13卷4期

• Link 原著 Original Article
• 環境香煙微粒的粒徑成份分佈The Size-Composition Distribution of Environmental Tobacco Smoke
• 鄭新權、王秋森
  Hsin-Chuan Cheng, Chiu-Sen Wang
• 環境香煙 ； 懸浮微粒 ； 粒徑成份分布
  environmental tobacco smoke ; solanesol ; the size-composition distribution
• 本研究的主要目的在於探討有人吸煙的室內環境中懸浮微粒的粒徑與成份分布。因粒徑是決定微粒在呼吸道內不同位置沉積的主要因素，透過環境香煙微粒杜徑成份分布的研究，可進一步了解環境香煙對人體健康危害的機轉。 本研究選擇三個撞球場為採樣地點，以微孔均勻沉積衛擊器(MOUDI(上? TM))進行空氣中懸浮微粒採樣。此種衛擊器原有八階，本研究只使用其中四階。其裁取粒徑分別為0.17、0.56、1.8、10μm。採樣流量為30L/min。採樣時間依氣懸微粒濃度而定，介於3~5小時。香煙中的solanesol性質安定，且佔有一定的質量比例，故選用為香煙從紅成份的追蹤劑。Solanesol在高溫時易分解，所以樣本經萃取後再作衍生處理，然後使用氣相層析儀連接火燄離子檢測器分析solanesol衍生物。 根據現場採樣結果，三家撞球場細微粒（氣動直裡小於2.5μm）濃度介於53~461μg/立方公尺之間，平均189μg/立方公尺；solanesol濃度介於0.259~9.91μg/立方公尺之間，平均3.03μg/立方公尺；solanesol佔細微粒質量分率介於0.0037~0.0244之間，平均0.0150。分布在大於0.56μm微紅中的solanesol佔所有微粒中solanesol的百分比介於10%~32%之間。根據文獻，推估細微粒由香煙貢獻的百分比平均介於700%~93%。
  The primary objective of this study is to investigate the size-composition distribution of environmental tobacco smoke (ETS) in indoor environment. Particle size is one of the major factors which influence the rates and sites of particle deposition in the human respiratory tract. Study of the size-composition distribution of the environmental tobacco smoke would therefore lead to a better understanding of its health effects. Samples of airborne particles were obtained from three billiard parlors in Taipei by a micro-orifice uniform deposit impactor (MOUDI(superscript TM)). While the original MOUDI(superscript TM) has eight stages, only four stages and the after- filter were used in this study. The cut sizes of the four stages are 0.17, 0.56, 1.8, 10µm respectively. The sampling flowrate was 30L/min and the duration of sampling was in the range of 3~5 hrs, depending on the indoor particulate concentration. Solanesol was chosen as a tracer in this study, because it is stable and has a relatively fixed mass ratio in tobacco smoke particles. The solanesol extracted from the samples was derivatized and then analyzed by the GC-FID method. The derivatization was made to avoid the decomposition of solanesol at higher temperatures. The results show that the mass concentration of fine particles (smaller than 2.5µm in aerodynamic diameter) is in the range of 53~461µg/m^3, with an average of 189µg/m^3; the solanesol concentration is in the range of 0.259~9.91µg/m^3, with an average of 3.03µg/m^3 the mass fraction of solanesol in fine particles is in the range of 0.0037~0.0244, with an average of 0.0150; and 10~32% (average 22%) of ETS are in particles larger than 0.56µm in aerodynamic diameter. The estimated contribution of ETS to fine particles is in the range of 70~93%.
• 285 - 299
• 10.6288/CJPH1994-13-04-01

• Link 原著 Original Article
• 全國衛生所檢驗作業狀況調查結果A Survey of Current Clinical Laboratory Practices of Primary Medical Care Units in Taiwan
• 廖素娥、劉嘉斌、蔡宗仁、李寧、郭有淼、楊炳炘、杜啟安、唐皇、劉武哲
  Suh-Er Liaw Hwu, Chia-Bin Liu, Johnson Tsai, N. Lee, You-Miau Kuo, Yang P. C., Chi-An T, Tang Huang, Wu-Tse Liu
• 衛生所 ； 一般衛生所 ； 群醫中心
  Primary medical care unit PMCU ; general primary medical care unit GPMCU ; group medical care center GMCC
• 為瞭解國內衛生所的檢驗作業狀況，作者設計了一份“衛生所檢驗作業調查表”表內包含檢驗作業內容、執行情形、作業量、人事現況以及儀器設備等項。於1991年6月寄出336件給全省所有衛生所，至11月止兵收回215件，回收率64.0%。其中有執行檢驗作業的共123所，有73所是群醫中心，50所是一般衛生所。設有檢驗作業的衛生所，其檢驗部門及作業內容之普及性依序為生化學88所(71.5%)，一般檢驗學80所(65.0%)，血液學77所(62.6%)，血庫學54所(43.9%)及血清免疲學51所(41.5%)。將檢體全部委託其他單位代檢的主要部門是血清免疲及細胞學。檢驗的作業量依序為一般鏡檢學、生化學、血清免疲學、血液學、血庫學、細胞學及細茵學。檢驗作業的負責人有72所(58.5%)是醫檢師，有29所(23.6%)是醫檢生。基本的儀器設備中，使用年限在5年內的離心機有44台(39.7%)，顯微鏡有46台(38.7%)。由本調查結果得知國內衛生所的檢驗現況，在全民健保實施時，若需要衛生所執行配合醫療需要的檢驗作業時，務必要再多充實專業人力及硬體設備的投資。
  In the process of developing a national health insurance program, the quality of clinical laboratory practices in primary medical care units (PMCUs) is vital. For this purpose, a survey including the quality of laboratory tests, test capacity, personnel, and current condition of instruments was designed. A questionnaire was sent to all PMCUs and the response rate was 64% (215/336), 36.6% of PMCUs (123/336) have laboratory testing. 73 of these belong to the group medical care centers (GMCCs), the others are general PMCUs. Biochemistry tests were the most common, 71.5% (88/123); microscopy tests came next, 65% (80/123). Hematology was next, 62.6% (77/123), then blood bank, 43.9% (54/123) and seroimmunology, 41.5% (51/123). Some PMCUs sent part or all of the specimens to nearby hospitals or other laboratories, especially those of the seroimmunology and cytology tests. The numbers of samples tested per year ranged from 0 to 35564. The largest number of samples was for clinical microscopy, followed by biochemistry, seroimmunology, hematology, blood bank, cytology and microbiology. In 72/123 units (58.5%) the laboratory staff were trained medical technologists and in 29/123 units (23.6%) they were trained medical technicians. As far as basic instruments were concerned, new microscopes had been purchased within the last 5 years in 46/119 units (38.7%); new centrifuges had been purchased within the last 5 years in 44/ 116 units (39.7%). Based on the survey data, suggested that the facilities and professional manpower of clinical laboratories in the PMCUs should be upgraded.
• 300 - 307
• 10.6288/CJPH1994-13-04-02

• Link 原著 Original Article
• 台灣地區肝癌、肺癌、胃癌多重危險因子之世代研究A Cohort Study on Multiple Risk Factors of Liver Cancer, Lung Cancer and Stomach Cancer in Taiwan
• 王琪珍、藍忠孚、陳建仁
  Chih-Jen Wang, Chung-Fu Lan, Chien-Jen Chen
• 世代研究 ； 多重危險因子 ； 肝癌 ； 肺癌 ； 胃癌
  Cohort study ; Multiple risk factors ; Liver cancer ; Lung cancer ; Stomach cancer
• 癌症是台灣地區居民的首要死因，而肝癌、肺癌、胃癌更佔癌症死亡的前三位。為瞭解這三大癌症的多重危險因子，本研究乃於1982-1986年間，自台灣省十二個鄉鎮區收案13910名男性成人居民，進行長期追蹤研究。以結構式問卷及標準化訪視，收集研完對象之社會人口學特徵，抽煙、喝酒及飲食習慣等危險因子資料，並且採取血液進行B型肝炎表面抗原的檢驗。研究對象之存活及罹病狀況，則以電話或家戶訪現、戶籍死亡資料查核等方法追蹤獲得。 Cox複迴歸分析結果顯示：平均每天抽煙11-20支及21支以上者，得肺癌的相對危險性分別是不抽煙者的4.13及5.67倍。平均每天飲用酒精多於50cc者，罹患肝癌的相對危險性是50cc以下者的3.54倍；HBsAg陽性者，得肝癌相對危險性是陰、陸者的13.7倍；平均每週進食黃綠色蔬菜六餐以下者，得肝癌的相對危險性是六餐以上者的3.16倍。抽煙26包年以上者，得胃癌的相對危險性是不抽煙者的3.06倍。
  The non-infectious diseases has become one of the most important public health problems for their rapid increase in mortality rates. Malignant neoplasm is the leading cause of deaths in Taiwan, and cancers of liver, lung, stomach are three major cancers for man. This cohort study was carried out to explore multiple risk factors of these three cancers. Study subjects of the cohort included 13, 910 men who were recruited from 12 precincts and townships in Taiwan and had been followed up for five to eight years. A structured questionnaire was used to collect the information on risk factors including demographic characteristics, cigarette smoking, alcohol drinking and dietary habits. The information on the deaths from cause of the cohort was obtained from telephone interviews, household registry and death certification system. Analysis based on Cox's proportional hazard models showed that the relative risks of developing lung cancer for those who smoked 11-20 and>20 cigarettes per day were 4.13 and 5.67, respectively, compared with nonsmokers. The relative risks of developing liver cancer were 3.54 for those who drank alcohol>50cc daily corn- pared with non-drinkers; 13.7 for HBsAg-positives compared with HBsAg-negative; 3.21 for those who consumed vegetable for less than six meales per week compared with those who consumed vegetable more than six meals; and 3.16 for those who had a vegetarian habit for>10 years compared with those who had no vegetarian habit. The relative risk of developing stomach cancer was 3.06 for those who smoked 26 pack-years of cigarettes compared with non-smokers
• 308 - 314
• 10.6288/CJPH1994-13-04-03

• Link 原著 Original Article
• 勞保門診醫療費用支付制度對醫療供給者診療行為之影響The Effect of Changes of Opd Payment System of Labor Insurance on the Providers Medical Care Behavior
• 郭信智、楊志良
  Hsin-Chih Kuo, Chih-Liang Yaung
• 勞工保險 ； 支付制度 ； 醫師行為
  Labor insurance ; payment system ; physician behavior
• 全民健康保險預計於民國83年實施，政府將進一步干預醫療市場，加深對醫療供給與需求之影響。實施全民健康保險之國家，其健康保險之鉅額赤字常成為政府財政上沉重負擔；而醫療供給者對於醫療保險透過支付制度強制約束醫療行為與計算醫療報酬方式，常持反對態度。茲探討甲乙丙表實施前復，勞保門診醫療費用支付制度，對醫療供給者診療行為之影響；並闡示醫療院所特性、病人及疾病特性，對醫療供給者診療行為之影響，以供全民健保現劃之參考。 本文以80年3月台問地區勞工保險局收受醫療院所申報之「勞工保險醫療給付門診就診單」為研究母全體。塞於實務上需要，採分層二階段系統集束隨機方法抽樣，共獲有效樣本5213件。其分析結果與70年之研究結果比較，主要香現如下： 1.醫療費用支出中，內服藥費比例降低。由於甲乙丙表實施後，診察費提高、藥事服務費明列、藥價依照進價申報等因素，使得內服藥費比例降低（70年42.5%、80年3月29.3%）。 2.平均每張處方所開藥品數仍偏高（70年4.13、80年3月4.74)。 3.抗生素重覆使用情形仍相當嚴重。醫療院所愈基層愈傾向使用較多抗生素與重覆使用抗生素（80年3月重覆使用抗生素1種及以上之比例，基層醫療院所55.3%，醫學中心13.1%）。 4.大型醫療院所檢查費、X光診斷費比例偏高。 5.同一傷病之醫療費用變異，在一般申報與專案中報兩部份中，其解釋因素不同。一般申報方面，病人年齡、性別對費用變異均不具解釋能力；而專案中報方面，病人年齡、性別對費用變異卻具較強之解譯能力。 6.大型醫療院所傾向於治療慢性、複雜之傷病，而小型醫療院所則傾向於治療急性、簡單之傷病。
  We randomly sampled 5, 213 outpatient medical records submitted by hospitals and clinics to the Bureau of Labor Insurance for reimbursement in March 1991 for this study. In 1990, the fee schedule, or the so-called ”point system” of reimbursement was drastically changed in which the physician fee rate increased and surcharge was not allowed for the costs of drugs. The case mix, the structure of expenses, and medical care behaviors of hospitals and clinics were analysed; the results were compared with those of 1981. The major findings are as follows: (1) The proportion of expenses of drugs for oral administration reduced from 42.5% (1981) to 29.3% (1991). (2) The drug intensity rate (DIR) among prescriptions kept high from 4.13 (1981) to 4.74 (1991). (3) The proportion of over prescription of antibiotics was prevalent in 1991, e.g. 55.3% with one or more antibiotics among prescriptions from cilinics, 13.1% with those among prescriptions form medical centers. (4) The proportion of expenses for laboratory tests and X-ray examinations increased, especially among those of medical centers. (5) The patients' age and sex explained much more cost variations in general applications than in special applications under the same disease type. (6) Medical centers tended to take care of more patients with chronic diseases than those primary medical care units did.
• 315 - 329
• 10.6288/CJPH1994-13-04-04

• Link 原著 Original Article
• 肝硬化病人支持系統、憂鬱與焦慮反應及其因應行為之相關性研究The Study on the Support Systems Depression/Anxiety Reaction and Coping Behaviors among Cirrhosis Patients
• 陳美倫、郭憲文、 陳滋彥
  Mei-Lun Chen, Hsien-Wen Kuo, Tzy-Yen Chen
• 肝硬化病人 ； 社會支持 ； 憂鬱／焦慮 ； 因應 ； 壓力
  Cirrhosis patient ; Social support ; Depression/Anxiety ; Coping ; Stress
• 本研究目的在探討肝硬化病人的社會支持系統，因應行為及其憂鬱與焦慮反應之相關性影響。研究樣本係以中部某教學醫院肝膽門診科求診病人為對象共收集了106位肝硬化患者，以結構式問卷方式分別以訪視，個人病歷來收集資料，其問卷內容包括個人基本資料，求醫行為，社會支持量表，知覺生活壓力量表，憂鬱／焦慮症狀量表及其因應方式量表。事前經過專家效度及信度之測試，再進行個案之訪視工作。 研究結果顯示：肝硬化患者年齡是以45至60歲年齡層最多佔41.5%，男性佔73.6%，且88.7%急者為已婚，按社經地位程度以較低者56.6%，較高者只佔2.8%。患者之支持來源及強度，均以配偶最多，其次為子女及醫護人員，而滿意程度亦有相同趨勢，前兩者以經濟支援及居家照顧為主，後者則以心理支持較多。在影響肝硬化息者之知覺壓力程度，以多變項迴歸分析中以憂鬱焦慮、因應方式及社經地位有統計上意義，而影響患者憂鬱焦慮症狀則以個人知覺壓力、性別及因應方式。顯示著個人知覺壓力越大者，其憂鬱焦慮症狀亦越嚴重，而因應方式較佳者，其憂鬱焦慮症狀則越輕。因此建議對肝硬化急者除給予適當醫療照顧外，亦應增強對此病之因應行為，醫療人員也應給予適當心理支持及良好醫療照顧，定能逐漸改善病情。
  The main objective of this study is to investigate the support systems, depression, anxiety and their coping behaviors for cirrhosis patients. 106 patients enrolled from a clinical division of hepatology are interviewed by using a structural questionnaire through a reliability and validity test in pre-test steps. The result indicates that the age distribution of cirrhosis patients mostly concentrated on aged 45 to 60. 88.7% of the cirrhosis patients are married and the percentage of the male patients is 73.6%. Owing to the financial resoure of these patients is from governmental insurance, the loading of medical cost is tolerate to ask for western medicine as their treatment method. The sources and strength of social support are attributed to their spouse and then next to their children and medical personels, and the degree of satisfaction also has the same trend. Most of the economic support and home care are provided by their relatives. The medical staffs focus to consult with the mental and emotional supports. Using the multivariate analysis, the affecting variables of perceived stress level among cirrhosis patients contain depression/anxiety, coping ways and their social support, meanwhile, the explanatory variables of depression/anxiety level include the perceived stress, sex, and coping ways. The poorer the coping way is happened, the more the perceived stress and the strength of depression/anxiety is dominant. The study suggests that the medical care and coping behaviors for cirrhosis patients should be provided from medical personals as well as their relatives for decreasing their complication in the future.
• 330 - 341
• 10.6288/CJPH1994-13-04-05

• Link 原著 Original Article
• 精神分裂病患及其配偶在夫妻治療中的關注主題與溝通型態The Concerned Themes and Communication Patterns of Schizophrenic Patients and Their Spouses in the Couple Therapy
• 林梅鳳、蕭淑貞
  Mei-Feng Lin, Shu-Jen Shiau
• 精神分裂病患夫妻 ； 關注主題 ； 溝通型態 ； 田野研究法
  concerned theme ; communication pattern ; couple therapy ; field method
• 本研究目的是由深入探討八對慢性精神分裂症病患及其配偶在夫妻治療中，所呈現的關注主題與溝通型態。採用敘述性的質性研究方法，個案來源於蕭淑貞等人（民80）國科會研究「精神分裂患者其家庭養育功能與其子女社會行為發展問題」，在本研究中，研究者採觀察式參與和護理治療法進行收集資料。於連績三個月的治療過程中，每次以一小時為原則，就其關心主題進行討論；徵得其同意林現場錄音，當治療結束復立即文字化，將病患及其配偶在治療中所表達的言語和行為，寫成敘述體式過程記錄，以內容分析法，將治療過程的主題與溝通行為加以系統分析、歸類。 研究結果發現，病患夫妻所關注的主題，可歸納為疾病資訊過程、個人內在認同過程、人際互動過程三項建構類目。在每一主題之下，病患夫妻所表達的溝通型態，可歸納為促進溝通、阻礙溝通二個向度，其中包含同理性、表達性、壓抑性、排斥性四項概念類目。此研究之結果，可增加對居家照顧中夫妻治療有關的知識；及對精神分裂病患夫妻關注主題與溝通型態的了解同，提供臨床服務、護理研究及教育方面的參考應用價值：期望能配合病患回歸社區之趨勢，提昇護理專業照顧之能力。
  The purpose of this study was to explore the concered themes and communication patterns of chronic schizophrenic patients and their spouses in the process of couple therapy. The research used the quilitative research design. Eight couples were tape recorded for one hour discussion across three months during the therapy. Data were transcribed into narratives and systematically analyzed and categoried. Results showed that the concerned themes during the therapy process could be categoned as illness information processing, intrapersonal identity processing, and inter-personal interaction processing. Communication patterns expressed by the couples under each theme could be viewed as facilitating or hindering communication; empathetic, expressive, suppressive, and rejected were categoried. Study findings highlighted the major foci during couple therapy of schizophrenic patients and their spouses were on the illness information. Couple therapy could improve communication pattern and facilitate change. The significance of the result demonstrated that nurse could take active roles in couple therapy.
• 342 - 351
• 10.6288/CJPH1994-13-04-06

• Link 原著 Original Article
• 母親職業，餵食互動行為與嬰兒發展之關係Relations among Maternal Working Status Feeding Behaviors, and Infant Development
• 蕭淑貞、張桂玲、洪文綺、余玉眉
  Shu-Jen Shiau, Gei-Lin Chang, Win-Chin Hung, Yu-Mei Yu
• 餵食行為 ； 嬰兒發展
  Feeding Behavior ; infant Development
• 在傳統的食行餵為中，父母盡量將食物“餵”進子女。中，其實餵食行為是一種非常複雜且豐富的親情互動行為。就營養觀點而言，餵食是嬰兒生命中重要的一部分；由互動的觀點來看，餵食行動是母親與嬰兒共同參與互動的第一件事，也是母親與嬰兒互相傳遞訊息、反應、適應彼此的一種活動過程。本研究主要的目的在於：(1)探討Dr. Barnard's之餵食量表在國內應用於評量照顧者與嬰兒在餵食過程中的互動行為之適當性，(2)了解照顧者（主要是母親）與嬰兒在餵食過程中的互動情形(3)探討照顧者教育程度、職業狀況等因素對餵食互動行為之影響。(4)了解餵食行為與嬰兒發展之關孫。本研究中應用Dr. Barnard餵食量表(Feeding scale)及貝萊嬰幼兒發展量表(Bayley Test)為研究工具。本研究以某醫學中心第一胎的產婦及使康正常之新生兒為對象；37名職業婦女組和36名家庭主婦組，於產後第三－五天，第一個月、第三個月作訪視及評估。研究結果發現職業婦女在對第二、三天嬰兒的“訊息敏感度”及“困擾的解決方面”之表現較家庭主婦組產婦為佳，但在嬰兒第一個月、第三個月卻有退步之現象，而家庭主婦組的嬰兒在餵食中所表現的行為有越來越好的情形。且家庭主婦組的嬰兒在貝萊嬰兒量表測驗中「動作」、「行為」表現較職業組好。
  Feeding, that places food into an infant's mouth by a mother, is not only to supply nutrition for maintaining the life and promoting the growth of the infant, but also a very complex and profound interactive process between them. Feeding is the first task that needs the participation from both of mother and her infant to accomplish, requiring an informative communication, and mutual interaction and adaptation between each other. The primary purposes of this study were to (1) determine whether the ”Barnard's Feeding Scale” is appropriate to assess the interactional behaviors during feeding for domestic mothers and their infants or not, (2) understand the interactional behaviors between the mothers and their infants during feeding, (3) investigate the influences of educational background and working status of mothers on the interactional behaviors during feeding, and (4) explore the relation between the feeding behaviors and the infant development. Dr. Barnard's ”Feeding Scale” and Bayley's Test were adopted in this study. Subjects were recruited from a general hospital who had just delivered their first and healthy infants. Two groups of mothers were formed according to their working and non-working status. Three assessments were made for each infant at: three days, one month, and three months after the infant was born. The results indicated that the working mothers had better performances in the items of ”sensitivity to cues” and ”alleviation of distress” at the first assessment than the nonworking mother did, but these performances regressed at the second and third assessments. Contrastly, the infants of the non-working mothers improved their behaviors during feeding better and even better at these three assessments, and performed better in the items of ”motor” and ”behavior” than the infants of the working mothers did.
• 352 - 361
• 10.6288/CJPH1994-13-04-07

• Link 原著 Original Article
• 國際衛生之教育研究及發展The Development of Education and Research in International Health
• 紀駿輝
  Chun-Huei Chi
• 國際衛生 ； 衛生發展 ； 國際合作 ； 永續性衛生發展 ； 環球衛生發展
  International Health ; Health Development ; International Cooperation ; Sustainable Health Development ; Global Health Development
• 國際衛生是一門教學與研究的學科且正在成長中。雖然有許多的機構與學者對國際衛生很熱裏，但對於國際衛生卻一直沒有一致的定義。本文的目的在介紹國際衛生的起源及其在教育、研究與實務上的發展。經由其發展及學者們實際所從事之研究與實務，本文嘗試定義國際衛生的本質及範圍。因為國際衛生的研究與活動範圍不斷的在改變，因此為其所下定義必須具包容性及適應性以便能妥切的反應其領域。藉此定義，本文接下來討論並簡要的分析一些當前全球所面臨的重要國際衛生問題。在結論中本文針對這些國際衛生問題提出學術機構因應這些挑戰的策略，以及我國在國際衛生發展上可扮演之角色。
  International health as a field of research, practice, and a curriculum has been growing. While many institutions and researchers are interested in international health, there is little consensus on its definition. This paper examines the origin and development of international health activities, researches, education and training. By looking at what institutions and researchers are practicing in their fields, this paper tries to develop a definition for international health. Since the focus and interests in international health are changing from time to time, its definition needs to be inclusive and adaptive to the frontiers of its field. Using this definition, this paper then reviews the development of international health. This is followed by examining the practice, research, education and training in international health, and several contemporary issues. Finally, the author makes recommendations on how institutions can better prepare researchers and practitioners in addressing these issues, and promoting a sustainable health development in our global community.
• 362 - 370
• 10.6288/CJPH1994-13-04-08