21卷3期

• Link 綜論 Review Article
• 臺灣醫療保健支出之趨勢分析Analysis on Trends for Healthcare Expenditures in Taiwan
• 江東亮
  Tung-Liang Chiang
• 無
  none
• 無
  none
• 157 - 163
• 10.6288/TJPH2002-21-03-01

• Link 原著 Original Article
• 台北市某高中一年級學生的班級人際網路位置與吸菸行為的關係The Relationship Between Classmates' Interpersonal Network and Smoking Behavior: a Preliminary Investigation Among the 10th Graders
• 楊雪華、陳端容、李蘭、柯姍如
  Hsieh-Hua Yang, Duan-Rung Chen, Lee-Lan Yen, Shan-Ru Ke
• 高中生 ； 人際網絡位置 ； 同儕團體 ； 吸菸
  high school student ; social network ; peer group ; smoking
• 目標：採討高中生在班級中人際網絡位置與吸菸行為的相關性。方法：針對台北市一所綜合高中一年級男女合班的學生，利用自行發展的社會網絡問卷，以全班集體填答方式收集資料。應用KrackPlot3.2及Ucinet5社會網絡分析軟體，描繪同班學生之人際網絡，並以Logistic Regerssion驗證人際網絡位置與吸菸行為的關聯性。結果：高中生在其班級中人際網絡位置可分為三種類型：小團體成員、團體外圍者及孤立者。班別、網絡位置與學生的吸菸行為有關係，且具交互作用。以班別比較，職業班學生的吸菸勝算比是普通班學生的6.82倍；以網絡位置比較，孤立者的吸菸算比是小團體成員的2.96倍。相反地，職業班孤立者的吸菸勝算卻比小團體成員低，為其0.09倍。結論：班級中人際網絡位置與吸菸行為有關，且因班級類別而有差異，此結果可提供進一步探討同儕影響機轉及趼擬菸害防制教育的參考。
  Objectives: Social network analysis was applied to examine whether high school students who fill various social positions that characterize peer group structure differ in prevalence of smoking. Methods: Using a set of structured questionnaires, two hundred and seventy four (274) students in a comprehensive high school named their seven best friends. KrackPlot3.2 and Ucinet 5 were applied to map and analyze the social network. Logistic regression analysis was applied to test the relationship between sex, class type, social network position and smoking behavior. Results: The peer network position was mapped clearly allowing the identification of each adolescent as a clique member, clique outsider, or isolated. The class type and social network position had an interaction on smoking behavior. For occupation class students, compared with academic class students, the odds ratio of smoking was 6.82. The odds ratio of isolated adolescents compared with clique members, was 2.96. But for isolated adolescents in the occupation class, the odds ratio of smoking was 0.09, compared with clique members. Conclusions: Peer social network position and class type were important factors simultaneously influencing adolescent smoking. Social network analysis is a promising method for measuring it. Its implication for research and intervention are considered.
• 164 - 172
• 10.6288/TJPH2002-21-03-02

• Link 原著 Original Article
• 1996~2000年台灣地區糖尿病盛行率與住院率Prevalence and HospitalizationRates of Diabetes Mellitus in Taiwan, 1996-2000
• 魏榮男、莊立民、林瑞雄、趙嘉玲、宋鴻樟
  Jung-Nan Wei, Lee-Ming Chuang, Ruey-Shiung Lin, Chia-Ling Chao, Fung-Chang Sung
• 糖尿病 ； 盛行率 ； 住院率
  diabetes mellitus ; prevalence ; hospitalization rate
• 目標：估計台灣地區1996~2000年糖尿病盛行率與住院率，並比較年齡別和性別的年代趨勢。方法：以1996~2000年全民健康保險學術資料庫的糖尿病門診與住院資料，分析台灣地區各年齡別就診的糖尿病人數與糖尿病住院人數，估計每個年齡別的糖尿病盛行率與糖尿病住院率及住院盛行率。標準化盛行率與標準化住院率的參考人口分別是以台灣地區2000年男女總人口與2000年所有糖尿病人數為依據。結果：國人糖尿病盛行率隨著年齡與年代的增加而升高，五年間男女年齡別糖尿病盛行率由0~9歲的0.4-1.2/1000增加到≧70歲的129-210/1000。五年間所有年齡的男性標準化盛行率介於29-37/1000，女性標準化盛行率介於38-46/1000。男性歷年糖尿病標準化住院介於18.6~20.0%，女性糖尿病標準化住院率介於16.5~17.8%。結論：台灣地區糖尿病盛行率逐年上升，已成為重要的健康問題，住院盛行率居高不下，醫療效應值得進一步探究。
  Objectives: This study depicted the prevalence and hospitalization rates of diabetes in Taiwan, from 1996 to 2000. Methods: The prevalence of diabetes among population, and hospitalization rates among diabetes patients, and annual trend of diabetes were estimated and compared by sex and age using the National Health Research Insurance Database available from 1996 to 2000. The age-standardized prevalence rates were estimated against the year 2000 population in Taiwan and the hospitalization rates were estimated against the year 2000 diabetes population available in the data file. Results: The prevalence rates of diabetes increased from 0.4-1.2/1000 for the population aged <10 years, to 129-210/1000 for the population aged 70 years and above. The overall annual age-standardized prevalence rates ranged between 29-37/1000 for males and 38-46/1000 for females. Among the diabetes, 18.6-20.0% male patients and 16.5-17.8% female patients experienced at least one hospitalization annually. Conclusions: The prevalence of diabetes for all ages in Taiwan is in increasing trend. The annual hospitalization rates among the patients remained at high levels. Further study on treatment effectiveness is deserved.
• 173 - 180
• 10.6288/TJPH2002-21-03-03

• Link 原著 Original Article
• 計程車司機尿液中1-羥基芘與氧化傷害的比對Urinary 1-Hydroxypyrene Relative to Oxidative Damage in Taxi Drivers
• 莊淳宇、洪瑞琦、張祐剛、宋鴻樟
  Chun-Yu Chuang, Jui-Chi Hung, Yu-Kang Chag, Fung-Chang Sung
• 計程車司機 ； 1-羥基芘 ； 氧化傷害 ； 8-羥基去氧鳥糞嘌呤核
  taxi drivers ; 1-hydroxypyrene ; oxidative damage ; 8-hydroxydeoxyguanosine
• 目標：尿液中的1－羥基芘(1-hydroxypyrene; 1－OHP) 可為暴露到多環芳香烴化合物(polycyclic aromatic hydrocarbons; PAHs)之標記，本研究旨在探究以尿液中8－羥基去氧鳥糞嘌呤核?（8-hydroxydeoxyguanosine;8-OHdG）評估暴露PAHs所造成的氧化傷害之相關程度。方法：在台北市計程車司機休息站，募集95位全職工作三年以上的男性計程車司為暴露組，以及依據環保署空氣品質監測站資料，選擇空氣品質良好之台北地區，募集75位男性社區居民為對照組。研究對象均接受問卷訪視，並提供尿液樣本知做為尿液１－OHP及8－OHdG含量分析。結果：進行多變項迴歸分析發現1－OHP濃度與從事駕駛計程車之職業司機和抽菸者有明顯正相關性。以四分位分析顯示1－OHP的平均含量由小於０.15ug/g creatinine增加到大於0.35ug/g creatinine時，8－OHdGl由平均9.7ug/g creatinine增加到1.47ug/g creatinine。在控制研究對象組別、年齡、教育程度、抽菸、嚼檳榔和運動習慣後，8－OHdG濃度與１－OHP濃度有顯著正相關性（r=0.239,p=0.002）。結論：從事計程車駕駛之職業或抽菸都與尿液中1-OHP濃度的增加有顯著相關，由於尿液中8－OHdG濃度與1-OHP間有正相關性，因此8－OHdG濃度可以作為一生物標記反映出個人暴露PAHs所造成之氧化傷害。
  Objectives: Urinary 1-hydroxypyrene (l-OHP) is an exposure marker of polycyclic aromatic hydrocarbons (PAHs). This study investigated the relationship between the urinary 1-OHP and 8hydroxydeoxyguanosine (8-OHdG), a biomarker of DNA oxidative damage. Methods: With consents from subjects, the levels of urinary 1-OHP and 8-OHdG were determined for 95 men, with at least three years of taxi driving, recruited at taxi rest stations and 75 men residing in the community with the least air pollution in Taipei City. Results: Multiple regression analysis showed that urinary l-OBP excretion was significantly associated with traffic exposure and smoking. In the quartile distribution of urinary 1-OHP level, the average 8-OHdG level increased from 9.7ug/g creatinine to 14.7 ug/g creatinine when the average 1-OHP level increased from less than quartile. After adjusting for study group, age, education, smoking, areca quid chewing and exercise, there was a significant positive correlation between 8-OHdG and 1-OHP levels (r=0.239,p=0.002). Conclusions: Taxi driving and smoking may contribute independently to the elevation in urinary l-OHP level. Because there is a positive association between the level of 8-OHdG and l-OHP in urine, the 8-OHdG may be considered as a useful biomarker of induced oxidative damage from PARs exposure.
• 181 - 188
• 10.6288/TJPH2002-21-03-04

• Link 原著 Original Article
• 氣象與老年人循環系統疾病死亡－台北、台中、高雄的比較Circulatory Diseases Mortality and Meteorological Factors in the Elderly. In Taipei, Taichung and Kaohsiung Areas
• 劉怡焜、林瑞雄、李源德、謝信良、陳永仁、宋鴻樟
  Yi-Kuen Liu, Ruey S.Lin, Yuan-The Lee, Shinn-Liang Shieh, Yeong-Ren Chen, Fung-Chang Sung
• 循環系統疾病死亡 ； 季節性 ； 氣溫 ； 氣壓
  circulatory disease mortality ; season ; temperature ; barometric pressure
• 目標：探討氣象因子和台北、台中、高雄三個地區循環系統疾病死亡的季節趨勢與相關性。方法：以衛生署死亡統計資料中設籍於台北地區（台北市、台北縣）、台中地區（台中縣、台中市）、高雄地區（高雄縣、高雄市）65歲以上，自1989年至1998年間死於循環系統疾病(ICD 390-459)者為對象，並對應氣象局台北、台中、高雄氣象測站之氣溫、氣壓、濕度等氣象資料，分析循環系統疾病日死亡率最低的氣溫，以卜瓦松迴歸(Poissin Regression)分析每日平均氣溫、日氣壓變化及濕度對循環系統疾病死亡的影響，及相對最適溫度之危險比。結果：這三個地區在冬天的循環系統疾病死亡率比夏天高出27.7%~33.4%。台北地區的最適溫度為26°C，台中、高雄則為27°C，當溫度降低到11°C以下時，台北地區循環系統疾病死亡的危險比達1.62(95% confidence interval (CI)1.45-1.80)；台中則為1.51(95%CI 1.06-2.14) ；高雄地區溫度降至15°C以下時，循環系統疾病死亡危險比為1.50(95% CI 1.28-1.77)。日平均相對濕度引起的死亡效應小，但統計相關顯著；氣壓的效應也較小，但在台北地區卻為顯著。結論：氣溫是主要影響循環系統疾病死亡的氣象因子，三個地區季節性變化大致相似，但是，增加50%循環系統死亡危險的最低溫度，高雄的比在台北的高，顯示氣溫下降時保暖的重要性。
  Objectives: This study investigated circulatory deaths associated with weather conditions in Taipei, Taichung and Kaohsiung areas. Methods: Using vital and meteorological statistics in 1989 to 1998, deaths from circulatory diseases (ICD 390-459) in the elderly in Taipei, Taichung and Kaohsiung areas were analyzed for seasonal variations of the mortality the optimum temperature with the least deaths. Risk ratios were measured against the optimum temperature for Taipei. Taichung and Kaohsiung areas. The effect of barometric pressure change and relative humidity was also evaluated. Results: Compared with summer, the excess risks of circulatory deaths in winter ranged between 27.7% and 3J.4% in the three areas. Compared with the optimum temperature, 26°C, in Taipei area, the risk ratio of death from the diseases was 1.62 (95% confidence interval (CI) 1.45-1.80) when the temperature decreased to <11 °C. In both Taichung and Kaohsiung areas, the optimum temperature was 27°C. When the temperature was <11°C, the risk ratio was l.51 (95% CI 1.06-2.14) in Taichung; when the temperature was <15°C the risk ratio was 1.50 (95% CI 1.28-1. 77) in Kaohsiung. The effect of daily relative humidity was weak but statistically significant in all three areas. The effect of barometric pressure change was also weak and significant only in Taipei area. Conclusions: Temperature is the major meteorological factor associated with the circulatory death for the elderly. The seasonal mortality patterns were generally consistent among the three study areas. However, the lowest average temperature leading to a 50% excess risk of the death is higher in Kaohsiung than in Taipei, reflecting that it is important for the elderly to keep the body warm when the temperature declines.
• 189 - 196
• 10.6288/TJPH2002-21-03-05

• Link 原著 Original Article
• 焚化爐產生之大氣戴奧辛暴露與生殖危害之相關性研究Ambient Dioxin Exposure to Incinerators in Association with Adverse Birth Outcomes
• 林志銘、李中一、毛義方
  Chih-Ming Lin, Chung-Yi Li, I-Fang Mao
• 戴奧辛及喃 ； 斷代研究 ； 暴露評估 ； 生殖危害 ； 低出生體重
  PCDD/Fs ; cross-sectional study ; exposure assessment ; adverse birth outcomes ; low birth weight
• 無
  Objectives: To investigate the relationship between ambient exposure to incinerator generated polychlorinated dibenzo-p-dioxins and dibenzofurans (PCDD/Fs) and the risks of adverse birth outcomes. Methods: We used a cross-sectional design in Taipei metropolitan areas to explore the relationship between exposure too elevated PCDD/Fs concentration and various birth outcomes in 1991 (one year before the incinerator started to operate) and 1997 (four years later), respectively. With the US EPA Industrial Source Complex Model-Sort Term modeling technique, we determined the ambient PCDD/Fs concentrations within the catchments of the study areas in which 40 districts with PCDD/Fs exposure of >= 0.03 pg TEQ/m3 were considered ill1~il1y exposed areas, whereas the lowly exposed areas comprised the same number of districts with an estimated exposure of zero. Information on birth outcomes was retrieved from Taiwan’s Birth Registry. The study participants included all singletons. For multiple births, we also randomly selected one of them as the ruuay participant. The exclusion criteria included a gestation age of <20 weeks or a birth weight of < 500 grams. These rules gave rise to a total of 6994 and 6520 neonates included in the analysis for 1991 and 19997, respectively. Results: Multivariate analysis indicated that the 1991 or 1997 year specific odds ratios (Ors) of low birth weight (OR= 1.08 or 1.06), preterm (OR= 1.06 or 1.15), term low birth weight (OR=0.98 or 0.74), being females (OR=0.96 or 0.94), and multiple birth (OR=0.94 or 1.46) in relation to higher exposure to PCDD/Fs were all close to unity, and were statistically insignificant. Test of heterogeneity in Ors further suggested no significant difference between the two year-specific Ors for all birth outcomes. As birth weight was analyzed as a continuous variable, the high/low exposure difference in mean birth weight decreased from 7.36 grams in 1991 to –2.16 grams in 1997. However, the above year-specific high/low exposure differences in mean birth weight were close to null statistically. Conclusions: The study tends to suggest little influence of the operation of incinerators on the risk of adverse birth outcomes. However, the use of modeling for exposure characterization might entail a certain degree of exposure misclassification in the study. Additionally, it is somewhat arbitrary to use a level of 0.03 pg TEQ/m3. This might be lower than the threshold concentration that can affect the risk of adverse birth outcomes as a cutoff point in discriminating highly from lowly exposed areas. Hence, the null findings of the study could be the result of information bias.
• 197 - 206
• 10.6288/TJPH2002-21-03-06

• Link 原著 Original Article
• 全民健保醫療利用集中狀況及高、低使用者特性之探討Concentration of Health Care Expenditures in Taiwan-Analysis of Patient's Characteristics
• 張鴻仁、黃信忠、蔣翠蘋
  Hong-Jen Chang, Shin-Chung Huang, Tsui-Ping Chiang
• 全民健保 ； 年齡結構 ； 疾病分類 ； 慢性病
  national health insurance ; age ; disease pattern ; chronic conditions
• 目標：本研究旨在呈現醫療使用的集中狀況，並比較醫療高、低使用者在年齡結構及就醫疾病上的差異。方法：以健保局89年曾經參加健保之所有保險對象為研究對象（N＝22,161,422），本研究每人平均醫療費用為14,662元，百分位數為79.4，取接近平均數之80分位數（15,174） 為高、低使用之分界點，進行資料分析。結果：（1）醫療低使用者佔全體保險對象之80％，使用約25％的醫療費用，其中有7.7％的人全年未使用健保醫療資源；而高使用者人數佔全體保險對象之20％，則花費約75％的醫療費用，其中使用最高的１％人口，約使用全部費用的28％（2）高使用者人口結構之慢性疾病，醫療費用居首位者為腎炎相關疾病，其次為惡性腫瘤及高血壓性疾病。在低使用者方面，醫療費用則以感冒及牙科疾病等輕微疾病為主。結論：全民健保醫療利用呈現集中化，高使用者主要為老年人口、住院、慢性病及重症病患，足見健保制度確已達到照顧弱勢及風險分攤之成效。
  Objectives: The objective of the study was to explore the distribution of health care expenditure among enrollees of different levels of service utilization in Taiwan’s national health insurance. Methods: In 2000, 22161422 beneficiaries were entitled to receive NHI services. Claim data retrieved from the NHI database indicated that the average expenditure per person in 2000 was $NTl4,662, at the 79.4th percentile. Accordingly, the enrollees were divided into “high user” and “low user” at the 80th percentile ($NT15174). Age, types of services received and disease pattern were analyzed to compare the two groups. Results: (l) About 25% of NHI total medical expenditure in 2000 was accounted for by low users, 80% of the enrollee population, of whom 7.7% never used the services. On the contrary, for high users, being only 20% of the enrollee population, accounted for 75% of the expenditure. The top 1 % of users alone accounted for 28% of the expenditure. (2)People in the high-expenditure group are relatively older than those in the lowexpenditure group. There were more high users in the older age groups than the younger ones. (3) Most of the utilizations among high users occurred in the inpatient department and chronic conditions that required long-term services; while primary services, such as influenza and dental diseases, accounted for a large proportion of health care of low users. Conclusions: The findings of the research showed that health care expenditure was concentrated on a small proportion of the population. Age, diseases pattern, and whether or not hospitalized were factors influencing the medical expenditure of high users. The results of this study indicated that the goals of pooling the risk and providing care to the disadvantaged had been achieved through the implementation of NHI.
• 207 - 213
• 10.6288/TJPH2002-21-03-07

• Link 實務 Public Health Practice
• 亞太經濟合作會議衛生計畫參與度分析The Analysis of the Participation of APEC Health Projects
• 許瑜真、施金水、涂醒哲
  Yu-Chen Hsu, Chin-Shui Shih, Shing-Jer Twu
• 亞太經濟合作會議 ； 新興傳染病
  APEC ; EID
• 目標：提供亞太經濟合作（APEC）會議有關新興傳染病（ EID）議題之推動策略及未來發展，探討會員體參與傳染病防治計畫與台灣參與情形。方法：透過APEC的組織架構及運作模式說明衛生議題在APEC亞太區域受到重視的源起，並透過網際網路資料搜尋方式，回溯、分析5年來的 EID相關計畫之報告及相關會議資料。結果：21個會員體5年來執行了11項 EID相關計畫。其中5項計畫已於2001年執行完畢，計畫內容包括電子交換資訊、疾病監測、訓練課程等。計畫參與率最高的是美國(0.9)、韓國次之(0.6)、印尼第三(0.5),台灣則與澳洲、墨西哥、菲律賓、新加坡、泰國並列第四(0.4) 。此外，EID相關計畫亦由原本以新興傳染病議題之討論範疇擴大至醫療衛生照護之層面，使得衛生議題APEC會議上形重要。結論：雖然APEC會員體已經意識到傳染病防治對經貿之影響及其重要性，但是由研究結果發現會員體參與 EID計畫之意願不高，而 EID議題之討論範疇亦擴展至更廣的衛生領域。因此，我國政府與學術界應善用APEC機制，有計畫的主導 EID／衛生議題走向，提出對我國公共衛生發展有利之計畫，對我國傳染病防治與學術研究將有所助益。
  Objectives: To describe the APEC regional strategies and future development for communicable diseases, and the participation of member economies. Methods: By introducing the APEC framework and its operational protocol to explain the burgeoning APEC EID strategies. Materials include documents published on APEC ASTweb and EINet and distributed in every biannual ISTWG meeting. Results: Over the period of 1997 to 2001, the ISTWG approved 11 projects, proposed by 4 economies. Among them, 5 projects were completed. The United States of America had the highest participation rate, 0.9, followed by Korea (0.6), Indonesia (0.5). For Taiwan, as well as Australia, Mexican, Philippines, Singapore, and Thailand, the participation rate was 0.4. In addition, we also found that the APEC expands concerns from EIDs to HEALTH issues. Conclusions: Although the APEC member economies realize the influential impact of communicable diseases to the growth rate of trade and economics, our findings suggest the economies’ participation in communicable diseases projects is low, however, the issues are expanding. We would like to encourage the academic institutes to join the health authority to take advantage of the APEC framework as a vehicle to lead or participate in APEC regional projects.
• 214 - 221
• 10.6288/TJPH2002-21-03-08