18卷1期

• Link 公衛論壇 Public Health Forum
• 精省後省屬醫療機構的組織再造與歸屬精省後省屬醫療機構的組織再造與歸屬
• 張睿詒
  Ray-E. Chang
• 無
  none
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  none
• 1-2
• 10.6288/CJPH1999-18-01-01

• Link 綜論 Review Article
• 游離輻射暴露對孩童成長影響之探討The Effects of Excessive Radiation Exposure on the Growth of Children
• 王蓉君、 張武修、王榮德
  Jung-Chun Wang, Wushou P. Chang, Jung-Der Wang
• 游離輻射；孩童成長；機制；骨骼生長板；內分泌
  ?ionizing radiation?;?children growth?;?mechanism?;?epiphyseal plate?;?endocrine
• 長期低劑量游離輻射暴露是否會造成各類健康影響，非常值得我們探討。有鑑於此，本文回顧綜述近一世紀以來有關游離輻射對孩童成長影響的研究。動物實驗極早即發現骨骼成長遲滯的現象與輻射劑量的高低和實驗動物的年齡呈明顯的相關。人體接受異常輻射暴露後所造成負面的生長影響，在廣島、長崎原爆暴露，以及罹患癌症兒童接受放射性治療存活者身上獲得證實；且發現暴露時間越早，效應越大。造成此效應之兩種可能機轉為：輻射直接對骨骼生長的抑制，同時亦可能抑制部分內分泌系統，進而抑制了正常的生長。
  This article reviews studies done in the 1900's related to the physical growth of children exposed to radiation. Many animal studies have demonstrated strong correlations between bone growth and both the dose of radiation and age at radiation exposure. Human population studies come mainly from survivors of the atomic bombs in Hiroshima and Nagasaki and from children who have received radiotherapy, which also show evidence of inhibition of physical growth. Radiation exposure at a younger age had a greater impact on growth. There are two possible mechanisms for this effect: inhibition of epiphyseal plate growth, or impairment of endocrine organs due to radiation exposure. Although most studies were conducted after a large radiation dosage, they can still provide some guidance for conducting studies in populations at lower exposure levels.
• 3-12
• 10.6288/CJPH1999-18-01-02

• Link 綜論 Review Article
• 多氯戴奧辛類化學物質之暴露與毒性The Exposure and Toxicities of Polychlorinated dibenzo-paradioxin-like Chemicals
• 張火炎、李俊璋、桂椿雄、郭育良
  Ho-Yuan Chang, Ching-Chang Lee, Chun-Hsiung Kuei, Yue-Liang Leon Guo
• 戴奧辛 ； 夫喃 ； 多氯聯苯 ； 暴露 ； 毒性
  dioxins ; furans ; PCBs ; toxicity ; exposure
• 由於多氯戴奧辛（以下稱戴奧辛），與其化學結構類似的化學物質，如多氯夫喃（以下稱夫喃）與多氯聯苯等，被發現在動物實驗中有極?的致癌性及對環境的衛擊，在公共衛生上引起很大的關切。其中2,3,7,8-四氯戴奧辛甚至在已開發國家中被稱作『世紀之毒』。這篇研究就其發生源、環境流行與各種環境介質之暴露量、重大人類的暴露族群、戴奧辛的吸收、代謝、與排出暨戴奧辛的毒性作用作一綜合介紹。第一次世界大戰以來工業需求甚大的多氯聯苯已逐漸因其對環境與生態的衝擊被多國禁用。待解決的是殘留的多氯聯苯如何處置，對於環境的衝擊才會較小，而毒性較大的戴奧辛與夫喃卻是含氯物質因高熱或處理過程產生之不純物，很難避免，未來公共衛生的挑戰即是致力於改善工作流程，減少戴奧辛類化合物之產生，發展分解戴奧辛類化合物之生物或工程技術上加以努力。
  Due to the carcinogenicity and the considerable impact on our environment and ecosystems, polychlorinated dibenzo-para-dioxins (Dioxins) and their structurally similar compounds such as polychlorinated dibenzo-para-furans (Furans) and polychlorinated biphenyls (PCBs) have become concerns to public health. Among them, 2,3,7,8 tetra-dioxin has been called the ”poison of the century” because it is the strongest hepatocarcinogen. The sources, exposure levels in various environmental media and corresponding environmental fates, number of significant episodes, and toxicities of these compounds were extensively reviewed. We concluded that, residual PCBs, further efforts should focus on reducing the harmful effects. However, for dioxins and furans, the challenges are to improve the technology to decrease the production of these impurities within the manufacturing process, and to develop the biotechnology to decompose these persistent compounds.
• 13 - 27
• 10.6288/CJPH1999-18-01-03

• Link 原著 Original Article
• 機動車事故傷害發生地、死亡地與戶籍地關係之初探：花東經驗A Preliminary Study of the Relationships between Place of Occurrence, Place of Death and Pacce of Residence in Motor Vehicle Injury: Experience in the Huatung Area
• 呂宗學、黃熾楷、陳宜冠、陳愛娣、李孟智、周明智
  Tsung-Hsueh Lu, Chee-Kai Hong, I-Kuan Chen, Ai-Di Chen, Meng-Chih Lee, Ming-Chih Chou
• 機動車事故傷害 ； 地區別死亡率 ； 流行病學 ； 方法學
  motor vehicle injury ; regional mortality ; epidemiology ; methodology
• 為探討以戶籍地歸屬的縣市別機動車事故傷害死亡率問題，本研究以問卷回溯訪視民國83及84年花蓮縣台東縣居民死於機動車事故傷害者的家屬，詢問有關機動車事故發生地的相關訊息。本研究發現花蓮縣機動車事故傷害發生地在外縣市者之比例為17%(94/559)，台東縣為35%(113/323)。發生地在外縣市者（與發生地在縣內者比較）有較高比例是青少年與年輕人，較多使用小客車與貨車。在確知發生地與死亡地的樣本中，問卷所問出之發生地與死亡證明書所記錄之死亡地屬於相同縣市者，花蓮縣有548人(99%)；台東縣有301人(96%)。由於花束地區機動車事故傷害發生地在外縣市的比例相當高，所以不宜以戶籍歸屬的縣市別機動車事故傷害死亡率推論該地區道路環境因素。本研究顯示，至少在花東地區，死亡地可作為發生地的替代。此外，機動車事故傷害發生地在外縣市者與發生地在縣內者特徵不同，所以防制計畫的標的團體也應不同。
  To assess the problems of regional mortality rates from motor vehicle injury (MVI) calculated according to place of residence, we retrospectively interviewed families of people who died from MVI during the years 1994 and 1995 in Hualien County and Taitung County. Seventeen percent(94/559) of MVI deaths occurred outside the resident county in Hualien County and 35% (113/323) in Taitung County. The characteristics of victims whose accidents occurred outside the county differed significantly in age distribution and pattern of road use. Among those in which the exact place of occurrence and place of death (recorded on death certificates) were known, in 99% (548/551) in Hualien County and 96% (301/315) in Taitung County, the place of occurrence and the place of death were in the same county. Because a high proportion of deaths occurred outside the resident county, the use of county-level regional mortality from MVIs calculated according to the place of residence should be evaluated very cautiously. At least in the Huatung area, the place of death recorded on the death certificate can be used as a proxy of the place of occurrence of the MVI. A control program targeting injuries which occur outside the resident county should be different from a program dealing with injuries which occur within the resident county.
• 28 - 33
• 10.6288/CJPH1999-18-01-04

• Link 原著 Original Article
• 中醫醫院門診病人選擇醫院之考慮因素及就醫滿意度研究－以台中市七家中醫醫院為例Factors Influencing Patient's Choice of Hospital and Satisfaction with the Ambulatory Service of Seven Chinese Medicine Hospitals in Taichung
• 侯毓昌、黃文鴻
  Yu-Chang Hou, Weng-Foung Huang
• 中醫門診 ； 醫院選擇 ； 就醫滿意度 ； 因素分析
  Chinese medicine ambulatory care ; patient's choice ; satisfaction ; factor analysis
• 本研究在探討病人選擇中醫門診時考慮之因素及消費決策，與就醫後之滿意度。樣本取自台中市七家中醫醫院或醫院中醫門診部病人共2072名，採問卷調查，共回收有效問卷1935份。研究結果顯示，中醫門診病人選擇醫院之考慮因素最重要的前三項為醫師之醫德、醫師之醫術和醫師之服務態度。在消費決策方面，出現頻率最高的前三項為醫師之醫術、醫師之醫德和醫師之服務態度；訊息來源則以來自親戚朋友之推薦與家人之告知為最多。滿意度最高的前三項為醫師之服務態度、醫師之治療能力及醫師對病情之解釋。病人選擇醫院之考慮因素可簡化成可近性等六個因素，可解釋原始變項變異量60.0%；就醫滿意度亦可簡化成醫師以外工作人員滿意度等三個因素，可解釋原始項目變異量64.3%。
  The aim of this study was to explore the factors influencing patient's choice of hospitals and differences in decision-making about Chinese Medicine ambulatory care. It also sought to evaluate patient satisfaction with their choices. Questionnaires were delivered to 2072 patients who visited seven Chinese medicine hospitals for ambulatory service in Taichung City from November 28~29, 1994. A total of 1935 valid questionnaires were collected for analysis. The results indicated that the most important three factors when choosing a Chinese medicine hospital were: 1) the physician's moral values; 2) the physician's treatment skills; and 3) the physician's service attitude. The physician's moral values, treatment skills, and service attitude were also the three most important factors influencing the decision to visit the hospital. The two most frequent sources of information related to hospital choice were 1) recommendation from relatives and friends; and 2) information from family members. The three most important items related to patient satisfaction were: 1) physician's service attitude; 2) physician's treatment skills; and 3) physician's explanation of the patient's disease. The factors influencing the patient's choice of hospital were further simplified to six factors. It contributes to 60.0% of variance in the patient's choice of hospital. The factors contributing to patient satisfaction were further simplified to the three factors. It contributes to 64.3% of variance in patient's satisfaction.
• 34 - 43
• 10.6288/CJPH1999-18-01-05

• Link 原著 Original Article
• 台灣功能障礙老人家庭照護者的全國概況剖析A national Profile of Family Caregivers of the Disabled Elderly People in Taiwan
• 吳淑瓊、林惠生
  Shwu Chong Wu, Hui-Sheng Lin
• 家庭照護者 ； 老人 ； 長期照護
  family caregivers ; aged ; long-term care
• 由於台灣絕大多數的功能障礙老人係由家庭提供照護，因此家庭照護者的特質及他們提供照護的現況是規劃台灣長期照護體系不可或缺的資料。有鑑於此，本研究乃進行1994年全國功能障礙老人及其家庭照護者調查，從全國3，155老人機率樣本中篩選出349位(111%)由家庭照護的功能障礙老人，再從中找到309位(925%)家庭照護者調查之，發現290位為真正家庭照護者，故納入分析。分析結果發現，照護者中將近三成為65歲以上的老人，七成以上為女性。將近一半的女性老人是由媳婦照護，而將近一半的男性老人由配偶照護。照護老人是一項漫長的工作，44%已經提供5年以上的照護。照護者除了照護老人之外，尚須面對其他競爭需求：38%同時需要照護未成年子女，18%曾經因工作衝突而調整工作，更有24%曾因而辭去工作。照護者並對外來的協助表示需求：七成認為需要協助他們防範老人發生意外；四到五成的照護者希望有人幫忙打電話向老人問安、或帶老人做休閒活動、或提供諮詢服務；42%希望能開辦短期臨託服務。由以上分析發現，家庭對功能障礙老人提供長期且密集的照護，家庭照護者大多為女性，他們在照護老人的同時，還面對其他照護競爭需求。
  Almost all disabled elderly people in Taiwan are cared for by their family members. This study examined family caregivers' characteristics and their commitment to caregiving. Potential subjects were identified from 1994 National Survey on Disabled Elderly. Among the 3,155 elderly subjects interviewed in that survey, 349 (11.1%) were considered as disabled elderly cared for by the family. Among these, 309 (92.5%) of their caregivers responded to this further interview. However, only 290 were true family caregivers. Approximately 30% of these caregivers were over 65 years of age, and over 70% were female. About half of the female elderly were cared for by their daughters-in-law; and half of the male elderly were cared for by their spouses. Forty-four percent of the respondents had been caregivers for at least 5 years. In addition, caregivers also had other competing demands: 38% of them reported child care responsibilities, 18% experienced work conflicts, and 24% had even quitted their jobs. A few caregivers(6%) had additional ill family members to care for. A sizeable proportion of caregivers expressed a need for other types of assistance; accident prevention was the most often demanded (70%) assistance, followed by friendly calls/leisure time activities/counseling (40-50%), and respite care (42%). In conclusion, family care for the disabled elderly is a long-term intensive commitment more likely to be undertaken by women. Caregivers also have other competing demands at the same time. These findings should be very important it decision making for the development of long-term care system in Taiwan.
• 44 - 53
• 10.6288/CJPH1999-18-01-06

• Link 原著 Original Article
• 衛生教育對於榮民之家高血壓老人自我照顧行為與血壓控制之影響The Effect of Health Education on self-care Behaviors and Hypertension Control in Elderly Hypertensive Patients at a Veterans Home
• 杜明勳
  Ming-Shium Tu
• 高血壓 ； 老人 ； 自我照顧行為 ； 衛生教育
  hypertension ; elderly ; self-care ; health education
• 明白施予衛生教育六個月後，高血壓個案之疾病認知、態度、自我照顧行為及血壓變化情形如何，又影響其變化之因素為何。以83年某榮家全體住家榮民健康調查時，篩檢出懷疑高血壓個案為對象。於其每月門診追蹤時，施予衛教前測驗，後予衛教。衛教以隨機分組分為每月衛教及隔月衛教兩組。85年7月至86年元月共收集有效問卷222份。個案以71-80歲老人居多，教育年數大多不及六年，視力及聽力不佳，智能狀況不理想，對高血壓之認知、態度及行為得分好壞各半。464%個案之朋友亦患高血壓或中風，716%個案除高血壓外尚志有其他疾病。衛教後，其高血壓之認知、「在意血壓」態度、及「依指示用藥」、「定期看診」和「自刻血壓」行為各分數均有顯著改進。衛教方面，每月組之認知改善比隔月組明顯，但態度或行為之差異則不顯著。血壓方面，不論縮壓或舒壓於衛教後均比衛教前稍高，而舒壓之增高於隔月組比每月組明顯。衛教後促成各因素改變之探討，鈴認知、態度、或各項行為方面，各別均或與個案之「年齡、智能、亦患他病、衛教分組、朋友數、及衛教前個別健康信念得分」有關。另舒張壓方面，除上述因子可能相關外，個案之「教育、讀寫能力、聽力、認知、及用藥行為」均亦有關。就本榮家高血壓老人而言，除定期追蹤給予藥物治療對個案血壓控制有幫忙外，每月一次重複衛教，給予清楚簡單的訊息，對其疾病照顧也很重要。另外，增進人際關係及彼此關懷應該也有助益。
  This study examined the effect of health education (HE) on individual's hypertension (HT) cognition, attitude, self-care behaviors and blood pressure (BP) control after 6 months HE for those suspected HT subjects at a veterans home. All suspected hypertensive individuals screened in 1994 were included as subjects. Pre-test and HE were applied at clinic before participant's regular monthly followup. Subjects were randomly allocated to monthly education group (MEG) and everyother-month group (EOMG). A total of 222 complete interviews were collected from July 1996 to January 1997. Most subjects were 71 to 80 years old with less than 6 years of education, had poor vision and audition, and had low mental scores. Only half of the subjects had good HT cognition, attitude and self-care behaviors. Of these individuals, 46.4% had friends with HT or a stroke history. In addition to HT, 71.6% were co-morbid with other diseases. After HE, the HT cognition, the attitude toward BP, and self-care behaviors, such as medical compliance, on-schedule clinic visits and self-check of BP, improved. MEG was better than EOMG in disease cognition, but not in attitude or behaviors. The BP measurements, both systolic and diastolic, were slightly higher after HE than before. From analysis of factors that influence the changes after HE, the promotion of HT cognition, attitude, and behaviors were related to individual's age, mentality, co-morbidity, HE group, the number of friends and pre-educational HT health believes. In addition to above factors, the diastolic BP reduction was also related to individual's educational level, writing or reading ability, audition, disease cognition and medical compliance. For those HT residents, in addition to physician's regular follow up and medication, repeated monthly education, giving simple and clear messages, was helpful for their disease care.
• 54 - 65
• 10.6288/CJPH1999-18-01-07

• Link 原著 Original Article
• 急診室醫療工作人員針刺與體液血液意外事件調查The Prevalence of Sharps Injury, Blood and Body Fluids Exposure among Emergency Department Staffs in Taiwan
• 洪美娟、蕭淑銖、莊銀清、黃崑巖、郭育良
  Mei-Chuan Hung, Judith Shu-Chu Shiao, Yin-Ching Chuang, Kun-Yen Huang, Yue-Liang Leon Guo
• 針刺傷害 ； 血液體液暴觸事件
  health care workers ; emergency department ; sharps injury ; exposure ; blood and body fluids
• 針刺傷害是醫療工作人員常見的職業傷害之一，而醫院的急診室是個緊急的救護單位，經常需要在短時間內處理大量的傷患。因此，發生針刺或體液血液暴觸的意外事件可能較為嚴重。為了解此類事件的嚴重程度，我們調查了台灣地區醫學中心、區域醫院、地區醫院與地區教學醫院共14家醫院的急診部門，共完成372份問卷。有342位(919%)醫療工作人員主訴曾發生針刺傷害。以最後一次醫療人員的針刺事件來進行分析，針頭刺傷種類是以一般注射用的針頭（189人，55.30/0）為多；因回蓋而被針頭刺傷者有73人(21.3%)。被刺傷後約有80%的醫療工作人員未向所屬單位報告。在刺傷或體液血液暴觸事件的次數方面，平均每人每年被針頭或銳物刺傷的次數分別為1.43次與1.54次，其自身的皮膚或黏膜接觸到病人的血液體液的次數分別為受傷且破皮的皮膚0.98次、眼睛黏膜0.28次、鼻子黏膜0.13次、嘴巴黏膜0.16次，且發現其使用個人防護用具的情況過低。因此，建議醫院應加強宣導針刺與體液血液防治措施，以減少此類意外事件的發生。
  It has been well documented that health care workers (HCWs) in the emergency departments (EDs) are at high risk of sustaining sharps injuries (SIs) as well as exposure to blood and body fluids (BBFs). Nevertheless, limited information is available on the prevalence and predisposing factors of these episodes among ED staff in Taiwan. A total of 372 HCWs from EDs of 14 hospitals were surveyed. Questions concerning their most recent SIs were measured. Of those surveyed 91.9% (342/372) had experienced of least 1 SIs. Ordinary needles (55.3%) were responsible for most of the episodes and recapping (21.3%) was the most frequently reported behavior associated with the accidents. The non-reporting rate was 80%. The average rates of needlesticks and other SIs were 1.43 and 1.54/person/year, respectively. The frequencies of exposure to BBFs were 0.98/person/year to non-intact skin, 0.28/person/year to the eyes, 0.13/person/year to mucosa membrane of the nose, and 0.16/person/year to mucosa membrane of the mouth. We conclude that HCWs in EDs in Taiwan are at high risk of SI as well as exposure to BBFs. A tailor-made preventive education program and provision of protective equipment to HCWs in the EDs are warranted.
• 66 - 76
• 10.6288/CJPH1999-18-01-08

• Link 實務 Public Health Practice
• 某醫學中心洗縫部門作業流程改善實證研究Empirical Study of Laundry Department Operation-A Case Study at a Medical Center
• 蘇喜、黃俊智、 莊逸洲、謝長堯、戴東原
  Syi Su, Chun-Chih Huang, Yi-Chou Chuang, Chang-Yao Hsieh, Tung-Yuan Tai
• 醫院洗衣房 ； 作業流程再造
  hospital laundry department ; Business process redesign ; Business re-engineering
• 本研究乃為改善某教學醫院之洗衣房作業，做時序性的觀察研究，除記錄作業流程的各種現象外，並蒐集醫院洗衣房現行業務量、人力配置及成本等資料，評估並比較改善前後的成本效益。第一次評估自民國八十二年四月至八十二年十月，實地參觀與蒐集其作業資料，經分析問題後提出改善方案，建議該部門採行之。其後在民國八十四年七月至八月，針對第一次觀察所提之建議事項做再次的觀察。研究結果顯示，對象醫院經改善方案後，人員編制由46人精簡為36人，每公斤衣物洗滌成本由第一次觀察時的30.5元降低為第二次觀察時的27.0元，生產力由每人時15.3公斤提升為21.7公斤。在工作環境方面，增設定點正壓空調系統，改善了悶熱的工作環境，並改善衣物發送體系以掌握布品耗用情形。建議今後的目標為加強機器設備利用率、研擬一套獎勵制度提升工作效率、累積「病房需求布品報表」以評估各單位病房的布品適當存量、使污衣物能直接在病房分類、洗淨衣物能有特定的放置空閒及洗縫部門設有常態性品質改善研究小組等。
  To evaluate the operation performance of the laundry department of a subject hospital, the staffing levels, job descriptions, operation flow, capacity and costs were examined before and after an operation intervention. The first evaluation was conducted from April 1993 to June 1993, and suggestions for operation improvement and system modification were proposed to the department. The second observation was carried out from June 1995 to August 1995, to evaluate the impact of the intervention. Observed accomplishments are summarized as follows: (1)The number of employees in the laundry department decreased from 46 before the intervention to 36 after the intervention. (2)The average laundry costs for linen were NT$ 30.5/kg and NT$ 27.0/kg at the first and second observations. (3)The productivity improved from 15.3 kg/man-hour, prior to the intervention to 21.7 kg/man-hour after the intervention. (4)An air conditioning system was installed to provide an improved environment for employees. We recommend that the laundry department continue to improve the utilization of the equipment, plan an employee incentive system, and estimate the most adequate level of linen stock at each nursing station.
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• 10.6288/CJPH1999-18-01-09