12卷2期

• Link 原著 Original Article
• 差額負擔：公平、效率與醫療品質間之衝突Balance Billing: Conflicts among Equity, Efficiency and Quality of Health Care
• 賴辛癸、藍忠孚
  Shin-Goei Lai, Chung-Fu Lan
• 差額負擔 ； 國家健康保險 ； 健康政策 ； 支付制度
  balance billing ; national health insurance ; health policy ; reimbursement system
• 本文旨在探討全民健康保險時代來臨後，差額負擔應否存在？是否一套標準化的支付制度，可以滿足所有被保險人的醫療需求？是否允許被保險人在保險給付之外，?追求不同醫療品質而付出額外的費用。 本文從不同的角度，來檢視實施差額負擔所可能帶來的衝擊，在考量就醫可近性時，會造成低所得民眾的就醫意願降低；在品質的改善方面，差額負擔雖提供提高品質的誘因，但成本的投入與品質的改善之間並沒有一定的正面關係；在醫療費用的控制方面，差額負擔所強調的市場競爭會導致醫師費用高漲；在另一方面，醫師自主權透過差額負擔的機制保障下，並不可能兼顧民眾的利益。而且行政成本的增加，造成醫療資源的浪費。此外，本文將就美國及加拿大實施差額負擔的現況，及台灣目前公勞農保制度下，差額負擔的實施的現象，提出檢討。最後結論：在強制性的全民健康保險制度下，不應透過差額負擔的方法來達成不同醫療品質的追求，因其所帶來的負面影響將大過於正面影響。
  The primary purpose of this paper is to discuss whether or not balanced billing should be allowed after implementation of the National Health Insurance plan? Can a standardized reimbursement system satisfy the health care demands of all beneficiaries? Should beneficiaries be allowed to pay extra money for different levels of quality of health care beyond those provided by this insurance plan? In this paper, the possible impacts of implementing balanced billing are examined from different perspectives. Considering access to health care, balanced billing will decrease the willingness of low-income groups to use health services. In impoving the quality of health care, however balanced billing will provide incentives for higher quality. The relationship between the input of cost and quality of health care is not always positive. In the control of medical expenditures, market competition, which balanced billing will emphsize will result in the inflation of costs. On the other hand, the autonomy of physicians will be protected by the mechanism of balanced billing. However, it may not provide optimal public care. Moreover, the increase in administrative cost will result in a waste of medical resources. Additionally, this paper discusses the implementation of balanced billing in American, Canada, and the existing insurance plans in Taiwan. The conclusion is that different levels of health care quality under the statuatory National Health Insurance should not be pursued by balanced billing, as it will have more negative effects than positive effects.
• 107 - 120
• 10.6288/JNPHARC1993-12-02-01

• Link 原著 Original Article
• 套裝統計軟體應用於臨床細菌檢驗作業統計之探討Application of a Statistical Software Package for Routine Work of a Clinical Bacteriology Laboratory
• 楊炳炘、施木青
  Biing-Shin Yang, Mu-Ching Shih
• 臨床細菌學 ； 工作量 ； 統計 ； 品質保證 ； 檢驗室管理
  Clinical bacteriology ; Workload ; Statistics ; Quality assurance ; Laboratory management
• 利用SPSS/PC+統計套裝軟體，建立一套普遍適用的程式，將細菌檢驗室常規作業的記錄加以整合分析；除了建立資料庫以利查詢、報告、保存等例行業務之外，同時定期完成送檢單位分析、檢體類別統計、送檢單位與檢體類別比較分析、陽性菌株頻度分析與分布情形、陽性檢出率統計、特定條件的分布情形與比較分析、抗生素敏感性型式等分析報表。一方面協助提升品質管制的效率；一方面擴展細菌檢驗記錄的運用層面，以利管理、溝通、評鑑、教育、院內感染管制、流行病學研究等的發展。本系統是?管理者提供決策的參考訊息，而不是某種行動的結果；所以，本系統仍然具備相當高度的可塑性，有識者參考採用時，可以依照本身的需要，加以適當的修改與增補。
  To improve the total performance of a clinical bacteriology laboratory, basic statistical programs from the Statistical Program for the Social Sciences for personal computers (SPSS/PC+) wera aplied to develop a descriptive system for routine work. Examples of frequencies for requisitions, specimens, departments, positive isolation rates, identifications, grouped reports of antibiotics sensitivity patterns, and comparative studies among elected conditions with two-way tables, are presented. The system yields an abundance of references for quality assurance, administrative acreditation, nosocomial infection control, epidemiological studies, and education programs.
• 121 - 137
• 10.6288/JNPHARC1993-12-02-02

• Link 原著 Original Article
• 長途客運汽車乘客的吸菸行為與相關因素探討Smoking Behavior and Its Correlates: An Investigation among the Passengers of Long-Distance Buses
• 李蘭、潘怜燕
  Lee-Lan Yen, Ling-Yen Pan
• 吸菸 ； 行 ； 知識 ； 態度
  smoking ; behavior ; knowledge ; attitude
• ?探討長途客運汽車東客與吸菸有關的知識、態度和行?，並進一步分析影響其態度和行?的因素，採立意取樣方式，自往來於高雄與台北之間的公營與民營汽車客運公司中各選一家?對象。根據兩家汽車公司的行車時刻表，隨機選出共68個車次的1162名來客完成問卷填答。結果發現，公營車和民營車來客在背景因素，及吸菸有關的知識、態度和行?上，有明顯的差異。整體來說，民營車來客中有吸菸習慣者較公營車乘客來得多（15.8%比25.2%）、認知較差、態度偏負向。這些來客幾乎都已看過禁菸標示且知道是指公共場所不要吸菸的意思，但有14.8%的人認?根本無效。有63.4%的人不知道有禁菸小組拜會活動；有43.1%的人不知道有公共場所禁菸辦法；有87.8%的人支持政府推動公共場所禁菸政策。有吸菸者在公共場所看到禁菸標示時，會馬上熄菸者佔63.3%；不吸菸者經常勸別人不吸菸之行?，以家裡的發生率最高(41.7%)、工作場所次之(21.4%)、而公共場所最低(8.8%)。對於吸菸行?而言，性別、年齡和教育程度是背景因素中最具影響力的三個變項。有關吸菸的知識和態度、對禁菸政策的支持程度及吸菸行?之間有互?因果的關係。公共場所禁菸之宣導、教育和政策是必須的，而且有待推廣。
  The purpose of this study was to investigate passengers knowledge of, attitude towards and habits of smoking. Buses commuting between Taipei and Kaoshiung, some public and same private, were purposely selected as the samples. Based on the time schedules, 68 buses were randomly selected and 1162 passengers were studied. The backgrounds of passengers on public buses were different from those on private buses. Of these two groups, those on private buses smoked more (45.8% vs 25.2%), had less knowledge about the hazards of smoking and had more positive attitudes toward smoking. Almost all of the subjects had seen the antismoking signs and understand that smoking in public places is prohibited. A small number, 14.8%, of the subjects thought that the labels were useless, and 63.4% of the passengers were not aware of the surveilance activities performed by the Antismoking Group. A total of 43.1% of the subjects reported that they were unaware of the Public Sites Antismoking Regulation, and 87.8% of the subjects indicated that they support the antismoking policy. A majority, 613%, of the smokers indicated that they would extinguish their cigarettes in areas where antismoking signs were posted. The places where the non-smokers would advise smokers not to smoke are the home (41.7%), workplace (21.4%), and public sites (8.8%). Background factors including gender, age, and education were significantly related to a subjects smoking behavior. There were close correlations between a subject’s knowledge, attitude, policy support, and smokng behavior. An educational program focused on antismoking is expected to be propagated.
• 138 - 152
• 10.6288/JNPHARC1993-12-02-03

• Link 原著 Original Article
• 台北地區兒童壓力源的初探Study of Children's Perceived Stressors in Taipei City
• 張珏、葉莉薇、張月英、 陳寶雲、方金雪
  Chueh Chang, Lei-Wei Yeh, Yueh-Ing Chang, Pao-Yun Chen, Chien-Sheue Fong
• 兒童 ； 壓力源 ； 城市區／郊區
  Children ; Stressor ; Urban/Suburban
• ?了明瞭兒童對其周遭日常生活中所感受到的壓力源有那些，特別比較台北地區位於城市中心區部份（文、教、政區）的學童516名，以及403名邊緣郊區學童（陽明山帶），檢視是否因不同地區而感受壓力源有差異。本調查採用開放式問卷取得30項壓力來源，再歸類成七大類別成?封閉式問題，探詢學童的主觀感受壓力來源。結果發現，在所列出30項的壓力源上，其排行前十名的有所異同，城市中心區學童較?強調自然環境的壓力（至少十名中的四名），包括空氣污染、交通擁擠、和環境污染；而只有環境污染一項出現在郊區學童的前十名中，對於社會環境的壓力源如示威遊行，則亦?城市中心地區孩子較敏感其傷害性，並能覺察而感受壓力，郊區則較少。在二組學童中共同有的壓力源淤前十名的則?：手足失和、考試、生病。文中並討論這些壓力源對兒童生活品質以及心理健康的影響，且指出與目前快速變遷的社會因素有大關連，是公共衛生工作中需注意的一環。
  To better understand children's perception of stress in their own lives, a study was undertaken comparing children in Taipei city with those in suburban environments. A total of 516 students (282 boys and 234 girls) in a central Taipei elementary school and 403 students (192 boys and 211 girls) from five suburban elementary schools were presented with a questionnaire listing 30 stressors. The top ten stressors varied between the two groups. Central city children reported more stress from the natural environment (four of the ten), including air pollution, traffic, noise pollution, and other environmental pollution. Only one of these stressors (other environmental pollution) appeared in the top ten list of suburban students. While street demonstrations appeared in the central city ranking, suburban students did not rank them among the top ten. Common to both groups was a concern with sibling rivalry, examinations, and illness. The significance of these stressors on the quality of life and mental health of students are discussed along with the particular stresses associated with rapid social change in an urban center.
• 153 - 163
• 10.6288/JNPHARC1993-12-02-04

• Link 原著 Original Article
• 比較高社經與低社經情境母子互動關係之初步研究A Comparative Study of Maternal-Child Interaction between High and Low Social Economic Groups
• 蕭淑貞
  Shujen Shiau
• 親子互動 ； 生活互動量表 ； 教導量表
  maternal-child interaction ; life interaction scale ; teaching scale
• 親子互動關係對子女成長的重要性，已不容置疑。國內有關親職教養態度的研究，大多偏向問卷法。本研究希望發展出健康專業人員在臨床或社區服務時能觀察到母子互動的情形，以作?更進一步增進親職教育的參考。 本研究主要目的在於：(1)發展觀察母子“生活互動量表”、“教學量表”；(2)探求教育及經濟因素對母子互動關係及影響；本研究乃採用量性、差異性研究設計。由方便取樣找到社經地位較高和社經地位較低之幼稚園。經取得教師及家長同意，護理人員至個案家中觀察在進餐前至進餐後母子互動關係而完成“生活互動量表”、及觀察母親在教導兒童學某項目時之母子互動關係而完成“教學量表”。 研究結果顯示：(1)有34位高社經情境組的家庭及30位低社經情境組的家庭參與，兒童性別男女約各半。兒童年齡有一半在2-3歲，其餘在4-5歲。(2)由觀察法評估的“生活互動量表”、“教學量表”大部分的項目得到適當的一致度之支持。(3)高社經情境組的母親或兒童在生活情境或教導情境中皆表現得比低社經情境組的正向。(4)在生活情境（進食前至後）中，母親正向、溫暖、自由及鼓勵的態度可促使幼兒行?正向、自主及較少好動。(5)在教情境中母親與兒童之表現並未呈現有意義相關。 本研究最主要的貢獻乃在於發展出具體觀察親子互動關係的評估工具；了解不同社會經濟情境對母子互動關係的影響；以及母子互動關係中彼此影響的相關性。希望此研究結果能增進對親子關係之了解，希望健康專業人員或相關專業人員能在臨床或社區服務時能觀察與評估母子互動的情形，以進一步能促進正向親子關係，協助兒童正向行?的發展，並作?未來相關研究之參考。
  There is little doubt that maternal-child interaction plays a very important role in child development. Most domestic studies utilize questionnaires to assess parenting attitudes. This study was aimed at developing an observational measurement, which could be adapted by health professionals to clinical or community services and could be used to provide advanced knowledge of parenting educational needs. The specific goals of this study were: 1) to develop two observational measurements, the ”Life Interaction Scale” (US) and the ”Teaching Scale” (TS); and 2) to understand the influence of socio-economic factors on maternal-child interaction. In this study, a quantitative research design was used. The subjects, recruited from kindergartens, were from 34 families with a high socio-economic status and 30 families with a low socio-economic status. Both groups included the same number of boys and girls. Half of the children were aged from 2 to 3 yeaus, and the other half were aged from 4 to 5 years. With the consent of the teachers and parents, nurses observed and assessed the maternal-child interactions at the clients' home during a time when the children were eating or were being taught. The results showed: 1) the observational tools of the US and the TS in this study were supported by satisfactory inter-rater agreement; 2) better maternal-child interaction (LIS and TS) was observed in families with a higher socio-economic status; 3) more positive, warmer and encouraging maternal attitudes facilitated more positive and spontaneous attitudes and less activity in children, according to the US; and 5) there were no significant associations between maternal and childhood behavior in the TS. The contributions of this study are the development of observational measurements, and an understanding of the influence of socio-economic status on maternal-child interactions. Health personnel can use these tools to assess maternal-child interactions, to enhance positive interactions, to facilitate good child development, and to provide a reference for related research in the future.
• 164 - 176
• 10.6288/JNPHARC1993-12-02-05

• Link 原著 Original Article
• 台灣南部地區石化廢水之致突變性研究Mutagenicity of Wastewater Emitted by the Petrochemical Industry in Southern Taiwan
• 藍忠孚、 毛義方、陳美蓮、 張禹斌、張勝祺
  Chung-Fu Lan, I-Fang Mao, Mei-Lien Chen, Yu-Pin Chang, Sheng-Chyi Chang
• 廢水 ； 石化工業 ； 阿姆氏試譣
  Wastewater ; petrochemical industry ; Ames test
• 本研究以國內19家石化工廠和2家綜合污水處理廠之廢水?對象，取得樣品21個，利用XAD-2樹脂抽取廢水樣品中之有機物質，再以丙酮洗下樹脂上吸附之有機物質，經濃縮之後進行沙門氏菌／微粒體系統(Salmonella/microsome system)之效突變性試驗。 研究結果發現有11個水樣(52.4%)呈現陽性的致突變性反應，而在沙門氏菌TA98菌種且有大白鼠肝臟微粒體酵素混合液下有較多的廢水出現陽性反應，結果亦顯示此21家工廠中有三家其廢水有較高的致突變性。
  Twenty-one wastewater samples were collected from 19 petrochemical plants and two united wastewater treatment plants located in southern Taiwan during 1991. Water samples were passed through an XAD-2 resin column and the resin was then eluted by acetone. The mutagenicity of the wastewater was determined by the Ames Salmonella/microsome test. A total of 52.4%of the wastewater samples in the survey were found to exhibit mutagenic activity in Salmonella typhimurium TA98 and TA 100 in the presence and absence of S9 mixture. Three samples among the 21 samples, had very high levels of mutagenicity. The measurement and identification of mutagenic pollutants in wastewater need further investigation.
• 177 - 184
• 10.6288/JNPHARC1993-12-02-06

• Link 原著 Original Article
• 市售冷熱燙劑化妝品之品質調查An Investigation of the Quality of Cold and Hot Hair-Waving Lotions
• 劉春英、楊明玉、連美華、許美智
  Chun-Ying Liu, Ming-Yu Yang, Mei-Hwa Lien, Mei-Chich Hsu
• 冷燙劑 ； 熱燙劑
  Cold permanent wave lotions ; Hot permanent wave lotions
• ?了解市售冷燙劑及熱燙劍之品質，本局曾於民國74、75及77年陸續完成冷燙劑或熱燙劑之品質調查，結果不合格率偏高，79年度?探討市售品品質改善情況，並提供行政參考，再度進行冷、熱燙劑之品質調查，終79年7月至80年2月止，由本局派員至全省各縣市不定點抽購冷燙劑檢體70件及熱燙劑檢體30件，逐一進行各項定性與定量分析，包括冷燙劑第一劑之外觀、游離鹼（鹼度）、酸鹼度（pH值）、主成分之鑑別與含量測定，第二劑之外觀、酸鹼度（pH值）、主成分之鑑別與含量測定；以及熱燙劑之外觀、游離鹼、酸鹼度（pH值）、主成分之鑑別與含量測定，並請衛生署藥政處協助調查各外盒標示之許可字號，將各項檢驗結果依據原許可字號之檔存資料予以判定。結果冷燙劑全部檢驗項目皆合格者3件(4.3%)，不合格者67件(95.7%)；熱燙劑全部檢驗項目皆合格者2件(6.7%)，不合格者28件(93.3%)，與近幾年所作調查結果之不合格率相較，顯示市售冷燙劑及熱燙劑之品質仍未見改善。
  In order to determine the quality of cold and hot permanent wave lotions on the market, 100 samples (70 cold and 30 hot lotions) were purchased from different counties and cities in Taiwan during the 1991 fiscal year. The items examined for both the cold and hot permanent wave solutions included: appearance, identification of pH value assay of active ingredients, and alkalinity of the first solution of cold and hot permanent wave lotions. The results indicated that 64 samples of the cold permanent wave lotions and 13 samples of the hot permanent wave lotions did not comply with the manufacturers' specifications. Furthermore, three samples of the cold permanent wave lotions and 15 samples of the hot permanent wave lotions were sold without a license. We conclude that the quality of commercial permanent wave lotions have not improved during the last 7 years and education and enforcement is needed to make sure that manufacturers improve their quality.
• 185 - 190
• 10.6288/JNPHARC1993-12-02-07

• Link 原著 Original Article
• 高雄地區居家照護實施情況及其病人特徵之研究A Study of Home Health Care Services and Characteristics of Patients in the Kaohsiung Metropolis Area
• 劉慧俐、黃培琳、楊志良
  Hui-Li Liu, Pei-Lin Huang, Chih-Liang Yaung
• 居家照護 ； 長期照護
  Home Health Care ; Long-Term Care
• 本研究探討南區以護理師護士公會?基礎之居家照護三年來之業務。目的?了解居家照護患者的來源；並分析居家照護病人的特本研究探討南區以護理師護士公會?基礎之居家照護三年來之業務。目的?了解居家照護患者的來源；並分析居家照護病人的特徵及疾病性質，進而探討居家照護實施情形。結果發現三年來的收案個案呈不穩定增長，主要來源皆多透過「醫院聯擊」，而聯擊案未收案的主要原因是「家屬因經濟因素考慮，而未再聯絡」。個案以女性居多占52.2%，且多數是65歲以上老人(70.6%)，他們多不識字(36.1%)但有宗教信仰(73.9%)，大部份是本省籍(67.8%)，近36%的個案是鰥寡、離婚及未婚者。具公保居家照護給付條件近半數(42.8%)且多數的個案(87.7%)有家人配合照顧；在疾病診斷方面，以腦血管疾病患者居多46.1%而依診斷群分析則糖尿病、高血壓的病患亦不少；案家分佈區域，以公會所在的苓雅區最多占28.3%，外縣市的個案主要是鳳山市。在居家訪視服務實際需求方面，「心理支持」尤多於「生理服務」；居家護理師依責任區來分派個案，其交通時間約佔訪視時間二分之一；非公保給付患者每次需自付千元左右之費用，是公保患者的五倍。此外，並建議建全轉診制度，加強民眾及醫護人員連續性照顧的概念，爭取保險居家照護給付，及其它社會制度之配合，是拓展居家照護業務首要考量者。慢性病患需長期醫療照護，對主要照顧者負荷之關懷，及協助建立支持體系是需要的。又規劃居家照護記錄、身體評估方式，以作?評鑑居家護理人員工作之準則亦急需發展。另從社區的觀點來發展居家照護，當有助於服務的成本效益。
  The purpose of this study was to evaluate the three-year, association-based home health care program which was launched in March 1988 in the Kaohsiung Metropolitan area. Specifically, we wanted: 1) to understand the source of patients home health care services; 2) to analyze the demographic characteristics of the patients and their disease patterns; and 3) to evaluate the efficacy of the program. A total of 441 communicating cases and 180 visiting patients have participated during the past three years. All records were reviewed, and the findings are summarized below. The number of annual cases has increased unevenly, with most patients being referred by hospitals. Demographically, 52.2% of the patients were female, 73.9% were more than 65 years old, 36.1% were illiterate, 73.9% were religious, and most were widowed, divorced or single. As for the source of payment, 42.8% of patients were ensured government employees, and 87.8% were cared for by their families. About half, 46.1%, of the patients had CVA (write out). Most had multiple diseases; 28.3% of the patients lived at Linya Ch'u, a. The demands of the home health services were focused on treating psychological problems. The nurses' working areas were assigned by districts, and the travel time took half of the visiting time. Noninsured patients paid about one thousand dollars per each visit; five times more than the insured. The possible causes for this are discussed, and some suggestions for home health care are proposed.
• 191 - 201
• 10.6288/JNPHARC1993-12-02-08

• Link 綜論 Review Article
• 近年來臺灣地區職業性鉛暴露的巨觀變化A Macroscopic View of Occupational Lead Exposure in Taiwan
• 林佳谷、陳叡瑜
  Chia-Ku Lin, Ruey-Yu Chen
• 職業性鉛暴露 ； 技術 ； 社經 ； 調節改變
  occupational lead exposure ; technological ; socio-economic ; regulatory changes
• 科技的進步，導致原料、製程、污染防制技術等方面的改進，加上法規、人文、經濟等因素之變化，職業性鉛暴露的情形也隨之有所改變。本文列舉多種因科技、社會意識、法規、和國際趨勢的變化，致使鉛暴露人數和嚴重度明顯減少的實例。不過，當我們慶幸舊的職業性危害日漸減低的同時，應隨時留意新製程、新產品可能仍然存在一些污染與危害。唯有時時警惕，平日做好整潔與整頓工作，並瞭解鉛暴露途徑與防護方式，才能將職業性鉛危害降至最低程度。
  Along with changing technology, new regulations, socio-economic impacts, occupational lead exposure in Taiwan in recent years has been modifined. By examining lead-related industries, including battery recycling, lead powder, lead stabilizing agents, cable, printing, glaze, leaded glass, drifting net, petroleum, ship demolition, electronic soldering, it was found that most occupational exposure has been significantly reduced. Factors such as automation, granulation, new technology with little or no lead, stringent environment and occupational health regulations, the shutdown of obsolete and polluted factories, societal changes (including labor shortages & changes in human value concepts), and international trade factors unfavorable to leadrelated businesses, are the driving forces in the lowering of occupational lead exposure.
• 202 - 207
• 10.6288/JNPHARC1993-12-02-09