36卷6期

• Link 綜論 Review Article
• 從美國經驗探討台灣長期照護制度改革An exploration of long-term care policy reform in Taiwan: what can we learn from the U.S. experience
• 傅健豪、 林翠芳
  Chien-Hao Fu, Tsui-Fang Lin
• 長期照護政策改革 ； 居家照護 ； 社區照護 ； 社區居住照護法案 ； 長期照護保險
  long-term care policy reform ; in-home care ; community care ; Community Living Assistance Services and Supports Act (The CLASS Act) ; long-term care insurance
• 本文探討美國長期照護制度及近年長期照護政策改革方案，期望能借鏡美國經驗，提供我國發展長照政策之參考。綜觀美國近年長照改革，除強化機構服務品質外，並持續發展個人化、家庭化、及社區化的長照服務，鼓勵家庭照顧者成為長照體系的一環，建立在地化的服務輸送體系。美國長照政策改革失敗之主因繫於長照財務，1988年老年醫療保險擴張改革，因保費調漲及稅負分配問題引發反彈，而2010年隨醫改通過的社區居住照護法案，雖欲建立自願投保的公共保險，卻無法確保清償能力下仍能維持可負擔的低廉保費。借鏡美國經驗，我們認為長照2.0以發展居家照護與社區照護為主，政府應重視家庭成員提供失能者無償照顧背後隱含的龐大社會成本，考慮讓家庭成員成為長照產業供給人力，實施現金給付政策並提供完善喘息服務。此外，家庭化及社區化的長照服務可能易因地區收入間的差異，而導致服務品質落差。未來政策應強化照顧者專業能力，及確保照護品質的地域平等性。最後，待長照服務體系建置完善及照顧人力充足後，實施具互助精神且財源相對穩定之長期照護保險是政府可以思考的選項。參考美國改革之例，若日後實施長照社會保險，為避免嚴重之逆選擇問題，建議採強制納保，以維持保險制度之永續經營。
  The main purpose of this paper is to investigate the long-term care system and recent long-term care policy reforms in the United States (U.S.). Overall, recent policy reforms in the U.S. have focused on improving the quality of institutional care while pushing for more development in personalized in-home and community care. Previous attempts at major reforms in long-term care failed mostly because of issues in financing them. In 1988, the expansion of Medicare and Medicaid coverage and eligibility were quickly overturned due to concerns about rising costs and unequal contributions from taxpayers. Recently, the Community Living Assistance Services and Supports Act (The CLASS Act) was enacted as part of the Patient Protection and Affordable Care Act. The CLASS Act would have established a voluntary national public insurance program for long-term care, but its design prevented the Act from satisfying the requirement to be actuarially sound while keeping the insurance premiums affordable. Learning from the U.S. experience, we suggest that the government should take into account the social costs associated with uncompensated care provided by family members. The government may consider using a cash payment policy and strengthening respite care programs. It is also worth noting that the quality of in-home care and community care might not be equal in different areas. Equipping caregivers with professional knowledge and ensuring the equality of services across regions are therefore critical in designing a successful service-delivery system. Finally, if the government plans to implement long-term care insurance in the future, then, in order to ensure its financial sustainability, a compulsory insurance scheme is needed to avoid adverse selection.
• 531 - 544
• 10.6288/TJPH201736106107

• Link 原著 Original Article
• 從綜合性學校衛生計畫看學校健康教育的發展：以巴基斯坦卡拉奇一所高中為例Development of the School Health Education Program from the perspective of Comprehensive School Health Model: an example at a Higher Secondary School of Karachi, Pakistan
• 無
  Saleema A Gulzar , Parvez Nayani, Syed Shajee Husain , Amna Khan
• 學校衛生；護士的角色和責任；健康促進；學校衛生計劃
  school health ; nurses' roles and responsibilities ; health promotion ; school health program
• 目標：透過將綜合性學校衛生計畫應用在巴基斯坦卡拉奇的一所高中，藉以評估學校健康教育計劃的需求、常見的健康議題、對健康的知識和態度，以及學生、教師與家長的自覺需求。方法：採焦點團體法與250位學生、35位教師進行訪談，以及對16名家長進行問卷調查，將收集到的資料進行主題分析，並依據主題，由一位學校保健室的護理人員制定並實施健康教育課程。結果：學生們傾向於注重身體健康，而父母則傾向於心理和社會發展的相關層面，教師則強調輔導學生的社會心理問題。在課程實施後，帶來一些新的影響，例如：食堂委員會的成立以確保供應健康的食物，以及增設輔導設施，協助學生應付日常生活壓力。結論：此計畫在執行學生健康促進方面來說是成功的，且此架構可作為發展中國家其他有相似需求，並希冀經營和指導學生有關學校健康促進之概念的參考。
  Objectives: To assess need for school health program, common health issues, knowledge and attitude towards health, perceived needs of students, teachers and parents. Thereafter apply Comprehensive School Health Model in a higher secondary school of Karachi; and gather outcome of the program through anecdotal evidences from stakeholders. Methods: Baseline assessment was conducted through focus group discussions and individual views from through interactive activities from 250 students; focus group discussions with 35 teachers and administered questionnaires to 16 parents. We thematically analyzed the data. Based on the thematic analysis, assigned school health nurse developed and implemented health education curriculum. We gathered anecdotal evidence from stakeholders to gauge success of the program. Results: The responses of students were more inclined towards physical aspects of health, and those of parents on issues related to mental and social development. Teachers emphasized broad and important aspects of counseling on psychosocial problems of students. After implementation of the curriculum, there were developments like establishment of a cafeteria committee to ensure healthy food availability and extended counseling facilities to help students cope with daily life stressors. Conclusions: The program was successful in terms of executing health promoting initiatives for school children. The framework can act as a reference for other schools in developing countries that share similar needs and want to administer and direct the concept of school health promotion for their students.
• 545 - 555
• 10.6288/TJPH201736105118

• Link 原著 Original Article
• 中文多面向健康識能量表（MMHLQ）之發展Development of Mandarin Multidimensional Health Literacy Questionnaire (MMHLQ)
• 魏米秀、 王英偉、張美娟、 謝至鎠
  Mi-Hsiu Wei, Ying-Wei Wang, Mei-Chuan Chang, Jyh -Gang Hsieh
• 健康識能 ； 測量 ； 多面向 ； 中文 ； 成人
  health literacy ; measurement ; multi-dimensions ; Mandarin ; adults
• 目標：本研究目的在發展一個適用於台灣成人的中文多面向健康識能量表。方法：首先經焦點團體訪談、專家內容效度、語文適讀修正等程序發展檢測題目；接著以566名成人為測定樣本，用以檢測量表心理計量特質及檢定測量模型適配度；最後以2,394名成人為效化樣本，用以檢測量表複核效度。結果：結果顯示二階五因素的測量模型適配度良好。量表包含五個面向：「獲取健康資訊」、「理解健康資訊」、「評估健康資訊」、「應用健康資訊」及「溝通與互動」，共20題自陳式題目。心理計量分析顯示量表的內部一致性信度、再測信度、建構效度、聚斂效度、區辨效度、效標關聯效度及已知群組效度表現良好。複核效度檢定結果，符合跨樣本的量尺不變性。最後，以標準參照方式訂出健康識能程度分級的切分點。結論：MMHLQ為具有良好信、效度的多面向健康識能測量工具，可用以評量群體的健康識能程度，也可做為教育介入的需求評估工具。
  Objectives: The objective of this study was to develop a tool capable of measuring multidimensional health literacy among adults in Taiwan. Methods: In the first phrase, we adopted focus-group interviews, consultations with experts, and readability check to formulate calibration items. In the second phrase, a calibration sample of 566 adults was recruited to examine the psychometric characteristics of the items and test the fitness of the measurement model. In the last phrase, a validation sample of 2394 adults was used for evaluating cross-validation. Results: CFA demonstrated the high degree of fitness of the proposed second-order five-factor model. The proposed scale covers the following five dimensions: accessing, understanding, appraising, and applying health information, and communication and interaction. The scale includes 20 self-reported items. Psychometric analysis demonstrated that the scale has high internal consistency and test-retest reliability as well as good construct, convergent, discriminant, criterion-related, and known group validity. Cross-validation analysis demonstrated the metric invariance of the scale across the two samples. Cutting scores were selected for criterion-referenced grading. Conclusions: Our findings indicate that the Mandarin Multidimensional Health Literacy Questionnaire (MMHLQ) is a reliable and valid measure of multi-dimensional health literacy. The tool is useful in evaluating the level of health literacy among adult populations as well as in needs assessments geared toward interventions to improve health literacy.
• 556 - 570
• 10.6288/TJPH201736106061

• Link 原著 Original Article
• 以理論為架構探討影響孕婦季節性流感疫苗接種意圖之相關因素：以臺北市立聯合醫院為例Factors associated with the behavioral intention towards receiving a seasonal influenza vaccine during pregnancy - an empirical study at Taipei City Hospital
• 蔡秉修、 林陳立、施淑芳
  Ping-Hsiu Tsai, Chen-Li Lin, Shu-Fang Shih
• 孕婦；流感疫苗；健康信念模式；行為意圖
  pregnant women ; influenza vaccines ; Health Belief Model ; behavioral intentions
• 目標：本研究旨在探討影響孕婦接種季節性流感疫苗行為意圖之相關因素。方法：本研究為橫斷性研究，並運用健康信念模式及參酌相關文獻設計測量工具。研究對象為2016年8至9月間至臺北市立聯合醫院婦產科候診之孕婦共315位。本研究以SAS 9.4版進行資料處理，以STATA 13版進行多元線性迴歸分析。結果：孕婦自覺利益越大、自覺障礙越小、行動線索越多、自我效能越好、主觀規範程度越高、預期擔心越多，以及社會規範越低，其流感疫苗接種意願越高。結論：建議針對影響孕婦接種流感疫苗之重要因子如自覺利益、自覺障礙，以及自我效能等設計衛生教育策略，如強化接種疫苗對孕婦及胎兒的利益或移除其對疫苗安全性疑慮等障礙。
  Objectives: This study aimed to investigate the factors associated with the behavioral intention towards influenza vaccination. Methods: This was a cross-sectional study. The instruments were developed based on the Health Belief Model and related literature. The participants were the 315 pregnant women who had prenatal visits between August and September 2016 at the Fuyou Branch of Taipei City Hospital. We used SAS 9.4 for data processing, and STATA 13 for multiple linear regression analysis. Results: The participants with more perceived benefits, less perceived barriers, more cues to action, higher self-efficacy, higher subjective norms, more anticipated worry, and lower social norms were more willing to receive influenza vaccine. Conclusions: Our findings suggest that health education strategies should be designed with a focus on the important determinants influencing intention towards vaccination, such as self-perceived benefits, self-perceived barriers, and self-efficacy. Such strategies include enhancing perceived benefits for the pregnant women and their babies, and clarifying the safety issues to remove the barriers.
• 571 - 588
• 10.6288/TJPH201736106085

• Link 原著 Original Article
• 台灣台東縣學齡前兒童的咀嚼能力與進食行為之關係探討A study on masticatory ability and eating behaviors for preschool children in Taitung County, Taiwan
• 黃愫芬
  Su-Fen Huang
• 咀嚼能力 ； 進食行為 ； 咀嚼力判定口香糖
  masticatory ability ; eating behaviours ; color-changeable chewing gum
• 目標：本研究旨在瞭解台東縣學齡前兒童咀嚼能力與進食行為之現況，及探討影響咀嚼能力之因素。方法：採用咀嚼力判定口香糖檢測咀嚼能力和研究者自編之「兒童進食行為調查表」為工具，以分層叢集抽樣方式，抽取台東縣滿五足歲403位學齡前兒童為研究對象。採用卡方檢定與多變項羅吉斯迴歸進行資料分析。結果：(一)約22.83%兒童咀嚼能力較弱，約26.30%經常會喜歡吃軟不喜歡吃硬的食物。(二)以多變項羅吉斯迴歸分析顯示，影響兒童咀嚼能力較弱之顯著因子包括：從不吃早餐、每天都吃零食、很偏食、不會吃東西細嚼慢嚥、經常會狼吞虎嚥、經常會吃東西咬一咬吐出來、經常會食物久含在口中、經常會喜歡吃軟不喜歡吃硬的食物、經常會邊吃飯邊看電視及經常會邊吃飯邊喝水或喝湯。結論：兒童咀嚼能力近二成半屬於弱的程度，進食時咀嚼動作愈不確實會提高咀嚼能力愈弱的風險，建議改變烹飪形式和提供稍微較硬的食物，並宣導牙齒保健和正確咀嚼進食，如不偏食、關掉電視專心吃飯及叮嚀細嚼慢嚥。
  Objectives: This study aimed to investigate the current status and factors related to the masticatory ability and eating behaviors of preschool children in Taitung County, Taiwan. Methods: The study subjects included 403 five-year-old preschool children in Taitung County, Taiwan. The study tools included a masticatory ability test (color-changeable chewing gum) and questionnaire on eating behaviors. All data obtained were analyzed using a chi-square test and multivariate logistic regression analysis. Results: (1) Among the children studied, 22.83% had reduced masticatory ability. Further, 26.30% avoided eating chewy foods regularly. (2) The multiple logistic regression analysis indicated various eating behaviors that were associated with the poor masticatory ability of preschool children. These behaviors were never eating breakfast, having a snack daily, having particular food preferences, unable to chew food properly, eating quickly, regularly spitting out after chewing, usually keeping food in the mouth for a long time, preferring soft foods to hard foods, eating while watching television, and generally eating while drinking water (other beverages) or consuming soup. Conclusions: Almost one-quarter of the included preschool children had poor masticatory abilities. The masticatory ability of the preschool children correlated with their eating behaviors. Based on these results, it is recommended to change cooking methods or to provide harder foods and to promote the concepts of good oral hygiene and eating behaviors such as a balanced diet, no television while eating, and eating slowly.
• 589 - 602
• 10.6288/TJPH201736106092

• Link 原著 Original Article
• 孕婦對羥基苯甲酸酯暴露之生物偵測及其對新生兒出生結果之健康影響Biological monitoring of parabens in pregnant women and the health effects on newborns
• 梁海薇、 張嘉晃、 黃鈺芳、王培瑋、黃禮偉、楊文理、 陳美蓮
  Hai-Wei Liang, Chia-Huang Chang, Yu-Fang Huang, Pei-Wei Wang, Li-Wei Huang, Winnie Yang, Mei-Lien Chen
• 對羥基苯甲酸酯；產前暴露；體重；體長；頭圍
  paraben ; prenatal exposure ; birth weight ; birth length ; head circumference
• 目標：對羥基苯甲酸酯具防腐之特性，故常被應用於各式消費產品中，造成民眾暴露機會大增。對羥基苯甲酸酯為已知的環境干擾物質，對於健康之影響，目前結果仍不明確。因此，本研究將建立台灣第一份對羥基苯甲酸酯之暴露資料、探討可能之暴露來源、並了解產前對羥基苯甲酸酯暴露與嬰兒出生指標之相關性。方法：本研究追蹤241位孕婦及其嬰兒、蒐集第三孕期尿液、並使用高效能液相層析串聯四極柱飛行時間式質譜儀檢測尿液中甲基、乙基、丙基、及丁基四種常見之對羥基苯甲酸酯。結果：對羥基苯甲酸酯（甲、乙、丙、丁基）的幾何平均濃度分別是37.3、1.00、3.04、0.84 ng/mL。與國外研究相比，本研究檢測濃度較低。乳液使用頻率及每周蔬菜攝入量較多者，對羥基苯甲酸酯暴露量較高。總對羥基苯甲酸酯高暴露組，對胎兒體重具相關性；乙基對羥基苯甲酸酯高暴露組，對胎兒體長具相關性。結論：本研究為台灣首次對羥基苯甲酸酯之暴露資料。可提供孕婦減少使用含對羥基苯甲酸酯產品之建議，以維護嬰兒健康發展。
  Objectives: Parabens are a group of esters of parahydroxybenzoic acid and widely used as antimicrobial preservatives. Human can be easily exposed to them through food additives and personal care products (PCPs). However, epidemiological studies on the adverse effects of paraben are limited. This study was to determine parabens levels in urine of pregnant women in Taiwan for the first time and the growth of newborns. Methods: In this study, pregnant women and their fetuses were followed-up. Maternal urine samples were collected at the third pregnancy trimester. We measured four common parabens (methyl, ethyl, propyl, butyl) in urine extract using off-line solid phase extraction-Ultra performance liquid chromatography- Quadrupole time of-flight mass spectrometer method and the concentrations were adjusted with creatinine. Results: The geometric mean levels of urinary MP, EP, PP, and BP were 37.3, 1.00, 3.04 and 0.84 ng/mL, respectively, which were lower than levels measured in most of other countries. Higher paraben exposure was associated with the frequency of using cosmetics and the weekly vegetable intake. Birth weight was associated with total paraben exposure (p<0.05) and birth length was associated with ethyl paraben exposure (p<0.01). Conclusions: Although the parabens exposures in pregnant women were lower in Taiwan than in western, the exposure may have association with fetus growth. Future study is needed to confirm the causal correlation, and we suggested reducing the use of parabens in PCPs products during pregnancy.
• 603 - 612
• 10.6288/TJPH201736106089

• Link 原著 Original Article
• 運用修正型德菲法與健保資料庫開發具可行性的兒科品質報告卡指標The use of modified Delphi method and health insurance database to develop feasible indicators for pediatric quality report card
• 陳宗泰、 鄒國英、 徐世達、 蔡宜蓉、 許巍鐘、鍾國彪、黃莉茵
  Tsung-Tai Chen, Kuo-Inn Tsou, Shyh-Dar Shyur, I-Jung Tsai, Wei-Chung Hsu, Kuo-Piao Chung, Li-Ying Huang
• 兒科 ； 品質指標 ； 資訊公開 ； 修正型德菲法
  pediatric ; quality measures ; open disclosure ; modified Delphi
• 目標：訂出適合我國國情並能與國外接軌的兒科品質報告卡指標。方法：參考國際組織與國外文獻發展的兒科指標，並邀請兒科及家醫科等相關的專家，以按照重要性、效度及改善機會等準則來萃取出專家偏好的指標，最後再陸續以不同的方法（如專家會議、修正型德菲法及健保資料庫輔助）來產生最終的代表性指標。結果：本研究選擇了4項兒科領域（3項疾病領域）：氣喘、積液性中耳炎、尿道感染及一般結果（例如死亡率）等，此4項領域共辨識出49項相關候選指標，最後選出7項兒科品質報告卡代表指標，包括氣喘4項，積液性中耳炎1項，以及尿道感染2項，這7項品質報告卡代表性指標的比率大部分呈現逐年惡化的品質趨勢。結論：本研究以修正型德菲法選出7項適合我國國情以及與國際接軌的指標，政府單位可參考本研究成果發展兒科品質報告卡來改善品質。
  Objectives: To develop pediatric indicators of public report card that are suitable for Taiwan's context and aligned with international standards. Methods: We referenced the pediatric indicators developed by international organizations and the literature and invited experts with specialties in pediatric and family medicine in order to extract their preferred indicators according to the selection criteria of importance, validity, and feasibility. The final results of the representative indicators were subsequently produced through different methods (i.e. professional meetings, modified Delphi, and aid from the National Health Insurance Administration (NHIA)'s claims database). Results: We chose four pediatric disease fields: asthma, otitis media with effusion (OME), urine tract infection (UTI), and general outcomes (e.g. mortality). We next identified a total of 49 candidate indicators from these 4 fields (3 disease categories) and then finally selected 7 representative indicators for the pediatric quality report card, including 4 asthma-related indicators, 1 OME indicator, and 2 UTI indicators. The adherence rates for most of these indicators demonstrated steadily deteriorating trends of quality. Conclusions: We employed the modified Delphi method to elicit 7 representative indicators that are suitable for our context and aligned with international standards. The government can utilize our study's results to develop a pediatric quality report card for improving quality of pediatric care.
• 613 - 622
• 10.6288/TJPH201736106054

• Link 評論 Commentary
• 評論：運用修正型德菲法與健保資料庫開發具可行性的兒科品質報告卡指標Commentary: the use of modified Delphi method and health insurance database to develop feasible indicators for pediatric quality report card
• 洪錦墩
  Chin-Tun Hung
• 無
  none
• 無
  none
• 623 - 623
• 10.6288/TJPH20173610605401

• Link 評論 Commentary
• 作者回覆：運用修正型德菲法與健保資料庫開發具可行性的兒科品質報告卡指標Authors' response to commentary; the use of modified Delphi method and health insurance database to develop feasible indicators for pediatric quality report card
• 陳宗泰、鄒國英、 徐世達、 蔡宜蓉、許巍鐘、鍾國彪、黃莉茵
  Tsung-Tai Chen, Kuo-Inn Tsou, Shyh-Dar Shyur, I-Jung Tsai, Wei-Chung Hsu, Kuo-Piao Chung, Li-Ying Huang
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  none
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• 624 - 625
• 10.6288/TJPH20173610605402

• Link 原著 Original Article
• 台灣診所之歇業與存活研究及其相關因素探討－以2000年至2010年新設西醫診所研究為例Taiwan's new clinic closures (survivals) and their associated determinants: 2000 to 2010
• 蔣靜怡、 郎慧珠
  Rica Ching-Yi Chiang, Hui-Chu Lang
• 診所 ； 歇業 ； 專科診所 ； 存活曲線 ； 市場競爭
  clinics ; closures ; specialist clinics ; survival curve ; market competition
• 目標：探討西醫診所存活趨勢並提供相關經營建言。方法：資料來源有二：1.2000-2010年國衛院「全民健康學術研究資料庫」。2.主計處「中華民國統計資訊網」之縣市社經指標。研究範圍排除外島、中醫與牙醫診所，統計分析以存活曲線（Survival Curve）以及Cox比例風險分析模式（Cox Proportional Hazard Model）探討各專科診所及縣市別之存活情況與生存風險。結果：西元2000-2010年新增加西醫診所7,347家，有5,361家存活，1,986家最終歇業。研究顯示西醫診所於經營約第700天皆進入歇業/存活之關鍵決定。歇業幅度最高之前三名科別：不分科（37.5%）、家醫科（33.9%）與復健科（28.7%）。存活診所其醫師較為年輕、醫事人員編制較大，診所收入點數與就診人次較高。歇業幅度最高之前三名縣市為雲林（41.3%）、台東（39.1%）與苗栗（37.0%）。結論：西醫診所經營前期700天為歇業/存活關鍵，等同為「診所黃金生存七百天」。家醫科歇業率居各專科診所之冠。台灣診所高歇業率地區多屬非都會區，與國外文獻指出歇業多發生於大城市的結果相異。
  Objectives: This study aimed to determine the survival trends in Taiwan clinics. We expect the results to provide important information for practitioners and the government for their operation and health policy making. Methods: We used 2000-2010 NHI claim data and statistics from the Statistical Bureau, National Statistics of Taiwan. Clinics located in outlying islands, as well as Chinese physicians and dentists, were excluded from this research. Survival curves and Cox regression were used to analyze the trends in clinic closures and explore the factors influencing the survival of clinics during the study period. Results: A total of 7,347 clinics were initiated between 2000 and 2010. Among the clinics, 5,361 remained open and 1,986 closed. The survival curve indicated that 7,347 clinics had significantly decreased after the 700th day of operations. The top 3 closure specialties were general medicine (37.5%), family medicine (33.9%), and rehabilitation medicine clinics (28.7%). The age of physicians, number of staff members, income, and clinic visits were significant determinants associated with closure. The top 3 counties of clinic closures were Yun-Lin, Tai-Tung, and Miao-Li counties. Conclusions: Between 2000 and 2010, of the 7,347 initiated clinics studied, closures occurred after the 700th day of operations. The highest three specialties of closure were general medicine, family medicine, and rehabilitation medicine.
• 626 - 639
• 10.6288/TJPH201736105110