15卷2期

• Link 原著 Original Article
• 各類市售飲料的酸鹼度、酸度及重金屬含量研究Study on the pH Value, Acidity, and Heavy Metal Concentration of Soft Drink
• 陳美蓮、毛義方、藍忠孚
  Mei-Lien Chen, I-Fang Mao, Chung-Fu Lan
• 市售飲料 ； 酸鹼度 ； 酸度 ； 重金屬含量
  soft drink ; pH value ; acidity ; heavy metal
• 本研究是探討市售常見飲料之酸鹼度、重金屬含量、濁度及酸度，並與水果榨汁比較，藉以了解其特性及可能對飲用者的健康影響。 以台北市市售知名碳酸及非碳酸飲料共22種為對象，包括可樂、沙士、運動飲料、果汁汽水及汽水等類。結果顯示非碳酸性飲料之pH值為3.2~4.0，碳酸類飲料為2.2~3.4，部份飲料之pH值低淤家庭用之工研醋。天然水果榨汁之pH值介於2.8~4.3之間，酸度介於950~9100mg CaCO3/1之間。清淡果汁飲料之酸度與天然水果之酸度（檸檬除外），並未發現明顯之差異，而pH值則以清淡果汁飲料較低。非果汁飲料除運動飲料之濁度為40~50濁度單位(NTU)，表示飲料中加有一些不溶性物質外，其他之非果汁飲料約在0.5NTU以下；另外，鋁罐裝飲料中之Ca、Mg、Zn、Pb之含量分別為21.1±11.2m/l，5.38±4.19m/l，0.07±0.04mg/1，ND~0.2mg/l；As均未檢出；Na則為12~520mg/l。 本研究結果，市售碳酸飲料pH值偏低，其主要來自添加之磷酸等，如大量飲用可能不利人體血液之酸鹼平街，且可能使體內鈣磷比失衡。而運動飲料含較高量之Na，高血壓患者不宜常常大量飲用。
  To realize the characteristics and potential health effect of soft drink, the pH value, acidity, heavy metal, and turbidity containing were measured. The pH and acidity of natural juice were also determined to compared with those of mixed fruit juice drink. Twenty-two kinds of carbonated and non- carbonated drinks were sampled in this study. Results show that the pH ranges from 2.3 to 3.4 and from 3.2 to 3.7 for carbonated and non-carbonated drinks, respectively, and some have pH value lower than that of vinegar. The turbidity of most soft drinks are below 0.5 NTU except 2 kinds of drink with turbidity between 40-50 NTU. The concentrations of calcium, magnesium, zinc, and lead in aluminum-canned drinks are 21.1±11.2 mg/l, 5.38±4.19 mg/l, 0.07±0.04 mg/l, and below 0.2 mg/l, respectively. Arsenic is not detectable in all samples. The sodium concentration ranges from 12 to 520 mg/l and the variation depends on different kinds of drink. The pH values of natural juice ranges from 2.8 to 4.3 and acidity from 950 to 9100 mg CaCO3/1. Compared with mixed fruit juice drink, although the acidity is not significant difference, the pH value of mixed fruit juice drink is lower than that of natural juice. Adverse health effect caused by the low pH and calcium/phosphate imbalance due to the supplement of phosphate in soft drinks need to be concerned while plenty of soft drink is intake daily. Since sport drinks contain high amount of sodium ion, frequent uptake this kind of drink especially in large volume by the hypertension patients is not recommended.
• 109 - 115
• 10.6288/CJPH1996-15-02-01

• Link 原著 Original Article
• 舊船解體業勞工世代之罹病住院率分析Morbidity Analysis of Ship Breaking Workers-A Cohort Study
• 楊冠洋、吳聰能、林浩稜、 陳以新、柯桂女、劉紹興、 賴俊雄
  G.Y. Yang, T.N. Wu, Y.S. Chen, H.L. Lin, K.N. Ko, S.H. Liou, J.S. Lai
• 舊船解體業 ； 標準化罹病住院率 ； 勞工健康保險 ； 焊工 ； 肺部疾病
  ship breaking ; morbidity ; Labor Insurance ; flame cutter ; pulmonary disease
• 舊船解體作業的主要過程可分成清艙、以乙炔氧氣燄切割船板、與分離船體等作業。勞工長期暴露於切割鋼板所產生的燻煙微粒中，可能會發生呼吸器官的慢性疾病。為瞭解過去拆船業工作環境對勞工健康的影響，本研究以民國七十四年高雄市舊船解體職業工會的4,189名男性會員年籍資料為基礎，建立舊船解體業勞工的族群世代。其中以從事船艙鋼板切割工作的瓦斯工人數最多（2,834人），吊工（875人）、與雜工（248人）等次之。經由比對民國七十四年起的國人死亡登記與勞工保險住院給付中請資料，本研究追蹤世代的罹病住院情形至民國八十年底止。與民國七十七年全國勞工罹病住院率相比較，舊船解體業勞工全世代於同年的上呼吸道（罹病住院率比：2.50）、呼吸系統（罹病住院率比：1.89）等項疾病之直接年齡標準化罹病住院率顯著地偏高；瓦斯工在上呼吸道疾病（罹病住院率比：2.02）的罹病住院率也顯著地偏高。在次世代間之比較則要現：瓦斯工在急性支氣管炎之間接年齡標準化發病住院率顯著的高鈴非瓦斯工（吊、雜工等）次世代。本研究的結果雖與文獻上所報告的發現類似，但是因為受資料本身的限制，所以仍需要進一步的研究加以驗證。本研究的經驗顯示：以職業工會會員資料合併健康登錄資料進行世代健康危害追蹤的方式，所需人力、經費與時間較少，應是可行且經濟之前驅研究的糢式。
  Using ethylene-oxygen torch to cut shipboard was the major operation in the ship breaking industry in Taiwan. Metal fume exposure, which might result in pulmonary disorders, was one of the major hazardous occupational exposures for the workers. To study the adverse health effects of metal fume exposure, this historical cohort study enrolled 4, 189 ship breaking labors who were active members of Kaoshung Ship Breaking Workers Union in 1985. Health status (causes and dates of hospitalizations) of the cohort workers were followed up till December, 1991, by linkage of the personal identifier of worker to the death registry and the database of hospitalization claims to the Labor Insurance. In comparison to the disease prevalence (by selecting the first hospitalization in the particular year) of all labors covered by the Labor Insurance in 1988, the whole ship-breaking cohort had more hospitalizations for upper respiratory diseases (prevalence ratio: 2.5), and also in pulmonary diseases (prevalence ratio: 1.89). Subcohort analysis, using ”non-exposed” workers (875 lifters and 248 manual workers) as a control, showed that the flame cutter (n=2,834) had more attacks (by selecting the first hospitalization in the whole follow up period) of acute bronchitis, with an indirect age-adjusted disease specific hospitalization ratio at 5.06. The finding of an elevated risk of flame cutters in pulmonary diseases was compatible with other published studies. And, the experience of this study also demonstrates the feasibility of conducting a pilot cohort study through database linkage, which is probable easy and cost-effective in Taiwan.
• 116 - 123
• 10.6288/CJPH1996-15-02-02

• Link 原著 Original Article
• 台灣麥寮地區大氣中懸浮微粒化學組成之探討Chemical Compositions of Ambient Aerosols in the Meliao Area
• 魏致中、陳宛青、王秋森
  Chih-Chung Wei, Wan-Ching Chen, Chiu-Sen Wang
• 懸浮微粒 ； 化學組成 ； X射線螢光分析儀
  ambient aerosols ; chemical compositions ; XRF analysis
• 無
  The primary objective of this study was to measure the mass concentration and chemical compositions of ambient aerosols in the Meliao area, where the construction of a petrochemical complex was underway. The results could be used as the background data for evaluating the nature and health effects of particulate air pollutants from the petrochemical complex in the future. Samples of ambient aerosols at Meliao, Taihsi, and Dacheng were obtained by cascade impactors and dichotomous samplers from November 1992 to January 1994. Samples were analyzed for 20 elements by an X-ray fluorescence (XRF) spectrometer. In addition, concentrations of elemental carbon (EC) and organic carbon (OC) in the samples were determined by an elemental analyzer. The mass concentration of ambient aerosols in the Meliao area was found to be mainly in the range of 10-50µg/m^3 in the fine fraction (aerodynamic diameter < 2.5 µm) and mainly in the range of 15-45µg/m^3 in the coarse fraction (2.5
• 124 - 133
• 10.6288/CJPH1996-15-02-03

• Link 原著 Original Article
• 1981及1991兩年高雄市區頭部外傷發生率原因及嚴重度之比較Comparison of the Incidence, Causes, and Severity of Head Injuries between 1981 and 1991 in Kaohsiung City, Taiwan
• 洪純隆、 陳建立
  Shen-Long Howng, Chien-Li Chen
• 無
  head injuries ; incidence rate
• 意外事故及不良影響為台灣地區十大死因第三位，其中有一半係因頭部外傷所致。本研究以1981年及1991年高雄市地區頭部外傷調查資料為基礎，比較十年間，此地區頭部外傷的發生率及其危險因子等變化情形。1981年高雄市有2305位被確認為頭部外傷病例，每十萬人口發生率為187人，男女性各為255人與115人。1991年高雄市有3729位被確認為頭部外傷病例，每十萬人口發生率為267人，男女性各為358人與171人。十年來頭部外傷要生率成長了1.43倍。1981年頭部外傷發生率以20-29歲的264/100,000為最高；1991年則以七十歲以上年齡層的482/100,000為最高，已有顯著的改變。不論性別、年齡別皆明顯的惡化，其中女性較男性成長的快，尤其以七十歲以上人口群，最為嚴重。頭部外傷發生的原因，兩個年度皆以車禍引起為主，佔七成以上，且車禍中有七成為機車肇事所致；第二受傷原因為跌落。1991年發生的原因中，遭外力攻擊所引起的頭部外傷有增加的趨勢。頭部外傷發生的時間，有一致的時間分布趨勢，夜間高於白天，以入夜後的下午6-8點之間為最高峰。頭部外傷嚴重度以Glasgow昏迷度表分類，將頭部外傷分為輕微、中度、嚴重三類，隨著醫療環境與技術的進步，在嚴重及中度頭部外傷的發生率雖未增加，但輕微頭部外傷的發生率卻成長了1.59倍。十年來高雄市區頭部外傷發生情形，確已產生變化且較嚴重，兩個年度的比較，可看出頭部外傷發生的情形，及其高危險群、發生原因、發生時間等演變狀況，可提供防治計劃之參考。
  Accidents and adverse effects are currently ranked as the number three leading causes of death in Taiwan, and half of the cases are the result of head injuries. This study was designed to compare the incidence rates and demographic characteristics of head injuries over a ten-year period. Data were collected from the survey of head injuries in 1981 and 1991 of Kaohsiung City, which was conducted by Kaohsiung Medical College. A total of 2,305 cases of head injuries were collected in 1981. The average incidence rate was 187/100,000 (255/100,000 for males and 115/100,000 for females). In 1991, a total of 3,729 cases were collected. The average incidence rate for head injuries increased to 267/100,000 (358/100,000 for males and 171/100,000 for females). The average incidence rate of head injuries was increased by 1.43 times over the past ten years. Moreover, there were demographic changes in head injuries during this period. The age group with the highest incidence rate of head injuries was 20-29 in 1981 (264/100,000), as compare with the age group with the highest incidence rate was 70 and over in 1991 (482/100,000). The sex-specific and age-specific distributions of head injuries have been changed with the incidence rate growing faster for females than males, specially for the 70 and over age group. With respect to the causes of head injuries, seventy percent were motor vehicle- related causes, followed by falls in 1981 and 1991. The difference was the number of head injuries caused by assault was increasing in 1991. Also, the cases of head injuries were occurred more often at night than during the day with a peak of 6-8 P.M for the both years. The Glasgow Coma Scale (mild, moderate, severe) was used to assess the severity of head injuries. Over the 10 year period, the incidence rates of severe and moderate cases did not increase. It was possibly due to the improvement in medical technology. However, the incidence rates of mild cases were increased by 1.59 times over the past 10 years. In sum, the incidence rates of head injuries was increased and the determinants of head injuries were changed over the ten years in Kaohsiung city. The finding may be useful for prevention programs.
• 134 - 144
• 10.6288/CJPH1996-15-02-04

• Link 原著 Original Article
• 子宮外孕危險因子之病例對照研究Risk Factors for Ectopic Pregnancy: A Hospital-Based Case-Control Study
• 葉季森、林平衡
  Chi-Sen Yeh, Ping-Heng Lin
• 子宮外孕 ； 病例對照研究 ； 危險因子
  ectopic pregnancy ; case-control study ; risk factors
• 本研究的目的在於瞭解國內婦女子宮外孕的發生比例及其危險因子。選擇85名子宮外孕的婦女為病例組，並以1:2的比例取年齡相距三歲以內並完成一次生產的婦女為對照組，進行以醫院為基底之病例對照研究。以病歷摘錄法為主要資料收集法。結果發現，子宮外孕的平均發生比例是1:44。以年齡20-29歲，30-39歲，40-4歲分層，其發生比例分別是1:67，1:23，1:6。以單變項統計，有顯著差異的危險因子，包括：婚姻狀態、教育程度、孕次、產次、流產次、子宮內避孕器、口服避孕藥、輸卵管結紮、骨盆腔發炎、骨盆腔手術、抽煙。以多變項對數複回歸分析得到的重要危險因子則是有與骨盆腔發炎和有與裝五子宮內避孕器，其多變項調整對比值分別是28.84和5.10。
  To evaluate the association between ectopic pregnancy and potential risk factors, we conducted a hospital-based case-control study. The investigation including 85 cases was diagnosised from January to December, 1992, by laparotomy, and 95 matched controlls selected from live-birth deliveries. Risk factors information was obtained via the abstract of medical records. The ratio of ectopic pregnancy to deliveries was 1 to 44. The ratios by age of 20-29, 30-39, 40-44, are 1 to 67, 1 to 23, and 1 to 6 respectively. Univariate matched analyses reveal 11 variables associated with a significantly elevated relative risk of ecropic pregnancy. According to following multiple logistic regression, there are two variables remained as stronged independent risk factors for ectopic pregnancy, which are a history of pelvic inflammatory disease (relative risk 28.84) and intrauterine device use(relative risk 5.10).
• 145 - 152
• 10.6288/CJPH1996-15-02-05

• Link 原著 Original Article
• 門診精神病患主要照顧者的需求與社會支持之研究The Primary Caregivers' Needs and Social Support of the Psychiatric Outpatients
• 陳秋瑩、許世寬、陳朝灶、 賴俊雄
  Chiu-Yin Chen, Shih-Kuan Hsu, Jim-Shoung Lai, Chao-Tsao Chen
• 無
  caregivers ; social support ; psychiatric patients
• 本研究立意選取草屯療養院門診病患家屬，以當面訪談的方式，至病患家中對主要照顧者進行面訪，共完成有效樣本296位。 研究結果顯示：主要照顧者多為女性，為患者的母親，年齡以50歲以上者居多。病患多為男性，年齡集中在20-39歲，多為患有精神分裂症者。主要照顧有59.8%認為經濟上需要醫療費用的補助；心理及生理的狀況尚可；而社會生活上，有52.4%的主要照顧者認為受到影響。主要照顧者遇到的困難以照顧上的經濟困難、對病人的發病及預後情形不瞭解、與病人的溝通及協助病人恢復工作能力等五個困難最多。社會支持網絡的分佈，情緒性支持提供者多為配偶及朋友等非正式組織成員，而工具性支持主要是來自精神科醫生及護士。情緒性支持量的大小會受到照顧者的性別、照顧者和患者的關係及居家護理有與等三個因素影響。工具性支持量僅受到居家護理有與的影響，本研究証實居家護理方案的實施對病患照顧者的幫助。但對於社會支持對照顧者的需求之探討中，發現不論是情緒性支持或工具性支持，其對照顧者的經濟、生理、心理及社會生活等四項需求皆與減輕的效果。即支持量不足以減輕照顧者照顧的經濟困難、生理及心理的不良狀況和社會生活受影響的程度。
  296 primary caregivers of psychiatric patients were investigated on their needs and social support. Results show that 59.8% of them think they need more money to care patients. Their psychological and physical status are not bad, but 52.4% of them think their social lives are affected. Over 50% of them encounter some difficulties in their caring, which are financial problems of caring, not understanding the prognosis of patient's disease, having fear for the recurrence of patient's disease, having trouble in communicating with patients and in helping patients be able to work. Social support systems are divided into two dimensions in this study-emotional and instrumental support. Most of emotional support networks are from caregivers' spouse, friends, children and relatives. But, instrumental support networks are mainly from psychiatric doctors and nurses. The amount of social support can not significantly influence caregivers' needs. Sex, relationship between primary caregiver and patient, and having home care program or not can influence the amount of emotional support. But, just having home care program or not can influence the amount of instrumental support.
• 153 - 161
• 10.6288/CJPH1996-15-02-06

• Link 原著 Original Article
• 某些省市立醫院組織氣候、工作滿意度及士氣之研究Organization Climate, Job Satisfaction and Morale in Some Provincial and Metropolitan Hospitals
• 楊樹昌、蘇喜
  Shu-Chang Yang, Syi Su
• 醫院 ； 工作滿意度 ； 組織氣候 ； 士氣
  Hospital ; Organization Climate ; Job Satisfaction ; Morale
• 以許士軍修訂自Litwin & Stringer發展之組織氣候問春，Smith等人發展之「工作描述指數」工作滿意度問卷，及修訂自許士軍之士氣問卷對兩家分別為區域醫院及醫學中心級之台灣省立醫院，及區域醫院級之台北市立醫院做組織氣候、工作滿意度及士氣調查研究。醫院員工普遍表現出超過“同意指標”之組織氣候，人情、結構構面是得分較高者，獎酬、衝突構面是得分較低者。醫院員工之滿意度及士氣尚超過“滿意指標“，醫院員工普遍對於同仁及對主管之滿意度高，對升遷及對薪水之滿意度低。 三家醫院分別觀之，對滿意度各構面及對士氣之組織氣候影響構面各有不同。一致的地方是對升遷滿意度以獎酬構面為主要影響因素；對士氣及對同仁滿意度以認同構面為主要影響因素。兩家省立醫院對主管滿意度及整體滿意度之主要影響因素是結構構面，兩家區域醫院對工作本身滿意度之主要影響因素是認同構面。 工作滿意度諸構面中以工作本身這一構面最能影響士氣。影響醫院員工之滿意度及士氣，組織氣候是比個人特徵、工作性質更重要的因素。整體觀之，認同、結構，獎酬諸構面，關連著對主管滿意度及士氣。培養一個富於認同感，結構分明，獎酬適當的組織氣候，可能提昇醫院員工工作滿意度及士氣。
  With 3 kinds of Questionnaires: 1. Questionnaires for Organization Climate, developed by Litwin and Stringer, and modified by Hsu. 2. Questionnaires of Job Description Index (JDI), developed by Smith et al, 3. modified Morale Questionnaires, developed by Hsu; We had a cross-sectional survey of Organization Climate. Job Satisfaction and Morale to one regional hospital and one medical center in Taiwan Province, and one regional hospital in Taipei Metropolitan. The hospital employees showed somewhat ”more than common index” Organization Climate. With higher scores in dimension of ”structure” and ”warmth”, and lower scores in dimension of ”reward” and ”conflict”. Generally speaking, the employees had higher satisfaction to both ”partners” and ”heads”, and lower satisfaction to both ”promotion” and ”salary”. The Organization Climate is more influential than demographical characteristics to both Job Satisfaction and Morale. Generally, ”identity” ”structure” and ”reward” dimensions are related to both ”heads”-satisfaction and Morale. It is the ”job itself”-satisfaction most influential to Morale. There are some differences among three hospitals with regard to influential factor to each dimension of Job Satisfaction & Morale. There are the same that the major influential factor to satisfaction of promotion dimension is ”reward”, and that the major influential factor to Morale and satisfaction dimension of ”head” is ”identity”. The major influential factor to both ”head” satisfaction and ”whole” satisfaction is ”structure” in both provincial hospitals, the major influential factor to ”Job itself”-satisfaction is ”identity”. We would cultivate an Organization Climate full of identity sensation, clear structure and adequate reward, in order to increase the Job Satisfaction and Morale in hospital.
• 162 - 169
• 10.6288/CJPH1996-15-02-07

• Link 實務 Public Health Practice
• 全民健保同病同酬之規定與診斷組合(DRGs)相關內容之探討A Review on the Case Payment Design of the National Health Insurance Program in Taiwan, ROC
• 韓揆、趙忠文
  Kuei Han, Chung-Wen Chao
• 醫療費用支付制度 ； 健康保險 ； 醫院管理 ； 診斷組合DRGs
  health care insurance ; health care payment ; hospital administration ; DRGs
• 同病同酬是社會大眾為實現醫療價付公義而持有的一種觀念，但正如人類生而平等這一思想，在確定其含義上，不免又出現一些類詞，如齊頭式的平等、立足點的平等一樣，需要向學者或專業人員進一步發掘其內容，詮釋其真意，才能落實執行，不致以詞害義，反而妨害公義之實現。 民國八十四年實施之全民健保將同病同酬概念納入法律條文中，但未詳訂其內容及如何作到同酬。本文根據全民健保法及健保局有關規定，推定有關當局主張之同病同酬意義為“對ICD-9-CM前三碼相同之疾病，除藥品及藥事服務費外，支付同等金額之診療報酬制度”。 如所周知，全民健保法之立法及其實施不僅充滿變化，有些規定更未盡周全，同病同酬即其一端。本文參照美國DRGs/PPS制有關診療報酬支付之規定，檢視全民健保法實施之內容，認為後者最大問題在於只秉持了一個模糊的概念，未對不同的醫療狀況擬訂不同的報酬對策，簡言之，就是過於粗略，是引起混亂之根源。為健全制度之實施，不但要更精確的界定什麼是同病，而且要區別其是否同工，唯有同病又同工才同酬之支付制度，才能落實施行並實現公義。
  The Taiwan National Health Insurance Program which enacted last year and enforced this March, 1995 carried out an article of ”one price for one category of diseases” or ”case payment” plan. According to the National Health Insurance Bureau's supplementary document, the ”case” means diseases having the same first three digits of ICD-9-CM code. This is not appropriate because factors of clinical practice and the patient's condition cannot be excluded if the regulation is to apply. Moreover, the whole structure of the so called ”case payment” in the program, does not like DRGs/ PPS in the Medicare, bears few supporting measures to assist its implementation. The main problem of the plan is its over primitive. Only cognation both in disease and patient category and in effort produced by health care providers can make a justifiable and workable payment device.
• 170 - 174
• 10.6288/CJPH1996-15-02-08