27卷4期

• Link 綜論 Review Article
• 職場健康促進：國際與台灣經驗之比較Health Promotion in the Workplace: Comparison of the Experiences of Taiwan and Other Countries
• 范國棟、李蘭
  Kuo-Tung Fan, Lee-Lan Yen
• 員工 ； 充權 ； 健康促進 ； 安全衛生 ； 工作場所
  employee ; empowerment ; health promotion ; safety and health ; workplace
• 職場健康促進計畫是以職場員工為主要介入對象，透過充權過程凝聚員工們的集體意識，並提升其自覺與自決之能力，進而達到促進健康之目標，其具體作為異於傳統的職業安全衛生。近年來，職場健康促進的理論思維與介入計畫雖受到國內學官產界的重視與推廣，但是在實際規劃與執行職場健康促進計畫時，仍不免流於「由上而下」與個人層次行為改變的傳統巢臼。由於職場健康促進的概念興起與國際經驗，以及其與傳統職業安全衛生的關聯性鮮少被深入探討，故本文透過文獻回顧與整理，並比較國際與台灣經驗的成效與缺失，期能提供相關單位及人員未來在訂定政策與研擬介入計畫時之參考。
  Workplace health-promotion intervention programs focus on employees as agents of change. In this way, they differ in practice from traditional occupational safety and health initiatives. The goal of health promotion is achieved by empowering workers as a group to attain higher levels of self-awareness and self-determination. In Taiwan, academia, government, and industry have considered and disseminated the concepts and specific techniques of workplace health promotion in recent years. Nevertheless, the design and practice of workplace health-promotion programs in Taiwan are still limited to the traditional top-down model and a focus on changing individual behavior. International experiences with workplace health promotion and its relationship to traditional occupational safety and health have seldom been explored in depth in Taiwan. In this article, we review the literature and compare the experiences of Taiwan and other countries in an effort to facilitate future policy-making and design of workplace health-promotion intervention programs.
• 271 - 281
• 10.6288/TJPH2008-27-04-01

• Link 綜論 Review Article
• 笑與健康研究的回顧：中西方觀點Cultural Perspectives on Laughter and Health
• 張珏、徐欣萍
  Chueh Chang, Hsin-Ping Hsu
• 笑 ； 健康 ； 正向心理健康
  laughter ; health ; positive mental health
• 本文以近年來中西方針對「笑」所進行的相關研究與探討觀點進行簡要回顧：首先針對「笑」的定義與種類進行說明，其次以國內外針對笑與健康的研究進行探討，同時再統整以往研究的發現與缺失，以提供未來對此議題感興趣的研究者之參考。國外研究發現：「笑」對人體的免疫功能、疼痛忍受度、內分泌、神經系統等諸多重要生理指標都能產生正向改變，認為「笑」有益於健康；然而在傳統的中醫學觀點卻認為「笑」會損精耗氣，自古醫書多認為「笑」有礙養生，直到二十世紀初才有醫者對「笑」採取較正向的評價，但依然提醒民眾應要量力而為，不可過度。由國語辭典中也反映出我國對「笑」的定義採取較廣義的討論，不若西方僅以正向的角度看待，而是包含有動作與情緒間的關係，以及正負向並存的意涵，中西方截然不同的觀點論述與發現，對於未來有興趣探討笑與健康的研究者，本文應能提供多元層面的思考與建議，此外「笑」與「正向心理健康」的開展與研究也可以相呼應。
  A review was conducted of recent scientific research results, both international and regional, on the relationship between laughter and health. The findings revealed conceptual differences due to variations in cultural traditions. The Western studies indicated that laughter could strengthen the immune system, enhance metabolic functions, reduce stress, and increase tolerance for pain. In contrast, studies based on traditional Chinese medicine indicated that laughter could be detrimental to physical and mental balance. These differences are also found in the definitions of ”laughter” in the different cultures. In the West, the definition of laughter is entirely positive. The Chinese definition, however, refers to both positive and negative relationships between emotion and action. It was not until the 20th century that the Taiwanese began to have more positive attitudes toward laughter, although still with a reminder to not ”overdo it.” More research is needed on these drastically different opinions about laughter to shed light on the influence of cultural perspectives. The relationship between laughter and mental health should be further explored.
• 282 - 291
• 10.6288/TJPH2008-27-04-02

• Link 綜論 Review Article
• 醫療市場競爭的測量：從市場劃區與競爭指標著手Measuring Competition in the Health Care Market: Starting with Market Area Definition and Competition Indicators
• 陳啟禎、 鄭守夏
  Chi-Chen Chen, Shou-Hsia Cheng
• 市場 ； 競爭指標 ； 醫院
  market ; competition indicators ; hospital
• 過去有大量研究探討市場競爭對醫院行為的影響，但結論卻不甚一致，而市場競爭程度的測量為主要的因素之一，其中造成差異的來源包括市場範圍的界定與競爭指標的選取。本文回顧市場範圍界定在概念上和方法學上的演進、競爭指標的發展，以及上述兩者在實證研究上的應用情形。綜合來說，在市場區域劃分方式上，研究者應該針對不同的研究目的選定適當的市場劃區方式；在市場競爭指標方面，靜態市場競爭指標如醫院家數或賀芬達指標最常被使用，然而在探討競爭對醫院行為影響時，應該考量其適用性。
  Extensive empirical literature has examined the impact of competition on hospital behaviors; however, findings were inconclusive. One of the major reasons concerns the measure of competition, primarily resulting from market area definitions and the competition indicator selection. This study reviews the conceptual and methodological evolution of market area definitions, development of competition indicators, and their empirical applications. In conclusion, hospital market areas should be defined according to particular research issues. Static competition indicators, such as the number of hospitals or the Herfindahl-Hirschman Index (HHI) have been commonly employed in previous studies. The appropriateness of these indicators should be considered, especially for studies examining the impact of competition on hospital behaviors.
• 292 - 300
• 10.6288/TJPH2008-27-04-03

• Link 原著 Original Article
• 不同超長住院定義對急性住院病患之影響Implication of Different Definitions of Overstay for Acute Inpatients
• 葉馨婷、吳肖琪
  Shin-Ting Yeh, Shiao-Chi Wu
• 超長住院 ； 住院日數 ； 診斷關聯群 ； 風險校正
  overstay ; length of stay ; DRGs ; risk adjustment
• 目標：針對急性病患，探討不同超長住院定義下超長住院之情形。方法：以台灣地區2000年全民健保申報急性住院病患為對象，依超過住院日數30日、25日、90百分位、DRGs校正法及迴歸風險校正法定義超長住院；DRGs校正法及迴歸風險校正法皆是以校正後偏離常態分佈1.285個標準差（90百分位）定義超長住院，而迴歸風險校正法除校正病患疾病組合，亦校正病患性別及年齡。結果：超長住院率以超過30日定義為2.41%，超過25日定義為3.65%，超過住院日數90百分位定義為9.49%，以DRGs校正法定義為10.13%，以迴歸風險校正法定義為8.49%。各評鑑層級別醫院、公私立別醫院或不同科別之病患經由DRGs及迴歸風險校正法所計算出的超長住院率，均較傳統上超過30日或25日定義之超長住院率為高，顯示急性病患實際超長之住院情形嚴重。結論：將DRGs校正、或迴歸風險校正納入超長住院定義中有其重要性；DRGs校正或迴歸風險校正法能呈現病患超長住院的真實情形，建議健保局及醫院管理者可據以訂定可以改善超長住院的措施、提高急性病床之利用。
  Objectives: To investigate the condition of overstay in acute inpatients under the different definitions of overstay. Methods: The subjects were acute inpatients from the Taiwan National Health Insurance (NHI) databases in 2000. The five different definitions of overstay are: 1) over 30 hospital days, 2) over 25 hospital days, 3) over 90 percentile of hospital days, 4) over DRGs adjusted, and 5) over regression risk adjusted days of hospitalization. The DRGs adjusted and regression risk adjusted overstay are defined as being over the 1.285 standard deviation and standardized residual of normal distribution. Regression risk adjusted patients' case mix, age and sex. Results: According to the different definitions of overstay, the rate of overstay is 2.41% as defined by over 30 days, 3.65% as defined by over 25 days, 9.49% as defined by over 90 percentile of hospital days, 10.13% as defined by the DRGs adjusted method and 8.49% as defined by the regression risk adjusted method, respectively. The rate of overstay as defined by the DRGs and regression risk adjusted method is significantly higher than the traditional definition (over 30 or 25 days) used in different departments and levels of hospitals. It exposes the serious nature of overstay in acute patients. Conclusions: It is important to calculate overstay using the DRGs adjusted or regression risk adjusted methods. These adjusted methods could reveal the actuality of overstay for the administrators of NHI and hospitals, which could be applied to policy that would eliminate the problem of overstay and increase the utility of hospital beds for acute patients.
• 301 - 308
• 10.6288/TJPH2008-27-04-04

• Link 原著 Original Article
• 應用SERVQUAL量表建構中醫醫療服務品質指標Applying the SERVQUAL Questionnaire to Establish Quality Indicators for Chinese Medicine
• 蔡文正、龔佩珍、 翁瑞宏、張永賢、李思儀
  Wen-Chen Tsai, Pei-Tseng Kung, Rhay-Hung Weng, Yung-Hsien Chang, Szu-Yi Lee
• 中醫 ； 醫療服務品質 ； SERVQUAL量表 ； 分析層級程序法 ； 驗證性因素分析 ；
  Chinese Medicine ; Health Care Service Quality ; SERVQUAL Questionnaire ; Analytic Hierarchy Process ; Confirmatory Factor Analysis
• 目標：為確保總額支付制度實施後之中醫醫療服務品質，建立中醫院所的醫療品質指標有其必要性。本研究欲應用SERVQUAL量表來建立中醫醫療服務品質評估指標。方法：先以專家座談方式，建立中醫醫療服務品質指標項目，再以分析層級程序法對於所建立之構面與指標給予不同的重要性權重，以區分指標間之重要性，之後再以全國910位中醫病患問卷結果進行驗證性因素分析，以檢驗品質指標的建構效度。結果：共訂定五個評估構面共22項指標，其中「有形性構面」5項、「可靠性構面」4項、「回應性構面」5項、「保證性構面」4項、「同理心構面」4項。各構面的相對權重如下：「有形性構面」為0.122、「可靠性構面」為0.354、「回應性構面」為0.145、「保證性構面」為0.238、「同理心構面」為0.141。驗證性因素分析結果亦顯示，本研究所訂定之品質指標的鑑別效度與收斂效度皆屬良好。結論：本研究所建構之指標可作為醫務管理者進行中醫醫療服務品質評估或研究時的重要參考。
  Objectives: In order to assure quality health care after the implementation of global budgeting payments at our institutions, it was necessary to establish quality indicators for Chinese medicine services. The SERVQUAL questionnaire was used to build a set of Chinese medicine service quality indicators. Methods: The expert panel method was applied to build up the appropriate indictors for Chinese medicine service quality, and the analytic hierarchy process was employed to establish the importance of each dimension or indicator. Further, for testing the construct validity of quality indicators, we adopted confirmatory factor analysis (CFA) to analyze the questionnaires of 910 Chinese medicine outpatients. Results: The result of this research has set 5 dimensions and 22 indicators that include 5 tangible indicators, 4 reliability indicators, 5 responsiveness indicators, 4 assurance indicators and 4 empathy indicators. The weight for each dimension is the following: 0.122 for the tangible aspect, 0.354 for the reliability aspect, 0.145 for the responsiveness aspect, 0.238 for the assurance aspect and 0.141 for the empathy aspect. In addition, the CFA indicated that convergent validity and the divergent validity of the quality indicators established by this study are all acceptable parameters. Conclusions: Health care managers can use these indicators set by this research to evaluate or study the service quality for Chinese medicine.
• 309 - 319
• 10.6288/TJPH2008-27-04-05

• Link 原著 Original Article
• 腦部傷害病患生活品質問卷中文版信度、效度與感應度之評估Reliability and Validity of and Responsiveness to the Taiwanese Version of the QOLBI Questionnaire
• 張孟卿、邱文達、林茂榮
  Meng-Ching Chang, Wen-Ta Chiu, Mau-Roung Lin
• 創傷性腦部傷害 ； 生活品質 ； 信度 ； 效度 ； 感應度
  traumatic brain injury ; quality of life ; reliability ; validity ; responsiveness
• 目標：利用特定疾病生活品質問卷來測量腦部傷害病患的健康相關生活品質的適用性。方法：評估翻譯後中文版「腦部傷害病患生活品質問卷」(Quality of Life of Brain Injured，簡稱QOLBI)，其中包含生理、智能、心理、功能、社會和個人等六個範疇生活品質問卷的信度、效度與感應度等心理計量特性。研究對象是台北地區22家醫院因創傷性腦部傷害而就醫年齡18歲以上的病患，共有100位病患接受電話訪談。結果：內部一致性信度的數值在各範疇中高巴氏α(Cronbach's α)值為0.74~0.97；再測信度中，相同訪員的內在等級相關係數(Intraclass correlation coefficients)值為0.73~0.99。收斂效度方面，QOLBI與世界衛生組織生活品質簡明版問卷(WHOQOL-BREF)，在生理、心理、社會、及個人範疇的皮爾森相關係數(Pearson's correlation)皆高於0.4；鑑別效度方面，QOLBI的六個範疇都能顯著區辨有工作者其生活品質分數較無工作者高；驗證型因素分析之比較適合度指標(CFI)為0.86。感應度(responsiveness)分析發現工作對生活品質所產生的變化以生理範疇最明顯，感應度為0.56，其他範疇為0.17~0.43。結論：「腦部傷害病患生活品質問卷」雖然尚適用於測量國內腦部傷害病患健康相關生活品質，但仍有改善之處。
  Objectives: The suitability of the disease-specific Quality of Life of Brain Injured questionnaire (QOLBI) was determined in individuals with traumatic brain injury (TBI). Methods: One hundred subjects with TBI aged 18 or older were recruited from 22 hospitals in northern Taiwan. The translated Taiwanese version of the 37-item QOLBI is categorized into six domains: physical, intellectual, psychological, functional, social, and personal. Results: Cronbach's a coefficients for internal consistency ranged from 0.74 to 0.97, while the interclass correlation coefficients for test-retest reliability were from 0.73 to 0.99. For convergent validity, Pearson’s correlation coefficients comparing the QOLBI and WHOQOL-BREF in the domains of physical, psychological, social, and personal were each more than 0.4. When discriminant validity was assessed, all six QOLBI domain scores were significantly higher for subjects who returned to work compared with those who did not return to work. The Comparative Fit Index of the confirmatory factor analysis was 0.86. As the return to work was used as an external indicator to measure the responsiveness of each QOLBI domain, the effect sizes of the six QOLBI domains ranged from 0.17 to 0.56. Conclusions: Results indicate that, although there is room for improvement, QOLBI is an acceptable instrument for assessing quality of life persons with TBI.
• 320 - 329
• 10.6288/TJPH2008-27-04-06

• Link 原著 Original Article
• 單次跌倒與反覆跌倒之盛行率與相關因素探討－以都會區老人為例Prevalence and Associated Factors of a Single Fall and Recurrent Falls in an Urban Elderly Population
• 張念慈、楊南屏、李建賢、周碧瑟
  Nien-Tzu Chang, Nan-Ping Yang, Chen-Hsen Lee, Pesus Chou
• 單次跌倒 ； 反覆跌倒 ； 老人
  a single fall ; recurrent falls ; the elderly
• 目標：探討台灣都會區的老人單次跌倒與反覆跌倒之盛行率及其相關因素。方法：本研究是以社區為基礎的調查研究法，以1999-2002年設籍並居住在台北市北投區年滿65歲以上的老人為研究樣本，總共4,056人完成跌倒事件調查及問卷訪查。再透過單變項分析及多變項邏輯斯迴歸分析，以嘗試建立跌倒預測模式。結果：都會區老人一年內曾經跌倒的比例為13.8%；單次跌倒的盛行率是10.0%，反覆跌倒是3.8%。女性不論是單次跌倒或反覆跌倒的盛行率都顯著高於男性。多變項邏輯斯迴歸分析顯示單次跌倒的主要相關因子為性別、關節炎、精神疾患和視力障礙等病史。多變項分析顯示反覆跌倒顯著相關的因子包括：性別、糖尿病、心臟病、關節炎、精神疾患等病史。結論：本研究發現女性、關節炎病史、精神疾患病史是台灣都會區老人單次跌倒和反覆跌倒的共同相關因素。視力障礙與單次跌倒有關，而糖尿病和心臟病等慢性病況則與反覆跌倒有關。
  Objectives: The aim of this study was to investigate the prevalence and associated factors of a single fall and recurrent falls among the elderly in an urban community in Taiwan. Methods: A community-based, cross-sectional study involving interviews with residents aged 65 years and over was conducted in Beitou, Taipei, Taiwan, between 1999 and 2002. A total of 4,056 subjects completed a structured questionnaire that included items on falling episodes and possible associated factors. Chi-square tests and multiple logistic regression models were used to examine the relationship between falls and possible related factors. Results: Among the elderly urban residents who participated in this study, 13.8% had experienced falls in the preceding year; the prevalence of a single fall and recurrent falls were 10.0% and 3.8%, respectively. Females were found to be much more susceptible to falls than males (p<0.001). Multiple logistic regression showed that female gender, history of arthritis, psychiatric disorder, and visual impairment were the major factors associated with a single fall, while female gender, history of diabetes, cardiovascular disease, arthritis, and psychiatric disorder were the major factors associated with recurrent falls. Conclusions: Falls were prevalent among elderly residents of the urban community studied. Females and several medical conditions were found to be associated with falls in this population, with arthritis and psychiatric disorder being related to both a single fall and recurrent falls.
• 330 - 340
• 10.6288/TJPH2008-27-04-07

• Link 原著 Original Article
• 南部某大學新生友誼網絡演變與健康行為之相關探討The Dynamic Friendship Networks and Health Behavior of University Students in Southern Taiwan
• 楊雪華、魏慶國、楊宏仁
  Hsieh-Hua Yang, Ching-Kuo Wei, Hung-Jen Yang
• 友誼網絡 ； 健康行為 ； 社會網絡長期資料分析
  friendship network ; health behavior ; longitudinal social network analysis
• 目標：探討長期的社會網絡演變與健康行為之間的關係。方法：採取長期貫時追蹤設計，以南部某大學90名新生為研究對象，結構式問卷搜集社會網絡與健康行為的資料，於94學年度上、下二學期收集七次資料；應用SIENA社會網絡分析軟體進行分析。結果：友誼網絡的改變速率漸減，表示友誼的演變漸趨穩定，相互性、傳遞性與改變速率呈現正相關，表示友誼關係的建立是需要互惠的來往，共同的朋友也會增強友誼網絡的形成。運動及吃早餐是影響友誼網絡形成初期重要的健康行為，友誼形成後期，吸菸及飲酒行為才成為顯著的影響因素。結論：健康行為是否合乎社會規範，在友誼發展過程中是重要關鍵，合乎社會規範的健康行為通常是外顯的，且有相同行為者易形成友誼網絡；不合乎社會規範的，則隱而不顯，直至友誼發展的後期，才會顯現出來。
  Objectives: This study investigated the relationship of dynamic friendship networks and health behaviors. Methods: Panel data were collected in seven waves at intervals of one academic semester on 90 university freshmen in southern Taiwan with questionnaires. The Simulation Inverstigation for Empirical Network Analysis (SIENA) was applied to analyze the panel data. Results: The decreasing rate of the network evolution indicated that the friendship dynamics slowed down across time. The positive parameter of reciprocity and transitive triplets demonstrated the strong tendency of friendship toward reciprocity of choice and toward transitivity. In the meeting process, healthy behaviors such as taking exercise and eating breakfast were important to determine the changes of friendship networks; while in the later stages, unhealthy behaviors such as smoking and drinking were important determinants. Conclusions: In the process of friendship formation, healthy behaviors were practiced as visible characteristics and had similarity effect on friendship formation. Social norm would keep unhealthy behaviors invisible until later stages.
• 341 - 348
• 10.6288/TJPH2008-27-04-08