17卷4期

• Link 公衛論壇 Public Health Forum
• 從變項定義和分析方法檢討行為研究的問題從變項定義和分析方法檢討行為研究的問題
• 李蘭
  Lee-Lan Yen
• 無
  none
• 無
  none
• 273 - 274
• 10.6288/CJPH1998-17-04-01

• Link 綜論 Review Article
• 胃癌之流行病學特徵及危險因子Epidemiologic Characteristics and Risk Factors of Gastric Cancer
• 陳淑媛、林肇堂、陳建仁
  Shu-Yuan Chen, Jaw-Town Lin, Chien-Jen Chen
• 胃癌 ； 地區別變異 ； 遷徙效應 ； 危險因子
  gastric cancer ; geographical variation ; migrant effect ; risk factor
• 胃癌是目前世界第二位最常見癌症及第二位癌症死因，具有相當大的地區別變異及遷徙效應。世界各國包括台灣之胃癌死亡率皆呈下降趨勢，而且胃癌在台灣地區也是重要癌症，死亡率隨年齡的增加而上升，1994年胃癌的發生率和死亡率分別位居全國十大癌症的第六位和第三位。臨床上胃癌可分為早期胃癌及進行性胃癌，其五年存活率分別為90%及10%。和胃癌有關的環境因子包括蔬菜、水果、維生素A和E、胡蘿蔔素、硒、醃製或鹽漬食物的攝食，抽菸酗酒，幽門螺旋桿菌感染，電冰箱的使用及社經地位。胃癌有關的法因研究包括一等親胃癌家族史，麩胺基硫轉移酵素M1基因多形性。胃癌的多因子多步驟致病機轉，可能包括正常胃組織經幽門螺旋桿菌的感染而發生表面胃炎，而後受到鈉鹽的刺激，進一步造成萎縮性胃炎，此時胃內部環境若是高pH值、有細菌生長以及亞硝腔致突變物的作用，可能導致腸性化生，再經異生而導致胃癌。
  Gastric cancer is the second common cancer in the world with striking geographical variation and migrant difference in spite of its declining secular trend in nearly all countries including Taiwan, where the incidence and mortality of gastric cancer still ranked as sixth and third leading cancer site, respectively, in 1994. Early gastric cancer and advanced gastric cancer have different 5-year survival rates of 90% and 10%, respectively. The investigation of risk factors for gastric cancer is essential for effective prevention and early detection of gastric cancer. The environmental risk factors of gastric cancer include low intake of vegetable, fruit, vitamin A and E, carotenes, and selenium, high intake of salty food, cigarette smoking, habitual alcohol consumption, Helicobacter pylon infection, and low socioeconomical status. Genetic components including family aggregation and glutathione S-transferase M1 null genotype have been documented as risk factors for gastric cancer, but their roles in gastric carcinogenesis remains controversial and needs further elucidation. A multistep and multifactorial process of human gastric carcinogenesis was suggested. Excessive salt intake and infection with Helicobacter pylon play important roles on the initial stages of gastritis and atrophy, and ß-carotene and excessive salt intake on the final stages with a sequence of intestinal metaplasia, dysplasia, and carcinoma.
• 275 - 292
• 10.6288/CJPH1998-17-04-02

• Link 原著 Original Article
• 高雄市肺結核患者與非患者對肺結核知識、態度與預防行為之比較Comparison of Knowledge, Attitude and Preventive Behavior between Tuberculosis Patients and Non-Tuberculosis Patients in Kaohsiung City
• 郭素娥、 藍忠孚、 陳惠珠
  Su-Er Guo, Chong-Fu Lan, Hui-Chu Chen
• 肺結核 ； 知識 ； 態度 ； 預防行為
  pulmonary tuberculosis ; knowledge ; attitude ; preventive behavior
• 本研究目的旨在瞭解高雄市肺結核患者與非肺結核患者對肺結核的認知、態度及預防行為，並探討其肺結核知識來源、動機及需求，以提供有關單位日後針對肺結核患者與一般民眾制訂肺結核衛生教育之參考。 本研究以台灣地區第八次肺結核盛行率調查中，高雄市受檢者經胸部X光攝影檢查及複診後確定為肺結核患者且已就醫治療者43人為舊肺結核患者，以尚未就醫者100人為新肺結核患者；另以盛行率調查中胸部X光攝影檢查結果呈現未罹患肺結核者，簡單隨機抽出143人做為對照組。以自擬的問卷收集資料，經統計分析所得結果如下： 1．舊肺結核患者的肺結核知識屬於中下程度，其中對肺結核預後的認知最好，肺結核照護方法的知識最差；新肺結核患者及非肺結核患者的肺結核知識屬於中等程度，但對於肺結核傳染方式的認知，尚待加強。 2．影響舊肺結核患者知識得分最重要的因素是「是否由醫護人員處獲取肺結核知識」，而影響非肺結核患者知識得分的重要影響因素為「是否聽過肺結核」、「希望獲知肺結核知識」。 3．所有研究對象對於肺結核的態度大多屬於正向，唯有在「防治肺結核是民眾責任」的項目上偏向真向態度。 4．影響舊肺結核患者態度得分的最重要因素是肺結核知識得分。而影響非肺結核患者態度得分的重要因素是肺結核知識得分和「是否希望獲知肺結核知識」，新肺結核患者與非肺結核色者在知識得分和是否定期執行胸部X光攝影檢查方面皆具有顯著差異，顯示要有正向的肺結核預防行為，必須從肺結核的衛生教育著手。
  The purpose of this study was to compare the knowledge, attitude and preventive behaviors about pulmonary tuberculosis for tuberculosis patients and non-tuberculosis patients and to investigate patients' knowledge resources, motivations to search the knowledge, and the needs of patients. The results could help to set up health education strategies for the public. This research was based on the eighth survey of tuberculosis prevalence in Taiwan. Three groups of subjects were recruited. Group ? consisted of 43 subjects who had been diagnosed to have tuberculosis and had received treatment. In this research, they were labeled as old-tuberculosis patients. Group ? consisted of 100 subjects who hadn't any treatment and were labeled as new-tuberculosis patients. Group ? consisted of 143 subjects without abnormal chest films. Data were collected by questionnaires. Major results are shown as below: 1. The old-tuberculosis patients' knowledge of tuberculosis was at medium-low level. Their knowledge of tuberculosis prognosis was good overall but the study revealed some misconceptions about nursing care of tuberculosis. New-tuberculosis and non-tuberculosis patients’ knowledge of tuberculosis is at medium level. But their knowledge of transmission of tuberculosis was poor. 2. The significant predictors of the knowledge of tuberculosis scores in the old-tuberculosis patients' group were ”their knowledge comes from health team members”, in non-tuberculosis patients were ”they hear about tuberculosis” and ”hope to get tuberculosis knowledge”. 3. All three groups showed positive attitude. But they reported low attitude scores in ”prevention of tuberculosis is the duty of the public”. 4. The most influential factor of attitude for old-tuberculosis patients was knowledge scores, and for non-tuberculosis patients were knowledge scores and hope to get tuberculosis knowledge. In new-tuberculosis patients and non-tuberculosis patients, knowledge scores were found to be significantly related to regular chest X-ray check up. Chest X-ray was one of the important screening tests for tuberculosis. Based on the finding in this research, we can improve participation in regular chest X-ray check up through health education program to improve their tuberculosis knowledge.
• 293 - 302
• 10.6288/CJPH1998-17-04-03

• Link 原著 Original Article
• 台灣在校青少年對生活人權的認知與行為現況以及與抽菸、喝酒的相關之探討The Present Status of Human Rights Perception and Behavior and Their Relationship to Smoking and Drinking among Adolescent Students in Taiwan
• 周碧瑟、劉美媛、張鴻仁
  Pesus Chou, Meei-Yuan Liou, Hong-Jen Chang
• 人權 ； 抽菸 ； 喝酒
  human rights ; cigarette smoking ; alcohol drinking
• 本研究的主要目的在探討台灣地區在校青少年在「尊重」、「信任」、「評價」、「隱私」等生活人權方面的認知與行為；以及收集抽菸與喝酒習慣的資料，並分析「尊重」、「信任」、「評價」與「隱私」等變項與抽菸、喝酒習慣的相關情形。 本研究以結構性問卷進行資料收集，以分層集束抽樣方法，依國中、高中、高職、專科（五專的一至三年級）等類別分層，按學生人數比例，抽取總學生人數的0.5%為研究樣本。隨機抽取具代表性之50所國中、14所高中、21所高職、15所專科學校，共計100所學校。於各年級隨機抽取一個班級，共抽出12557位同學為研究樣本，完成有效問卷數為12355份，總回收率為97.3%。整體來看，國中組女生對父母、師長不尊重、家人不信任、父母評價不好特別敏感，較易反應於抽菸或喝酒的偏態行為。在「尊重」方面，師長對同學的尊重度較父母對子女的尊重度更易反應於青少年在抽菸或喝酒的偏態行為。在「信任」方面，家人不信任者之抽菸、喝酒可能性皆較高，但家人不信任與國中生之喝酒則無顯著相關。在「評價」方面，父母評價不好者之抽菸、喝酒可能性皆較高。但同學評價的結果正好相反，無論是國中組或高中、高職、專校組的男生，同學評價好的反而抽菸、喝酒的可能性較高。可見青少年間同儕評價的標準與父母評價的標準有極大的差異存在。在「隱私」方面，侵犯隱私權的情形嚴重，不過與抽菸、喝酒無顯著相關。
  This study has three major goals: (1) to survey the present status of adolescents attending schools in Taiwan about 4 values associated with human rights, (2) to survey the same population about smoking and drinking habits and possible related factors for smoking and drinking, and (3) to thoroughly analyze both sets of survey data to determine relationships. Multi-stage stratified cluster sampling with proportional allocation was used to determine the study population, which was equal to approximately 0.5% of all students in that age group in Taiwan. A total of 100 schools throughout Taiwan were chosen (50 junior high schools, 14 high schools, 21 vocational schools, and IS junior colleges), and the proportions were determined by the percentage of all students attending each type of school. One class from each year level at each school was selected. 12,355 of the 12,557 eligible students participated (97.3%). The 4 human rights values were respect, trust, esteem, and privacy, and all questions were related to daily life. Regarding attitudes toward privacy, a number of negative trends were found which warrant concern, but no significant relationships were found between privacy issues and smoking and drinking. Questions on ”respect” covered the attitudes of both parents and teachers toward the student as perceived by the student. Questions on ”trust” all dealt with the family. Questions on ”esteem” dealt with 2 facets family members and friends/classmates. Multiple instances were found of statistically significant correlations between student perceptions of respect, trust, and esteem with student smoking and drinking habits. This suggests that there is a significant relationship present and it is hoped that human rights education might decrease drinking and smoking prevalence, which in turn might decrease illicit drug use.
• 303 - 316
• 10.6288/CJPH1998-17-04-04

• Link 原著 Original Article
• 全民健康保險實施前後勞工意外事故發生率之變化及其涵意Workers' Unintentional Injuries Associated with the Change of Insurance Policy in Taiwan-The Implications of the Change
• 李中一、杜宗禮、 陳秋蓉
  Chung-Yi Li, Chung-Li Du, Chiou-Jong Chen
• 職業 ； 傷害 ； 殘廢 ； 死亡 ； 潛在工作生命損失數
  occupation ; injury ; disability ; mortality ; potential work years of life lost
• 本研究利用「勞工保險現金給付資料」分析1994與1996年勞工保險（以下簡稱勞保）被保險人職業與非職業傷害、疾病、殘廢、與死亡發生率，以及潛在工作生命損失率之變化，以探討全民健康保險（以下簡稱全民健保）實施前後勞保被保險族群特性是否改變，及估計勞工意外事故發生率的變化。分析結果發現：全民健保實施後，勞保總投保人數減少了近一百萬人，降幅約為125%，職業相關事故年齡標準化發生率(?)由3.97人次上升為4.26人次，而非職業事故年齡標準化發生率(?)則由31.37人次大幅下峰為21.20人次，其中非職業事故發生率大幅下降主要則是由於非職業疾病之發生率大幅下降所致。作者推測：由於全民健保實施前有許多「寄保」人口，因此使得1994年實際的職業意外事故發生率可能被低估，而在「寄保」人口退出勞保後留在勞保者則是真正具有職業意外事故風險的勞工，因此1996年之職業意外事故發生率估計值相對而言較為正確，因而造成職業意外事故發生率在全民健保實施後上升的現象。此外，非職業相關疾病發生率在全民健保實施後明顯下降，也反應出全民健保實施後的勞保族群似乎是比較健康的一群人。本研究建議：未來研究利用勞保現金給付資料比較1995前後勞工意外事故發生率時，對於結果的闡述必需小心。此外，未來研究亦應探討如何結合全民健保與勞保現金給付資料，期能更精確地估計台灣地區勞工意外事故之發生率及嚴重性。
  Using compensation records of the National Labor Insurance, this study estimates workers' incidence rates of injury or illness, disability, and mortality from occupational or non-occupational causes for 1994 and 1996, the year prior to and the year post the effectiveness of the National Health Insurance, respectively. The purpose is to assess changes in these rates and to propose implications related to those changes. The number of workers covered by the Labor Insurance decreased by some one million or 12.5% after the national health insurance program became effective in March 1995. While the rate of overall occupational injury increased slightly from 3.97/10^3 in 1994 to 4.26/10^3 in 1996, rate of overall non-occupational injury, on the other hand, declined dramatically from 31.37/10^3 to 21.20/10^3, respectively, largely due to a substantial reduction of non-occupation-related diseases. The results may lead to two implications. Firstly, the increase of occupational injury might be associated with the substantial dropout of people who were not ”real” workers but covered in the system leading to a reduced population size of workers actually at potential risk of occupational injury. Secondly, a remarkable decrease in risk of non-occupation-related diseases may lead to a speculation that the labor-insured workers were relatively healthier in 1996 than in 1994. Our findings call for a particular caution to use the labor health compensation records documented before and after 1995. Future studies should be devoted to merge data from both compensation records and national health insurance registry for the attainment of accurate estimation of incidence rate and severity of workers' injuries in Taiwan.
• 317 - 325
• 10.6288/CJPH1998-17-04-05

• Link 原著 Original Article
• 提供社區式家庭支持方案能否減少機構式長期照護服務之使用意願？Will Community-Based Family Supporting Programs Reduce the Use of Institutional-Based Long-Term Care?
• 徐慧娟、吳淑瓊
  Hui-Chuan Hsu, Shwu-Chong Wu
• 長期照護 ； 社區式家庭支持方案 ； 機構式照護 ； 照顧者 ； 媳婦
  long-term care ; community-based family supporting programs ; institutional care ; care givers ; daughters-in-law
• 本研究採取回溯性研究設計，希望了解安養中心院民家屬，當初在他們送功能障礙住進安養中心時，若提供社區式家庭支持方案，是否會延緩或不送院民至機構療養（即持續家庭照護），而減少機構式服務的使用。資料來源為台灣大學公共衛生研究所「1994年台北市安養中心調查」，於126家安養中心中訪視院民及家屬，選取回答家屬為院民過去的主要家庭照顧者為研究樣本，共得270人，包括院民的配偶、兒子、女兒、媳婦等。社區式家庭支持方案包含居家護理、社會服務、短期臨托、日間照護、金錢補助等五類。本研究並探索影響家屬意願的因素，以做為日後發展家庭支持方案的參考。 家庭照顧者表示若當初提供家庭支持方案的話，有28.5%的照顧者願意選擇居家照護替代機構照護；在其他的方案中，有27.0%願意選擇社會服務，24.8%顯選擇日間照護，21.1%願選擇短期臨托，23.3%願意選擇金錢補助，來替代機構照護的使用。媳婦相對於兒子願意選擇以居家照護替代機構照護的勝算比為2.9。其他願意採用家庭支持方案以替代機構照護的因素，包括家屬過去照顧時有照顧競爭、無次要照顧者、照顧時間安排負荷低、照顧財務負荷高、院民入院前無認知功能障礙者、曾使用社區照護者等。本研究結果顯示提供社區式家庭支持方案有替代部份機構照護的潛力。
  The purpose of this retrospective study investigated whether family caregivers of nursing home residents would delay, or perhaps give up, the decision of placing their care recipients in institutions if community-based family supporting programs were available, including Home Health Care, Social Service, Day Care, Respite Care and Financial Support. Study subjects were 270 former primary family caregivers of residents at 126 nursing homes, including these residents' spouses, sons, daughters, daughters-in-law, and other relatives who participated in ”The 1994 Taipei City Nursing Home Survey”. Factors relating to the transition choice recommendations were also explored to provide information for future policy decision. The results showed that if family supporting programs were available, approximately 28.5% former caregivers would choose Home Health Care instead of institutional care for their care recipients. The other preferences included 27.0% to Social Service, 24.8% to Day Care, 21.1% to Respite Care, and 23.3% to Financial Support. The daughters-in-law were 2.9 times more likely than sons to choose to provide Home Health Care. The caregivers with other care competition, lack of secondary caregivers, low time constraint, heavy financial burden, care recipient with no cognitive impairment prior to admission, and having experience in using community care, were also factors associated with the choice of family supporting programs. This implies that the community-based family supporting programs have the potential to replace the institutional care.
• 326 - 336
• 10.6288/CJPH1998-17-04-06

• Link 原著 Original Article
• 全民健康保險下疾病分類編碼品質與相關影響因素研究Study on the Quality and Its Related Factors of International Classification of Disease Coding System in National Health Insurance
• 賴憲堂、楊志良、范碧玉
  Hsien-Tang Lai, Chih-Liang Yaung, Bih-Yuh Fan
• 全民健康保險 ； 國際疾病分類 ； 疾病分類編碼品質
  National Health Insurance ; International classification of diseases ; Coding quality
• 我國已實施全民健保，目前正逐步實施論病例計酬支付制度，未來將進一步實施診斷關係群前瞻性支付制度(DRG/PPS)，故疾病分類編碼將成為醫院獲得有利醫療償付的重要媒介，在此一關鍵時刻急需評估全民健保實施後的疾病分類編碼品質及探討其影響因素，並提高其品質。本研究以八十四年九月份健保局之住院抽樣審查樣本為母全體，分層隨機抽取1,300件樣本進行疾病分類專家第二次編碼審查，並比較原始疾病分類編碼與專家第二次編碼間之一致性，以判斷原始疾病分類編碼正確與否，進一步並訪查該病例之原始疾病分類人員的各項基本特質，探討影響疾病分類編碼品質之相關因素。 研究結果發現63%的病例其疾病分類編碼至少有一個以上的錯誤。平均每個病例之疾病分類編碼錯誤率為35.56%，平均每個病例的編碼錯誤數為1.42個，而整體疾病分類編碼錯誤率為52%，其中主診斷之錯誤率為33%，主處置之錯誤率為39%。而影響疾病分類編碼品質的因素則發現醫院權屬別、評鑑級別、規模（床數）對疾病分類編碼品質均有統計上顯著影響。其中財團法人醫院優於公、和立醫院，但公、私立醫院間無顯著差異。醫學中心、區域醫院均優於地區醫院，而醫學中心與區域醫院間無顯著差異。此外疾病分類甄審資格、每月疾病分類工作負荷量、每日疾病分類工作時數對疾病分類編碼品質均有統計上顯著影響。
  Taiwan has implemented the National Health Insurance (NHI) program, and DRG based prospective payment system will be adopted. Under DRG/PPS, the coding of disease classification certainly relates directly to the payment rate. To transit from fee-for-service system to prospective payment system, it is imperative to evaluate the coding quality of disease classification, to understand its influencing factors, and to study how to improve the quality of coding. The study used a stratified sample of 1,300 inpatient cases from the NHI claim data in September, 1995. The discharge summary of these cases were reviewed and recoded by coding specialists to compare with the original coding. The characteristics of the original coders were also collected in order to explore the related factors affecting the quality of disease classification. The study found that there were 63%of the study cases with at least one coding error. The average rate and number of miscoding for each case was 35.56% and 1.42, respectively. The overall rate of coding errors of the whole sample was 52%. Among the errors, 33% occurred in the principal diagnosis, and 39% were due to coding errors in the principal procedure. Ownership, accreditation level and the scale(number of beds) of hospitals were found to be significantly important in determining coding quality. The coding quality of the proprietary hospital was better than that of those public and private hospitals. However, there was no significant difference in coding quality between public and private hospitals. Both medical centers and regional hospitals had better coding quality than district hospitals did, whereas no significant difference was found between medical centers and regional hospitals. In addition, coding qualification of coders, the work load of coders per month, and the time devoted to disease coding per day were also important determinants of coding quality.
• 337 - 348
• 10.6288/CJPH1998-17-04-07

• Link 實務 Public Health Practice
• 環境衛生評估燈號系統之建構：台北縣七縣轄市之個案探討A Signal System for Assessing Environmental Sanitation: Taipei County Case Study
• 王俊秀
  Juiu Chin-Shou Wang
• 登革熱 ； 環境燈號系統 ； 台北縣
  dengue ; environmental signal system ; Taipei county
• 台灣北部登革熱的發生凸顯出了環境及衛生兩系統間的因果關係，改善環境衛生乃為防治登革熱的治本之道，本論文主要針對台北縣七個縣轄市為對象，建構一套燈號系統，用來評估其環境衛生的情況，並定期分佈。結果發現：(1)環境衛生的品質很不穩定；(2)環境衛生工作並未內化至民眾的生活中；(3)本土性登革熱遇加成因素(amplifier)必定會再發生。除了建構及實施燈號系統外，並以本次個案之平均值來推估環境衛生的「客觀指標值」。
  The recurrence of dengue fever cases in Northern Taiwan has further amplified the linkage between environment and health events. Taking seven major cities in Taipei prefecture as a case study, this paper intends to set up a signal system for assessing environmental sanitation and carry it out in 1996. Major findings indicated that: (1) environmental quality is in rather an unstable status in the study area; (2) public sanitation has not yet become part of their daily life among residents; and (3) dengue fever, often accompanied with amplifiers such as flood, will appear again in these cities. In addition to the design and implement of the signal system, an average score method has been developed in this study to measure the sanitation in an area as an ”objective standard”.
• 349 - 359
• 10.6288/CJPH1998-17-04-08

• Link 實務 Public Health Practice
• 台灣地區藥物濫用社會成本推估初報Preliminary Estimation of the Social Cost on Drug Abuse in Taiwan, R.O.C.
• 余萬能、胡文琳、李志恆
  Wan-Nan Yu, Wen-Lin Hu, Jih-Heng Li
• 藥物濫用 ； 醫療成本 ； 在監成本 ； 人力資本法
  drug abuse ; cost of treatment ; cost of incarceration ; human capital approach
• 本研究旨在探討我國藥物濫用者每年所耗費之社會成本，以監獄（在監人犯）及醫療機構（求治病人）所支出之各項經費，分析其單位成本，併同計算生產力損失之人力資本法，作總體成本之推估。八十五年度監所收容麻煙犯，總經費約為20.6億元，每人日單位成本約為248元。醫療機構收治藥物濫用者總費用約為23.8億元，專門收治藥物濫用者之醫療機構平均每人日單位成本約為6,831元。八十五年度監所及醫療機構對收容（治）藥物濫用者所率備之經費約為44.4億元，因藥物濫用結果致人力資本耗損金額約為60.5億元，總計社會因藥物濫用耗損金額約為104.9億元。然而因為我國目前有關入監及就醫資料皆以安非他命及嗎啡海洛因之濫用為限，並未涵括其他易被濫用之藥物，且本研究尚未針對其他藥物濫用相關之疾病相對危險性及犯罪關聯性等成本予以估計，故推估之社會成本可能較實際成本為低，值得再詳加探討。
  In this study, we applied the prevalence and human capital approaches to estimate the total social cost of drug abuse in Taiwan in 1996 through the analysis of the cost of medical treatments, incarceration and the productivity loss caused by drug abuse. The preliminary results are as follows: (1)The total cost of incarceration was ca.2.06 billion NT dollars, and the average daily cost per person was Ca. 248 NT dollars. (2)The total cost of drug- related medical treatments was ca. 2.38 billion NT dollars, and the average daily cost per person was 6,831 NT dollars. (3)The productivity loss due to drug abuse was Ca. 6.05billion NT dollars. (4)The total aforementioned social cost was Ca. 10.49 billion NT dollars. However, the total cost is likely to be underestimated because our data were mainly based on the abuse of methamphetamine, morphine and heroin. Other addiction-induced diseases, productivity loss and law offences were not included in this study yet. We anticipate a more detailed estimation of social cost on drug abuse to be obtained through a rational adjustment of research design in the second-year study.
• 360 - 369
• 10.6288/CJPH1998-17-04-09