37卷2期

• Link 原著 Original Article
• 台灣地區道路密度、長期細懸浮微粒暴露與發生高血壓之研究Roadway density, PM_(2.5), and hypertension: a retrospective cohort study in Taiwan
• 邱聖崴、吳治達、 張奕彩、 潘文驥
  Sheng-Wei Chi, Chih-Da Wu,Yi-Tsai Chang,Wen-Chi Pan
• 道路密度 ； 細懸浮微粒 ； 高血壓 ； 因果中介變項模型
  roadway density ; PM_(2.5) ; hypertension ; casual mediation model
• 目標：檢視台灣地區道路密度與發生高血壓之相關性，及利用因果中介變項分析了解細懸浮微粒、交通噪音在關係中之角色。方法：研究利用全民健康保險2000年百萬承保抽樣歸人檔（Longitudinal Health Insurance Database [LHID] 2000）之世代追蹤研究資料，以確認2003年至2012年間罹患高血壓者的新病例。暴露資料則以交通部運輸研究所之路網數值圖2006第1.3版，透過地理資訊系統計算研究對象就醫鄉鎮之道路密度而細懸浮微粒資料取自2006至2012年空氣品質監測網之每小時PM_(2.5)自動監測資料，並以克力金模型推估至研究對象就醫地點所在之鄉鎮，做為受試者之長期暴露數值。最後再以Cox比例風險模型估計道路密度與發生高血壓之危險比及利用因果中介變項量化交通汙染所產生之細懸浮微粒所造成之高血壓效應（例：間接效應[Natural Indirect Effect, NIE]）。結果：研究對象所就醫之鄉鎮如有較高之縣道道路密度時（? 125.3 m/km^2），則其對之高血壓風險約略增加17%（危險比[Hazards Ratio, HR]=1.17, 95%信賴區間：1.14-1.19），而較高之鄉道道路密度（? 473.2 m/km^2）也發現相同的趨勢（危險比[Hazard Ratio, HR]=1.09, 95%信賴區間：1.07-1.10）。結論：本研究發現研究對象就醫鄉鎮之道路密度與發生高血壓有正向的相關性，此相關可能為細懸浮微粒所造成。
  Objectives: To assess the association between roadway density and the incidence of hypertension and to evaluate the role of fine particulate matter (PM_(2.5)) on that association by using mediation analyses Methods: We included participants' health information retrieved from the Longitudinal Health Insurance Database 2000. We retrieved roadway density (e.g. county road) from the Institute of Transportation's Digital Road Network Map 2006. Participants' long-term exposure to traffic-related pollution was based on the roadway density of the township in which they resided. We applied Cox proportional hazards models to assess the association between the incidence of hypertension and road density. Casual mediation models were utilized to estimate the mediation effect of PM_(2.5) on the roadway density-hypertension association. Results: During a median follow-up time of 11.01 years, 108,733 cases of hypertension were identified. After we controlled for potential confounders, participants who resided in townships with a higher density of county roads (? 139 m/m^2) had a 17% higher risk for hypertension when compared to the reference group (Hazard Ratio [HR]=1.17; 95% Confidence Intervals [CIs]: 1.14-1.19), and similar results were also found for country roads (HR=1.09, 95% CIs: 1.07-1.10). Results were not materially different when we included only participants who lived in a metropolitan area (e.g. Taipei city). Furthermore, PM_(2.5) imposed a statistically significant mediating effect on the incidence of roadway density-associated hypertension for county roadway exposure (HR=1.01, 95% CIs: 1.00-1.02) and country roadway exposure (HR=1.001, 95% CIs: 1.00-1.02). Conclusions: This study provided evidence that roadway density was positively associated with the risk of hypertension in an Asian population. We also found that PM_(2.5) served as a mediator for this association.
• 125 - 136
• 10.6288/TJPH.201804_37(2).106088

• Link 原著 Original Article
• 頭頸癌病人放射治療毒性反應預測因素之研究Predictors of radiation therapy toxicity in patients with head and neck cancer
• 馬震中、葉世安、郭光明、林佩蓉
  Chen-Chung Ma, Shyh-An Yeh, Kuang-Ming Kuo, Pei-Jung Lin
• 放射治療 ； 頭頸癌 ； 放射治療毒性反應
  radiation therapy ; head and neck cancer ; radiation therapy toxicity
• 目標：放射治療產生之毒性反應，反映著治療品質之好壞，進而影響病人後續生活品質。本研究目的為探討頭頸癌病人放射治療毒性反應之預測因素。方法：採回溯性研究設計，以病歷回顧方式收集資料，個案來源為台灣南部某區域醫院2013年1月1日至2015年12月31日，共606名頭頸癌病人納入研究；本研究經人體試驗倫理委員會通過後執行。資料進行敘述性性統計、卡方檢定及多元羅吉斯回歸分析，找出影響放射治療口腔及皮膚治療毒性反應之預測因素。結果：男性546人（90.1%），女性60人（9.9%），平均年齡54.0歲，經多元羅吉斯迴歸分析結果以治療次數、治療固定方式為頭頸癌放射治療皮膚呈現輕微或嚴重反應之預測因素；年齡、身體質量指數為口腔呈現輕微反應之預測因素，癌症部位則為口腔呈現輕微或嚴重反應之預測因素。結論：結果發現改變治療固定方式即能減少皮膚輕微或嚴重反應，由此可供臨床醫師擬定治療計畫時之參考運用，其他預測因素則可促進醫療照護人員對毒性反應之瞭解並提高治療期間對病人毒性反應之關注，能即時給予適當醫療照護處置，以降低毒性反應程度並藉此提升病人的放射治療品質。
  Objectives: Toxicity from radiation therapy is a reflection of the quality of treatment, and will influence the quality of life of patients. The aim of this study was to investigate the effects of demographic, disease and radiotherapy factors on the toxicity of radiation therapy for patients with head and neck cancer. Methods: This was a retrospective study with secondary data analysis. A total of 606 head and neck cancer patients were enrolled in this study from January 1, 2013 to December 31, 2015 in a regional hospital in Southern Taiwan. This study was approved by the institutional review board of E-DA hospital. Descriptive statistics and logistic regression analysis were used to analyze the factors associated with radiation therapy toxicity of the mouth and skin. Results: The results of multivariate logistic regression analysis showed that treatment fraction and immobilization techniques had a significant influence on the side effects on the skin to a mild or severe degree, age and body weight index had a significant influence on the side effects on the mouth to a mild degree, and tumor site had a significant influence on the side effects on the mouth to a mild or severe degree. Conclusions: Immobilization technique is a controllable factor in that changing the selection of immobilization technique can reduce the effects on the skin. This may provide valuable information for radiology physicians when they design a patient's treatment plan. The results may also help medical care staff understand radiation side effects, provide immediate medical services, and improve the quality of radiation therapy.
• 137 - 147
• 10.6288/TJPH.201804_37(2).106117

• Link 原著 Original Article
• 應用SERVQUAL量表探索台灣中南部偏遠地區長期照護服務使用者與家屬對長照據點滿意度與相關因素Exploring user satisfaction with factors related to long-term care service stations in remote areas of Taiwan using SERVQUAL
• 李懿珍、 劉立凡
  Yi-Chan Lee, Li-Fan Liu
• 長期照顧服務 ； 據點偏遠地區 ； 服務缺口模式 ； 據點功能 ； 衛生所
  long-term care service stations ; remote area ; PZB model ; function of the stations ; health station
• 目標：由「服務品質模式」（PZB model）缺口五角度切入，檢視偏遠地區及資源不足區長照服務據點之滿意度及相關因素。方法：本研究發展的SERVQUAL問卷內容效度與信度良好。以方便抽樣於各偏遠長照據點訪問6-10名服務使用者，共完成23個據點有效樣本206份。結果：受訪者有六成來過據點，使用者多為女性、失能程度較低。約六成的據點成立不到3年，照顧管理個案量高。服務品質滿意度得分以保證性最高、有形性最低，總平均分數為4.37分。受訪者認為據點的功能以直接服務顯著高於整合平台與衛教。不同失能程度在可靠性、反應性、關懷性與滿意度總分有顯著差異，而事後檢定發現無失能者在可靠性、滿意度總分顯著高於輕度失能者。衛生所（30.4%）承接的據點滿意度較高，在有形性、關懷性與滿意度總分有顯著差異。回歸結果顯示，了解據點功能及由衛生所承接的據點對使用者及家屬滿意度有正向且顯著影響。結論：本研究結果建議強化使用者及家屬對據點功能之了解以及未來由衛生所承接的政策考量。
  Objectives: To examine user satisfaction and factors influencing the function of long-term care service stations in remote areas of Taiwan. Methods: In a PZB model, 6-10 users were recruited by convenience from each long-term care service station to complete the SERVQUAL questionnaire. A total of 206 user questionnaires from 23 long-term care service stations were collected. Results: Sixty percent of the respondents had been to the service stations, and most users were female or with a mild disability. Nearly 60% of the service stations had been set up for fewer than three years, and a large caseload was managed by each care manager. From the respondents' perspective, the highest satisfaction was in the assurance domain, and the lowest in tangibles. The mean score was 4.37. More users perceived the function of service stations as providing direct service rather than functioning as integration platforms or health education facilities. There were significant differences in the accessible, reliable, and empathy domains and total scores for satisfaction at different levels of disability. Scores in the accessible domain and total scores for non-disabled users were significantly higher than those of those with a mild disability. There was also higher user satisfaction in the tangibles and empathy domains and total score if their health station (30.4%) provided services. Finally, regression analysis showed that there were positive significant effects on the respondents' satisfaction with clear recognition of the function of long-term care service stations and the services they provided. Conclusions: This study suggested that in order to promote user satisfaction, it would be useful to deliver a clear message about service station features and the services they provided.
• 148 - 164
• 10.6288/TJPH.201804_37(2).106091

• Link 評論 Commentary
• 評論：應用SERVQUAL量表探索台灣中南部偏遠地區長期照護服務使用者與家屬對長照據點之滿意度與相關因素Commentary: exploring user satisfaction with factors related tp long-term care service stations in remote areas of Taiwan using SERVQUAL
• 李怡娟
  I-Chuan Li
• 無
  none
• 無
  none
• 165 - 165
• 10.6288/TJPH.201804_37(2).10609101

• Link 原著 Original Article
• 民眾對全民健保給付合理論責機制之態度調查Employing accountability for reasonableness in Taiwan's National Health Insurance: exploration of public opinions
• 吳全峰、 董鈺琪
  Chuan-Feng Wu, Yu-Chi Tung
• 合理論責機制 ； 全民健康保險 ； 給付決策流程 ； 分配正義
  accountability for reasonableness (A4R) ; National Health Insurance (NHI) ; treatment/drug reimbursement decision-making process ; distributive justice
• 合理論責機制（accountability for reasonableness, A4R）為健康照護分配正義評估提供完整連貫之理論架構，本研究目的便係瞭解民眾（作為重要利害關係人）對於將A4R要件納入全民健保給付決策機制之態度與認知，並探討可歸因性之相關因素。方法：研究對象為20歲以上全國民眾，採隨機抽樣並輔以電話訪問，樣本數為1,140位，以多項式邏輯斯迴歸探討可歸因性與民眾特性、公開性、參與性及可修正性之關聯性。結果：多數受訪者認為可歸因性、公開性、參與性與可修正性為健保給付決策機制之重要要素，但僅少數受訪者認識相關機制。就健保給付決定因素分析，重視藥物/醫療服務價格勝於治療效果者，與年齡、教育程度、收入、醫療利用、公開性及參與性有關；重視疾病負擔勝於治療效果者，與年齡、收入、慢性病及參與性有關。結論：民眾普遍認為健保給付決策機制納入A4R要件有其重要性，但認知與態度存在差距；且可歸因性與民眾特性、公開性、參與性有關。
  Objectives: Accountability for reasonableness (A4R) provides a coherent theoretical framework to evaluate healthcare distributive justice as part of healthcare policy. This study aimed to analyze people’s knowledge about and attitudes toward employing A4R (including relevance of decisions, transparency, involvement of stakeholders, and revisability) in the National Health Insurance (NHI) treatment/drug reimbursement decision-making process, and to explore factors associated with the relevance of such decisions. Methods: A total of 1,140 adults aged 20 and over were randomly sampled from a nationwide population and interviewed by telephone. Multinomial logistic regression was used to examine the associations of individual characteristics, transparency, involvement of stakeholders, and revisability with the relevance of decisions. Results: Most respondents regarded A4R as essential to the NHI reimbursement decision-making process, but only few recognized how A4R was implemented. Additionally, with regard to considerations about setting healthcare priorities - (medical efficacy, disease burden, treatment/drug price), respondents' concerns about price were associated with age, education, income, medical utilization, and their subjective perspectives about transparency and the involvement of stakeholders. Their concerns about disease burden were associated with age, income, chronic disease status, and subjective perspective about the involvement of stakeholders. Conclusions: Even though most people agree on employing A4R to support fair priority-setting in NHI's reimbursement decision-making, a gap exists between their attitudes and knowledge. Additionally, public attitudes about the relevance of decisions are associated with socio-economic characteristics and concerns about transparency and the involvement of stakeholders.
• 166 - 181
• 10.6288/TJPH.201804_37(2).106132

• Link 原著 Original Article
• 促成獎勵措施對於甘比亞接受都治治療的肺結核病人生活品質影響之研究The effects of the enablers incentive package on the quality of life among tuberculosis patients receiving DOTS in the Gambia
• 謝朗明、黃嵩立、楊振昌、顏璧梅
  Lamin M. Ceesay, Song-Lih Huang, Chen-Chang Yang, Pi-Mei Nancy Yen
• 甘比亞 ； 健康相關生活品質 ； 誘因 ； 肺結核
  Gambia ; health-related quality of life ; incentives ; tuberculosis
• 目標：本研究目的在探討甘比亞肺結核病患的生活品質及就醫時是否接受促成獎勵措施（enablers package）對於病人健康相關生活品質的影響。方法：本研究利用橫斷式研究，以至少接受兩週以上肺結核治療的肺結核病人為研究對象。利用世界衛生組織健康相關生活品質滿意度問卷進行面對面訪談，以瞭解其健康相關生活品質之狀況，並比較接受及未接受促成獎勵措施的兩組病人的整體及不同範疇的健康相關生活品質平均分數之差異。最後以複線性迴歸模式分析探討可能與較佳的生活品質有關的預測因子。結果：有接受促成獎勵措施者較無接受相關措施者有顯著較高的整體健康相關生活品質（p＜0.001）；且與生理、心理與環境等範疇之健康相關生活品質也都有顯著的正相關。在複線性迴歸模式分析中，有接受治療的誘因（促成獎勵措施）、女性及居住在城市者有顯著較高的整理健康相關生活品質。結論：本研究結果為首次瞭解甘比亞肺結核病人的健康相關生活品質。未來需要更進一步的研究以瞭解肺結核病人的需求，並提升該族群的生活品質。
  Objectives: The purpose of this research was to explore the quality of life among tuberculosis patients in the Gambia and assess the effects of the enablers package on it. Methods: A cross-sectional study was conducted among patients receiving anti-TB treatment for at least two weeks in the Gambia. Health-related quality of life was assessed using the WHOQOL-BREF questionnaire through face-to-face interview. The mean overall and domain-specific scores of the WHOQOL-BREF were compared for recipients and non-recipients of the enablers package. Multiple linear regression analyses were employed to identify predictors of a better quality of life. Results: Receipt of the enablers package had a positive association with the overall quality of life (p<0.0001) and all domain-specific quality of life scores except that of the social domain. Multiple linear regression analyses revealed that the receipt of incentives, female gender, and urban residence had positive significant impacts on the overall quality of life. Conclusions: The results of this study mark the beginning of the understanding of quality of life studies in the Gambia, especially among TB patients. Further research is warranted to explore the needs of TB patients in order to improve their quality of life.
• 182 - 195
• 10.6288/TJPH.201804_37(2).106127

• Link 原著 Original Article
• 學校結盟藥師推動正確用藥教育提升用藥知識、效能與行為之成效評價Evaluating the effects of school-pharmacist partnerships to improve medication knowledge, efficacy and behavior
• 李俊賢、 張鳳琴、紀雪雲、黃莉蓉
  Chun-Hsien Lee, Fong-Ching Chang, Hsueh-Yun Chi, Li-Jung Huang
• 學校 ； 藥師 ； 結盟 ； 正確用藥教育 ； 評價
  school ; pharmacist ; partnership ; correct medication education ; evaluation
• 目標：本研究目的為評價台灣推廣學校結盟藥師執行正確用藥教育對學生正確用藥知識、效能及行為之影響。方法：以102年及105年度全台灣地區國小高年級、國中、高中職學生為母群體，採等比機率抽樣。研究工具為自填結構式網路調查問卷，102年受訪學生共計8,635人，105年受訪學生共計6,226人。以廣義估計方程式（GEE）分析台灣推廣學校結盟藥師執行正確用藥教育對學生正確用藥知識、效能及行為的影響。結果：學生表示學校有辦理過正確用藥教育相關活動的比率從102年73%增加至105年的79%。多變項結果顯示，在控制學制與學生的性別後，102年至105年推廣學校結盟藥師執行正確用藥教育後，對學生的正確用藥知識、正確用藥效能及行為有顯著正面影響。此外，學校有辦理正確用藥教學活動學生的正確用藥知識、效能及行為也顯著較高。結論：台灣推廣學校結盟藥師推動正確用藥教育可以顯著提升學生正確用藥知識、效能及行為，建議持續推動學校與藥師結盟推動正確用藥教育以增進學生正確用藥素養。
  Objectives: The aim of this study was to evaluate the effects of promoting and implementing a school-pharmacist partnership correct medication education program to improve students' medication knowledge, efficacy, and behavior in Taiwan. Methods: A probability proportionate to size sampling method was used to select the study population. A total of 8,635 students in 2013 and 6,226 students in 2016 completed the self-administered online questionnaire. Generalized Estimating Equation (GEE) analysis was used to examine the effects of a school-pharmacist partnership correct medication education program to improve students' medication knowledge, efficacy and behavior. Results: The proportion of students who reported that their schools had implemented correct medication educational intervention increased from 73% in 2013 to 79% in 2016. The GEE analysis results showed that, after controlling for school level and gender, the promotion and implementation of a school-pharmacist partnership correct medication education program from 2013 to 2016 had a positive impact on improving students' medication knowledge, efficacy, and behavior. In addition, schools implementing a correct medication educational intervention also showed positive effects in increased student medication knowledge, self-efficacy, and behavior. Conclusions: The promotion and implementation of a school-pharmacist partnership correct medication education program had positive effects on enhancing students' knowledge, efficacy and behavior. We recommend continued implementation of school-pharmacist partnerships to enhance students' medication literacy.
• 196 - 205
• 10.6288/TJPH.201804_37(2).106135

• Link 原著 Original Article
• K他命膀胱炎患者中止物質濫用歷程之探究The desistance process of substance abuse in people with ketamine cystitis
• 齊沛瑜、王炯珵、陳心怡、唐宜楨、童伊廸
  Pei-Yu Chi, Chung-Cheng Wang, Hsin-Yi Chen, I-Chen Tang, Yi-Ti Tung
• K他命膀胱炎 ； 物質濫用 ； 中止
  ketamine cystitis ; substance abuse ; desistance
• 目標：近來毒品濫用與施用者年輕化的問題甚為嚴重，初次接觸毒品常以K他命為主。本研究目的為探究K他命膀胱炎患者中止濫用K他命的經驗，瞭解K他命膀胱炎患者其中止K他命濫用的歷程與影響因素。方法：本研究採質性研究設計，以立意取樣方式，對9位K他命膀胱炎患者進行面對面深度訪談，並將訪談資料轉成逐字稿進行內容分析。結果：將中止K他命濫用歷程分為：K他命濫用成型、掙扎階段、初步中止、穩定中止或失敗等四階段。促進中止K他命濫用因素有健康信念與自我覺察、家庭支持與正向人際關係、宗教信仰寄託、偏差友伴網絡瓦解、司法矯治介入。結論：建議重視醫療人員在K他命戒治中的積極性角色、毒品濫用中止需跨單位的協調與合作、輔導戒治宜從脈絡檢視物質濫用者的需求、建立保護性通報機制、透過醫療系統的治療輔導替代行政裁罰以中止K他命濫用的問題。
  Objectives: Drug abuse is more common among young people than it is in other age groups. For some, their initial exposure to drugs is ketamine. The purpose of this study was to investigate the experiences of people with ketamine cystitis who had desistance ketamine abuse. Methods: The study adopted a qualitative research design, and conducted in-depth interviews with nine patients with ketamine cystitis. The interview data were converted into transcripts for content analysis. Results: The desistance process of ketamine abuse was divided into four stages: The start of Ketamine abuse, struggling to stop, initial desistance, and stable desistance or failure. The causes of trigger desistance Ketamine abuse were health concerns and self-awareness, family support and positive interpersonal relationships, religious beliefs, and collapse of the supply network. Conclusions: It is recommend that medical professionals become involved in programs to end ketamine addiction and coordinate and cooperate in interdisciplinary team work with drug abusers. Treatment should assess the context of drug abuse and establish a secure notification mechanism. Medical treatment could substitute for administrative sanctions for ketamine addition, and an emphasis on preventing ketamine abuse could reduce the abuse of more harmful drugs.
• 206 - 219
• 10.6288/TJPH.201804_37(2).106103

• Link 實務 Public Health Practice
• 母親接受子宮頸抹片篩檢及女兒接種HPV疫苗之相關因素分析－以桃園市育有12-17歲青少女之母親為例Factors associated with mothers' health behaviors with regard to receiving Pad-smear screening for themselves and human papillomavirus vaccination for their adolescent daughters in Taoyuan City: a health belief model approach
• 蔡炯青、 林國甯、 陳效君
  Chiung-Ching Tsai, Kuo-Ning Lin, Hsiao-Chun Chen
• 子宮頸癌 ； HPV疫苗 ； 子宮頸抹片篩檢 ； 健康信念
  cervical cancer ; HPV vaccine ; Pad-smear screening ; health belief
• 目標：本研究旨在以健康信念模式探討母親讓女兒接種HPV疫苗、自己接受子抹篩檢之相關因素，以及兩項健康行為之間的關係。方法：透過NIIS系統選取桃園市12-17歲女學生之家戶資料，依分層隨機抽樣並以女學生之母親為對象進行電話調查，最後以羅吉斯複迴歸檢視影響其健康行為之相關因素。結果：職業、地區都市化程度、對HPV疫苗有效性認知是影響女兒接種HPV疫苗的顯著因子；母親接受子抹篩檢的顯著影響因子則有年齡、職業、醫療院所之行動線索、以及對子抹篩檢的障礙性認知。女兒接種HPV疫苗與母親接受子抹篩檢這兩項健康行為呈正相關，並且女兒接種HPV疫苗可以顯著影響母親後續接受子抹篩檢的意願與行為。結論：加強母親對HPV疫苗之有效性認知、降低母親對子抹篩檢之障礙性認知，乃是促使母親採取子宮頸癌預防行為之重要關鍵。而推動青少女免費HPV疫苗政策非僅可達一級預防效果，也可促進母親接受子抹篩檢的意願與行為，對於推動子宮頸癌之二級防治亦有實質助益。
  Objectives: The purpose of this study was to explore factors influencing mothers' health behaviors with regard to Pad-smear screening for themselves and human papillomavirus (HPV) vaccination for their adolescent daughters. Methods: Based on data from the National Immunization Information System (NIIS), we selected families with daughters aged 12-17 in Taoyuan City and interviewed the mothers. We adapted the stratified random sampling method, and a computer assisted telephone interview was conducted in October 2016. We used chisquare tests, point-biserial correlations, and multiple regression models to analyze the 1,031 valid samples. Results: After multiple logistic regression analysis, we found that the statistically significant factors influencing HPV vaccination of teenage girls were: mothers' occupation, living area, and perceived effectiveness of the HPV vaccine. We also found that mothers' cues to action, perceived barriers to Pad-smear, and particularly, the daughters' HPV vaccination, could significantly predict mothers' later use of Pad-smear screening. Conclusions: The policy of HPV vaccination for adolescent girls could not only achieve the primary prevention of HPV, but could also improve the secondary prevention of cervical cancer. Base on this win-win policy, we suggest that health sectors should provide more comprehensive information for the public about the HPV vaccine in order to improve mothers' perceived benefits, and therefore to increase the rate of HPV vaccine of adolescent girls. Furthermore, the most significant predictor, a convenient and friendly environment for women to receive Pad-smear screening, should be taken into account in order to reduce the perceived barriers to Pad-smear screening.
• 220 - 235
• 10.6288/TJPH.201804_37(2).106123