39卷2期

• Link 政策論壇 Policy Forum
• 高齡營養促進的前端預防Front-end preventive strategies for nutrition care for older adults
• 曾櫻枝
  Ing-Jy Tseng
• 無
  none
• 無
  none
• 103 - 104
• 10.6288/TJPH.202004_39(2).PF02

• Link 公衛今與昔 Public Health Now and Then
• 解讀台灣1995年嬰兒死亡率上升Interpretation of the rise of infant mortality in 1995 in Taiwan
• 呂宗學、江東亮
  Tsung-Hsueh Lu, Tung-liang Chiang
• 無
  none
• 無
  none
• 105 - 111
• 10.6288/TJPH.202004_39(2).108136

• Link 綜論 Review Article
• 高齡社區長者社會衰弱之範域文獻回顧Scoping review of social frailty among community-dwelling older adults
• 方佩欣、張睿詒
  PEI-HSIN FANG, RAY-E CHANG
• 老化 ； 失能 ； 衰弱評估 ； 社區介入
  aging ; disability ; frailty assessment ; community intervention
• 本文以範域文獻回顧討論社會衰弱評估工具、分析社會衰弱的決定因子以及其不良結果相關的實證研究，經搜尋PubMed、Web of Science、PsycINFO、華藝中文資料庫，篩選納入37篇（2008至2019年）研究。本文歸納出幾點結果：（一）37篇文獻共有10種評估社會衰弱的工具；（二）年齡較大、低教育程度、獨居等17類變數會有較高的社會衰弱風險，而性別、居住城鄉則有不一致的結果；（三）社會衰弱與失能、死亡率、認知障礙、生理衰弱顯著相關，也與生活品質、生活滿意度有負相關。未來研究可發展適合台灣本土之社會衰弱評估工具，利用縱貫性研究實證社會衰弱與健康不良結果的因果關係，作為政府應用於社區介入、預防失能政策之參考。
  The study conducted a scoping review on empirical studies on social frailty's determinants and health-related outcomes. We collected studies from PubMed, Web of Science, PsycINFO, and Airiti Library (Chinese), and 37 studies from 2008-2019 met the inclusion criteria for this study. The study revealed the following findings: (1) The 37 studies included 10 assessments. (2) Seventeen variables, such as older age, lower education, and living alone, have a higher risk of social frailty; on the other hand, gender and residing in an urban/rural areas show inconsistent results. (3) Social frailty was positively correlated with disability, mortality, cognitive impairment, and physical frailty and negative correlated with quality of life and life satisfaction. Future studies can develop an indigenizing scale and provide evidence for the causal relationship between social frailty and adverse outcomes through longitudinal research designs. Governments can use these results for community intervention and disability prevention.
• 112 - 128
• 10.6288/TJPH.202004_39(2).108113

• Link 綜論 Review Article
• 東亞已開發國家的性別平等、家庭政策對生育之影響：對台灣的啟示Influence of gender equality and family policies on fertility in developed countries in East Asia: lessons for Taiwan
• 許碧純
  PI-CHUN HSU
• 性別平等 ； 家庭政策 ； 生育 ； 已開發國家 ； 東亞
  gender equality ; family policies ; fertility ; developed countries ; East Asia
• 持續的低生育率是諸多已開發國家共同面對的問題，儘管生育率都是低於人口替代水準，從晚近三十年的發展而言，北歐及西歐國家有止跌回升的趨勢，東亞及南歐國家則仍持續低迷。為何會有這樣的差異？本文從性別平等、家庭政策及外在環境不穩定等因素分析台灣、日本與南韓之低生育，企圖建立一個解釋東亞已開發國家低生育的分析架構，特別著重於分析台灣、日本及南韓低生育趨勢及政府相關政策的因應與挑戰，最後討論台灣低生育的現況，並進行反思。針對台灣持續的低生育問題，作者建議政府應更積極的投入支持性別平等及相關支持家庭的友善政策，以避免陷入低度生育的陷阱。
  Persistent low fertility rate, especially below replacement level, is a critical problem in many developed countries. These rates have been reversed in Nordic countries and Western Europe, but rates have declined to all-time lows in East Asian and Southern European countries since the early 1990s. This study examined differences between the fertility rates of these groups of countries to analyze the factors underlying this difference. Gender inequality, flawed family policies, and macro-level uncertainties are the critical factors that have resulted in low fertility in Taiwan, Japan, and South Korea. In this study, we developed a framework to explain the trend of low fertility in these three East Asian countries, with a particular focus on government responses to this challenge. This study also analyzed the current problem of low fertility in Taiwan to furnish prescriptions for the government. To mitigate the problem of low fertility in Taiwan, government policies should proactively support gender equality and work-life balance.
• 129 - 142
• 10.6288/TJPH.202004_39(2).108085

• Link 原著 Original Article
• 台北市社區空氣汙染與皮膚老化之關係Association between air pollution and skin aging in Taipei City communities
• 詹馥妤、詹長權、李睿桓、袁子軒、施淑芳、陳政友、 胡益進
  FU-YU CHAN, CHANG-CHUAN CHAN, JUI-HUAN LEE, TZU-HSUEN YUAN, SHU-FANG SHIH, CHENG-YU CHEN, YIH-JIN HU
• 皮膚老化 ； 都市空氣汙染 ； 台北市
  skin aging ; urban air pollution ; Taipei
• 目標：本研究旨在探討台北市社區之空氣汙染與其居民皮膚老化之關係。方法：本研究選擇以台北市大同區及北投區作為收案地點，研究對象選擇居住於台北市滿一年以上、年齡介於20至70歲且皮膚無傳染性疾病之社區民眾。本研究採用之方法包括運用微析皮膚照相機及臉部膚質影像分析測量皮膚老化、以自填問卷蒐集與皮膚老化之相關變項，以及依照研究對象居住地址估算暴露值之資料推估民眾暴露於PM_(10)、PM_(2.5)與NO_2之程度，最後以多變項羅吉斯迴歸探討空氣汙染暴露與皮膚老化之關係。結果：空氣汙染物NO_2與皮膚老化兩者具有正向關係，NO_2的暴露程度愈高，皮膚老化1歲以上之風險亦較高（OR=1.05, 95% CI, 1.004 to 1.10）。結論：研究對象暴露於NO_2的濃度愈高，皮膚老化的風險也越高。
  Objectives: This study investigated associations between air pollution and skin aging among residents of Taipei City. Methods: We selected Datong District and Beitou District as research sites. The participants were residents aged 20 to 70 years who had lived in Taipei City for more than 1 year and had no communicable diseases. We used a microscopic skin camera and facial image analysis to measure degrees of skin aging. We investigated factors related to skin aging through self-administered questionnaires. We estimated exposure to PM_(10), PM_(2.5), and NO_2 based on participants' residential address. Finally, we conducted multiple logistic regression analysis to examine association between air pollution exposure and skin aging. Results: A positive and statistically significant association between NO_2 exposure and skin aging was identified. The risk of skin aging increased with the degree of exposure to NO_2 over 1 year (OR = 1.05, 95% CI, 1.004 to 1.10). Conclusions: Higher exposure to NO_2 is associated with a higher risk of skin aging.
• 143 - 154
• 10.6288/TJPH.202004_39(2).108108

• Link 原著 Original Article
• 細懸浮微粒重金屬組成與肝癌發生或死亡之相關性研究Association between the heavy metal constituents in fine particulate matter and the risk of liver cancer incidence or death in Taiwan
• 呂姿儀、蕭雅萍、吳治達、陳建仁、楊懷壹、潘文驥
  TZU-YI LU, YA-PING HSIAO, CHIH-DA WU, CHIEN-JEN CHEN, HWAI-I YANG, WEN-CHI PAN
• 細懸浮微粒 ； 重金屬組成 ； 肝癌 ； 土地利用迴歸
  fine particulate matter ; metal constituents ; liver cancer ; land-use regression
• 目標：利用回溯型世代追蹤設計，評估細懸浮微粒中重金屬組成與肝癌的發生或死亡風險之相關性。方法：納入REVEAL-HBV世代（1991－1992年基線收案）居住在台灣本島之13,515名參與者，透過國家癌症登記與死亡檔進行資料連結，定義追蹤期間（1993－2014）之新發生或死於肝癌病患。參與者之長期暴露濃度乃使用土地利用迴歸模型推估細懸浮微粒中八種重金屬濃度（2002－2006），包含鋇、銅、錳、銻、鋅、鉛、鎳和鎘。本研究使用Cox比例風險模型估計PM_(2.5)中重金屬組成與肝癌之風險比和95%信賴區間。除此之外，還應用雙暴露模型校正細懸浮微粒中重金屬彼此之干擾效應，以評估重金屬組成與肝癌之相關性。結果：本研究追蹤期間共有322名新發生或死於肝癌病例。每增加一個對數尺度單位之PM_(2.5) Cu（銅），其校正過後之風險比（95%信賴區間, p-value）為1.15（1.03－1.29, 0.017）。在雙暴露模型中，發現PM_(2.5) Cu與肝癌風險仍然存在正相關，風險比（95%信賴區間, p-value）為1.13（1.00, 1.27, 0.045）。結論：大氣中PM_(2.5)中重金屬組成之銅可能和罹患或死於肝癌之風險有關。
  Objectives: To investigate the association between the heavy metal constituents in PM_(2.5) and liver cancer incidence or death in a large Taiwanese cohort. Methods: A subset of 13,515 participants of the REVEAL-HBV cohort who lived in Taiwan (excluding outlying islands) during 1991-1992 was adopted for this study. Patients with liver cancer were identified through computerized data linkage with the national cancer registry and death certification systems during 1993-2014. Long-term exposure levels to eight metal constituents of PM_(2.5) (i.e., Ba, Cu, Mn, Sb, Zn, Pb, Ni, and Cd) during 2002-2006 were determined using land-use regression models. Cox proportional hazards models were used to estimate the hazard ratios (HRs) of PM_(2.5) metal components on liver cancer incidence or death, after adjustment for potential confounders. To investigate mutual confounding effects, we further applied two-pollutant models for evaluation of the association between metal constituents of PM_(2.5) and liver cancer. Results: During a median follow-up of 23.2 years, 322 cases of liver cancer or death were identified. With a one-unit increment on a log scale, the adjusted HR of PM_(2.5) Cu was 1.15 (95% confidence intervals [CIs]: 1.03-1.29). In addition, the association between PM_(2.5) Cu and liver cancer incidence or death was significant. The two-pollutant model revealed a positive association of PM_(2.5) Cu with liver cancer incidence or death (HR = 1.13, 95% CI: 1.00-1.27). Conclusions: The findings suggest that exposure to metals within ambient PM_(2.5), and PM_(2.5) Cu in particular, may increase the risk of liver cancer occurrence or death.
• 155 - 169
• 10.6288/TJPH.202004_39(2).108075

• Link 原著 Original Article
• 攝食米食之砷、鎘、鉛、銅暴露健康風險評估－以桃園、彰化、台中稻米樣本為例Assessment of the health risks of arsenic, cadmium, lead, and copper exposure through rice consumption: using rice samples from Taoyuan, Changhua, and Taichung as examples
• 黃耀輝、范致豪、顏筠庭、周宜蓁、賴思齊
  YAW-HUEI HWANG, CHIHHAO FAN, YUN-TING YEN, YI-CHEN CHOU, SZU-CHI LAI
• 米食 ； 砷 ； 金屬 ； 健康風險評估 ； 致癌風險
  rice ; arsenic ; metal ; health risk assessment ; carcinogenic risk
• 目標：本研究利用國內桃園、彰化、台中等地稻米樣本實地資料為例進行健康風險評估，以瞭解攝取米食的潛在重金屬暴露風險等級。方法：本研究在桃園與彰化／台中兩地區分別採集167筆與200筆稻米樣本，以感應耦合電漿質譜儀測定銅、砷、鎘及鉛等金屬含量。再結合蒙地卡羅模擬分析法評估健康風險。結果：研究結果顯示，國人經米食攝取金屬之非致癌風險值最高為砷暴露，0.518（5%，95%百分位：0.166,1.663）。另外，攝取米食之砷暴露致癌風險值中位數為2.33×10^(-4)（7.48×10^(-5)，7.48×10^(-4)）。再以無機砷為例，若米食中濃度管制標準分別設在0.20、0.15、0.10 μg/g，國人經米食攝取之砷暴露致癌風險值中位數降低幅度分別為4.3%、13.3%與31.8%，健康風險值小於1×10^(-4)的人口比例則分別為12.1%、14.3%、22.7%。結論：利用健康風險評估過程可檢視國人體重、米食攝食量、金屬種類與濃度、致癌或非致癌性風險參考係數等因素對健康風險值的影響程度，推估不同管制標準對改善健康風險的幅度，做為米食安全政策評估的重要參考依據。
  Objectives: This study investigated data of rice samples from Taoyuan, Changhua, and Taichung to rank the potential health risks of heavy metal exposure through rice consumption. Methods: In this study, 167 rice samples were collected from the Taoyuan area, and another 200 rice samples were collected from the Taichung and Changhua areas. The copper, arsenic, cadmium, and lead levels were assessed in the rice samples and used for health risk assessment through Monte Carlo simulation. Results: The results indicated that arsenic exposure resulted in the highest non-carcinogenic risk of 0.518 (5th percentile to 95th percentile: 0.166-1.663). The median carcinogenic risks were 2.33 × 10^(-4) (7.48 × 10^(-5), 7.48 × 10^(-4)) for arsenic exposure. If the standards for arsenic content in rice are set at 0.20, 0.15, or 0.10 µg/g, the corresponding median carcinogenic risks for arsenic exposure through rice consumption in Taiwan were reduced by 4.3%, 13.3%, and 31.8%, respectively, and the proportions of the population with a health risk less than 1 × 10^(-4) were 12.1%, 14.3%, and 22.7%, respectively. Conclusions: The extent of the effects of body weight, rice intake, metal type, metal concentration, cancer slope factor, and non-cancer reference dose on the health risk assessment could scrutinized through the health risk assessment processes. The reduction of health risk through the implementation of various rice arsenic standards could also be evaluated and used accordingly as reliable reference for making policy decisions pertaining to rice food safety.
• 170 - 186
• 10.6288/TJPH.202004_39(2).108114

• Link 原著 Original Article
• 癌症與非癌生命末期病人使用安寧療護對照護利用及費用的影響Effect of hospice care use on the utilization and expenses of care for end-of-life patients with and without cancer
• 萬宣慶、周盈邑、張冠民、董鈺琪
  SHUAN-CHING WAN, YING-YI CHOU, GUANN-MING CHANG, YU-CHI TUNG
• 安寧療護 ； 生命末期病人 ； 醫療利用 ； 醫療費用 ； 照護品質
  hospice care ; end of life patients ; medical utilization ; medical expenses ; care quality
• 目標：我國人口快速高齡化，安寧療護需求持續增加，自2009年將八大非癌末期患者納入安寧療護給付範圍後，安寧療護的照護層面更為全面，過往安寧療護影響之研究未包含非癌末期患者，因此，本研究目的係探討癌症與八大非癌患者使用安寧療護對照護利用及費用的影響。方法：本研究採用百萬承保抽樣歸人檔，研究對象為2012年死亡之罹患癌症與八大非癌末期成年患者共5,062人，使用多元邏輯斯迴歸和線性迴歸分析，探討安寧療護使用對於生命末期積極照護利用及整體醫療費用之影響。結果：生命末期病人使用安寧療護可使死亡前30天接受較少侵入性治療，包含加護病房的使用、插管的使用、呼吸器的使用、心肺復甦術的使用，以及死亡時是在醫院。在醫療費用上，使用安寧療護可以減少死亡前1個月的總醫療費用。結論：生命末期病人使用安寧療護，在死亡前積極照護率呈現下降，顯示有使用安寧療護的末期患者，在照護品質上較佳、醫療利用較少且在死亡前一個月的醫療總費用較低。
  Objectives: The demand for hospice care is increasing because of the rapidly aging population in Taiwan. Since 2009, health insurance payments have been expanded to cover eight categories of noncancer terminal diseases, thus making hospice care accessible to more people. Previous discussions on hospice care have focused only on patients with end-of-life cancer, to the neglect of other patients. This study fills this gap by exploring the effect of hospice care expenses and utilization on patients with cancer and patients with noncancer terminal diseases. Methods: Data were obtained from the Million People File - a study of 5,062 adult patients with either cancer or diseases in one of the eight categories of noncancer terminal diseases who died in 2012. Multivariate logistic regression and linear regression were used to verify the use of hospice care for end-of-life aggressive care utilization and overall medical expenses. Results: End-of-life patients receiving hospice care used fewer aggressive treatments 30 days prior to death, including use of intensive care units, intubations, mechanical ventilation, and cardiopulmonary resuscitation, and were less likely to die in a hospital. The use of hospice care reduced the total cost of medical care in the final months before death. Conclusions: In general, for end-of-life patients receiving hospice care, the use of aggressive care before death has been declining. End-of-life patients treated with hospice care had better care quality and less medical utilization. The total medical expenses for hospice care decreased during the final month prior to death.
• 187 - 201
• 10.6288/TJPH.202004_39(2).108073

• Link 原著 Original Article
• 收治長期呼吸器依賴病患之醫院集群網絡關係分析Social network analysis of hospitals admitting ventilator-dependent patients in Taiwan
• 莊秀文、郭迺鋒、鄭佳欣
  SHEU-WEN CHUANG, NAI-FONG KUO, CHIA-HSIN CHENG
• 呼吸器依賴病患 ； 呼吸器整合性照護制度 ； 程度中心性 ； 社會網絡分析 ； 全民健保
  ventilator dependent patients ; integrated prospective payment system ; degree centrality ; social network analysis ; National Health Insurance
• 目標：呼吸器依賴患者整合性照護制度（簡稱IDS）已執行十八年久，本研究目的是釐清歷年來收治呼吸器依賴病患（簡稱VDP）醫院之集群網絡的結構變化與特性差異。方法：採用社會網絡分析法（SNA），針對以2000－2013年中區業務組之所有申報VDP醫院之健保資料，分析醫院間病患移動的互動脈絡，並以程度中心性指標，結合圖形理論與地理資訊進行集群結構分析，以及運用ANOVA比較集群網絡內各項特性值之差異性。結果：依歷年VDP人數消長分為成長期、穩定期與緩降期。前三大醫院集群是以醫學中心為核心醫院的網絡，其結構無大幅度變動，僅呈現明顯的集中、地域性區隔分佈。網絡特性值較明顯一致性的變化，包括醫療費用、病患醫院網絡間轉院次數、與每人平均轉院次數，均在緩降期間時顯著降低，但如ICU回轉率、每人平均ICU回轉次數，各集群則是上升後到緩降期無明顯下降，集群網絡程度中心性平均值僅A01與A03有顯著性增加。研究意涵指出集群間、集群內醫院呈現既競爭又依賴的關係，為因應VDP人數遞減，降低病患轉院頻率，增加ICU回轉率似乎成為醫院的因應對策。結論：運用SNA可以更加瞭解在IDS下各時期醫院網絡結構的樣態與特性變化，不但適用來解釋醫院網絡關係與經營現象，做為未來IDS政策發展的參考，亦可做為其他衛生政策之實行、醫院群體反應研究的參考範例。
  Objectives: The integrated delivery system (IDS) for ventilator-dependent patients (VDPs) has been in implementation for more than 18 years. This study clarified structural changes and differences in characteristics among hospital networks admitting VDPs. Methods: Social network analysis (SNA) was used to analyze the health insurance data of VDPs during 2000-2013 from all hospitals a part of the national health insurance administration, Central Division. Patient transfer and interaction between hospitals were analyzed; thereafter, degree centrality index was used to combine graph theory and geographical information for cluster structure analysis. Finally, analysis of variance (ANOVA) was used to test the differences in various characteristics between hospital networks. Results: According to the number of VDPs, three phases were classified: growing phase, stable phase, and decline phase. The top three hospital clusters comprised the networks in which medical centers operated as core hospitals, showing a clear concentration and geographical boundary over time. Medical expenditures of each cluster network, the average number of patient transfers between hospitals, and the average number of transfers per patient showed a consistent pattern of changes across the networks. However, intensive care unit (ICU) return rate and average number of ICU returns per patient did not decrease significantly during the three phases in each cluster. The average of degree centrality of networks A01 and A03 showed a significant increase. The findings imply that hospitals within and between the cluster networks exhibit competitive and interdependent relationships. In response to the declining number of VDPs, which reduced the frequency of patient transfers, the increased ICU return rate seemed to be a common strategy among hospitals. Conclusions: Employing SNA can broaden the understanding of structures and characteristic changes of hospital networks, which not only helps interpret hospital network relationships and business operating patterns but also can be used as a reference for future IDS policy development. The use of SNA in the IDS study also obtains a reference example for the implementation of other health policies and research into hospital behavior.
• 202 - 214
• 10.6288/TJPH.202004_39(2).108135

• Link 評論 Commentary
• 評論：收治長期呼吸器依賴病患之醫院集群網絡關係分析Commentary: social network analysis of hospitals admitting ventilator-dependent patients in Taiwan
• 楊式興
  Shih-Hsing Yang
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  none
• 無
  none
• 215 - 215
• 10.6288/TJPH.202004_39(2).10813501

• Link 原著 Original Article
• 中文版家庭照顧者給藥管理困擾量表之發展與信效度評估Development and validation of the Family Caregiver Medication Administration Hassle Scale-Chinese version (FCMAHS-CH)
• 顧德璉、吳淑英、蘇億玲、賴嘉敏、季瑋珠
  TE-LIEN KU, SHU-YING WU, YI-LIN SU, CHIA-MING LAI, WEI-CHU CHIE
• 家庭照顧者 ； 給藥管理 ； 困擾 ； 信度 ； 效度
  family caregiver ; medication administration ; hassle ; reliability ; validity
• 目標：本研究旨在發展一份適合評估台灣家庭照顧者給藥管理相關心理負荷之測量工具，並測試其信、效度。方法：本研究採橫斷面研究設計，分為三個階段，首先透過雙向翻譯及專家內容效度進行中文版家庭照顧者給藥管理困擾量表編制；接著邀請本國籍家庭照顧者及醫療專業人員共15名進行前驅研究；最後以138名本國籍家庭照顧者為研究對象進行量表施測，並於兩週後以便利取樣方式從原本138名個案中選取30名進行後測。結果：中文版家庭照顧者給藥管理困擾量表包含：「資訊取得／資訊分享」、「給藥時間安排」、「安全性議題」、「藥品領取/處方箋管理」四構面，共計24題，可解釋總變異量為65.76%。量表具備良好內容效度，心理計量分析顯示量表具備良好內在一致性信度、再測信度、建構效度、區辨效度及已知組比較效度。結論：中文版家庭照顧者給藥管理困擾量表具有良好信、效度，可應用於評估國內家庭照顧者族群給藥管理照顧工作之心理負荷，亦可作為衛生教育介入方案之需求評估工具。
  Objectives: The aim of this study was to develop a Chinese version of the Family Caregiver Medication Administration Hassle Scale (FCMAHS-CH) and examine its psychometric properties, reliability, and validity for Taiwanese caregivers. Methods: A cross-sectional methodological design was executed in three phases. First, the original English version of the FCMAHS was translated into Chinese through a two-way translation process, and an expert panel was then convened to evaluate the content validity. Second, a pilot study was conducted with 15 Taiwanese family caregivers and health care professionals to test the readability of the FCMAHS-CH. Finally, a sample of 138 Taiwanese adult family caregivers completed the FCMAHS-CH, and 30 of the participants were retested after 2 weeks. Results: The FCMAHS-CH contained 24 items classified into the following four domains: information acquisition and sharing, medication scheduling, safety issues, and prescription filling and management. The overall scale with four domains explained 65.76% of the total variance. The scale had acceptable content validity; psychometric analysis demonstrated high internal consistency and test-retest reliability as well as good construct, discriminant, and known-group-comparison validity. Conclusions: The FCMAHS-CH can be used to assess medication administration-related stressors among Taiwanese family caregivers. The scale has well established reliability and validity, thus providing a new tool for future practice and research into family caregiving in Taiwan.
• 216 - 230
• 10.6288/TJPH.202004_39(2).108098