38卷5期

• Link 政策論壇 Policy Forum
• 減少農藥自殺死亡的策略：支持禁用巴拉刈的證據Strategies to reduce pesticide suicide: evidence supporting the ban on paraquat
• 張書森
  Shu-Sen Chang
• 無
  none
• 無
  none
• 453-456
• 10.6288/TJPH.201910_38(5).PF05

• Link 綜論 Review Article
• 日本介護制度沿革對台灣長期照顧體系發展之啟示Lessons learned from the evolution of long-term care programs in Japan and the implications for Taiwan’s long-term care system development
• 游曉微、鞏愛華、植村尚史、陳雅美
  Hsiao-Wei Yu, Ai-Hua Gong, Hisashi Uemura, Ya-Mei Chen
• 日本介護制度、長期照顧十年計畫2.0、社區整合照顧
  long-term care program in Japan, Taiwan’s National 10-Year Long-Term Care Plan 2.0, community integrated care
• 台灣長期照顧十年計畫2.0和日本介護制度皆以發展社區照顧為目標。本文回顧日本介護政策因應國內「照護意識轉變」和「政策永續原則」啟動社區力量、整合醫療和福祉支持服務之變革。本研究與日本早稻田大學合作，透過日本長照學者剖析介護政策脈絡，反思並提出我國長照政策建議。日本介護制度從「社會福利制度」轉變為建構「地域性整合照顧服務體系」，並融入在宅、醫療、介護、介護預防、生活支援等要素，讓高齡及獨居長者能在習慣居住的區域持續生活終老，目前日本介護制度的改革方向已朝抑制照護費用並強化失能預防策略。本文就日本介護制度修正軌跡，提出三項政策建議，包括「落實長照和醫療一體化」、「強化社區預防照顧實證策略」、「健全台灣照顧服務體系全天照護與多元整合機制」，並作為台灣長照政策省思。
  The Taiwanese 10-year Long-Term Care Plan (LTC) 2.0, which is in line with Japanese LTC program, aims at developing an integrated community-based care system. This study reviewed the paradigm changes in elderly care and sustainable policy development principles implemented in Japan, the evolution of community empowerment, and the integration of Japan’s health care and LTC services. This study collaborated with researchers from Waseda University, who outlined the historical context for the development of the Japanese LTC system; reflected on the lessons learned from Japan’s experiences; and developed recommendations for Taiwan’s future LTC policy. The Japanese LTC system evolved from a government welfare system to an integrated community-based care system, with the primary aim of providing assistance to the elderly—with and without family caregivers—by incorporating home health care, medical care, LTC, disability care, and support for daily activities. Japan’s current LTC programs are designing strategies to decrease the burden of LTC costs and develop evidenced-based practices for the prevention of disabilities in their high-risk population. The current study reflected on the trajectories of Japanese LTC policy revolution and developed the following proposals for future Taiwanese LTC policymaking: (1) implement a comprehensive care continuum for medical and LTC services; (2) strengthen evidence-based disability prevention programs for community elderly; and (3) develop an efficient, 24-hour integrated home- and community-based LTC service system.
• 457-469
• 10.6288/TJPH.201910_38(5).108020

• Link 綜論 Review Article
• 老年歧視概念分析Conceptual analysis of ageism
• 陳伊如、邱怡玟、龍紀萱
  Yi-Ru Chen, Yi-Wen Chiu, Chi-Hsuan Lung
• 老年歧視、刻板印象、偏見、歧視、概念分析
  ageism, stereotype, prejudice, discriminate, concept analysis
• 長久存在的種族和階級歧視，孕育了對高齡者的刻板印象及偏見，即形成第三大歧視—「年齡歧視」（Ageism），尤指對年長之老人所產生的歧視，也就是所謂的「老年歧視」。在全球老年人口的快速增長下，「老人照護」成為21世紀健康照護的主要議題之一，若老年歧視存在於健康照護或長期照護中，將會影響老人的感受與權利，對其健康會產生有害的影響。護理人員是老人照護團隊中的重要成員，其對老人的價值、看法及信念等將會影響他們對老人的照護行為。然而，「老年歧視」在台灣仍是一個相當模糊的名詞，有著許多不同的概念性及操作性定義，少數的研究僅著重於探討學生或護理人員對老年之刻板印象及態度，在照護上之實務探討相當不足。因此，本文將分析老年歧視與刻板印象、偏見和歧視行為之間的相互影響，對老年歧視提出定義性特徵，並舉例說明老年歧視概念與實證，以期能增進從事老人照護相關人員對老年歧視概念之了解，提供照護高齡者人員參考，並有助於護理臨床實務及未來研究之應用。
  Ageism is stereotyping, prejudice, and discrimination against people based on their age; this is fostered by longstanding racism and classism. It is the third major type of discrimination and affects older adults in particular. With the elderly populations increasing rapidly worldwide, care for older adults is becoming a main healthcare-related issue of the 21st century. Ageism in healthcare or long-term care affects the feelings and rights of older adults and jeopardizes their health status. Nurses are crucial carers for older adults. Their values, views, and beliefs regarding older adults affect their care behavior. However, in Taiwan, no consensus has been reached on ageism, and the topic has not been sufficiently discussed or researched. Related studies have focused on examining the stereotypes and attitudes, but not care practices, of students or nurses toward older adults. This study analyzed the interactions between stereotypical, prejudicial, and discriminatory behavior and ageism, elucidating the defining attributes related to the concept and providing examples and evidence of ageism in action. This study may provide staff involved in elderly care with a better understanding of ageism while providing a useful reference for caregivers of older adults. This conceptual analysis may improve current nursing practices and lead to value future research on the topic.
• 470-477
• 10.6288/TJPH.201910_38(5).108095

• Link 原著 Original Article
• 從工作要求資源模式檢視公共衛生護理人員職業倦怠因素：以公共服務動機為調節變數Factors associated with public health nurses’ burnout from the perspective of job demands-resources model: public service motivation as a moderator
• 陳敦源、吳舜文、陳揚中、王光旭
  Don-Yun Chen, Shun-Wen Wu, Yang-Chung Chen, Guang-Xu Wang
• 職業倦怠、工作要求資源模式（JD-R）、公共服務動機（PSM）、公共衛生護理人員
  occupational burnout, job demands-resources model (JD-R), public service motivation (PSM), public health nurses
• 本研究以全國的公衛護理人員為研究對象，企圖系統性分析衛生所護理人員工作負荷與疲憊之問題癥結，藉以提出對維持公衛護理人員職場健康與福利保障的改善建議。方法：以E-mail寄送網路問卷給全國提供郵件的衛生所護理人員，調查期間自2018年7月25日起，至2018年8月13日止，實際寄件總數為3,742份，問卷回收量為1,215份，回覆率為32.5%。在排除台北市與非護理人員之樣本後，本研究針對剩餘751名護理人員進行分析。結果：在工作要求部分，工作負荷、繁文縟節均會正向的影響工作與服務對象倦怠，而每週工時僅對工作倦怠有正向影響；工作資源部分，組織支持能減緩工作倦怠，同事支持能減緩服務對象倦怠；而公共服務動機（PSM）與工作和服務對象倦怠皆有負向關連，但在PSM的調節效果上，PSM卻會強化工作負荷、繁文縟節與工作倦怠的關連性。結論：建議應檢討衛生所護理人員的工作負荷，以及工作上繁文縟節的情形，並避免加班超時工作；PSM高可能是促進公衛護理人員積極投入工作的美德，有助於減緩職業倦怠，但可能會因為其投入意願更多，導致在高工作負荷與繁文縟節的工作環境下，工作倦怠的情形更嚴重。
  Objectives: To analyze the relationship between the work burden and burnout of nursing staff in public health centers to propose suggestions for improving their health and welfare. Methods: An online survey of nursing staff in public health centers was conducted by contacting the said staff through email. The survey was conducted from July 25 to August 13, 2019. The authors sent out 3,742 emails and received 1,215 responses (response rate: 32.5%). After survey samples from Taipei and non-nursing staff were excluded, the sample size was 751. Results: Regarding the work demands dimension, work burden and red tape were positively correlated with work burnout and client burnout; weekly working hours were positively correlated with work burnout. In he work resources dimension, organizational support relieved work burnout, while client support alleviated client burnout. Although public service motivation (PSM) was negatively correlated with work and client burnout, it exacerbated the relationships of work burnout with work burden and red tape when it was analyzed as a moderator. Conclusions: The authors suggest that policy makers should reduce the workload, red tape, and over time working hours of nursing staff in public health centers. PSM could be an impetus for increasing work engagement and thus alleviate work burnout. However, it could also exacerbate the work burnout of the nursing staff due to increased work engagement in scenarios of a heavy workload and red tape.
• 478-497
• 10.6288/TJPH.201910_38(5).107067

• Link 原著 Original Article
• 台灣非愛滋替代治療藥癮者全民健康保險資源使用情形探討Medical care utilization under National Health Insurance by people with heroin addiction enrolled in a methadone substitution treatment program
• 黃紀諺、董鈺琪、諶立中、鄭淑心、洪嘉璣、楊銘欽
  Chi-Yen Huang, Yu-Chi Tung, Lih-Jong Shen, Sheu-Shin Cheng, Chia-Ji Hung, Ming-Chin Yang
• 美沙冬替代治療、藥癮者、全民健康保險資源使用、傾向分數
  methadone substitution treatment program, drug addicts, National Health Insurance utilization, propensity scores
• 目標：我國於2009年起對非愛滋病之藥癮者提供治療補助，本研究以回溯性世代研究法，探討穩定使用美沙冬替代治療與否，對於藥癮者健保使用之影響。方法：以2009至2014年間之美沙冬替代治療藥癮者作為研究樣本，以傾向分數加權後使用加權複迴歸分析美沙冬替代治療之穩定組與中斷組間健保資源使用情形之差異。結果：在門急診點數對數值之加權複迴歸檢定結果顯示，在控制性別、年齡、收入、就醫場所層級別、權屬別、地區別後，穩定組年平均門急診點數對數值比中斷組增加9%（p=0.0023）；在門急診就醫次數部分之卜瓦松複迴歸分析結果顯示，控制前述變項後，穩定組年平均門急診次數較中斷組增加14%（p<0.001）。結論：穩定組之健保門急診之年平均次數、年平均點數對數值都顯著高於中斷組，惟傾向權重配分後之中斷組年平均住院點數多於穩定組，雖未達統計上顯著差異，仍可後續研究探討其原因。
  Objectives: Since 2009, the Taiwanese government has subsidized treatment for non-AIDS-related drug addiction. The aim of this retrospective cohort study was to investigate the effect on National Health Insurance (NHI) resources of treatment for people with addiction who enrolled in a methadone substitution treatment program. Methods: Data from 2009 to 2014 of people with drug addiction who were treated with methadone were collected as samples. Analytical tools such as the Inverse Probability of Treatment Weighting (IPTW), which is based on propensity score and weighted multiple regression, were used to further compare the use of NHI resources by the stable-treatment and interrupted-treatment groups. Individual characteristics of sex, age, and income level were controlled for in addition to the level, ownership, and Bureau of NHI branch of the medical institution. Results: According to the weighted multiple regression analysis results of the NHI point values of the outpatient and emergency departments, the NHI point values of the stable-treatment group increased by 9% relative to the interrupted-treatment group (p = 0.0023). The results of a Poisson regression on the NHI utilization frequency of outpatient and emergency department visits indicated that with the same control variables, the average NHI utilization frequency of the stable-treatment group increased by 14% relative to the interrupted-treatment group (p < 0.001). Conclusions: Among people with addiction who enrolled in the methadone substitution treatment program, those in the stable-treatment group had not only higher logarithmic NHI point values but also higher NHI utilization frequency in their outpatient and emergency department visits compared with the interrupted-treatment group. Although no statistical significance was observed, further research should investigate why, after IPTW, the average annual inpatient point values for the interrupted-treatment group were higher than those for their stable-treatment counterparts.
• 498-508
• 10.6288/TJPH.201910_38(5).107067

• Link 原著 Original Article
• 影響台灣家庭使用長照十年計劃2.0的相關因素分析Factors influencing the utilization of the National Ten-Year Long-Term Care Plan 2.0 in Taiwan
• 鄧桂芬、李玉春、楊哲銘、黃國哲
  Kuei-Feng Teng, Yue-Chune Lee, Che-Ming Yang, Kuo-Cherh Huang
• 長照十年計劃2.0、長照服務使用、政策宣傳、家庭照顧者
  the National Ten-Year Long-Term Care Plan 2.0, long-term care service utilization, propaganda, caregiver
• 目標：探討影響台灣家庭使用長照十年計劃2.0（簡稱長照2.0）服務項目的相關因素。方法：收案對象為符合長照2.0申請資格民眾的家庭照顧者，利用半結構式問卷進行面訪或電訪，共完成212位照顧者的調查。結果：長照2.0服務項目使用狀況與前傾因素構面中的教育程度（p = 0.011），使能因素構面中的社會福利身份別（p = 0.008）及曾接觸長照2.0資訊（p <0.001），需要因素構面中的罹患失智症（p = 0.018）及領有身心障礙手冊（p = 0.008），以及照顧者因素構面中的性別（p = 0.002）、年齡（p = 0.031）、及工作情形（p = 0.035）等因素，有顯著的關連性。另一方面，整體而言，前傾因素構面、使能因素構面、需要因素構面、及照顧者因素構面，均對長照2.0服務項目使用狀況有顯著性的影響力（F = 1.737, p = 0.007; adj-R2 = 0.149）。結論：調查結果顯示，前傾因素構面、使能因素構面、需要因素構面、及照顧者因素構面，均會影響民眾使用長照2.0服務項目。建議衛生福利部應持續擴大長照2.0服務政策之宣傳，正視將可能成為中低收入戶家庭之長照需求，以及鼓勵男性照顧者使用長照服務支持資源。
  Objectives: To explore the factors associated with the use of the National Ten-Year Long- Term Care Plan 2.0 (NTLCP 2.0) in Taiwan. Methods: Research data were collected using a semistructured questionnaire. Study samples were caregivers of people qualified to receive care under the NTLCP 2.0. Completed questionnaires (n = 212) were obtained using face-to-face or telephone interviews. Results: The results indicated that education (p = 0.011; in the predisposing dimension); social welfare status (p = 0.008); awareness of the NTLCP 2.0 (p < 0.001; both were in the enabling dimension); dementia diagnosis (p = 0.018); being a disability identification cardholder (p = 0.008; both were in the needs dimension) of those people being cared for, as well as gender (p = 0.002), age (p = 0.031), and working conditions (p = 0.035) of caregivers had significant effects on NTLCP 2.0 utilization. Moreover, the results of the multiple regression analysis demonstrated that all four dimensions were significantly associated with NTLCP 2.0 utilization (F = 1.737, p = 0.007; adj R2 = 0.149). Conclusions: The results of this study demonstrated that all four dimensions were significantly associated with NTLCP 2.0 utilization. It is suggested that the Ministry of Health and Welfare continuously promote the NTLCP 2.0 and even expand it to cover those people who currently do not qualify. Furthermore, efforts should be devoted to increase the willingness of male caregivers to use the NTLCP 2.0.
• 521-536
• 10.6288/TJPH.201910_38(5).108081

• Link 評論 Commentary
• 評論：奉養父母的末代，子女棄養的首代Commentary: the last generation to take care of their parents and the first generation to be abandoned by their kids
• 李丞華
  Cheng-Hua Lee
• 無
  none
• 無
  none
• 537
• 10.6288/TJPH.201910_38(5).10808101

• Link 作者回覆 Authors' response to commentary
• 作者回覆：奉養父母的末代，子女棄養的首代Authors' response to commentary: the last generation to take care of their parents and the first generation to be abandoned by their kids
• 鄧桂芬、李玉春、楊哲銘、黃國哲
  Kuei-Feng Teng, Yue-Chune Lee, Che-Ming Yang, Kuo-Cherh Huang
• 無
  none
• 無
  none
• 538
• 10.6288/TJPH.201910_38(5).10808102

• Link 原著 Original Article
• 環境低溫對於類流感急診就診之影響：時間序列分析Impact of low ambient temperatures on influenza-like illnessesrelated hospital emergency visits: a time series analysis
• 黃彥嘉、林育如、施惟量、方啟泰
  Yen-Chia Huang, Yu-Ju Lin, Wei-Liang Shih, Chi-Tai Fang
• 流感病毒、環境低溫、時間序列分析
  influenza-like illness, low ambient temperature, time series analysis
• 目標：2016年初，年假期間出現前所未有的長時間冬季低溫，流感病例數爆增。但低溫與此波流感疫情之間相關性迄今仍未有研究。本研究目標為以時間序列方法分析低溫是否為急診流感就診比例上升之預測因子。方法：以時間序列方法分析2007年1月至2016年12月疾病管制署「即時疫情監視及預警系統」大台北區類流感（influenza-like illness）急診就診人次占全部急診人次比例（下稱就診比例），並將中央氣象局台北測站氣溫紀錄納入動態迴歸模式分析。另因例假日流感病患湧向醫院急診，將每週放假天數作為干擾因子。最後以2017年1月至2017年12月實際數據對預測模式進行外部驗證。結果：大台北區類流感急診就診比例時間序列符合ARMA（1,1）模式，前一週就診比例與當週就診比例具高度相關性（自迴歸係數0.92, p <0.001）。動態迴歸模式分析發現：前一週最低溫（係數-0.07, p = 0.01）與當週放假天數（係數0.2, p < 0.001），為類流感急診就診比例之顯著預測因子。外部驗證結果顯示：含有氣溫及放假天數的時間序列模式能準確預測2017年初流感高峰時間點；全年預測值R2達85%。結論：環境氣溫與下一週類流感急診就診比例具高度相關性，最低溫愈低，下一週類流感急診就診比例愈高。流感防治整備應變需將低溫預報納入考量。
  Objectives: Taiwan had its longest recorded cold wave during the 2016 Chinese New Year holiday; a surge in influenza cases followed. To assess the effect of a cold wave on influenza activity, we used a time series model to analyze the relationship between low ambient temperatures and influenza-related emergency visits. Methods: We obtained weekly data on the proportion of influenza-like illnesses (ILIs) among emergency room visits in Taipei from January 2007 to December 2016. Data were from the Real-time Outbreak and Disease Surveillance of the Taiwan Centers for Disease Control. Ambient temperature data were from the Taiwan Central Weather Bureau. We used an autoregressive integrated moving average (ARIMA) model to analyze the association between low temperatures and ILIs. The validity of predictive models was tested against January 2017 to December 2017 data as external validation. Results: The time series of ILI-related emergency visits in Taipei was consistent with the ARIMA (1, 1) model at an autoregression coefficient of 0.92 (p < 0.001). ARIMA analysis indicated that the lowest temperature in the previous week (coefficient: -0.07, p = 0.01) and the number of holiday days in the week (coefficient: 0.2, p < 0.001) were significant predictors of the proportion of ILI-related emergency visits. External validation demonstrated that the time series model with temperature and holiday covariates accurately predicted the timing of the ILI surge in the 2017 winter vacation, with an R2 of 85% for the overall fit in 2017. Conclusions: Cold waves are a predictor of increased ILI-related emergency visits. Thus, influenza preparedness measures should incorporate ambient temperature forecasts.
• 539-550
• 10.6288/TJPH.201910_38(5).108031

• Link 原著 Original Article
• 膝關節置換術前使用免疫抑制劑與感染的關係Association between immunosuppressive medications and postoperative infection following total knee arthroplasty
• 柯絲珊、劉冠麟、鍾和肯、溫淑惠
  Sih-Shan Ke, Kuan-Lin Liu, Ho-Ken Chung, Shu-Hui Wen
• 全人工膝關節置換術、抗腫瘤壞死因子、術後感染、類風濕性關節炎
  total knee arthroplasty, anti-tumor necrosis factor alpha, post-operative infection
• 目標：類風濕性關節炎（Rheumatoid Arthritis，簡稱RA）使用抗腫瘤壞死因子（antitumor necrosis factor alpha，簡稱anti-TNF α）在全人工膝關節置換術（Total Knee Arthroplasty，簡稱TKA）後發生感染的風險較高，但仍未有定論。本研究欲探討RA患者術前使用anti-TNF α在TKA術後發生感染的風險。方法：我們使用2012至2015年全民健康保險資料庫之全 人口檔，納入1,126位RA患者並接受TKA手術，追蹤術後三個月內發生感染情形。研究樣本 TKA術前三個月RA用藥分為三組：疾病調節抗風濕藥物（Disease-modifying anti-rheumatic drugs，簡稱DMARDs）組（n=854）、anti-TNF α組（n=178）與皮質類固醇組（n=94），並以多重邏輯斯迴歸分析RA用藥與術後感染之勝算比（Odds Ratio，簡稱OR）及95%信賴區間（confidence interval，簡稱CI）。結果：三組TKA術後感染發生率（人月）依序為DMARDs組0.011（95%CI: 0.006~0.014），anti-TNF α組0.008 （95% CI: 0.0002~0.0176）與皮質類固醇組為0.005 （95%CI: 0.0002~0.0157）。校正干擾因子後，anti-TNF α組發生術後感染的OR為DMARDs組之0.862倍（95%CI: 0.291~2.548）；若與皮質類固醇組相比，發生術後感染的OR為2.662倍（95%CI: 0.25~28.342），皆無統計顯著。結論：RA患者TKA術前三個月使用anti-TNFα，與DMARDs或皮質類固醇相比，術後三個月之感染風險並無顯著不同。
  Objectives: Patients with rheumatoid arthritis (RA) receiving anti-tumor necrosis factor alpha (anti-TNFα) therapy may have an increased risk of infection after total knee arthroplasty (TKA). However, conflicting results have been provided for the association of anti-TNFα and postoperative infection. In this study, we examined whether RA patients receiving anti-TNFα therapy have an elevated risk of postoperative infection after TKA. Methods: We used the Taiwan National Health Insurance Research Database of the whole population from 2012 to 2015. The medical records of patients with RA who had undergone TKA were obtained (n= 1126). We divided patients into three groups based on RA medications: disease-modifying anti-rheumatic drugs (DMARDs) (n = 854), anti-TNFα (n = 178), and corticosteroids (n = 94). Multivariate logistic regression was used to estimate the odds ratio (OR) of infection as well as the corresponding 95% confidence interval (CI). Results: The incidence rate (per personmonth) of postoperative infection for each group was as follows: DMARDs: 0.011 (95% CI: 0.006–0.014), anti-TNFα: 0.008 (95% CI: 0.0002–0.0176), and corticosteroids: 0.005 (95% CI: 0.0002–0.0157). After adjustment for potential confounders, RA patients with anti-TNFα use did not have increased risk of infection compared to those with DMARDs (OR = 0.862, 95% CI: 0.291–2.548). Similar finding was found for comparison with corticosteroids (OR = 2.662, 95%CI: 0.25–28.342). Conclusions: The risk of postoperative infection in RA patients receiving anti-TNFα is similar to the risk in those treated with DMARDs or corticosteroids.
• 551-561
• 10.6288/TJPH.201910_38(5).108074