30卷1期

• Link 公衛論壇 Public Health Forum
• 全民健保向論人支付邁進全民健保向論人支付邁進
• 鄭守夏
  Shou-Hsia Cheng
• 無
  none
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• 1-4
• 10.6288/TJPH2011-30-01-01

• Link 原著 Original Article
• 雇主對精神障礙者就業之看法與聘用意願：現況、問題與政策因應Attitudes of Employers toward People with Mental Illness: Conditions and Problems with the Employment Policy for the Disabled in Taiwan
• 張鳳航、張珏、鄭雅文
  Feng-Hang Chang, Chueh Chang, Ya-Wen Cheng
• 精神障礙者 ； 雇主 ； 就業政策
  mental illness ; employment ; policy intervention
• 目標：本研究旨在了解雇主對於精神障礙者就業的看法與聘用意願，並探討相關政策和服務之現況與問題，以做為政策因應建議之參考。方法：研究以立意取樣，深度訪談13位一般性企業或機構的雇主（7位目前有僱用精障者，3位曾雇用過精障者，3位未僱用精障者）。訪談內容皆騰為逐字稿，進行登錄、分類與分析。結果：儘管13位雇主都認同精神障礙者之工作權，但多數雇主仍因對精障者的症狀和工作能力感到疑懼而缺乏聘僱意願，或因精障者的症狀和表現限制其工作類型。在就業相關政策部份，我們也發現：1)雇主普遍不清楚相關就業政策及法規；2)政府罰鍰及獎勵補助金對於提升精神障礙者之就業效果有限；3)雇主對精神疾病缺乏正確知識；及4)就業服務員的素質不一。結論：就訪談結果，我們除提出對政府建議的雛議外，也建議未來量性調查雇主意願及影響因素。雛議包括應加強就業服務人力、提升服務內涵、調整經濟誘因、相關就業政策與法令宣導，並加強去除烙印的社會教育。
  Objectives: The aims of this study were to explore employers' perceptions of people with mental illness, and to understand their attitudes and concerns about the employment policy for the disabled in Taiwan. Methods: In-depth interviews with 13 employers (including 7 employers who hired people with mental illness, and 6 who did not) were conducted. Responses were audio taped, transcribed, and coded. All the data were synthesized and interpreted. Results: Despite the fact that all employers agreed that people with mental illness had the same right to work as did normal people, over half were not willing to hire them because of concerns about their symptoms and work competencies. With regard to the employment policy, we found: 1) most employers were not aware of the employment policy; 2) the economic incentives seemed weak to employers; 3) most employers had insufficient knowledge about mental illness; 4) the quality of job coaches and employment support services was low. Conclusions: In order to increase employers' willingness to hire people with mental illness, the government should strengthen the support system for both employers and employees. Efforts should also be made to improve the quality of employment support services, adjust the economic incentives, increase awareness of the employment policy, and enhance knowledge and acceptance with regard to mental illness.
• 5-18
• 10.6288/TJPH2011-30-01-02

• 評論 Commentary
• 評論：雇主對精神障礙者就業之看法與聘用意願：現況、問題與政策因應Commentary:Attitudes of Employers toward People with Mental Illness: Conditions and Problems with the Employment Policy for the Disabled in Taiwan
• 蔡欣玲
  Sing-Ling Tsai
• 無
  none
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• 評論 Commentary
• 作者回覆：雇主對精神障礙者就業之看法與聘用意願：現況、問題與政策因應Author's response to Commentary:Attitudes of Employers toward People with Mental Illness: Conditions and Problems with the Employment Policy for the Disabled in Taiwan
• 張鳳航、張珏、鄭雅文
  Feng-Hang Chang, Chueh Chang, Ya-Wen Cheng
• 無
  none
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• 無none

• Link 原著 Original Article
• 糖尿病照護成效與影響因素之探討：以台東某區域醫院糖尿病共同照護網為例The Outcomes and Factors Associated with Diabetes Care: The Diabetes Shared Care Program in a Regional Hospital in Taitung, Taiwan
• 黃憶玫、張慈桂
  Yi-Mei Huang, Tzu-Kuei Chang
• 台東地區 ； 糖尿病 ； 共同照護網 ； 糖化血色素
   Taitung area ; Diabetes mellitus ; diabetes shared care program ; HbA1c
• 無
  Objectives: The aim of this study was to assess 3-year outcomes and factors associated with those outcomes in type 2 diabetic patients who joined the diabetes shared-care program in Taitung, Taiwan. Methods: 242 type ? diabetic patients in a Taitung regional hospital were enrolled in this study and completed 4 follow-up measures. The principal measure was the patient's mean HbA1c at baseline and at each annual follow-up. A logistic regression model was used to examine the factors associated with poor glycemic control. Results: (1) The mean HbA1c level showed the greatest reduction in the first follow-up year. The level gradually increased over time (the mean values for HbA1c at baseline, 1(superscript st), 2(superscript nd), and 3(superscript rd) years were 9.12%, 7.93%, 8.20%, and 8.27% respectively, p<0.05); however, the 3(superscript rd) year level of HbA1c was still a significant improvement over baseline. (2) Age<65, aborigines, a higher HbA1c level at baseline, a longer duration of illness, and higher doses of medication were significantly associated with poor glycemic control. Conclusions: Our study demonstrated the long-term efficacy of a diabetes shared- care program in HbA1c control. Age, ethnicity, initial HbA1c level, duration of illness, and medication used were significantly associated with poor diabetes control. It would be helpful in improving the quality of diabetes-care among the Taitung population if case management were combined with community resources.
• 19 - 28
• 10.6288/TJPH2011-30-01-03

• Link 原著 Original Article
• 衛生傳播中的醫療行銷－醫師的記者會對其門診量之影響Medical Marketing in Health Communication: The Impact of Physicians' Press Conferences on the Number of Outpatients
• 張耀懋、張秀惠、謝敏青、許怡欣
  Yao-Mao Chang, Hsiu-Hui Chang, Min-Ching Hsieh, Yi-Hsin Elsa Hsu
• 醫療行銷 ； 新聞行銷 ； 門診量 ； 報紙 ； 記者會
  medical marketing ; news marketing ; outpatient amount ; newspaper ; press conference
• 目標：現代經營醫療機構除要講究醫療專業與服務品質外，尚須結合行銷觀念以建立正面形象與知名度。本研究旨在探討記者發表會的操作對醫師門診量之影響以及其效果之持續性。方法：本研究整合2002年至2003年台灣某知名診所召開記者會與門診資料人數資料。結果：部分科別醫師召開記者會與當科別醫師的門診量呈正相關，且持續一段時間。結論：召開記者會的行銷活動有助於門診病患人數之增加。
  Objectives: The aims of this study were to understand the effect of press conferences on the number of new outpatients for medical clinics or physicians and to determine what particular medical news was correlated with the number of new outpatients for specific clinic divisions and physicians. Methods: Data were collected from a clinic in Taipei during the period from 2002 to 2003. Results: The results indicated that the impact of press conferences on the number of new outpatients was positive and persistent. Conclusions: Calling press conferences as a marketing device contributed to the increase in the number of new outpatients.
• 29 - 35
• 10.6288/TJPH2011-30-01-04

• Link 原著 Original Article
• 台灣中老年男性戒菸因素之探討Predictors of Smoking Cessation among Older Male Smokers in Taiwan
• 林芸安、蔡仲弘
  Yun-Ann Lin, Alan C. Tsai
• 戒菸 ； 中老年 ； 行動功能 ； 預測因子
  Smoking cessation ; Older adults ; Functional activity ; Predictor
• 目標：吸菸是影響人類健康的最主要危險行為之一。然而至今為止，台灣中老年人之戒菸行為及其相關因素之探討不多。故本研究之目的在探討台灣中老年男性戒菸的預測因子。方法：本研究之資料來源為國民健康局的「台灣地區中老年身心社會生活健康狀況長期追蹤調查研究」。以其補充樣本（50~66歲）2,462人中，於1996年吸菸的男性673人中，2003年完成訪談，且資料完整者502人為分析對象。以邏吉斯迴歸分析其隨後7年間停止吸菸的預測因子。結果：本研究發現，日常生活活動功能(ADL)變差及首次住院，為台灣中老年男性吸菸者戒菸的主要預測因子。只罹患重大慢性疾病如糖尿病、高血壓、心臟病等，仍不足以預測戒菸。此外，較高齡及有婚姻伴侶與戒菸行為呈正關聯，而高菸齡及高吸菸量與戒菸行為呈負關聯。結論：本研究為國內首次以長期追蹤調查資料探討中老年人戒菸的預測因子。結果顯示擔心健康(health concern)為戒菸的主要動機，而行動功能惡化或重大健康事故如住院為中老年男性戒菸的主要 預測因子。本研究的結果可供有關單位研擬台灣中老年人有效戒菸介入政策之參考。
  Objectives: Smoking is a major risk factor for several diseases; however, the predictors of smoking cessation in older male Taiwanese have not been studied very well. The objective of this study was to determine these predictors. Methods: The study analyzed the 1996 and 2003 databases of the ”Survey of Health and Living Status of the Elderly in Taiwan”. Subjects were 673 50 to 66 year-old male smokers sampled in the second cohort (2462 persons) in 1996. Logistic regression analysis was performed to determine the associations among socio-demographic, lifestyle and health-related variables and the changes in these variables which occurred between baseline and the endpoint (2003) of the study for those who stopped smoking. Results: The study found that physical functional decline was the major predictor of smoking cessation. Major medical events such as a first hospitalization were also associated with an increased likelihood of smoking cessation; however, the new diagnosis of a major chronic disease such heart disease, diabetes or hypertension was not. The study also found that older age and being married were associated with an increased likelihood of smoking cessation, whereas a longer smoking history and greater daily cigarette consumption were associated with a reduced likelihood of stopping. Conclusions: Results suggested that concerns over health particularly a major medical event such as functional impairment or a first hospitalization were the major predictors of smoking cessation in older male Taiwanese smokers. These findings may be useful for public health planners in designing more effective smoking cessation programs.
• 36 - 44
• 10.6288/TJPH2011-30-01-05

• Link 原著 Original Article
• 提升國中生乳製品攝取營養教育課程設計及成效評估Design and Evaluation of a Dairy Products Nutrition Education Program for Adolescents
• 林薇、杭極敏、鄭惠文
  Wei Lin, Chi-Ming Hang, Hui-Wen Cheng
• 乳製品 ； 乳鈣攝取 ； 國中生 ； 飲食行為 ； 營養教育
  dairy products ; dairy calcium intake ; adolescent ; eating behavior ; nutrition education
• 目標：本研究主要目的是發展提升國中生乳製品攝取教育課程，並評估其成效。方法：整合健康信念模式(Health Belief Model)、計畫行為理論(Theory of planned behavior)及社會認知理論(Social cognitive theory)之重要概念，發展之乳製品教育介入課程包括五個單元（每單元45分鐘）的課堂教學，以及兩份家長簡訊，選擇台灣地區城市型、鄉村型、山地型及離島型的國民中學各二所，394位八年級學生為成效評估研究對象。研究設計分兩組，實驗組(N=189)實施每週一單元課堂教學，並發家長簡訊；控制組(N=205)則無任何相關的營養教育活動。在介入前、後一週，分別對兩組學生進行前測及後測評量。結果：研究結果顯示，實驗組學生在接受五次課程介入後，其乳製品相關營養知識、行為結果態度、主觀規範、自我效能、行為改變階段、攝取行為及乳鈣攝取量皆顯著改善，且對於城市、鄉村、山地及離島四種地區學生皆有成效，只是在某些層面對於山地地區學生之成效低於其他地區。結論：本研究課程設計除教授健康有關知識外，尚注重增加與選食乳製品行為能力有關之知識和技能；藉品嚐降低行為障礙（口味不好）；結果顯示這種設計確實達到提升乳製品攝取立即的成效。但由於對山地地區成效低於其他地區，而此地區學生鈣質攝取又低於其他地區，顯示需要針對此族群之鈣質攝取改善作深入探討與設計。
  Objectives: The purpose of this study was to design and evaluate a dairy calcium intake nutrition education program which was developed based on important constructs in the Health Belief Model, the Theory of Planned Behavior, and Social Cognitive Theory. Methods: A total of 394 eighth graders from four area middle schools in Taiwan participated in the study. The intervention group (N=120) received a dairy calcium intake nutrition education program which included five 45-min classroom sessions and 2 newsletters for parents. The control group (N=112) received no nutrition education program. The outcomes of intervention were measured by questionnaires administered one week before (pre-test) and after (post-test) the intervention. Results: The results indicated that the intervention group knowledge about dairy products, subjective norms, self-efficacy, behaviors, stage of change, and dairy calcium intake improved (p<.01) on post-test in 4 areas with different degrees of urbanization. Conclusions: The dairy calcium intake nutrition education program which included not only the teaching of health-related knowledge, but also activities to increase behavioral capability and decrease behavioral barriers was found to be effective immediately after the intervention. The program was less effective for students in an aboriginal area and they also consumed less calcium when compared to students in other areas; therefore, we suggest further studies focused on aboriginal areas, as well as studies of the longer term effects of the intervention.
• 45 - 57
• 10.6288/TJPH2011-30-01-06

• Link 原著 Original Article
• 台灣地區老人教育程度差異對死亡率影響探討The Effect of Educational Differentials on Mortality of the Elderly in Taiwan
• 林正祥、鄭維芬
  Cheng-Hsiang Lin, Wei-Fen Cheng
• 教育 ； 老人保健與生活問題調查 ； 存活狀況 ； 脆弱Cox比例風險模式
  education ; survey of health and living status of the elderly ; survival status ; Coxfrailty proportional hazard model
• 目標：探討教育程度差異對台灣老人死亡率的影響。方法：採用前衛生署家庭計畫研究所起始於1989年5次「台灣地區老人保健與生活問題調查」實際訪察4,049個案為研究對象，排除與教育無關的死亡案例，蒐集其與死亡率相關之變數，並考慮可能存在模式中未能辨識的干擾因子，以脆弱Cox比例風險存活模式探討教育程度差異與死亡率間的關係。本研究以外在因子（教育及相關人口變數）等變數建構模式一，其他三個模式則分別為模式一加上一個、二個或三個中介因子（健康狀況、健康行為及社會參與），故模式四則為包含外在因子及三個中介因子，藉此探討教育對死亡率的間接影響。結果：在未考慮三個中介因子之情形下，教育程度較高者死亡風險較低，受教育每增加一年，死亡風險下降13.7%。另一方面，在模型中加入和健康因子相關的變數會使教育對死亡率的影響不顯著，惟每增加一年教育，死亡風險下降6.1%。結論：教育對死亡率之影響係其藉由健康狀況、健康行為及社會參與等相關變數，其中又以健康狀況因子之影響為最。另外，不論是否考慮健康相關因子，本研究中人口相關變數均與老人死亡率有密切關係。
  Objectives: To study the effect of educational differentials on mortality of the elderly in Taiwan. Methods: Our research uses five waves of surveys of health and living status of the elderly conducted from 1989-2003 in Taiwan to investigate the trend of effect of education on elderly mortality. Exogenous factors (education and other demographic characteristics) were included in Model 1. The other 3 models are with each adding one, two or three mediating factors (health status, health behaviors and social relationships) from Model 1. Both exogenous and mediating factors were included in Model 4. The 4 models present information of the decomposition of the effect of education on the mortality of older Taiwanese from 1989 to 2003. This study exclude those death cases due to accident which is not related to education and adopt Cox-frailty proportional hazard model which accounts for heterogeneity caused by some other unidentified factors related to the effect of social dynamic on old-age mortality. Results: Without considering the three mediate factors, there is a 13.7% reduction on mortality pre year education increased. On the other hand, it turns out the effect of education on the mortality is insignificant when the three mediate factors are included in the model. The hazard ratio reduced 6.1% on mortality with a 1-year increase in education. Conclusions: The effect of education on the mortality of the elderly is by means of the 3 mediating factors, particularly health status. Besides, no matter health related factors are in the model or not, demographics characteristics show strong relationship with the mortality of the elderly.
• 58 - 71
• 10.6288/TJPH2011-30-01-07

• Link 原著 Original Article
• 第二類型糖尿病人之身體活動建議量初探A Preliminary Study of Recommendations for Physical Activity for Patients with Type 2 Diabetes
• 徐錦興、曹德弘、張蕙雯
  Chin-Hsing Hsu, Te-Hsung Tsao, Hui-Wen Chang
• 身體活動 ； 糖化血色素 ； 走路時間 ； 劑量反應關係
  physical activity ; glycated hemoglobin ; walking time ; dose-response relationship
• 目標：本研究目的在探討糖尿病人身體活動量與病情控制的關係，並運用劑量反應關係解釋研究結果，以提供糖尿病照護上對身體活動的建議量。方法：研究採橫斷性調查設計，初期招募220名糖尿病人為預備受試對象。研究工具為國際身體活動量表；以12個月為期，對所有受試對象進行身體活動量前後調查。在確認一年間維持同一生活型態的前提下，選擇210位為正式受試對象，再依糖化血色素控制情形分為控制良好與控制不良組。身體活動資料並與生理及血液生化檢測值進行羅吉斯迴歸分析。結果：不同生活型態的糖尿病人在血糖與糖化血色素控制上，其劑量反應關係圖形皆呈“反J”曲線，顯示中度與高度身體活動之糖尿病人的病情控制顯著優於低度身體活動者。糖化血色素控制良好組平均每天步行時間為37分鐘、控制不良組為28分鐘；其勝算比值為1.26。結論：建議糖尿病人可用「走路」為提高身體活動量的主要模式，頻率為每週6天、每天至少37分鐘，在病情控制上較易得到顯著成效。
  Objectives: The aims of this study were to investigate the association between physical activity and the status of diabetes mellitus control and to provide recommendations for physical activity for patients with type 2 diabetes. Methods: In this cross-sectional study, 220 patients were recruited in the initial phase. The International Physical Activity Questionnaire was used to determine the level of physical activity for each subject. The study was carried out over 12 months with a pretest/posttest design to determine if patients still maintained the same lifestyle; 210 patients met this criterion. These subjects were then divided into two groups based on their glycated hemoglobin (HbA1c) control: an HbA1c under-control group and an out-of-control group. Logistic regression analysis was used to estimate relationships among subjects' physical activity, physiological measures, and blood biochemical parameters on the posttest. Results: The results indicated that there was an inverse-J shape relationship between lifestyle and blood glucose/HbA1c. This demonstrated that moderate/vigorous physical activity might play an important role in the treatment of type 2 diabetes. The average duration of walking time/per day was 37 min in the HbA1c under-control group, while only 28 minutes in the HbA1c out-of-control group; the odds ratio was 1.26. Conclusions: We suggest that an appropriate physical activity for patients with type 2 diabetes is walking, 6 days/week, at least 37 min per day. This produced significant effects in HbA1c control.
• 72 - 81
• 10.6288/TJPH2011-30-01-08

• Link 原著 Original Article
• 利用體外試驗研究探討短期臭氧暴露之揮發性有機物質變化An in vitro Study of short-term Ozone Exposure Induced Volatile Organic Compounds
• 胡佩儀、 馬一中
  Pei-Yei Hu, Yee-Chung Ma
• 臭氧暴露 ； 人類肺部細胞 ； 揮發性有機物 ； 氣相層析質譜儀
  Ozone exposure ; MRC-5 ; VOCs ; GC/MS
• 目標：探討人類肺部細胞MRC-5在不同濃度、時間暴露之臭氧衝擊式系統下，藉由產生揮發性有機物質(Volatile organic compounds, VOCs)之種類及含量變化，間接從細胞脂質過氧化了解氧化壓力程度。為確認VOCs為臭氧與細胞膜上不飽和脂肪酸PUFA (Polyunsaturated fatty acids)所反應物質，再進行臭氧暴露至PUFA (Arachidonic Acid, AA; Linoleic Acid, LA)。方法：在細胞部分，暴露時間為30分鐘，臭氧濃度範圍在0.1至2ppm，暴露後觀察時間為30，60，120分鐘。10ppm PUFA暴露至1ppm臭氧30分鐘後，以採樣管進行收集，再以氣相層析質譜儀分析。結果：比較臭氧與空氣暴露之收集氣體並分析後，有18種物質在兩組間達統計上顯著差異。其中以methyl cyclopentane物質為最，不論是在高或低濃度臭氧暴露皆達顯著差異。3-methyl-butanal在暴露30分鐘於高濃度臭氧暴露下有顯著；carbon disulfide及dimethyl disulfide兩者暴露臭氧1.5ppm 30分鐘後亦有顯著。此外，暴露空氣與臭氧至PUFA （AA及LA），結果顯示暴露至AA有顯著差異為2-methyl-1-propene，而LA則為pentane。結論：利用體外試驗之臭氧暴露系統所得到有顯著差異之VOCs物質，可做為臭氧暴露後氧化壓力之生物標誌。
  Objectives: The aim of this study was to evaluate the impinger in vitro exposure system used to investigate ozone exposure induced oxidative stress. Comparisons of Volatile Organic Compounds (VOCs) levels in collected gas and MRC-5 cell membrane integrity were made after ozone exposure. In order to validate the source of the VOCs, the reactions of ozone with two polyunsaturated fatty acids (PUFA); Arachidonic Acid (AA) and Linoleic Acid (LA) were also determined. Methods: MRC-5 cells were treated with air and ozone concentrations ranging from 0.1 to 2 ppm for 30 min, and VOCs were collected during and after ozone exposure at 30, 60, 90, and 120 min intervals. PUFAs 10 ppm were exposed to 1 ppm ozone for 30 min. Sampling tubes were used to collect the reacting gas after ozone exposure on human lung cells or PUFAs and these were then analyzed by GC/MS. Results: When the VOCs from air and ozone exposure in MRC-5 cells were compared at different time points, 18 compounds were found to be significantly different. The methyl cyclopentane level increased acutely after oxidative stress to lung tissue. 3-methyl butanal was significantly associated with a high ozone level; carbon disulfide and dimethyl disulfide increased immediately following ozone exposure at 1.5 ppm for 30 min. 2-butanal and methyl cyclopentane were significant different after exposure to ozone 2 ppm as measured by the Tukey HSD test. 2-methyl-1-propene and pentane were also significantly different in the reactive gases of AA and LA after ozone exposure. Conclusions: VOCs may be significant markers of oxidative stress after the human lung cell is exposed to ozone in the impinger exposure system.
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• 10.6288/TJPH2011-30-01-09