33卷4期

• Link 原著 Original Article
• 利害相關者對颱洪災害預警系統規劃要素之價值評估：多屬性效用理論之應用Evaluating Stakeholders' Preferences in Typhoon-flood Hazard Warning System Planning Using Multiple-attribute Value Theory
• 洪鴻智、林家鈺
  Hung-Chih Hung, Jia-Yu Lin
• 預警系統 ； 災害風險溝通 ； 公共安全 ； 多屬性效用 ； 調適
  warning system ; hazard risk communication ; public security ; multi-attribute utility ; adaptation
• 氣候變遷與極端天氣帶來的挑戰，使許多國家致力於建置災害預警系統，以降低傷亡與風險，及促進公共衛生與安全。然預警系統規劃過程，需更廣納利害相關者參與及不同價值觀，以利於溝通與降低衝突。本文主要目的，在於探討利害相關者對颱洪災害預警系統價值判斷，及對其構成要素之偏好選擇，以提供災害風險管理決策參考。文中應用多屬性效用理論（multi-attribute utility theory），透過政府官員與專家問卷調查，引用價值函數與多變量分析，比較受訪者對預警系統不同構成因素重要性之判斷與偏好。分析結果發現政府官員與專家對預警系統設計考慮的要素，多數無顯著差異；多偏重在技術、容易標準化及「由上而下」之因素。認為主導預警系統運作的核心，仍以災害資訊提供及緊急應變為主，較忽略末端使與者反應與調適行為。因災害潛勢與衝擊充滿不確定性，公共安全與災害風險管理難完全依賴科技。而需更有效掌握居民脆弱度與調適力分布，及藉由雙向溝通與利害相關者參與，建立居民導向之預警與緊急救助系統。
  Many countries are developing hazard warning systems to confront the impact of climate change and other extreme events in order to reduce the risk of disasters and casualties, as well to enhance public health and security. As part of policymaking, a warning system also needs to more effectively minimize conflicts while communicating the risk of disaster to policymaking by inviting the participation of various stakeholders and incorporating their values into the process of system planning. The aim of this study was to explore the value preferences of stakeholders with regard to the components of typhoon-flood hazard warning systems. This study used multi-attribute utility theory to model stakeholder values for typhoon-flood hazard warning system choices. We interviewed officers and experts to determine weight and value preferences for the components of a warning system, and these were compared using value function and multivariate approaches. The differences in most value preferences between officers and experts were insignificant. They assigned higher weights to the provision of information and emergency preparedness functions in building warning systems. This implied that the warning system plan tended to be conceived largely as a 'top-down' and standardized process, with relatively little engagement of the end-users in terms of their characteristics, responses and adaptive capabilities. The uncertainties of the impact of hazards require that warning systems function not only on a sound technical basis, but also effectively consider the vulnerability, adaptive capacity and participation of the people exposed to risk. A people-centered warning system should be built to empower communities to prepare for, respond to and adapt to disaster risks. These findings could improve the process of planning warning systems to maximize public security and risk management.
• 349 - 361
• 10.6288/TJPH201534103111

• Link 原著 Original Article
• 職業安全衛生法適用範圍之回顧與展望A Review and Prospects of the Applied Scope of the Occupational Safety and Health Act
• 黎博文
  Po-Wen Li
• 職業安全衛生法 ； 勞工安全衛生法 ； 適用範圍 ； 行業標準分類
  Occupational Safety and Health Act ; Labor Safety and Health Act ; applied scopes ; standard classification of industries
• 目標：本研究主要探討職業安全衛生法適用範圍之意義與變革，發現問題，並予檢討。方法：本研究採用文獻分析法、內容分析法與歷史研究法，蒐集歷年法規與行業標準分類沿革相關文獻，透過時間序列分析、比對，歸納適用範圍修正原因與方向。另採比較分析法，與勞動基準法適用範圍比較。結果：本法適用範圍可區分為4期，即「適用範圍4階段論」。第1階段係草創期，當時僅明定適用5大行業。第2階段為擴大期，適用範圍由5大行業擴大為14種事業。第3階段為改革期，刪除適用行業標準分類之規定，使適用範圍與行業標準分類脫鉤。第4階段為成熟期，適用範圍由14種事業，修改為「適用於各業」。結論：勞工安全衛生法從最初適用於5大行業，修正為職業安全衛生法「適用於各業」，可謂劃時代進步。除具體回應國際公約對「人人享有安全衛生工作環境」之宣示，更象徵我國職業安全衛生標準與各重要國家接軌的決心。新法施行後，當可樹立我國職業安全衛生新標竿。
  Objectives: The aims of this study were to explore the meaning and scope of and amendments to the Occupational Safety and Health Act, and to identify issues of concern. Methods: We utilized literature review, content analysis and historical research to review the evolution of regulations and classifications of the industrial standards of safety and health. Time series analysis and matching were also used to evaluate the generalization, reasons for, scope and direction of amendments. This study also used the analytical method to compare the applied scope of the Labor Standards Law. Results: The scope of the laws that have been applied in Taiwan can be divided into 4 periods, known as the ”the 4-stage application scope”. The first phase was the initial period of implementation of the law, which was applied to only 5 major industries. The second phase was the expansion of the Act to include 14 types of industries. The third phase was reformation of the law by removing specific provisions for standard classifications applicable to industries, and removing links between standard classification and the scope of the law applicable to them. The fourth phase was the stage of maturity of the Act, and expanded the scope from the original 14 industries to ”applicable to all industries”. Conclusions: Progress from the Labor Safety and Health Act for 5 major industries to the Occupational Safety and Health Act for all industries has been significant. The evolution of the Act has been a reflection not only of specific responses to the International Convention for ”safe and healthy working conditions for all”, but also symbolizes our determination to link our occupational safety and health standards to other countries. In the future, the new law may require additional modification in order to establish new benchmarks for occupational safety and health in Taiwan.
• 362 - 378
• 10.6288/TJPH201534104015

• Link 原著 Original Article
• 台中地區水域環境的細菌抗藥性之研究Bacterial Antibiotic-resistance in Water Bodies in the Taichung Area
• 林劭均、宋立垚
  Shao-Chun Lin, Lih-Yau Song
• 都市 ； 水域 ； 微生物 ； 抗藥性
  urban ; water body ; microorganism ; antibiotic-resistance
• 目標：抗生素的大量使用，已導致細菌抗藥性的問題日趨嚴重。本研究檢測台中地區的一些「封閉式」水域環境，以及流經都市的「開放式」水路，以瞭解其中之含菌量、細菌抗藥型態及抗藥菌種。方法：於各水域環境中共採集23個樣本。採樣後，檢測水質酸鹼度，再分別塗抹於不含抗生素，以及含安必西林（Ap）、卡那黴素（Km）及四環素（Tc）之培養基上，計算菌落數量（CFU），觀察菌落外觀，分析抗藥型態，並鑑定多重抗藥之菌種。結果：「封閉式」水域環境中的菌量介於0至11,800 CFU/ml；「開放式」水路的水樣菌量介於3,900至79,200 CFU/ml。抗藥性微生物普遍存在於水域中，尤其是「開放式」水域環境。在檢測的水樣中，對安必西林與卡那黴素具抗性的菌種最普及。對上述三種抗生素皆具抗性的菌種包含6種革蘭氏陰性菌。結論：可能有大量未經處理的污水排放於流經台中市的河川，其中包含具多重抗藥性之大腸桿菌，對人體健康具威脅。研究結果突顯台中市亟須建立污水處理系統之必要性。
  Objectives: Extensive use of antibiotics has caused an increase in bacterial drug resistance. Unfortunately, bacteria get into various water bodies easily. The purpose of this study was to determine the amounts and drug-resistance patterns of bacteria present in the closed water bodies and the streams flowing through Taichung City. Methods: A total of 23 water samples were collected. After measuring the pH values, viable bacterial counts (expressed as colony forming units [CFU]) were determined in the samples, as well as resistance to antibiotics, including ampicillin (Ap^s), kanamycin (Km^r), and tetracycline (Tc^r), and morphology of the colonies. Results: The total viable counts in the samples obtained from the closed water bodies and streams ranged between 0 and 11,800 CFU/ml and 3,900 and 79,200 CFU/ml, respectively. Drug-resistant microorganisms were commonly found, especially in the streams, with Ap^s Km^r Tc^r strains the most prevalent and Aps, Kmr, Tcr strains the least common. Species identification revealed that the Ap^s Km^r Tc^r strains included ”Escherichia coli”, ”Klebsiella rhinoscleromatis”, ”K. pneumonia”, ”Serratia plymuthica”, Proteus mirabilis, and one kind of glucose non-fermenting gram-negative bacilli. Conclusions: The presence of high levels of bacteria indicates that streams flowing through Taichung City are receiving large volumes of untreated sewage discharge. More importantly, high levels of multiple drug-resistant bacteria, especially coliforms, pose a high risk to human health. Based on these findings, establishment of sewage treatment systems for Taichung City is highly recommended.
• 379 - 390
• 10.6288/TJPH201534104033

• Link 原著 Original Article
• 受僱者之自評非致命職業傷病的盛行率、分布與相關因素Prevalence, Distribution, and Correlates of Self-reported Non-fatal Occupational Injuries or Diseases among Employees in Taiwan
• 陳介然、鄭雅文、何俊傑
  Chieh-Jan Chen, Ya-Wen Cheng, Jiune-Jye Ho
• 非致命職業傷病 ； 受僱者 ； 工時 ； 職場社會心理特質
  non-fatal occupational injuries or diseases ; employee ; working hours ; psychosocial work characteristics
• 目標：探討受僱者在過去一年中，自評曾有非致命職業傷病之盛行率、分布及其相關因素。方法：分析2010年受僱者調查資料共男性9,511人與女性7,779人，以問卷詢問受訪者在調查之前的12個月中，是否曾因工作關係而受傷或罹患疾病，問卷也測量年齡、教育程度、工作年資、工作時段、僱用關係、每週工時、公司規模、職業等級、職場社會心理特質等變項。結果：受僱者在過去12個月曾有非致命職業傷病的盛行率，男性為12.86%，女性為9.82%；多變項迴歸分析顯示，無論男女，年齡較高者、工時較長者、受僱於員工人數10人以下或政府部門者（相較於受僱於員工人數50人或以上者）、營造業與製造業（相較於服務業）之受僱者、工作體力負荷高者、工作心理負荷高者，以及缺乏工作保障者，其非致命職業傷病之風險較高。結論：本研究指出發生職業傷病之高風險族群，為職業安全健康促進工作應重視的議題。
  Objectives: This study determined the prevalence, distribution, and correlates of selfreported, non-fatal occupational injuries or diseases among employees in Taiwan. Methods: Data from a 2010 national survey of 9511 male and 7779 female employees 25~65 years of age were analyzed. Information regarding the experience of work-related injuries or diseases occurring over the 12 months prior to the survey was obtained using a standardized questionnaire. The age, level of education, work tenure, work shift, employment conditions, working hours, enterprise size, employment grade, and psychosocial work characteristics were also obtained. Results: The prevalence of non-fatal occupational injuries or diseases in males and females were 12.86% and 9.82%, respectively. For both genders, multivariate regression analyses showed that the following employees were at higher risk for non-fatal occupational injuries or diseases: older age; longer working hours; employment in smaller enterprises (<10 workers) or in public sectors compared to larger enterprises (?50 workers); employment in construction and industrial sectors compared to service sectors; higher psychological job demands; higher physical job demands; and job insecurity. Conclusions: The Occupational Safety and Health Authority should pay attention to susceptible working populations to in an effort to minimize the risk for occupational injuries and diseases.
• 391 - 402
• 10.6288/TJPH201534104018

• Link 原著 Original Article
• 評論：職業傷病年盛行率高，其所引起的心理傷害及精神疾病亦不可忽視Commentary: psychological trauma and psychiatric diseases caused by occupational injuries cannot be ignored due to the high prevalence rates of occupational injury and disease
• 蕭淑銖、郭育良
  Judith Shu-Chu Shiao, Leon Yue-Liang Guo
• 無
  none
• 無
  none
• 403 - 403
• 10.6288/TJPH20153410401801

• Link 原著 Original Article
• 慢性阻塞性肺病門診照護連續性之相關因素探討The Determinants of Continuity of Care for Patients with Chronic Obstructive Pulmonary Disease
• 林宜柏、吳肖琪
  I-Po Lin, Shiao-Chi Wu
• 慢性阻塞性肺病 ； 照護連續性 ； 照護連續性指標
  chronic obstructive pulmonary disease ; continuity of care ; continuity of care index
• 目標：測量慢性阻塞性肺病(chronic obstructive pulmonary disease, COPD)病人的COPD相關門診照護連續性，並探討影響其門診照護連續性的相關因素。方法：採用國家衛生研究院全民健保「2005年承保抽樣歸人檔」為主要資料來源，並自其中選取2,611位2006年COPD新個案為研究對象。本研究以照護連續性指標(continuity of care index, COCI)，測量研究個案自確診日後3年內之COPD門診照護連續性，且以多項式邏輯斯迴歸(multinomial logistic regression)分析病人特質對照護連續性的影響。結果：本研究對象COCI整體平均值為0.64(SD=0.32)，其中有33.6%的個案在研究期間，COPD相關門診皆由同一位醫師診療。多項式邏輯斯迴歸結果顯示，於控制其他變項後，以照護連續性高組為參考組，男性、年長者、低月投保金額且COPD相關急診次數多的研究對象發生低照護連續性的風險較高。結論：個人特質顯著的影響COPD病人照護連續性，在面臨高齡化社會多重慢性病人增加的環境之下，無論處於何種支付制度或整合式照護體系，皆應深入探討影響照護連續性的原因，並積極尋求提升病人照護連續性的方法。
  Objectives: To examine the determinants of continuity of care (COC) for patients with chronic obstructive pulmonary disease (COPD) in Taiwan. ”Methods: The data source was the 2005 Longitudinal Health Insurance Database which included data about one million beneficiaries randomly sampled from all National Health Insurance (NHI) enrollees in Taiwan in 2005. The study population included 2,611 subjects who were newly diagnosed as COPD patients in 2006. Every subject was traced for 3 years after the date of confirmed diagnosis. We used the continuity of care index (COCI) as the dependent variable to measure COC for patients with COPD and multinomial logistic regression to analyze the determinants of COC. ”Results”: The mean value of the COCI for the entire study sample was 0.64 (SD=0.32). There were 878 subjects (33.6%) with a COCI value of 1, indicating that these patients visited the same physician for all COPDrelated visits. The logistic regression model showed that, after controlling for covariates and using the high COCI group as a reference, subjects who were male, elderly, in the low NHI monthly insured amount group, and with a high number of COPD-related ED visits were more likely to be in the low COCI group. ”Conclusions”: There were significant associations between COC and the personal characteristics of COPD patients. In an aging society with an increasing number of patients with multiple chronic conditions, we suggest that any health authority should investigate the factors influencing COC and seek innovative approaches to improve patients' COC, whatever the health care system may be.
• 404 - 412
• 10.6288/TJPH201534103118

• Link 原著 Original Article
• 安寧療護使用天數對末期病人醫療資源耗用之影響The Impact of Length of Hospice Stay on Cost
• 陳雪姝、謝秋萍、李幸諭、蔡瓊玉、李哲瑋
  Sheue-Shu Chen, Chy ou-Ping Hsieh, Hsin-Yu Lee, Chiung-Yu Tsai, Jhe-Wei Li
• 安寧療護 ； 資源耗用
  hospice care ; medical expenditure
• 目標：以健保資料庫探討安寧天數對末期病患醫療資源耗用的影響，期以研究結果推動安寧療護觀念以減少無效醫療。方法：此為實驗對照研究，選取2013年死亡時67歲以上接受安寧之病患，依據性別、年齡、死前366天至730天醫療點數、特定疾病等變項與非安寧者進行1:1隨機配對，兩組各有7,890人。結果：兩組皆離死亡愈近資源耗用愈高，其中安寧組死前7天內之每人醫療點數較非安寧組為低，且其差值愈接近死亡愈明顯，從65點至2,325點。而安寧使用天數與死前0~10天及0~15天之每人費用成反比，安寧天數每多一天，費用減少523及598點；再與非安寧組比較，安寧天數越多點數節省越多，惟該現象於天數達9天及17天以上才顯現。結論：安寧療護可以節省資源，但安寧天數需相當或大於每人費用觀察期間的天數，才能觀察到其資源節省的效益。另精算，安寧組7,890人相較於非安寧組於死前7天內減少約6,056萬之醫療點數。
  Objectives: To explore the impact of the length of hospice stay on the medical expenditure for terminally-ill patients by analysis of the database of National Health Insurance (NHI). Methods: This case-controlled study compared decedents over 67 years of age who were hospice users with non hospice decedents in 2013. After one-to-one random matching, there were 7,890 persons in each group. The variables used to create matches were age, gender, specific disease and the medical expenditure between the 366^(th) and 730^(th) days before the date of death. Results: Both hospice users and non hospice users had increased medical expenditure while approaching the date of death. In the 7 days before death, the medical expenditure per hospice users was 65 NT$ lower than that of non hospice users; the saving increased to more than 2,325 NT$ on the final day before death. The medical expenditure of within 10 days before death showed per hospice day reductions of 523 NT$. Conclusions: The longer the hospice stay, the greater the saving in medical expenditure.
• 413 - 423
• 10.6288/TJPH201534104039

• Link 原著 Original Article
• 以計劃行為理論探討女大學生未來使用棉條之行為意圖：檢視性取向、性別氣質之調節作用An Exploration of Tampon Use Intentions among Female College Students Based on the Theory of Planned Behavior: Examining Sexual Orientation and Gender Characteristic as Effect Modifiers
• 張佳婷、黃俊豪、吳淑靜
  Chia-Ting Chang, Jiun-Hau Huang, Shu-Ching Wu
• 計劃行為理論 ； 棉條使用意圖 ； 女大學生 ； 性取向 ； 性別氣質（陽剛／陰柔）
  Theory of Planned Behavior ; tampon use intentions ; female college students ; sexual orientation ; gender characteristic (butch/femme)
• 目標：以計劃行為理論（Theory of Planned Behavior）探討其三大構念（行為態度、主觀規範及自覺行為控制）之直接測量與間接測量，對女大學生棉條使用意圖之影響，並探討性取向與性別氣質對其之潛在調節作用。方法：透過網路對女大學生發放收得有效問卷363份，並使用多變項逐步羅吉斯迴歸進行資料分析。結果：直接測量部分，行為態度為相對正向者（AOR=15.18）、主觀規範為相對高度支持者（AOR=5.81），具顯著較高之棉條使用意圖。此外，具有棉條使用經驗者（AOR=13.14），未來亦有顯著較高之棉條使用意圖。間接測量部分，發現性取向、性別氣質對棉條使用意圖具顯著之調節作用，例如：對可減少經血外漏之態度為相對正向時，陽剛者較陰柔者（AOR=0.25）具顯著較低之棉條使用意圖。結論：本研究以計劃行為理論探討女大學生之棉條使用意圖，發現其行為態度與主觀規範為最主要之影響因子，且性取向與性別氣質可能具調節作用。本研究結果可作為未來學生健康中心及相關衛生教育單位進行性別教育之實證參考依據。
  Objectives: This study explored female college students' intentions to use tampons by applying the direct and indirect measures of the three constructs of the Theory of Planned Behavior (TPB): Attitude toward the Behavior, Subjective Norm, and Perceived Behavioral Control. The potential moderating effects of sexual orientation and gender characteristic were also examined. Methods: Data were collected from 363 female college students through an anonymous online survey. Multivariate stepwise logistic regression analyses were conducted. Results: When the TPB direct measures were applied, a relatively positive attitude toward the behavior (AOR=15.18) and a relatively supportive subjective norm (AOR=5.81) were found significantly associated with high tampon use intentions. In addition, those with tampon use experience (AOR=13.14) were significantly more inclined to use tampons in the future. When the TPB indirect measures were applied, both sexual orientation and gender characteristic (butch/ femme identity) were found to have significant moderating effects on tampon use intentions. For example, among those with a relatively positive attitude toward preventing menstrual blood leakage, those with a butch identity (AOR=0.25) were significantly less inclined to use tampons than their femme counterparts. ”Conclusions”: Using the TPB as a theoretical framework, this study found that attitudes toward the behavior and subjective norms were strongly associated with tampon use intentions among female college students. In addition, sexual orientation and gender characteristic appeared to be effect modifiers. The empirical findings of this study could provide useful information for future gender health education programs in the student population.
• 424 - 436
• 10.6288/TJPH201534104012

• Link 原著 Original Article
• 2003至2013年台灣地區登革熱併發登革出血熱危險因子分析Risk factors for dengue hemorrhagic fever in Taiwan, 2003-2013
• 劉英姿、方啟泰、顏哲傑
  Ying-Tzu Liu, Chi-Tai Fang, Jer-Jea Yen
• 登革病毒 ； 危險因子 ； 預後因子 ； 病例對照研究 ； 世代追蹤研究
  dengue virus ; risk factors ; prognostic factors ; case-control study ; cohort study
• 目標：登革出血熱致病機轉迄今仍未完全了解。本研究目標為釐清登革熱併發登革出血熱的危險因子，以及併發登革出血熱後死亡的預測因子。方法：本研究之研究對象為2003－2013年間所有確診登革熱或登革出血熱個案。以病例對照研究探討登革熱併發登革出血熱之危險因子，以世代追蹤研究分析登革出血熱個案死亡的預測因子，以邏輯斯迴歸進行統計分析。結果：病例對照研究納入142例登革出血熱病例，並從同時期9,787例未併發登革出血熱之登革熱病例中，以隨機抽樣方式選出568位依發病時間及居住縣市1:4配對之對照。60歲以上長者（OR=4.53, p＜0.0001）與第二型登革病毒感染（OR=5.39, p=0.0081）是發生登革出血熱的獨立危險因子。世代追蹤研究納入142例登革出血熱病例，其中24例死亡。60歲以上長者（OR=3.21, p＜0.027）及糖尿病患者（OR=3.08, p＜0.005）是登革出血熱死亡的獨立預測因子。結論：本研究結果可提供民眾對登革出血熱危險因子及預後因子的正確認知，加強醫事人員臨床警覺、早期診斷及治療，以降低登革出血熱死亡率。
  ”Objectives”: The pathogenesis of dengue hemorrhagic fever is not fully understood. The aims of this study were to examine the risk factors for developing dengue hemorrhagic fever after acquiring dengue infection and to identify the predictors of mortality after developing dengue hemorrhagic fever. ”Methods”: All confirmed dengue and dengue hemorrhagic fever cases during 2003-2013 in Taiwan were included in this study. In this case-control study, we compared cases of dengue hemorrhagic fever with controls who were randomly selected from identified patients with dengue but without hemorrhagic fever, individually matched by month of onset and residential county in a 1:4 ratio. We tracked the outcomes of patients with dengue hemorrhagic fever, and analyzed the predictors of mortality. Multivariate logistic regression was used to analyze the data. ”Results”: The study included 142 dengue hemorrhagic fever cases and 568 controls. Age over 60 (OR=4.53, p<0.0001) and infection by the type 2 dengue virus (OR=5.39, p=0.0081) were two independent risk factors for dengue hemorrhagic fever. There were 24 deaths among the 142 dengue hemorrhagic fever cases. Age over 60 (OR=3.21, p<0.027) and diabetes mellitus (OR=3.08, p<0.005) were the two independent predictors of mortality. ”Conclusions”: Knowledge about risk factors and prognostic factors will enable communities and health care professionals to better coordinate the effort to make early diagnoses, initiate treatment for dengue hemorrhagic fever, and minimize dengue-associated morbidity and mortality.
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• 10.6288/TJPH201534104001