14卷5期

• Link 綜論 Review Article
• 臺灣地區的醫師人力政策：1945-1994Physician Manpower Policy in Taiwan, 1945-1994
• 江東亮
  Tung-Liang Chiang
• 醫師人力政策 ； 供給 ； 地理分布 ； 素質
  physician manpower policy ; supply ; geographic distribution ; quality
• 光復以後，臺灣地區醫師人力政策的發展大致可以分三期：首先是自由放任期(1945-1970)，侷限於醫師資格的管理；接著是擴張期(1970-1985)，以培養醫師人力為目標；現在則已經進入綜合期（1985-迄今），強調醫師人力地理分布的均衡與素質的提升。本文旨在回顧這三時期臺灣地區醫師人力政策的發展，並檢討政策過程以及對醫師人力供給、地理分布以及素質的影響。
  The historical development of physician manpower policy in Taiwan after World War ? includes three phases: (1) laissez-faire stage (1945-1970), confined to the administration of licensing; (2) expansion stage (1970-1985), focused on the production of physicians; and (3) comprehensive stage (1985-present), concerned with the geographic distribution and quality of physician manpower. The objectives of this paper are twofold: to review the historical progress of physician manpower policy in Taiwan and to examine the policy process and the impact of the physician manpower policy on the supply, geographic distribution and quality of physician manpower in Taiwan.
• 383 - 391
• 10.6288/CJPH1995-14-05-01

• Link 原著 Original Article
• 果農的農藥暴露與神經系統的變化探討Pesticide Use and Neurological Effects in Fruit Farmers
• 林明松、周淑媛、郭乃文、賴明亮、郭育良
  Ming-Song Lin, Shu-Yuan Chou, Nai-Wen Guo, Ming-Liang Lai, Yue-Liang Leon Guo
• 農業 ； 神經疾病 ； 農藥
  Agricultural ; Pesticide ; Neurological
• 在農業從業人員中農藥暴露是已知的健康危害之一，而一般果農在使用時又常混合多種以上不同之農藥，且噴灑時通常無適當防護措施，簡單棉質或紗布口罩及長袖衣物之防護常不足以保護其健康，農忙時噴灑次數頻繁，常有中毒事件發生，因此針對其暴露做危害調查有其意義所在。 本研究以台南縣楠西鄉果農為對象，探討果農農業從業人員長期農藥暴露對神經系統功能的影響。從80年12月至81年4月期間共收集到研究對象205人，經過濾排除會導致神經病變之危險因子，計有暴露組果農109名和對照組居民38人合計147名符合研究條件進入分析。 以問卷及農藥使用手冊調查其使用的農藥種類及每公頃用藥有效成份量劑量並做神經理學和神經電生理學檢查，由多變數迴歸分析結果顯示在果農尺感覺神經遠端電位振幅及腓腸感覺神經遠端電位振幅上有明顯振幅降低現象出現，其原因可能因長期受到農藥暴露所引起的輕度慢性神經病變。至於這些病變的臨床意義如何，尚須進一步研究以探討。
  Exposure to pesticides is known as a health hazard to agricultural workers. Fruit farmers frequently applied combinations of pesticides without adequate work practice, protective equipment and clothing during the operation. We studied the fruit farmers occupational exposure and neurological effects in Nan-Si town in Tainan County. Questionnaire was used to obtain information of general health, pesticide use, work practice, and the use of protective equipment and clothing. Physical examination was performed for assessing more apparent neurological abnormalities. Nerve conduction velocity, proximal and distal latencies, F-wave latency, and amplitude of evoked potential were measured using a Neurostar MS-92B Complete Clinical EMG System. A total of 109 farmers who had been exposed to pesticides and 38 control subjects from the same town who had nerver applied pesticides participated in the investigation. The fruit farmers used more than a hundred brand names of pesticides, including those reported to cause delayed peripheral neuropathy. During mixing and application of pesticides, and harvesting the fruits, protective equipment or clothing was not used adequately. In the sensory nerve studies, the exposed group had reduced distal amplitude in ulnar and sural nerves compared with the controls. We conclude that fruit farmers had work exposure to many kinds of pesticides and had changes in peripheral nervous system compared with the controls by nerve conduction studies.
• 392 - 399
• 10.6288/CJPH1995-14-05-02

• Link 原著 Original Article
• 台南地區各層級醫療機構新生兒生命統計概況Neonatal Vital Statistics at Different Hospital Levels in Tainan Area
• 陳德人、林其和、王琪珍、王新台、葉純甫
  Te-Jen Chen, Chyi-Her Lin, Chih-Jen Wang, Shan-Tair Wang, Tsu-Fuh Yeh
• 新生兒 ； 區域規劃 ； 生命統計
  newborn ; regionalization ; vital statistics
• 無
  In Taiwan, with the increasing demands of better care for newborn infants, neonatal intensive care units have been established in many medical institutions. However, neonatal intensive care requires relatively high cost and additional health care manpower. Regionalization is an alternative in meeting the following objectives: quality care for all newborns, maximal utilization of highly trained perinatal personnel and intensive care facilities, as well as assurance of reasonable cost-effectiveness. The purposes of this study were to disclose neonatal vital statistics at different hospital levels and to prepare for regionalization in the Tainan area. The data of cesarean section rate, birthweight and gestational age distribution, and neonatal outcome from each of three levels of medical institution in Tainan area from July, 1991 to April, 1992 were collected and analyzed. Fifteen medical institutions were included on a voluntary basis; eight from level ? (obstetric clinic/hospital), six from level ? (community hospital) and one from level ? (tertiary medical center). In 14,307 newborn deliveries, the cesarean section rate was 26.38%. The incidence of low birthweight(<2500gm) was 5.69%, and the incidence of very low birthweight(<1500gm) was 1.08%. The results also showed that part of high risk newborn infants and pregnant women have been transferred to higher level medical institution for better care. Furthermore, 40% of the transferred newborn infants were born in the obstertric clinic/hospital(level ?). The incidences of premature(3.97%)and low birthweight(4.20%) infants born in the obstetric clinic/hospital should be reduced. Further improvement of regionalization of perinatal medical care in the community is needed.
• 400 - 406
• 10.6288/CJPH1995-14-05-03

• Link 原著 Original Article
• 乳房自我檢查衛生教育對婦女乳房自我檢查知識動機及技巧之影響The Effects of a Breast-Self-Examination Education in Women's Knowledge, Motivation and Skill about Breast Self Examination
• 吳南宏、盧豐華、張翠珍、張瑩如、張智仁
  Nan-Hong Wu, Feng-Hwa Lu, Tsui-Chen Chang, Ying-Zu Chang, Chih-Jen Chang
• 乳房自我檢查 ； 動機 ； 自信度 ； 知識
  Breast self-examination ; Motivation ; Confidence ; Knowledge
• 乳房自我檢查為早期發現乳癌最方便經濟的方法，衛生教育則是達到此目標的有效途逕；為了解乳房自我檢查衛生教育對婦女乳房自我檢查知識、動機及技巧之影響，本研究設計一套乳房自我檢查的教學模式，包括課程講授、檢查步驟示範和模型腫塊體驗，並以問卷及乳房模型來評估教學前後學員之乳房自我檢查動機、技巧自信度、自我檢查知識及摸出乳房模型內腫塊數目，以了解教學的成效並探討其影響因素。對象為報名參加成大醫院家庭醫學部所舉辦的乳房自我檢查衛生教育課程之民眾，共381位。結果發現，教學前有71.4%的學員曾經由不同的管道聽過乳房自我檢查，但只有7.1%的人每個月定期做乳房自我檢查；阻礙學員未能定期每個月做乳房自我檢查的因素以對自己的檢查技巧沒信心最多(61.80%)。教學前後學員無論在乳癌和乳房自我檢查知識、檢查動機、檢查技巧自信度及腫塊摸出能力上都有顯著的進步。影響此教學成效的因素，主要為教育程度。
  Breast self examination(BSE) is the most convenient and economical method for the discovery of breast cancer at its inital stage. Health education is an efficient approach to attain this goal. In order to determine the effects of BSE education on BSE knowledge, motivation, and BSE technique, the educational activities including lecture, demonstration and practice were conducted. The questionaire and breast model were used to assess the subjects BSE motivation, BSE skills confidence, BSE knowledge, and ability to find the tumors inside breast models. A total of 381 women participated in the BSE class which was sponsored by the Family Medicine Department of Cheng Kung University Hospital. The results indicate that 71.4% of the subjects had heard BSE before the BSE class. However, only 7.1% of the subjects reported that they conducted the examination every month. Among the subjects who failed to perform the BSE periodically, 61.8% of them reported low confidence in BSE skills. After the educational activities were implemented, the subjects showed significant change in the knowledge of cancer and BSE, the BSE motivation, confidence in performing BSE, ability to detect breast tumors in the models. The educational level was significantly related to the educational effects.
• 407 - 416
• 10.6288/CJPH1995-14-05-04

• Link 原著 Original Article
• 護理人員面對病患家屬時的工作壓力與因應方式之探討Stress and Coping in Nurses Confronting with Patients' Families
• 巫慧芳、蕭淑貞
  Hui-Fang Wu, Shujen Shiau
• 護理人員 ； 病患家屬 ； 壓力 ； 因應
  Nurse ; patients' families' ; stress ; coping
• 本研究目的在藉由探討護理人員面對病患家屬時的工作壓力及因應方式，以作為提供護理人員協助時的參考。 研究以台大醫院109位工作經驗滿六個月以上之臨床護理人員為對象，藉由結構式問卷進行調查。以因素分析、t-檢定、GLM變異數分析、典型相關等方法進行資料分析。研究結果顯示，護理人員面對病患家屬的工作壓力，可分為「來自病患家屬醫療資訊不足的壓力感」、「來自病患家屬情緒波動的壓力感」、「來自病患家屬承受照顧負荷的壓力感」三個因素。壓力程度會因年齡、教育程度、目前工作科別、目前家庭護理做到的層次等個人因素不同而有顯著差異。 護理人員面對病患家屬的因應方式，可分為「積極地面對問題」、「消極地思考」、「逃避問題」三類別。以「積極地面對問題」較常被使用。「逃避問題」之因應方式受到教育程度的影響，即專科畢業者較大學畢業者常使用「逃避問題」的方式。護理人員面對來自病患家屬的壓力與因應方式間可發現一種典型相關，當來自病患家屬的壓力愈高時，護理人員愈易使用消極地思考和逃避問題等兩種方式因應。
  The purpose of this study was to investigate stress and coping in nurses confronting with patients families. The subjects included 109 nurses who have been working at National Taiwan University Hospital for more than six months. Structured questionaires were used for data collection and advanced statistics including Factor analysis, t-Test, GLM ANOVA, and Canonical correlation were used in this study. The results revealed that the sources of nurses' stress from patients' families could be divided into 3 major categories stress from families' lack of medical information, stress from families' emotional problems, and stress from families' care burdens of patients. Degree of stress was significantly different across nurses' age, education, hospital units where nurses works, and level of family nursing which had been done. The coping methods adopted by the nurses could be divided to active problem-solving, passive-thinking, and avoidance. Active problem-solving was the most commonly used coping methods. The graduates of junior college adopted avoidance more frequently than nurses with bachelor degree. In the canonical correlation analysis, one significant variate set differentiated nurses on stress. Nurses who experienced higher degree of stress more often adopted passive- thinking and avoidance, as their coping methods.
• 417 - 425
• 10.6288/CJPH1995-14-05-05

• Link 原著 Original Article
• 精神衛生法中強制住院之知識：醫療與非醫療人員之比較Knowledge of Involuntary Admission in the Mental Health Act: Comparison between Medical and Nonmedical Personnel
• 張珏、許蓉雰
  Chueh Chang, Jung-Feng Hsu
• 精神衛生法 ； 強制住院知識 ； 嚴重精神病人
  Mental Health Act ; Involuntary Admission ; Psychiatric Patients
• 本研究希望瞭解社區中精神病患家屬與相關人員（包括衛生所護士、警察以及村里幹事）對於精神衛生法中強制護送鑑定與住院治療相關規定的知識，藉此提供評估宣導的依據。研究對象包括：175位社區嚴重病患家屬，以及475位相關工作人員（包括：194位公共衛生護士、104位警察、180位村里幹事），進行問卷調查。 四類研究對象對強制護送鑑定與住院治療相關規定的知識，皆相對地不高，各題答對比率由26%-78%。研究對象間的比較，以衛生所護士最佳，病患家屬較不理想。 本研究結果，反應出精神衛生法自介佈至今宣導上不足，民眾有關知識不足，尤其對保護人的權責，由誰擔任，強制護送鑑定過程的困擾與強制住院條件等，皆有待釐清。因此，建請有關單位加強宣導精神衛生法、提供適切的醫療知識，此外，並宜做各項相關法令的評估研究，以為宣導教育的依據。
  By using a structured questionnaire, 175 families and 478 psychiatric-mental health related personnels i.e. 194 public nurses, 104 local policemen, and 180 neighborhood workers are surveyed for knowledge of the Mental Health Act especially in involuntary evaluation and compulsory admission to the hospital. The subjects knowledge level of Mental Health Act is relatively low. The percentage of correct answer from different groups of the subject are ranged from 26% to 78%. However, the public nurse group has the highest percentage. The result shows that propaganda for Mental Health Act is inadequate since the law has been enacted. Both mental health worker and lay people are not clear about the obligation and right of the caretakers (gardians). This study further implies that the knowledge of social resources and process of helping the mentally disturbed hospitalized should be strengthened.
• 426 - 437
• 10.6288/CJPH1995-14-05-06

• Link 原著 Original Article
• 疑似嚴重精神病患住院過程之探討Hospitalizing the Suspected Severely Mental Ill Patients
• 張珏、許蓉雰
  Chueh Chang, Jung Feng Hsu
• 精神衛生法 ； 嚴重精神病人 ； 強制護送
  Mental Health Act ; Mental ill patients ; Hospitalization
• 本研究希望瞭解社區中精神病患家屬與相關人員（包括衛生所護士、警察以及村里幹事）在護送疑似嚴重精神病患就醫的過程中所遇到的困難，藉此明瞭社區實際的運作情形，以提供未來修法的參考。 病患家屬資料以地段護士親自面談訪視而得，共完成175份，完訪率93%；三類相關人員則以郵寄方式，自行填答後寄回，回收結果為：衛生所護士194份(89%)、警察104份、村里幹事180份(32%)。 整體來看，護送過程出現的問題可從三方面來看，（一）行政方面：精神衛生法目前尚無有關實務細則的提出，並未詳細規定強制護送的程序，使得護送者不清楚本身應該扮演何種角色，法令規定的權責不祥，再加上相關人員隸屬不同單位，彼此間的協調聯擊更加不易；（二）個人互動方面：「病人抗拒厲害」是家屬與相關人員頭痛的問題。護送成員彼此的合作度也是護送過程常被抱怨的；（三）醫院方面：「一床難求」是最常出現的問題。 本研究結果，反應出精神衛生法自公佈至今宣導上不足，對保護人的權責也不清，由誰擔任也不明，強制護送鑑定過程的困擾與強制住院條件，皆有持釐清。因此，建請有關單位加強宣導有關精神衛生法強制護送鑑定與住院治療的知識，以及建立完善的強制護送鑑定與住院治療的體系，協助各相關單位達成共識，並成立研究機構，專文出版精神衛生法相關實務或實施手冊。
  This study is intended to understand the difficulties in process of hospitalizing the disturbed psychiatric patients in the community. 175 family members of psychiatric patients, 194 public health nurses, 104 police officers, and 180 neighborhood workers have been interviewed and answered by them either through one-to-one interview or through mailing questionnaires. The problems during the hospitalizing process included: (1) administrative perspective: the Mental Health Act did not clearly indicate how personnel involved would coordinate during the compulsory escorting process; (2) Interactive perspective: ”the resistence of the patients” was the tough issue of the related persons. In addition, ”how to cooperate with other related workers” was also a problem; (3) Hospital perspective: ”difficult to get a bed for admission into the hospital” was complained by the relatd persons.. Based on these results, the needs of better publicity for the Mental Health Act, the obligations of the guardians, the conditions of compulsory hospital admission, etc. are discussed and recommendations are made for revision of the Mental Health Act in the future.
• 438 - 445
• 10.6288/CJPH1995-14-05-07

• Link 原著 Original Article
• 醫院血庫經濟訂購量模式之建立－個案研究The Economic Order Quantity Model Building for a Hospital Blood Bank
• 蘇喜、莊逸洲、孫建峰、林曉薇
  Syi Su, Yi-Chou Chuang, Chien-Feng Sun, Hsiao-Wei Lin
• 血液經濟訂購量 ； 血液管理系統 ； 血液持有成本 ； 血液訂購成本 ； 全血／成分血
  Blood Economic Order of Quantity ; Blood Management System ; Blood Carrying Cost ; Blood Ordering Cost ; Whole Blood/Component Blood
• 本研究為採用存貨理論中的經濟訂購量模式來建立醫院血庫血液存貨管理模式。由79、80年年平均使用量資料分析，血液年持有成本為9,763,977元，年訂購成本為121,600元，每次訂購成本為468元。以各血型平均年使用量乘以各血品容積作為分攤持有成本的依據，各血品再依其平均用量比率估算分擔之持有成本，而得經濟訂購量結果與訂購次數。成本資料由長庚醫院配合提出。為配合實際情況，以血品或血型來區分、合併分組方式來規劃。運輸時間為捐血中心考量運輸成本時的一大變項，如何將時間變項合理考量進而納入運輸模型中，為後續研究方向之一。
  The research is conducted to establish an economic order of quantity (E.O.Q.) of whole blood (WB), Red Blood Cell concentrated (RBC) platelet concentrated (PC), frozen fresh plasma (FFP) and frozen plasma (FP) from hospitals perspective. Using the information of patients demand, incorporared with the carrying cost, ordering cost and investment cost incurred to the hospital, the economic order of quantity (E.O.Q.) for whole blood and above mentioned popularly used component blood can be developed. The E.O.Q. models can lend themselves to blood ordering decision making, and as the base data for national blood demand/supply transportation network.
• 446 - 454
• 10.6288/CJPH1995-14-05-08