登革熱防治行為的環境觀、社區觀與疾病觀：一個混合研究

背景與目的：登革熱是臺灣近年來最重要的蟲媒傳染病。以社區為基礎的登革熱防治被證實對防疫工作的落實較有效，然而在實務上發現這樣的登革熱防治工作似乎未能永續進行。因此考量「登革熱是一種社區病、環境病」的特性，本研究之目的為瞭解個人的環境觀、社區觀與疾病觀為何，及其對個人進行登革熱防治行為之影響。方法：本研究為一混合研究。以臺南市為研究田野，根據登革熱流行程度與社區發展營造情形等條件，至不同社區鄰里進行研究。運用參與式觀察、訪談等質性田野研究方式收集資料並進行分析，最終共走訪32個里，並訪問54人。根據質性研究結果發展問卷，針對臺南市與高雄市20歲以上民眾進行家戶面訪調查，透過抽取率與單位大小成比例之PPS抽樣法決定受訪里別，再以立意取樣選定受訪者。量性資料分析包括描述性統計、雙變項分析，並透過階層線性模式釐清個人層次與里層次變項對個人登革熱防治行為之影響，最終共有1400個樣本進入分析。最後再透過三角交叉檢驗法，使質性資料與量性資料相互解釋與釐清。結果：首先，民眾的疾病觀顯示其對登革熱有一定程度的認識，但是在細節處仍存在誤解及迷思；且儘管歷經大規模疫情流行，因而對疾病嚴重度的感知提升，然對自己疾病易感受性之評估仍然偏低，需直至危險逼近己身，才會較意識到疾病風險；而對於里的疾病流行與個人罹患登革熱之歸因，受訪者多指出是民眾或個人的因素，然這樣的內在歸因卻由於民眾想像的人為因素往往指涉的是他人，因而實則為外在歸因。其次，民眾的環境觀體現在對噴藥的質疑上，是化學與天然價值觀的角力；此外，在環境觀上還有一種更全面性的視角，以整體環境為考量進行防治，而不限於登革熱。本研究發現環境觀尚可發展出微觀的環境維護表現與巨觀的環境保護表現兩個概念，且應用在較大範圍的防疫，例如在里層次可對於各類登革熱防治行為都有最大的影響。最後，民眾對不同層次場域(家戶之內、家戶外周圍、里公共空間)的擁有權及責任感，及在場域內與他人發生不同層次的人際互動(自己人、熟人、外人)，以上物理界線與人際界線之劃分共同影響民眾會在何種領域中如何進行登革熱防治。一般而言，民眾較願意參與家戶內的防治，並希望他人僅在家戶外執行防疫措施，對其他類型的防治則較排拒；而研究結果發現，里層次的巨觀與微觀環境、社區氛圍可促進個人參與里範圍之防治頻率及對家戶內防疫配合意願之程度。結論與建議：綜合而論，個人的疾病觀影響其是否認為需要進行防治、環境觀則影響民眾選擇何種防治方式、對物理界線與人際界線之管理決定其在不同層次領域中如何進行防治。而逼近的疾病威脅、透過交好的人情溝通，以及里層次的環境與社區因子皆能使個人的領域界線有所變動，而有利於登革熱防治。根據研究結果，建議未來防治工作應該將民眾對登革熱防治之參與有不同層次領域之差異納入考量，並根據登革熱的環境病、社區病之特質，透過營造里層次的環境與社區鄰里氛圍達到促進民眾執行登革熱防治行為之目的。

關鍵字

登革熱；界線；領域行為；風險感知；歸因；社區氛圍

並列摘要

Background and purpose: Dengue is the most important vector-born disease in Taiwan in recent years. Community-based dengue vector control interventions were improved their effectiveness for prevention, however, these kinds of interventions seems lack of sustainability in practice. To consider the nature of dengue as a environment, community diseases, the purpose of this study is understanding lay person’s viewpoint about environmental-community- disease aspects of dengue, and their effects on one’s dengue prevention related responsible environmental behavior. Methods: A mixed-methods study was conducted. Tainan was the main research field, and neighborhoods were chose based on different dengue prevalence and various community development types. Data were collected by participant observation, in-depth and informal interviews. Finally, 32 communities were visited, and 54 people were interviewed. According to the results of qualitative study, the questionnaire was developed. Household face-to face survey was done with interviewers who should be at least 20 years old, and living in Tainan or Kaohsiung. Probability proportional to size sampling was used to decide which communities were interviewed, the quota sampling was conducted to choose interviewees. Descriptive analysis, bivariate analysis, and hierarchical linear model were applied to examine the effect of personal level and community level factors on one’s dengue preventive behavior. Finally, there were 1400 data be analyzed. Additionally, triangulation was used to corroborate and explain the results of qualitative and quantitative data. Results: The results demonstrated that people became knowledgeable about dengue, but there were still some misunderstanding. Although they experienced severe dengue outbreak, people’s perceived disease susceptibility still low while their perceived severity increased. Until threaten of disease approaching, people became more aware of the risk of dengue. Mention to attributions of dengue outbreak and one infected with dengue, most respondents pointed out personal factors which seems like internal attribution; however, the actual meanings of the factors often refers to others except themselves. So in fact respondents made external attribution. Secondly, people’s questions about sprying reflected value conflict of natural and chemical. Furthermore, there was still one kind of holistic viewpoint to consider the overall environment to conduct prevention, not limited to dengue. People’s environment perspectives of dengue could further divid into two concepts: environmental maintenance (macro) and environmental protective practice (micro). Both concepts could be applied in li level to propomt different kinds of dengue prevention behavior with large effects. Finally, people displayed different degree of ownership and responsibility on settings with varying centrality, from inside the household, outdoor residential spaces close to home, to public spaces, and various interpersonal interaction categorizations in these settings, including spectrum between family people, familiar people to strangers. This physical and interpersonal boundary delimitation influenced how people conducted dengue prevention in different settings. Basically, people were willing to involve domestic dengue prevention, to accept health officals’ preventive practices in outdoor spaces, and to resist other types of prevention. The findings of the study showed that the macro and micro environment and community climates of li could increase the frequency of people participated in dengue prevention in public space and the degree of compatibility of indoor preventive practices. Conclusion and suggestion: Finding of the study demonstrated that people’s disease and environment prespectives of dengue influenced oneself consider need to conduct prevention or not and the ways to prevent, and their management of physical and interpersonal boundary delimitation decided how they conducted prevention in varying settings. Moreover, approached disease threaten, good interpersonal communication, and environment and community factors of li level made personal territorial boundaries shift, and then contribut to dengue prevention. Based on findings derived from this study, it is suggested that the difference between people prarticipated in various settings should be take into consideration in future preventive practices. Besides, according to the traits of dengue, the environment and community climates of li level should be built to promote people‘s dengen prevention behavior.