32卷6期

• Link 公衛今與昔 Public Health Now and Then
• 美國在華醫藥促進局（ABMAC）與台灣公衛和醫護發展ABMAC and Taiwan Pubic Health and Medical Development
• 賴慧仙 、李孟智
  Meng-Chih Lee
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  none
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  none
• 517 - 525
• 10.6288/TJPH201332102097

• Link 綜論 Review Article
• 以家戶總所得為健保費基方案相關爭議之反思A Review of the Controversies over the National Health Insurance Premium Being Set on the Basis of Overall Family Income
• 韓幸紋、梁景洋
  Hsing-Wen Han, Ching-Yang Liang
• 二代健保 ； 三代健保 ； 家戶總所得為費基
  second-generation National Health Insurance ; third-generation National Health Insurance ; premium base basing on family income
• 日前衛生福利部表示「三代健保」將回歸家戶總所得為費基的改革方案，本文從公平性、中立性、行政執行性等三個角度分析現制保費收費方式（含補充保險費）與「以家戶總所得為費基」方案之優缺點；再就2010年推動以家戶總所得為費基改革方案時所衍生的相關爭議進行討論，並提出相關建議，作為政府未來三代健保政策制定時之參考。
  The Ministry of Health and Welfare in Taiwan has indicated that a new financing mechanism broadening the premium base from the payroll tax to family income will be proposed under third-generation National Health Insurance. This study compared the existing system with the new financing mechanism, analyzed the advantages and shortcomings based on considerations of equity, neutrality and administration, and reviewed the related controversies caused by enlarging the premium base. We also provide suggestions for the government in formulating third-generation National Health Insurance in the future.
• 526 - 536
• 10.6288/TJPH201332102066

• Link 原著 Original Article
• 糖尿病共同照護對病患糖化血色素、健康信念與健康行為之影響The Effects of Diabetes Shared Care on Patients' Glycated Hemoglobin, Health Beliefs, and Health Behaviors
• 吳淑靜、黃俊豪
  Shu-Ching Wu, Jiun-Hau Huang
• 糖尿病共照 ； 糖化血色素 ； 健康行為 ； 健康信念 ； 類實驗
  diabetes shared care ; glycated hemoglobin (HbA1c) ; health behaviors ; health beliefs ; quasi-experiment
• 目標：探討加入糖尿病共照網之病患與未加入者之糖化血色素控制與健康行為改變是否有異，並檢視兩組病患之糖尿病相關健康行為改變，分別與何種健康信念之改變有關及其影響之程度。方法：採類實驗研究法，收案對象為第二型糖尿病病患，分成「共照組」與「非共照組」，依性別、年齡配對，以1：2比例分別收案208與421人，並於首次收案時及6個月後，進行糖化血色素與問卷資料收集。結果：自迴歸多變項分析顯示，共照組之後測糖化血色素較低（β=-0.18），後測健康行為得分亦較高（β=0.13）。共照組後測健康行為與自覺利益（β=0.29）、行動線索（β=0.15）之提升具顯著關聯，非共照組後測健康行為則與自覺罹患性（β=0.13）、自覺利益（β=0.19）之提升，以及自覺障礙（β=-0.16）、行動線索（β=-0.12）之下降具顯著關聯。結論：共照組病患之糖化血色素控制與健康行為改變均較非共照組佳，但兩組之健康行為改變係由不同健康信念所驅動，故未來糖尿病健康照護介入，可參考本研究之發現，於兩組分別針對不同之健康信念設計合適之介入策略。
  Objectives: The aims of this study were to determine if patients in a diabetes shared care group had better glycated hemoglobin (HbA1c) control and changes in health behaviors than did their regular care counterparts, and to explore which changes in health beliefs contributed to changes in health behaviors in these two groups. Methods: A quasi-experiment, this study recruited 208 and 421 patients with type II diabetes in the shared care and regular care groups, respectively, at a 1:2 ratio, matched by gender and age. HbA1c levels were measured and survey data about diabetes-related health behaviors and health beliefs were collected at both pre-test and 6-month post-test. Results: Multivariate linear autoregression analysis indicated that patients in the shared care group had significantly lower HbA1c levels (ß=-0.18) than did those in the regular care group at post-test. Similarly, patients in the shared care group had significantly higher health behavior scores (ß=0.13) than did their regular care counterparts at post-test. In the shared care group, increased health behavior scores at post-test were directly related to elevated levels of perceived benefits (ß=0.29) and cues to action (ß=0.15). By contrast, in the regular care group, increased health behavior scores at post-test were positively associated with increased levels of perceived susceptibility (ß=0.13) and perceived benefits (ß=0.19), as well as decreased levels of perceived barriers (ß=-0.16) and cues to action (ß=-0.12). Conclusions: Compared with diabetic patients in the regular care group, those in the shared care group had better HbA1c control and changes in health behaviors. The diabetes-related health behavior changes could be attributed to different changes in health beliefs in the two groups. These findings could inform future interventions to improve diabetes care.
• 537 - 550
• 10.6288/TJPH201332102054

• Link 原著 Original Article
• 運動與蔬果攝取對預防台灣中老年人新發糖尿病的組合效應The Combined Effect of Physical Activity and Fruit-Vegetable Consumption on New-Onset Diabetes in Older Taiwanese
• 陳奕儒、蔡仲弘、王俊毅
  Yi-Ru Chen, Alan C. Tsai, Jiun-Yi Wang
• 中老年人 ； 糖尿病 ； 運動 ； 蔬果攝取 ； 組合效應
  elderly ; diabetes ; physical activity ; fruit and vegetable intake ; combined effects
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  Objectives: Many factors impact the onset of diabetes. Higher levels of physical activity and fruit-vegetable (FV) consumption are considered to be effective in reducing the risk; however, the combined effect is largely unknown. This study attempted to determine the combined effect of a higher level of physical activity and higher FV consumption on the subsequent risk of new diabetes. Methods: Data for this analysis were taken from the 1999 and 2003 datasets of the ”Taiwan Longitudinal Survey on Aging”. A total of 4,400 participants (? 53 years old) completed the survey in 1999. After excluding those who had diabetes, heart disease, cancer, BMI<18.5, or incomplete data at baseline, those who died during 1999-2003, and those who failed to complete the 2003 survey, the net N was 2,243. Multivariate binary logistic regression analysis was performed to determine the independent or combined effect of physical activity and FV consumption on the risk of new diabetes four years later. Results: When the combination of high physical activity and high FV consumption was compared to no physical activity and low FV consumption, the risk of having new diabetes four years later was reduced to 39% (OR=0.39, 95% CI=0.20-0.76, p=0.006). All other combinations were not significant. When analyzed independently, only high physical activity was significant, high FV consumption was not. Conclusions: The combination of high physical activity and high FV consumption was highly effective in reducing the risk of new-onset diabetes in older Taiwanese. High physical activity alone was significant but high FV consumption alone was not. These results highlight the importance of having both daily physical activity and FV intake. Our results could provide the basis for a national policy on diabetes prevention.
• 551 - 561
• 10.6288/TJPH201332102052

• Link 原著 Original Article
• 台灣老人成功與活躍老化之健康餘命探討Healthy Life Expectancy for Successful Aging and Active Aging Elderly in Taiwan
• 林正祥、劉士嘉
  Cheng-Hsiang Lin, Shih-Chia Liu
• 成功老化 ； 活躍老化 ； 健康餘命 ； 馬可夫鏈
  successful aging ; active aging ; healthy life expectancy ; Markov chain
• 目標：基於生命質的改善和量的增加同等重要，對老人健康之關注，不應侷限於以往罹病或功能障礙老人之照顧，而是積極提升其整體生活品質及安適狀態為目標，即「成功老化」與「活躍老化」的概念。不論成功老化或活躍老化，均同時涵蓋老年人身體、心理、社會三個面向。本研究旨在探討台灣老年人口在成功老化及活躍老化之變遷及可能影響因素。方法：利用國民健康署所建立之「台灣地區中老年人身心社會狀況長期追蹤研究調查」資料，依成功老化與活躍老化定義，就老人成功、活躍老化變動趨勢，以馬可夫鏈模式軟體IMaCh（interpolatedMarkov chain，IMaCh）推算60歲以上老人世代平均餘命，成功、活躍老化健康餘命及各年齡盛行率；另亦就高血壓、心臟病及糖尿病等重要慢性疾病探討其對成功、活躍老化健康餘命影響差異。結果：影響成功老化、活躍老化之各組成項目（ADL、IADL、無憂鬱症狀、認知功能正常、良好社會支持、具生產力）正常百分比大致隨著年齡增長而逐年下降，成功老化及活躍老化盛行率亦呈現相同趨勢；平均餘命方面，成功老化健康餘命佔平均餘命約四至五成間，其中活躍老化在15%～25%間。三種慢性疾病中，糖尿病成功、活躍老化健康餘命百分比在各年齡組均較高血壓及心臟病為低。結論：提升活躍老化應是有關單位努力的理想目標；在慢性疾病上，以糖尿病的負面影響最為明顯，相對於其他慢性疾病，糖尿病的防治有極大的改善空間。
  Objectives: Improvements in the quality and quantity of life are equally important based on the concepts of successful aging and active aging. These include physical, mental and social well-being in old age. Instead of the past emphasis on improving morbidity or malfunction, the goal for health care of the elderly should focus on actively improving their comfort and overall quality of life. Methods: In order to explore the factors affecting the long term changes in the trends of successful aging and active aging of older people in Taiwan, we analyzed the data from a survey of Health and Living Status of the Elderly in Taiwan conducted by the Health Promotion Administration, Ministry of Health and Welfare. Using the interpolated Markov chain approach, we projected the prevalence and healthy life expectancy. We also investigated the effects of chronic diseases e.g. hypertension, heart disease and diabetes on the differences in healthy life expectancy, successful aging, and active aging. Results: The influence of variables which positively affected successful aging and active aging declined as age increased. Similar results were observed for prevalence. For successful aging, healthy life expectancy accounted for approximately 40-50% of all life expectancy; of this, active aging accounts for about 15-25%. For each age group, diabetes lowered the percentage of healthy life expectancy compared to hypertension and heart disease. Conclusions: Achieving a high quality of active aging is an ideal goal for the government and health institutes. Among chronic diseases, diabetes had the most serious impact on healthy life expectancy and its prevention and treatment should be emphasized.
• 562 - 575
• 10.6288/TJPH201332102078

• Link 原著 Original Article
• 勞工發生職業傷害後12個月復工狀況之探討Factors Influencing Return to Work among Workers at 12 Months after Occupational Injury
• 秦唯珊、林冠含、郭育良、蕭淑銖
  Wei-Shan Chin, Kuan-Han Lin, Leon Yue-Liang Guo, Judith Shu-Chu Shiao
• 職業傷害 ； 復工 ； 勞工
  occupational injury ; return to work ; worker
• 目標：每年約有五萬名勞工發生職業災害，研究發現職傷後有一定比例的勞工會發生精神疾病，進而影響其復工。目前台灣鮮少研究探討職業傷害勞工之復工需求。期望了解勞工發生職災到順利復工的協助需求，以提供相關單位作為擬訂職災勞工照護之參考。方法：本研究以2009年02月01日至08月31日因職業傷害住院超過3天以上的職業傷害勞工（N=4,403）為研究對象，於其職業傷害發生後12個月寄發問卷。本問卷是採自填式問卷，問卷內容包括基本資料、職業傷害處理狀況、身體受傷狀況、與復工情形。結果：共有1,233人回覆，回覆率為28.0%。受傷後一年已復工者969位（78.6%），未復工者264位（21.4%）。相較於已復工者，未復工者的平均年齡較高、教育程度較低、離開原公司的比例較高、對於公司提供職災協助的滿意程度較低、覺得職災補助取得不容易、自覺受傷程度較嚴重，且身體外觀有明顯缺陷。已復工者，僅18.1%（n=175）有接受復工評估，有接受復工評估者的休養週數比未進行復工評估者長（14.3±13.1 vs. 10.7±12.0），復工主要決定者多為雇主決定（n=109，62.3%），而接受復工評估者比沒有接受復工評估的人有較高的比例發生受傷部位復發的狀況為（39.4% vs. 31.2%，p=0.03）。結論：建議政府結合社區資源，建立常設之職災服務單一窗口，普及職災個案照護，並建議職業傷病勞工的復工評估與醫療應經由各地區之職業傷病防治中心或職業病專科醫師執行，以強化職業傷病防治中心與職業病專科醫師的角色並落實復工的功能。
  Objectives: Fifty-seven thousand occupational injuries occur in Taiwan each year. Previous studies have found that a certain proportion of workers developed psychiatric symptoms after the injury and those symptoms were an important obstacle to their return to work. The aim of this study was to investigate workers' need to return to work 12 months after an occupational injury. Methods: The study population was composed of workers who were injured at work, hospitalized for 3 or more days, and later received Inpatient Hospitalization Benefits as part of Occupational Accident Medical Benefits from Labor Insurance between February 1 and August 31, 2009. The subjects were recruited consecutively 12 months after injury and assessed by a self-reported questionnaire which included demographic data, severity of injury, the process of workers compensation, and their return to work. Results: A total of 1,233 injured workers completed the self-reported questionnaire for a response rate of 28.0%. Among those who completed the questionnaire, 78.6% (n=969) returned to work while the other 21.4% (n=264) did not. Compared to subjects who returned to work, those who were unable to do so were older, received less education, had a higher proportion of leaving their original employer, had lower scores for the workers compensation process, and consider workers compensation approval difficult to obtain. Among injured workers, only 18.1% (n=175) had received an assessment for return to work. Compared to those who did not receive such an assessment, injured workers who did had longer sick leaves and returned to work later (14.3 ± 13.1 vs. 10.7 ± 12.0 weeks). In general, the assessment and decision to return to work were made mostly by employers (62.3%, n=109). Moreover, workers who received an assessment had a higher risk of relapse after returning to work compared to those who did not (39.4% vs. 31.2%, p=0.03). Conclusions: The integration and re-orientation of the existing resources for severely occupationally injured workers and strengthening single unit service for them are warranted if the government is to succeed in providing a reasonable health care system for these workers.
• 576 - 585
• 10.6288/TJPH201332102047

• Link 原著 Original Article
• 精神疾病社區復健使用者再入院及危險因素之探討Readmission and Risk Factors among Community Rehabilitation Users with Psychiatric Diseases
• 李亞璇、謝碧晴、李中一、蘇慧芳
  Ya-Hsuan Li, Pi-Ching Hsieh, Chung-Yi Li, Hui-Fang Su
• 精神疾病 ； 社區復健 ； 再入院 ； Andersen醫療利用模式 ； Cox比例風險迴歸模式
  psychiatric disease ; community rehabilitation ; readmission ; Andersen's behavioral model of health service utilization ; Cox proportional hazard model
• 目標：參考Andersen第一與第二階段醫療服務利用行為模式，擬欲探討2000至2009年精神疾病社區復健使用者之個人特質，並且分析使用精神疾病社區復健病患歷經指標出院一年期間，其往後一年內再入院風險及相關危險因子。方法：採回溯性世代設計，資料出處為國衛院所發行之全民健康保險資料庫1999至2009年「居家照護特殊需求檔」，研究對象為2000至2007年精神疾病社區復健使用者為新收個案，共25,218人。以Cox比例風險迴歸模式預測精神疾病社區復健使用者在指標出院後經歷一年期間，其往後一年內再入院之風險。結果：研究發現以Cox迴歸模式在出院後一年內精神疾病社區復健使用次數為8－14次與?15次的再入院風險較使用1－7次者低，女性、中區分局病患、精神分裂症患者與住院小於55天等變項，再入院之風險較低。結論：精神疾病社區復健使用次數越少之個案，其爾後再入院之風險比使用次數多者還高，值得健康照護相關人員進一步思考影響其使用的因素，另外，其使用的模式及其與再入院之關係為何？亦值得未來進一步探究。
  Objectives: With reference to phase I and phase II of Andersen's behavioral model of health service utilization, the aims of this study were first to investigate the characteristics of community rehabilitation care users and then to analyze the frequency of readmission and its risk factors within one year after discharge from a hospital for the treatment of mental illness. Methods: A retrospective cohort study design was used. Data analyzed in this study were retrieved from the 'home care specific files' of the National Health Insurance Research Database issued by the National Institutes of Health between 1999 and 2009. A total of 25,218 people were new cases of community rehabilitation care between 2000 and 2007. In order to forecast these community rehabilitation care users' risk of readmission within one year after discharge, the Cox proportional hazard model was utilized. Results: We found that the adjusted hazard ratio was significantly lower for groups of 8-14 times users and 15 or more-times users of community rehabilitation care than for 1-7 times users (0.73 & 0.72 respectively) in the Cox regression model. Furthermore, the risk of readmission was lower for females, clients who were insured by sub-bureau in the middle of Taiwan, a diagnosis of schizophrenia, and a length of hospital stay less than 55 days. Conclusions: The lower the frequency of psychiatric patients' using community rehabilitation care, the higher the risk of readmission.
• 586 - 598
• 10.6288/TJPH201332102057

• Link 原著 Original Article
• 父母需要子女的關心：探討台灣中老年人的代間關係與主觀經濟壓力之相關性研究Parents Who Need Children's Care: Exploring the Association between Intergenerational Relations and subjective Economic Strain among Older Adults in Taiwan
• 林子鏞、喬芷
  Tzu-Yung Lin, Chi Chiao
• 代間關係 ； 主觀經濟壓力 ； 中老年父母 ； 廣義估計方程式
  intergenerational relations ; subjective economic strain ; middle-aged and older parents ; Generalized Estimating Equation (GEE)
• 無
  Objectives: In the context of Confucian culture, the main unit of support for older parents in Taiwan is the family system. This points out the important connection between intergenerational relations and subjective economic strain. We utilized the intergenerational solidarity theory to explore whether ”intergenerational emotional bond” (affection solidarity) predicted a lower level of subjective economic strain than did ”received money from children” (functional solidarity). Methods: This study used data from the Taiwan Longitudinal Study on Aging, a nationally representative sample of older adults aged 60 and above, collected between 1989 and 2003. Generalized linear modeling with GEE estimates was employed because of the repeated measures. Results: After SES and other covariates were controlled, females who felt that their children were reliable when they were sick were 0.36 points lower on the four point scale of economic strain (ß=-0.36, p<0.001) while those who received monetary support from sons were 0.09 points lower (ß=-0.09, p<0.001). Males who felt that their children were reliable when they were sick were also less likely to experience economic strain (ß=-0.22, p<0.001); however, the effect of monetary support from sons was insignificant. Conclusions: These findings suggest that ”children's care” produced a stronger and more positive effect on alleviating parents' subjective economic strain than did monetary support. Health and Welfare policy makers promoting economic well-being among older adults should take mutual emotional respect and an understanding of intergenerational relations into consideration.
• 599 - 612
• 10.6288/TJPH201332102051

• Link 評論 Commentary
• 評論：誠意呷水甜或有情飲水飽？Commentary: Parents Who Need Children's Care: Exploring the Association between Intergenerational Relations and subjective Economic Strain among Older Adults in Taiwan
• 徐慧娟
  Hui-Chuan Hsu
• 無
  none
• 無
  none
• 613 - 613
• 10.6288/TJPH20133210205101

• Link 評論 Commentary
• 作者回覆：誠意呷水甜或有情飲水飽？Author's Response to Commentary:Parents Who Need Children's Care: Exploring the Association between Intergenerational Relations and subjective Economic Strain among Older Adults in Taiwan
• 林子鏞 、喬芷
  Tzu-Yung Lin, Chi Chiao
• 無
  none
• 無
  none
• 614 - 614
• 10.6288/TJPH20133210205102