effect of a self regulatory focus. In Study 2, a 2 (fear /non-fear) by 2 (positive /negative framed message) experimental design with 185 subjects was used to examine the moderating effect of message framing on the persuasive effect of an appeal to fear. Results: Audiences' perceived efficacy and behavioral intent were greater when the ad contains appeals to fear. Both a self-regulatory focus and message framing moderated the impact of appeals to fear on the attitudes toward ads and behavioral intent. Conclusions: According to these empirical studies, we found that an appeal to fear could enhance the persuasive effect: however, a self-regulatory focus might moderate the impact of appeals to fear on attitudes toward anti-tobacco advertisements and behavioral intent. Message framing might also moderate the persuasive effect of appeals to fear.
• 62 - 74
• 10.6288/TJPH2013-32-01-07

• Link 評論 Commentary
• 作者回覆：拒菸廣告的恐懼訴求對年輕族群的說服效果：調控焦點與訊息框架之影響Response: The Persuasive Effect of an Appeal to Fear in Anti-tobacco Advertisements: The Influences of Self-regulation and Message Framing in Young Adults
• 楊運秀
  Yun-Hsiou Yang
• 無
  none
• 無
  none
• 75 - 75(2)
• 10.6288/TJPH2013-32-01-09

• Link 評論 Commentary
• 評論：拒菸廣告的恐懼訴求對年輕族群的說服效果：調控焦點與訊息框架之影響Commentary: The Persuasive Effect of an Appeal to Fear in Anti-tobacco Advertisements: The Influences of Self-regulation and Message Framing in Young Adults
• 陳芬苓
  Fen-Ling Chen
• 無
  none
• 無
  none
• 75 - 75
• 10.6288/TJPH2013-32-01-08

• Link 原著 Original Article
• 比較身體質量指數及腰圍預測台灣中老年人糖尿病風險之能力A Comparison of the Abilities of Body Mass Index and Waist Circumference to Predict the Risk of Diabetes in Mid- and Old-age Taiwanese
• 王琴惠、蔡仲弘
  Chin-Hui Wang, Alan C. Tsai
• 身體質量指數 ； 腰圍 ； 糖尿病 ； 中老年人
  BMI ; waist circumference ; diabetes ; older Taiwanese
• 目標：比較台灣中老年人身體質量指紋（BMI）及腰圍與糖尿病的關聯，及其預測罹患糖尿病風險的能力。方法：分析「台灣地區中老年身心社會生活健康狀況長期追蹤調查」2003及2007年4987位?50歲個案的資料。以邏輯斯迴歸分析BMI和腰圍與糖尿病風險的橫斷關聯，及預測2007年新罹患糖尿病的風險。又以受試者工作特徵（Receive r Operating Characteristics, ROC）曲線計算兩指標的預測切點。結果：兩指標都與糖尿病的風險呈顯著關聯，且都具預測未來罹患糖尿病的功能，但是腰圍比BMI關聯強，預測力也較強。腰圍每增加1cm，男性增加6%風險（p=0.001）；女性增加4%（p=0.005）。而兩指標判定糖尿病風險的切點因年齡及性別而異，從50-64歲到?75歲，男性由BMI 24.52 kg/m^2 減到21.82 kg/m^2；女性由24.27 kg/m^2減到22.88 kg/m^2；而腰圍男性由84.5cm增至的89.5 cm；女性由82.5 cm增至91.5 cm。結論：BMI和腰圍皆具預測中老年人罹患糖尿病的能力，但腰圍預測力較強。而兩指標預測罹患糖尿病風險的切結則因性別、年齡而不同。此結果與現行台灣中老年人糖尿病風險的建議切點有所不同。國人的理想切點值應考量性別及年齡的差別。
  Objectives: To evaluate the association of Body Mass Index (BMI) and waist circumference (WC) with the risk for diabetes, and to examine the ability of these measures to predict new cases of diabetes in ?50-year old Taiwanese. Methods: We utilized the 2003 and 2007 ”Survey of Health and Living Status of the Elderly in Taiwan” datasets. We analyzed the cross-sectional associations in 4987 subjects (?50 years old) and the ability of BMI and WC to predict new cases of diabetes in these subjects four years later. We also analyzed the cutoffs with Receiver Operating Characteristics (ROC). Results: Both indicators were associated with a risk for diabetes but WC showed a stronger association. Both indicators significantly predicted the risk for new diabetes, but WC was a stronger predictor. For each 1 cm increment in WC. there was a 6% increase in the risk for new diabetes in men (p=0.001) and a 4% increase in women (p=0.005). The cutoffs for the risk of new onset diabetes differed by age and gender. The BMI cutoff was reduced from 24.52 to 21.82 kg/m^2 for men and 24.27 to 22.88 kg/m^2 for women, whereas the WC cutoff was increased from 84.5 to 89.5 cm for men and 82.5 to 91.5 cm for women. Conclusions: Both BMI and WC were significantly associated with the risk for diabetes or the risk for new diabetes, but the association was stronger with WC for both. The predicted cutoffs for diabetes varied according to age and gender and were different from the current Bureau of Health Promotion recommendations.
• 76 - 84
• 10.6288/TJPH2013-32-01-10

• Link 原著 Original Article
• 國人使用輔助與替代醫療現況及其相關因素：2011年全國性調查分析Conditions for the Use of Complementary and Alternative Medicine in Taiwan: A Nationwide Survey Analysis for 2011
• 章美英、劉介宇、朱美綺、吳宗懋、陳美麗、朱梅綾
  Mei-Ying Chang, Chieh-Yu Liu, Mei-Chi Chu, Tsung-Mao Wu, Mei-Li Chen, Mei-Ling Chu
• 輔助與另類醫療 ； 全國性調查 ； 盛行率 ； 健康資訊來源 ； 使用原因
  Complementary and alternative medicine ; Nationwide Survey ; prevalence ; source of health information ; reason for using
• 目標：瞭解台灣民眾在過去一年內使用輔助與替代醫療（complementary and alternative medicine, CAM）之現況、健康資訊來源、使用原因及使用CAM與人口特徵、健康狀態的相關性。方法：研究對象為18歲以上台灣地區民眾，採用分層隨機抽樣，並且使用中選機率與人數等比例（probability proportional to size. PPS）方式抽樣，並以電腦輔助電話訪問系統（Computer Assisted Telephone Interview, CATI）進行問卷調查，有效樣本數為2,266位。結果：台灣民眾在過去一年內使用CAM用以促進健康或治療疾病的使用率為37.6%。使用CAM的樣式以中藥最多，並以用來治療腰酸背痛、肩頸僵硬／痠痛之肌肉骨骼系統與結締組織問題居多。CAM之健康資訊來源以親朋好友最多，而主要的使用原因是民眾認為西醫常有副作用或誤診。CAM的使用率以女性、青年及中壯年人（20-59歲）、高教育程、具醫療相關教育背景、有工作、高收入、居住高度都市化程度地區及健康狀態較差者居多。結論：台灣民眾使用CAM以促進健康或治療疾病的經驗相當多元，建議政府衛生主管機構應將CAM的相關議題納入健康政策，學校及醫療院所亦須將CAM納入必要之教育訓練，進而加強CAM之實證研究，以確保障國人使用CAM之有效性與安全性。
  Objectives: The purposes of this study were to determine the use of complementary and alternative medicine (CAM), sources of health information, and reasons for using CAM among people in Taiwan in the previous year. The relationships between CAM use, demographic characteristics, and health status were examined. Methods: The participants in this study were people 18 years old or older in Taiwan. Stratified random sampling and probability proportional to size methods were employed for sampling. The Computer Assisted Telephone Interview system was used to conduct a questionnaire-based survey with a total of 2,266 valid samples. Results: The rate of CAM use for health promotion or treatment of diseases during 2011 was 37.6%. Taking Chinese herbal medicine was the most common type of CAM use and people typically utilized CAM to manage musculoskeletal and connective tissue conditions such as waist or back pain or stiff or painful neck and shoulders. Relatives and friends were the primary sources of health information for CAM use, and the primary reasons for using CAM were the beliefs that conventional medical treatments were based on misdiagnoses or often had side effects. Women, adults between 20 and 59 years of age, people with a high level of education, those with a medicine-related educational background, and those who were employed, had a high income level, lived in highly-urbanized areas, or had poor health were more likely to use CAM. Conclusions: When using CAM for health promotion or treatment of disease, people in Taiwan cited diverse experiences. We recommend that health authorities and agencies incorporate CAM-related issues as part of health policy, and schools and healthcare institutions consider CAM as required education and training. Moreover, empirical studies on CAM should be emphasized in order to ensure the effectiveness and safety of CAM use in Taiwan.
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• 10.6288/TJPH2013-32-01-11