31卷1期

• Link 綜論 Review Article
• 台灣醫療保健支出成長率的分析：醫療通膨，質量與公平性An Analysis of the Growth of Healthcare Expenditure in Taiwan: Healthcare Inflation, Volume-intensity, and Equity
• 文羽苹、黃旭明、江東亮
  Yu-Ping Wen, Shiuh-Ming Huang, Tung-Liang Chiang
• 醫療保健支出 ； 醫療通貨膨脹 ； 人口老化 ； 醫療保健質量 ； 醫療安全差距
  nominal national healthcare expenditures ; healthcare inflation ; aging ; healthcare volume-intensity ; disparity in healthcare security
• 近年來，台灣醫療支出不斷擴張，經濟發展卻幾見負成長，本研究旨在檢視不同因素對醫療保健支出成長率的影響以及不同所得家戶的醫療安全差距變化，以供健保改革政策參考。本研究利用Schieber and Poulier的分解方法，假設名目醫療保健支出受醫療保健物價、人口數量等因素影響，殘值為醫療保健質量。利用健保保障率及受益率兩指標，分析不同所得族群之醫療安全變化；所有原始資料來自政府部門公開統計及家庭收支調查。結果顯示：（1）21世紀以來，名目醫療保健支出年增率4.49%，主要來自醫療通貨膨脹（2.43%）及人口老化（1.68%）；調整人口老化後醫療保健質量的成長幾乎呈現停滯。（2）隨著自付醫療費用增加，全民健保的保障率由68%下降至66%。（3）雖然就健保受益率而言，窮人仍舊受益最多（5.27至5.05倍），但家戶所得越高，健保給付增加越快（2.13至2.33倍），現在貧富之間的醫療安全差距已相對擴大。建議未來政府在推動健保改革時，應重視醫療品質的確保，通貨膨脹的影響以及醫療安全差距擴大的挑戰。（台灣衛誌 2012；31（1）：1－10）
  Taiwan's healthcare expenditures have increased in recent years despite occasional periods of negative growth in national income. This study examined the contributions of price, population, and volume-intensity to the growth of healthcare spending, and the change in healthcare expenditure security across income groups. We followed the method of Schieber and Poulier to break down the growth of nominal national healthcare spending into increases in healthcare prices and population. Volume-intensity was calculated as a residual and was affected by aging of the population. Healthcare expenditure security was defined by the rate of National Health Insurance (NHI) coverage and the benefit-premium ratio, and was compared across income quartiles. All data were based on public government statistics and the Survey of Family Income and Expenditure. Results indicated that: (1) Since the beginning of the 21th century, nominal growth in health care spending has stayed around 4.49% and came mainly from health care inflation (2.43%) and population aging (1.68%). Volume-intensity grew sluggishly. (2) The NHI coverage rate declined from 68 to 66% with an increase in out-of-pocket spending. (3) In terms of the benefit-premium ratio, NHI remained generally pro-poor (5.27 to 5.05 times); however, disparity in healthcare security widened because the NHI benefit-premium ratio increased faster for the rich (2.13 to 2.33 times). We suggest that future NHI reform should focus on quality assurance, the effects of inflation, and equity in healthcare security. (Taiwan J Public Health. 2012; 31(1):1-10)
• 1-10
• 10.6288/TJPH2012-31-01-01

• Link 綜論 Review Article
• 人類安全與亞太經濟合作會議衛生議題之制度發展Human Security and Institutional Development of Asia-Pacific Economic Cooperation Health Issues
• 廖舜右、張照勤
  Shun-Yo Liao, Chao-Chin Chang
• 亞太經濟合作會議 ； 人類安全 ； 衛生任務小組 ； 衛生工作小組 ； 議題聯結
  APEC ; Human security ; Health Task Force ; Health Working Group ; Issue linkage
• 本文以人類安全觀點解釋「亞太經濟合作會議（APEC）」之演變，說明「衛生任務小組（health task force; HTF）透過議題聯結方式結合衛生安全、經濟安全、食物安全，以及緊急應變議題，由臨時編組轉化為「衛生工作小組（health working group; HWG）」正式編制之過程。首先，本文就人類安全概念進行探討，闡述此一概念在後冷戰國際事務之應用與相關實踐。其次，檢視APEC衛生安全議題及HTF之演進，說明該項機制在區域衛生安全合作的主要功能，以及人類安全觀點如何解釋HTF之演變。最後，結合人類安全與APEC衛生安全機制相關討論，評估台灣參與APEC衛生合作機制之可能成效，並提出拓展台灣衛生外交之現階段與中長期具體策略。（台灣衛誌2012；31（1）：11－20）
  This article, inspired by the concept of human security, studies the development of health issues within the framework of Asia-Pacific Economic Cooperation (APEC)by looking at the institutional evolution of the Health Task Force (HTF) from a temporary task force to a permanent Health Working Group (HWG). Issues linking health, economics, food, and emergency preparedness are examined. We discuss the broad concepts of human security and their applications to international affairs. After a review of APEC health issues, the human, security perspective is applied to describe the historical phases of the HTF. This study combines viewpoints from human security and the health regime to evaluate the effectiveness of Taiwan's participation in APEC health issues. Policy suggestions are also provided. (Taiwan J Public Health. 2012; 31(1):11-20)
• 11 - 20
• 10.6288/TJPH2012-31-01-02

• Link 原著 Original Article
• 行動功能指標「日常生活功能」及「工具性日常生活功能」預測台灣老年人跌倒風險之探討Predicting the Risk of Falling Based on ADLs and IADLs in Older Taiwanese
• 鄭秀瑮、蔡仲弘
  Hsiu-Li Cheng, Alan C. Tsai
• 日常生活功能 ； 工具性日常生活功能 ； 跌倒風險 ； 老年人
  ADL (Activities of Daily Living) ; IADL (Instrumental Activities of Daily Living) ; Risk of fall ; Elderly
• 無
  Objectives: To determine the association between functional ability as indicated by ADLs (Activities of Daily Living) and IADLs (Instrumental Activities of Daily Living) and the risk of falling in older Taiwanese. Methods: Data were drawn from the 2003 and 2007 datasets of ”The Survey of Health and Living Status of the Elderly in Taiwan”. Subjects were 3778 participants who completed both surveys. Logistic regression analysis was employed to determine the association of ADL and IADL status with the risk of falling in 2003 and 2007 after controlling for demographic, lifestyle and health-related variables. Results: In cross-sectional analysis, IADLs but not ADLs were significantly associated with the risk of falling during the prior year. Those who had 1-2, 3-4 or 5-6 dependencies in 2007 had 1.49 (1.17-1.89, p<0.001), 1.71 (1.20-2.25, p<0.003) and 2.10 (1.31-3.38, p<0.002) times the risk of falling, respectively, during the previous 12 months when compared to those who had no dependency. Mild (1-2 dependencies) or moderate (3-4 dependencies) ADL dependency was not associated with the risk of falling and severe (5-6 dependencies) ADL impairment was negatively associated with the risk of falling. Longitudinal analysis showed that neither IADLs nor ADLs could predict the risk of falling four years later. Conclusions: Results suggested that IADL but not ADL status predicted the current or near term risk of falling; however, neither was a predictor of the risk four years later. These results highlight the importance of maintaining the functional ability of the elderly through regular exercise, proper nutrition, and routine monitoring of functional status. (Taiwan J Public Health. 2012; 31(1):21-30)
• 21 - 30
• 10.6288/TJPH2012-31-01-03

• Link 原著 Original Article
• 台灣高血壓用藥之問題處方及其影響因素的研究A study on the Inappropriate Prescription of Medications to Treat Hypertension in Taiwan
• 陳世欽、 蔡文正、黃昱瞳、 謝儀靜、黃光華
  Shiu-Ching Chen, Wen-Chen Tsai, Yu-Tung Huang, Yi-Chung Hsieh, Kuang-Hua Huang
• 高血壓 ； 問題處方 ； 重複用藥 ； 交互作用 ； 超量處方
  hypertension (HTN) ; inappropriate prescription ; duplicated medication ; drug-drug interaction ; over-dosage
• 目標：高血壓是心血管疾病的重要危險因子，不僅威脅民眾健康，更是公共衛生重要議題，本研究目的為利用全民健保資料庫分析，瞭解我國高血壓用藥之問題處方，並探討其影響因素。方法：資料來源為「全民健康保險學術研究資料庫」之2005年100萬人承保抽樣歸人檔。本研究分析2004至2008年之申報資料；採用ATC分類系統原則，進行健保藥品之藥理分類；擷取ICD-9-CM前3碼為401至405之高血壓門診個案為研究對象；問題處方分為重複用藥、交互作用及超量處方。結果：2004年至2008年共有161,003位高血壓患者，高血壓門診處方共有3,988,024人次。問題處方方面，重複用藥發生率為2.1%，交互作用高達33.41%，超量處方為12.39%。高血壓問題處方影響因素方面，在「公立及私立醫療機構」、「男性醫師」及「醫師年資越低」等特性之發生率較高。結論：本研究呈現台灣2004至2008年健保高血壓門診問題處方之現況結果，希望提供衛生政策決策者有效的資訊，以制訂用藥相關政策，俾利提升高血壓病患之用藥安全。（台灣衛誌 2012；31（1）：31－42）
  Objectives: Hypertension (HTN) is an important risk factor for cardiovascular disease, and not only is a major health threat for the general population, but is also an important public health issue. Using National Health Insurance (NHI) claims data, this research investigated the inappropriate prescription of medications to treat hypertension under NHI in Taiwan. Methods: The data for 2004 to 2008 were collected from the National Health Insurance Research Database (NHIRD) published by the National Health Research Institutes. The dataset contains information about 1,000,000 beneficiaries randomly sampled from the year 2005 Registry for Beneficiaries of the NHIRD. The NHI Pharmaceutical Subsidy Anatomical Therapeutic Chemical classification system was used to extract the pharmaceutical classification records. The study subjects were identified based on major diagnoses of ICD-9-CM codes 401.xx-405.xx. Inappropriate prescriptions were defined as duplicate medications, drug-drug interactions, or over-dosage. Results: There were 161,003 patients with hypertension and 3,988,024 prescriptions from 2004 to 2008. For inappropriate prescriptions, the frequencies of over-dosage, duplicate medications, and drug-drug interactions were 2.1%, 33.41%, and 12.39%, respectively. The incidence of inappropriate prescriptions was considered high, and most were prescribed by public and private medical facilities, male physicians, and physicians with low seniority. Conclusions: This research demonstrated the inappropriate prescription of medications to treat HTN from 2004 to 2008 under NHI in Taiwan. It may provide useful information for policy-makers to enact relevant policies to ensure prescription safety for HTN patients. (Taiwan J Public Health. 2012; 31(1):31-42)
• 31 - 42
• 10.6288/TJPH2012-31-01-04

• Link 原著 Original Article
• 藍領移工健康問題之初探性研究：以南部某健康服務站的諮詢移工為例Migrant Workers' Health in Southern Taiwan: An Exploratory Study Based on the IACT Health Service Project
• 尤素芬、鄭惠珠、劉浩熏
  Su-Fen You, Huei-Chu Cheng, Hao-Hsung Liao
• 移工 ； 健康諮詢 ； 健康工人效應 ； 台灣國際醫療行動協會
  migrant worker ; health consultation ; healthy worker effect ; IACT
• 目標：台灣在客工政策之下，對於移工的健康管理主要目的在於傳染病管控，然而，藍領移工大都從事所謂三K行業的工作，職災發生率遠高於本國勞工，加上普遍超時工作，故其健康情形值得關注。方法：本研究以台灣國際醫療行動協會在北高雄所執行的健康服務方案為基礎，以歷年累積的諮詢單資料作為主要分析素材，針對菲律賓籍為主的移工族群之健康問題進行初探，並著重全面性健康的社會脈絡分析。結果：本研究發現，楠梓地區移工的血壓有偏高現象，其隱含著移工在身心健康狀況可能也比較有問題。統計值中，教育程度較低、男性、工廠組裝移工的血壓較容易偏高，這可能和移工的工作性質、生活適應及住宿條件等有關。此外，移工在生活適應與權益保障部分，也很欠缺制度性協助與資訊取得管道。結論：移工的健康問題是相當多樣化的，移工健康問題應扣連到移工的勞動社會處境，政府需要正視與回應移工的需求，而職業健康的風險應該納入成為雇主與社會的健康成本。（台灣衛誌 2012；31（1）：43－57）
  Objectives: Because of the guest worker policy in Taiwan, health management for migrant workers focuses on controlling infectious disease rather than protecting the right to health. Many migrant workers in Taiwan are engaged in so-called 3K industries where there are higher occupational injury rates, and they generally work overtime. This study, therefore, explored the extent to which migrant workers suffered from health hazards. Methods: This study was based on the IACT (International Action and Cooperation Team) project concerning health consultation outreach to migrant workers, the majority of whom are Filipinos, in North Kaohsiung. It analyzed the health consultation charts accumulated over almost three years, and focused on the social context of health issues. Results: The migrant workers in this study tended to have higher blood pressure, suggesting that they might also have other physical and mental problems. Workers who were less educated, male, and working in manufacturing plants were liable to have higher blood pressure, and this phenomenon may be related to their working conditions, environmental adaptation, and accommodations. In terms of social well-being as part of the complete meaning of health, migrant workers were short on access to institutional information and assistance. Conclusions: The health issues of migrant workers are diverse and intertwined with their social and working conditions. The government should response to the health needs of migrant workers, and employers and society should bear the cost of dealing with workers’ occupational health risks. (Taiwan J Public Health. 2012; 31(1):43-57)
• 43 - 57
• 10.6288/TJPH2012-31-01-05

• Link 原著 Original Article
• 人口老化趨勢下的健康均等與醫療照護公平性之年齡比較Health Equality and Equity of Healthcare Utilization in Different Age-groups Given the Trend of an Aging Population
• 陳文意、林玉惠、梁亞文
  Wen-Yi Chen, Yu-Hui Lin, Yia-Wun Liang
• 人口老化 ； 偏集中指數 ； 健康不平等 ； 水平不公平
  aging population ; partial concentration index ; health inequality ; horizontal inequity
• 目標：本研究旨在探討人口老化所達「健康均等性」與「醫療照護公平性」之年齡趨勢假說。其中，「健康均等性」之年齡趨勢假說為：人口老化所達健康分佈均等性之年齡趨勢，應呈現所得相關的健康不均度，將隨著年齡增加而逐漸縮小的趨勢。而「醫療照護公平性」之年齡趨勢假說為：人口老化所達醫療照護公平性之年齡趨勢，應隨著年齡的增加，在考量健康分配差異下，所得相關的醫療利用不公平性，將逐漸縮小，並呈現為「扶貧」分配。方法：我們估計健康生產函數與醫療利用函數，並使用其估計係數計算健康偏集中指數與醫療利用偏集中指數。結果：我國的醫療照護系統，在健康均等性的部份無法達到「健康均等性」的年齡趨勢假說，但醫療利用公平性的部份應能符合「醫療照護公平性」的年齡趨勢假說。結論：全民健保的實施達到人口老化之醫療利用公平性的年齡趨勢後，未來的改革應將國民群體間健康分配不平等的議題列為最重要之考量。（台灣衛誌 2012；31（1）：58－70）
  Objectives: The purpose of this study was to investigate two hypotheses about the fairness of healthcare for an aging population. These two hypotheses were (1) the health equality hypothesis, i.e. income-related health inequality should decrease as age increases; (2) the equity of healthcare utilization hypothesis, i.e. given the same health condition, income-related utilization inequity should decrease and tend to be pro-poor as age increases. Methods: We estimated the functions of health production and healthcare utilization, so that these estimates could be used to calculate the partial concentration indices of health and healthcare utilization. Results: Our results indicated that Taiwan's healthcare system failed to meet the standards proposed by the health equality hypothesis, but satisfied the requirements of the equity of healthcare utilization hypothesis for the aging population. Conclusions: Taiwan's healthcare system has reduced the income-related inequity of healthcare utilization due to implementation of National Health Insurance. Healthcare reform should now focus on decreasing health inequality. (Taiwan J Public Health. 2012; 31(1):58-70)
• 58 - 70
• 10.6288/TJPH2012-31-01-06

• Link 原著 Original Article
• 喪偶、休閒活動與中老年婦女身體功能之長期分析Widowhood, Leisure Activity, and Physical Function among Middle-aged and Older Taiwanese Women: Relationships over Time
• 詹帛勳、喬芷
  Bo-Syun Jhan, Chi Chiao
• 中老年婦女 ； 休閒活動 ； 身體功能 ； 喪偶 ； 廣義估計方程式
  middle-aged and older women ; leisure activities ; physical function ; widowhood ; GEE
• 目標：本研究應用壓力過程模式，探討喪偶在中老年婦女的休閒活動與身體功能間長期關係，以進一步瞭解喪偶對台灣中老年婦女是否為負向的生活事件。方法：使用「台灣地區中老年身心社會生活狀況長期追蹤調查」資料庫，以1996年50－66歲的中老年婦女（1,070人）追蹤至2003年的資料為研究對象。考慮樣本重複測量的相依性，多變項迴歸以廣義估計方程式進行分析。結果：研究顯示中老年婦女休閒活動與身體功能間具有正相關。相較於已婚的中老年婦女，喪偶者參與社交性與宗教性休閒活動的比例較高；喪偶者的身體功能並沒有顯著較差。結論：休閒活動的參與會提昇中老年婦女的身體功能，喪偶的中老年婦女可藉由參與休閒活動，減少身體功能障礙的可能性，調適喪偶的衝擊。喪偶對中老年婦女未必是長期負向的生活事件，建議衛生與社會福利相關單位在制定中老年婦女健康政策時，考量在生活事件對中老年婦女衝擊下，休閒活動參與對其身體功能提昇的可能。（台灣衛誌 2012；31（1）：71－82）
  Objectives: In order to explore whether being widowed was a negative life event for older women, we employed the stress process model to examine the associations between widowhood, leisure activities, and physical function among middle-aged and older Taiwanese women. Methods: This study was based on data from the Taiwan Longitudinal Study of Aging (TLSA), a nationally representative sample (n=1,070) of middle-aged and older women aged 50-66, begun in 1996 and with 7-year follow-ups. Generalized linear modeling with GEE estimates was used due to repeated measures. Results: The results showed a significant, positive association between leisure activities and physical function in middle-aged and older women. The widowed women were more likely than married women to participate in social and religiously related leisure activities, and their physical function was not significantly poorer than that of the married women. Conclusions: The findings suggested that participation in leisure activities promoted physical function in the study population. Being widowed was not a negative life event in terms of function for middle-aged and older Taiwanese women. Social welfare and health-related policies that aim to promote well-being should consider participation in leisure activities as an important mechanism through which widows can maintain their physical function. (Taiwan J Public Health. 2012; 31(1):71-82)
• 71 - 82
• 10.6288/TJPH2012-31-01-07

• Link 原著 Original Article
• 年輕女性性工作者危險行為與工作內容及對性病與愛滋病防治政策之建議Risky Behaviors of Young Female Sex Workers and Policy Recommendations for the Prevention of Sexually Transmitted Infections in Taiwan
• 許嘉芳、丁志音、顏慕庸、莊苹、季瑋珠
  Jia-Fang Syu, Chih-Yin Lew-Ting, Muh-Yong Yen, Peing Chuang, Wei-Chu Chie
• 年輕性工作者 ； 性病與愛滋病防治
  young sex workers ; prevention and control of sexually transmitted infections
• 目標：探討年輕女性性工作者進行性交易時，所面臨的實際情況與危險性行為發生的原因，並探討公共衛生政策能夠介入的方向。方法：研究族群以30歲以下的女性性工作者為主，以滾雪球方式邀請，使用質性研究的方式，運用深入訪談收集訪談資料；訪談內容主要在了解年輕女性性工作者在職場危險與性病、愛滋病的關係。訪談內容分析的方式，是根據訪談內容的逐字稿，歸納受訪者共同經驗，訪談時間約90～120分鐘，視情況會二度或是三度訪談。結果：訪談個案總計19人，研究發現受訪的年輕女性性工作者，保護自己免於感染的能力不夠完整與健全。由於年輕女性的社會化不足或教育程度有落差，造成與顧客談判磋商的能力低落。錯誤的自我保護措施與不完整的性觀念，使得年輕女性性工作者，在性行為頻繁的狀況下，罹患性病的機會增加。結論：在性傳染疾病的防治策略上，可選擇減害的思維，建立諮詢站提供諮詢，教導安全性行為觀念以及與顧客磋商的技巧，配合全面篩檢以遏止性傳染疾病的盛行。（台灣衛誌 2012；31（1）：83－94）
  Objectives: This study assessed the actual situations that young female sex workers must face in order to provide policy advice for the prevention and control of sexually transmitted infections. Methods: We conducted tape-recorded in-depth interviews with female sex workers under 30 years of age by snowball sampling. The main content of the interviews included working conditions and the actual use of condoms. We spent about 90 to 120 minutes for the first interview, and extended to second or third interviews if necessary. We analyzed the tape recordings to summarize the common experiences of the participants. Results: A total of 19 young female sex workers participated in this study. We found that the participants had little ability to avoid sexually transmitted infections. They had inadequate socialization skills and minimal knowledge obtained from school; therefore, they had little ability to negotiate with their customers. Incorrect measures of self-protection further increased their opportunity to get infected. Conclusions: We recommend a preventive strategy of harm reduction by establishing a peer-consultation model to deliver correct knowledge and bargaining skills, combined with passive, comprehensive screening to help young sex workers prevent and detect sexually transmitted infections. (Taiwan J Public Health. 2012; 31(1):83-94)
• 83 - 94
• 10.6288/TJPH2012-31-01-08

• Link 評論 Commentary
• 評論：年輕女性性工作者危險行為與工作內容及對性病與愛滋病防治政策之建議Commentary: Risky Behaviors of Young Female Sex Workers and Policy Recommendations for the Prevention of Sexually Transmitted Infections in Taiwan
• 楊靖慧
  Chin-Hui Yang
• 無
  none
• 無
  none
• 95 - 95
• 10.6288/TJPH2012-31-01-09

• Link 評論 Commentary
• 作者回覆：年輕女性性工作者危險行為與工作內容及對性病與愛滋病防治政策之建議Response: Risky Behaviors of Young Female Sex Workers and Policy Recommendations for the Prevention of Sexually Transmitted Infections in Taiwan
• 許嘉芳、丁志音、顏慕庸、莊苹、季瑋珠
  Jia-Fang Syu, Chih-Yin Lew-Ting, Muh-Yong Yen, Peing Chuang, Wei-Chu Chie
• 無
  none
• 無
  none
• 96 - 96
• 10.6288/TJPH2012-31-01-10