23卷1期

• Link 綜論 Review Article
• 臺灣醫務管理人力培育之現狀與未來Health Care Administration Staff Development Program in Taiwan: The Present and Future
• 蕭世槐、楊銘欽、蘇喜
  Shih-Huai Hsiao, Min-Ching Yang, Syi Su
• 醫務管理人員 ； 人力供給 ； 高等教育 ； 技職教育 ； 人才培育
  health care administration staff ; manpower supply ; higher education system ; vocational and technical education system ; manpower development
• 本文的目的在於介紹台灣正式教育體系內之醫管人才培育現況與未來，嘗試將醫務管理人才培育予以分期，並探討醫疾照護、及教育政策等對醫管人才培育走向之影響。經由文獻回顧、網際網路蒐尋、及專家訪談等方式，廣泛蒐集有關於教育政策、醫療衛生政策對醫務管理人力供給之影響，並輔以重要醫療資源指標佐證本研究結果。台灣醫務管理教育始於1965年，現行醫務管理人力培育主要由13所屬教育部技術與職業教育體系之技術學院、科技大學，與10所屬教育部高等教育體系之獨立學院、綜合大學共同培育，所授予之學位有專科、學士、碩士及哲學博士等四類，截至2001年累計培育16,745位醫管人力。臺灣由光復後至今的醫務管理教育分為五個時期：荒原期（1945～1971年）、萌芽期（1972～1985年）、成長期（1986～1994年）、擴張期（1995～2001年）及轉型期（2002年至今）。而醫管人才培育體系由早期的技職體系，擴及高等教育體系，辦理醫管教育學校數由1965年的1所擴張到現今的23所，頒授的學位有專科、學士、碩士及哲學博士等四類臺灣醫務管理教育體系至今可謂發展完臻，惟錯綜複雜的教育學制，及大量擴張的結果，使醫管教育面臨許多問題，如人才培育過剩…等等。此刻，醫管教育者應思考如何克服目前問題，並將醫務管理教育重新整合、定位與轉型，始能有足夠的能力因應醫療產業環境的迅速變動與醫療政策的快速發展。
  The article describes the current status and future planning of health care administration staff development in the formal education system of Taiwan. It also traces the different stages of development in the education of health care administration staff and examines the impact of national health care and education policies on the health care staff formation through a comprehensive review of the previous literature, internet website search, and expert consultation. There are five stages of development in the history of health care staff formation, namely beginning (1945-1971), developing (1972-1985), maturing (1986-1994), expanding (1995-2001), and transforming (2002 onward). In the early stages of development, health care staff formation was mainly offered by vocational and technical schools, while at present there are 23 colleges forming junior college graduates specialized in health care administration and conferring bachelor, master and doctoral degrees in health care administration. To date, the development program for health care administration personnel is well developed. However, the complex and rapidly expanding education system has led to problems such as excess of manpower. Effects should be made to overcome the present problems, and to integrate and reform the health care staff development program in order to meet the ever changing needs of the health care environment and the newly formulated health care policies.
• 1-17
• 10.6288/TJPH2004-23-01-01

• Link 綜論 Review Article
• 國際衛生發展的全球性挑戰Global Challenges of International Health Development
• 紀駿輝
  Chun-Huei Chi
• 國際衛生；衛生發展；全球化；公正性
  international health ; health development ; globalization ; equity
• 過去十年來，國際衛生的實務與學術研究逐漸受到國內的重視。本文目的在介紹國際衛生界目前及未來所面臨的全球性挑戰及因應的策略。本文開始先簡介國際衛生之範疇，然後探討國際衛生在學術研究與實務上最新的發展。接下來則將國際衛生所面臨的全球性挑戰歸納為六項：多科技整合、跨部門及同部門協調、方法論之挑戰、全球化之影響及不平等的衛生發展、傳染病及新興疾病、以及自然和人為災難，並逐一深入討論。針對這些挑戰，本文介紹並探討目前國際衛生界回應的策略，並將之歸納為五項：（1）因應經濟全球化及貧富差距擴大的策略、（2）多層面發展策略、（3）以受援助國為核心的協調方案、（4）和平策略、以及（5）多科際合作策略。最後一節則討論這些挑戰及因應策略對我國參與國際衛生學術及實務發展之意義，並提出政策建議。
  In the past decade, international health practice and research have gradually gained recognition in Taiwan. The purpose of this article is to introduce global challenges of international health and strategies to meet these challenges. This article is divided into five sections. The first section introduces the nature and scope of international health. This is followed by a discussion of new developments in the research and practices of international health. In the third section, the author categorizes global challenges to international health into six groups. These challenges are: multidisciplinary integration; inter-sector and sector-wide coordination; methodological challenges; the impacts of globalization and inequality in health development; old and newly emerged communicable diseases; and natural and human-made disasters. The fourth section discusses five strategies for addressing these global challenges. These strategies include: (1) strategies to address economic globalization and the widening inequality in wealth; (2) multiple approaches to development; (3) Sector-Wide Approaches (SWAp); (4) peace movements; and (5) multi-disciplinary collaboration. Finally, the last section presents policy recommendations for Taiwan’s development of its international health programs.
• 18 - 31
• 10.6288/TJPH2004-23-01-02

• Link 原著 Original Article
• 臺灣醫療次區域醫院產業擴張與診所醫師人力消長的關係The Relationship between the Expansion of the Hospital Industry and the Growth of Office-Based Physician Manpower in Sub-Medical Regions in Taiwan
• 劉容華、江東亮
  Jung-Hua Liu, Tung-Liang Chiang
• 醫院產業擴張 ； 診所醫師人力 ； 臺灣
  expansion of hospital industry ; office-based physician manpower ; Taiwan
• 無
  Objective: To examine the relationship between the expansion of the hospital industry and the growth of office-based physician manpower in sub-medical regions in Taiwan. Methods: We used the sub-medical region as the unit of analysis. There were tow study periods: 1995-1995 (early stage) and 1997-1999 (late stage). Data for the analysis came from “The National hospital and Services Survey” and “Taiwan-Fukien Demographic Fact Book”. The expansion of the hospital industry was measured using three indexes: the growth in hospital bed supply, the growth in hospital physician manpower, and the growth in hospital outpatient services. Multiple regression analysis was applied to explore the relative importance of early versus late expansion of the hospital industry to the growth of office-based physician manpower in the sub-medical region. Results: Between 1995 and 1999, the supply of hospital beds, the number of hospital physicians, and the volume of outpatient services provided by the hospital increased by 5.9%, 16.8%, and 21.8%, respectively. Through using multiple regression analysis, we found that the expansion of the hospital industry was negatively associated with the growth of office-based physician manpower in the sub-medical region, and that the early-stage expansion was more important than the late-stage expansion. However, after controlling for the physician-population ratio, we found that only the growth of hospital physician manpower in the early stage and the growth of outpatient services in the early stage were significantly related to the growth of office-based physician manpower (p<0.05). Conclusions: The expansion of the hospital industry in the early stage is important in determining the growth of office-based physician manpower in sub-medical regions in Taiwan.
• 32 - 36
• 10.6288/TJPH2004-23-01-03

• Link 原著 Original Article
• 1996-2001年之全民健康保險兒童預防保健服務利用率Utilization Rates of Preventive Health Services Provided for Children by the National Health Insurance Program, 1996-2001
• 陳麗光、 盧鴻興、張華志
  Li-Kwang Chen, Henry Hong-Shing Lu, Hua-Chih Chang
• 全民健康保險 ； 兒童預防保健服務 ； 利用率
  national health insurance ; preventive health services for children ; utilization rate
• 目標：本研究的目的有兩個：（1）估計1996年到2001年之間的全民健康保險兒童預防保健服務年度利用率以及世代利用率；（2）探討兩種估計值的差異。方法：我們利用國家衛生研究院所建構之全民健康保險承保抽樣歸人檔來進行估計，並分析兩種估計值的差異來源。結果：從1996年到2000年之間，零至一歲兒童之四次預防保健服務的年度總體利用率由28.26%上升到59.29%。從1996年到2001年之間，一至三歲之兒童和三至四歲之兒童的年度利用率則分別由35.59%上升至79.16%，以及由10.58%上升至26.70%。世代利用率的趨勢大致和年度利用率相似。結論：全民健康保險兒童預防保健服務利用情形從1996至2001年之間逐漸改善，利用率增加為兩倍以上，不過仍有明顯的改善空間，尤其是三至四歲之兒童預防保健服務利用水準。年度利用率對於預測尚未完整觀察到之世代利用率有很大的參考價值，不過做推估時應注意世代利用率之變化、出生人口數之變化以及不同世代使用服務時程之變化所導致的估計值誤差。
  Objective: The two purposes of this study were: (1) to estimate the yearly utilization rates and the cohort utilization rates of preventive health services provided for children by the National Health Insurance Program (NHIP) for the period from 1996 to 2001; and (2) to explore differences between these two kinds of estimates. Methods: We estimated and analyzed the differences based on a National Health Insurance Database that the National Health Research Institutes constructed for a random sample of the population in the NHIP. Results: From 1996 to 2000, the yearly total utilization rate of preventive health services for infants increased from 28.26% to 59.29%. From 1996 to 2001, the yearly utilization rates for children aged 1-3 and 3-4 increased from 35.59% to 79.16% and from 10.58% to 26.70%, respectively. The trends of the cohort utilization rates were similar to those of the yearly utilization rates. Conclusions: The utilization level of preventive health services provided for children by the NHIP gradually improved from 1996 to 2001, with an overall increase of more than 100%. However, there is still much room for improvement, especially for the utilization level of children aged 3-4. The yearly utilization rate can be a good reference for predicting the cohort utilization rate of a cohort that has not been completely observed. Nevertheless, when making relevant inferences, we should pay attention to estimation errors due to changes in the cohort utilization rates, the number of births, and the distribution of timing for receiving preventive health services for children.
• 37 - 44
• 10.6288/TJPH2004-23-01-04

• Link 原著 Original Article
• 傳染病照護的選擇性歧視：醫師及牙醫師的愛滋病專業倫理觀與照護意願Selective Discrimination in the Health Care of Infectious Diseases: Professional Ethics and Willingness to Treat AIDS Patients among Physicians and Dentists
• 丁志音、涂醒哲
  Chih-Yin Lew-Ting, Shing-Jer Twu
• 愛滋病；專業倫理；照護意願；選擇性歧視
  AIDS ; professional ethics ; willingness to treat ; selective discrimination
• 目標：在新興傳染病不斷侵襲的時代，本研究試圖以愛滋病的醫療照護為例，瞭解醫療專業在遭逢危機及挑戰時，其專業成員的反應方式，特別是檢視專業倫理的價值觀及照護愛滋病患及感染者（people with AIDS, PWAs）的意願。方法：研究資料來自於1995及1996年分別針對全國的醫師及牙醫師所做的郵寄問卷調查。在剔除曾有照護PWAs經驗之220名醫師及94名牙醫師以後，本研究的樣本共包括了1482名醫師及1685名牙醫師等從未照護PWAs之專業成員。針對每一個專業群體，以雙變項分析及多變項邏輯斯迴歸分析，來檢視照護焦慮及專業特質對照護倫理觀與照護意願的影響。結果：兩群專業人員對愛滋病所具有的專業知識不足，對此病表達出極其負向的反應，且對照護倫理與意願欠缺利他傾向，顯現出違反專業倫理的選擇性歧視。只有25.2%的醫師及18.1%的牙醫師自述願意照護所有的PWAs，不願照護任何PWAs則分別為9.7%及53.0%；介於兩者間的則為「只願意照護不知情感染者」（27.7% vs. 14.5%），而有37.5%的醫師及11.6%的牙醫師則能更進一步地接受某些類別的高風險PWAs群體（37.5% vs. 11.6%），其中最無法忍受的則為靜脈注射毒癮者。如此的負向反應主要源於對感染AIDS之恐懼及對PWAs的情感性的心理不舒服感。而專業歸屬感、專業知識及執業型態等測量專業性的變項扮演次要的角色。結論：面臨新興不確定性高的新型傳染病，醫療專業人員的憂懼有時會凌駕科學理性與專業價值，而顯現出悖離社會期許的反應。在傳染病侵襲日漸嚴重的時代，醫師養成教育必須強調醫療執業場所中潛伏的執業風險及預防方法，並應重申醫者專業角色的重要性。
  Objective: In the era of continuous attack from newly emerging infectious diseases, this paper, by taking AIDS as an example, aims to explore the medical professionals’ responses to the challenges of an epidemic. Particularly emphasized are individuals’ ethical values and willingness to treat people with HIV and AIDS (PWAs) among physicians and dentists. Methods: Structure questionnaires were mailed to practicing physicians and dentists in 1995 and 1996, respectively. The final physician sample consisted of 1482 and dentist sample 1685 respondents after excluding 220 physicians and 94 dentists who reported having experience in treating PWAs. For each professional group, bivariate analysis and logistic regression were used to explore the effects of perceived care-related worry and anxiety and professional attributes on ethical values and willingness to treat. Results: A lack of AIDS clinical knowledge was commonly found among both groups of medical professionals. They showed very negative, un-altruistic reactions to AIDS and PWAs, such as rejecting the value for ethical responsibility and being reluctant to treat PWAs. An obvious tendency of selective discrimination was observed. Only 25.2% physicians and 18.1% dentists were willing to treat all PWAs. The percentages of those unwilling to treat any PWAs were 9.7% and 53.0%, respectively. In between were those who were only willing to treat the uninformed (27.7% vs. 14.5%), and who were still willing to treat some of the high risk individuals (37.5% vs. 11.6%). Among the high risk groups, the most unaccepted category was IV drug users. The extremely negative reactions mainly came from the fear of infection and psychological discomfort towards PWAs. Sense of professional belongingness, AIDS knowledge and type of practice, all characterizing professional attributes, played relatively less significant roles. Conclusion: In the face of uncertainty inherent in the emergence of new infectious diseases, the medical professionals’ worry and anxiety might go beyond scientific reasoning and professional values, and their responses may be against the expectations of the society. With the increasing threat posed by infectious diseases, medical education should urgently pay greater attention to the prevention of occupational risks which are inherent in clinical settings. Likewise, the critical roles physicians are expected to play during the time of epidemic are to be emphasized.
• 45 - 58
• 10.6288/TJPH2004-23-01-05

• Link 原著 Original Article
• 青少年菸品消費認同與吸菸行為之研究：以臺北縣某兩所高職學生為例A Study of Adolescent Cigarette Consumption Behavior: Case Study of Two Vocational High School in Taipei Area
• 陳富莉、李蘭
  Fu-Li Chen, Lee-Lan Yan
• 吸菸行為 ； 菸品廣告 ； 消費文化 ； 認同 ； 青少年
  smoking behavior ; cigarette advertisements ; identity ; consumer culture ; adolescent
• 目標：預防青少年吸菸是公共衛生的重要課題，國內青少年吸菸率雖然持續呈現持平的情況，但品牌的選擇卻出現進口菸取代國產菸現象。青少年為何喜愛及選擇進口菸是值得探究的議題，本研究目的是藉由青少年選擇吸菸品牌的過程探討其菸品消費認同。方法：主要利用焦點團體訪談，並輔以深度訪談方法得到相關資料。研究對象為某二所高職學校共44名吸菸學生，選樣過程及訪談方式隨著研究進展的需要與避免重覆的原則彈性進行。資料處理採編輯式的分析法，先決定分析單位、並將訪談之文本重新裁剪，以找尋出有意義的類別及關聯。結果：受訪學生第一次吸菸以七星菸佔多數，主要是認同同儕與家人抽的菸品；部份受到菸品流行文化，以及口味、經濟等認同因素的影響。至於菸品消費行為改變的情形，多數學生之所以輪換或轉換其吸菸品牌，菸品廣告行銷與菸品流行次文化是主要的影響因素。結論：青少年吸菸行為與消費市場中的菸品消費文化有關，基於健康促進的立場，運用學校菸害反行銷教育讓青少年辦識廣大的菸品市場行銷機制是降低青少年吸菸率重要的一環。
  Objectives: Preventing adolescent smoking is an important health issue. Statistics from 1990 to 2001 show that the prevalence rate of smoking amongst teenagers aged 15 to 18 in Taiwan has remained the same. However, the consumption of imported cigarettes has replaced that of domestic cigarettes. The reason accounting for such switch is worth further investigation. The main purpose of this study was to understand how teenagers identify their cigarette consumption behavior by the process of selecting special cigarette brand. Method: Focus group discussion and individual interviews were conducted to explore the cigarette consumption behavior of 44 student smokers purposively selected from two vocational high schools in Taipei area. These interviews were tape-recorded, transcribed, and coded. Matrices were constructed to identify themes and evolving concepts. Results: Most of the student subjects smoked Mildseven brand and followed the choice of their peer groups of family when selecting cigarette brand. Only a few students were influenced by adolescent cigarette subculture, considering cigarette price and taste. Students switching to other cigarette brands were mainly affected mostly by symbolized advertisements and adolescent cigarette subculture. Conclusion: The results show that adolescent cigarette consumption behavior was significantly related to youth cigarette subculture and the image of cigarette advertisements. From the heath promotion perspective, using anti-smoking marketing strategies in schools to decrease the myth of cigarette consumption was an important strategy to prevent adolescent smoking.
• 59 - 70
• 10.6288/TJPH2004-23-01-06

• Link 原著 Original Article
• 院所競爭對醫療處置的影響：以剖腹產為例Impact of Provider Competition on the Medical Treatment: Using Cesarean Section as an Example
• 羅紀琼、劉素芬
  Joan C. Lo, Su-Fen Liu
• 剖腹產 ； 競爭 ； 出生時間
  cesarean section ; competition ; timing of birth
• 目標：以往勞農保的生育是採現金給付，婦產科診所在醫療可近性高以及收費低的優勢下，業績興隆。全民健康保險開辦後，生育改為實物給付，服務價格由保險人統一訂定，診所的優勢不再。本研究擬檢驗在競爭的壓力下，婦產科診所會對產婦出生時間的訴求有比醫院更為正面回應的假說。方法：以民國87年的出生證明資料為基礎，利用邏輯迴歸模式，在控制醫療因素後，觀察醫院與診所在工作時間、週末與週間、以及日子吉凶分類下的剖腹產率差異。結果：醫院星期六、日的剖腹產率皆較週間為低；診所星期六的效果相反。吉日吉時白班的剖腹產率超過50%，凶日夜班的剖腹產率低於20%；晚班及夜班的剖腹產率以診所為高。結論：為了維持競爭力，婦產科診所比醫院更願意在非正常工時內施行剖腹產。夜班兇日時段的剖腹產率接近WHO建議的15%水準，應是努力的目標。
  Objectives: Since the maternity benefits in the Labor Insurance and Farmers’ Health Insurance schemes were cash benefits, obstetric & gynecological clinics attracted more clients due to their easy accessibility and lower charges. However, the implementation of the National Health Insurance altered their comparative advantages by changing the cash benefits to in-kind services. We believe that clinics have reacted more positively than hospitals toward the maternal requests regarding the timing of birth. Methods: In this study we used data from birth certificates issued in 1998 to examine the difference in cesarean section rates between hospitals and clinics during office and non-office hours, weekdays and weekends, as well as auspicious and inauspicious days. Results: After controlling for all the confounding factors, the regression results indicated that the cesarean section rates are lower on Saturdays and Sundays for hospitals; however, the rates are higher on Saturdays for clinics. During regular office hours of auspicious days, the cesarean section rates are above 50 percent, but the rates are below 20 percent for the night shift of inauspicious days. During the evening and night shifts, the rates are higher in clinics. Conclusions: To stay competitive, clinics are more likely to perform cesarean sections during their non-office hours. Cesarean section rates for the night shift of inauspicious days are close to the WHO recommended level (15%), which should be our ultimate goal.
• 71 - 79
• 10.6288/TJPH2004-23-01-07

• Link 實務 Public Health Practice
• 幼稚園學童的氣喘經驗與管理計劃Asthma Experience and Management Program for Preschoolers
• 洪兆嘉、高碧霞
  Chao-Chia Hung, Bih-Shya Gau
• 幼稚園 ； 氣喘 ； 學童 ； 老師 ； 氣喘管理計劃
  preschool ; asthma ; pupils ; teacher ; asthma management program
• 目標：介紹兒童氣喘特性並陳述可行的幼稚園氣喘管理計劃及執行策略，冀能增進衛生專業人員對幼稚園氣喘照護的瞭解及執行效能。方法：藉由網際網路來進行系統性文獻搜尋方式，彙集1987年至2002年資料庫並配合筆者之實務經驗，來陳述幼稚園學童氣喘管理計劃與執行內容。結果：環境控制、藥物治療、肺功能監測及病人教育等四方面是氣喘兒童照護之重要內涵。完善的幼稚園氣喘兒童健康管理宜包括：建立學童醫療記錄、確保患童容易獲得氣喘藥物、協助學生避免或控制氣喘的誘發因子、確立急性發作或氣喘惡化的處理流程。結論：台灣目前的兒童氣喘發病年齡有逐年下降的趨勢，需整合健康專業系統、幼教系統及家庭，建立完整的幼稚園氣喘管理機制，俾使廣大族群的氣喘幼童獲得更完整的醫療照護。
  Objectives: To introduce the characteristics of asthma and propose feasible asthma management programs and strategies for enhancing the knowledge and management efficacy of asthma care of preschoolers among health professionals. Method: A systematic literature review was conducted to explore the documents published at websites from 1987 to 2002, to integrate the empirical experience of asthma care practices and to propose asthma management programs and strategies. Results: Environmental control, pharmacological approach, pulmonary function evaluation and patient education are the essential components of asthma care for children. A comprehensive asthma management program should include establishing the medical record in school, ascertaining the accessible asthma medicine, avoiding or controlling the triggers of asthma, and regulating the management protocol of urgent episodes or exacerbations. Conclusion: Since the age of children suffering from asthma is declining yearly, the collaboration of health care professionals, preschool education system and family is emphasized to establish a comprehensive asthma management program for enhancing the quality of care for preschoolers with asthma.
• 80 - 89
• 10.6288/TJPH2004-23-01-08