在台灣，每年秋冬屬流行性感冒肆虐季節，尤對抵抗力較差老人造成嚴重威脅。流感疫苗是目前預防流行性感冒之最佳成本效益方法，接種流感疫苗是國際上所建議甚具成本效益的有效預防方式，我國自2001年起對於65歲以上老年人全面提供免費接種，但國內老年民眾之接種率尚未達到衛生署預期之目標，本研究旨在利用全民健保之次級資料庫資料，並且引用外在環境威脅理論，探討影響我國六十五歲以上老人對於接種疫苗的重要因素。
方法:
採用回溯性研究法長期觀察老人流感疫苗接種情況，並採用健康行為模式中「健康信念理論」以及外在環境威脅理論加以修訂成為研究架構。使用中央健保局資料庫中2000年至2004年之全國抽樣歸人檔案，為次級資料分析。選取年齡等於或大於六十五歲之老人為研究樣本。依自變項與依變項屬性，採用次數分配、百分比、平均數、標準差描述樣本在老年人流感疫苗接種率以及人口學特質、本身健康狀況、醫療利用率及醫療可近性等趨勢情況。 以卡方檢檢視變項之顯著性。利用邏輯式回歸做為數據分析，以odds ratio 呈現特定變數之顯著性。
結果:
本研究發現老人過去接種流感疫苗的經驗為影響再次接種之最重要因素；其他影響因素包含年齡在70-80歲，本身罹患一種以上慢性病、居住在中南部、最常就診於地區醫院及診所。流感間季及前季因流感使用門診次數越多(間季的機率比前季高)，選擇接種流感疫苗機率越高。

結論:
本研究是以修改健康信念模式及外在環境威脅理論為架構探討台灣四年來抽樣老人之接種率，發現過去經驗及本身健康狀況等相關因素顯著影響當年度接種意願，故如何提升這項政策的普及率可為政府單位努力之方向。建議有關政策擬定單位可在流感季節來臨前，結合區域醫院以及基層診所醫師為衛教宣導的中心，結合附近社區在流感疫苗開始接種季節進行衛教做好足夠宣導，適度運用民眾對於外在環境威脅的反應，進而讓民眾自我採取接種疫苗的保護措施，使接種率大幅提升。

Research Objectives :
Studies indicated that influenza vaccination is a cost-effective clinical prevention for elderly persons. Higher influenza vaccination rate will reduce disease threat and related health care utilizations in a health care system. From 2001, Taiwan provided free influenza vaccine for all of its elderly persons. Nevertheless, the influenza vaccination rate was lower than the expected goal and less than 50%. Therefore, this study aims to evaluate the key factors which affect elderly persons receiving influenza vaccination in Taiwan.
Study Design :
This is a retrospective study using national representative data from year 2000 to 2004. The vaccination information was linked with outpatient and inpatient records in individual level. The data was also linked with medical institution’s characteristics. We modified Health Belief Model and threat-responsiveness theory to hypothesize previous experiences on vaccination and medical utilization were important factors affecting individual’ s probability of receiving influenza vaccination. Population-based descriptive analysis was conducted to assess the demography characteristics, health status, and health care utilizations. We tested the significance by t-test and Chi-Square test. Moreover, we applied multivariate logistic regression to analyze the associations between controlled factors and the probability of receiving influenza vaccination.
Population Studied :
People aged 65 years and older were drawn from Taiwan’s national health insurance database from 2000 to 2004. The total sample size is 23,023 elderly persons.
Principle Finding:
The study results indicated that the most important factor affect elderly persons continue to receive influenza vaccination is whether the person had received influenza vaccination during last flu season or not. Elderly persons who had received influenza vaccination in last flu season were significantly seven times more likely to receive influenza vaccination in this year (OR: 7.66 [95%CI:7.34-8.00]). Other key affecting factors include age, health status, flu-related inpatient and outpatient utilizations in last year, locations of receiving influenza vaccination, and the health care organizations’ levels.
Conclusion :
This research combines Health Belief Model and threat-responsiveness theory as framework to analyze the national dataset of four year’s elderly influenza vaccination rate change in Taiwan. We found that lagged effects such as vaccination status and flu-related health care use in previous flu season significantly affect the volition of influenza vaccination. Therefore, further research on how to adopt this critical finding and promote higher vaccination rate are in great needs.
Implications for Policy, Delivery or Practice:
Free coverage and easy access does not guarantee high influenza vaccination rate in Taiwan, even it is under universal health insurance program. This study provides empirical investigations on key factors that might affect the elderly persons’ intention to receive influenza vaccination. Elderly persons’ responses to regular clinical prevention and disease threat were positively associated with probability of having influenza vaccination. By focusing on the major factors and conducting related promotion programs, effective prevention policy can be reinforced. Moreover, this study result could serve as valuable reference for other countries which also has or plans to have free influenza vaccination policy, particularly for those countries also with national health insurance program.

第一章 緒論……………………………………………………………1
第一節、研究背景與動機……………………………………………………1
第二節、研究之重要性………………………………………………………3
第三節、研究目的與問題……………………………………………………4
第四節、論文架構……………………………………………………………5
第二章 文獻回顧………………………………………………………6
第一節 簡介流行性感冒及流感疫苗………………………………………6
第二節 國內外相關文獻對於流感疫苗接種所做研究……………………11
第三節 流感疫苗接種因素探討……………………………………………17
第四節 相關理論應用探討…………………………………………………26
第三章 研究方法………………………………………………………30
第一節 研究架構……………………………………………………………30
第二節 研究假設……………………………………………………………31
第三節 資料處理……………………………………………………………32
第四節 統計方法……………………………………………………………41
第四章 研究結果………………………………………………………42
第一節 樣本老人基本特質以及歷年接種因素變化………………………42
第二節 影響老人接種流感疫苗因素之迴歸分析…………………………55
第五章 研究討論………………………………………………………59
第一節 流感疫苗政策推行現實與理想狀況………………………………59
第二節 影響老年人接種與否之因素探討…………………………………60
第三節 樣本代表性之討論…………………………………………………64
第六章 研究結論與建議………………………………………………66
第一節 研究限制……………………………………………………………66
第二節 研究結論……………………………………………………………67
第三節 研究貢獻……………………………………………………………68
參考文獻…………………………………………………………………………69

參考文獻
Aballea, S., Chancellor, J., Martin, M., Wutzler, P., Carrat, F., Gasparini, R., et al. (2007). The cost-effectiveness of influenza vaccination for people aged 50 to 64 years: An international model. Value in Health : The Journal of the International Society for Pharmacoeconomics and Outcomes Research, 10(2), 98-116.
Ambrosch, F., & Fedson, D. S. (1999). Influenza vaccination in 29 countries. an update to 1997. PharmacoEconomics, 16 Suppl 1, 47-54.
Andrew, M. K., McNeil, S., Merry, H., & Rockwood, K. (2004). Rates of influenza vaccination in older adults and factors associated with vaccine use: A secondary analysis of the canadian study of health and aging. BMC Public Health, 4, 36.
CDC. Http://www.cdc.gov/flu/professionals/acip/coveragelevels.htm.CDC accessed at 2006.
Chen, Y., Yi, Q. L., Wu, J., & Li, F. (2007). Chronic disease status, self-perceived health and hospital admissions are important predictors for having a flu shot in canada. Vaccine, 25(42), 7436-7440.
Damiani, G., Federico, B., Visca, M., Agostini, F., & Ricciardi, W. (2007). The impact of socioeconomic level on influenza vaccination among italian adults and elderly: A cross-sectional study. Preventive Medicine, 45(5), 373-379.
David S. Gochman. (1997). Handbook of health behavior research I: Personal and social determinants. NY: Springer.
de Andres, A. L., Garrido, P. C., Hernandez-Barrera, V., Del Pozo, S. V., de Miguel, A. G., & Jimenez-Garcia, R. (2007). Influenza vaccination among the elderly spanish population: Trend from 1993 to 2003 and vaccination-related factors. European Journal of Public Health, 17(3), 272-277.
Fedson, D. S., Hannoun, C., Leese, J., Sprenger, M. J., Hampson, A. W., Bro-Jorgensen, K., et al. (1995). Influenza vaccination in 18 developed countries, 1980-1992. Vaccine, 13(7), 623-627.
Fedson, D. S., Hirota, Y., Shin, H. K., Cambillard, P. E., Kiely, J., Ambrosch, F., et al. (1997). Influenza vaccination in 22 developed countries: An update to 1995. Vaccine, 15(14), 1506-1511.
Fleming, D. M., & Elliot, A. J. (2006). Estimating the risk population in relation to influenza vaccination policy. Vaccine, 24(20), 4378-4385.
Georges C Benjamin. (2004). Pandemic influenza preparedness. Physician Executive, 30(5), 76-78.
Gilman, B. H., Bonito, A. J., & Eicheldinger, C. (2007). Impact of influenza immunization on medical expenditures among medicare elderly, 1999-2003. American Journal of Preventive Medicine, 32(2), 107-115.
Hoshi, S. L., Kondo, M., Honda, Y., & Okubo, I. (2007). Cost-effectiveness analysis of influenza vaccination for people aged 65 and over in japan. Vaccine, 25(35), 6511-6521.
Icek Ajzen, Dolores Albarracín, & Robert Hornik. (2007). Prediction and change of health behavior : Applying the reasoned action approach
Influenza and pneumococcal vaccination coverage among persons aged > or =65 years and persons aged 18–64 years with diabetes or asthma–United states, 2003.(2004). MMWR, 53(43), 1007-1012.
Jimenez-Garcia, R., Arinez-Fernandez, M. C., Garcia-Carballo, M., Hernandez-Barrera, V., de Miguel, A. G., & Carrasco-Garrido, P. (2005). Influenza vaccination coverage and related factors among spanish patients with chronic obstructive pulmonary disease. Vaccine, 23(28), 3679-3686.
Jimenez-Garcia, R., Hernandez-Barrera, V., Carrasco Garrido, P., del Pozo, S. V., & de Miguel, A. G. (2006). Influenza vaccination among cardiovascular disease sufferers in spain: Related factors and trend, 1993-2003. Vaccine, 24(23), 5073-5082.
Jimenez-Garcia, R., Jimenez, I., Garrido, P. C., Hernandez-Barrera, V., de Andres, A. L., del Barrio, J. L., et al. (2008). Coverage and predictors of influenza vaccination among adults with diabetes in spain. Diabetes Research and Clinical Practice, 79(3), 510-517.
Joseph, C., & Goddard, N. (2003). Influenza vaccine uptake in the elderly: Results from a rapid assessment of the effectiveness of new government policy in england for the winters 2000/2001 and 2001/2002. Vaccine, 21(11-12), 1137-1148.
Julie Denison. (1996). Behavior change -- A summary of four major theories. Family Health International,
Kamal, K. M., Madhavan, S. S., & Amonkar, M. M. (2003). Determinants of adult influenza and pneumonia immunization rates. Journal of the American Pharmacists Association : JAPhA, 43(3), 403-411.
Kroneman, M., van Essen, G. A., & John Paget, W. (2006). Influenza vaccination coverage and reasons to refrain among high-risk persons in four european countries. Vaccine, 24(5), 622-628.
Li, Y. C., Norton, E. C., & Dow, W. H. (2004). Influenza and pneumococcal vaccination demand responses to changes in infectious disease mortality. Health Services Research, 39(4 Pt 1), 905-925.
Lyn-Cook, R., Halm, E. A., & Wisnivesky, J. P. (2007). Determinants of adherence to influenza vaccination among inner-city adults with persistent asthma. Primary Care Respiratory Journal : Journal of the General Practice Airways Group, 16(4), 229-235.
Maciosek, M. V., Solberg, L. I., Coffield, A. B., Edwards, N. M., & Goodman, M. J. (2006). Influenza vaccination health impact and cost effectiveness among adults aged 50 to 64 and 65 and older. American Journal of Preventive Medicine, 31(1), 72-79.
Macroepidemiology of Influenza Vaccination (MIV) Study Group. (2005). The macro-epidemiology of influenza vaccination in 56 countries, 1997--2003. Vaccine, 23(44), 5133-5143.
Mangtani, P., Breeze, E., Stirling, S., Hanciles, S., Kovats, S., & Fletcher, A. (2006). Cross-sectional survey of older peoples' views related to influenza vaccine uptake. BMC Public Health, 6, 249.
Mayo Montero, E., Hernandez-Barrera, V., Carrasco-Garrido, P., Gil de Miguel, A., & Jimenez-Garcia, R. (2007). Influenza vaccination among persons with chronic respiratory diseases: Coverage, related factors and time-trend, 1993-2001. Public Health, 121(2), 113-121.
Mok, E., Yeung, S. H., & Chan, M. F. (2006). Prevalence of influenza vaccination and correlates of intention to be vaccinated among hong kong chinese. Public Health Nursing (Boston, Mass.), 23(6), 506-515.
Mullahy, J. (1999). It'll only hurt a second? microeconomic determinants of who gets flu shots. Health Economics, 8(1), 9-24.
Nichol, K. L. (1992). Long-term success with the national health objective for influenza vaccination: An institution-wide model. Journal of General Internal Medicine : Official Journal of the Society for Research and Education in Primary Care Internal Medicine, 7(6), 595-600.
Nichol, K. L. (2001). Cost-benefit analysis of a strategy to vaccinate healthy working adults against influenza. Archives of Internal Medicine, 161(5), 749-759.
Nichol, K. L., Baken, L., & Nelson, A. (1999). Relation between influenza vaccination and outpatient visits, hospitalization, and mortality in elderly persons with chronic lung disease. Annals of Internal Medicine, 130(5), 397-403.
Nichol, K. L., Baken, L., Wuorenma, J., & Nelson, A. (1999). The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease. Archives of Internal Medicine, 159(20), 2437-2442.
Nichol, K. L., & Goodman, M. (1999). The health and economic benefits of influenza vaccination for healthy and at-risk persons aged 65 to 74 years. PharmacoEconomics, 16 Suppl 1, 63-71.
Nichol, K. L., Nordin, J. D., Nelson, D. B., Mullooly, J. P., & Hak, E. (2007). Effectiveness of influenza vaccine in the community-dwelling elderly. The New England Journal of Medicine, 357(14), 1373-1381.
Nicholson, K. G., Snacken, R., & Palache, A. M. (1995). Influenza immunization policies in europe and the united states. Vaccine, 13(4), 365-369.
O'Malley, A. S., & Forrest, C. B. (2006). Immunization disparities in older americans: Determinants and future research needs. American Journal of Preventive Medicine, 31(2), 150-158.
Ompad, D. C., Galea, S., & Vlahov, D. (2006). Distribution of influenza vaccine to high-risk groups. Epidemiologic Reviews, 28, 54-70.
Pappano, D., Humiston, S., & Goepp, J. (2004). Efficacy of a pediatric emergency department-based influenza vaccination program. Archives of Pediatrics & Adolescent Medicine, 158(11), 1077-1083.
Rosenstock, I. M. (1974) Historical origins of the Health Belief Model. Health Education Monographs, 2: 328-335.
Sarria-Santamera, A., & Timoner, J. (2003). Influenza vaccination in old adults in spain. European Journal of Public Health, 13(2), 133-137.
Thomas, D. R., Mason, B. W., Beer, L., Scourfield, S., James-Hatherill, H., & Hayes, S. (2006). Surveillance of influenza immunisation uptake in people aged under 65 years with chronic disease. Vaccine, 24(49-50), 7027-7029.
Tsai, Y. W., Huang, W. F., Wen, Y. W., & Chen, P. F. (2007). The relationship between influenza vaccination and outpatient visits for upper respiratory infection by the elderly in taiwan. Value in Health : The Journal of the International Society for Pharmacoeconomics and Outcomes Research, 10(2), 117-127.
Turner, D. A., Wailoo, A. J., Cooper, N. J., Sutton, A. J., Abrams, K. R., & Nicholson, K. G. (2006). The cost-effectiveness of influenza vaccination of healthy adults 50-64 years of age. Vaccine, 24(7), 1035-1043.
van Essen, G. A., Palache, A. M., Forleo, E., & Fedson, D. S. (2003). Influenza vaccination in 2000: Recommendations and vaccine use in 50 developed and rapidly developing countries. Vaccine, 21(16), 1780-1785.
Vu, T., Farish, S., Jenkins, M., & Kelly, H. (2002). A meta-analysis of effectiveness of influenza vaccine in persons aged 65 years and over living in the community. Vaccine, 20(13-14), 1831-1836.
WHO. (2003). Resolution of the World health assembly WHA 56.19, prevention and control of influenza pandemics and annual epidemics, 56th WHA,10th plenary meeting.
Wiese-Posselt, M., Leitmeyer, K., Hamouda, O., Bocter, N., Zollner, I., Haas, W., et al. (2006). Influenza vaccination coverage in adults belonging to defined target groups, germany, 2003/2004. Vaccine, 24(14), 2560-2566.
Zimmerman, R. K., Raymund, M., Janosky, J. E., Nowalk, M. P., & Fine, M. J. (2003). Sensitivity and specificity of patient self-report of influenza and pneumococcal polysaccharide vaccinations among elderly outpatients in diverse patient care strata. Vaccine, 21(13-14), 1486-1491.
Zimmerman, R. K., Santibanez, T. A., Janosky, J. E., Fine, M. J., Raymund, M., Wilson, S. A., et al. (2003). What affects influenza vaccination rates among older patients? an analysis from inner-city, suburban, rural, and veterans affairs practices. The American Journal of Medicine, 114(1), 31-38.
中央健康保險局. Http://www.nhi.gov.tw/webdata/webdata.asp?menu=1&menu_id=4&webdata_id=805. accessed at 2003.
中華民國統計資訊網. Http://www1.stat.gov.tw/ct.asp?xItem=15409&CtNode=4693 accessed at 2006.
孫幸筠, & 陳世英. (2005).漫談流行性感冒及流感疫苗. 健康世界, (229), 8-14.
林倩伃, 蕭靜怡, 吳宗樹, 朱育增, 高全良, 廖宜真, et al. (2007). 人類流行性感冒的流行病學與偵測系統. 疫情報導, 23(5), 254-272.
林天送. (2008).為什麽流行性感冒多發生在冬天？. 健康世界, (265), 48-49.
林智暉, 邱淑君, 張佳琪, 劉定萍, & 陳豪勇. (2000). 預防與治療流行性感冒的新選擇. 疫情報導, 16 (11)
楊素盆. (2004).流行性感冒. 臨床醫學 2004；52：92-9。
楊秋蘭. (2007) 以健康信念模式探討老人族群接種流感疫苗之因素. 中山大學醫管所碩士論文
衛生署疾管局流感資訊網. Http://www.cdc.gov.tw/mp.asp?mp=110. accessed at 2006.
衛生署統計資訊網. Http://www.doh.gov.tw/statistic/index.htm. accessed at 2006.