32卷4期

• Link 公衛論壇 Public Health Forum
• 醫療旅遊對醫療體系的潛在衝擊Pootential impact of medical tourism on medical care systems
• 吳彥莉、 鄭雅文
  Yawen Cheng
• 無
  none
• 無
  none
• 303 - 308
• 10.6288/TJPH2013-32-04-01

• Link 綜論 Review Article
• 人類乳突病毒疫苗接種政策：公共衛生倫理觀點Human Papillomavirus Vaccination Policy: a Public Health Ethics Perspective
• 詹明錦、邱勝康、吳建昌、方啟泰
  Min-Chin Chan, Shen-Kang Chiu, Kevin Chien-Chang Wu, Chi-Tai Fang
• 人類乳突病毒 ； 疫苗 ； 子宮頸癌 ； 公共衛生倫理
  human papillomavirus ; vaccine ; cervical cancer ; public health ethics
• 人類乳突病毒（Human papillomavirus, HPV）是子宮頸癌的主要致病因子。目前已有兩種HPV疫苗，分別為四價（HPV-6, 11, 16及18）及二價（HPV-16, 18），核准於26歲以下的青少女使用。由於定價昂貴，且長期保護力及疫苗安全性有待觀察，對HPV 疫苗接種政策出現若干不同意見。本文回顧相關文獻，並從美國Centers for Diseases Control and Prevention與Public Health Leadership Society共同制定的歷史性文獻Principles of the Ethical Practice of Public Health所揭櫫的公共衛生倫理（Public health ethics）原則來剖析「是否應強制全面接種HPV疫苗」及「是否應公費補助接種HPV疫苗」兩個議題。我們認為，在目前有限之資料下，是否強制施打，仍有商榷餘地，將來更需要進行公開透明之政策討論，取得公眾之信任，以決定HPV疫苗之強制施打是否能夠通過比例原則之考量。是否公費補助則必須考量成本效益，在最佳條件之假設下，成本效益分析顯示HPV疫苗在台灣具成本效益，因此，以公費補助低收入戶少女接種HPV疫苗，應是目前適當的做法。
  Human papillomavirus (HPV) is a major factor in the etiology of cervical cancer. Two HPV vaccines, HPV4 (against HPV types 6, 11, 16, and 18) and HPV2 (against HPV 16 and 18), have been approved for adolescent girls younger than age 26. Due to concerns about the price, duration of protection, and vaccine safety, opinions differ on HPV vaccination policy. We reviewed the literature, and considered two issues from the public health ethics perspective highlighted in ”Principles of the Ethical Practice of Public Health” co-issued by the United States Centers for Diseases Control and Prevention and the Public Health Leadership Society: (1) whether or not HPV vaccination should be mandatory, and (2) whether HPV vaccination should be paid for by the government. Given the limited current information, it is still debatable whether to adopt an obligatory HPV vaccination program. In the future, it will be necessary for policy makers to engage the public in open and transparent deliberation and earn the public’s trust in seeing obligatory HPV vaccination as compatible with the principle of proportionality. In the best case scenario, analysis shows that it is cost-effective for people to voluntarily receive HPV vaccination. Currently, it is appropriate for the government to provide financial support to girls from lowincome families.
• 309 - 319
• 10.6288/TJPH2013-32-04-02

• Link 原著 Original Article
• 區域透析資源對基層腎臟科醫師產出表現之影響The Impact of Regional Dialysis Resources on Primary Nephrologists' Productivity on Terms of Patient Care
• 陳怡潔、吳肖琪
  Yi-Chieh Chen, Shiao-Chi Wu
• 區域透析資源 ； 基層腎臟科醫師人力 ； 產出表現
  regional dialysis resources ; primary nephrologist labor ; output performance
• 目標：應用標準位置理論及環境選擇模式分析台灣各鄉鎮市區血液透析床資源與基層腎臟科醫師產出表現的關係。方法：利用國家衛生研究院全民健康保險資料庫，以回溯性世代研究探討2007年鄉鎮市區透析資源對已執業及新執業基層腎臟科醫師於2009年產出表現之影響，採piecewise迴歸及逐步複迴歸分析。結果：血液透析床資源飽和程度對已執業醫師與新執業醫師產出未達統計上顯著差異，基層腎臟科醫師之總申報金額隨血液透析床資源飽和程度僅有小幅下降。醫師產出隨都市化程度往鄉鎮市區降低而增加，2007年每萬人口醫院血液透析床越多，已執業醫師2009年總申報金額會減少0.5%，而新執業醫師總申報金額降低0.38%。結論：血液透析床資源飽和程度可能影響醫師間的競爭情形，使基層腎臟科醫師之產出增加趨勢有減緩現象，且每萬人口醫院血液透析床越多則基層腎臟科醫師之產出下降。
  Objectives: This study applied standard location theory and the environmental selection mode to examine the relationship between a township's dialysis resources and primary nephrologists' productivity in Taiwan. Methods: This was a retrospective cohort study using the National Health Insurance database. The study subjects were licensed nephrologists who had practiced dialysis services from 2007 to 2009. Piecewise regression and stepwise linear regression were applied to explore whether a township's dialysis resources in 2007 were associated with primary nephrologists' production in terms of patient care in 2009. Results: The number of hemodialysis beds per ten thousand population had no significant impact on the nephrologists' total outpatient income. The nephrologists' production in terms of patient care increased over time, but at a descending pace. Primary nephrologists who practiced in suburban townships tended to raise their production of patient care. In townships with more hemodialysis hospital beds per ten thousand population in 2007, established primary nephrologists' output decreased by 0.5% in 2009, while new primary nephrologists' output decreased by 0.38%. Conclusions: Fewer than 10 hemodialysis beds/10,000 population may have an impact on competition among primary nephrologists and lead to the descending pace of increase in productivity. In townships with more hemodialysis hospital beds per ten thousand population, practicing primary nephrologists' output decreased.
• 320 - 330
• 10.6288/TJPH2013-32-04-03

• Link 原著 Original Article
• 重大傷病患者家戶所得與醫療利用、存活狀況之相關—以末期腎臟病與癌症為例The Association of Household Income, Healthcare Utilization, and Survival of Catastrophic Illnesses Patients: Using ESRD and Cancer as Examples
• 魏璽倫、楊銘欽
  Shi-Lun Wei, Ming-Chin Yang
• 全民健康保險 ； 重大傷病 ； 家戶所得 ； 醫療利用 ； 存活狀況
  National Health Insurance ; catastrophic illness ; household income ; healthcare utilization ; survival
• 無
  Objectives: To investigate the association of household income and healthcare utilization as well as survival status of patients with catastrophic illnesses under the NHI system in Taiwan. Methods: Data from the ”Survey of Family Income and Expenditure” (2003 to 2006) and the ”Registry of patients with catastrophic illness” were first linked to identify subjects. Patients with cancer or end stage renal disease (ESRD) holding only one NHI catastrophic illness card were included in this study. Information related to healthcare utilization was obtained from NHI claims data (2002 to 2007) and survival data was obtained from the ”National Registry of Deaths” (2003 to 2009). Negative binominal regression, multiple regression, and the Cox proportional hazard model were used to analyze the relationships among healthcare utilization, survival, and socioeconomic variables. Results: Regarding the healthcare utilization, the average length of stay (ALOS) of ESRD patients in the highest income bracket was 8.987 days longer than that of patients in the lowest bracket (p<0.05). Hemodialysis usage, the number of outpatient visits and hospitalizations presented no correlation with household income. Among cancer patients in the highest income bracket, the IRRs of outpatient visits and hospitalization were 1.18 (p<0.05) and 2.11 (p<0.001), respectively. The ALOS of those in the highest income bracket was 11.36 days longer than that of patients in the lowest income bracket (p<0.001). With respect to survival status, male ESRD patients had a higher mortality than females (HR=1.82, p<0.05). Among cancer patients, being males (HR=1.66, p<0.05) and in the highest income bracket had higher mortality (HR=1.6, p<0.05), those with the highest education level had lower mortality (HR=0.52, p<0.05). Conclusions: The relationship between household income and healthcare utilization varied according to type of diseases. Income level was positively associated with healthcare utilization among cancer patients while patients in the highest income bracket had higher mortality. But the association was not significant among ESRD patients. Future researchers can conduct further analyses on other catastrophic illnesses.
• 331 - 345
• 10.6288/TJPH2013-32-04-04

• Link 原著 Original Article
• 長期追蹤台灣學齡前兒童二至五歲含糖飲料及糕餅點心與精製糖攝取情形A Long-Term Follow-Up Study of Sugar Sweetened Beverages, Snacks and Desserts, and Refined Sugar Consumption among Preschoolers Aged 2 To 5 in Taiwan
• 盧立卿、楊蕓菁、尤宣文
  Li-Ching Lyu, Yun-Chin Yang, Hsuan-Wen Yu
• 學齡前兒童 ； 含糖飲料 ； 糕餅點心 ； 精製糖 ； 世代研究
  Preschoolers ; sugar sweetened beverages ; snacks and desserts ; refined sugar ; prospective cohort study
• 無
  Objectives: The purpose of this study is to examine the consumption of sugar-sweetened beverages, snacks and desserts among pre-school children and estimate the intake of refined sugar among children aged 2 to 5 by a prospective cohort. Methods: Total 301 infants were followed up annually to the age of 5 (n=132). The intake of refined sugar is calculated by using 24-hour recalls. Estimated percentages of refined sugar in various food products are used in order to obtain the average daily intakes. Results: The consumption of sugar-sweetened beverages increased with age. ”Flavored and fermented milk” contributed to the highest percentage among children aged 2-5, while the ”whole grains drinks” and ”tea drinks” showed an increasing trend over the years and the ”tea drinks” increased its consumption sharply. For snacks and desserts, ”biscuits” contributed the highest percentage among children aged 2 to 4, while ”Chinese sweet soup” showed an upward trend over the years with the highest percentage among children aged 5. The estimated refined sugar consumption was 13 ± 12g, 19 ± 16g, 32 ± 18g, 29 ± 20g (p for trend<0.01), energy intake from refined sugar was 5%, 6%, 9% and 8% among children aged 2, 3, 4 and 5, respectively. Conclusions: Over one-third of 5-year old children had over 10% of their caloric intakes from refined sugar. The caffeine in tea may not be suitable for young children. Proper eating habits and a balanced diet could facilitate the normal growth and development of healthy children.
• 346 - 357
• 10.6288/TJPH2013-32-04-05

• Link 原著 Original Article
• 運用修正型健康信念模式比較不同健康風險族群接受口腔黏膜檢查之信念與可能性—以台灣無檳社區計畫活動為例Application of the Modified Health Belief Model for Undergoing Oral Mucosal Examination: Comparison of Different Health Risk Groups
• 吳美宜、郭鐘隆、李明憲、沈婉平
  Mei-Yi Wu, Jong-Long Guo, Ming-Shinn Lee, Wang-Ping Shen
• 健康信念模式 ； 口腔黏膜檢查 ； 不同健康風險族群 ； 結構方程模式
  Health Belief Model ; oral mucosal examination (OME) ; different health risk groups ; Structural Equation Modeling
• 目標：口腔黏膜檢查為偵測口腔癌之有效措施，口腔癌為台灣男性第四位之惡性腫瘤，本研究旨在探討具有酒精、檳榔及吸菸等習慣造成罹患口腔癌之不同健康風險族群接受口腔黏膜檢查的社會心理差異。方法：本研究運用修正型健康信念模式探討參與無檳社區活動計劃居民接受口腔黏膜檢查之信念，共有866位完成問卷測量，我們依據參與者是否有喝酒、嚼食檳榔、吸菸等習慣區分為罹患口腔癌之高、中與低風險組，並採用結構方程模式建立及比較三組不同健康風險族群接受口腔黏膜檢查的可能性與影響路徑之差異。結果：證明修正後的健康信念模式對高、中與低風險組模型配適度良好並可解釋三組接受口腔黏膜檢查之可能性分別為50%、37%、30%，且三組在健康信念影響接受口腔黏膜檢查可能性之直接與間接路徑上有顯著差異。結論：不同健康風險族群接受口腔黏膜檢查可能性之健康信念與影響路徑有顯著差異，建議未來教育介入針對不同健康風險族群宜採取不同介入模式以提高無檳社區計畫之有效性。
  Objectives: Oral mucosal examination (OME) is an effective measure for detecting oral cancer, which is the fourth leading cause of cancer deaths among males in Taiwan. Despite this fact, there is a lack of literature concerning the likelihood of undergoing an OME among different health risk groups based on individuals’ habits of drinking alcohol, chewing betel quid, and smoking cigarettes. Methods: We applied a modified form of the Health Belief Model (HBM) to explore the likelihood that a sample of individuals participating in a ”Community Free from Betel Quid Chewing” campaign would undergo an OME. Eight-hundred and sixty-six participants completed questionnaires measuring demographic characteristics, alcohol drinking, betel quid chewing, cigarette smoking, health beliefs, cues to action, self-efficacy, and likelihood of undergoing an OME. We used structural equation modeling (SEM) to investigate the direct and indirect paths, to predict the likelihood of undergoing an OME, in three different health risk groups. Classification of participants into groups of high, moderate, and low risk of developing oral cancer was based on the whether or not the participants drank alcohol, chewed betel quid, or smoked cigarettes. Results: The modified HBM demonstrated a good fit among the high, moderate, and low-risk groups, and explained 50%, 37%, and 30% of the variance of undergoing an OME, respectively. The direct and indirect paths influencing the likelihood of undergoing an OME varied significantly among the three groups. Conclusions: Based on the findings, care must be taken when selecting responsive health education for provision to participants with different health beliefs and levels of risks.
• 358 - 371
• 10.6288/TJPH2013-32-04-06

• Link 原著 Original Article
• 台灣地區國中學生霸凌角色之分佈及其與個人和家庭因素之分析Individual and Family Correlates of Bullying Roles among Junior High School Students in Taiwan
• 吳文琪、陸玓玲、李蘭
  Wen-Chi Wu, Dih-Ling Luh, Lee-Lan Yen
• 霸凌角色 ； 盛行率 ； 台灣國中生
  the roles of bullying ; prevalence ; Taiwanese junior high school students
• 目標：霸凌事件是值得研究的公共衛生議題。本文目的乃描述台灣地區公立國中學生之霸凌角色的分佈，並探討與其相關之個人及家庭因素。方法：為獲得台灣地區具代表性之公立國中生樣本，因此先自台灣北、中、南、東各區，以系統抽樣的方式抽出五間學校，每校每年級選兩班作為研究樣本。最後共20間學校，120個班級參加調查，於2010年9至12月完訪3,441人。為考量設計效果，以抽取率的倒數作為權值，並以SAS 9.1.3之Proc Survey模組進行描述統計及多項式邏輯斯迴歸分析。結果：台灣地區國中生有8.71%為霸凌者、7.01%為被霸凌者，2.91%為雙重身份者，共18.63%為霸凌事件的涉入者。性別、衝動人格、自覺受歡迎程度、父母最高教育程度、家庭衝突頻率、口語責罵頻率及體罰頻率分別與霸凌角色有不同的關連性。結論：霸凌事件在國中盛行，建議在國中之前即可發展預防介入計畫。不同霸凌角色之相關因素不同，應針對不同角色設計介入方案。整體而言，建議家庭增加良性互動和減少衝突及過度責罰。
  Objectives: Bullying is an important public health issue. The aims of this study were to demonstrate the prevalence of bullying roles and to investigate individual and family correlates of these roles among 7th to 9th graders in Taiwan. Methods: Participants included 3,441 students from 120 classes in 20 schools via stratified, multistage, random cluster sampling. To estimate the prevalence of roles in bullying, the weighting index was calculated from the inverse of the sampling rates. Descriptive analysis and multinomial logistic regression were performed using SAS Survey Analysis PROCs software. Results: Our survey revealed that 18.63% of the students were involved in bullying with 8.71% as bullies, 7.01% as victims, and 2.91% in both roles. Gender, level of impulsiveness, self-perceived popularity, parental educational attainment, the frequency of family conflict, scolding, and corporal punishment were significantly related to the probability of being classified in one bullying role or another. Conclusions: School bullying is not uncommon in Taiwan. Our results suggested that individual characteristics and family factors associated with bullying roles should be taken into account in the development of programs to prevent bullying.
• 372 - 381
• 10.6288/TJPH2013-32-04-07

• Link 評論 Commentary
• 評論：台灣地區國中學生霸凌角色之分佈及其與個人和家庭因素之分析Commentary: Individual and Family Correlates of Bullying Roles among Junior High School Students in Taiwan
• 李明憲
  Ming-Shinn Lee
• 無
  none
• 無
  none
• 382 - 382
• 10.6288/TJPH2013-32-04-08

• Link 評論 Commentary
• 作者回復：台灣地區國中學生霸凌角色之分佈及其與個人和家庭因素之分析Author's Response to Commentary: Individual and Family Correlates of Bullying Roles among Junior High School Students in Taiwan
• 吳文琪、陸玓玲、李蘭
  Wen-Chi Wu, Dih-Ling Luh, Lee-Lan Yen
• 無
  none
• 無
  none
• 382 - 382
• 10.6288/TJPH2013-32-04-08

• Link 原著 Original Article
• 台灣中老年人慢性期中風患者身心健康之退化狀況The Decline in Physical and Mental Health among Older Chronic Stroke Patients in Taiwan
• 王思涵、王俊毅
  Szu-Han Wang, Jiun-Yi Wang
• 中老年人 ； 中風 ； 退化 ； 心理健康 ； 身體功能
  older people ; stroke ; decline ; mental health ; physical functions
• 目標：中風是造成老人身心障礙的主因之一。本研究旨在探討台灣中老年中風患者之身心健康退化狀況。方法：擷取「台灣中老年人身心社會生活狀況長期追蹤調查」1999及2003二個年度資料，依二年度中風病史紀錄將個體分為「無中風病史組」（3,207人）、「新發中風個案組」（170人）及「慢性期中風個案組」（109人），分析三組中老年人身心健康狀態。身心健康指標，包括健康自評、基本／工具性日常生活功能、認知困難、憂鬱傾向及生活滿意度等測量。以成對樣本t檢定、Wilcoxon符號化等級檢定及廣義線性方程式分析三組中老年人在二年度間身心健康的退化及其差異。結果：三組中老年人自1999年其後4年的身體健康狀態均明顯退化，「新發中風個案組」身體功能退化尤其明顯；但「慢性期中風個案組」在身心健康六項指標中，有五項的退化幅度與「無中風病史組」無顯著差異。結論：中風是造成患者身心健康狀態改變的重要因素。而慢性期中風患者在多數的身心健康指標之退化並未比無中風者明顯，顯示中風患者在慢性期後身體功能的退化，雖有部分是中風後遺症導致，但老化可能是更大的影響因素。建議慢性期中風患者可透過各種健康促進活動，延遲老化所帶來的衝擊。本研究將中風對患者的影響初步量化，其結果可作為社會政策擬定及照護資源分配的部分參考。
  Objectives: Stroke is one of the main causes of physical and mental disability among the elderly. This study investigated the decline in physical and mental health among older stroke patients in Taiwan. Methods: Subjects who completed interviews as part of the Taiwan Longitudinal Study of Aging in both 1999 and 2003 were included. According to their stroke histories, subjects were grouped into three sub-groups: 3,207 never had a stroke, 170 had a stroke between 1999 and 2003, and 109 had a stroke before 1999. Several measures of physical and mental health were analyzed. These included self-rated health status, basic/instrumental activities of daily living, cognitive disability, depression and life satisfaction. Paired-t tests, the Wilcoxon signed-rank test and generalized estimating equations were used to analyze the decline and the differences in physical and mental health of the three groups. Results: After 4 years of followup, all three groups of older people declined in physical health, especially those subjects who had strokes between 1999 and 2003. There was no difference in the decline in physical and mental health between those subjects who had a stroke before 1999 and those who never had a stroke. Conclusions: A stroke could have a significant impact on the physical and mental health of older people; however, on most health indicators, the decline among chronic stroke patients was not significantly different from that of those who never had a stroke. This suggests that the decline in chronic stroke patients is not only a sequel to a stroke but also a result of aging. Chronic stroke patients could participate in health promotion programs to slow down the impact of aging. This study roughly quantified the impact of strokes on older people and could serve as a reference for social welfare planning and the allocation of health care resources.
• 383 - 392
• 10.6288/TJPH2013-32-04-10

• Link 原著 Original Article
• 台灣簡易七題版口腔健康衝擊量表（OHIP-7T）之發展與驗證Development and Validation of the Taiwanese Short-form of the Oral Health Impact Profile (OHIP-7T)
• 郭曉菁、 陳人豪、 賴辛癸、沈雅春、 王震乾、楊奕馨
  Hsiao-Ching Kuo, Jen-Hao Chen, Shin-Kuei Lai, Ya-Chun Shen, Jen-Chyan Wang, Yi-Hsin Yang
• 口腔健康衝擊量表 ； 生活品質 ； 老人 ； 復物
  oral health impact profile ; quality of life ; elderly ; prosthesis
• 無
  Objectives: The aim was to develop and validate the Taiwanese short-form of the Oral Health Impact Profile-an instrument used to assess oral health-related quality of life. Methods: A sevenitem short form was developed using the best subset controlled regression procedure. Two samples, one from the general elderly population (n=1,402) and the other from among patients with prostheses (n=116) were used to investigate validity and internal consistency. Responsiveness was assessed in 91 of the patients treated with prostheses. Results: Associations between (OHIP-7T) scores and self-reports of oral health status and disorders in the general elderly population and among prosthetic patients were interpreted as support for validity. The instrument's internal consistency (Cronbach's alpha: 0.79–0.83) and responsiveness (effect size: 1.51) were sufficient. Conclusions: This study developed and validated the sufficient discriminatory ability and responsiveness of the shortform OHIP-7T, and it may now be used in national surveys in Taiwan.
• 393 - 402
• 10.6288/TJPH2013-32-04-11