32卷5期

• Link 綜論 Review Article
• 以系統性文獻回顧探討台灣居家老年人跌倒之相關或危險因素Risk Factors Related to Falling among the Home-Dwelling Elderly in Taiwan: A Systematic Review
• 陳美芳、林家綾、蔡宗廷、朱素鳳、洪淑玲、顏碧汝、 黃國儀、蔡錦墩
  Mei-Fang Chen, Chia-Lin Lin, Chung-Ting Tsai, Su-Feng Chu, Shu-Ling Hung, Bi-Ju Yen, Kuo-Yi Huang, Jin-Duen Tsai
• 系統性文獻回顧 ； 老人 ； 跌倒
  systematic review ; elderly ; fall
• 本文目的是採系統性文獻回顧法，統整國內居家老年人跌倒之相關或危險因素。搜尋台灣期刊論文索引系統等七個中英文資料庫。經收案與排除條件審核後，共30篇文章符合篩選標準。結果發現有一半以上的研究指出居家老年人跌倒之相關或危險因素有（1）生物因素，包括自評健康差、跌倒危險因子數目多、疾病症狀多、疾病數目多、身體功能惡化、大小便失禁、步態不穩、活動功能差或平衡愈差、日常生活活動或工具性日常生活功能不佳、腰圍愈粗、血中白蛋白愈低、憂鬱、愈害怕跌倒、有跌倒史等。（2）行為因素，包括跌倒預防知識、行為與服用多種藥物等。（3）環境因素，包括支持性環境愈低、臥室、浴室、樓梯安全性差、雜物堆積、昏暗的燈光等。然而，只有少部分的研究發現社經因素，包括婚姻狀況、教育程度與獨居等，與跌倒相關。此結果可做為防範社區老人跌倒之參考。
  The purpose of this article was to review the risk factors related to falling among the home-dwelling elderly in Taiwan. The literature search included seven medical databases in either Chinese or English, including the Periopath index to Taiwan's periodic literature. Thirty studies that met the inclusion criteria for this study were reviewed. The results showed the risk factors related to falling included: (1) Biological factors: poor self-reported health, multiple signs and symptoms of disease, a number of diseases, poor physical function, unstable of gait, poor balance, stool or urinary incontinence, dysfunction in ADLs or IADLs, higher waistline, lower albumin, depression, fear of falling, and a history of falling. (2) Behavioral factors: lack of knowledge about ways to prevent falling and taking multiple medications. (3) Environmental factors: poor supportive environment, poor location of bedrooms and the safety of bedroom bathrooms and stairs, accumulation of debris, smooth ground, and dim lighting. Only a few studies found that social and economic factors, including marital status, level of education, and living alone were significantly associated with falling. The results may serve a reference for preventing falling among the home-dwelling elderly.
• 403 - 423
• 10.6288/TJPH2013-32-05-01

• Link 綜論 Review Article
• 醫療人員針扎之流行病學、經濟耗損與政策議題Needlestick Injuries among Healthcare Workers: Epidemiologic, Economic and Policy Issues
• 吳雪菁、 郭育良、蕭淑銖
  Hsueh-Ching Wu, Leon Yue-Liang Guo, Judith Shu-Chu Shiao
• 針扎 ； 醫療人員 ； 安全針具 ； 流行病學
  needlestick injury ; healthcare workers ; safety needle ; epidemiology
• 針扎是醫療照護人員最常見的職業傷害，對醫療人員的工作安全與健康造成極大的威脅，且遭受針扎後的通報流程與追蹤處理費用，也是醫院的重要經濟成本。而預防針扎最有效的方法為使用安全針具，為了讓醫療人員有更安全的工作環境，除了衛生福利部將「安全針具」列入醫院評鑑內容及感染管制查核外，立法院亦修正「醫療法」，規定五年內醫療機構須逐步完成安全針具的全面性替換。故本文擬就醫療人員發生針扎的流行病學、針扎後造成醫療院所經營成本的經濟耗損，並針對美國於2000年通過「針扎安全及預防法案（The Needlestick Safety and Prevention Act）」後，政策對其醫療人員針扎狀況所造成的影響等相關文獻進行整理，以提供國內未來臨床執業環境改善、政策及相關研究方向的參考。
  Needlestick injury (NSI) is the most common occupational hazard among healthcare workers (HCWs). Not only do NSIs present a great threat to HCWs' safety and health, but they also result in substantial costs to hospitals as a result of subsequent tracking expenses, including blood tests and preventive treatments. The most effective measure to avoid preventable NSIs is to provide safe needles to HCWs. In order to provide a safer working environment for HCWs, the Department of Health has listed the use of safety devices as one of the criteria for hospital accreditation. The Legislature Yuan has also imposed a regulation by amending the Medical Act to require that hospitals replace conventional medical devices with ones with safety features within five years. This article reviews the epidemiologic, economic and policy aspects of NSIs. It also examines the overall situation of NSIs in the United States after the passage of the Needlestick Safety and Prevention Act of 2000.
• 424 - 434
• 10.6288/TJPH2013-32-05-02

• Link 原著 Original Article
• 醫師對愛滋病照護經驗、知識及態度的變遷：1994及2012年調查之比較Evolving Hiv-related Clinical Experiences, Knowledge, and Attitudes of Physicians: A Comparison of 1994 and 2012 Survey
• 丁志音、李芳盈、方啟泰
  Lew Chih-Yin Ting, Fang-Ying Li, Chi-Tai Fang
• 照護意願 ； 風險知覺 ； 愛滋臨床知識 ； 專業倫理
  willingness to treat ; risk perceptions ; HIV clinical knowledge ; professional ethics
• 目標：比較1994及2012年醫師的愛滋病照護經驗、知識與態度的差異。方法：分別於1994及2012年針對70歲以下之執業西醫師進行全國性郵寄問卷調查，並以加權分布、卡方、趨勢檢定、羅吉斯迴歸、Gamma（95％ CL）、及標準化進行年代間比較。結果：1994及2012年有效樣本各為1,702及1,590人。整體而言，曾直接照顧過HIV感染者的醫師比例大幅上升（從13.1％至45.5％），愛滋專業知識水準亦顯著提升，而臨床場域中的愛滋照護氛圍也有顯著改善，此反映在願意照護所有感染者的比例大幅提升（從26.7％至43.2％），且恐懼與憂慮顯著下降。但本研究亦發現兩個值得關注的現象，（1）感染HIV的注射藥癮者持續為醫師最不願意照顧的族群；（2）持續有極高比例的外科系醫師憂懼遭病人傳染HIV（從85.7％至84.6％）。結論：隨時間演進，整體而言，醫師對感染者的照護經驗、知識及態度皆有大幅度正向改善。然而藥癮HIV感染者的醫療照護問題及外科系醫師的職業風險仍需持續關注。在醫學繼續教育中安排藥癮者醫療照護專業課程，以及在制度面上確保外科醫師執業受傷後皆能盡快接受抗HIV病毒藥物預防性投藥是可思考的方向。
  Objectives: This study compared physicians' HIV clinical experiences, and their knowledge and attitudes toward HIV care in 1994 and 2012. Methods: National mailing surveys among practicing physicians 70 years old and younger were conducted in 1994 and 2012. Weighted distribution, Chi-Square, trend test, logistic regression, Gamma (95% CL), and standardization were employed to make between-year analyses. Results: There were 1,702 and 1,590 doctors participated in 1994 and 2012 study, respectively. The percentage of physicians who had ever provided care for HIV-positive patients increased considerably (from 13.1% to 45.5%) along with a moderately improved average knowledge on HIV diseases. The climate of HIV care delivery has been markedly improved over this time period, which can be reflected in the significantly increased willingness to treat all HIV patients (from 26.7% to 43.2%) and a substantial decline in fear and anxiety. Nonetheless, we did identify two points of concern: (1) HIV-positive injecting drug users (IDUs) continued to be the most undesirable group for whom physicians provided care; (2) there continued to be a very high percentage of surgeons expressing fear/anxiety about the risk of being infected by HIV-positive patients. Conclusions: Even with the evolving HIV epidemic in Taiwan, there has been a remarkable overall improvement in the clinical experiences, knowledge and attitudes of physicians in treating HIV patients. However, there is still a need to strengthen continuing medical education on HIV care, particularly targeting the care of IDUs. It is also necessary to ensure that all surgeons who are exposed to HIV have access to post-exposure prophylaxis with highly active antiretroviral therapy as soon as possible.
• 435 - 448
• 10.6288/TJPH2013-32-05-03

• Link 原著 Original Article
• 台灣兒童之健康平等及醫療照護利用公平性探討Health Equality and Equity in Health Care Utilization among Children in Taiwan
• 李昭琴、盧瑞芬
  Sherina Chao-Chin Lee, Rachel Jui-Fen Lu
• 兒童健康 ； 醫療利用公平性 ； 集中指標 ； 水平不公平性 ； 健康不均度
  child health ; equity in health care use ; concentration index ; CI ; Index of Horizontal Inequity ; HI ; health inequality
• 目標：由於兒童為國家未來主人翁，健康水平應格外受到重視，故本研究針對台灣兒童的健康平等及醫療使用之分布公平性和影響因素進行深入探討。方法：資料取自2001年台灣國民健康調查資料，並串連2001年健康保險資料庫，研究對象為12歲以下兒童共3,470名。採用集中指標衡量兒童健康發展情形，並以水平不公平性指標評估所得相關的醫療利用公平性，並進一步分解影響因子。結果：家戶較貧困的兒童較易有學習障礙和發展遲緩的情形。在兒童的醫療使用部分，西醫門診（非預防保健）、牙醫門診和急診的利用均呈現偏富分布，在住院醫療利用則未發現不公平性。同時發現影響兒童醫療利用偏富因素為主要照顧者的教育程度及所得因素。結論：建議政府應投入較多資源以提昇主要照顧者的健康促進觀念，同時在推動兒童醫療補助相關政策時，應考量弱勢家庭的特性，方能有效提供低收入家戶兒童適當的醫療照護。
  Objectives: As children represent the future assets of a country, their access to care to maintain their health is critical. This study assessed the distribution of health and health care uses among children. The determinants of the equity distribution were also explored. Methods: The data were taken from the 2001 Taiwan National Health Interview Survey (NHIS) linked with the 2001 National Health Insurance Research Database (NHIRD); 3,470 children aged 12 and younger were identified as the sample. Income-related distribution of health and health care uses were examined by adapting the concentration index and the Index of Horizontal Inequity (HI). Decomposing the concentration index facilitated the identification of factors which contributed to the unequal and inequitable distribution of health and health care uses. Results: Children in poorer households were more likely to encounter developmental problems in hearing and learning. Visits to Western doctors (excluding visits for preventive services), dentists, and emergency rooms tended to show a pro-rich distribution; however, the rich and the poor showed similar patterns of hospital admissions. In general, the educational attainment of the main care giver and household income were the two major factors contributing to the observed inequity. Conclusions: More resources should be devoted to health promotion among care givers. Family characteristics of the socially disadvantaged should be considered when devising subsidy policies targeting children to effectively provide appropriate care to children in need.
• 449 - 461
• 10.6288/TJPH2013-32-05-04

• Link 評論 Commentary
• 評論：台灣兒童之健康平等及醫療照護利用公平性探討Commentary: Health Equality and Equity in Health Care Utilization among Children in Taiwan
• 喬芷
  Chi Chiao
• 無
  none
• 無
  none
• 462 - 462
• 10.6288/TJPH2013-32-05-05

• Link 原著 Original Article
• 2012年台北市5歲以下兒童肺炎鏈球菌結合疫苗接種率及其影響因素研究Factors Influencing the Rate of Pneumococcal Conjugate Vaccination of Children under 5 Years of Age in Taipei City during 2012
• 林國甯、陳政友、蔡炯青、朱玉如
  Kuo-Ning Lin, Cheng-Yu Chen, Chiung-Ching Tsai, Yu-Roo Chu
• 疫苗接種 ； 肺炎鏈球菌疫苗 ； 健康信念
  vaccination ; Pneumococcal Conjugate Vaccine ; health belief
• 目標：本研究調查2012年台北市5歲以下兒童接種肺炎鏈球菌結合疫苗（PCV）情形及探討影響接種之因素。方法：以全國預防接種資訊管理資料庫系統（National Immunization Information System，NIIS）系統中台北市家中育有5歲以下兒童之家戶為母群，依台北市12個行政區採分層隨機抽樣，以各區家中育有5歲以下兒童之家戶數比例配置各分層樣本數，於2012年12月抽取樣本進行電話訪問調查。有效樣本707份，以卡方、點二系列相關及邏輯斯複迴歸分析兒童接種PCV之相關因素。結果：台北市家中5歲以下兒童已接種PCV者逾八成，以邏輯斯複迴歸分析顯示父親年齡、主要照顧者自覺對兒童感染肺炎鏈球菌之罹患性、自覺疫苗有效性等健康信念為影響疫苗接種之統計顯著因素。結論：為提升主要照顧者自覺兒童感染肺炎鏈球菌之罹患性及疫苗有效性等認知，建議衛生機關可於衛教宣導海報及單張，完整呈現疾病侵襲風險、疫苗成份及保護效果等資訊，供主要照顧者決策時參考。且建議未來可對台北市進行PCV疫苗接種率與群體免疫的效益研究。
  Objectives: The aim of this study was to investigate the factors influencing the rate of Pneumococcal Conjugate Vaccine (PCV) vaccination of children under 5 years of age in Taipei City during 2012. Methods: Based on data from the National Immunization Information System (NIIS), we selected families with children under 5 years of age in Taipei City as the study population. We adopted the stratified random sampling method to sample 12 administrative districts in Taipei City and allocated samples proportionally according to the number of families in each district. In December 2012, a computer assisted telephone interview was conducted. We used chi-square tests, point-biserial correlations, and a multiple logistic regression model to analyze the 707 valid samples. Results: The PCV vaccination rate of children under 5 years of age in Taipei City exceeded 80%. After multiple logistic regression analysis, we found that the statistically significant factors influencing PCV vaccination were: father's age and primary caregiver's acknowledgement of health beliefs such as perceived susceptibility to invasive pneumococcal disease (IPD) and PCV's effectiveness. Conclusions: In order to raise primary caregivers' acknowledgement of perceived susceptibility to IPD and the effectiveness of PCV, we suggest that the health authorities provide more comprehensive information for the public. Campaign materials might include educational posters and brochures in which the severity of IPD and the ingredients and protective effects of PCV shots are explained. We also suggest further research on vaccination and herd immunity based on the PCV vaccination rate in Taipei city.
• 463 - 475
• 10.6288/TJPH2013-32-05-06

• Link 原著 Original Article
• 台灣地區長期照護機構女性照顧服務員工作壓力源與工作適應、離職意願之研究Job Stressors, Work Adjustment and Intention to Leave: A Study of Female Nursing Assistants in Long-term Care Facilities in Taiwan
• 蔡淑鳳、陳文意、林育秀、梁亞文
  Shwu-Feng Tsay, Wen-Yi Chen, Yu-Hsiu Lin, Yia-Wun Liang
• 長期照護機構 ； 照顧服務員 ； 工作壓力 ； 工作適應 ； 離職意願
  long-term care facility ; nursing assistant ; job stressor ; work adjustment ; intention to leave
• 目標：女性照顧服務員是國內長期照護工作第一線的照護提供者，直接影響照護品質。然因工作壓力高、負荷重、低社會形象等負向因素，人員招募不易且不易留任，人力長期處於不足又高流動的狀態。爰此，本研究旨在探討女性照服員工作壓力源對工作適應與離職意願的影響。方法：本研究為一橫斷性研究，以分層比例抽樣，採結構式問卷，調查450位照服員的工作壓力源、工作適應及離職意願。我們以多層次線性迴歸和多層次邏輯斯迴歸模型，分別探討工作壓力源對工作適應及離職意願的影響。結果：多層次線性迴歸分析結果顯示平均月收入、機構開業年數、機構類型、工作控制、心理負荷及社會支持顯著影響照服員的工作適應；而多層次邏輯斯迴歸分析結果顯示：婚姻狀況、工作資歷、照顧住民數、社會支持顯著影響照服員的離職意願。結論：本研究證實工作壓力源會影響照服員的工作適應及離職意願。照服員的工作適應及離職意願，可能對所照顧對象造成傷害，機構經營管理者不應輕忽此一問題所可能導致的影響。
  Objectives: The aim of this study was to examine the effect of job stressors on work adjustment and intention to leave on female nursing assistants (NAs) in Taiwan's long-term care facilities. Methods: This was a cross-sectional study using a structured-questionnaire to gather information about job stressors, work adjustment, and background. Data was collected through proportional stratified random sampling of 450 female NAs serving in long-term care facilities over three months. Multi-level linear regression and multi-level logistic regression models were utilized to identify factors associated with work adjustment and intention to leave, respectively. Results: The multi-level linear regression model showed that the significant factors associated with work adjustment included salary per month, type of institution, years of operation, job control, psychological demands, and work-related social support. The multi-level logistic regression model indicated that marital status, length of employment at the current facility, care loads, and work-related social support were significantly associated with NAs' intention to leave. Conclusions: This study demonstrated that job stressors were the key determinants in female NAs' work adjustment and intention to leave. NAs' work adjustment and intention to leave may cause serious medical, social, and financial hardships to residents and their families in long-term care facilities. We suggest potential management strategies to provide assistance to female NAs in order to alleviate work strain.
• 476 - 490
• 10.6288/TJPH2013-32-05-07

• Link 原著 Original Article
• 菸品健康捐調升前後的需求價格彈性The Price Elasticity of Cigarettes after an Increase in Tobacco Health and Welfare Surcharge
• 李卓倫、林霖、陳江明
  Jwo-Leun Lee, Lin Lin, Chiang-Ming Chen
• 菸品健康捐 ； 菸品價格 ； 菸品需求 ； 價格彈性 ； 品牌轉換
  tobacco health and welfare surcharge ; cigarettes price ; cigarettes demand ; price elasticity ; brand switching
• 目標：我國於2009年將菸品健康捐由10元調高為20元，本研究嘗試分析此次菸品健康捐增稅前後對菸品需求量價格彈性是否有所影響。方法：本研究結合2007年與2010年兩次全國性調查的資料，比較提高菸品健康捐前後的菸品需求是否改變；在控制人口變項的條件下，本研究分別估計2007年與2010年吸菸者的價格彈性。結果：2010年菸品需求曲線相較於2007年更為平坦，表示菸品健康捐調升後民眾對於菸品價格的敏感度增加，當菸價伴隨健康捐調升時，如果暫不考慮走私菸品的攝取因素，則菸品健康捐對於2010年吸菸者的吸菸量有較強的抑制作用；另一方面，2010年的調查顯示有20.33％的吸菸者，因為菸品健康捐之課徵而開始使用其他品牌之菸品，月收入較低之吸菸族群較容易改用其他品牌的菸品。結論：菸品政策會使菸品消費行為產生結構性改變。
  Objectives: The Health and Welfare Surcharge on Tobacco in Taiwan increased to NT$20 per pack in 2009, following two other increases of NT$5 and NT$10 in 2002 and 2006, respectively. The aim of this study was to examine whether the 2009 increase in earmarked tax created changes in the pattern of tobacco consumption. Methods: This study compared cigarette consumption before and after the surcharge increase in 2009 by examining the 2007 and 2010 Taiwan Adult Tobacco Survey data. After controlling for demographic variables, we estimated the cigarette price elasticity in the 2007 and 2010 surveys. Results: The demand curve in the 2010 survey was flatter than that in the 2007 survey; this indicated that smokers became more price-elastic after the Tobacco Health and Welfare Surcharge increase in 2009. When the price of cigarettes increased gradually, the surcharge created a stronger effect on discouraging smoking based on the 2010 observations. Moreover, 20.33% of the smokers in the 2010 panel reportedly switched their cigarette brands after the 2009 surcharge increase. Smokers with lower income were more likely to switch brands. Conclusions: A tobacco-related price strategy as part of health policy can lead to substantial quantitative and qualitative changes in tobacco consumption.
• 491 - 501
• 10.6288/TJPH2013-32-05-08

• Link 原著 Original Article
• 「2010台北國際花卉博覽會」疾病與外傷之流行病學The Epidemiology of Illness and Injury during the 2010 Taipei International Flora Exposition
• 林孟臻、李欣岱、游文瑜、汪世潔、林茂榮
  Menu-Chen Lin, Hsin-Dai Lee, Wen-Yu Yu, Shih-Chieh Wang, Mau-Roung Lin
• 大型活動 ； 緊急醫療救護 ； 嚴重度 ； 博覽會
  mass gathering ; emergency medical services ; severity ; exposition
• 目標：瞭解「2010台北國際花卉博覽會」期間尋求醫療站協助之疾病與外傷病人人口學特性、疾病與外傷類型與原因及嚴重疾病與外傷之影響因子。方法：採橫斷式研究於博覽會活動期間收案，從2010/11/06至2011/04/25，171天共累計8,963,666參觀人次。博覽會於四個園區設置醫療站（圓山、美術、新生及大佳河濱公園區），共提供11,489醫療服務人次。測量變項為病人人口學及疾病與外傷相關特性，並用邏輯斯迴歸分析較嚴重疾病與外傷之相關因子。結果：醫療使用率為每天每百萬旅客7.5次，救護車轉送率為每天每萬名病人2.3次。疾病前三名為腸胃道疾病、頭痛、發燒／感冒，外傷前三名為擦傷／撕裂傷、拉／鈍／扭傷、燙／曬傷／起水泡。嚴重疾病發生於旅客密度低於124人／100 m^2、2010年十一、十二月與2011年一月、二月及三月；嚴重外傷發生於年齡七十歲以上、早上、雨天、旅客密度低於57人／100 m^2、2010年十一、十二月與2011年三月。結論：未來大型活動應將疾病與外傷相關資料分析並找出危險因子，進一步預防或減少疾病與外傷，讓旅客及工作人員安全更有保障。
  Objectives: The aim of this study was to investigate the demographics, types and causes of illness and injury, and risk factors for serious illness and injury among visitors at the 2010 Taipei International Floral Exposition. Methods: During the 171-day period from November 6th to April 25th 2011, 8,963,666 people visited the Exposition. There were four medical stations located in parks in Yuanshan, Arts, Xinsheng, and Dajia-Riverside during the Exposition period. Of these visitors, 11,489 people received medical services, and 470 of them were sent to a hospital for further treatment. Logistic regression analysis was used to examine factors associated with serious illness and injury. Results: The medical usage rate was 7.5 per million person-days, and the rate of ambulance to hospital usage was 2.3 per 10,000 patient-days. The three most prevalent illnesses were gastrointestinal disorders, headaches, and flu, while the three most prevalent injuries were abrasions/lacerations, strained muscles/contusions/sprains, and burns/sunburns/blisters. Serious illnesses were associated with a population density of < 124 persons per 100 m^2, and the time periods of November and December 2010, and January to March 2011. Serious injuries were associated with age over 70, morning sessions, rain, a population density of < 57 persons per 100 m^2, and the time periods November and December, 2010 and March, 2011. Conclusions: We suggest that the occurrences and severity of illness and injury be monitored during an exposition in order to provide immediate and effective medical interventions.
• 502 - 515
• 10.6288/TJPH2013-32-05-09