醫院推動社區健康促進的地方生態與實務：新北市金山區的田野觀察

The Local Social Networks and Implementations of Promoting Community Health by A Hospital: A Field Observation in Jinshan, New Taipei City

林民浩(Min-Hau Lin)

指導教授 ： 陳端容

共同指導教授 ： 鄭守夏

國立臺灣大學/公共衛生學院/健康政策與管理研究所/博士(2015年)

https://doi.org/10.6342/NTU.2015.02265

摘要

背景與動機：健康促進(health promotion)是公共衛生界不斷努力的目標。近年來，除了對個人行為介入，也強調社區健康促進所扮演的角色和功能。對醫院而言，渥太華憲章揭示「重新定位健康服務」(reorient health service)的行動綱領，期盼醫療機構自原有疾病診斷與治療，進一步擴增了其健康促進的功能，讓醫療機構(medical care organization)成為名副其實的健康照護組織(health care organization)，肩負在其環境與社區中倡議健康促進與改變的媒介。臺灣政府部門自1999年開始推行社區健康營造， 2012年近一步推動醫院以被保險人健康為目標的論人計酬(capitaion)試辦計畫。這些措施，都導引醫院正視自身在社區健康促進的角色。然而，現階段仍缺乏研究探索醫院在社區健康促進的背景成因，也尚未釐清醫院與社區在健康促進事務上的分工與整合，更缺少對醫院執行健康促進實務的探討。綜合前文所述，本研究之目的有三：（一）瞭解醫院推動社區健康促進的背景與原因；（二）分析醫院在社區健康促進的內容和與社區之整合；及（三）剖析醫院在社區健康促進實務之經驗。

研究方法：本研究以新北市金山區為研究田野。金山區位於北海岸地區，與主要城市相隔，境內僅有國立臺灣大學醫學院附設醫院金山分院一家醫院，其不只承接社區健康促進計畫，更以區域整合模式參與健康保險署論人計酬試辦計畫，使金山成為回答前述問題最適宜的場域所在。本研究以田野研究的方法，透過參與觀察、深度訪談、非正式訪談與檔案分析等方式進行資料收集。

結果：金山分院以承接論人計酬試辦計畫及相關健康促進計畫，獲得政府額外資源挹注，增強其社區健康事務參與的動機。然而資源不充足，且相關規範缺乏整合，限制醫院在社區健康促進的發展。其次，醫院的社區健康促進會受制於地方政治脈絡與社區人際網絡。醫院雖可協助社區內對健康有自覺意識的社群，提供健康專業，以補足社區之不能。但是對於未能覺察自身健康促進需求的社群，則需透過非正式的人際關係奠基，才能獲得資訊，以協助社區民眾健康促進與改善健康問題。此研究結果指出，醫院在社區健康促進實務中，非制度化與非正式化的特質及其結構限制。

結論：本研究透過質化的分析，討論醫院投入社區健康促進的可能原因與限制。醫院－社區的合作與經營，需要人際情感為基礎，顯示合作關係的不確定性與脆弱性。本研究可供臺灣發展醫院為基礎的社區健康促進政策參酌。建議未來研究持續深化醫院社區健康促進實務與理論的對話，以期建構具可行性的醫院－社區整合之健康促進運作模式。

關鍵字

社區健康促進 ； 論人計酬 ； 資源與體制 ； 醫院與社區關係 ； 過程評估

並列摘要

Backgrounds: Health promotion is a key of improving the public’s health. In recent years, reorienting health care toward health promotion has been considered as a major challenge for health service providers. The Department of Health started the Building Healthy Communities Program since 1999 and the National Health Insurance Administration also introduced a 3-year pilot capitation payment program which is similar to the accountable care organization in the United States in 2011. With these policy incentives, participating hospitals are encouraged to improve or maintain the health status of their enrollees, and community health promotion approaches are usually adopted. Given this groundwork, the aims of this study are to (1) investigate the backgrounds of promoting health in the community by a hospital; (2) figure out the processes and structures of the hospital-community partnership; and (3) profile the implementation of health promotion tasks by a hospital in the community context.

Methods: The National Taiwan University Hospital Jinshan Branch was established in 2010 and it was also the only hospital in the northeast district of Taiwan. After participating in the capitation payment program of the National Health Insurance Administration and health promotion programs led by the Health Promotion Administration, the Jinshan hospital initiated several community-based health programs. This study, a field research, collected data by participant observation, documentary analysis and open-ended interviews with hospital staffs, community residents and relevant stakeholders.

Results: The hospital participated in the capitation payment program and health promotion programs for gaining more resources and incentives in order to perform community health services. Nevertheless, scarcity of resources and conflicts among institutions limited the development of the hospital’s community health promotion works. On the other hand, promoting health in the community was also subjected to local social networks. Facing those community groups with high perception of health, the role of the hospital was to provide specialized healthcare services to meet the demands. On the contrary, the hospital had to approach local social networks to learn the needs of community members and assist them in improving or promoting health. The results showed non-institutionalized and informal characteristics of the hospital-community partnership and the structure constrains influenced the hospital's community-based health promotion implementations.

Conclusions: Through qualitative approach, this study observed that the relationship between local community and the hospital is multi-faceted and dynamic. The results also provided first-hand information for future policy formulation. By exploring the real practices of hospitals’ community health promotion works will help develop a proper operation model.

並列關鍵字

Community Health Promotion ； Capitation ； Resources and Institution ； Hospital-Community Partnership ； Process Evaluation

參考文獻

行政院衛生署國民健康局（2006）。社區健康營造工作手冊。臺北縣新莊市：衛生署國民健康局。

楊鈺雯（2008）。健康促進醫院經驗分享∼彰化基督教醫院。醫療品質雜誌，2（3），46-51。

黃暉庭、羅佳琳、葉淑華（2008）。健康促進醫院經驗分享∼臺安醫院。。醫療品質雜誌，2（3），42-45。

林俊龍（2008）。WHO健康促進醫院標準與台灣醫院評鑑指標之比較。醫療品質雜誌，2（3），33-41。

行政院衛生署（2011）。臺灣公衛 百年記事。臺北市：行政院衛生署。