Health Promotion Administration Research Articles

Elucidating Higher FIT Interval Caners in Proximal than Distal Colon: Population-Based Periodical Screening Cohort Design

Background: The risk of fecal immunological test (FIT) interval cancer (IC) is higher in the proximal colon than the distal colon but the underlying mechanism explaining the disparity remains elusive. Therefore in this study, we aimed to investigate whether the disparity is attributed to FIT accuracy or the fast progression rates from early to late stage (upstaging) within preclinical-detectable phase (PCDP) and from PCDP to clinical phase (CP). Methods: We did a population-based periodical screening cohort study. Data derived from Taiwanese nationwide colorectal cancer (CRC) organized service screening program. A total of 5,417,699 eligible population aged 50-69 with 3,074,538 individuals ever attending until the end of 2014. The incidence rate of entering the PCDP, the upstaging rate within PCDP, the rate of surfacing to CP, and the test sensitivity classified by early (stage 0/I) and late (stage 2+) stage analyzed with the five-state Markov model. Findings: The proportions of ICs (19% vs 16%) and late CRCs (76% vs 67%) were higher in the proximal colon than the distal colon, which was caused by a faster progression rate from PCDP to CP by 19% and a higher likelihood of upstaging in the proximal colon than the distal colon by 1.6-fold, resulting in the corresponding survival difference of IC, but not site-specific FIT accuracy. Interpretation: Faster progression noted in proximal colon not only supports the previous evidence on rapid transition from dysplasia to malignancy for sessile serrated adenomas but also explain the disparity of effectiveness of FIT and provide a new insight into precision medicine for identifying those who are susceptible to the proximal IC of CRC. Funding: None Declaration of Interests: All authors declare no competing interests. Ethics Approval Statement: This study was approved by the Health Promotion Administration, Ministry of Health and Welfare prior to data retrieval and analysis (A1081113) of Taiwanese government and approved by the Research Ethics Committee of National Taiwan University Hospital prior to data collection pursuant to the regulation of the Institutional Review Board (20192023W).

Children Conceived by Assisted Reproductive Technology Prone to Low Birth Weight, Preterm Birth, and Birth Defects: A Cohort Review of More Than 50,000 Live Births During 2011-2017 in Taiwan.

Objectives: The use of assisted reproductive technology (ART) has increased rapidly in Taiwan. The purpose of this study is to discuss the risks of low birth weight, preterm birth, and birth defect for children conceived by assisted reproductive technology in Taiwan.Methods: Both National ART report database and National birth reports were obtained from the Health Promotion Administration in the Ministry of Health and Welfare in Taiwan. The cohort included live births (n = 1,405,625) and children conceived by ART (n = 50,988/172,818 cycles) from 2011 to 2017. The prevalence of low birth weight, preterm birth, and birth defect were compared between the ART and natural pregnancy groups.Results: Children conceived by ART displayed a higher rate of low birth weight as compared to those in the natural pregnancy group (p < 0.001), even when analyses were restricted to singleton births (p < 0.001). A higher rate of preterm birth (p < 0.001) was also observed in children conceived by ART even when analyses were restricted to singleton births (p < 0.05). A significant increased rate of birth defects was noted from children conceived by ART (p < 0.05).Conclusions: With the increasing need for and use of ART-conceptions, the likelihood of risks induced or related to Assistant Reproductive Technology (ART) has drawn considerable attention in recent years. Taiwan, as one of the leading countries with outstanding ART performances and modern medical care, the result of the current study suggests that further consideration and tighter regulations and policy are needed with regard to the use of ART.

Prognostic Factors for Survival in Patients with Oral Cavity Cancer: A Comparison of the Netherlands and Taiwan Using Privacy-Preserving Federated Analyses

Background: The difference in incidence of oral cavity cancer (OCC) between Taiwan and the Netherlands is striking. Different risk factors and treatment expertise may result in survival differences between the two countries. However due to regulatory restrictions, patient-level analyses of combined data from the Netherlands and Taiwan are infeasible. Methods: We implemented a software infrastructure for federated analyses on data from multiple organisations. We included 41,633 patients with single-tumour OCC between 2004 and 2016, undergoing surgery, from the Taiwan Cancer Registry and Netherlands Cancer Registry. Federated Cox Proportional Hazard was used to analyse associations between patient and tumour characteristics, country, treatment and hospital volume with survival. Findings: Five factors showed differential effects on survival of OCC patients in the Netherlands and Taiwan: age at diagnosis, stage, grade, treatment and hospital volume. The risk of death for OCC patients younger than 60 years, with advanced stage, higher grade or receiving adjuvant therapy after surgery was lower in the Netherlands than in Taiwan, but patients older than 70 years, with early stage, lower grade and receiving surgery alone in the Netherlands were at higher risk of death than those in Taiwan. The mortality risk of OCC in Taiwanese patients treated in hospitals with higher hospital volume (≥50 surgeries per year) was lower than in Dutch patients. Interpretation: In this study, we conducted analyses without exchanging patient-level information, overcoming barriers for sharing privacy sensitive information. We found that the outcomes of patients treated in the Netherlands and Taiwan were slightly different after controlling for other prognostic factors. Funding Statement: This work is supported by grants from the Health Promotion Administration, Ministry of Health and Welfare, Taiwan (tobacco control and health care funds). Declaration of Interests: None. Ethics Approval Statement: This study was approved by the Data Release Review Board of the Health Promotion Administration, Ministry of Health and Welfare in Taiwan, which waived the requirement for informed consent.

The Association between Metabolic Syndrome and Elevated Alanine Aminotransferase Levels in an Indigenous Population in Northern Taiwan: A Community‐Based and Cross‐Sectional Study

Our study aims to determine the prevalence of metabolic syndrome (MetS) among the Northern Taiwanese indigenous population and to explore the relationship between MetS and liver enzyme, especially serum alanine transaminase (ALT). This is an observational and cross-sectional study that was conducted in remote villages of an indigenous community in Northern Taiwan between 2010 and 2015. MetS was defined based on the revised NCEP/ATPIII criteria from Taiwan Health Promotion Administration. A total of 454 participants were included in the analysis. There were 277 people with MetS and 177 people without. The prevalence of MetS was 61.01%. The average age was 49.50 years. People with MetS had a significantly higher liver enzyme (ALT) level than those without MetS. In addition, the study showed that participants with higher ALT had a tendency towards a higher prevalence of MetS (76.7% vs. 57.3%, p = 0.001). The adjusted odds ratio (OR) of ALT levels >36 U/L for MetS was 2.79 (95% CI = 1.24–6.27, p = 0.01). The area under the ROC curve (AUC) of the ALT level was 0.63 (95% CI = 0.58–0.68, p < 0.001), which showed that the ALT level was positively associated with MetS. The overall prevalence of MetS was 61.01% in the highland indigenous population in Northern Taiwan; this study indicated that higher serum ALT levels were associated with an increased risk of MetS.

A survey of current use, dilemma and outlook of antenatal ultrasonography in Taiwan

ObjectiveAccording to World Health Organization's Jungner and Wilson criteria for competent screening programs, routine antenatal ultrasound screening is legit and effective to improve both maternal and perinatal outcomes. Health Promotion Administration, Ministry of Health and Welfare in Taiwan followed expert recommendations and started reimbursing one antenatal ultrasonography around mid-second trimester since 1995. However, medical disputes pertaining to examination results grew, while confusions challenged doctors and patients alike. The aim of this study is to assess current use of antenatal ultrasonography for low-risk pregnancies in Taiwan. Specifically, the indications, test frequencies, test items, methods of payment, obstetricians' opinions on important scan timing and areas to be improved are surveyed and analyzed. An overview of international antenatal ultrasound practice guidelines are examined and compared to enhance the quality of antenatal ultrasound screening in Taiwan. Materials and methodsFrom December 2015 to December 2016, 925 questionnaires were distributed to all licensed obstetricians registered to Taiwan Association of Obstetrics and Gynecology as well as Taiwan Society of Perinatology. A 10-min self-reporting questionnaire was sent by mail, with stamped return envelopes included. Respondents remained entirely anonymous and disclosed no personal information. Data was collected and analyzed for statistical analysis. ResultsMost hospitals are well equipped with ultrasound machines of 3 or more functions. Eighty-eight percent of the obstetricians in Taiwan perform prenatal ultrasonography in every office visit for their patients, mostly free of charge. Scans at gestational age 15–22 weeks, <10 weeks, 11–14 weeks and 28–32 weeks are polled as the most importance in the order of significance. In general, they perceive the one-time antenatal scan offered by the Health Promotion Administration as for general obstetrics scan but not higher-leveled studies. Patient education and doctor-patient communications are opined as the 2 most important aspects to enhance antenatal ultrasound quality. ConclusionThis report is the first of its kind in Taiwan. It could potentially serve as guidance for national health policy innovations in maternal and fetal care, such as increasing frequency of scans, specifications of scan timing, indications and consequences as well as patient education about this screening modality.

Different Survival Can Not Be Fully Explained by Stage of Colorectal Cancers with Various Detection Modes within the Fecal Immunochemical Test-Based Screening Program

Background: Survival of colorectal cancer detected within a screening program may largely affect effectiveness of screening. Survival of colorectal cancer by different detection modes within fecal immunochemical test (FIT)-based screening program is, however, rarely reported. Methods: Colorectal cancers with various detection modes within a population-based FIT screening program comprise the study cohort. Totally 8 992 colorectal cancers were identified from the cohort who were considered as eligible for screening during 2004-2012 in Taiwanese Colorectal Cancer Screening Program and were followed up until 2016. Their survival status was compared and stratified by different detection modes. Multivariable analyses were conducted with Cox proportional hazards regression models. Findings: Colonoscopy interval cancer, FIT interval cancer, and colorectal cancer in colonoscopy noncompliers presented at a more advanced compared with screen-detected colorectal cancers. The 5-years survival rate was higher for subsequent screen-detected colorectal cancers and worst in FIT interval cancer and colorectal cancer in colonoscopy noncompliers. In multivariable analysis, when compared with subsequent screen-detected colorectal cancers, colorectal cancers in colonoscopy noncompliers, the adjusted hazard ratio and its 95% confidence interval for colorectal cancer death was 1·25(1·04-1·50) for prevalent screen-detected colorectal cancers, 1·62(1·21-2·18) for colonoscopy interval cancers, 1·79(1·48-2·15) for FIT interval cancers, and 1·95(1·61-2·37) for colorectal cancer in colonoscopy noncompliers even after adjusting for stage. Interpretation: Interval colorectal cancer and colorectal cancers in colonoscopy noncompliers had worse survival than screen-detected colorectal cancers and factors other than stage might have affected survival and screening organizers should elaborate on relevant aspects. Funding Statement: This study was supported by the Health Promotion Administration, Ministry of Health and Welfare (A1011119, A1021227, A1031135, A1041122, A1051013, and A1061224). Declaration of Interests: The authors stated: None. Ethics Approval Statement: This study was approved by Health Promotion Administration of the Ministry of Health and Welfare of the Taiwanese government.

Impact of Parent-Child Relationship and Gender on Trajectories of Children Internalizing Problems

Background: Parenting and parental-child relationship may lead children to develop behavior problems that can affect many aspects of their later life, such as happiness, health, intelligence and mental illness. This study aimed to examine the impact of parent-child relationship and gender on the development of internalizing behavior problems (IBP) in children. Methods: Childhood and Adolescent Behaviors in Long-term Evolution (CABLE) is a longitudinal healthy-lifestyle research for which 18 elementary schools were randomly selected respectively in Taipei and Hsinchu in Taiwan. Data were collected on family interactions, lifestyle, problem behaviors and physical health. Data on gender, parent-child relations, and internalizing problem behaviors from four waves of follow-up were analyzed in this paper: 2003 (9 year olds), 2006 (12 year olds), 2009 (15 year olds) and 2012 (18 year olds). A latent growth model (LGM) was used to examine the impact of parental-child relationship and gender on the trajectory of children's IBP. Results: Results show that IBP is more severe (r = 0.21, p < 0.01) and their growth rate faster (r = 0.15, p < 0.01) in girls than in boys. Results from latent growth model show that parent-child relationship is negatively related to the IBP intercept (r = -0.59, p < 0.01) and is positively related to the IBP slope (r = 0.18, p < 0.01). Conclusions: The findings suggest that girls are more susceptible to IBP in puberty, and better parent-child relationship can have a protective influence although the protective impact reduced through time. Health professionals should be sensitive to gender, family functioning and provide positive parenting programs for children at risk for IBP. Funding Statement: National Health Research Institutes and Health Promotion Administration, Ministry of Health and Welfare Taiwan, grant number HP-090-SG-03. Declaration of Interests: The authors have no conflicts of interest relevant to this article to disclose. Ethics Approval Statement: This study protocol was reviewed and approved by the human protection committee of the National Health Research Institutes Taiwan.

Development and Validation of a Self-Assessment Tool for an Integrative Model of Health Promotion in Hospitals: Taiwan's Experience.

The Health Promotion Administration of Taiwan launched an integrative certification initiative in 2016 to streamline a plural system of certifications of health promotion in hospitals. It endeavored to replace original certifications, thereby establishing the proposal of a self-assessment instrument to aid in this integration. This study aimed to verify the robustness of this self-assessment tool by conducting exploratory factor analyses through stratification, reliability tests, content and construct validity tests, and specialist evaluations, which were convened to judge the comprehensibility, applicability, and importance of the standards and measures of this tool. A stratified random sampling of 46 hospitals was performed to confirm the validity of this tool. The tool rendered a floor effect of 0% and a ceiling effect of 13%. A valid factor structure and internal consistency (α ranged from 0.88 to 0.96) in each standard were verified. Hospitals with previous certificates or with 300+ beds achieved high compliance scores. A majority of experts agreed that the sub-standards were comprehensible (≥80%), applicable (≥70%), and important (≥70%). Finally, we conclude that the self-assessment tool is valid and can serve as a reference for other countries with hospitals committed to health promotion in hospital settings.

Planning Mass Eradication of Helicobacter Pylori Infection for Indigenous Taiwanese Peoples to Reduce Gastric Cancer

Background: To identify the gastric cancer burden in Indigenous Taiwanese peoples and conduct a project to evaluate how to reduce the disparities most effectively in Indigenous communities. Methods: First, we quantified the gastric cancer burden for Indigenous peoples using data from Taiwan Cancer and Mortality Registries. Risk factor analyses were carried out based on literature review and data from ongoing mass screening for other cancers. Second, we identified parameters that might be associated with Helicobacter pylori infection or help identify a good eradication strategy. Findings: Gastric cancer incidence (24·4 vs. 12·3 per 100,000 person-years) and mortality rates (15·8 vs. 6·8 per 100,000 person-years) were higher in Indigenous peoples than in non-Indigenous, with 2·19-fold (95% Confidence Interval [CI]: 2·06-2·33) and 2·47-fold (2·28-2·67) increased risk, respectively. Despite similar cancer stage at diagnosis, the survival rate in Indigenous peoples was 9·6% (0·1-20·1%) lower. Helicobacter pylori infection is a well-documented risk factor and smoking for >10 years increased the risk by 26·3% (7·9-47·8%). In Indigenous communities, both H. pylori infection (56·1%, 95% CI: 53·6-58·6%) and smoking (28·4%, 95% CI: 25·7-31·0%) were prevalent. Program eradication rates using clarithromycin-based triple therapy were suboptimal (73·7%, 95% CI: 70·0-77·4%); the habits of smoking (1·49-fold, 95% CI: 1·10-2·02) and betel nut chewing (1·40-fold, 95% CI: 1·03-1·89) were associated with the higher risk of treatment failure. Interpretation: Gastric cancer burden is higher in Indigenous Taiwanese than in their non-Indigenous counterparts. Eliminating risk factors, including H. pylori eradication and smoking cessation, is a top priority to reduce this health disparity. Funding: Health Promotion Administration, Ministry of Health and Welfare, Taiwan. Declaration of Interest: The authors report no conflicts of interest. Ethical Approval: The Research Ethics Committee of National Taiwan University Hospital (201804108RINB) and the Council of Indigenous Peoples in Taiwan (1070056368) approved the protocol for this program. The informed consent has been obtained from each participant.

Less barium enema, more colonoscopy: A 12-year nationwide population-based study in Taiwan.

Colorectal cancer (CRC) is the second most common and third most fatal cancer in Taiwan. To reduce incidence and mortality rates from cancer, including CRC, the Health Promotion Administration in Taiwan initiated the National Program on Cancer Prevention in 2005. For patients who have a positive fecal occult blood test, colonoscopy is recommended, and double-contrast barium enema (BE) is reserved as an alternative for those who cannot receive colonoscopy. In addition, single-contrast BE is sometimes used in pediatrics to evaluate colonic condition. This study evaluated the usage trends of BE and colonoscopy in Taiwan. Data from the National Health Insurance Research Database from 2001 to 2013 were used in this study. Patients who received BE and colonoscopy were identified using the procedure codes of the National Health Insurance program. Age-standardized, yearly rates of BE and colonoscopy procedures were calculated. According to the data, the total number of colonoscopies increased 3.7-fold from 2001 to 2013. The compound annual growth rates for BE and colonoscopy were -5.36% and 10.47%, respectively, during the same period. The compound annual growth rates for BE and colonoscopy were -3.89% and 11.64% from 2005 to 2009, and -11.36% and 9.82% from 2010 to 2013, respectively. BE was conducted significantly more frequently than colonoscopy in patients who were aged <12 years and in female patients. Professional association guidelines, national cancer prevention programs, patient and physician preferences, and increasing awareness and knowledge of CRC may all contribute to the increasing use of colonoscopy and the dramatic decline in the use of BE in Taiwan.

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine

The trends of prenatal screening and prenatal diagnosis in Taiwan from 2006 to 2015

Objective To determine the trends in the impact of combined first-trimester testing in conjunction with second-trimester maternal serum screening and non-invasive prenatal diagnosis in Taiwan from 2006 to 2015 Methods This national registry-based cohort retrospective study examined a total of 2,019,369 births from January 2006 to December 2015. In the 10-year period, the prenatal screening methods evolved from second-trimester serum test screening to the combined first-trimester test and the secondary-trimester quadruple test, followed by non-invasive cell-free DNA prenatal screening. Official policy indications were implemented for prenatal cytogenetic diagnosis among pregnant women. Personal registration numbers of women who had an amniocentesis or chorionic villus sampling (CVS) were retrieved from the Taiwan Central Cytogenetic Registry and cross-linked with the National Registry of Patients to determine the outcome of each pregnancy. The data used were provided by the Health Promotion Administration of Ministry of Health and Welfare. Results We estimated that the total number of invasive prenatal diagnoses was 410,972, and the overall rate of invasive procedures was 21.82%. The proportion of advanced maternal age (AMA) increased from 11.8% in 2006 to 24.9% in 2015. The rate of the indication for invasive prenatal diagnosis in AMA increased from 62.7% in 2006 to 91.2% in 2015. The prenatal detection rate of trisomy 21 and 18 increased from 74.1% and 83.3% in 2006 to 93.7% and 99.1% in 2015, respectively. The population prevalence's of trisomy 21, 18, and 13 were one in 739, 2920, and 10847, respectively. Discussion The amount of AMA pregnant women increased year by year, and the number of invasive procedures increased with age. However, the detection rate was also increased by the improvements in screening methods.

Use of assisted reproductive technologies before and after the Artificial Reproduction Act in Taiwan.

BackgroundLow birth rates and infertility are growing concerns for many countries. The Artificial Reproduction Act (ARA) was implemented in 2007 to better support the use of assisted reproductive technology (ART) in Taiwan. This study aims to examine trends in the use of ART and to determine impacts of the ARA on ART use.MethodThis study used data from the Health Promotion Administration in Taiwan. We used auto-regression models to examine the recent trends (1998–2017) in fertility related indicators and the use of ART. An interrupted time series design and segmented linear regression models were applied to analyze the changes in number of ART treatment cycles and birth rates by ART following the ARA.ResultsThe number of births by ART has gradually increased, with an annual growth rate of 21.55%. The rate of births by ART increased from 0.86% in 1998 to 1.44% in 2007, and to 4.33% in 2016 (annual growth rate: 41.23%). We estimated a relative increase of 78.51% (95%CI: 46.13%, 110.90%) in the number of births by ART and a relative increase of 35.67% (95%CI: 18.87%, 52.47%) in rate of births by ART 5 years following the ARA was implemented.ConclusionART has been seen as an approach to improve fertility. Our analysis suggests that the ART use and births associated from ART use both increased in Taiwan following the implementation of ARA. This experience in Taiwan may offer important lessons for other countries that are facing low fertility challenges.

Geographical Distribution of Fast Food and CRC Incidence in Young Adults

Background: There is an increasing trend of colorectal cancer (CRC) in young adults who also used to take fast food. However, little is known about the association between fast food and the occurrence of CRC in young adults. Aim: To investigate the impact of fast food diet on the incidence rate of CRC in terms of geographic distribution. Methods: Geographic distribution of fast food diet was measured by the density of fast food stores (numbers of fast food stores/population per 105) according to each county. We summed up total numbers of the fast food stores ranking the top 3 in Taiwan from the corresponding official Web sites. The incidence of CRC from 2004 to 2013 for young adults aged 15 to 49 years old was computed from Interactive Information System of the National Cancer Registry, provided by Health Promotion Administration, Ministry of Health and Welfare. Multilevel random-effect regression model was applied to estimating the effects of geographical location of fast food stores at city/county level on incidence of CRC with adjustment for age and gender at individual level. Results: The incidence rate of CRC in young adults aged 50 years or below was in parallel with the distribution of fast food stores in geographical pattern. After adjusting for age and sex, the results show that an increase in the growth of 1 unit of density in fast food store led to an increase in incidence of CRC by 2%. Approximately 87% accuracy was noted in predicting the highest one-third percentage of incident CRC cases in young adults. Conclusion: The density of fast food stores was highly associated with the increased risk of colorectal cancer incidence in young adults. This may account for the increasing trend of CRC in young adults in Taiwan.

Determining Potential Target Groups for Oral Cancer Screening by Investigating Risk Behaviors Among Occupations

Background: Oral cancer is a major public health burden in Taiwan. Studies have suggested that habits of betel quid chewing, tobacco smoking and alcohol drinking as well as their interaction effects are important risk factors for oral cancer and oral potentially malignant disorders (OPMD). A population-based oral cancer screening program has been implemented by Health Promotion Administration, Ministry of Health and Welfare, Taiwan. People with betel quid chewing and/or cigarette smoking habits are recommended for biennially screening. Previous studies found that majority of betel quid chewers were in labor intensive occupations. Given the fact that high risk groups of oral cancer are often reluctant to attend screening, targeted approach should be applied to improve the effectiveness of screening program. Aim: The aims of this study are to identify occupations with high prevalence of betel-quid chewing and also to investigate changing trends using the National Health Interview Survey (NHIS) database. Methods: The NHIS database of 2009 and 2013 were used to conduct this study. We identified current users of betel quid and/or cigarette from adults with aged 20-64 years old and working on jobs. Occupations were classified using the International Standard Classification of Occupations (ISCO-88). Statistical analyses included indirect standardized rate ratios and cluster analysis of chewing/smoking habits. Results: From the total survey participants (2009: 19,201, 2013: 17,249), we extracted 11,507 and 10,760 persons for the study. In the year of 2013, using the 2-digit code of ISCO-88, drivers and mobile-plant operators (code 83 in ISCO-88) had the highest prevalence of betel quid chewing habit (30.9%), followed by extraction and building trades workers (code 71 in ISCO-88, 29.6%). These two groups also had the 2 highest smoking prevalence (61.2% and 62.2%). The betel quid chewing prevalence decreased from 2009 to 2013 slightly (32.3%-30.9%). However, the prevalence of smoking increased (60.0%-62.2%). Among the betel quid chewers of the two focused occupations, the corresponding rates of receiving oral cancer screening were rather low (35.47% and 21.52%). The indirect standardized ratios using the total sample as the reference showed 6 occupations (2 digit of ISCO-88) with significantly higher ratios (larger than 2). Cluster analysis demonstrated that the group with high prevalence of betel quid chewing also had high prevalence of cigarette smoking habit. Conclusion: The betel quid chewing prevalence has been decreased in all occupations. While at the same time, prevalence of cigarette smoking did not largely decrease. We analyzed the NHIS databases and found that workers in some occupations tend to have higher prevalence in both betel quid chewing and smoking. The oral cancer screening and cancer awareness need be targeted on certain occupations.

The Effect of a Financial Incentive Designed of Transtheoretical Model–Based Interventions on Betel Quid Cessation

Background: Betel quid (BQ) and cigarette smoking (CS) are oral cancer risk factors. It has been estimated that hundreds of million people mainly in the Asia-Pacific region were consume certain variety of BQ. BQ is the fourth most commonly used psychoactive substance in the world and require assist the chewers to withdraw it. In Taiwan, Health Promotion Administration (HPA) has initiated a hospital-based in-reach screening services for oral cancer to chewers and smokers since 2010 and proposed a financial incentive BQ cessation program designed based on Transtheoretical Model (TTM) to BQ chewers within entrusted “Cancer Control Advanced Program” hospitals in 2017. Aim: This study aims to examine whether this strategy can assist BQ chewers to diminish or quit chewing BQ. Methods: This study was a longitudinal study design used an administration database. BQ chewers were interviewed with 3 times within 1 year follow by a uniform TTM-based BQ cessation intervention by HPA-trained health educators. A face-to-face questionnaire interview were conducted to obtain baseline information, 3 interventions' behavior change stages as well as final BQ chewing status. Generalized linear mixed model was used to determine the association between TTM changing process and effectiveness of BQ chewing behavior changes. Results: A total of 5476 BQ chewers completed 3 times interventions and classified into high-reduction group (N = 2698), middle-reduction group (N = 1978), and low-reduction group (N = 800) after 1-year follow-up. We found BQ chewers were primarily men and aged 40 to 60 years. Over half participants chewed BQ ≤10 BQ per day. Most of them were higher percentage on cigarette smoking and alcohol drinking. Almost 45% BQ chewers did not have regular oral mucosa screening. The stages of change were shift from precontemplation and contemplation stage to action and maintenance stage during 3 interventions. After adjusting for covariates, participants in preparation stage compared with those in precontemplation stage were associated with an increasing odds ratio in middle-reduction BQ (odds ratio = 2.79, 95% confidence interval = 2.27-3.44) and in high-reduction BQ (odds ratio = 3.75, 95% confidence interval = 3.02-4.66). Moreover, BQ chews who chewed BQ ≤10 BQ per day and did not a cigarette smoking had higher chance to had high-reduction of BQ. Conclusion: This modified TTM BQ cessation provides according to behavior change 5 stages could benefit from hospital-based health education to lower BQ, however, future relapse rate should be concerned.

Health Without Boundaries

'Sow in spring, grow through the summer, harvest in autumn, store in winter' reflects the ancient wisdom of the Chinese people, passed down for thousands of years. As this year comes to a close, this journal would like to pause to recognize that Taiwan's national health insurance system has been looking after and caring for the health of Taiwan's people for more than 20 years. What can we do to better follow global care trends and to perform better for public health in Taiwan? Many thanks to Director Wang of the Health Promotion Administration for introducing to readers the concept of 'health without boundaries' and examining Taiwan's future healthcare blueprint from a global perspective. In addition, under the influence of fast-changing medical technologies and rising life expectancies, the increase in the population with chronic diseases prompted Health Promotion Administration's Chronic Disease Division Chief Jia Shuli to provide a comprehensive description of his division's work, from developing chronic disease self-care regimens to developing follow-up control protocols. Professor Lin, with years of diabetes prevention, treatment and innovative experience, has also written an article for this issue that explains why health professionals should go beyond dealing with diseases in order to listen, cooperate with, and interact with patients in order to expand the adoption and effectiveness of diabetes self-management programs. Finally, Professor Guo's article stresses the importance of promoting a healthy environment by going beyond focusing on one's health to address the improvement of the overall environment in order to shape the urban health landscape and achieve A+ health quality. In these cold winter days, brew a pot of hot tea and let us taste together these rare journeys of wisdom.

Chronic Disease Prevention: Present and Future

Non-communicable diseases (NCDs) have risen to become a major threat to health worldwide. According to the World Health Organization, NCDs accounted for 68% of all global mortality in 2014, with over 40% of NCD-related mortality incidents defined as premature deaths under the age of 70 years. Among the top-10 causes of death named by the Taiwan Ministry of Health and Welfare in 2017, 28% were cancers, 22.3% were cardiovascular diseases, 5.7% were diabetes, and 3.6% were chronic obstructive pulmonary diseases. These four major NCDs currently account for nearly 60% of all mortalities in Taiwan and reflect the threat of NCDs to global health. Taiwan's increasingly ageing society faces an increasing risk of NCDs, which threatens the health and wellbeing of Taiwan's population. A survey by the Health Promotion Administration in 2013 found that over 80% of senior citizens in Taiwan are afflicted with one or more NCD and that the presence of a comorbidity further exacerbates the problem of living and coping with NCDs. This article introduces the primary, secondary, and tertiary public health prevention measures related to NCDs in order to help caregivers better understand the importance of reducing the risk factors of NCDs and of screening to promote early detection and treatment. This article further proposes a systemic framework for the future care of NCDs.

The Development of Cancer Patient Navigation Program in Taiwan

Background and context: Cancer has been the leading cause of death since 1982 in Taiwan. Taiwan cancer case management program started from major 4 cancers (breast cancer, liver cancer, colorectal cancer, oral cancer) since 2004. However, only 82% of patients with a confirmed cancer diagnosis received their first cancer treatment within 3 months in 2012. Aim: To increase the navigation coverage for all cancer patients, Health Promotion Administration (HPA) sets the goal that 91% of patients with a confirmed cancer diagnosis should receive their first cancer treatment within 3 months in 2018. Strategy/Tactics: (1) Subsidize cancer hospitals (2) Accreditation for oncology case management (3) Pay for performance (P4P) Program/Policy process: We subsidized hospitals to establish oncology case manager since 2004. Gradually, hospitals in Taiwan accept this new nursing role and recognize its positive impacts on cancer care. Moreover, Taiwan Accreditation Program of Cancer Care mandated all cancer care institutes to establish the program for oncology case management since 2010. However, there were only 4-6 major cancer patients got the case management service. Thus HPA launched P4P Cancer Patient Navigation Program in 2014 and established reporting system. Outcomes: 95% of newly cancer diagnosis patients (including 92 hospitals) in Taiwan receive the service and 96% of patients with a confirmed cancer diagnosis receive their first cancer treatment within 3 months in 2017. Through the implementation of subsidy, accreditation and P4P, the relative survival rate showed significant improved. The 5-year relative survival rate for all cancers increases from 49% during 2003-2007% to 55.8% during 2011-2015. What was learned: A successful program might start small from few trial sites, should be fully supported and well established the systems by government and will move fast by all healthcare professionals.

Dual Use of E-Cigarettes and Traditional Cigarettes Among Adolescents in Taiwan, 2014-2016.

We investigated the use of electronic cigarettes (e-cigarettes) with traditional cigarettes among adolescents during 2014 to 2016 to identify risk factors for using e-cigarettes only, traditional cigarettes only, or both products. We used cross-sectional data from the Taiwan Global Youth Tobacco Survey, (conducted over a 3-year period by the Health Promotion Administration, Ministry of Health and Welfare, Taiwan), which is representative of tobacco use among adolescents aged 12-18 years. The outcome variable was smoking behavior. Dependent variables included gender, grade, monthly income/allowance, parents' educational level, parents' smoking status, close friends' smoking status, use of other tobacco products, contact with cigarette/e-cigarette advertisements, and access to free cigarettes/e-cigarettes. Multinomial regression identify factors influencing the smoking behaviors of adolescents, as manifested in the use of traditional cigarettes only, e-cigarettes only, e-cigarettes with traditional cigarettes, and nonsmoking. When weighted to the population, the sample included 1723150 adolescents in 2014, 1691568 adolescents in 2015, and 1627216 adolescents in 2016. The rates averaged over three years were as follows: nonsmoking (91.6%), traditional cigarettes only (5.4%), e-cigarettes only (1.5%), and dual usage (1.6%). Among adolescents in Taiwan, the following were risk factors for dual use: male, older, high monthly allowance, smoking parents, smoking friends, use of other tobacco products, contact with cigarette advertisements, and access to free cigarettes. Our results revealed an increase in the number of adolescents using e-cigarettes with traditional cigarettes. We recommend that the government continue smoking cessation programs while maintaining control over advertisements and promotions for tobacco products. This is the first study to examine the dual use of e-cigarettes and traditional cigarettes among adolescents in Taiwan. This study identified the risk factors of using traditional cigarettes only, using e-cigarettes only, and the dual use of e-cigarettes and traditional cigarettes, with nonsmokers used as a reference group. This study examined the relationship between exposure to cigarette promotions and the use of various tobacco products including the dual use of e-cigarettes and traditional cigarettes, both of which have been disregarded in previous studies.