社區健康營造推動現況與推動者概念之研究

The Current Situations and the Realization of the Promoters of the Health Community Building

陳毓璟

指導教授 ： 黃松元

國立臺灣師範大學/教育學院/衛生教育學系/博士(2002年)

摘要

本研究以深度訪談的方式，訪問行政院衛生署，以及台北市、台北縣和台東縣三個縣市的衛生局、衛生所和社區健康營造中心的主要推動者共計95人，來了解我國社區健康營造計畫推動的現況，與推動者對社區健康營造的概念，作為這項政策改進的參考。本研究結果如下：

一、影響社區健康營造政策落實的因素包括衛生行政組織、專家輔導組織、承辦機構的組織特性、社區的特性與族群的特性。中央部份，行政院衛生署當初推動平地社區健康營造計畫時，因為擴展的速度太快，在缺乏共識與前置作業沒有很周詳的規劃之下就上路，衍生後續許多管理上的問題。因為針對推動的議題、範圍與目標做了許多的規範，造成許多社區健康營造中心的困擾與不滿。整體計畫的設計，以營造健康的生活為目標；部落與離島社區部分，則強調兼顧原住民的傳統文化與經濟就業的問題，偏向以社區總體營造的概念來推動；在縣市部分，因為縣市原本的城鄉差距，以及首長的重視程度的不同，而有不同的執行情形與推動的困難。

二、民間團體主要是因為社區健康營造的理念和承辦單位的宗旨部分一致，而來承辦社區健康營造中心。對於經費不豐的非營利性團體，除可以獲得最需要的經費補助以外，還可以同步擴大推動原有的業務；對於營利性質的醫療機構而言，承接社區健康營造中心的計畫，有助於業務的行銷與機構形象的建立；對於學校而言，則是為了讓師生可以獲得社區實務的經驗與進行研究的機會；衛生所大部分是因為上級主管的指定、為了獲得經費的補助，以及少部分的為了突破目前衛生所工作的框架而來承辦；除了台北市衛生局以外，台北縣和台東縣衛生局不希望由衛生所來承辦社區健康營造中心；衛生所大多逃避由自己來推動社區健康營造的業務，寧願讓民間團體來承辦，自己退居協助的角色。

三、各營造中心共同的推動困難是（1）健康議題很難單獨被推動，因為民眾對健康不重視，加上健康行為不容易改變，需要花很長的時間才能看到成效，因此健康議題很難成為社區的共同議題。（2）志工管理方面對於台北市而言，志工的資源雖不缺乏但容易流失；對於台東縣和台北縣的鄉鎮地區，則有志工資源不足的困難。（3）在資源整合方面，台北市的資源豐富卻有整合困難的問題；台北縣與台東縣卻是資源缺乏，有些社區除了衛生所以外，沒有其他的團體可以承辦社區健康營造的工作。

四、推動社區健康營造的時候，受訪者認為應該要把握的原則包括深入了解社區、全民參與、整合社區的資源、本土化、因地制宜、持續性的推動、融入日常生活之中、建立支持性的環境、以及運用創造性來設計活動等；推動時切入的主題，主要分為民眾的需求或文化產業、預防性篩檢、健康宣導與教育等三大類；實施步驟方面，則大致不脫離世界衛生組織推動健康城市的二十個步驟。

五、對社區健康營造計畫的批評，主要集中於平地社區計畫部分的缺乏整體規劃，不僅政策方針不明，計畫的持續性也不明確，缺乏有效的評估標準，以及規範太多，衛生行政機關上下之間缺乏充分的溝通，對於推動者所提供的訓練與輔導不足，以及相關的行政作業不完善等。建議的部分，共通點是不要做太多的規範、容許有更多元的推動策略。
六、大家所討論的社區健康有關的概念相去不遠，只是有些已取得推動者完全的共識，有些仍有差距。主要概念包括：「社區」有著多元而不斷變動的面向；「健康社區」則是一個多元的面向，融入自己對社區的感情之後，再依當地的需求而做思考；「社區健康營造」的目的主要是從促進健康的知識、健康的行為與健康的生活的面向來考量；營造的精神包括參與的、民主的、賦權與永續發展；社區健康營造的項目，應該從社區整體性來規劃，而不應該單獨從健康的議題來推動；營造的手法，主要包括資源整合、跨部門合作、因地制宜、政治的運作等。

七、本研究最後從政策層面、實務研究層面以及輔導者與衛生工作者的反省與學習方面提供建議。在政策層面，短期應該重新檢討政府的角色並進行政策的總盤點、進行衛生行政機關內部改造與教育、系統式建立成功多元的推動模式，以及建立社區健康營造推動成效的評估基準。中期應該建立溝通的機制與資源分享的平台、推展成功的模式、推展以場域為基地向外推動的模式並且建立合作聯盟、建立跨部會的合作機制，並且重新檢討社區衛生促進委員會的功能。長期則應該以縣市為主體推動「健康城市」、成立財團法人社區健康營造推廣中心，以及推動跨國健康城市的結盟與合作等；實務研究層面的建議包括研究的主題、建置社區健康營造研究資料庫與建立跨領域的研究團隊；輔導者與衛生工作者方面則必須學習放手，並且花時間深入社區和社區一起學習與成長。

關鍵字

社區衛生 ； 社區健康營造 ； 健康促進

並列摘要

This research interviewed the key promoters of the health centers and Health Community Building (HCB) centers of the Health of Department, Executive Yuan, the Taipei City, the Taipei County and the Taitung County. Total 95 key promoters are interviewed. The objective of this research is to realize the current situations of the HCB project and the realization of the HCB promoters. The results of this research can be used as references of improving the HCB policy. The results of this research are showed in the followings.
1.The factors that affecting the implementation of HCB policy include the organization of health administration, the organization of consultants and experts, the characteristics of the organization who promoting the HCB, and the characteristics of the communities and the people. Due to the lack of common understandings and detailed plans from the Department of Health, Executive Yuan, resulting in a lot of management problems by implementing the HCB project. Due to many regulations set up for the promoting issues, the scopes, and goals of the HCB resulting in perplexities and resentment from the HCB Centers. In the communities of mountain and island, the HCB took the issues of traditional culture and employment into account just like the promoting of the total community building. Due to the differences between cities and counties as well as different degrees of emphasis from the supervisors of the HCB centers resulting in different implementing situation and difficulties.

2.The nongovernmental organizations recognize the concepts of the HCB, therefore, they promoting the HCB. By carrying out the HCB, the nonprofit organizations can not only receive their necessary funds but also extend their original business simultaneously. For those profit-oriented hospitals, carrying out the HCB project can help them to promote their business and build their images. For the schools, the carrying out of HCB let the teachers and students obtain experiences and the opportunities of research. As for the health centers, the reasons for carrying out the HCB are appointed by their supervisory officers, to gain the support of funds, and to make a break through on their jobs. The Taipei county and Taitung county do not wish their health centers to carry out the HCB project, but Taipei city do. Most health centers wish the nongovernmental organizations to carry out the project of HCB rather than carrying out by themselves.

3.The difficulties of carrying out the HCB are:
a. the issue of health activities are hard to promote due to a lot of people do not pay too attention to their health, the health behaviors are not easy to change, and it takes a long time to see the effects of the HCB. Therefore, the issues of health are usually hard to a common concern of the communities.
b.The Taipei city is not lack of volunteers but is easy to lose them. However, the volunteer resources are short for some villages or towns of the Taipei county and Taitung county.
c.As for the integration of resources, the Taipei city have plentiful resources but are not easy to integrate those resources. On the contrary, the Taipei county and Taitung county are short of resources. In some areas of the Taipei county and Taitung county, health centers usually is the only organization can carry out the HCB.

4.The interviewees think that there are several principles should be assured: realize the community deeply, involve the people of the community, integrate the resources of the community, localization, carry out HCB with local conditions, carry out HCB continuously, merge the HCB into the daily life, build a supporting environment, and design creative activities. The topics of the HCB can be divided into categories: a. the needs of the people or the product of the culture; b. preventive screening; c. the propagation and education of the health. The procedures to implement the HCB are similar to the twenty steps of carrying out the Healthy City promoted by the World Health Organization.

5.The major criticism of the HCB project are: the lack of integrated planning, unclear policy, the uncertainty of the continuity of the project, the lack of evaluation standards, too many regulations, the lack of communication between the organizations of health, the lack of trainings and guidance to the promoters, and the incomplete of related administrative works. The interviewees also gave common suggestions such as: do not give too many regulations, and allow multiple promoting strategies.

6.Though the concept of health community is well acknowledged, the disparity between promoters still exists. “Community”is a multi-dynamic concept. “Health community”is the different perspective: to plan it according to the desire and the demand of the community itself. The project of Health Community Building is to improve the knowledge, action and healthy living. To achieve this goal, we have to fulfill the plan with ingredients of active participation, democracy, empowerment, and sustainability. Further, we have to organize the project of Health Community Building according to the integrated issues but not the single issue of community health problem. The approaches of the project should involve resource integration, collaboration, flexibility, and political concerns.

7.Some suggestions come out from this study. 1) At the policy level, we have to reassess our government role, organization structure, and the policies shortly. From that, we can establish a multi-systematic promoting model and set criteria for evaluating the performance of the program. Further, we have to set the platform for communication, resource sharing, promoting the successful model, building collaboration alliance, putting the cooperation of multi-sectors into practice, and rethinking about the function of the committee for community health promotion. For the long run, in order to fulfill the program of healthy city, we have to set a non-profit private organization in each city to improve the network and cooperation with foreign healthy city. 2) At the practical research level, we suggest the further research on the issue of establishing the research data bank and establishing the research team. 3) For the consultants and health workers, we have to learn how to share the responsibilities between stakeholders and to develop the chance for the community improvement.

並列關鍵字

community health ； health community building ； health promotion

參考文獻

行政院衛生署（2000d）：社區健康營造工作手冊。台北：行政院衛生署。

行政院衛生署（2002f）：衛生統計。台北：行政院衛生署。

行政院衛生署（2002g）：死因統計摘要表。台北：行政院衛生署。

行政院衛生署（2002h）：國民醫療保健支出。台北：行政院衛生署。

行政院衛生署（2002i）：台灣地區各衛生所人事動態統計表（未出版）。