12卷3期

• Link 原著 Original Article
• 國三學生日常壓力的因素結構及其與自覺症狀的關係Factor Structure of Perceived Stress from Daily Events and Its Relation to Perceived Symptoms among Ninth Graders in Taipei City, Taiwan
• 李蘭
  Lee-Lan Yen
• 壓力 ； 症狀 ； 個人特質 ； 社會支持
  stress ; symptom ; personal trait ; social support
• 本研究以橫斷式調查設計，瞭解國中三年級學生自覺的日常壓力事件並分析其因素結構：同時探討與學生自覺症狀相關的因素。台北市某國民中學的469名三年級全體學生接受調查“根據主成份分析的結果，日常壓力事件可界定成三個主要因素，即不良的親子關係、耽心自己的未來、和讀書方面的困難”學生的神經質特質、不良的親子關係、和耽心自己的未來，是預測學生自覺症狀的重要變項，本研究建議以學校為實施親職教育，推動壓力調適的理想場所。
  This study employs a cross-sectional design to analyze the principal components of perceived stress from daily events and to examine whether certain factors are associated with the perceived psychosomatic symptoms in the ninth graders. Data were available on 469 students of a selected junior high school in Taipei City. According to the result of principal components analysis, three factors including poor parent-child relationship, concerning prospects, and study problems were defined for the perceived stress from daily events. A student's neurotic trait, poor parent-child relationship, and concerning prospects were selected as important predictors of perceived symptoms. School is suggested as a setting for delivering the parent-child education for stress coping.
• 211 - 218
• 10.6288/JNPHARC1993-12-03-01

• Link 原著 Original Article
• 腦血管疾病分佈的種族差異－中國人與其他種族之比較Racial Differences in Cerebrovascular Diseases: A Comparison between Chinese and Other Races
• 張娟娟、陳建仁
  Chung-Chung Chang, Chien-Jen Chen
• 無
  Epidemiology ; Racial differences ; Cerebrovascular diseases
• 腦血管疾病?中國大陸最常見的死因；在台灣，自1963年至1982年腦中風亦?十大死因之首，1983年始?第二死因，僅次於癌症，每年仍有15000人左右死於該病。根據大陸六萬人的大型研究中指出，中國人腦中風的發生率約?心肌梗塞的5倍，?北美人發生率的1.5位：其疾病的發病型態有三分之一?腦出血，是北美人的3倍。 腦血管疾病病灶分佈有很大的種族差異，黑人及日本人有較多的顱內血管病變；白種人的病灶部位則大都分佈於顱外。中國人有明顯的顱內血管病變，與黑人及日本人較?相似。 一般而言，中國人與亞洲其他種族（包括日本人）腦出血比例及顱內血管病變，比西方種族相對較多，此種種族上的差異，至今仍無法解釋，有待進一步探討。就腦血管疾病的發生，雖然高血壓、及某些環境、飲食習慣扮演重要角色，遺傳因子的影響對亞洲人而言也是一可能的決定因素。
  Cerebrovascular diseases are the most common cause of death in mainland China. It was the leading cause of death from 1963 to 1982, and has become the second cause of death afterward in Taiwan. The stroke incidence in China is more than fivefold that of myocardial infarction. The incidence is about 1.5 times of that in North America. Intracerebral hemorrhage causes about one third of all strokes in China, nearly three times the proportion reported by stroke registries in North America. The distribution of cerebrovascular lesions varies in different races. Blacks and Japanese have more intracranial cerebrovascular disease, while whites have more extracranial disease. The preponderance of intracranial vascular leisons in Chinese is similar to that seen in blacks and Japanese. The reasons why Chinese and other Asian populations including Japanese are proned to intracerebral hemorrhage and intracranial leisons remain to be elucidated. Although environmental and dietary factors and hypertension play some important roles, genetic components supported by the relative higher incidence of other intracranial artheriopathies (e.g., moyamoya disease) may also be singnificant determinants in Asians.
• 219 - 230
• 10.6288/JNPHARC1993-12-03-02

• Link 原著 Original Article
• 母親社會心理因素與嬰兒出生體重過重的關係Maternal Psychosocial Factors and Large for Gestational Age Newborns
• 杜明勳
  Ming-Shium Tu
• 無
  Psychosocial factors ; Large for gestational age
• 一如早產兒及體重不足會升高嬰幼兒之罹病率及死亡率，體重過重對嬰兒之罹病率亦有影響，本研究在篩檢去除母親生理疾病後，探討孕婦人口學特質（含健康習慣）及社會心理因素對嬰兒過重之影響。 76年6月至77年5月一年期間於台北榮民總醫院產房收集足月生產嬰兒體重過重組及正常對照組各148人，以其母親?調查對象。在去除母親具有疾病及無效問卷後，共得體重過重組131份，正常對照組138份資料進行分析。 以逐步鑑別分析得知，影響嬰兒過重之獨立因素於母親人口學部份?產次、孕期體重增加、及具有相同嬰兒過重過去史，而健康習慣方面?母親未懷孕前體重，社會心理因素?社會支持多寡。 經由本研究之探討，闡述多項因素與嬰兒出生體重之關係，並強調母親未懷孕前體重及社會支持對嬰兒出生體重亦有重要之影響。
  Not only preterm delivery arid low birth- weight will increase infant morbility and mortality, large for gestational age (LGA) babies will also have higher morbility rate than normal group. After excluding maternal medical diseases, this study is to analyze the relationship of maternal demographic data, health practices, and maternal psychosocial factors to fetal birthweight. We herein collected 131 available guestionnaires from the LGA group mothers and 138 from the normal birthweight group mothers, then analyzed the data with stepwise discriminant procedure. Results indicate that the independent varibles for LGA babies are maternal demographic data (parity, weightgain during pregnancy, and prior pregnancy history), usual body weight before pregnancy and social support for psychosocial factor. This survery finds out factors that relate with baby birthweight and emphasizes the important influence of maternal health behavior and soical support on the weight.
• 231 - 238
• 10.6288/JNPHARC1993-12-03-03

• Link 原著 Original Article
• 農漁村社區垃圾特性及清理狀況A Survey on Characterization and Disposal of Solid Wastes in Rural Areas
• 李芝珊、呂清雄、陳俊雄、 陳秀卿、林瑞雄
  Chih-Shan Li, Ching-Shiung Lue, Jiunn-Shyong Chen, Ahsiu-Ching Chen, Ruey-Shiung Lin
• 無
  Solid Waste ; Rural Area
• 台灣地區近年來的垃圾問題，由於垃圾量的劇增、種類的日益複雜、污染的全面性及地狹人稠等因素，已成?最棘手的污染防治工作之一。本研究調查鄉村地區家戶，處理、回收及製造垃圾的情形，以做?政府在鄉村地區誰行資源物質回收及垃圾減量的參考。本研究在考慮地理位置、鄉鎮特性等因素後選出具有代表性的二十個鄉鎮做?研究對象，並區分成農村輔導區、農村一般區、漁村地區及山地地區等四種。各鄉鎮經多步驟隨機抽樣選出六十個家戶，總計一千二百戶做?樣本進行問卷訪視。結果有效回收問卷?一千一百三十七份，回收率?93.2%。 本研究結果發現，18.2%的家戶有自己焚燒垃圾的行?，其中又以農村輔導區最多。主要的原因是認?燃燒乾淨又衛生。9.8%的家戶有任意傾倒垃圾的行?，尤以山地地區最嚴重，主要的原因是垃圾車沒有來。在資源垃圾的回收方面，廢機車最好，佔80.9%；而寶特瓶最差，僅佔8.2%。在製造用完即丟及巨大垃圾方面，家戶一年內曾購買塑膠袋最多，佔36.1%；保麗龍餐具最少，佔14.4%；而電視機的使用年限多數超過十年，洗衣機超過五年。 本研究建議：（一）改進清運狀況。擴大指定清除區，購買較小型垃圾車深入巷道內清運，因定清運時間，提高清運頻率較少的地區之清運頻率等，以減少家戶任意傾倒垃圾的情形。（二）全面普遍的建立適合當地的回收糸統管道。目前有些可回收物質尚無回收管道，有些回收管道並不普及，都有持改善。（三）鄉村垃圾問題亦應受重視。不該只將垃圾推往鄉村地區，應針對農、漁、山地等地之地區及垃圾特性，加強減廢、堆肥、壓縮固化之研究及可行性探討，以減輕日益嚴重的垃圾問題。
  In Taiwan, the production amounts of solid wastes increased significantly in recent then years. Solid waste becomes a new emerging serious enviromnent problem lately. The major purpose of this investigation was to characterize the productions and displsal methods of solid waste in the rural areas of Taiwan. This study was conducted in twenty rural townships, including twelve agriculture, five fishing, and three mountainous villages. These twenty areas were selected in terms of sanitary situation, geogrpphical location, and characteristics of economic activity. Sixty households were chosen by stratified sampling method from each of these twenty rural townships for interview using a predesigned-questionnaire. The qrestionnaires contain basic demographic data and economic conditions of the household; frequency and disposal methods of solid waste such as composting, incinerating, or dumping; practice of recycling/reusable waste, the frequency of collection, the opinions on current waste disposal, and so on. In addition, the characteristics of treated waste, the efficiency of treatment; the possibility of secondary air pollution, and the cost-benefit of self-treated methods were also evaluated during the household survey. The results strongly suggested that a lot of works need to be done regarding the disposal of solid waste in rural areas. First, the frequency of solid waste collection in rural areas should be increased in order to prevent dumping. Second, an effective recyling system should be established islandwide to collect reusable resources. Third, the solid waste problems in rural areas should also be paid attention ahead by the Environmental Protection Agency.
• 239 - 251
• 10.6288/JNPHARC1993-12-03-04

• Link 原著 Original Article
• 臺灣大學生的健康保險需求研究Demand for Health Insurance by University Students in Taiwan, R.O.C
• 林芸芸
  Yun-Yun Lin
• 健康保險需求 ； 需求隱性結構模式 ； 保險涵括項目 ； 保險費 ； 強制投保
  Demand for health insurance ; latent structure model of demand ; insurance coverage premium ; compulsory insurance
• 本研究以全國公和立大學（院）一、四年級學生?研究對象。採複式隨機抽樣法抽取醫學院、非工學院、及師範學院的大一及大四2733名學生，完成有效樣本數?1215名；回收率?44%。本研究的主要目的在於瞭解大學生對全民健康保險的參加意願及需求；建立大學生對健康保險需求的隱性結構模式；並分析其相關因素。 76%受訪學生知道自己投保學生平安保險。10%的學生有人壽保險。99%聽過全民健康保險。85%學生知道全民健康保險的用意在於風險分擔。81%的學生表示一定會參加全民健康保險。54%認?應強制參加。63%認?目前勞保保費是合理的。七成左右的學生認?健康檢查、門診、生育、住院應列?全民健康保險醫療給付項目。47%認?老人應優先納入。42%認?全民健康保險的財源，應一半來自稅收、一半來自保費。 分析醫學院及非醫學院學生的全民健康保險看法結構顯示：非醫學院學生，7%?「反保險型」、90%?「保險開放型」、3%?「盲從型」。醫學院學生，13%?「反健保型」、82%?「保險開放型」、5%?「擁護型」。非醫學院學生「反保險型」較「盲從型」者，有較高的比例認?目前460元的保費不合理。醫學院「反健保型」較「擁護型」有較高的比例傾向自由參加；「保險開放型」較「擁護型」有較高的人毒保險率。同時，不願意參加全民健康保險者較願意參加者，有較高的比例知道有學生平安保險、較高的認?保費不合理率、且認?合理的保費金額較高、並贊成採自由參加方式。本研究結果將對全民健康保險保險對象的逐步納入；保險給付內容、保險費率、部份負擔等的訂定提供基本的重要參考資料。
  This study examined university students' demand for Health Insurance in Taiwan. The data were collected from a questionnaire administered to 1215 university students of their first and fourth grades in 1990 (response rate of 44%). The results showed that 76% of participants knew about Student Security Insurance, but only 10% had life insurance. Regarding National programs, a total of 99% had heard about National Health Insurance, 81% intended to join NHI and 54% agreed on compulsory insurance. 63% considered the current premium of Labor Insurance to be reasonable, while 42% thought that the major financial source If NHI should come from taxes and premium. Most students admitted that the insurance coverage should include physical examination, physician visits, hospital admission, and maternity care, and that aged people should be included as the first priority group. The latent structure model lf the demand for health insurance showed that: for non- medical students, anti-insurance level was 7%, insurance-open level was 90%, and ignorance level was 3%. For medical students, anti-NHI level was 13%, insurance-open level was 82%, and NHI-support level was 5%. For non-medical students, the anti-insurance level had a higher proportion considering the current premium to be unreasonable as compared to the ignorance level. For medical students, comparing with the NIH-support level, the anti-NHI level were more likely to choose voluntary participation in NHI and the insurance- open level had a higher rate of enrolling in life insurance. The students, who not willing to join NHI, were more inclined to choose voluntary participation in NHI, and expeccted a higher rational primium than those who were willing to.
• 252 - 265
• 10.6288/JNPHARC1993-12-03-05

• Link 原著 Original Article
• 醫師對全民健康保險意見隱性結構的相關因子研析Factors Associated With the Latent Structure of Physicians' Opinions toward National Health Insurance
• 林芸芸
  Yun-Yun Lin
• 無
  National Health Insurance ; Physicians' opinion ; Latent Structure
• 本研究目的在於分析醫師對全民健康保險意見隱性結構的相關因素。以分層隨機、等距系統抽樣法，自醫師公會全國聯合會18029名會員中抽出7500名樣本醫師。於1990年年初郵寄調查，共得1619名有效樣本，回收率?22%。 全民健康保險看法結構：醫院醫師具「固守型」看法者較「改行型」多?甄訓或特考醫師。若進一步將醫師分?「改行型」及「不改行型」（包括「因守型」及「跳槽型」），則發現：醫院醫師以年齡較輕、住院醫師訓練年數及執業年數較短者，較傾向「改行型」。而診所醫師則以年齡較輕，具專科資格者，較傾向「改行型」。衝擊結構：醫院醫師具「不利型」或「悲觀型」，較「不變型」者年輕；又「不利型」較「不變型」者多?醫院負責人；「悲觀型」較「不變型」者有較高比率未取得專科資格。診所醫師「悲觀型」及「不變型」者的執業年數、住院醫師訓練年數，皆高淤「調適型」。工作預期結構：醫院醫師「減少型」較「增加型」多?男醫師、未取得專科資格、且多?醫院負責人。診所醫師「減少型」較「增加型」多?男醫師、年齡較輕、保險病人百分比較少；「不變型」較「增加型」的保險特約比率較高。執業理想結構：診所醫師「下鄉型」較「傳統型」的執業年數較短，且有較高的專科資格比率。醫療支付期望結構：醫院醫師「同酬評等型」、「專科同酬型」較「評等專科型」的住院醫師訓練年數長，又有保險特約的「同酬評等型」較「評等專科型」者有較低的保險病人百分比。「同酬專科型」較「評等專科型」者多?醫院負責人、但具專科實格比率較低。診所醫師「評等型」及「城鄉型」較「同酬型」有較高比率未取得專科資格，而「混合型」較「同酬型」的得專科資格比率較高。
  Thes study examined the characteristics of physicians with the different latent structure of opinions on National Health Insurance (NHI). The data source came from a mail survey of 7500 physicians (resulted in 1619 respondents with 21.6% response rate) in Taiwan, 1990. Structure 1. Physicians' viewpoint on NHI. Hospital physicians with change-career pattern were younger, had shorter period of internship or practice years than the steady ones. Clinic physicians, who were younger or more by certified specialist, were more intended to change career. Structure 2. Physicians' expected impact of NHI. Hospital physicians with pessimistic or disadvantaged expectations were younger, more in charge of the hospitals, or more had a specialist certificate than those with the constant expectation. Clinic physicians, who had longer period of internship or longer practice years, were more intended to be pessimistic. Structure 3. Physicians' expected workload change. More of the hospital physicians, who expected a decreasing workload change after the implement of NHI, were male, without specialist certificate, or in charge of hospitals than those expected to be increasing. Clinic Physicians with decreasing expectation were more male, younger, and had less insured patients than those with increasing pattern. Also, clinic physicians with no-change expectation on workload had a higher percentage of having an insurance contract than those with the increasing pattern. Structure 4. Ideal practice pattern. Rural-orientated clinic physicinas had longer practice years, and higher rate of certified specialists than the traditional ones. Structure 5. Expected reimbursement methods for Physicians. Hospital physicians, who preferred to be reimbursed by the uniformed payment level for the same service item, or based on credentiality-base, had a longer period of internship, or lower rate of insured patients than those who preferred the speciality-base. Clinic physicians, who preferred credentiality-base or urbanization level-base, had a lower rate of having a specialist certificate than those who preferred to be reimbursed on the uniformed payment level for the same service item.
• 266 - 281
• 10.6288/JNPHARC1993-12-03-06

• Link 原著 Original Article
• 研究設計之樣本數決定Determination of Sample Size for Research Design
• 林正祥
  Cheng-Hsiang Lin
• 無
  Sample size determination
• 在規劃研究設計時，研究人員往往忽視樣本多寡的問題，因而造成統計推論上的嚴重偏差。忽視樣本的結果，將使得：(1)由於樣本數不足，雖已達到臨床上的顯著差異，卻冉法達到統計上的顯著差異；(2)因樣本過多，雖研究結果沒有臨床上的意義，卻達到統計上的顯著差異及(3)由於樣本有限，雖然研究結果皆達臨床及統計上的意義，但檢力過低無法肯定其對立假說是否成立。本文提出了在單一及雙常態母體平均值檢定、二項分佈檢定、邏輯斯迴歸分析、變方分析世代死亡率之樣本計算公式，並援引數例說明之，俾提醒研究人員能藉此瞭解樣本數之重要性並妥?運用之。
  Researchers always ignore the problem of sample size when they are planning a research design. This might lead to the incorrect result of statistical inference. In this paper, we present three examples to describe the problems when sample size are small or too large in research design. Also, we provide the formulas of sample size and some examples for comparing the means of one and two normal distribution, binomial test, logistic regression, ANOVA and mortality of chort study to remind researchers paying attention to the importance of sample size for research design. Although there are limitations on the formula of sample size related to some statistical analysis, this paper do provide a guideline for handling the quality of research design by carefully considering the requirement of sample size.
• 282 - 290
• 10.6288/JNPHARC1993-12-03-07

• Link 原著 Original Article
• 持續性品質政善(CQI)理論及實證研究－以長庚醫院醫療供應作業改善為例Continuous Quality Improvement (C.Q.I.) Theory and Empirical Study: An Example for Chang-Gung Memorial Hospital's Supporting Service Improvement
• 莊逸洲、吳振隆
  Yi-Chou Chuaug, Chen-Lung Wu
• 無
  Q.A. Quality Assurance C.Q.I. Continuous Quality Improvement Managed Care FOCUS/PDCA
• 美國醫療品管活動的發展，由傳統的『品質保證』(Q.A., QUALUTY ASSURANCE)演進至目前的『持續性品質改善』(C.Q.I., CONTNUOUS QUALITY IMPROVEMENT)，其主要精神在強調“積極地不斷玫善來提昇品質”，而不僅是“消極地檢討異常來維持品質”。 『醫療品管』無論其概念(CONCEPT)或導入實務(APPROACH)均源自『產業模式』(INDUSTRIAL MODEL)，而其與產業模式最主要的不同即是永遠把病人擺在第一順位，優先考慮。在醫療品質改善計劃裡，醫院一方面應依其宗旨與經營哲學提供以病人?中心的卓越醫療照護品質，一方面在執行醫療照護的過程中亦應不斷地去改善作業來節制醫療成本。 長庚醫院從創院迄今，始終抱持“改善永無止盡”的精神，在日常工作中即不斷進行各項作業改善，而最近的醫療供應作業改善，只是過程中的一例。醫療供應作業改善內容包括（一）『供應品』之檢討改善：以『即棄式』(Disposable)取代目前『回收使用』(Reusable)材料並依每項醫療處置別整理需使用之材料，再透過個別材料的合併、簡化、取代及預先組合成單一『處置包』(PACKAGE)等作業，進而設定品質標準、檢驗規範、進行成本分析後再交專業製造商製作供應。（二）『供應作業流程』之檢討改善：包含材料之開發引入、存量管制、採購、檢驗、付款、收料及自動補充等事務作業電腦化。經此改善後，醫療供應作業人力由41人精簡?13人(-68.3%)，作業空間需求由586坪減?186坪(-8.3%)，每月材料成本由646萬元減?421萬元(-34.8%)，另節省設備投資229萬元；同時供應品質獲得雙重確保、作業效率提高、庫存成本亦降低。惟如上述，醫療供應作業改善只是本院各項改善作業的一部份，其目前的改善成果對本院追求“精益求精，止淤至善”的理想而言，不過是中間過程。
  The main purpose is to emphasize the idea of ”ENHANCED MEDICAL QUALITY THROUGH ACTIVE & CONTINUOUS IMPROVEMENT”, not that of ”MAINTAINED MEDICAL QUALITY THROUGH ELIMINATING VARIATION PASSIVELY”, when the development of medical quality evolves into the current continuous quality improvement (CQI) from the traditional quality assurance (QA) in the U.S.A. Either the concept or practical experience of medical quality management comes from those of the industrial model. Considering the patients as the first priority forever is the medical models major difference from the industrial model. In the planning of medical quality improvement, on the one hand, hospitals must provide excellent medical services through concentrating on the patients services with regard to their mission statements & management philosophy. On the other hand, hospitals must also contain health care costs through improving the process continuously in the implementation of health care. Supporting service improvement is just one example of the process improvement, which is done routinely in our hospital under the mission standard of ”IMPROVEMENT IS ENDLESS”, which our hospital sticks to since the establishment. The first step of the supporting service improvement is improvement of supplies selection. Namely, we use disposable supplies to replace reusable ones and we assemble different individual packages, which contain the necessary supplies for different procedures through ways of mergence, simplification & replacement. Then we cooperate with supplies companies to produce those packages after spelling out quality standard, inspection guideline & cost analysis. Secondly, the improvement on the process of supplies is our target, for example, including the computerization of development of materials, inventory control, purchasing, inspection, billing , receiving, & automatic filling. The result is that the total NO. of personnel in the supplies department reduce to 13 from 41 (DECREASING PERCENT 68.3%), and that space requirements reduce to 186 PYNG from 586 PYNG (DECREASING PERCENT 68.3%), and that supplies cost per month is NT$4.21 million from NT$6.46 million. In addition, the facility investment of NT$2.29 million is saved. In summary, double assurance on quality, increased efficiency & reduced inventory costs are achieved. As we mentioned earlier, supporting service improvement is just one part of our total quality management. The current improvement resulting just one step in our endless journey of ”IMPROVEMENT IS ENDLESS”.
• 291 - 311
• 10.6288/JNPHARC1993-12-03-08

• Link 原著 Original Article
• 社區保健服務－陽明十字軍十六年之經驗(1978-1993)Community Health Service-The Experience of the Yang-Ming Crusade 1978-1993
• 郭乃文、楊南屏、張武修、周碧瑟
  Ni-Wen Kuo, Nan-Ping Young, Wu-Shou P. Chang, Pesus Chou
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  none
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  Health care services have harnessed two major goals in the past decades. The first is to raise the ratio of physician and the served citizens. The second is to get even distribution of health care manpower. Instead of the varieties of education systems which are shaped by its individual cultural environment, the medical education has been most influenced universally by the greater demand of the health care industry. The first such movement comes from the civilian's demand for more and better community health care services. Increased numbers of medical students is reflected in many medical schools immediately. Nonetheless, most of them are trained toward physicians providing community health care services. This had been demonstrated in Australia, Belgium, Canada, Norway and Poland from 1905 to 1980s. In Taiwan, several strategies have been employed to enhance physicians serving in the community and establishment of the National Health Services. One of this was to establish The National Yang-Ming Medical College In 1975. These medical students have been provided with full scholarship, Including tuition and living expenses, during the years as medical students. Post appropriate clinical training, most of they are assigned to public hcalth care sectors, like rural community health units or group practice centers. Moreover, In order to induce the interest in serving the community, they are provided with practical field training during the years in the medical schools, particularly joining the activities of the Yang-Ming Crusade. This report illustrating the experiences of Yang-Ming Crusade is to serve as a real example of preventive medicine in the field. Through it roots the first successful example of community health care services provided by the medical students, teachers and medicel professionals.
• 312 - 321
• 10.6288/JNPHARC1993-12-03-09