22卷4期

• Link 綜論 Review Article
• 更年期婦女健康是公共衛生政策的議題Menopausal Women's Health is an Issue of Public Health Policy
• 張玨
  Chueh Chang
• 更年期 ； 雙盲實驗 ； 賀爾蒙替代療法
  Menopause ; Double blind experiment ; HRT
• 本文以歷史脈絡釐清為何在2002年七月美國國家衛生研究院會停止原本預定十三年目前才進行到第八年的長期追蹤研究，表示美國公共衛生與醫學界對HRT藥物實驗的認真與用心，強調藥物只適合用於短期治療而非長期預防用，也看到民間婦女團體和女性主義學者在監督藥物不使之濫用的貢獻；以此反觀國內反應，顯示出我國醫界或部分衛生署官員對公共衛生流行病學調查的不了解，對相對風險觀念的不明白，以及對預防醫學的誤解，對健康促進的不重視，對婦女團體的排斥，對性別分析和婦女健康的忽視，更缺少藥物倫理的監督，也輕忽衛生署應有的職責。再次提出更年期婦女健康是公共衛生需關注的議題。
  This review focuses on the July 2002 JAMA paper submitted by the Women's Health Initiative investigators. The investigators (representing the National Institute of Health, USA) seriously announced their suggestion that the 13-year long Hormone Replacement Therapy (HRT) research needs to be discontinued in its 8th year because its harms outweighed its benefits. They emphasize HRT is oily beneficial as a short-term remedy but not for long-term prevention. This drastic action obviously reveals the conscientiousness and integrity of the US researchers. From the historical point of review, we discovered how the women activist organization aid feminist scholars in USA monitored the trial of HRT, which reduced the rate of abuse. However, the response of the medical sector in Taiwan, primarily gynecologists, has been defensive. The Department of Health, unlike the NIH of USA, have neither responded to the investigation in time nor have they responded properly. They have not provided necessary information on health care for menopausal women. Both the medical field aid the DOH misconceive the prevention aid treatment issue; misunderstand the cost/benefit ratio of epidemiological studies on clinical trials, neglect the reminding of women's organization; bypass the study of gender analysis and women's health; lack the monitoring of the medical ethic, and neglect its basic duty. The results show that menopause related to women's health should be an essential issue of public health policy in Taiwan.
• 245 - 250
• 10.6288/TJPH2003-22-04-01

• Link 綜論 Review Article
• 汽車安全氣囊的安全性與眼球傷害Airbag Safety and Associated Ocular Injury
• 胡兆宇
  Chao-Yu Hu
• 汽車安全氣囊 ； 眼部外傷
  Airbag ; Ocular injury
• 汽車安全氣囊已被證實可以有效的?少因正面碰撞車?所造成的重大傷亡，但它也會連?造成一些不必要的傷害，尤其是發生在原本應不致造成重大傷害的中低速碰撞，而其中最常傷及眼部，但是大多數是輕微而且可以痊癒的。汽車安全氣囊的設計與作用機制仍有改善的空間，尤其是對解剖構造上?具有潛在危?性的女性及身材矮小者。為了?少這些傷害，駕駛人及前座乘客應綁上三點式安全?並與安全氣囊保持25公分以上的距離，如果因為身材矮小或有其他原因導致無法維持此安全距離時，可考慮?安全氣囊的功能關掉，僅使用三點式安全?可能比?安全。
  Airbags are widely available nowadays since they have been proved effective in decreasing the mortality and morbidity during frontal-collision car accidents. However, more and more occupants have been injured by airbags, even in low-speed collisions, according to many case series. These injuries happened more frequently among women and short-statured persons. To prevent this untoward effect, passengers should wear the three-point lap-shoulder seatbelt and keep at least 25cm away from the airbag. It may be better to turn off the airbag if the passenger cannot keep this distance. Airbags deserve further modifications to deploy at the proper time, in the proper direction, with appropriate power and dimension.
• 251 - 257
• 10.6288/TJPH2003-22-04-02

• Link 綜論 Review Article
• 致發大腸直腸癌之基因多形性與環境因素Genetic Polymorphisms and Environmental Factors in the Etiology of Colorectal Caner
• 葉志清、謝玲玲、宋鴻樟
  Chih-Ching Yeh, Ling-Ling Hsieh, Fung-Chang Sung
• 大腸直腸癌；環境因子；基因多形性
  Colorectal cancer ; Environmental factors ; Genetic polymorphisms
• 包括飲食及生活型態等環境因子在大腸直腸癌的發生上扮演重要的角色，遺傳性和偶發性大腸直腸癌基因的調控途徑已經在近10年被廣泛研究。例如高外顯率的錯誤配對修補基因突變即為導致遺傳性大腸直腸癌的重要因素，而常見的低外顯率代謝酵素和DNA修補酵素之多形性則可能是引起偶發性大腸直腸癌的主要因素。基因多形性會影響個體對環境物質中造成DNA傷害者的反應，因此，評估多形性基因的影響及其與環境因子間的交互作用能夠辨別易感受性族群，同時更能闡明偶發性大腸直腸癌的病因。本文獻探討針對大腸直腸癌的研究，就有關基因與環境因子交互作用的部分作一綜論，特別對近10年代謝酵素（包括細胞色素P450 1A1、細胞色素P450 1A2、麩氨醯硫轉移酵素及乙醯轉移酵素）和DNA修補酵素等基因多形性與大腸直腸癌相關之研究文獻，進行一簡要之整理，並探討未來具有希望的研究方向以及這些研究的限制。
  Environmental factors, including dietary and lifestyle factors, play an important role in the etiology of colorectal cancer. Advances in technology for gene analysis have generated many opportunities to elucidate genetic pathways of hereditary and sporadic colorectal cancer in the last decade. Highly penetrant mutations in certain genes, such as mismatch repair genes, play a major role in the development of hereditary colorectal cancer, while low penetrant polymorphisms play a role in metabolizing and DNA repair enzymes. Because these mutation are common, they may contribute to a large proportion of sporadic colorectal cancer. Since genetic polymorphisms may modulate an individual's response to DNA-damaging agents derived from the environment, evaluating the impact of these polymorphic genes and their interactions with environmental factors may enable us to identify susceptible subgroups and better characterize the etiology of sporadic colorectal cancer. In this review we summarize the current studies regarding the role of gene-environment interactions in the development of colorectal cancer, including genetic polymorphisms of metabolic enzymes (cytochrome P4501A1, cytochrome P4501A2, N-acetyltransferase and glutathione S-transferase) and DNA repair enzymes. We also briefly discussed areas of particular promise for further study and the limitations of these studies.
• 258 - 278
• 10.6288/TJPH2003-22-04-03

• Link 原著 Original Article
• 從國際比較探討台灣每千人口需要多少醫師？How Many Physicians per 1000 People Do We Need in Taiwan an International Comparison
• 吳肖琪、朱慧凡、黃麟珠、雷秀麗
  Shiao-Chi Wu, Hui-Fan Chu, Lee-Gyu Haung, Hsiu-Li Lei
• 醫師 ； 醫師人力 ； 人口老化 ； 醫療照護
  physician ; physician workforce ; aging ; medical care
• 目標：比較台灣與其他國家醫師人口比之差異及探討世界各國醫師人口比之相關因素，提供台灣訂定醫師人口比目標參考。方法：採行政院衛生署統計室資料、主計處及世界銀行等網站的250個國家或地區之統計資料，進行分析。結果：依據世界銀行之分類我國屬於高所得國家，但每千人口醫師數僅接近中高所得之國家，2000年每千人口西醫師數為1.33人，若含中醫師為1.50人。由世界各國資料分析所得迴歸模式，顯示國內生產毛額、女性識字率、女性60歲以上人口百分比及女性平均餘命會影響各國對醫師人口比需求，整體解釋力81.5%。推估未來醫師人力供需時，若考慮女性60歲以上人口百分比增加的需求，則2010年醫師供給即有不足，必須加入中醫師才約可平衡，至於2020年，則將會不足。結論：建議政府醫師人力政策規劃應考慮國內人口高齡化的影響，並加強醫師在長期照護、老人專科方面的知識與能力。
  Objectives: The purpose of this study was to explore the number of physicians per 1000 people among Taiwan and other countries through international comparison. Which factors were related to the number of physicians per 1000 people? Should we adjust the number of physicians per 1000 people while facing a rapid increase in the aged population in the coming 20-30 years in Taiwan? Methods: The database was collected from the statistics report of the Department of Health, Directorate General of Budget Accounting and Statistics Executive Yuan and the World Bank Report on 250 countries or areas. Results: According to the World Bank's classification, Taiwan is a high GNP country. The number of physicians per 1000 people in Taiwan in 2000 was 1.33. If the physicians of Chinese Medicine are included the figure is 1.50.This is only getting close to middle-high GNP countries. Stepwise regression analyses give an R2 value of up to 81.5% for the number of physicians per 1000 people, which was influenced by GDP, female literacy, the percentage of female population aged over 60 years and female life expectancy. The percentage of female population aged over 60 years was an important factor influencing the ratio of physicians to the population in the future. According to this demand factor, the supply of physicians in Taiwan in 2010 will be lower, unless the physicians of Chinese Medicine are included, and it definitely will be lower in 2020. Conclusions: We suggest the government should consider the effect of the aging population when they draw up the policies for the physicians' workforce. Also, they should plan the composition of specialists and enhance the ability and knowledge of physicians for long term care and particularly care of the elderly.
• 279 - 286
• 10.6288/TJPH2003-22-04-04

• Link 原著 Original Article
• 台南區域全民健保實施前後居家護理資源使用比較Comparison of Home Nursing Service Utilization in the Tainan Area before and after National Health Insurance Execution
• 葉莉莉、溫敏杰
  Li-Li Yeh, Miin-Jye Wen
• 全民健保 ； 居家護理資源使用
  National Health Insurance ; use of home nursing service
• 目標：比較全民健保實施前後，台南區域居家護理資源之使用狀況。方法：健保前結果依研究者1998發表之文獻為比較依據[20]，健保後以提供台南區域居家護理服務之九家機構消案個案為對象（條件為在健保實施後收案管理，並於88年終止管理個案）。採病歷查閱法，由專任助理至機構填寫所需資料。所得資料鍵入SPSS10.0系統進行百分比同質性檢定，分析健保前後資源使用是否有差異。結果：健保後年齡層偏高，以81歲以上居多，女性略多於男性，診斷於健保前後皆以循環系統為主，惟健保後腫瘤個案比率降低。個案轉介來源由個案家屬自行聯繫居首轉為病房轉介居首。消案原因仍以死亡居首，惟轉入長期機構者比率由4.9%增為18.2%。本區域居家護理需求滿足率由83年之15.1%上升為88年之21.6%。資源使用顯示平均每案管理日數由110.4天增為185.2天，但平均每週家訪次數則由0.57次降為0.44次。結論：健保實施刺激居家護理服務產業，台南區域居家護理需求滿足相對增加，惟城鄉資源分佈仍顯不均；此外，健保規範及長期照護機構之多樣性與可近性增加亦衝擊居家護理資源使用。
  Objectives: To compare home nursing service utilization before and after National Health Insurance (NHI) execution in the Tainan Area. Methods: Clients who enrolled after the NHI program and who were discharged in the period of 1999 were selected as the sample. Also, their nursing care record had been reviewed. A total of 449 patient records were collected from nine hospital-based oriented home nursing agencies. Data were coded and analyzed using the Spss10.0 software system. Results: After the NHI program, we saw a change in the clients' age (older), gender (more female), medical diagnosis (still dominated by circulatory system disease, but the rate of neoplasm had decreased), referral source (more from hospital than by client/ family), termination reason (more clients went to long term care facilities), service provided in this area (before NHI=15.1%, after NHI=21.6%), duration of home nursing service (before NHI=110.4 days, after NHI=185.2 days), and frequency of home visits per week (before NHI=0.57, after NHI=0.44). Conclusions: The NHI program stimulates the provision of home nursing services, but those who live in rural areas still receive less resources. Regulations by NHI and the increased number of long term care facilities has impacted on home nursing resource use.
• 287 - 294
• 10.6288/TJPH2003-22-04-05

• Link 原著 Original Article
• 健康知識、教育程度與肥胖之關係Health Knowledge, Schooling, and Obesity
• 鄒孟婷、 鄒孟文
  Meng-Ting Tsou, Meng-Wen Tsou
• 健康知識 ； 教育程度 ； 肥胖 ； 主觀體重認知
  health knowledge ; schooling ; obesity ; body weight perception
• 目標：本研究的目的在瞭解台灣成年人身體質量指數(body mass index)與主觀體重認知情形，並探討健康知識、教育程度和肥胖之關係。方法：針對2001年7月至12月至台北市立馬偕紀念醫院接受成人免費健康檢查的民眾為研究對象進行分析。實證模型採用普通最小平方法和logit模型來估計肥胖迴歸式。結果：全體樣本中大約有42%的受訪者有不正確的體重認知，這在女性尤其明顯。其中，28%的女性根據BMI的定義屬於標準或過瘦體態，卻主觀認為自己體重過重或肥胖。相對地，僅有10%的男性有同樣的錯誤認知，這顯示肥胖對女性帶來的社會壓力遠比男性來得高。實證結果顯示，愈瞭解肥胖可能引發諸多疾病的民眾，肥胖的傾向愈低，證實了健康知識對健康行為的重要性。而教育程度愈高的女性，肥胖的機率明顯較低。這項發現支持Grossman的假說，顯示教育有助於減少肥胖發生的可能性。此外，肥胖在攝取足夠蔬果的女性中較少出現，年齡則與女性肥胖有正向關係。不論男性或女性，主觀肥胖認知與實際肥胖呈現高的關聯性。職業為白領階級的男性，肥胖的情形則較少見。結論：為了抑制國內肥胖人口增加的趨勢，政府可採取的有效方式是針對低教育程度的民眾加強肥胖之衛教並持續增加教育投資。隨著國人教育水準的提高與健康知識的累積，會更注重體重控制，進而減少肥胖造成的醫療負擔。
  Objectives: The purpose of this study is to examine the BMI (body mass index) and weight perceptions among Taiwanese and to investigate the relationship between health knowledge, schooling, and obesity. Methods: The survey was conducted at the Mackay Memorial Hospital with a target sample of 40 years and older who participated in the adult physical examination free-of-charge from July 2001 to December 2001. Obesity equation is estimated using ordinary least squares and logit model. Results: It is worth noticing that about 42 percent of the respondents have inaccurate weight perceptions. While 28 percent of females perceive themselves as being overweight or obese even though they are lot, about 10 percent of males have a similar inaccurate weight perception. This indicates that there is a pervasive stigmatization of obesity among Taiwanese women. We find that health knowledge is inversely related to the probability of being obese. Our results also support Grossman's hypothesis that schooling has a direct positive effect on health through reducing obesity. Schooling has a statistically significant negative effect on obesity among females. Older women appear to carry more excess weight, and obesity is associated with lower fiber intake. White-collared male workers are less likely to be obese and the perception of obesity is significantly associated with obesity. Conclusions: Our results suggest that increasing expenditures on general education and provisions of health knowledge could be viewed as effective policies in terms of their roles in reducing obesity.
• 295 - 307
• 0.6288/TJPH2003-22-04-06

• Link 原著 Original Article
• 以生活型態調整探討減重及健康相關生活品質之改善Lifestyle Modification, Weight Reduction, and Health Improvement
• 張敬仁、張文道、張文瀚、蔡森蔚、周崇頌、陳妍蒨、趙蘭芬
  Ching-Jen Chang, Wen-Dau Chang, Bruno Man-Hon Cheung, Sen-Wei Tsai, Chorng-Sonq Chou, Yen-Chien Chen, Lan-Fen Chao
• 生活模式調整 ； 健康相關生活品質 ； 代謝症候群 ； 肥胖 ； 減肥
  lifestyle modification ; health-related quality of life ; metabolic syndrome ; obesity ; weight loss
• 目標：生活模式的調整可以改善許多肥胖相關的共病，如糖尿病、高血脂症等，已在許多研究中證實；但在健康相關的生活品質、及暴食習慣上的改變，在國內尚沒有太多的研究觸及。方法：我們針對本院健康減重門診的病患進行生活模式改變(Therapeutic Lifestyle Change, TLC)的減重治療，並於治療開始及三個月後，作血液檢查及自填結構式問卷調查。結果：自九十年九月至九十二年一月間，總共收案40位門診患者，有效完成三個月追蹤者有32人（男13人，女19人），平均年齡39.0歲(SD:11.6)。減重前平均體重84.5公斤(SD:15.8)，減重後平均體重79.1公斤(SD:15.7)，平均減重5.4公斤(SD:3.0)，減輕體重佔原始體重百分比之平均值為6.5%(SD:3.6%)。BITE中文版暴食問卷總分呈現有意義的下降。SF-36健康相關生活品質量表在「身體疼痛」、「整體健康」、「活力」、「社會功能」四個向度及「體能綜合評估」呈現統計學意義上的進步。結論：三個月生活模式改變的減重治療，雖然只減少原始體重的5-10%，但已足以改善肥胖病人的輕度高血糖症及高膽固醇血症、控制暴食傾向並明顯改善以SF-36所測得的體能方面健康相關生活品質。
  Objectives: It has been proved in a number of studies that lifestyle modification can improve many obesity-related comorbid conditions such as diabetes mellitus and hyperlipidemia. Yet, so far little investigation has been done in this country regarding the change in Health-Related Quality of Life (HRQL), and binge eating habit. Methods: Participants in our Healthful Weight Reduction OPD program received blood biochemical examinations and were asked to complete several self-administered structured questionnaires before and after three months of therapeutic lifestyle change (TLC) weight reduction therapy. Results: From September 2001 to January 2003, a total of 40 patients were included in the present study. We completed a three-month follow-up on 32 patients (13 males and 19 females), their mean age being 39.0 y/o (SD:11.6). Their mean body weight was 84.5 kg (SD:15.8) before and 79.1 kg (SD:15.7) after the treatment. With a weight loss of 5.4 kg (SD:3.0), they lost 6.5% (SD:3.6%) of their original weight. The scores of the BITE (Chinese Version of Bulimic Investigatory Test Edinburgh) lowered significantly. Bodily pain, general health, vitality and social functioning dimensions and physical component summary in the Medical Outcomes Study Short-Form 36 Health Survey (SF-36, as the assessment of HRQL) showed significant improvement. Conclusions: Although the weight loss was only 5-10%, the three-month TLC weight reduction program succeeded in improving mild hyperglycemia and hypercholesterolemia, controlling binge-eating tendency, and improving physical aspects of HRQL as measured by SF-36 in obese patients.
• 308 - 317
• 10.6288/TJPH2003-22-04-07

• Link 實務 Public Health Practice
• 廢棄物回收政策－台灣經驗Waste Recycling policy-Taiwan Experience
• 陳永仁、 黃揮原
  Yeong-Ren Chen, Hui-Yan Huang
• 廢棄物資源回收 ； 回收基金 ； 稽核認證
  resources recycling ; recycling funds ; Bauditing
• 目標：本研究比較不同年代二種不同的資源回收制度，對資源回收效果之影響。方法：比較1998年前後台灣地區之資源回收制度，回收基金管理，地方政府清潔隊執業方式和稽核認證等方式運作情形。統計研究期間廢棄物總回收量及部分回收物品，例如廢保特瓶等之回收量。結果：發現在5年內清潔隊資源回收量由每年10.62萬公噸增加為每年87.83萬合噸，全國資源回收率由2.56%增加為15.48%；垃圾量變化情形在1988到1997年平均每年增加4.5%，在1998到2002年間年遞減率為5.9%。不論是那一種指標性資源回收物，在5年內，增加幅度在1.71倍到10.77倍之間。結論：以經濟誘因配合行政管制措施之資源回收制度，可以有效提升資源回收效率。
  Objective: This study compared the efficacy of two types of resource recycling systems in two periods. Methods: Two recycling strategies adopted before and after 1998 were compared because of changes in the management of recycling funds, the performance of sanitation workers, and the auditing system. The overall volumes of all recycled materials and the amount of selected items recycled such as disposed PET bottles were compared. Results: In the five years from 1997 to 2002, the materials collected for recycle by sanitation teams increased from 106.2 thousand tons per year to 878.3 thousand tons. This meant that the nationwide recycling rate had increased from 2.56% to 15.48%, respectively. During the periods of 1988-1997, the average amount of solid waste in Taiwan increased 4.5% annually. On the other hand, from 1998 to 2002, the average amount of solid waste decreased 5.9% annually. The amount of various specific recycled materials increased from 1.71 times to 10.77 times in five years. Conclusion: The resource recycling system based on monetary incentives incorporating a command-and-control strategy can raise the recycling rate significantly.
• 318 - 326
• 10.6288/TJPH2003-22-04-08

• Link 研究紀要 Research Brief
• 台灣與日本之間主要死因之比較研究A Statistical Comparison of Main Causes of Death Taiwan and Japan
• 唐誌陽、田中豐穗
  Chih-Yang Tang, Toyoho Tanaka
• 意外災害 ； 交通事故 ； 糖尿病 ； 死亡率 ； 生命損失率
  Accidents ; traffic accidents ; diabetes ; death rates ; years of potential life lost
• 目標：本研究目的是透過死亡率及生命損失率之分析比較，同時找出下個研究題目。方法：本研究的方法是根據台灣地區衛生統計和日本的人口動態統計來比較，性別、年齡別及10大死因的死亡率、生命損失率。結果：本研究其結果發現(1)台灣和日本有許多的死因在死亡率和生命損失率上，皆有減少的趨勢。台灣方面有很多死因在標準化死亡比和標準化生命損失比上都要比日本高。(2)以1990年為例，台灣和日本之間差別較大的死因為意外災害，交通事故，高血壓性疾病及糖尿病。(3)考察有關交通事故和糖尿病的背景原因。交通事故因種種的因素的不同，使台灣和日本間有所差異。關於交通事故及糖尿病，兩國有做更詳細比較研究之價值。結論：許多死因在死亡率和生命損失率上台灣和日本同時逐漸減少。台灣有許多死因在兩指標上較日本高。關於交通事故及糖尿病，兩國有做更詳細比較研究之價值。
  Objectives: The purpose of this research is first to identify the differences in the causes-of-death of people from Taiwan and Japan, using death rates and years of potential life lost (YPLL), and we tried to find out some valuable research topics for further research. Methods: Comparisons of death rates and YPLLs of 10 major causes-of-death in the two countries were by sex based on the relevant official statistics compiled by Vital Statistics of Japan and Health and Vital Statistics of Taiwan from 1965 to 1995. Results: (1) A number of the death rates and YPLLs declined in both countries. Standardized mortality ratios and standardized YPLL ratios showed that death rates and YPLLs in many causes-of-death were higher in Taiwan than in Japan. (2) In 1990, the major differences between Taiwan and Japan had been for all accidents, traffic accidents, hypertensive diseases and diabetes. (3) It was considered that there were many differences in the background factors contributing to traffic accidents in these two countries. It is feasible to do an in- depth comparative study of both traffic accidents and diabetes as causes-of-death in these two countries in depth. Conclusions: Death rates and YPLLs declined in many causes-of-death in both countries. Taiwan had higher rates in both indices in more causes-of-death than did Japan. It is necessary to do an in-depth comparative study of both traffic accidents and diabetes as causes-of- death in these two countries in depth.
• 327 - 336
• 10.6288/TJPH2003-22-04-09