20卷3期

• Link 公衛論壇 Public Health Forum
• 正視先天性德國麻疹症候群的威脅正視先天性德國麻疹症候群的威脅
• 蘇世斌、郭浩然
  Shih-Bin Su, How-Ran Guo
• 無none
  無none
• 無none
  無none
• 169 - 171
• 10.6288/TJPH2001-20-03-01

• Link 公衛論壇 Public Health Forum
• 下背痛病因學和危險因子上的新焦點下背痛病因學和危險因子上的新焦點
• 鄭碧華、吳聰能
  Bi-Hua Cheng, Trong-Neng Wu
• 無none
  無none
• 無none
  無none
• 172 - 174
• 10.6288/TJPH2001-20-03-02

• Link 綜論 Review Article
• 全球醫療事業勞工罷工事件對台灣的啟示The Inspiration of Global Employees' Strikes in the Medical Industry to Taiwan
• 范國棟
  Kuo-Tung Fan
• 罷工 ； 醫療事業 ； 勞工 ； 健康
  Strike ; medical industry ; labor ; health
• 行政院勞工委員會宣稱新修訂的勞資爭議處理法，將送立法院審理，若依該版本修訂通過，則醫療事業勞工所發起之罷工需再經三十天的『冷卻期』。目前超過二十萬的台灣勞工，正受僱於私有化和大型化趨勢的醫療照護體系內。作者回顧過去全球醫療照護體系的罷工事件，分析其運用模式與成效。並試圖對台灣醫療工作者過去在勞資角力中所採取的抗爭手段，和其在國家醫療保健政策下的身份轉變、國家勞動法令對其爭取工作權益的束縛、以及醫療團隊中醫師身份的特殊性進行剖析。面對全球化浪潮，唯有醫務勞動者建立自信，結合民眾健康教育並團結其力量，進而迫使國家鬆綁勞動法令及修訂衛生政策，才可使罷工權真正備而不用，同時讓人民邁向生理、心理與社會健康的新境界。
  The Settlement of Labor Dispute Law (SLDL) put forward to revise by the Council of Labor Affairs of Taiwan will be reviewed at the Legislative Yuan. Upon enactment of the revised SLDL, no medical industry strikes can be staged before the 30-day 'cooling period'. In the healthcare system of Taiwan, there are more than 200 thousand medical workers employed in hospitals and clinics. This paper reviews global labor strikes in health care system and analyses the pattern and effect of strikes. Furthermore, it examines past struggles of the medical workers in Taiwan, the changes in their status as result of the government health policy, the constraint of their rights imposed by the national labor law, and physicians' specific characteristics in the medical team. To confront the trend of globalization, medical workers should build up greater confidence and unite with community in action to exert pressure on the government regarding labor laws and health policies. In this way, strikes will no longer need to be staged while the public can enjoy physical, mental and social health.
• 175 - 182
• 10.6288/TJPH2001-20-03-03

• Link 綜論 Review Article
• 台灣醫師人力研究之方法學探討Analysis of the Methodology Used for Physician Manpower Studies in Taiwan
• 洪錦墩、藍忠孚、宋文娟
  Chin-Tun Hung, Chung-Fu Lan, Wen-Chuan Sung
• 人力 ； 方法學 ； 醫師
  manpower ; methodology ; physician
• 醫師人力研究一直是衛生政策研究中重要的議題，其最主要目的在於探討醫師人力的數量、素質與分布三大問題，以及影響醫師數量，科別分布與地理分布因素之探討。雖然醫師人力議題研究並非是個新的研究領域或新的議題，但是隨著時空環境的的改變，醫師人力總是會有新的問題發生。本研究探考台灣地區過去以來的醫師人力研究文獻，其研究目的不外於下列三部分，第一部分為現況人力分析與未來數量推計，第二部分為專科別之分布，第三部分為地理別之分布。在台灣有關醫師人力研究常會面臨下列幾個問題：一、民眾需求之估計不易。二、醫師人力資料取得不易。三、醫師職業科別之不確定性。台灣地區於1995年實施全民健康保險，由於支付制度設計無法完全考量各專科別或次專科之服務特性，在經濟誘因之影響下，已對台灣地區醫師人力結構發生相當大之影響，如何去評估醫師人力之需求與利用政策改變或保險力量調整成為未來台灣地區醫師人力研究重要的課題。
  Research of physician manpower, one of the major issues in health policy, has focused on the quantity, quality and distribution of physicians. Although it is not a new issue, new definition and problems emerge as time goes by. Here, we review the research methodology of the physician manpower in Taiwan. The methodology employed in this regard was threefold: to analyze quantity by measuring the ratio of physician to the population; to analyze quality by studying the physi-cians' specialty; and to analyze distribution from a geographical point of view. There were, however, three limitations in these studies. l.Health needs were difficult to measure. 2.The physician enrollment and related material were unreliable. 3.The practitioner's specialty was not well defined. National Health Insurance began in 1995. The payment system had economic incentive consequence to the manpower structure. How to evaluate the needs of physicians and to change the constitution of physician manpower under the National Health Insurance or health care reform appears to be the most important subject.
• 183 - 191
• 10.6288/TJPH2001-20-03-04

• Link 綜論 Review Article
• 在地老化：台灣二十一世紀長期照護的政策方向Aging in Place:the Direction of Taiwan Long-Term Care Policy in the 21st Century
• 吳淑瓊、莊坤洋
  Shwu-Chong Wu, Kun-Yang Chuang
• 長期照護 ； 在地老化 ； 政策
  Long-term care ; Aging in place ; Policy
• 邁入二十一世紀，台灣人口立即飛快老化，老人的長期照護問題將嚴重挑戰我國公共政策。從國際經驗可知，世界主要國家的老人照護政策，均以在地老化(aging in place)為最高指導原則，認為老人應在其生活的社區中自然老化，以維持老人自主、自尊、隱私的生活品質。因此不論國家體制為何，其資源發展、服務提供、組織管理、財務支持等策略，均支持社區長期照護體系的建構，希望以『在地』的服務滿足『在地』人的照顧需求，盡可能延長他們留住社區的時間。反觀我國在行政院1998年核定的兩個三年計劃之下，機構式服務資源大量成長，但是，支持老人留住社區的服務資源卻依然十分欠缺。顯示我國的發展趨勢如不立即調整，將嚴重背離去機構化之世界潮流，將使我國不但必須負擔機構昂貴的照顧成本，又無法滿足我國民眾『在地安老』的願望。因此，我國的老人長期照護政策應全面目標『在地老化』發展，需要努力的方向包含：(一)評估地區長期照護需求，設定發展目標；(二)發展多元的『在地』服務，服務當地民眾；(三)連結資源建構社區照顧網路，提升服務成本效益；(四)優先提供居家支持服務，降低對機構式服務的依賴；(五)建構財務制度，支持社區式長期照護體系之發展。
  In the 21st century, long-term care has presented serious challenges to public policy as the elderly population in Taiwan increases rapidly. Many developed countries have used ”Aging in Place” as the guiding principle for devising elderly care policy. Aging naturally in the community has been a key ingredient in maintaining independence, self-respect, privacy and quality of life. Thus, to be consistent with the concept of community-based care, many countries have started a reform in long-term care resource development, service provision, management, and financial schemes, regardless of political systems. The focus is to develop supportive services locally with the intention of helping the elderly stay In the local community for as long as possible. Contrary to the developed countries, supportive services to help the elderly staying at home are seriously lacking in Taiwan. Two three-year projects, funded by the Executive Yuan in 1998, have led to the dramatic growth of institutions, while community-based care resources remained scarce. Such trend is in the exact opposite direction of ”Aging in Place” principle. If continues, it is expected the society will have to pay for the high cost of institutional-based care, and many elderly will be deprived of the opportunity to age naturally in the community. Therefore4 the elderly care policy in Taiwan needs some adjustments. To be consist with ”Aging in Place” principle and to achieve the goal of staying in the community, reforms and researches are needed in the following areas: (l) Perform need assessment for elderly care in the community level, in order to project resource development, (2) Develop various long-term care resources locally to serve local residents, (3) Integrate service network and to Improve efficiency of services, (4) Encourage home care and other supportive services to prolong time spent in the community, and to reduce the use of institutional care, and (5) Devise a financing scheme consistent with the development of community-based long-term care system.
• 192 - 201
• 10.6288/TJPH2001-20-03-05

• Link 原著 Original Article
• 環境荷爾蒙─壬基苯酚殘留調查及其對雄鯉魚生理效應之研究Residues Survey of Nonylphenol and Its Biological Effedt on Male Carp
• 王正雄、張小萍、黃壬塊、李宜樺、王世冠、洪文宗、陳珮珊
  Cheng-Hsung Wang, Schau-Ping Chang, Ren-Keui Huang, Yi-Hua Lee, Shi-Kwun Wang, Wen-Tsung Hung, Pei-Shan Chen
• 環境荷爾蒙 ； 外因性內分泌干擾物質 ； 壬基苯酚
  Endocrine disrupting substance ; Environmental hormone ; Nonylphenol.
• 目標：本研究在調查環境荷爾蒙化學物質─壬基苯酚在台灣河川水質及底泥之環境殘留，並探討其對雄鯉魚之內分泌干擾生理效應。方法：本研究於台灣40條河川採得107個水樣，及其中6條河川採得19個底泥樣品，以密閉容器盛裝攜回實驗室內，以毛細管柱氣相層析質譜儀，檢測分析水樣及底泥樣品中所含之壬基苯酚濃度。此外，並在實驗室內，將雄鯉魚以壬基苯酚暴露二週，觀察四週，再以酵素免疫分析法檢測魚體血漿中之卵黃前質濃度，據以探討對生物之內分泌干擾生理效應。結果：台灣40條河川河水壬基苯酚平均檢出率54.2%，陽性樣品平均濃度4.87ug/L(0.89-50.0ug/L)；以南部河川較為嚴重，其檢出率77.4%，陽性樣品平均濃度7.54ug/L(1.08-50.0ug/L)。底泥平均檢出率在6條河川為74%，陽性樣品平均濃度2,625ug/kg dry wt(250-8,580ug/kg dry wt)；北部河川比南部嚴重。但可能由於微生物好氧細菌分解之差別，各河川、河段變異極大。雄鯉魚於壬基苯酚暴露後第二週即發現血漿內之卵黃前質濃度明顯增加(8.21-12.22ug/mL)，約為空白對照組之8倍；第四週為5.38-75.36ug/mL，其中餵飼處理者為空白對照組之46倍，壬基苯酚確具干擾生物內分泌生理效應。結論：台灣地區由於衛生下水道普及率偏低，含非離子界面活性劑之清潔劑所衍生之壬基苯酚，已形成台灣河川嚴重污染，宜加強源頭管制，並加速衛生下水道之建設。
  Objectives: The purpose of this research was to survey the residual nonylphenol, one of the endocrine disruptors, in fivers and sediments in Taiwan. The potential endocrine disrupting effect on male carp was also investigated. Methods: A total of 107 water samples from 40 rivers and 19 sediment samples from 6 rivers in Taiwan were collected for measuring nonylphenol using capillary GC/MSD. USEPA 525.2 method was adapted for treating water samples and the ROC-EPA method NIEA R8IS.20B for sediment samples. As for the fish assay: male carps were exposed to nonylphenol for two weeks and followed up for four weeks. Vitellogenin in fish plasma was examined using enzyme-linked immunosorbent assay (ELISA) for the evaluation of biological endocrine disruption effect. Results: Nonylphenol was detected in 54.2% water samples with an average concentration of 4.87 ug/L , in the range of 0.89 to 50.0 j1g/L. The detectable rate was the highest for rivers of southern Taiwan (77.4%) with an average concentration of 7.54 ug/L. in the range of 1.08 to 50.0 ug/L, In the sediment of six rivers, the chemical was found in 74% samples with an average concentration 2625 f1g/kg dry wt, in the range of 250 to 8580 ug/kg dry wt. The detected concentrations varied among rivers and among different sections in a river. For fishes that exposed to water with 40 ug/L nonylphenol, vitellogenin in study fish plasma, ranged from 8.21 to 12.2 j1g/mL was about eight times higher than that of controls, by two-week follow-up. After four weeks, the vitellogenin contents rised to 5.38-75.4 J.1glmL. For fishes fed with nonylphenol,the vitellogenin level was 46- times higher than for control group. Conclusion: These data suggest that nonylphenol in river water and commercial detergents has a potential harmful impact on the environment and public health in Taiwan.
• 202 - 215
• 10.6288/TJPH2001-20-03-06

• Link 原著 Original Article
• 偏遠地區社區醫療照護計劃之評估─花蓮縣秀林鄉之實證研究Evaluation of Community-Based Medical Care Plans in Remote Areas-an Empirical Study of Shioulin Township, Hualien
• 李奕慧、尤瑞鴻、項秋梅
  Yi-Hwei Li, Jui-Hung Yu, Chiu-Mei Hsiang
• 社區醫療照護計劃 ； 準實驗設計 ； 縱貫研究 ； 醫療可近性 ； 醫療利用
  community-based medical care plan ; quasi-experimental design ; longitudinal study ; accessibility of medical care ; medical utilization.
• 目標：健保局為改善偏遠地區醫療照護，首先委託門諾醫院於花蓮秀林鄉實施社區醫療照護計劃，計畫內容以提供社區巡迴醫療服務為主，本文旨在評估該計畫中短期執行成效。方法：採用準實驗設計已崇德、和平為介入區，銅門、文蘭為對照區，結合縱貫性研究方法，以2年為研究期間，等分為４個階段，分析健保醫療利用資料，評比介入區與對照區介入前後醫療利用的演變，結果：介入前介入區之西醫門診次數為半年4.74次，介入後增至5.80次，對照區則由5.86次增至6.64次，呈平行成長趨勢。介入前介入區之牙科門診次數為0.17次，對照區為0.28次；介入後介入區增至0.24次，對照區降至0.23次，已無顯著差異。兩區住院率介入前後皆無顯著差異。介入後秀林衛生所於介入區服務量變化不大，仍提供介入區9%的西醫門診服務，門諾提供12%的服務，原住民；女性；嬰幼兒、老人等弱勢族群使用巡醫服務比例較高。結論：門諾計劃改善介入區醫療可近性，提昇當地門診利用；巡醫服務為補充性醫療資源，未取代原有衛生單位的醫療業務，提供弱勢族群更多就醫選擇。計劃工作內容濃縮至巡醫服務，門諾計劃中長期成效，現階段無法達成健康促進之目標，僅能以醫療利用的變化來評價其功能。
  Objectives: To improve medical care in remote areas has been one of the primary endeavors for the National Health Insurance Bureau (NHIB). Mennonite Hospital was the first institute sponsored by the mill to implement a community-based medical care plan in Shioulin. This program provided itinerant clinical services for the intervened communities. The objective of this study was to evaluate the short- and mid-term effects of the community program. Methods: A longitudinal quasi-experiment was carried out to compare the utilization of outpatient services and hospitalization between the intervened and controlled communities over four 6-month periods. The intervened villages were Chungde and Heping. Wenlan and Tungmen were selected as controls. Results: There was a parallel increase in the utilization of outpatient , services in both intervened and controlled areas. The number of visits was 4.74 before Intervention, and increased to 5.80 after intervention in the intervened area; it was 5.86 and increased to 6.64 in the controlled. Before intervention, the number of dental clinic visits was 0.17 in the intervened, and 0.28 in the controlled. After intervention, the number increased to 0.24 in the intervened, but decreased to 0.23 in the controlled. and the difference in the number of dental clinic visits between the two communities had diminished. There were no significant differences in the utilization of hospitalization between the two communities. After intervention, the total amount of outpatient services provided by the Shioulin Health Station did not change notably in the intervened area, but the share of the services had changed over the study period, it decreased tram 11.7% to 9.4% for the Health Station. The share for the Mennonite itinerant medical team became important and accounted for 11.9% of the outpatient services in the area after intervention. The clients of the two local outpatient facilities consisted mainly of aborigines, females, infants, and elders. Conclusions: The itinerant healthcare services provided by the Mennonite Hospital improve? the accessibility of medical care, and increased utilization significantly in the intervened area. These services were, on one hand, important resources to the community, but on the other hand, supplementary, and did not replace those offered by the Shioulin Health Station. However, the mid- or long-term effects of the community program were not obvious, and the ultimate goal, holistic health promotion, could not be achieved at this stage.
• 216 - 227
• 10.6288/TJPH2001-20-03-07

• Link 原著 Original Article
• 某醫學中心一般外科住院醫師臨床醫學訓練時間分配之探討A Time Study of General Surgical Residency Program in a Medical Center
• 周秋芳、史麗珠、莊逸洲
  Chiu-Fang Chou, Lai-Chu See, Yi-Chou Chuang
• 住院醫師 ； 臨床教育 ； 訓練工時 ； 一般外科
  Gresident ; clinical teaching ; training hours ; general surgery
• 無
  Objectives: To study the workload of general surgical residents and examine how it varied with resident's seniority or day-night shift. Methods: Time spent in each activity was recorded by the residents themselves and compared using repeated measure ANOV A. Results: Ten residents participated in the study and 52 daily work-sheets were collected. (l) A resident worked 16.3 hours daily and patient care study and 52 daily work-sheets were collected. (l) A resident worked 16.3 hours daily and patient care made up the largest proportion of workload (11.1 hours). (2) Residents provided inpatient service to 9.8-19.3 patients each day, equivalent to 0.3-0.45 hours per inpatient per day. It increased with the resident's seniority but decreased for R4. (3) About five to eight operations were performed daily by each resident. The more senior the resident was, the longer the operation time. (4) The working hours were .14.6 hours per day for Rl and increased to 22.3 hours per day for R4' but show no statistical significance (p=.1564). Only R4'had administrative duties. (5) Night shift (20.1 hours) was significantly longer than day shift (13.4 hours) (p<.000l). (6) Residents received only six minutes bedside teaching per inpatient per day. Conclusions: Operation learning was the major activity for surgical residents. Surgical residents often began day shift right after the night shift and day shift was usually overtime. The long working hours were not just stressful but also affected the quality of patient care. Our findings indicated an urgent need of reforming the traditional program of resident training.
• 228 - 237
• 10.6288/TJPH2001-20-03-08

• Link 原著 Original Article
• 護理之家照護品質指標：以老年住民、家屬以及護理人員的觀點探討Indicators of Quality of Care for Nursing Homes: From the Perspectives of Residents,Family, and Nurses
• 楊嘉玲
  Chia-Ling Yang
• 指標 ； 護理之家 ； 質性研究
  indicators ; nursing home ; qualitative research
• 目的：探討護理之家老年住民、家屬與護理人員三者所認為的護理之家照護品質指標。方法：利用質性研究的方法，分別對居住在護理之家中的老年住民，有親人居住在護理之家中的家屬，以及在護理之家中工作的護理人員，進行深度的訪談與參與式觀察。結果：可將護理之家照護品質指標分為七大類：環境、護理專業能力、品質管理、基本人權、提供照顧者的態度、社會互動，以及需求滿足；並且也發現三者間的差異。特別是在護理專業能力、基本人員與需求滿足的部分，有顯著不同的描述。結論：期望本研究的結果，有助於長期照護的從事人員，了解護理之家照護品質的相關指標；更期望相關的從業人員，可以藉由了解三者間的差異，進一 步促進與協調彼此間對護理之家照護品質的共識。
  Objectives:To explore and the compare the indicators of quality of care in nursing homes from the perspectives of different groups including residents, their family and nurses. Methods: A qualitative research method and in-depth interviews of participants were used to collect data. The partcipants were 10 residents, 11 families and 10 nurses in three nursing homes. Results: Seven important indicators of quality of nursing homes were identified. They included environment, nursing professional competence, quality assurance, basic human rights, direct care attitude, social satisfaction had been the subjects of much controversy between the study groups. Conclusions:This study may help the long-term care professionals to realize the needs of residents, and their families. The results can also provide common indicators of nursing homes quality to the residents, families and nurses.
• 238 - 247
• 10.6288/TJPH2001-20-03-09