34卷2期

• Link 公衛論壇 Public Health Forum
• 釐清健康不平等相關名詞釐清健康不平等相關名詞
• 呂宗學、 陳端容、江東亮
  Tsung-Hsueh Lu, Duan-Rung Chen, Tung-Liang Chiang
• 無
  none
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  none
• 115 - 118
• 10.6288/TJPH201534104013

• Link 綜論 Review Article
• 我國國際衛生合作進展之反思Reflections on Taiwan's Efforts in International Health Cooperation
• 黃怡碧、黃嵩立
  Yi-Bee Huang, Song-Lih Huang
• 國際衛生合作 ； 官方發展援助 ； 人權取徑
  international health cooperation ; ODA ; human rights-based approach
• 國際衛生合作是發展援助的重要一環；台灣近年來雖然官方與民間都付出相當的努力，但是國際合作計畫的規模和深度與我國的經濟發展程度不成比例。本文介紹發展援助的理論背景，尤其著重人權在其中的核心地位。接著探討四個影響我國目前國際衛生合作之因素，包括我國在全球經濟中的地位不明、官方發展對外援助與外交議程之混淆、國際空間壓縮、以及合作計畫的去政治化。由於我國對國際發展援助缺少討論與共識，政府因而缺乏整體策略。進而，作者建議我國應謹慎評估國際間對官方發展援助的概念，並參考國際間既有的發展架構，以促進國人客觀地檢視我國對外援助政策。作者建議，除應盡早參與國際討論，以理解千禧年發展目標2015年階段結束後的議程，並應考慮以人權取徑（human rights-based approach）為我國規劃和評估國際發展合作計畫的參考座標。
  International health cooperation is an important component of development assistance. Although both the governmental and nongovernmental sectors have made significant efforts in the past, the magnitude and depth of Taiwan's international cooperation programs have not matched its economic achievement. In this article the authors first describe the theoretical background of international development assistance, emphasizing the importance of human rights. This is followed by an analysis of the four factors which may the outlook for current international health cooperation: uncertainty about Taiwan's position in the global economy, the link between Official Development Assistance and the diplomatic agenda, limited international opportunities, and the apolitical nature of assistance projects. There has been limited discussion, let alone consensus, about Taiwan's participation in international development assistance, and this has resulted in the lack of an overall strategy. The authors suggest that Taiwan should calibrate its position and strategies against international frameworks for international cooperation in order to facilitate an objective assessment of the country's development assistance. In addition to preparing for participation in the post-2015 agenda, Taiwan should take a human rights-based approach as the basis for the design and evaluation of programs in international cooperation.
• 119 - 130
• 10.6288/TJPH201534103084

• Link 原著 Original Article
• 某醫學中心旅遊醫學門診留學生疫苗注射的認知及想法調查研究Knowledge and Attitudes about Vaccination among Students WHO Plan to Study Abroad
• 鄒孟婷、徐慶玶
  Meng-Ting Tsou, Ching-Ping Hsu
• 留學生體檢 ； 預防接種紀錄卡
  pre-matriculation immunization ; immunization records
• 目標：因為對於疫苗接種觀念的生疏，導致許多留學生無法在國內完成必要的檢查，造成延誤或多餘疫苗注射。本研究希望藉由問卷調查，分析留學生及家長對此議題的熟悉情況，並提供建議。方法：針對自2011年4月-2011年9月間，至本院家庭醫學科旅遊門診進行留學生體檢者，採自填問卷方式，有229位受訪者的資料進入分析，回應率高達91.6%。結果：本研究族群中女性出國留學的比例（61.1%）高於男性（38.9%）。58.1%的留學生認為施打疫苗可減少在國外被感染，年紀越大和男性的認知及想法較好。38.8%的族群沒有保存預防接種紀錄卡。自1983年政府開始有疫苗注射卡，及1991年後衛生所開始有電腦紀錄，發現對疫苗施打不清楚的情況明顯下降。結論：加強民眾瞭解疫苗接種的正確認知及態度，並瞭解自身疫苗史的重要性，及資料的保存，將有助建立日後出國留學及工作時的健康防護。
  Objectives: Most students are unaware of vaccination requirements or are unfamiliar with the reasons for vaccination. The limited time available may lead to incomplete evaluation and vaccination of students before departure. The aim of this study was to survey and analyze knowledge about vaccination among students in Taiwan. Methods: A total of 229 students who visited the travel clinic in a medical center between April and September, 2011 received self-administered questionnaires. The response rate was 91.6%. Results: A significantly higher percentage of female students planned to study abroad compared to male students (61.1% vs. 38.9%); 58.1% of the participants believed that vaccination could reduce one's susceptibility to infectious diseases. Males and older students had more knowledge and better attitudes abput vaccination; 38.8% of the participants had lost their childhood vaccination records. Conclusions: Since the Taiwanese government started using a vaccination record card in 1983 and local public health centers started using the electronic database in 1991, people have been less confused about vaccination requirements. Understanding the reasons for vaccination and saving the data will help protect their health when people study or work abroad.
• 131 - 142
• 10.6288/TJPH201534103089

• Link 原著 Original Article
• 自學式手冊介入策略對醫師面對罕見疾病急性紫質症之影響The Effect of an Acute Porphyria Self-Instruction Manual on Physicians
• 李雅琪、劉潔心、王建得
  Ya-Chi Lee, Chieh-Hsing Liu, Jiaan-Der Wang
• 自學式手冊 ； 醫師 ； 罕見疾病 ； 急性紫質症
  self-instructional manual ; physician ; rare disease ; acute porphyria
• 目標：本研究目的旨在探討以自學式手冊介入策略，對醫師面對罕見疾病急性紫質症的知識、態度與自我效能之影響。方法：本研究採用實驗組控制組前後測設計，並採立意取樣方式選取國內特定科別之臨床醫師為研究對象。研究工具為自行設計之自填式結構性問卷，問卷內容經信效度檢定及進行預試分析而完成。而自學式手冊內容為參考國內外相關文獻、訪談醫師和急性紫質症病患後，自行編製發展而成，最後經專家學者審閱後定稿。本研究招募方式採陌生拜訪，兩組前後測間隔時間相等，最終收得40位實驗組醫師及48位對照組醫師。其介入成效以單因子共變數分析方式檢定其成果。結果：研究結果顯示，自學式手冊內容符合醫師需求，且經介入後醫師在面對急性紫質症的知識、態度、自我效能等三方面，均達統計上顯著差異。結論：本研究為國內首次以衛生教育觀點，對醫師進行罕見疾病衛生教育之介入研究，其自學式手冊可供醫師參考使用，而研究成果可供未來罕病防治之參考。
  Objectives: The aim of this study was to investigate the effect of a self-instruction manual for physicians dealing with acute porphyria. Methods: This study was based on a ”pretest-posttest control group design” and selected specific field physicians as the target audience. A self-administered structured questionnaire was developed. The content of the manual was based on the relevant literature and interviews with physicians and patients, and finalized with expert reviews. Finally, we collected data from 40 physicians in the experimental group and 48 physicians in the control group (they had never met before, were randomly chosen and were willing to answer to our questionnaire), using the same time interval between the pre-test and the post-test. The intervention effects were evaluated by using one way analysis of covariance (ANCOVA). Results: The self-instruction manual increased knowledge, attitude, and self-efficiency with regard to acute porphyria, and all of these differences were statistically significant. Conclusions: To the best of our knowledge, this was the first time that the impact of a self-instruction manual on physicians dealing with a rare disease was studied in Taiwan. A self-instruction manual can provide a reference for physicians, and the results of this research can serve as a model for future references about rare diseases.
• 143 - 155
• 10.6288/TJPH201534103083

• Link 原著 Original Article
• 利用低劑量電腦斷層篩檢早期肺癌：系統性文獻回顧和統合分析Use of Low-Dose CT for Early Lung Cancer Screening: A Systematic Review and Meta-Analysis
• 曾健華、張慧如、邱韶薇、杜裕康
  Chien-Hua Tseng, Huei-Ru Chang, Shao-Wei Chiu, Yu-Kang Tu
• 低劑量電腦斷層 ； 肺癌 ； 篩檢 ； 統合分析 ； 陽性預測率
  low-dose CT ; lung cancer ; screening ; meta-analysis ; positive predictive value
• 目標：近年一個美國政府主導的大型隨機分派研究發現，針對重度抽菸者每年進行低劑量電腦斷層篩檢肺癌，相較於僅接受胸部X光篩檢者，三年內可相對降低20%肺癌死亡率；本文欲探討背後潛在的風險以及應用在台灣本土的適切性。方法：將過去10年針對此議題的研究進行系統性回顧（Systematic Review），蒐集每個研究的相關數據以及可能影響診斷工具效用的因子，再藉由統合分析（Meta-analysis）計算敏感度、陽性預測率等。結果：僅有5篇研究提供較完整追蹤資料，可推估低劑量電腦斷層的敏感度為87.43%（95% CI：72.79%~94.77%）、與特異度為96.45%（95% CI：80.39%~99.44%）；而由19篇文獻提供的資料，陽性預測率估計約為6.4%（95% CI：4.8~8.2%）。結論：雖然美國許多學會根據近年文獻紛紛建議對肺癌高危險群以低劑量電腦斷層篩檢肺癌，但過低的陽性預測率較少被強調，以目前的流程篩檢下來會造成許多的偽陽性個案，這會造成很多篩檢者被迫要面臨結果不確定性的壓力，甚至是接受不必要的侵入性切片或手術。尤其台灣肺癌發生率僅約美國一半，且女性抽菸比率較歐美國家低，而目前也未能確定台灣肺癌的主要危險因子，因此貿然大規模效仿美國指引進行篩檢，會導致更低的陽性預測率。因此，如何發展出適合台灣本土的建議，則是目前這個領域需要克服的難題。
  Objectives: Recent studies have demonstrated that low-dose computer tomography (LDCT) screening in place of X-ray screening for lung cancer could reduce relative mortality in heavy smokers by 20%. The aim of this study was to conduct a systematic review and meta-analysis for the performance of LDCT in lung cancer screening and to evaluate the potential benefits and harms of implementing such a screening program in Taiwan. Methods: We searched electronic databases (MEDLINE, EMBASE and Cochrane library) for studies on LDCT screening (1996 to 2014) and conducted meta-analyses of sensitivity, specificity, and positive predictive values (PPV). We also undertook meta-regression to examine the impact of study characteristics on LDCT screening. Results: Only 5 studies provided sufficient information for a meta-analysis of sensitivity (87.43%, 95% Confidence Interval [CI]: 72.79 to 94.77%) and specificity (96.45%, 95% CI: 80.39% to 99.44%). Twenty-one studies provided information for a meta-analysis of PPV (6.4%, 95% CI: 4.8 to 8.2%). Conclusions: Several studies from Western countries recommended the use of LDCT screening for lung cancer in high risk populations, especially for heavy smokers. However, the low PPV of LDCT was seldom discussed. Those false positive cases may suffer from mental stress and harm from unnecessary invasive interventions. Given the low smoking prevalence in Taiwan, implementing LDCT for population screening in lung cancer could represent a significant challenge.
• 156 - 167
• 10.6288/TJPH201534103133

• Link 原著 Original Article
• 台灣重要死因變動趨勢對潛在生命年數與經濟損失影響探討The Effects of Trends in Mortality due to the Leading Causes of Death on Potential Lost Life and Economic Loss in Taiwan
• 林正祥、劉士嘉、劉冠暐
  Cheng-Hsiang Lin, Shih-Chia Liu, Guan-Wei Liu
• 死亡率 ； Lee-Carter模式 ； ARIMA模式 ； 潛在生命年數損失 ； 經濟損失
  mortality rate ; Lee-Carter model ; ARIMA model ; years of potential life lost ; economic loss
• 目標：事故傷害、惡性腫瘤與糖尿病長期以來一直位居台灣前十大死因，三者分別為青少年，中、老年及老年人口的主要死因，本研究藉此探討三個重要死因對台灣潛在生命年數及經濟損失之影響。方法：利用Lee-Carter模式探討近30年來重要死因死亡率變動趨勢，另以平均餘命為基礎推算出其預期生命年數損失與工作年數損失，再以人力資本法計算1985-2012年重要死因所造成的經濟損失，最後利用時間序列ARIMA模式探討並預測重要死因的經濟損失變動趨勢。結果：事故傷害與惡性腫瘤的死亡水平指數近年來呈下降趨勢，而糖尿病則為上下震盪起伏；生命年數暨工作年數損失方面，事故傷害呈下降趨勢，惡性腫瘤與糖尿病則為直線上升趨勢；經濟損失方面，三死因自1985~2012年皆呈先上升後下降趨勢，惟惡性腫瘤自2001年後其經濟損失已超越事故傷害。結論：事故傷害經濟損失呈下降趨勢，意謂政府政策有所成效，應持續努力；惡性腫瘤疾病經濟損失自2001年即位居第一，對於其之防範與治療仍須加強；至於糖尿病經濟損失金額相對較小，惟其屬老年重要疾病，容易導致其他併發症發生，其防治仍有改善空間。
  Objectives: Injuries, malignancies and diabetes are always among the top 10 causes of death in Taiwan. Their occurrence varies among the young, the middle-aged, and the elderly. The aim of this study was to explore the effects of death due to these 3 causes on potential lost life and economic loss for the past 30 years. Methods: The Lee-Carter Model was used to explore the change in trends and to predict the future mortality rates of the 3 causes of death. The years of potential life lost/working life lost (YPLL/WPLL) were calculated based on information about life expectancy, and the Human Capital Method was used to determine the economic losses. Finally, a time series autoregressive integrated moving average (ARIMA) model was used to predict the economic losses. Results: The mortality indices for injuries and malignancies have decreased in recent years, while that of diabetes has fluctuated up and down. The YPLL/WPLL due to injuries decreased while the losses due to cancer and diabetes increased. The economic losses due to the 3 causes of death increased at the beginning and then went down from 1985 to 2012. Specifically, since 2001, the loss due to malignancies has been significantly higher than that caused by injuries. Conclusions: Economic loss due to injuries decreased, implying that the government's preventive policies were quite effective. Economic loss due to malignancies is the highest since 2001, meaning that effective preventive measures are still needed. Although diabetes causes a relatively small economic loss, prevention cannot be ignored since diabetes is highly correlated with metabolic syndrome in the elderly. There is still room for improvement in the prevention and treatment of diabetes.
• 168 - 179
• 10.6288/TJPH201534103102

• Link 原著 Original Article
• DRG為基礎前瞻性支付制度對髖關節骨折／置換術的醫療利用與照護結果之影響Impact of the Drg-Based Prospective Payment System on Medical Utilization and Outcomes of Care for Hip Fracture and Hip Replacement
• 羅郁婷、 張冠民、董鈺琪
  Yu-Ting Lo, Guann-Ming Chang, Yu-Chi Tung
• 髖部骨折 ； 髖關節置換術 ； 診斷關聯群 ； 照護結果
  hip fracture ; hip replacement surgery ; diagnosis related groups ; outcomes of care
• 目標：為了抑制上漲的健康照護費用，美國自1983年實施診斷關聯群（diagnosis related groups, DRG）為基礎的前瞻性支付制度，台灣於2010年1月實施以TW-DRG為基礎支付制度。很少研究探討實施DRG為基礎支付制度對於醫療利用及照護結果之影響，且研究結果並不一致。本研究目的係探討TW-DRG為基礎支付制度，對於髖部骨折與髖關節置換術之醫療利用與照護結果之影響。方法：資料取自2008年至2011年全民健康保險研究資料庫全國性樣本，選取主診斷為髖部骨折或主處置為髖關節置換術予以分析。本研究使用分段廣義估計方程式，控制趨勢、病人及醫院特性，以檢測實施TW-DRG為基礎支付制度，對於住院日數、30日再住院及30日死亡之影響。結果：實施TW-DRG為基礎支付制度與住院日數減少有關，及與30日再住院呈下降趨勢有關。結論：實施DRG為基礎支付制度，造成住院日數下降與30日再住院呈現下降趨勢。DRG為基礎支付制度的推行，可能促使醫療提供者建立較佳髖部骨折與髖關節置換術照護模式，以控制醫療利用，且改善再住院率。
  Objectives: To reduce rising health care costs, prospective payment systems based on diagnosis-related groups (DRGs) were introduced in the United States in 1983. Taiwan implemented the TW-DRG-based payment system in January 2010. Few studies have examined the impact of DRG-based payment systems on medical utilization and outcomes of care, and the results have been inconsistent. The objective of this study was to determine the impact of the TW-DRG-based payment system on medical use and outcomes of care for patients with hip fractures and patients undergoing hip replacement surgery. Methods: Data were derived from the nationwide sample through the National Health Insurance Research Database between 2008 and 2011. Patients admitted with a primary diagnosis of hip fracture or patients who underwent primary hip replacement surgery were selected for analysis. Segmented generalized estimating equations were used to determine the impact of the TW-DRG-based payment system on the length of stay, 30-day readmission rate, and 30-day mortality rate when adjusted for trend, patient, and hospital characteristics. Results: The implementation of the TW-DRG-based payment system was associated with a decrease in the length of stay, and with a decreasing trend in the 30-day readmission rate. Conclusions: The implementation of a DRG-based payment system in Taiwan led to a decline in the length of stay and a declining trend in the 30-day readmission rate. DRG-based payment systems might facilitate the development of a better model by which to contain medical utilization and improve readmission rates for patients with hip fractures and patients undergoing hip replacement surgery.
• 180 - 192
• 10.6288/TJPH201534103115

• Link 原著 Original Article
• 以德菲法建構醫療資源配置：政策利害關係人觀點Using the Delphi Method to Set Priorities for Health Insurance Benefit Schemes in Taiwan: A Policy Stakeholder Perspective
• 陳珮青、李玉春
  Pei-Ching Chen, Yue-Chune Lee
• 德菲法 ； 醫療資源配置 ； 優先順序
  Delphi method ; healthcare resource allocation ; priority setting
• 目標：本研究目的為從政策利害關係人觀點來建構醫療資源配置之原則與標準。方法：藉由德菲法以郵寄問卷方式，針對曾參與健保給付或支付、資源分配規劃或諮詢經驗之政府官員、醫療服務提供者、付費者代表、健保相關學者等共62專家，收集其對於醫療資源配置之看法。結果：兩回合德菲法回收44樣本，回收率70.97%，樣本68.2%為男性，年齡平均值為54.1歲，48.8%具有博士學歷，40.0%具有20年以上工作資歷。對醫療資源配置有以下5點共識：1.資源分配給「加權健康改善程度」最多的一群人，降低族群健康的不平等。2.對資源配置需考量「醫療成本效益」、「保險財務影響」、「有效性」、「公平性」、「人體健康影響」等標準。3.贊成對弱勢族群（除臨終病人及婦女外）給付加重考量。4.醫療資源配置標準重要性依序為「成本效益」、「有效性」、「公平性」及「個人負擔」。5.建立客觀可接受經濟評估閾值。結論：醫療資源配置應訂定原則與標準，及建立客觀可接受成本效益閾值，並考量弱勢族群給付加重。本研究結果可提供衛生福利部在進行醫療資源配置或給付優先順序決策之參考。
  Objectives: The aim of this study was to develop the principles of and criteria for healthcare resource allocation in Taiwan from the perspective of policy stakeholders. Methods: Sixty-two experts including government officials, health professionals, healthcare providers, and public/lay representatives were selected to participate via purposive sampling. The Delphi method was used for the collection of data. Two rounds of mailed questionnaires included questions aimed at identifying the criteria used by experts to establish priorities for healthcare insurance benefits. Results: Forty-four respondents completed two rounds of the Delphi exercise for a response rate of 70.97%. Most experts recommended the following: (1) Resources should be allocated according to their effectiveness in maximizing health services and eliminating health inequalities under fixed resources. (2) The criteria for resource allocation, such as cost-effectiveness, insurance financial impact, effectiveness, fairness, and human health outcome should be considered. (3) Disadvantaged groups should be assigned greater weights. (4) The relative importance of the priorities should be cost-effectiveness, effectiveness, fairness, and personal burden. (5) There is a need to establish an objective and acceptable economic assessment threshold. Conclusions: This study provides a valuable resource to guide the allocation of resources and identify the criteria used by governments in the establishment of priorities for the provision of healthcare insurance benefits.
• 193 - 203
• 10.6288/TJPH201534103122

• Link 實務 Public Health Practice
• 護理人員之社會心理工作特性、工作倦怠與身心健康相互影響－固定樣本追蹤研究The Reciprocal Effects of Psychosocial Job Characteristics, Burnout and Health among Nurses: A Panel Study
• 黃毓華、黃英忠、陳錦輝、杜佩蘭
  Yu-Hwa Huang, Ing-Chung Huang, Chin-Hui Chen, Pey-Lan Du
• 社會心理工作特性 ； 工作倦怠 ； 身心健康 ； 固定樣本追蹤研究 ； 螺旋論
  psychosocial job characteristics ; burnout ; health ; panel study ; loss/gain spiral
• 目標：過去有關工作壓力的研究著重於探討工作壓力對身心健康的單向影響，本研究從螺旋論的觀點，提出社會心理工作特性、工作倦怠與身心健康三者間相互影響之研究假設並加以驗證。方法：本研究以醫院護理人員為研究對象，採六個月間距的二波段縱貫性研究設計，總計完成502份完整之固定樣本追蹤資料。量表先經信度效度分析，再進行結構方程模型驗證。結果：研究結果證實，在順向影響方面包含：工作負荷對情緒耗竭與去人化具顯著正向影響、對心理健康具顯著負向影響；主管支持對情緒耗竭具顯著正向影響；同事支持對情緒耗竭與去人化具顯著負向影響、對身體症狀具顯著負向影響。在逆向影響方面包含：情緒耗竭對工作負荷感具顯著正向影響；心理健康對情緒耗竭與去人化具顯著負向影響；身體症狀對工作控制具顯著負向影響。結論：社會心理工作特性、工作倦怠與身心健康三者部分構面之間確實存在螺旋性相互影響的關係。研究者依據研究發現提出管理實務及學術研究方面的建議。
  Objectives: Work stress is a major concern in our society. Most previous studies have focused on the normal causal relationships between work stressors and their consequences rather than on the reverse and reciprocal relationships among them. The aim of the present study was to determine the reciprocal effects among psychosocial job characteristics, burnout and health, which resulting from the perspective of loss/gain spiral. Methods: Two-wave panel data were collected from nurses in both public and private hospitals in Taiwan. A total of 502 nurses completed valid questionnaires twice with a six-month time lag. Cronbach's a, confirmatory factor analysis and structural equation modeling were employed. Results: There were normal and reverse effects among psychosocial job characteristics, burnout and health. Conclusions: Theoretical and managerial implications and limitations were discussed.
• 204 - 217
• 10.6288/TJPH201534103090

• Link 評論 Commentary
• 評論：職場社會心理危害與工作者健康的相互影響Commentary: The Reciprocal Effects of Psychosocial Job Characteristics, Burnout and Health among Nurses: A Panel Study
• 鄭雅文
  Yawen Cheng
• 無
  none
• 無
  none
• 218 - 218
• 10.6288/TJPH20153410309001