19卷3期

• Link 公衛論壇 Public Health Forum
• 健保實施五年之回顧與未來興革之道健保實施五年之回顧與未來興革之道
• 楊志良
  Chin-Liang Yuang
• 無
  none
• 無
  none
• 159 - 160
• 10.6288/CJPH2000-19-03-01

• Link 綜論 Review Article
• 運動訓練對血液透析病患生理、心理之效應The Effects of Exercise Training on Physiological and Psychological Status in Hemodialysis Patients
• 林秋菊、賴曉蓉、周偉倪
  Chiu-Chu Lin, Hsiao-Jung Lai, Willy Chou
• 末期腎病；血液透析；運動訓練
  end-stage renal disease ; hemodialysis ; exercise training.
• 本文主要是針對運動訓練對血液透析病患生理、心理的影響，包括。活動無耐力、貧血、血糖、血脂、血壓控制和疲憊、憂鬱等方面進行文獻探討，期此能幫助健康專業人員更進一步認識運動訓練對血液透析病患在生狂、心理上之效應，俾以鼓勵病人運動，進而將運動訓練納為其常規的照護模式，使透析病人達到健康促進的目標，提昇其生活品質。透析治療是末期腎病患者最主要的治療方式，目前國內絕大多數的病人係採行血液透析。由於末期腎病變及透析治療的合併症常引起許多生理、心理問題，進而影響其家庭、工作、社交活動及生活品質。許多文獻指出，定期足量的運動對透析病患的生理、心理層面有良好效益。關於血液透析病人的運動原則，應包括：暖身運動、有氧運動及冷卻運動。而運動種類主要以踩固定式腳踏車的有氧運動為主；運動強度是依病人個別的耐受力來漸進調整，一般係以運動測試所得的最大負重量的40－85%作為訓練進度之指引。運動時間每次以20－25分鐘為宜，可施行於透析中、透析後或非透析日。運動訓練期限一般設在8至12週；運動頻率通常每週至少執行3次。
  This review was conducted to explore the effects of the exercise training on physiological and psychological status in hemodialysis patients, mainly focusing on activity intolerance, anemia, serum level of sugar and lipid, blood pressure control, fatigue, and depression. We hope this review will enable the health care professionals to realize the effects of exercise training in the patients undergoing hemodialysis and then encourage them to exercise. Furthermore, exercise training can be integrated into the routine care and can achieve the goal of health promotion as well as enhance the quality of the life of hemodialysis patients. Dialysis is the primary treatment in those patients with end-stage renal disease (ESRD). In Taiwan, the majority of ESRD patients accepted the hemodialysis therapy, which often caused many physiological and psychological problems, and further, affected their family, employment, social activities and quality of life. The findings from research indicated that regular and adequate exercises would be beneficial to the dialysis patients in physiological and psychological aspects. The exercise principle of hemodialysis patients should include warm-up, exercise and cool-down. The type of aerobic excise is mainly stationary bicycle; the exercise intensity can be adjusted according to the patient’s tolerance. The guide of training progress was generally about 40% to 85% of maximal workload measured by exercise testing. The exercise can be done during hemodialysis or after dialysis or non-dialysis day. The duration of exercise was suggested 20 to 25 minutes each time. The training course can be lasting 8 to 12 weeks and the exercise frequency has to be at least three times per week.
• 161 - 170
• 10.6288/CJPH2000-19-03-02

• Link 綜論 Review Article
• 輪狀病毒感染Rotavirus Infection
• 陳國東、許建邦、 陳豪勇、湯仁彬、黃繼慶
  Kow-Tong Chen, Jen-Pang Hsiu, Hour-Young Chen, Ren-Bin Tang, Jih-Ching Huang
• 輪狀病毒 ； 疫苗 ； 死亡率 ； 腹瀉
  Rotavirus ; vaccine ; mortality ; diarrhea.
• 輪狀病毒是引起全世界嬰幼兒及小孩嚴重腹瀉的主因。因此，應及早提供疫苗以預防輪狀病毒腸胃炎。因輪狀病毒腸胃炎造成的死亡率低，所以，在決定全面性的推廣疫苗前，必須先評估該疫苗所能減少的罹病率及因該病毒感染後所需要的醫護費用。目前，台灣地區有關輪狀病毒感染的流行病學資料仍然非常缺乏，本文的目的是回顧輪狀病毒腸胃炎流行病學以提供國人預防感染的策略，使輪狀病毒感染的罹病率及死亡率降到最低。
  Rotavirus is the leading cause of severe diarrhea morbidity in infants and children throughout the world. Rotavirus gastroenteritis should soon be a vaccine-preventable disease. Mortality due to rotavirus intestinal infection is very low; therefore, decision on introduction of mass rotavirus I vaccination will be based on ability of the vaccine to reduce morbidity and the associated health care cost associated with rotavirus infection. However, information of epidemiology of rotavirus infection is rare in Taiwan. The purpose of this study is to review the epidemiology of rotavirusassociated intestinal infection for prevention and intervention efforts.
• 171 - 179
• 10.6288/CJPH2000-19-03-03

• Link 原著 Original Article
• 預防為最上策－民眾的愛滋病性病防治信念與對保險套的看法Prevention is the Best Policy - The Public's Belief of AIDS and STDs Control and Attitudes towards Condom Use in Taiwan
• 丁志音、 陳欣欣
  Chih-Yin Lew Ting, Shin-Shin Chen
• 愛滋病 ； 性病 ； 預防 ； 保險套使用 ； 個人行為控制
  AIDS?;?STDs?;?Prevention?;?Condom use?;?Personal behavior control
• 目標：即使醫療科技高度發展，「預防」仍是疾病控制的最基本原則，而民眾對預防的信念亦攸關防治策略的設計與成效。本描述性研究旨在瞭解民眾對愛滋病及其他性病所持的「預防觀念」，以及對特殊預防策略「戴保險套」的意見與行為。方法：本研究之資料來自1997年及1998年兩次對全國20－70歲民眾之「健康信念與求醫行為」電話訪談。結果：（1）民眾多認為愛滋病的「可預防性」極高，且視預防比高科技的解決方式重要；（2）個人行為的控制（自我約束）乃最受民眾重視的防治途徑；但對政府的血液安全管制及他人行為所可能造成的危害較感無力；（3）民眾對保險套之使用持相當肯定之態度，不過曾使用者絕大多數以避孕而非以預防性病為主要目的，男女性在這方面的行為差異極大；（4）身體及心理上的不適與不稅被一般民眾指出是保險套使用率低的主要原因，（5）教育程度對民眾在預防的認知及信念扮演極重要的角色。結論：民眾目前正處於「準備就緒」的狀態，不但利於知識的宣導及教育，也助於態度與行為的形成與改變。有關單位應盡速發展整體性或特殊性的介入計畫，並能從行為的角度而非疾病類別的角度進行常規的行為偵測，以作為規劃同性質健康問題介入計畫之依據。
  Objectives: Despite the recent advances in medical technology, “prevention” is still the foundation for disease control, particularly in the case of Acquired Immunodeficiency Syndrome(AIDS) and sexually transmitted diseases (STDs). The general public’s attitude towards prevention is critical to the implementation and effectiveness of intervention programs. This descriptive study aims to explore the public’s belief of prevention and their attitude towards condom use for AIDS/STDs control in Taiwan. Methods: Data for the present study came from the 1997 and 1998 nation-wide Health Beliefs and Health-Seeking Behavior telephone interviews conducted among people 20-70 year of age. Results: The major findings are: (1)the public held strong belief in the preventability of AIDS/STDs and considered prevention was of greater importance than biomedical interventions, (2)of the possible prevention strategies proposed by the research participants, personal behavior control (self discipline) was deemed as the most effective; meanwhile a sense of powerlessness was expressed while mentioning the government’s responsibility for keeping the quality of blood supply and managing the potential dangers posed by other people’s behavior, (3)condoms were well accepted as an effective tool for AIDS/STDs prevention but were used mostly for the purposes of contraception than HIV/STDs prevention, and (4)people were unwilling to use condom mainly due to sensational and psychological discomforts. Conclusions: People were at the stage of being “ready “ for knowledge, attitudinal and behavioral changes. It is suggested that the government should develop and implement comprehensive as well as specific intervention programs. Behavioral-rather than disease-oriented surveillance should be carried out regularly together with rigorous behavioral science research as the foundation for health programs planning.
• 180 - 191
• 10.6288/CJPH2000-19-03-04

• Link 原著 Original Article
• 母親危險因子對低出生體重嬰兒、早產兒、及生長遲滯嬰兒之影響－前瞻性懷孕世代研究Influence of Maternal Risk Factors on Low Birthweight, Preterm Delivery, and Small for Gestational Age - A Prospective Cohort Study of Pregnancy
• 陳保中、 Patricia E Doyle 、 何啟功、 張蓓貞、 王榮德
  Pau-Chung Chen, Patricia E Doyle, Chi-Kung Ho, Pei-Jen Chang, Jung-Der Wang
• 母親危險因子 ； 低出生體重兒 ； 早產兒 ； 生長遲滯兒 ； 前瞻性世代研究
  maternal risk factors ; low birthweight ; preterm delivery ; small for gestational age ; prospective cohort study
• 目標：本前瞻性世代研究以探討母親危險因子對低出生體重兒、早產兒、及生長遲滯兒的影響，包括生物學背景、母親產科史、懷孕中疾病及吸菸的可能影響。方法：1984至1987年間，針對在台北市立婦幼醫院產前檢查的所有懷孕六個月以上孕婦使用結構化問卷進行訪視，並於嬰兒出生後閱覽孕婦及新生兒的病歷進行摘錄。總共使用12,273單胞胎活產兒進行出生結果logistic迴歸分析。結果：關於低出生體重兒方面，母親產前出血及高血壓是最強的危險因子，瘦小及肥胖的母親、二次以上的自然流產經驗、以前有低出生體重或早產兒、以及梅毒感染是中度的危險因子，女嬰及初產婦亦與低出生體重兒有顯著相關。關於早產兒方面，母親產前出血亦是是最強的危險因子，肥胖的母親、矮小的父親、二次以上的自然流產經驗、及以前有低出生體重或早產兒則有中等程度的影響。母親高血壓、低懷孕前體重、及初產婦皆是為對稱及非對稱生長遲滯兒的危險因子，除初產婦外對非對稱生長遲滯兒有較大的影響，矮小母親或父親及以前有低出生體重或早產兒亦與對稱生長連滯兒有顯著相關。結論：已知的危險因子持續存在，未來需要進行介入性預防措施。
  Objectives: This prospective cohort study investigated low birthweight (LBW), preterm delivery (PTD), and small for gestational age (SGA) in Taipei, Taiwan. Effects of maternal risk factors on birth outcomes were examined, including biological background, maternal obstetric history, as well as medical events and smoking during pregnancy. Methods: Between 1984 and 1987, each pregnant woman who came to the Taipei Municipal Maternal and Child Hospital for prenatal care was interviewed using a structured questionnaire. Maternal and newborn medical records were abstracted after delivery. A total of 12,273 singleton livebirths were analyzed. Potential risk factors associated with birth outcomes were examined using logistic models. Results: Antepartum hemorrhage and hypertension were the strongest risk factors for LBW or PTD history, and infection with syphilis had moderately increased risks. Female gender and primiparae were were also significantly associated with the risk of LBW infants. Antepartum hemorrhage was the strongest risk factor for PTD infants, whereas obese mothers, short fathers, two or more prior spontaneous abortions, and previous LBW or PTD history gave moderately increased risks. Maternal hypertension, low pre-pregnancy weight, and primiparae were the risk factors for both symmetric and asymmetric SGA infants Those effects except primiparae were considerably greater on asymmetric than symmetric SGA infants. Low parental height and previous LBW or PTD history were also significantly associated with the risk of symmetric SGA infants. Conclusions: The relationship between several known risk factors and birth outcomes consistently remains, and interventions should be promoted in Taiwan.
• 192 - 202
• 10.6288/CJPH2000-19-03-05

• Link 原著 Original Article
• 中老年男性血鎘及尿鎘與飲食的關係Association between Dietary Intake and Blood and Urine Cadmium Levels among Men in Taiwan
• 陳怡君、宋鴻樟、 李旻貞
  Yi-Chun Chen, Fung-Chang Sung, Ming-Chen Lee
• 血鎘 ； 尿鎘 ； 食物 ； 營養
  blood cadmium ; urine cadmium ; diet ; nutrition.
• 目的：鎘為具有毒性的微量金屬，有關國人人體鎘暴露量的探討並不多見，本研究旨在探討50歲以上男性的血鎘、尿鎘與飲食的相關性。方法：以健康檢查中心接受全身體檢的男性為對象，利用問卷記錄各種食物的攝取頻率，據以評估所攝取營養量是否適當，同時抽取血樣，收集尿液。利用石墨爐原子吸收光譜儀分析血鎘及尿鎘。自1999年6月至9月收集50歲以上男性的資料，共295人參加。結果：受試者的血鎘中位數值為0.84ug/L，95百分位為3.35ug/L，尿鎘的中位數值為0.94ugCd/g creatinine，95百分位為4.05ug Cd/g creatinine。營養素攝取有偏差，包括鈣質的攝取不足（91．9%），蛋白質、醣類及鐵質的攝取亦有60%以上的人不足，但有23.4%的人脂肪攝取過量。大部分的食物及營養攝取量，包括鈣、鐵之攝取，與血鎘及尿鎘沒有顯著相關性。魚貝類的攝取量高時，尿鎘含量達2.0ug Cd/g creatinine以上的勝算比（OR）為7.4（95%可信範圍（CI）為1.3－42.0），血鎘的含量亦較高，但不顯著。淡色蔬菜攝取量高時，血鎘含量達1.4ug/L以上的OR為7.0（95%CI為１．0－50.0）。飯麵類的攝取量高時，體內血鎘與尿鎘含量則低。結論：體檢中心中老年男性的血鎘及尿鎘含量與多數食物及營養素的攝取相關不顯著，魚貝類及淡色蔬菜攝取較多者，有較高之鎘負載，澱粉食物之攝取則反。
  Objectives: Human exposure to cadmium is rarely studied in Taiwan. This cross-sectional study measured blood cadmium and urine cadmium for men aged 50 and above and assessed their relationships with daily dietary and nutritional intakes. Methods: Blood and urine specimens were obtained from 295 men of eligible age while they were receiving a routine comprehensive health examination from June though September 1999. All data on dietary and nutritional intakes, socio-demographic and physical examination were obtained from the health examination center. Graphite furnace atomic absorption spectrometry was used to measure blood and urine cadmium contents. Results: The median and 95lh percentile levels of cadmium in blood samples were 0.84ug/L and 3.35µg/L, respectively. The corresponding values in urine samples were 0.94ug Cd/g creatinine and 4.05 ug Cd/g creatinine. Insufficient intakes of calcium were found for approximately 91.9% subjects. More than 60% subjects had insufficient intake of protein, carbohydrate, and iron while 23.4% subjects had over intake of fat. Relationships were not significant between blood and urine cadmium and most dietary and nutritional variables. Higher intake of seafood increased the risk of elevated urine cadmium level (>2.0 ug Cd/ g creatinine) (odds ratio (OR)=7.4, 95% confidence interval (CI)=1.3-42.0). An elevated blood cadmium level (> 1.4 ug/L) was also associated with higher intake of light-leaf vegetable (OR=7.0, 95%CI=1.0-50.0). But increased consumption of rice and noodle decreased such risk. Conclusions: Most dietary items do not explain cadmium content in specimens for these middle age and older men. A few men with higher consumption of seafood and light-leaf vegetables, and decreased consumption of rice and wheat products were found to have an elevated cadmium burden.
• 203 - 213
• 10.6288/CJPH2000-19-03-06

• Link 原著 Original Article
• 不同通風狀態室內燒香產生PM10濃度變化之研究Distribution of PM10 Concentration from Incense Burning under Different Ventilation Condition; Indoor Study
• 高玫鍾、龍世俊
  Mei-Chung Kao, Shih-Chun Lung
• PM10 ； 燒香 ； 室內空氣污染 ； 環境監測
  PM10 ; incense burning ; indoor air Polhaion ; environmental monitoring
• 目標：本研究模擬一般居家室內燒香情形，探討PM10濃度隨通風狀況、時間及距離之變化，以推估民眾在家燒香所可能暴露之PM10濃度範圍。方法：在密閉及通風狀態之室內各採樣4天，依照距燒香源之遠近取3採樣點，採樣時間則分燒香時、香燒完後3小時內及第4至第6小時等3小時段。以流量2L/min之採樣幫浦配上個人懸浮微粒採樣頭，內為直徑37mm之鐵弗龍濾紙。結果：密閉與通風室內PM10濃度達統計上顯著差異。燒香時密閉室內的PM10濃度平均值約為390～731μg/m3，通風之濃度平均值約為154～185μg/m3。通風時，在燒完香後3小時內濃度即已降至室內背景值；而密閉狀態在燒完香後6小時，其PM10濃度雖減少，但仍比室內背景值高出約300μg/m3。密閉室內燒完香後PM10濃度呈均勻分布；而通風室內PM10濃度則呈現隨距離稍稍遞減的現象。結論：民眾拜拜時暴露之PM10濃度比平時高出至少1倍以上，在通風不佳時甚至高出10位。建議民眾最好在通風良好之室內拜香，可減少約200－500μg/m3之PM10暴露濃度，降低燒香所導致之健康危害。
  Objectives: This study is to simulate incense burning in an indoor environment under two different conditions: closed and well-ventilated. The changes of PM10 concentration over time and distance were evaluated. Accordingly, personal exposures from incense burning indoors were estimated. Methods: Sampling was conducted for four days under each condition. Three sampling locations were chosen: near the burning place, in the middle of the room and in the farthest corner of the room. Samples were taken in three different periods: during incense burning, zero to three hours, and 4th to 6th hours after incense burning. Personal Environment Monitors were used as sampling instrument which were mounted with Teflon filters and connected to pumps with 2 L min flow rate. Resslts: The difference of PM10 concentration between the closed and well-venti-lated conditions was statistically significant. PM10 concentrations during incense burning were around 390~731µg/m3 and 154~185µg/m3 in the closed and well-ventilated environments, respectively. Concentrations reduced to background levels within 3 hours after incense burning under well-ventilated conditions, while the concentrations in closed environment were about 300µg/m3 higher than the background levels even after 6 hours of incense burning. In the closed room, PM10 concentrations were evenly-distributed after incense burning. However, in the well-ventilated condition, they were slightly decreased with the distance from the burning site. Conclusions: While burning incenses, people would be exposed to twice the PM10 concentrations than usually do. Exposure may be as high as 10 times under poor-ventilated environment. It is recommended to hum incenses in a well-ventilated environment in order to avoid the elevated particulate exposure.
• 214 - 220
• 10.6288/CJPH2000-19-03-07

• Link 原著 Original Article
• 綜合教學醫院推行品質管理與營運績效之關係研究The Relationship between Implementation of Quality Management and operating Performance of General Teaching Hospitals
• 董鈺琪、鍾國彪、 張睿詒
  Yu-Chi Tung, Kuo-Piao Chung, Ray-E Chang
• 品質管理 ； 營運績效 ； 資料包絡法
  quality management ; operating performance ; data envelopment analysis
• 目標：本研究之目的在瞭解國內綜合教學醫院，推行品質管理與營運績效間的關係。方法：本研究為橫斷性研究，以醫院評鑑為地區教學以上的123家醫院，以郵寄問卷方式進行普查，測量醫院至85年低為止，推行品質管理的情況。問卷的回收為54.47%，將這些資料與來自衛生署「台灣地區85年醫院現況及服務量量表資料」的次級資料作合併；再以資料包絡法，測量醫院的營運績效，最後以Tobit迴歸模式，分析品質管理與營運績效間之關係。結果：本研究結果發現在控制醫院特性、競爭環境等變項之後，醫院推行品質管理的時間超過4年且內容4項以上，醫院營運的績效較好。結論：因本研究屬橫斷分析，故僅能保守地推論此兩者存在某種程度相關，對於醫院是否因長期全面推行品質管理而造成醫院營運績效較好，尚待更長期的觀察與縱斷性的研究。
  Objective: The objective of this study was to explore the relationship between implementation of quality management and operating performance of general teaching hospitals. Methods: This is a cross-sectional study in all hospitals accredited above district teaching hospitals. A I structured questionnaire was developed and mailed to chief executive officers of 123 hospitals to measure the implementation of quality management through the end of year 1996. The response rate was 54.47%. The secondary data came from Department of Health, entitled “Service Volume and Current Status of Health Care Organizations in Taiwan Area in 1996” and was applied to measure the performance by “Data Envelopment Analysis”, Tobit analysis was then used to explore the relationship between implementation of quality management and operating performance. Results: After adjusting for confounding variables such as ownership status, accredited ranking, Cesarean section rate, and total hospital beds, those hospitals having implementing quality management for more than four years and with more than four items in quality management are showing significantly better operating performance. Conclusions: Due to the nature of crosssectional study, the results of this study can only conservatively conclude that there appears to be a positive relationship between quality management and operating performance to a certain degree. Whether the better operating performance is the result of long-term implementation of total quality management, requires further investigations such as longitudinal research.
• 221 - 230
• 10.6288/CJPH2000-19-03-08

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• 國內三份期刊的醫管論文分析：抽樣方法、信效度、統計方法Examination of Health Care and Hospital Administration Publications in Three Domestic Journals: Sampling Method, Validity and Reliability and Statistical Method
• 李芳年、 盧育誠、陳曉真、 盧佩玲、史麗珠
  Fang-Niarn Lee, Yu-Cheng Lu, Sheau-Jen Chen, Pei-Ling Lu, Lai-Chu See
• 抽樣方法 ； 信效度 ； 推論統計
  sampliug method ; reliability alld validity ; statistical method.
• 目標：本研究摘錄國內三份期刊近五年醫管論文使用之抽樣方法、研究工具信效度及統計分析方法，以瞭解其常用性、適切性。方法：選取83下半年至88上半年「醫院」、「中華衛誌」、「公共衛生」的醫管原著論文，由本文作者經訓練後作登錄並作描述性統計。結果：共收錄109篇。以描述性或分析性（80%）為大宗，類實驗研究（17%）次之，模擬性的論文最少（3%），描述性或分析性研究中有42.5%採用立意或方便取樣。7篇（8%）論文對已達顯著意義的單因子變異數分析沒有進行多重比較，或4篇（4.6%）沒有說明使用哪種多重比較方法；12篇論文使用相關係數論文中8篇沒有特別說明是使用哪種係數，5篇（10.4%）誤認為p值就是顯著水平，迴歸模式沒有進行殘差分析。自行研製的量表有近1／4沒有將量表內容全部刊登在論文內，研究工具之效度以專家效度為主，一半沒有做信度檢定。結論：近年醫管論文約一半的描述性或分析性研究仍採用立意或方便取樣，樣本代表性易受質疑，部份統計推論方法不夠嚴謹，研究工具之效度專家效度為主，一半沒有做信度檢定。
  Obiectives: The aim- of this study was to evaluate the appropriateness of sampling methods, validity and reliability or instruments, and statistical methods used in domestic publications of health care and hospital administration. Methods: Five-years health care and hospital administration publications in “Hospital”, “Chinese Journal of Public health”, “Public Health” (n=109) were evaluated. Abstractors were trained and descriptive statistic was used. Results: Descriptive or analytical study was most common (80%), followed by quasi-experiments (17%) and simulation study (3%). Purposive or convenient method was primarily used to obtain the study sample (42.5%), There were some problems such as failure to mention (4.6%) or non utilization (8%) of multiple comparisons in a significant one-way ANOV A, lack of specific methods used for correlation coefficients (66.7%), non-examination of statistical assumptions in multiple linear regression (100%), confusion between significant level and p-values (10.4%). About one-forth of the instruments developed by the researchers did not show the whole validity was primarily used for evaluation of validity. Reliability test for about half of the instruments were not carried out. Conclusions: Our evaluation on domestic health care and hospital management publications suggested that representative of the sample may be a problem in descriptive or analytical studies. Some statistical methods used were not stringent. Expert validity was primarily used in evaluation of validity of study. About hall’ or the instruments reliability tests were not performed.
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• 10.6288/CJPH2000-19-03-09