19卷5期

• Link 公衛論壇 Public Health Forum
• 正視有害廢棄物處理正視有害廢棄物處理
• 宋鴻樟
  Fung-Chang Sung
• 無
  none
• 無
  none
• 325 - 326
• 10.6288/CJPH2000-19-05-01

• Link 公衛論壇 Public Health Forum
• 落實廢棄物回收管理、確保台灣環境永續發展落實廢棄物回收管理、確保台灣環境永續發展
• 郭憲文
  Shien-Wen Kuo
• 無
  none
• 無
  none
• 327 - 328
• 10.6288/CJPH2000-19-05-02

• Link 公衛論壇 Public Health Forum
• 事業廢水傾倒事件之警訊－台灣河川與沿海水質監測之必須事業廢水傾倒事件之警訊－台灣河川與沿海水質監測之必須
• 郭育良、 邵于宣
  Yue-Liang Leon Huo, Yu-Hsuan Shao
• 無
  none
• 無
  none
• 329 - 331
• 10.6288/CJPH2000-19-05-03

• Link 綜論 Review Article
• 職業性下背痛Occupational Low Back Pain
• 郭浩然
  How-Ran Guo
• 下背痛 ； 職業衛生 ； 醫療人員 ； 肌肉骨骼不適 ； 人體工學
  Low back pain ; Occupational health ; Health-care worker ; Musculoskeletal disorder ; Ergonomics
• 目標：背痛是非常普遍的職業病。以美國為例，背痛佔去所有職業傷病賠償案件的四分之一，且有研究發現約17.6%的勞工在一年期間曾有背部疼痛至少持續一星期的情形，其中又以下背痛佔絕大多數。本文以一位職業性下背痛的個案為例，做一綜合性的實務報告，希望能提高國人對這一項職業傷害的警覺。方法：本文以一位因長期從事重物的搬運而引起下背痛的醫事技術人員為例，參考國內外文獻，討論職業性下背痛的危險因子、診斷、治療、及預防等事項。此外，也分析勞工安全衛生研究所「工作環境安全衛生狀況調查-受雇者認知調查」所收集的資料，估計臺灣勞工的下背痛盛行率，並試圖找出高危險行業。結果：回顧國內的調查報告發現，臺灣地區勞工下背痛的情形其實很普遍；男性以「土木工程業」，女性以「農、牧、狩獵業」盛行率最高。而文獻中記載的危險因子主要為搬動及舉起重物、費力的工作、不自然的姿勢、全身性的震動、長時間靜態的姿勢、肥胖、抽煙、及心理因素。職業性下背痛的診斷許要多方的考慮，其治療則有許多選擇，但最重要的工作室預防。結論：下背痛是國人常見但容易被忽視的職業傷害；我們應提高警覺，做好預防措施，以減低其危害。
  Obiectives: Low back pain is a very common occupational disorder. In the United States, for example, one fourth of the workers' compensation claims are filed due to back pain, and a survey period and that most of them suffered from low back pain. To call for raising the attention to this occupational disorder, a case of occupational low back pain is reported, and an overview of this problem IS provided. Methods: A case of low back pain in a medical technician due to long-term lifting is used as an example. Together with a review of literature, risk factors, diagnosis, treat ment, and prevention of occupational low back pain are discussed. In addition, data obtained from the Survey of Employees' Perceptions of Safety and Health in the Work Environment conducted by the National Institute for Occupational Safety and Health were analyzed to estimate the preva-lenee of low back pain among Taiwanese workers and to identify high risk industries. Results: The review of literature found that low back pain is quite prevalent among the workers in Taiwan. ”Infrastructure Construction” was the industry with the highest risk for males, and ”Agriculture, Animal Husbandry and Hunting” was the industry with the highest risk for females. Well-docu-mented risk factors included lifting and moving heavy objects, heavy physical load, awkward postures, whole body vibration, static work postures obesity, smoking, and psychological factors. The diagnosis of occupational low back pain requires consideration from multiple aspects, and a variety of choices are available for its treatment. The most important issue, however, is the pre-vention. Conclusions: Low back pain is a common but easily over-looked occupational disorder among workers in Taiwan. We should raise our attention to this problem and apply various pre-vention measures to reduce its impacts.
• 332 - 339
• 10.6288/CJPH2000-19-05-04

• Link 綜論 Review Article
• 美國發展管理式照護的經驗與啟示Managed Care: US Experiences and Lessons for Taiwan
• 江東亮、胡德偉
  Tung-Liang Chiang, Teh-Wei Hu
• 管理式照護 ； 醫療費用控制 ； 醫療品質 ； 醫療改革
  managed care ; health cost control ; quality of care ; health care reforms
• 美國發展管理式照護與其醫療費用不斷上漲息息相關。管理式照護的特色在利用種種管理技術將保險財務風險與健康服務提供相互結合，基本上分為兩大類，即健康維護組織(HMO)和擇優特約組織(PPO)。綜合實證研究結果，可以發現：不僅管理式照護的醫療費用顯著低於傳統論量計酬之健康保險，而且管理式照護市場佔率越高，則醫療費用的成長率越低，唯管理式照護的臨床醫療品質是否亞於傳統健康保險並無定論。本文以美國發展管理模式照護經驗為借鏡，建議全民健保改制必須重視深化醫療提供者的財務風險分擔並以增進國民健康為首要目標，同時亦必須注意配套措施的健全以及保障人人有適當醫療保健服務。
  The evolution of managed care in the United States has been attributed to the repidly increas-ing of health care costs. Characterized as a collection of systems that integrate the financing and delivery of health care services, managed care organizations might be grouped into two major groups:health mantenance organizaton (HMO) and preferred provider organization (PPO). A liter-atural review of empirical studies indicates not onlt that managed care has lower health care costs than traditional fee-for-service health insurance, but also that higher market share of managed care is associated with a lower growth rate of health care costs. Further, there has no conclusive evidence that traditional fee-for-service health insurance provides either consistently better or consistently worse clinical quality of care than managed care. Based on US experiences on man-aged care, we recommend that the National Health Insurance reform in Taiwan should pay more attention to increasing the finacial-risk sharing of health care provider and put pursuing population health as the formost priority. Besides, the infrastructure for reforming the National Health Insur-ance should be well developed and the premise of health care for all should be undersocored.
• 340 - 355
• 10.6288/CJPH2000-19-05-05

• Link 原著 Original Article
• 煙道粒狀物檢測比測統計模型之建立Establishment of a Statistical Model of stack Particulate Measurements
• 黃盛修、陳志傑、黃景祥、林文印、鄭福田
  Sheng-Hsiu Huang, Chih-Chieh Chen, Jing-Shiang Hwang, Wen-Yinn Lin, Fu-Tien Jeng
• 煙道採樣 ； 水泥粉塵 ； 效能檢定 ； 氣膠產生
  stack sampling ; cement dust ; proficiency testing ; aerosol generation
• 目標：煙道粒狀物濃度量測的準確性受到許多因素的影響，這些因素包括排氣速度、溫度、含水量、粒狀物濃度、採樣儀器的種類、甚至採樣人員的訓練與經歷等。而本研究的目的即是在於釐清可能的因子對於量測變異的貢獻程度，冀能針對主要的影響因子探討可能的誤差來源並加以改善。其次藉著因子分析的結果建立煙道粒狀物濃度之統計模型。方法：建置一套模擬煙道，主要由一內徑60cm、高13.4m之不銹鋼管、一具15匹馬力的風車，以及前後進氣與出氣口之過濾設備所組成。此風扇最高可造成每秒15米的風速。粉塵的產生主要將利用一粉塵飼餵器(Palas powder disperser)進行，此儀器可藉由輸送帶速度的調整來控制粉塵的濃度。一具750kw的熱風發生器可將排氣溫度揚升道150℃，此外，煙道內的排氣濕度藉由一具120kW的蒸汽產生器來調整，含水量可控制在2至10%2的範圍。在研究中主要的操作變項有：粉塵濃度、溫度、濕度、風扇轉速(風速)等。研究中首先邀請八家環檢所檢定合格之代檢業參與資料庫的建立以初步界定各因子之影響程度。結果：從變異數分析的結果得知，排氣速度是影響煙道內粒狀物平均濃度量測的主要因子，其次分別為粉塵供應率、以及風扇轉速和含水量的交互作用，至於排氣溫度與排氣濕度的影響並未達統計上顯著的水準。結論：本研究中建立了影響煙道內粒狀物濃度量測結果的初步模型，未來需進一步收集數據以檢驗該模型的適用範圍以及提升該統計模型的精準確度。
  Objectives: It is speculated that the dust concentration measurement is influenced by the interactions among exhaust velocity, temperature. humidity, dust concentration level. type of sam-pling equipment and trained and experienced members .of sampling team. The results of this work. can be used in the identification of the factor(s), which contribute to the variability of measure-ment results from ducts and stacks. Another objective of this study is to establish a statistical model to predict the mass concentration of particulate matter in the stack. Methods: This testing system simulating a stack is composed of an inlet filtration unit, a 15-Hp blower, a 13.4-m height, a 60-cm diameter stainless steel duct, and an outlet filtration unit. The blower lis capable of propelling the gas to reach the face velocity of 15 mfsec. A dust feeder, the Palas Powder Dispers-er, is used to generate aerosol particles. A heater of 750 kW with a feedback system is used to control the temperature of the exhaust gas. A 120 kW steam generator is used to change the humidity of the exhaust gas, i.e., water content ranging from 2% to 10%. The major operation parameters include dust concentration, temperature, relative humidity, and fan rotation speed. Re-suits: According to the analysis of variance, the duct velocity is the most influential operation factor, followed by dust feed rate, and the interaction of duct velocity and water content in deter-mining the aerosol concentration in the stack. However, neither temperature nor water content of the exhaust gas showed any significant effect. Conclusions: A statistical model for predicting mass concentration of particles in the stack was established. However, it needs further study before application.
• 356 - 365
• 10.6288/CJPH2000-19-05-06

• Link 原著 Original Article
• 台灣婦女健康政策的性別分析Engendering Women's Health Policy in Taiwan
• 張玨、陳芬苓
  Chueh Chang, Fen-Ling Chen
• 婦女健康政策 ； 將性別分析融入主流政策 ； 歷史分析 ； 政策分析
  women's health policy ; gender mainstreaming ; historical analysis ; policy analysis
• 無none
  Objectives: This article attempts to classify the definition of 'women's health policy,' and to examine the policies in Taiwan related to women's health by way of gender analysis, from a historical and critical perspective. Methods: Historical analysis is adopted to examine health poli-cies in Taiwan during 1912-present. Related legislation, schemes, activities, important announce-ments by political leaders, organizations, functional diffusions of government, administrative sys- terns and research subsidized by central government are included to review the gender meaning of policies. Results: the government in Taiwan has regarded his work for promoting 'maternal and child health' the same as promoting women's health. Some important characteristics have been found by this historical analysis: policies have focused on controlling women's reproductive abili-ties, and on women's roles as mothers; policy decision-making has maintained the authoritarian model; governmental policies have been determined for business and specialists' benefits rather than women's benefits; the disability of health administration to cope with new social problems; policies have dominated by patriarchal ideology; health promotion work for women has been full of gender bias. Conclusions: The government in Taiwan should adopt UN's new working mode, mainstreaming a gender perspective across all health policies process. including plan. implement and evaluation. Women and men should fully participate in health decision-making and govern-mental sectors.
• 366 - 380
• 10.6288/CJPH2000-19-05-07

• Link 原著 Original Article
• 醫師人力供給的多寡是否會影響被保險人的門診利用？－1994年國民醫療保健調查之發現Does Supply of Physicians Affect the Use of Ambulatory Services by the Insured? - Findings from the 1994 Taiwan Health Interview Survey
• 朱僑麗、 薛亞聖、江東亮
  Chiao-Lee Chu, Ya-Seng Hsueh, Tung-Liang Chiang
• 醫師人力 ； 門診利用 ； 健康保險
  Physician manpower ; Ambulatory services utilization ; Health insurance
• 檢視醫師人口比值的高低對有保險者西醫門診利用率的影響。方法：以有保險者為分析對象，採用兩部分模式(Two-Part model)進行分析，將醫療次區域中每萬人口醫師教分為高、中、低三組，檢視醫師數的高低對西醫門診利用的影響。有關個人門診利用與基本資料的來源，為1994年台灣地區國民保健調查資料，有關居住地區的醫師人口比資料來源，為1994年行政院衛生署的醫事八實現況調查與內政部編印的台閩地區人口統計。結果：控制了其它相關影響變項後，地區內醫師數量的多或少，對有保險者的門診醫療利用機率及次數並未造成顯著差異。結論：台灣地區醫療資源分佈雖不完全平均，但並未導致民眾醫療利用顯著的差異。是否穠示就醫可近性較差地區民眾已付出較高的時間及交通成本以尋求必要的醫療，值得注意與改善。(中華衛誌2000;19(5):381-388)
  Objective: To examine the effect of the number of physicians on the utilization of ambulato-ry services for insured persons. Methods: The insured population was the target population in this study, and a two-part analysis was used in this study, To test the impact of physician supply on ambulatory care utilization, we categorized the medical care sub-regions for three levels according to the density of medical doctors: low, median, and high. Information about individuals' medical utilization was collected from the 1994 Taiwan Health Interview Survey (THIS). The physician- to-population ratios for each region were obtained from the 1994 Medical Care Manpower Survey in Taiwan compiled by the Department of Health and from the Taiwan-Fukien Demographic Fact Book published by the Ministry of the Interior, Republic of China. Results: After controlling for extraneous factors, the effect of the number of community physicians on the use of ambulatory services by the insured was not found to be statistically significant for the differences among the high, median, and low groups. Conclusion: Therefore, there is insufficient evidence to support the view that the presence of fewer community physicians have discouraged the utilization of ambula-tory services by the insured. However, whether this indicates that people with less medical re-sources where they live have paid higher time and transportation costs to obtain the needed care deserves further investigation for policy formulation.
• 381 - 388
• 10.6288/CJPH2000-19-05-08

• Link 原著 Original Article
• 耳鼻喉科開業醫師服務量相關因素之探討Factors Related to the Service Volume of ENT Clinics
• 黃源甫、李丞華、王淑園、吳肖琪
  Yuan-Fu Huang, Cheng-Hua Lee, Shu-Yuan Wang, Shiao-Chi Wu
• 耳鼻喉科 ； 門診服務 ； 開業醫師 ； 高服務量
  GENT ; ambulatory care ; general practitioner ; high volume practice
• 目標：本研究旨在探討耳鼻喉科開業醫師個人開業能力、診所特性、執業環境與其服務量之關係。方法：以中央健康保險局特約之耳鼻喉科診所629家負責人為對象，問卷資料採用二次郵寄，回收率為37.5%，服務量資料來自中央健康保險局85年10月至86年9月之門診申報檔。結果：發現醫師基本特質、開業術、診所特性、及執業環境皆與醫師之服務量有關。在醫學中心接受住院醫師訓練、為當過科主任、解釋病情詳細、認知上不將擅用類固醇當做開業術的醫師其服務量愈高。在鄉鎮地區開業者、開業地點在7-ELEVEN超商或百貨公司附近者門診量較高。結論：研究結果可作為醫師規劃投入開業市場之參考，亦可鼓勵醫師至鄉鎮開業。
  Objectives: This study evaluates ENT practitioners in terms of the relationship between practitioner's ability, characteristic and environment of clinics, and service volume. Methods: The subjects of this study were 629 owner of ENT clinics contracting with the National Health Insur-ance (NHI) bureau. Questionnaires were mailed twice to collect basic data, with a response rate of 37.5%. The service volume data was from the out-patient-claimed file provided by NHI. Results: The service volume was related to physicians' personal characteristics, practicing ability, as well as the characteristic and environment of clinics. The service volume provided by those trained as residents in medical centers were higher than those trained in regional hospitals. The service volume was also higher for those who had never been the chief of an ENT department in a hospital, explained the symptoms in detail and prescribed fewer steroids to patients. Clinics with more physicians and auxiliary personnel had higher service volume. The service volume in a rural town was higher than in an urban area. Also, clinics close to convenience stores and department stores (within 5 minutes walk) had higher service volume. Conclusions: This study can be a reference for the physicians who are planning to start their clinics, also encouraging them to practice in rural towns.
• 389 - 396
• 10.6288/CJPH2000-19-05-09

• Link 原著 Original Article
• 傳染病爆發時民眾的預防行為－1998年的腸病毒流行General Public's Preventive Behavior During the Outbreak of Infectious Disease - The Case of Enterovirus Infection in Taiwan, 1998
• 丁志音、林怡靜、徐美苓、邢一如
  Chih-Yin Lew Ting, I-Ching Lin, Mei-Ling Hsu, I-Ju Hsing
• 腸病毒感染；預防行為
  Enterovirus Infection ; Preventive Behavior
• 目標：瞭解台灣地區民眾於1998年夏天腸病毒流行當時及之後，對勤於洗手、徹底洗手、少去公共場所及注意飲食／水衛生等四項預防措施的實施情形，及其與風險知覺及預防信念間的關係。方法：研究資料來自於1998年底的全國性電話訪談(健康信念及態度調查)，經由電腦輔助電話訪問系統共獲得3023有效樣本數(回應率為73%)，本研究樣本為其中2677名曾聽過腸病毒且對相關問題填答較完整者。結果：對每一項預防措施的實施可分為三種狀況：沒有改變、流行時改變流行後鬆懈、或持續改變。整體而言，民眾的預防措施有兩極化的現象，即高比例的「沒有反應」及，「持續改變」，而居於中的「先改變後鬆懈」者較少。四項措施中以飲食／水衛生最受重視，洗手頻度及品質次之。將四項措施合併觀之，可得出三類人群：如常型、因應型及警覺型。進一步分析可發現，個人的風險知覺對預防行為型態之影響遠大於腸病毒的預防信念。結論：本次腸病毒流行危機固然能在短期內引發民眾高度的風險知覺，採行最簡易的預防措施。然面臨新舊型態傳染病的肆虐，應於平時減少民眾對醫療科技的過度依賴，而強化其對個人基本衛生習慣的重視與施行。
  Objective: To examine the general public's practices of and factors related to four types of preventive behavior Gfrequent hand-washing, thorough hand-washing, avoiding public contact, and food/water safety in response to enterovirus epidemic during the summer of 1998 in Taiwan, and its relation to risk perceptions and belief of preventability. Methods: Data for the present study were derived from a nationwide telephone survey (Health Attitudes and Health Seeking Survey) at the end of 1998. A total of 3023 representative valid interviews were accomplished (response rate=73%), of which 2677 respondents who have ever heard of enterovirus infection and also provided valid responses to the questions pertaining to the study were included. Results: To each preventive behavior, the respondents could either practiced as before without any change, changed during the epidemic but slipped back while the epidemic was controlled, and changed continuously. Overall, the profiles of the sample's preventive behavior were somewhat bipolar, that is. higher proportions of ”without change” and ”changed continuously”, but tower proportion of ”changed then slipping back”. Of the four types of preventive behavior, food/water hygiene obtained the greatest attention, and hand washing followed. Three types of behavioral pattern were generated based on the four preventive practices: no responding, crisis coping, and keeping alert. Further analyses show that risk perceptions exerted substantially greater influence on the behav-ioral pattern of the respondents than did their belief in the preventability of enterovirus infection. Conclusion: The 1998 enterovirus epidemic in Taiwan has promptly raised risk perceptions among general public and impelled them adopt elementary preventive strategies in personal hygiene. Facing with the threat of resurgent and emergent infectious diseases, it is critical to emphasize personal hygienic practices and reduce dependence on medical technology.
• 397 - 406
• 10.6288/CJPH2000-19-05-10