29卷4期

• Link 綜論 Review Article
• 自僱就業者的工作與健康Work and Health of self-employed Workers
• 葉婉榆、黃沛盈、劉梅君、徐儆暉
  Wan-Yu Yeh, Pei-Ying Huang, Mei-Chun Liu, Jin-Huei Hsu
• 自僱工作 ； 自營作業者 ； 創業 ； 工作壓力 ； 職業健康
  self-employment ; own-account workers ; entrepreneurship ; work stress ; occupational health
• 在台灣企業無薪假、裁員潮頻傳之際，鼓勵民眾（特別是婦女、中高齡等弱勢就業族群）自行創業，是政府解決失業問題的一項重要策略。比起受僱者，自僱就業者（包括雇主與自營作業者）更直接暴露在市場競爭與景氣變動下，其社會背景、工作和健康問題卻很少受重視。本文整理國內外自僱工作相關文獻與統計資料，發現台灣自僱者佔就業人口的比例近年逐漸略微下降，和受僱者、雇主相較，自營作業者的年齡較長、教育程度偏低、在女性中離婚、喪偶的比例較高；這般變遷趨勢與就業競爭較不利的人口屬性，和國外先進國家的狀況有明顯差異。工作特性上，自僱者的工作量與報酬不像受僱者那樣受到勞動法令規範，自僱者常需在時間與身心方面高度投入工作，有些研究指出其工作滿意度較高，但工時較長、自覺工作壓力與疲勞較為嚴重，並遭遇較大工作與家庭的衝突。自僱工作有不同於受僱型態的工作環境、壓力來源、健康與家庭的風險，政策應加以關切並提供協助，以免自僱者為拼經濟犧牲了健康。
  Corporations in Taiwan are offering unpaid leave, downsizing staff, and encouraging entrepreneurship-especially among disadvantaged employment groups such as women and middle or advanced-aged groups. This has become one of the government's priorities in dealing with the problem of unemployment. Compared to salaried workers, self-employed individuals (including employers and own-account workers) are more exposed to market competition and economic fluctuations; however, their social background, work, and health problems have seldom been examined. Reviews of both the domestic and international literature and statistical data concerning self-employment show that the percentage of self-employed individuals in Taiwan has declined slightly. When compared with employers and salaried workers, own-account workers tend to be older and less educated and, among them, females tend to have a higher rate of divorce or being widowed. The tendency for this transition and job competition is disadvantageous to those self-employed individuals whose situation is significantly different from that in other developed countries. With regard to job characteristics, salaried workers have an advantage over self-employed individuals who have no standard workloads, no standards for remuneration, and often devote time and mental and physical efforts into work without any legal protection. Some studies have indicated that, although self-employed individuals enjoy a higher level of job satisfaction, their working hours are longer, work stress and burnout rates are higher, and they face a higher number of work-family conflicts. There are differences in the work environment, causes of stress, and risks to health and family between self-employed and salaried workers. More policies to care for self-employed individuals and to offer them support are needed since they sacrifice their health for wealth.
• 283 - 298
• 10.6288/TJPH2010-29-04-01

• Link 原著 Original Article
• 「愛滋病個案管理師計畫」對於個案行為與健康狀況之影響Effects of the HIV Case Management Program on the Behavior and Health Outcomes of Clients
• 邱珠敏、 丁志音
  Chu-Ming Chiu, Chih-Yin Lew-Ting
• 愛滋病個案管理 ； 性行為 ； 服藥遵從 ； CD4值 ； 健康狀況
  HIV case management program ; safer sex ; HAART adherence ; CD4 counts ; health status
• 目標：評量「愛滋病個案管理師計畫」對於個案在行為及健康狀況方面的成效，並檢視其相關因素。方法：本研究資料來自2007年「愛滋病個案管理師計畫」資料庫，針對參與初診及後續兩次複診的852名個案之行為與健康狀況進行分析。除了從群體層次觀察整個樣本的行為與健康狀況的整體變化之外，並由個體層次探索每一個案在行為與健康狀況的變化型態，最後以多變量分析檢視個案特質與個管計畫成效的相關性。結果：樣本整體的行為及健康狀況在第一次複診時即呈現正向且顯著之改善，且於第二次複診時多能持續維持或小幅繼續改善。而由個別的變化型態來看，除了告知家人這項之外，個案在所有的行為與健康狀況方面的持續維持正向或改善都能維持在70~90%。改變型態與個人特質的相關較弱，但行為的改變的確與健康狀況的變化有顯著關係。結論：半年的個管介入對於個案在各項行為與健康狀況方面多有正向的影響。應強化感染者對個管計畫的加入與持續參與，確保服務品質，並評估其長期效益。
  Objectives: This study assessed the effects of the HIV Case Management Program (HIVCMP) on behavioral and health outcomes among HIV infected clients in Taiwan. Factors associated with these effects were also explored. Methods: Utilizing the 2007 ”HIV Case Management Program” data set, this study analyzed the behaviors and health status of 852 HIV infected persons who had made a first consultation and two consecutive follow-up visits. Both ”group level” analysis describing the total sample's behavioral and health outcomes at each visit and ”individual level” analysis that followed the changes in individual behaviors and health status across the three visits were conducted. Multivariate analysis was applied to explore the factors associated with program effects. Results: Improvements in almost all aspects of behavior and health status were found from the baseline to the first follow-up visit. These were maintained or slightly increased at the second follow-up visit. Individual level analysis showed that, except for family awareness, other behavioral and health outcomes either maintained a positive condition or made a positive change for 70~90% of the participants. Weak relationships were found between personal characteristics and effects; however, behavioral changes made significant contributions to changes in health outcomes. Conclusions: The initial stage of HIVCMP implementation showed significant effects on clients' behavioral and health outcomes. Extended outreach efforts should be made to increase participation and maintain continuity. The long-term effects of HIVCMP should be regularly evaluated in order to assure quality.
• 299 - 310
• 10.6288/TJPH2010-29-04-02

• Link 評論 Commentary
• 評論：「愛滋病個案管理師計畫」對於個案行為與健康狀況之影響_Effects of the HIV Case Management Program on the Behavior and Health Outcomes of Clients
• 劉慧俐
  Hui-Li Liu
• 無
  none
• 無
  none
• 311 - 312
• 10.6288/TJPH2010-29-04-03

• Link 評論 Commentary
• 作者回覆：「愛滋病個案管理師計畫」對於個案行為與健康狀況之影響 Response: Effects of the HIV Case Management Program on the Behavior and Health Outcomes of Clients
• 邱珠敏、 丁志音
  Chu-Ming Chiu, Chih-Yin Lew-Ting
• 無
  none
• 無
  none
• 312 - 313
• 10.6288/TJPH2010-29-04-04

• Link 原著 Original Article
• 運用PRECEDE模式評估某社區之事故傷害問題Using the PRECEDE Model to Assess Injuries in a Selected Community
• 林莉茹、李蘭、莊莉菁、郭寶貞、白璐
  Li-Ju Lin, Lee-Lan Yen, Li-Ching Chuang, Pao-Chen Kuo, Lu Pai
• 安全社區 ； 事故傷害 ； PRECEDE模式 ； 介入
  Safe Community ; injury ; PRECEDE model ; intervention
• 目標：運用PRECEDE模式，評估台北市某一社區事故傷害狀況，以作為該社區之安全社區計畫推動最適介入策略之參考。方法：針對台北市某一社區，蒐集該社區事故傷害資料，包括事故傷害死亡率、醫院急診事故傷害個案、警察局交通事故。將事故傷害資料統計後，提供社區領袖票選優先議題及其影響因素之重要度及可改變度。參照PRECEDE模式，依序進行流行病學診斷，行為和環境診斷，及教育和生態診斷，完成該社區事故傷害問題之評估。結果：在流行病學診斷方面，該社區與事故傷害有關之議題以「跌倒墜落」及「交通事故」為優先；跌倒墜落的高危險群為10歲以下小孩及70歲老人以上；交通事故的高危險群為20-29歲機車騎士。在行為和環境診斷方面，老人跌倒之行為因素為精神不佳，環境因素為居家地面的濕滑；小孩跌倒之行為因素為沒有大人陪伴或大人沒注意，環境因素為居家或浴室的地面濕滑。機車交通事故之行為因素為違反交通規則，環境因素為天候光線不佳。在教育和生態診斷方面，所有前置因素、增強因素及促成因素，分析其重要度及可改善度之後，找出應優先改善之項目為：老人居家跌倒為浴室沒有把手或防滑墊未固定；小孩跌倒為主要照顧者防跌知識及警覺性不足；機車交通事故傷害為警覺性不夠及安全認知不足。結論：藉由PRECEDE模式進行社區事故傷害評估，透過社區事故傷害監測客觀數據蒐集，及社區領袖評量問題重要度及可改善度，評估結果可應用於該社區推動事故傷害防制計畫之參考。
  Objectives: To use the PRECEDE model to assess injuries in a selected community in Taipei City. The assessment results form the basis for a program of community safety. Methods: Injury data, including injury mortality, emergency room cases, and cases involved in traffic accidents, were collected from a selected district in Taipei City. Data were analyzed so that community leaders might prioritize the subtypes of injury and related factors by importance and improvability. Injuries in the community were assessed by following each phase of the PRECEDE model in terms of epidemiological, behavioral and environmental, and educational and ecological diagnoses. Finally, we completed a community assessment of the problem of injuries. Results: The epidemiological diagnosis revealed that motor vehicle injuries (MVI) and falls were priority issues. Children under age 10 and elders over 70 were the high-risk groups for injuries due to falls, as were motorcycle riders aged 20-29 years for MVI. The behavioral and environmental diagnosis showed that the elderly fell either at a low-spirited status or due to a wet floor at home; children fell due either to adults’ absence or negligence or due to a wet floor at home or in a bathroom; factors underlying motorcycle injuries were violation of traffic rules and a dim weather. For the education and ecological diagnosis, the importance and improvability of the predisposing, reinforcing, and enabling factors were examined. Priorities were identified: for the elderly, a grasp bar or fixation of a skid-proof mat in the bathroom; for children, provision of fall prevention knowledge and awareness for caregivers; for motorcycle riders, training in vigilance and safety concerns. Conclusions: The PRECEDE model was used to assess injuries in a designated community. The results of the assessment in combination with community injury surveillance data and local leaders' acknowledgement of the importance and improvability of various injuries, can be utilized to promote injury prevention and control programs in a community.
• 314 - 325
• 10.6288/TJPH2010-29-04-05

• Link 原著 Original Article
• 國小低年級學童家長對其子女接種流感疫苗意向之轉變情形及其相關因素分析－以雲林縣學童家長為例A Study of the Changes in Parental Intent to Approve Influenza Vaccine Inoculation for Their low-grade Primary School Children in Yunlin County
• 許淑雲、廖宏恩、洪百薰、林柏煌、高昆裕、王俊毅
  Shu-Yun Hsu, Hung-En Liao, Baai-Shyun Hurng, Po-Huang Lin, Kun-Yue Kao, Jiun-Yi Wang
• 流行性感冒 ； 疫苗接種 ； 健康信念模式 ； 行動線索
  influenza ; vaccine inoculation ; health belief model ; cues to action
• 目標：96年政府首度將國小一二年級學童納入流感疫苗免費接種實施對象，本研究在97年疫苗未開打前，調查學童家長對其子女接種流感疫苗的意向，並探討影響家長轉變意向之相關因子。方法：97年5至6月間採二階段集群抽樣，以結構式問卷調查雲林縣24所國小共1,125名家長。結果：96年子女有接種的家長佔57.9%，其中有7.7%在97年轉而不同意其子女接種流感疫苗；而96年子女未接種者則佔42.1%，其中有51.4%在97年轉而同意其子女接種流感疫苗。援引健康信念模式，並經由多項式羅吉斯迴歸分析發現，學童就讀私立學校、父母教育程度較高、未收到接種同意書及須知，對家長願意讓其子女接種疫苗的意向有負面影響；而家長自我效能較高、接種疫苗之利益性較高或障礙性較低、情境感受較強，則對家長意向有正面影響。結論：建議衛生單位可結合社區醫療網絡，藉由醫師的專業角色，提升家長對接種流感疫苗的認知與態度。並可針對未繳交同意書或不同意接種的家長，透過電話提醒和說明，降低其障礙信念。政府亦可利用大眾傳播宣導施打流感疫苗的重要性及優點，並公佈疫苗相關資訊，以澄清民眾對疫苗安全上的疑慮，提升民眾對疫苗接種的意願。
  Objectives: The government initiated a voluntary, free influenza vaccination program for lowgrade primary school students in 2007. This study was done before the inoculation program started in 2008 and investigated parental intent with regard to their children's inoculations and identified factors associated with a change in parental intent. Methods: Identified by two-stage cluster sampling, 1125 parents from 24 schools in Yunlin County were recruited and interviewed with a structured questionnaire in May and June, 2008. Results: Children of 57.9% of the parents had been inoculated in 2007. Among these parents, 7.7% changed their minds and now would not allow their children to have inoculations in 2008. On the other hand, 42.1% of the parents did not allow their children to have inoculations in 2007. Among these, 51.4% changed their minds and would allow their children to have inoculations in 2008. Multinomial logistic regression analysis showed that children attending private schools, a higher level of parental education, and failure to receive letters of notice and consent were negative factors associated with parental intent to vaccinate their children. The perceptions of higher benefits or lower barriers to inoculation, higher self-efficacy, and perceptions of a higher inoculation rate were all shown to be positively associated with parental intent. Conclusions: We suggest Health Bureaus to exploit physician resources in the network of community medical groups to enhance parental knowledge about and belief in inoculation, and remind those parents who did not receive notification or did not allow their children to have inoculations of the availability of this information. The government can promote the importance and advantage of inoculation via mass communications, and publish related information about influenza vaccine in order to eliminate public doubt about the safety of the vaccine and to let parents have strong intent to vaccinate their children.
• 326 - 336
• 10.6288/TJPH2010-29-04-06

• Link 原著 Original Article
• 流感疫苗接種行為相關因素探討－以台灣花蓮地區禽畜養殖業者為例The Correlates of Influenza Vaccination among Poultry and Livestock Workers in Hualien
• 朱正一、詹瑞慧
  Cheng-I Chu, Rui-Hui Chan
• 禽畜養殖業者 ； 健康信念 ； 流感疫苗
  poultry and livestock workers ; health belief ; influenza vaccination
• 無
  Objectives: This study investigated factors affecting influenza vaccination among poultry and livestock workers in order to promote influenza vaccination. Methods: The subjects of this study came from the Bureau of Health's 2007 list of poultry and livestock workers in Hualien County. The author personally interviewed each subject utilizing a structured questionnaire and research data was generated from 136 of the 202 listed poultry and livestock workers in Hualien City, Chian, and Shoufong townships. This represented an effective response rate of 67.33%. Results: The results of this study revealed that 35.3% of Hualien's poultry and livestock workers had not been vaccinated against influenza in the past five years. The primary factors affecting influenza vaccination were: education level (F=3.965, p<0.01), regular exercise (F=9.183, p<0.01), self-rated health (F=3.537, p<0.01), and presence of a high-risk disease (t=-4.925, p<0.01). The independent variables of health beliefs, self-efficacy, and social support had significantly positive correlations with influenza vaccination. Self-efficacy was the major independent variable in predicting influenza vaccination for poultry and livestock workers. Conclusions: This study demonstrated that subjects with a low education level, regular exercise, low self-rated health, and with high-risk diseases were more likely to have received influenza vaccination. Agricultural authority' channels are recommended to promote the benefit of influenza vaccinations to the poultry and livestock workers who are more educated, do fewer exercises, and have no high-risk diseases and better self-rated health in order to raise their belief in the value of influenza vaccination.
• 337 - 346
• 10.6288/TJPH2010-29-04-07

• Link 原著 Original Article
• 探討醫療資源和民眾健康差異的相關性－以台灣二十三縣市粗死亡率和事故傷害死亡率為例Exploring the Relationship between Medical Resources and Health Status: An Empirical Study of Crude and Accidental Death Rates in 23 Counties in Taiwan
• 洪乙禎、林錦鴻
  Yi-Chen Hong, Chin-Hung Lin
• 粗死亡率 ； 事故傷害死亡率 ； 交通可近性 ； 資源密集度
  crude death rate ; accidental death rate ; traffic access ; resource concentration
• 目標：本文控制地區人口特性和社經條件，以台灣各縣市醫療資源分配相對於當地地理幅員和人口數為指標，探討相關因子與各地粗死亡率和事故傷害死亡率差異的關係。方法：本研究利用1998至2007年台灣地區23縣市的跨時跨區資料，以羅倫茲曲線和吉尼係數呈現醫療資源分佈的不均程度，並透過泊松迴歸(Poisson regression)方法分析醫療資源密集度、就醫交通可近性、人口組成、教育和所得等因素，對於各縣市粗死亡率、事故傷害死亡率的影響效果。結果：在影響兩項死亡率指標的相關因子中，以醫療的交通可近性、人口老化程度和社會經濟狀況三類影響因素最為重要，醫療資源相對於人口的密集度、原住民人口兩特性，則非主要因子。結論：在控制人口組成、社會經濟條件等因素後，台灣各縣市間粗死亡率和事故傷害死亡率的差異，可相當程度歸因於各地醫療資源、地理幅員所衍生之交通可近性；而且交通可近性條件對於事故傷害死亡率的影響更甚於對粗死亡率的影響。
  Objectives: After controlling for population attributes and socio-economic factors, this article explored the allocation of medical resources among 23 counties in Taiwan and investigated the impact factors on the crude and accidental death rates. Methods: This study collected data from 23 counties in Taiwan for 1998 through 2007 and used the Gini coefficient and Lorenz curve to show the inequality of resource allocation among all counties. With Poisson regression, the crude and accidental death rates were dependent variables and resource concentration, access to medical facilities, population attributes, level of education, and income were treated as independent variables. Results: Access to medical facilities, age, and socio-economic status were the most influential and significant factors associated with the two death rates. Resource concentration and the aboriginal index were less important. Conclusions: After controlling for other factors, traffic access to medical resources was an important factor in the crude and accidental death rates for 23 counties in Taiwan, more for the accidental death rate than for the crude death rate.
• 347 - 359
• 10.6288/TJPH2010-29-04-08

• Link 原著 Original Article
• 醫院總額支付制度對住診醫療品質之初步影響The Preliminary Impact of Hospital Global Budgeting on the Quality of Inpatient Care
• 羅紀琼、尤素娟
  Joan C. Lo, Suchuan Yu
• 醫院總額 ； 總額支付 ； 醫療品質
  hospital global budget ; global budgeting ; quality of care
• 目標：本研究旨在探討全民健康保險醫院總額支付對住診醫療品質的初步影響。方法：以迴歸分析的方式探討在控制病患的疾病嚴重度及自主與卓越計畫的參與後，於2002年7月開始實施的醫院總額支付對病患住院30日內死亡機率、出院後30日內再住院機率及感染機率的影響。採用的資料為2000至2004年全民健康保險住院明細及衛生署之死因檔。結果：在醫院總額支付制度實施後，私立地區醫院（參考群）病患的再住院機率顯著減少，感染機率沒有顯著變化，死亡機率則顯著降低。與私立地區醫院比較時，公立及財團法人醫院的再住院機率顯著降低，感染機率顯著增加；醫學中心與區域醫院的再住院機率顯著增加，感染機率顯著降低。公立及區域醫院的死亡率也顯著降低。結論：醫院總額的實施對病患的再住院機率、感染機率與死亡機率在醫院層級及權屬間有不同的影響方向。整體而言，醫療品質有改善態勢。
  Objectives: To investigate the preliminary impact of hospital global budgeting on the quality of inpatient care. Methods: Hospital inpatient claims from 2000 to 2004 and cause of death files were utilized. After adjusting for patients' co-morbid conditions and hospitals' participation in self-control programs, regression analysis was employed to explore the quality of inpatient care as manifested by mortality 30 days after admission, readmission 30 days after discharge and rates of infection. Results: After the implementation of hospital global budgeting, patients in private district hospitals had significantly lower readmission and mortality rates. Compared to patients in private district hospitals, patients in public and not-for-profit hospitals had significantly lower readmission rates but higher infection rates; patients in medical centers and regional hospitals had significantly lower rates of infection but higher readmission rates. Conclusions: The implementation of the hospital global budgeting system by NHI had a differential impact on different types of hospitals with regard to patient readmissions and infection and mortality rates. Generally speaking, the quality of care has improved.
• 360 - 368
• 10.6288/TJPH2010-29-04-09

• Link 原著 Original Article
• 以多重投入產出模型評估台灣地區糖尿病友團體運作成效之區域性差異Performance Effectiveness of community-based Diabetic Groups in Districts of Taiwan
• 賴宜弘、楊雪華、 陳良娟
  Yi-Horng Lai, Hsieh-Hua Yang, Jennifer Chen
• 社區組織 ； 糖尿病 ； 糖化血色素 ； 資料包絡法
  community organization ; diabetes ; A1C ; data envelopment analysis
• 目標：在衛生署國民健康局鼓勵之下，台灣地區糖尿病友團體相繼成立，並委託非營利組織辦理輔導及運作增能計畫，本研究目的為評估這些團體的運作成效，分析各地區成效的差異，並指出各地區應加強的自我照顧項目。方法：採用國健局所設計的「2007年糖尿病友團體重點成效評值表」，以團體為對象，逐項詢問實際執行自我照顧的糖尿病友及高危險群的人數。分析方法採用資料包絡法，以多重投入產出模式評估成效。投入項目為各團體之糖尿病人數及高危險群人數，產出項目包括自我血糖監測、飲食、運動、體重控制、及糖化血色素等；高危險群的產出項目相同，但自我血糖監測改為每年至少一次，且不包括糖化血色素。結果：320個團體中，有效率的團體有57個，大多數病友團體的效率分數在41%到70%之間；糖尿病人應增強的項目是體重控制及飲食，高危險群應增強的項目是血糖監測。結論：糖尿病友團體的運作成效是具體的，且有區域性的差異，而各地區應該強化的自我照顧項目也不相同。
  Objectives: Community-based groups for diabetic patients were initiated by the Bureau of Health Promotion, Department of Health (DOH) in Taiwan. DOH invited an NGO to assist and empower these groups. The aim of this research was to evaluate the performance effectiveness of these community-based groups. Methods: The questionnaire in this study was designed by the Bureau of Health Promotion and distributed to the Bureau of Health in each city and county. These, in turn, asked community-based diabetic groups to complete the questionnaire. The Data Envelopment Analysis model was applied to evaluate performance effectiveness. The input items included the number of diabetic patients and their family members who had adhered to self-management behaviors. The output items included physical activity, healthy eating, body weight control, and blood sugar monitoring. For patients only, glycosylated hemoglobin (A1C) monitoring was done. Results: There were 57 efficient groups out of the 320 community-based groups. The efficiency scores were almost all between 41% and 70%. The self-management behaviors that should be reinforced for diabetic patients were body weight control and healthy eating, while for families with risk factors it was blood sugar monitoring. Conclusions: The evidence for performance effectiveness was robust and there were differences among districts.
• 369 - 378
• 10.6288/TJPH2010-29-04-10