37卷3期

• Link 政策論壇 Policy Forum
• 農業工作者的職業傷病與職災補償制度Occupational injuries and diseases in agricultural sector and worker’ compensation for agricultural workers
• 陳宗延、鄭雅文
  Chun-Yen Chen, Yawen Cheng
• 無
  none
• 無
  none
• 237 - 243
• 10.6288/TJPH.201806_37(3).107027

• Link 原著 Original Article
• 兒童固定就醫場所與醫療利用Regular sources of care and children’s health care utilization
• 黎伊帆、 江東亮
  YI-FAN LI, TUNG-LIANG CHIANG
• 兒童 ； 固定就醫場所 ； 門診 ； 急診 ； 住院
  children ; regular sources of care ; ambulatory care ; emergency services ; hospitalization
• 目標：探討兒童的固定就醫場所對門診、急診，以及住院利用的影響。方法：資料來自台灣出生世代調查研究，共有18,845名兒童同時完成6個月至66個月共4次調查，完訪率為88.7%。自變項為兒童在6個月至36個月時分別以診所、醫院為固定就醫場所，以及沒有固定就醫場所3組，依變項為兒童66個月時的醫療利用。結果：63.5%的兒童有固定就醫場所，其中44.7%為診所、18.8%為醫院。父母親教育程度較低、母親為非本國籍、家庭月收入多在3萬元以下的兒童，其沒有固定就醫場所的百分比較高。控制社會人口學特性及健康狀況，以診所為固定就醫場所者門診利用較高，然而，以醫院為固定就醫場所（急診OR=1.6；住院OR=1.8）與沒有固定就醫場所（急診OR=1.2；住院OR=1.4）其急診及住院情形顯著高於以診所為固定就醫場所者。結論：以診所為固定就醫場所的兒童，其急診、住院利用率顯著低於以醫院為固定就醫場所、或是沒有固定就醫場所的兒童，建議政府宜推出鼓勵相關財務誘因與診所品質資訊透明化的政策，以鼓勵家長選擇診所為固定就醫場所。
  Objectives: The aim of this study was to determine the relationship between children's regular sources of care (RSOC) and health care utilization including ambulatory care (AC), emergency services (ES), and hospitalization (HOSP) care in Taiwan. Methods: Data came from the Taiwan Birth Cohort Study. A total of 18,845 children were included. Their parents completed four waves of interview surveys between 6 and 66 months of age, with a response rate of 88.7%. The independent variable was children's RSOC including RSOC in clinics, RSOC in hospitals, and no RSC when the children were 6 to 36-months old, and the dependent variable was medical utilization when the children were 66-months old. Results: A total of 63.5% of the children had a RSOC including 44.7% in clinics and 18.8% in hospitals. Children were less likely to have a RSOC with parents' of lower education, foreign-born mothers, and a household monthly income less than 30,000 NTD dollars. After controlling for children's gender, maternal nationality, socioeconomic characteristics, and health status, children with RSOC in hospital was significantly associated with higher likelihood of ES and HOSP (ES, OR=1.6; HOSP, OR=1.8) as were those who did not have a RSC (ES, OR=1.2; HOSP, OR=1.4), compared with those who did not have a RSOC. Conclusions: Children with RSOC in clinics was significantly associated with lower likelihood of ES and HOSP. This suggests that the government implemented financial incentive and transparency of quality in clinics policies for encouraging parents to use clinics as the RSOC.
• 244 - 253
• 10.6288/TJPH.201806_37(3).106102

• Link 原著 Original Article
• 新進住院醫師對電子病歷的看法－以科技持續理論探討Perspectives on electronic medical records among new residents -applying Technology Continuance Theory
• 莊秋華、郭律成、楊銘欽
  CHIOU-HWA CHUANG, LU-CHENG KUO, MING-CHIN YANG
• 電子病歷 ； 醫療資訊系統 ； 科技持續理論 ； 知覺有用性 ； 知覺易用性
  electronic medical records (EMR) ; health information systems ; Technology Continuance Theory (TCT) ; perceived usefulness ; perceived ease of use
• 目標：本研究欲瞭解台灣某醫學中心新進住院醫師在擔任實習醫師時使用電子病歷後，對電子病歷的認知、態度、持續使用意向，以加強對實習醫師和新進醫師在電子病歷上的教育和臨床訓練。方法：本研究以科技持續理論（Technology Continuance Theory, TCT）為基礎設計結構式問卷，調查某醫學中心2017年新進住院醫師對電子病歷之認知、態度、滿意度及持續使用之意向，使用複迴歸分析驗證變項間的相關性。結果：本研究共發出292份問卷，回收276份（回收率94%）。填答者中，男性占65%，平均24.3歲，265位（96.0%）在擔任實習醫師時曾使用過電子病歷。複迴歸分析結果顯示，和受訪醫師是否會持續使用電子病歷有關的因素包括知覺有用性（p＜0.0001）、滿意度（p＜0.01）、病歷書寫表現（p＜0.0001）、書寫表現（p=0.01）。結論：新進住院醫師使用電子病歷和病歷書寫表現及學習表現具有正相關，且新進住院醫師對電子病歷之滿意度、態度及表現都和醫師持續使用電子病歷的意向呈現正相關。
  Objectives: This research aimed to understand the cognition, attitude, and intention for continued use of electronic medical records (EMRs) among new residents following EMR use in their intern year at one medical center in Taiwan. As such, the goal of this study was to improve education and clinical training among interns and new residents who use EMRs. Methods: A structured questionnaire was constructed based on Technology Continuance Theory (TCT), which was used to investigate the cognition, attitude, satisfaction, and intention for continued use among physicians-in-training at a medical center in 2017. Regression analysis was used to analyze the relationships among variables. Results: A total of 292 sets of questionnaires were distributed, of which 276 were collected for a response rate of 94%. Males represented 65% of all respondents, with an average age of 24.3 years. Two hundred sixty-five residents (96%) stated that they used EMRs during their intern year. Regression analysis showed that the factors which affected intention to continue using EMRs among physicians are as follows: perceived usefulness (p<0.0001); satisfaction (p<0.01); medical records writing performance (p<0.0001); and learning performance (p=0.01). Conclusions: Using EMR was positively associated with medical record writing and overall learning performance among new physicians. In addition, resident satisfaction, performance, and attitude towards EMR were positively associated with an intention to continue using EMRs.
• 254 - 264
• 10.6288/TJPH.201806_37(3).107015

• Link 原著 Original Article
• 台灣基層診所病人複雜度與提供服務項目之探討Patient complexity and services provided by primary care clinics in Taiwan
• 林奕穎、 郭年真
  YI-YING LIN, RAYMOND N. KUO
• 西醫基層診所 ； 病人複雜度 ； 基層醫療服務項目 ； 家庭醫師 ； 都市化程度
  primary care clinic ; patient complexity ; primary care service ; family physician ; urbanization
• 目標：經由分析台灣基層診所之病人複雜度，以及可提供文獻常見之基層醫療服務項目之比例，來探討台灣現況之下有多少基層診所可承擔家庭醫師的功能。方法：本研究以2009年至2013年全民健康保險資料庫之一百萬人承保抽樣歸人檔為資料，經由分析基層診所申報之診斷、檢查、年齡分布、藥物和特定診療項目，根據數量、變異性和多樣性變化等構面，進行「病人複雜度」之計算。此外，本研究參考文獻使用之基層照護品質指標，從中歸納出十一項常見之基層醫療服務項目，探討不同科別基層診所提供服務項目之差異。結果：台灣家醫科基層診所的病人複雜度最高，其次是兒科、內科。基層診所提供各項服務之比例，以2013年為例：空腹血脂36.45%，醣化血色素30.80%，微量白蛋白尿25.53%，眼睛檢查8.69%，成人健檢35.26%，流感疫苗有21.53%，子宮頸抹片檢查為8.31%，糞便潛血檢查為14.88%，而戒菸門診為7.46%。癌症篩檢項目中，結腸直腸鏡佔1.32%，乳癌篩檢佔0.17%。僅有不到一成的診所同時能提供流感疫苗等五項診所常見之服務項目，且高達四成的診所未能提供五項中任一項的服務。此外，本研究也發現，病人複雜度和提供服務項目之比例與都市化程度普遍成反比。結論：整體而言，台灣基層家醫科、內科和小兒科診所最接近家庭醫師的角色，但現況之下以達成的比例來說，能夠提供五項以上基層醫療服務項目的診所未達一成，相較於國外的基層診所常提供的服務項目上，仍有很大的進步空間。
  Objectives: The primary care system is responsible for the management and coordination of patient care. This study will explore how many primary care clinics are able to take on the functions of family physicians. This will be accomplished through exploring the patient complexity and the services provided by primary care clinics in Taiwan. Methods: In this study, we calculated patient complexity using different dimensions, including quantity, variability, and diversity. We assessed patient complexity in terms of diagnoses, exams, age distributions, medications, specific diagnosis and treatments provided by primary care clinics. In addition, we referenced the quality care indicators used in other countries and then summed up eleven primary care services indicators. Through linear regression and logistic regression, we examined the relationships between division, urbanization and patient complexity and services provided by primary care clinics. We also took into account the relationship between physicians' specialty, demographic characteristics, and primary care services. Results: Patient complexity is the highest for family medicine providers, followed by internal medicine and pediatrics clinics. In 2013, the results suggest that the eleven primary care services that primary care clinics can provide are: fasting blood lipids 36.45%, glycosylated hemoglobin 30.80%, microalbuminuria 25.53%, eye examination 8.69%, health examination 35.26%, influenza vaccine 21.53%, pap smears 8.31%, fecal occult blood test 18.7%, and smoking cessation clinic 7.46%. In cancer screening services, colorectal cancer screening are only 1.32%, and breast cancer screening only 0.17%. Fewer than 10% of primary care clinics provide the five most common services, and nearly 40% of those clinics did not provide any of the above services. In general, the degree of urbanization in the clinics is inversely proportional to the patient complexity and the ratio of clinics providing primary care services. Conclusions: Overall, family medicine, internal medicine and pediatrics clinics in Taiwan are able to take on the functions of primary care providers, but fewer than 10% of the primary care clinics provide top 5 primary care services. Ideally, primary care services could be spread more evenly between providers. Any effort to improve the referral system should be aimed at strengthening the clinics that aren't currently able to meet primary care service needs. This is particularly true of primary care clinics in highly urbanized areas.
• 265 - 279
• 10.6288/TJPH.201806_37(3).106081

• Link 原著 Original Article
• 丹麥孕產照護：助產師和產科醫師共同照護模式Maternity care practice in Denmark: a model of collaboration between midwives and obstetricians
• 施麗雯
  LI-WEN SHIH
• 丹麥 ； 孕產照護 ； 助產師 ； 產科醫師 ； 共同照護
  Denmark ; maternity care ; midwife ; obstetrician ; model of collaboration
• 目標：助產師和產科醫生共同照護是目前許多先進國家採用的孕產照護模式。本文介紹施行該模式的北歐國家丹麥醫院裡，助產師與產科醫師專業分工的實作，並分析這套模式的優勢和其運作邏輯。方法：本文採用文獻分析，針對丹麥的全國統計資料庫、和相關文獻、報章媒體等整理和分析丹麥的孕產照護制度發展，並在丹麥進行田野調查，透過訪談（產科醫師、助產師和剛生產的懷孕女性）、參訪、診間的參與式觀察等，了解助產師和產科醫生分工下的照護實作以及挑戰。結果：丹麥孕產照護的專業分工來自國家制度化的保障，不但讓助產師和產科醫生能夠各司其職，亦能因應不同孕婦的健康需求給予照護。面對助產人力不足、居家產率上升等挑戰時，仍能從孕婦、助產師和產科醫師等多元角度去思考對策提出改善策略。結論：這些經驗有助於台灣相關政府單位未來想推動要學習這套孕產照護模式政策時作為參考。
  Objectives: The shared care model between obstetricians and midwives is one of the most adopted maternity care models in advanced industrial countries. This article attempts to introduce the Danish maternity care system, which practices this model, to enrich our understanding of the practice in which a collaboration between obstetricians and midwives is practiced, and also to learn the advantages and logic of care embedded in its practice. Methods: To understand Danish maternity care practice, this article is based on data from the Danish media, the national database (Statistics Denmark), related articles and books, field work with interviews of obstetricians, midwives, and pregnant couples from 2014-2017, and participant observations in 7 hospitals in Denmark. Results: Danish law, which ensures a division of labor between obstetricians and midwives that enables midwifery and obstetric professionals to work following a model of collaboration that provides care according to a woman's need. The logic of the Danish maternity care means that when the system is facing challenges from a rising home birth rate and shortage of midwives, Danish society listens to different perspectives from obstetric and midwifery professionals and also to women's need when generating strategies to overcome those challenges. Conclusions: This model serves as a good example to the Taiwanese government and society, and it is therefore of value to learn the core value and care practice policy in this maternity care model.
• 280 - 294
• 10.6288/TJPH.201806_37(3).107005

• Link 原著 Original Article
• 高齡者口腔衛生教育介入效果之研究—以社區及長照機構長者為例Effect of oral health education for the elderly in the community and long-term care institutions
• 陳少卿、胡益進、張瑞珊、嚴明芳、 張進順
  SHAO-CHING CHEN, YIH-JIN HU, RUI-SHAN ZHANG, MING-FANG YEN, JIN-SHUN ZHANG
• 口腔衛生教育 ； 牙菌斑 ； 健口操 ； 咀嚼力 ； 老年人
  oral health education ; dental plaque ; oral function training ; chewing function ; elderly
• 目標：探討高齡口腔衛生教育介入對於社區及長照機構長者的進食、口腔衛生狀況、咀嚼力與口腔機能之影響調查。方法：以類實驗研究法立意取樣收集台北市社區與長照機構65歲以上長者232位，以非對等控制組設計，將社區126位與長照機構106位，區分為社區實驗組68位、社區對照組58位、長照機構實驗組53位與長照機構對照組53位，實驗組皆採12週健口操訓練與4次口腔衛教課程介入，對照組則無，經由牙醫師進行口腔檢測及訪員結構式問卷調查，分析介入前後成效。結果：機構長者在吞嚥、機能發音、鼓起雙頰及咀嚼力的表現上明顯較社區長者差。在介入成效上，高齡者對口腔狀況自評、舌苔、牙菌斑牙面比例、吞嚥秒數、咀嚼力，實驗組結果較對照組佳。合併社區及機構實驗組在舌苔及牙菌斑牙面比例有顯著後測改善。整體及機構實驗組在吞嚥秒數有改善，咀嚼力則發現整體及機構對照組後測較前測差，但實驗組沒有差異。結論：高齡者口腔衛生教育介入對長者舌苔、牙菌斑與口腔機能有改善或維持。建議社區及長照機構應持續鼓勵長者進行口腔健康促進活動，並協調口腔保健資源及其護理人員，規劃不同生理功能老年人的教育模式。
  Objectives: To investigate the influence of oral health education intervention on eating, oral health, chewing, and oral function of elderly in community and long-term care institutions. Methods: A quasi-experimental study involving a non-equivalent control group design was conducted in the community and long-term care institutions in Taipei City. Two hundred thirty-two elderly > 65 years of age were recruited; 126 were community residents (experimental group [n=68] and control group [n=58]) and 106 were from long-term care institutions (experimental group [n=53] and control group [n=53]). The intervention for the experimental group included 12 weeks of oral training and 4 oral hygiene courses; no intervention was provided to the control group. Dentists and oral hygienists collected a survey before and after the intervention, and a questionnaire on oral function and oral hygiene was administered. Results: The elderly in the institutional group was significantly worse than the community group with respect to swallowing, pronunciation, motor activity of the cheeks, and chewing function. The entire experimental group had significant improvement in self-evaluation of oral health, tongue coating, dental plaque, swallowing time, and chewing function compared to the control group. With respect to dental plaque check and tongue coating, the entire experimental group exhibited statistically significant improvement. The entire and institutional experimental groups had improved swallowing function. The entire and institutional control group had worse chewing function, but no difference was observed in the experimental group. Conclusions: Oral health education promotes improved tongue coating, dental plaque, and oral function in the elderly. Based on the current study, it is recommended that community and long-term care institutions should continue to carry out oral health promotion, coordinate oral health care resources, and plan the education mode of different physiologic functions for the elderly.
• 295 - 308
• 10.6288/TJPH.201806_37(3).107003

• Link 原著 Original Article
• 台灣成年族群飲酒型態與事故傷害、酒駕之關係探討Drinking patterns in relation to injuries and drunk driving among community-dwelling adults in Taiwan
• 楊涵纖、鄭凱元、張新儀、 陳娟瑜
  HAN-SIAN YANG, KAI-YUAN CHENG, HSING-YI CHANG, CHUAN-YU CHEN
• 狂飲 ； 飲酒頻率 ； 傷害 ； 酒駕
  binge drinking ; drinking frequency ; injuries ; drunk driving
• 目標：瞭解台灣成年族群中飲酒型態與自陳過去一年事故傷害、因酒後駕車而遭警察開單或逮捕之相關性。方法：本研究為一橫斷性研究。資料來源為台灣2013年國民健康訪問調查（National Health Interview Survey, NHIS），並以青壯年（18-39歲，n=7,251）及中年（40-64歲，n=8,003）兩族群為研究對象。飲酒型態的評估指標包含狂飲行為及飲酒頻率。統計採調查統計分析，按年齡分層，並以邏輯式迴歸探討飲酒型態和過去一年事故傷害（含跌倒、燒燙傷、其他事故傷害）及酒後駕車之關係。結果：青壯年族群有較高的事故傷害盛行率（如跌倒：12.9%），然中年族群有酒駕經驗者較多（3.8%）。相較於飲酒頻率，狂飲與事故傷害的相關性較強，且狂飲相關事故傷害風險在青壯年較為顯著（如狂飲者跌到勝算比1.75）。狂飲且日飲之青壯年其酒駕盛行率達22.6%；相較於非狂飲且非日飲者，其酒駕校正後勝算比為11.5（95%信賴區間：4.94-26.91）。結論：本研究發現狂飲與事故傷害（如跌倒）的風險增加有關，且此相關性於青壯年族群尤為顯著。本研究推論受限於橫斷性設計限制，未來可考慮由追蹤性研究或監測資料進一步確認並探討相關機制。酒害防治策略發展建議納入低頻過量飲酒之傷害，並將年輕族群視為酒駕重要介入對象。
  Objectives: This study aimed to determine the association linking drinking patterns with self-reported past-year injuries and drunk driving among community-dwelling adults in Taiwan. Methods: This was a cross-sectional study utilizing the dataset from the 2013 Taiwan National Health Interview Survey (NHIS). The analytic sample comprised young adults (18-39 years of age; n=7,251) and older adults (40-64 years of age; n=8,003). Complex survey analyses in the logit function were performed to estimate the odds ratio [OR] of injuries (i.e., past-year falls, burns, and other injuries) and drunk driving in relation to binge drinking and drinking frequency. Results: Young adults had a higher prevalence of injuries (4%~13%), whereas a higher prevalence of drunk driving existed in older adults (3.8%). In contrast to drinking frequency, binge drinking was associated with higher odds of injuries; this association was more prominent in young adults. Greater than 1 in 5 young adults with binge and daily drinking reported drunk driving (22.6%); the adjusted OR for drunk driving was estimated 11.5 (95% CI= 4.94-26.91). Conclusions: Our analyses revealed a slightly increased risk of injuries associated with binge drinking, which was more prominent in young adults. The causal inference was limited because of the cross-sectional study design. Further evidence derived from longitudinal or surveillance data is needed to validate the connection and explore possible pathways. Alcohol harm reduction strategies may address moderate drinking-related injuries and drunk driving intervention should focus on young drinkers as a priority target.
• 309 - 321
• 10.6288/TJPH.201806_37(3).107008

• Link 評論 Commentary
• 評論：把酒問青天Commentary: a drinking question to the heaven
• 林茂榮
  Mau-Roung Lin
• 無
  none
• 無
  none
• 322 - 322
• 10.6288/TJPH.201806_37(3).10700801

• Link 評論 Commentary
• 作者回覆：把酒問青天Authors' response to commentary: a drinking question to the heaven
• 楊涵纖、鄭凱元、張新儀、 陳娟瑜
  Han-Sian Yang, Kai-Yuan Cheng, Hsing-Yi Chan, Chuan-Yu Chen
• 無
  none
• 無
  none
• 323 - 323
• 10.6288/TJPH.201806_37(3).10700802

• Link 原著 Original Article
• 以系統性文獻回顧與整合分析探討瑜珈對更年期相關症狀之成效Effectiveness of yoga for improving menopause-related symptoms: a systematic review and meta-analysis
• 黃惠美、林小玲、 廖媛美、戴秀好、 明金蓮
  HUI-MEI HUANG, SHIR-LING LIN, YUAN-MEI LIAO, SHIU-HAO TAI, JIN-LAIN MING
• 瑜珈 ； 更年期相關症狀
  yoga ; menopause-related symptoms
• 目標：更年期相關症狀對於婦女的生活常造成相當程度困擾，瑜珈是常被用於處理更年期相關症狀之輔助方式之一，但其成效未獲確定。方法：此系統性文獻回顧與整合分析探討瑜珈對於改善更年期相關症狀之成效，於PubMed、MEDLINE、CINAHL、Cochrane Library及華藝線上圖書館等電子資料庫設定關鍵字搜尋2018年2月以前出版之中、英文文獻，依據納入及排除條件，排除不符合此研究主題之文獻後共納入11篇文獻，依考科藍隨機對照試驗誤差風險評估（The Cochrane risk of bias tool for randomized clinical trials）之評析標準進行文獻研究品質評價，並使用牛津大學之實證醫學證據等級表（Oxford centre for Evidence-based Medicine）評定證據等級。整合分析（Meta-Analysis）部分乃使用Review Manager軟體（RevMan）5.3版本。結果：整合分析結果顯示：瑜珈改善整體更年期症狀之效果量SMD為-0.96（95% CI:-1.60, -0.32, p=0.003; 異質性I^2=86%），改善憂鬱之效果量SMD為-0.23（95% CI:-0.42, -0.03, p=0.02; 異質性I^2=0%），改善睡眠障礙之效果量SMD為-0.21 （95% CI:-0.41, -0.02, p=0.03; 異質性I^2=0%），改善血管舒縮症狀之效果量SMD為-0.23（95% CI:-0.41, -0.05, p=0.01; 異質性I^2=0%）；但瑜珈對於改善壓力感受未呈現顯著成效。結論：此系統性文獻回顧與整合分析支持瑜珈可改善整體更年期相關症狀、憂鬱、睡眠障礙與血管舒縮症狀，針對此特殊族群提出練習瑜珈之相關建議將受限於納入研究之內外在信度的影響，仍需執行更多嚴謹研究以豐富現存文獻。
  Objectives: Menopause-related symptoms often cause considerable distress to women. Yoga is widely employed as a complementary method for managing menopause-related symptoms, but its effectiveness must still be determined. Methods: This systematic review and meta-analysis examined the effectiveness of yoga for improving menopause-related symptoms. Using identified keywords, a systematic literature search for relevant English and Chinese language studies published before February 2018 was conducted in the following electronic databases: PubMed, MEDLINE, CINAHL, the Cochrane Library, and the Airiti Library. Results of the literature search were screened using proposed inclusion and exclusion criteria. Eleven articles were included for systematic review after removing some articles on irrelevant topics. Study quality was assessed based on the Cochrane Risk of Bias Tool for Randomized Controlled Trials, and ranking of evidence was based on the Oxford 2011 Levels of Evidence. Meta-analysis was conducted using Review Manager version 5.3. Results: Meta-analysis results indicated that practicing yoga resulted in an improvement in overall menopause-related symptoms [standardized mean difference (SMD): -0.96, 95% confidence interval (95% CI): -1.60, -0.32, p = 0.003; heterogeneity I^2 = 86%], depression (SMD: -0.23, 95% CI: -0.42, -0.03, p = 0.02; I^2 = 0%), sleep disorders (SMD: -0.21, 95% CI: -0.41, -0.02, p = 0.03; I^2 = 0%), and vasomotor symptoms (SMD: -0.23, 95% CI: -0.41, -0.05, p = 0.01; I^2 = 0%). However, practicing yoga did not result in a significant reduction in the perception of stress. Conclusions: The results of this systematic review and meta-analysis support that yoga may improve overall menopause-related symptoms, depression, sleep disorders, and vasomotor symptoms. Recommendations related to practicing yoga for this specific population may be attenuated by influences associated with the internal and external validities of the included studies. Conducting additional rigorous studies is necessary to enrich the currently available information.
• 324 - 339
• 10.6288/TJPH.201806_37(3).107010