15卷4期

• Link 原著 Original Article
• 老人長期病患照顧者對取代方案之考量：潛在需求與困境之分析Alternative Care Choices Regarding the Chronically Ill Elderly: Implicit Needs and Barriers
• 胡幼慧、郭淑珍、王孝仙
  Yow-Huey Hu, Shu-Chen Kuo, Shaw-Shain Wang
• 居家照護需求 ； 長期照護 ； 取代方案
  home care need ; long-term care ; alternative care
• 慢性重症老人的照顧，除了治療部份外，特殊生活照顧及面臨疼痛、死亡、生存意義的心理照顧，更是老人醫療照顧體系的主要挑戰。台灣目前患慢性重症或行動極不便的老人，絕大部份仍留在社區向家人照護。不少研究已指出，居家照護由於普遍缺乏專業介入、缺乏設施及人手不濟，這些問題不但影響醫療品質，亦對老人及對家人產生了很大的社會心理負荷。如果再加上老人與照顧者（特別是媳婦或怨偶）已經存在長年人際衝突，則問題更為複雜。然而取代方案的缺乏和文化上的「標籤」一如居家安養代表子媳孝順的意義，送安養院代表了被家人遺棄的意義，同樣影響了抉譯及需求內涵。本研究從對安養院及看護工的潛在需求出今，探討結構因素（如財力困境、服務市場素質問題）與建構過程（文化象徵解釋及行動抉擇的說辭）所扮演的角色。根據262位出院慢性重症病家的半結構訪談結果之分析，我們要現將近八成病患採「居家家人照護」，僅8.4%雇看護工，13.7%送安養院。但如繼續探問病家，有五成考慮過採用取代方案，但都因「經濟上「品質」因素而打退堂鼓。「文化」反對因素並非唯一考量，且在「雇看護工」考量中，極少成為隙礙因素。此外，考量安養院者往往面臨病人意顯上困境，而採用「送安養院者」雖曾考慮用雇護工方式來取代，但雇護工花費更高，負擔不起而作罷，至於病患的失能程度雖對「取代方案」的考量程度上有所影響，但解釋力相當有限。因此，安養院與看護工之經濟與服務市場結構之困境與文化角色之障礙應將是未來長期照護體系發展政策考量重點。
  This study applies a structural constructivist approach to clarify the ways in which the care needs for the chronically ill elderly are made meaningful and socially organized. Today, the quality and the coverage of the elderly's long term care are in questions. The families dealing with the needs, are facing these daily difficulties which may create significant stresses and may require extensive emotional, physical, and social supports for the elderly and their caregivers. These difficulties are intensified in complicated real-world relations within the families, especially in longstanding and troubled relationships such as tensions between in-law. Since home care embodies the social meaning of filial piety (hsiao) as well as the symbol of success of the family, these cultural constraints may be reinforced by practical difficulties in obtaining affordable and quality alternative cares. In this study, we have examined these constraints and their effects on caregivers' psychosocial burdens. Based on the semi-structured interview, two hundred and sixly-two patients traced from one regional hospital released files were identified, and their caregivers were interviewed. The results indicated that only 22% of the elderly have used alternative forms of care. And more than fifty percent of those using primarily family care have actually looked into alternatives but have been discouraged due to financial problems and service quality. uurthermore, we have found that when family care was the sole care resource and when lacking of on-hand care supports from formal and informal networks, the caregivers (mainly women) will experience various forms psychosocial burdens. We also found that patient's physical conditon may have slightly effect on caregiver's sense of burden. The main effect is from the problems that are related to the service market. The policy considertion for such structural constraints were also discussed.
• 275 - 288
• 10.6288/CJPH1996-15-04-01

• Link 原著 Original Article
• 大台北地區主要照顧者之工作負荷量及對居家照顧服務之需求程度的調查Family Caregivers' Burdens and Perceived Need for Home Care Services in the Taipei Metropolitan Area
• 屈蓮、白璐、鄧光銳、王修平
  Lian Chiu, Lu Pai, Kwong-Yui Tang, Shiou-Ping Wang
• 居家照顧 ； 主要照顧者 ； 需求
  home care ; perceived need ; family caregiver
• 本研究目的在藉著了解主要照顧病人的家屬，對居家照護服務項目的需要程度及照顧病人的工作負荷量，以此評估何種居家照顧服務模式較能滿足民眾的需求。工作負荷量乃指主要照顧者需花多少時間來照顧病人；在照顧病人時所面對的問題；和週間和週末是否有其它家庭成員協助照顧病人等。對服務項目的需要程度是以Likert five-point Method測量主要照顧者對57項服務項目之每一項的需要程度；由”5”（非常需要）到，”1”（完全不需要）共分為五個層級。 本研究對象為台北市及台北縣使用居家照顧服務之病人的主要照顧者，而主要照顧者是指直接地花最多時間照顧病人；並和居家照顧服務接觸最頻繁的家屬。本研究共取得152位名冊，扣除拒訪和主要照顧者為僱工等，實得110筆資料。 研究結果顯示，超過96%的主要照顧者每一星期7天和每天至少12小時在照顧病人。大約80%與70.9%的受訪者表示由於照顧病人所以社交活動受到限制；和即使身體不舒服，仍須要勉強地照顧病人。百分之五十的主要照顧者指出除了照顧病人外，他們仍需負擔其它的家事。而且多於50%的主要照顧者無論在週間或週末，均無法獲得其它家屬的協助。 多於三分之二的主要照顧者表示需要獲得由社會工作人員、醫療儀器維修人員、復健人員、醫師、護理人員和由居家照顧機構所訓練並能替主要照顧者暫時照顧病人之工作人員的服務。大約四分之三的受訪者指出病人住院時，是教導主要照顧者回家後照顧病人所需之技術與知識的好時間。 研究結果指出，主要照顧者肩負沉重的照顧工作；並且他們希望獲得一些居家照顧服務，使他們在家照顧病人的工作能夠持續。本研究建議：社會福利政策與健康保險的共同配合，居家照顧系統應與其它健康服務系統相互聯結，以增加服務項目，建立滿足身、心、社會需求的居家照顧服務模式。
  This study was designed to evaluate the family caregivers' burdens and identify their perceived needs for home care services. The family caregiver was defined as the patient's family who spends most time to take care of the patient at home and frequently contacts with home care personnel. In total, 152 enrollment files of patients and care givers in the Taipei Metropolitan Area were obtained. Virtually, 110 family caregivers were interviewed at home. Family caregivers' burdens referred to the amount of time family caregivers spent in caregiving, problems related to the confinement from caregiving experienced by the family care giver, and how much support form family members during weekdays and on the weekend. Using a five-point Likert scale, family caregivers checked their degree of need for each of 57 items of home care services. Their responses ranged from ”strongly desired” to ”not at all desired”. More than 96.0% of the family care givers spent 7 days a week and at least 12 hours a day to take care of patients. About eighty per cent and 70.9% of the respondents suffered from limitations on social activities, and need to take care of the patients when they themselves are not well respectively. Fifty percent of family care givers needed to take on other housework and more than half of those interviewee had no assistance from family members during weekdays and over weekend. Services from social workers, technicians for maintaining medical equipment, rehabilitation personnel, physicians, home care nurses and someone, who was trained by the home care agency to temporarily take care of patients for family caregivers, were needed by more than two-third of the interviewee. About three-quarters of respondents stated that a good time for teaching them the needed skills is when patients are hospitalized. Fifty-one per cent of the interviewed stated that patients ought to get the needed preventive services. These findings indicated that the burden on family care givers were heavy; and they desired to receive some services to help them to continuously take care of patients in homes. According to results from this study, the combination of health insurance with social welfare to cover home care services; and better connection between home care system and other health care systems were recommended.
• 289 - 302
• 10.6288/CJPH1996-15-04-02

• Link 原著 Original Article
• 中壢市嬰幼兒使用中醫門診相關因素之研究A Study on Factors Related to Children's Use of Chinese Medicine Clinics in Chung-Li City
• 吳明玲、季瑋珠
  Ming-Ling Wu, Wei-Chu Chie
• 中醫門診；Andersen的健康行為模式；傾向因素；能力因素；需要因素
  chinese medicine ; Andersen's health behavior model ; predisposing enabling and need factors
• 本研究的目的在於探討嬰幼兒使用中醫門診的相關因素，採用Andersen的健康行為模式(Health behavior model)為研究架構，以系統抽樣法選取中壢市12-18個月的516位幼兒為研究對象，於民國81年9月至11月間，對其主要照顧者進行問卷訪視，共得有效樣本420位，完成率為81.4%。結果顯示：(1)1至1歲半之幼兒，生病時曾接受之不同醫療照顧方式如下：西醫門診、中醫門診、西藥房、中藥房，各為99.0%、39.0%、11.4%及5.2%。(2)接受中醫門診醫療的164位幼兒中，71.3%利用過1-3次，24.3%利用過4-10次，4.3%利用次數超過10次。(3)生病時曾接受中藥醫療照顧之幼兒，其第一次接受中藥月齡為未滿1個月至18個月，中位數7個月，其原因主要為呼吸道疾病(74.7%)及腸胃道疾病(16.3%)。(4)對數複迴歸分析顯示影響嬰幼兒是否使用中醫門診的因素主要有「幼兒籍貫、照顧者就醫習慣、對中式醫療滿意度、中西醫療行為取向、照顧者評定之幼兒健康狀況」等五項。綜合官之，具以下幾種特質之幼兒較傾向於使用中醫：本省籍幼兒，勝算比1.62（95%信賴區間1.07-2.44）；照顧者本身有使用中醫習慣者，勝算比1.69（95%信賴區間1.28-2.23）：對中式醫療綜合意度為普通及很好者，勝算比分別為1.48（95%信賴區間1.06-2.05）、2.39（95%信賴區間1.73-3.29）；中西醫療行為取向為中立或傾向中醫者，勝算比分別為1.90（95%信賴區間1.12-3.23）、3.16（95%信賴區間1.90-5.24）；照顧者評定之幼兒健康狀況為普通及不好者，勝算比分別為1.32（95、信賴區間1.00-1.75）、2.27（95%信賴區間1.27-4.06）。根據本研究的結果，吾人建議政府及國人共同重視嬰幼兒醫療保健照顧，培養正確育兒知識，並對醫療體系作一整體規畫，促進中西醫療之整合，以使不同型態的醫療服務，發揮最大的功效。
  The aims of the study were to investigate factors related to children's use of Chinese Medicine clinics. Using the Andersen's Health Behavior Model, a questionnaire-interview was taken in Chung-Li city from September to November in 1992. A systematic sample of 516 children aged 12-18 month was selected, 420 cases accomplished the study (the response rate was 81.4%). The subjects of this interview were chief care-taker of children. The major results were as follows: (1) The proportion of children who received each type of medical care when they were sick were Western Medicine clinics 99.0%, Chinese Medicine clinics 39.0%, Western Medicine dealers 11.4%, Chinese Medicine dealers 5.2%, respecitively. (2) In the 164 children who have visited Chinese Medicine clinics, the percentage of 1-3, 4-10, over 10 visits were 71.3%, 24.3% and 4.3%, respectively. (3) The age of children who received Chinese-style medical care for their illness in the first time was less than I month to 18 month, median 7 month. The major causes were respiratory tract disease (74.7%) and gastrointestinal disease (16.3%). (4) Logistic regression showed that children with characteristics listed below tend to use Chinese-Medicine clinics: nativity of Taiwan, odds ratio (O.R.)=1.62, 95% confidence interval (C.L)=1.07-2.44; the habit to use Chinese-style Medicine of chief care-taker, O.R.=1.69, 95% C.I.=1.28-2.23; moderate or high satisfication to Chinese-Medicine services, O.R.=l.48 (95% C.I.=1.06-2.05) or O.R.=2.39 (95% C.I.=1.73-3.29); moderate and high degree of behavior predisposition to Chinese-style Medicine, O.R.=1.90 (95% C.I.=1.12-3.23); or O.R.=3.16 (95% C.I.=1.90-5.24); fair and poor perceived health status by chief care-taker, O.R.=1.32 (95% C.I.=1.00-1.75) or O.R.=2.27(95% C.I.=1.27-4.06) respectively. Finally, the policy and research implications were discussed in this article.
• 303 - 318
• 10.6288/CJPH1996-15-04-03

• Link 原著 Original Article
• 高血壓患者服藥遵從行為及其相關因素之探討An Exploration of the Drug Compliant Behaviors and Associated Factors of Hypertensive Patients
• 胡文郁、 曾春典、戴玉慈、余玉眉
  Wen-Yu Hu, Chuen-Dean Tseng, Yu-Tzi Dai, Yu-Mei (Yu) Chao
• 高血壓 ； 服藥遵從行 ； 健康信念 ； 外控人格特質 ； 高血壓知識
  hypertension ; drug compliant behavior ; health belief ; locus of control ; hypertensive knowledge
• 本研究目的為探討國人罹患高血壓之服藥遵從行為、遵從率及其相關因素。採二階段分層不等比率系統隨機抽樣，自台灣地區17個醫療區域中，抽取桃園及台中醫療網之醫院、衛生所建檔之600位原發性高血壓患者，進行居家訪視會談及自陳式結構性問卷調查，所得資料以SAS為主進行統計分析，研究結果如下： 高血壓患者最常發生的不遵從服藥行為是更改服藥時間、停止或斷續服藥及減少服藥次數。服藥連從行為量表平約得分小於等於3.78分，即每星期有2天以上未服藥者，其收縮壓或舒張壓值會高於正常範圍（W.H.O.定義），據此標準，求得國人罹息高血壓之服藥不遵從率為22.03%，遵從率為42.6%。 因徑分析結果發現，權威型外控人格特質、抗高血壓藥物的認知、所有藥物種類（三、四種或五種以上）及服用抗高血壓藥物顆數（三、四顆），均對病人的服藥遵從行為有正向且直接之影響；抗高血壓藥物壞處的感受及服用抗高血壓藥物的次數，對病人服藥連從行為有直接且負向之影響，解釋力(R^2)為18.23%。而教育程度、年齡、主要使用語言、抗高血壓藥物知識、醫病關係及親友支持，則需透過健康信念對服藥連從行為產生間接之影響。 故醫護人員可從病人的年齡、教育程度、主要使用語言、服藥種類、次數、顆數及人格特質，預測病人是否為高危險人口群，易有不連從服藥之傾向，主動與病人建立良好之醫病關係，並加強其對抗高血壓藥物的認知，鼓勵親友關懷病人並提醒服藥，澄清且讓病人抒發對服藥壞處的感受，以促進病人的服藥連從行為。
  The purposes of this study were to investigate drug compliant behaviors, compliant rate and associated factors of hypertensive patients in Taiwan. The method of sampling was two phases of stratified, systemic random sampling. The sampling was composed of 600 hypertensive patients from hospitals and public health clinic in who had been treated over three months in Taoyuan and Taichung medical networks. Data was collected by interviewing and questionnaire and SAS computer programs. Structural equation model was selected as the multivariate analysis method to examine compliant behavior. Path multivareate analysis method to examine compliant behavior. Path analysis was used to test the hypothesized conceptural framework. The major findings of the study were: (1) An objective definition of drug noncom- pliant behavior is the score of compliant behavior scale less than 3.78, and systolic blood pressure more than l60mmHg or diastolic blood presure more than 95mmHg. The rate of drug noncompliant is 22.03%. (2) The six signigicant and directed variable in the model explained 18.23% of the variance in drug compliant behavior. Those variables were powerful-other-wxternal health locus of control knowledge of antihypertensive drug? kinds of pill? times of pill? pill counts and perception of antihypertensive drug's disadvantage. (3) The patients' age? education? language? doctor-patient relationship and family support affected drug compliant behavior indirectly, may be mefiated through health belief.
• 319 - 332
• 10.6288/CJPH1996-15-04-04

• Link 原著 Original Article
• 血液透析病人之健康相關生活品質問卷的設計與驗證The Design and Validation of a Questionnaire for Assessing Health-Related Quality of Life in Patients on Hemodialysis
• 林榮第、白璐、游芝亭、嚴澯鑫、王榮德
  Rong-Dih Lin, Lu Pai, Chin-Tin Yu, Tsann-Shin Yan, Juan-Der Wang
• 健康相關生活品質 ； 效度 ； 信度
  healthy-related quality of life ; validity ; reliability
• 健康相關生活品質的測量已逐漸被運用於公共衛生政策的決策分析上。健康相關生活品質的測量問春包括一般性與專一性兩種。一般性測量問卷適用於一般群體，所得的測量結果可用於比較不同群體間的差異，但其可能不適用終特殊群體。專一性測量問春則僅適用終特殊群體，所得的測量結果無法用於比較不同群體問的差異。本研究的目的在於發展一份一般性的中文問春，再針對不同疾病，加入較特定之問題，使其兼具一般性及專一性問春的優點。利用此問卷，向多向度觀點來測量血液透析患者的健康相關生活品質，並對問春的效度及信度進行檢定，希望能夸展出一份適合我國文化背景的健康相關生活品質問卷。 本研究採橫斷研究法，以1993年8月至11月期間，在臺北市三所教學醫院之血液透析中心接受長期血液透析，能夠並願意接受訪問的所有末期腎病息者為研究對象。由標準化訪視員以結構式問卷進行訪視及再劃。共有125名患者完成訪問，回應率為90%。 研究結果發現，本問卷經因素分析顯示包含生理社交功能、生理精神症狀及認知功能三個因素；在複迴歸模式中，生理、心理及社會三個向度所含各臨床量表之得分對於患者主觀自評之健康相關生活品質效用數值的變異量具有33.75%的解釋能力。由因素分析及複迴歸分析的結果顯示本問卷在健康相關生活品質的測量上具有良好的建構效度及不錯的預測效度。對於不同的訪視者、不同的訪視時間、不同的訪視方法或訪視情境，本問卷前後兩次的測量結果間均呈顯著的相關，顯示本問卷在健康相關生活品質的測量上具有良好的信度。 綜合言之，本問卷適合用於評估血液透析患者之健康相關生活品質。未來若能將本問卷中的一般性量表加以簡化，並加重專一性量表的份量，尤其是心理向度方面之量表，將能使本問卷更具效度、信度及接受性。
  The measure of health-related quality of life (HRQL) has been used progressively in public health decision making in recent years. HRQL can be assessed by either generic or specific instruments. A generic instrument is applicable to a wide variety of population and allows comparisons among different conditions, but may not be suitable for a specific population. A specific instrument can only be applicable to a specific population with the goal of detecting minimally important changes in condition-specific HRQL, but does not allow comparisons among different conditions. The purpose of this study is to develop a Chinese questionnaire using generic measures with disease- specific supplements based on multidimensional (phsical, mental and social) concept for assessing HRQL in patients and to evaluate its validity and reliability. This is a cross-sectional study. The subjects of this study consisted of all the patients of end-stage renal disease receiving maintenance hemodialysis at the hemodialysis room of three teaching hospitals in the Taipei between August 1993 and November 1993. Interviews were undertaken by standardized interviewers with a structured questionnaire. 125 subjects completed the interview. The response rate is about 90%. The result shows that this questionnaire contains three factors including physical-social function, physical-mental function and cognitive function; In the regression model, this questionnaire can explain 33.75% of the variance of the subjective utility value of HRQL of patients receiving hemodialysis. It implies this questionnaire has good performance in construct validity and predicting validity in the assessment of HRQL of patients receiving hemodialysis. It gets consistent results by different interviewers and methods and at different interviewing time and situations. That is to say, this questionnaire has good reliability in the assessment of HRQL of patients receiving hemodialysis. We conclude that this questionnaire is good enough for evaluating HRQL in hemodialysis patients. However, adding some more supplementary questions over mental dimension in the future will probably further improve its performance.
• 333 - 345
• 10.6288/CJPH1996-15-04-05

• Link 原著 Original Article
• 作業環境中環氧乙烷採樣分析方法之建立與運用The Development and Application of a Sampling and Analytical Method for Ethylene Oxide
• 詹長權、 張立德
  Chang-Chuan Chan, Li-Te Chang
• 環氧乙烷 ； 熱脫附裝置
  ethylene oxide ; thermal desorption unit
• 環氧乙烷(Ethylene Oxide, EtO)為各醫院所普遍使用的消毒氣體，亦是紡織與食品工業中常用的燻蒸劑。長期暴露在此工作環境下的作業者，會引起不良的健康效應，包括致癌性、中樞神經傷害、生殖危害、基因突變、及白內障等。由於法今對作業環境中EtO的濃度要求日益嚴格，為評估EtO在空氣毒性作用方面的影響，發展一套方便、安全且可偵測較低濃度的採樣分析技術實有其必要。本研究即針對作業場所中低濃度的EtO進行探討，嘗試利用熱脫附裝置將採集到的樣本脫附濃縮直接注入氣相層析儀火焰離子偵測器(GC/FID)中分析。空氣樣本的採集是利用低流量幫浦（流速60ml/min）帶動空氣通過充填Carbosieve Ⅲ吸附齊劑(600mg)的採樣管，將EtO吸附捕集。分析程序首先是以100℃的溫度將採樣管中EtO脫附出來，用液態氮將分析樣本冷凝濃縮於冷凝管，再以超高純度氦氣為載送氣體將脫附出來的EtO載送到氣相層析儀中，經長度為60m的Supelcowax 10層析管柱分離援，以火焰離子偵測器(FID)對作業環境中之EtO進行定性、定量之分析。分析測定結果發現，熱脫附裝置的脫附效益可達100%，偵測極限值為1.2μg (0.03ppm)，樣本在－10℃冰箱中可穩定保存9天，故此採樣方法可運用於作業環境中EtO之偵測。至醫院的消毒室現場採樣的結果發現，七個採樣點的EtO濃度雖均合於我國勞委會規定10ppm之標準，但亦高於美國職業安全衛生研究所(NIOSH)之建議值0.1ppm，其中以消毒室內的濃度最高，達l.99ppm，故長期暴露在此環境下作業者，其健康上恐有不良之虞慮。
  Ethylene Oxide (EtO) is widely used to sterilize of heat-sensitive and moisture-sensitive materials in hospitals. It is also used as a fumigant in the textile and food industries. EtO is found to be a carcinogen, therefore, its permissible exposure level is lowered in recent years. It becomes necessary to develop new sampling and analytical methods of measuring EtO at low concentrations in order to estimate potential health effects from EtO. This study is designed to develop a sampling and analytical method for measuring EtO exposures at ppm levels. We have successfully demonstrated that a sampling Carbosieve ? sampling tube (600mg) and a low-flow pump (60ml/min for 6 hours) is able to collect enough amounts of EtO. The adsorbed EtO can be thermally desorbed by a thermal desorption unit and be analyzed by a GC/FID system (HP5890). In analysis, EtO was first thermally desorbed at 100? (Tekmar Inc., Model 6000) from Carbosieve and then cryogenically focused by liquid nitrogen at -150? and finally carried into a 60m long Supelcowax 10 capillary column for seperation and a flame ionization detector for identification and quantification. For EtO, the desorption efficiency of thermal desorber was 100%, the detection limit was 1.2µg (0.03ppm), and the storage stability was 15days at -10? in the refrigerator. A field study of samples, that were obtaind form a hospital sterilization facility, showed that EtO concentration did not exceed the standard of an 8-hour average of l0ppm regulate by the Council of Labor Affairs (CLA). However, these levels exceeded the standard of 0.1ppm recommended by the NIOSH. So, workers exposed to ethylene oxide in long terms may have a variety of adverse effects in health.
• 346 - 356
• 10.6288/CJPH1996-15-04-06

• Link 原著 Original Article
• 台灣麥寮地區大氣中懸浮微粒之受體模式建立Development of Receptor Models for the Ambient Aerosols of the Meliao Area in Taiwan
• 陳宛青、魏致中、王秋森
  Wan-Ching Chen, Chih-Chung Wei, Chiu-Sen Wang
• 受體模式 ； 大氣中懸浮微粒 ； X射線螢光分析 ； 化學質量平衡 ； 微粒源貢獻量
  receptor models ; ambient aerosol ; chemical mass balance ; x-ray fluorescence spectroscopy ; source contribution
• 本研究之主要目的乃在建立一個適用於台灣麥寮地區一六輕石化工業區預定地－大氣中懸浮微粒之受體模式，以期將來能合理評估石化工業對該地區空氣品質的衝擊。 本研究於1992年11月至1994年1月期間在彰化縣大城國中、雲林縣麥寮衛生所及台西衛生所使用微孔均勻沈積部擊器及分道採樣器進行了六季密集的定點懸浮微粒採樣，並以X射線螢光分析及離子層析等方法分析粗粒徑（氣動直徑介於2.5-10μm）與細粒徑（氣動直程小於2.5μm）微粒樣本所含之20餘種化學元素及硫酸根。受體模式之建立係先以因子分析瞭解可能的微粒紅源類別；再應用CMB7軟體及國內、外微粒源化學組成資料，以化學質量平衡法推算不同微粒源於麥寮地區大氣中組、細粒徑懸浮和微粒之貢獻量。 研究結果顯示：麥寮地區大氣中粗粒徑懸浮微粒紅以海水噴沫（各季平均貢獻量估計百分率2.8-11.4%）、磚窯業等（燃煤、重油）工業排放(7.2-27.4%)、農作廢棄物燃燒(31.3-39.7%)及道路揚塵(21.1-42.1%)為主要貢獻來源。細粒徑部分則以農作廢棄物燃燒(31.2-39.7%)、磚窯業等（燃煤、重油）工業排放(10.9-18.9%)、柴油車排放(7.5-12.1%)及二次形成氣膠中之硫酸根(16.5-26.0%)等為主要微粒源。各季微粒源貢獻量大小隨盛行風向之變異有顯著的變化。本研究於麥寮地區建立之受體模式可現為六輕石化工業區運轉前之背景模式，對於未來在訂定污染控制相關策略時應有所幫助。
  The primary objective of this source apportionment study is to develop a receptor model in the Meliao area, where the construction of a petrochemical complex is underway. During November 1992 to January 1994, samples of aerosol particles were collected using cascade impactors and dichotomous samplers at Dacheng, Meliao, and Taihsi in central Taiwan. The concentrations of various chemical species in aerosol samples were determined by the X-ray fluorescence spectroscopy and ion chromatography. Factor analysis was used to characterize the major source categories first, and then the principle of chemical mass balances (CMBs) was used to estimate the contribution of each particle source. The results of calculations for the coarse particle fraction (2.5-10µm in aerodynamic diameter) show that the major sources were marine aerosols (average mass contribution percentage in the range of 2.8-11.4%), coal- or oil-fired kiln emission (7.2-27.4%), combustion of agricultural wastes (31.3-39.7%), road and soil dust (21.1-42.1%). The fine particles (smaller than 2.5µm in aerodynamic diameter) were mainly contributed by combustion of agricultural wastes (31.2-39.1%), coal- or oil-fired kiln emission (10.9-18.9%), diesel exhaust (7.5-12.1%) and sulfate in the secondarily-formed aerosols (16.5-26.0%). Variations of source contributions were strongly influenced by the prevailing wind. The receptor model established in this study should be useful for evaluating the impending impact of the petrochemical complex to the air quality of the Meliao area and for planning pollution control strategies.
• 357 - 372
• 10.6288/CJPH1996-15-04-07

• Link 原著 Original Article
• 一所教學醫院的死因診斷形式錯誤及準確度分析Analysis of Formative Errors and Validity of Cause-Of-Death Diagnosis in a Teaching Hospital
• 呂宗學、石台平、賴華山、李麗雪、李孟智、周明智
  Tsung-Hsueh Lu, Tai-Ping Shih, Hwa-Shan Lai, Li-Shu Lee, Meng-Chih Lee, Ming-Chih Chou
• 死亡診斷書 ； 死因診斷 ； 國際疾病分類 ； 準確度
  death certificate ; cause-of-death diagnosis ; ICD ; validity
• 本研究分析一所教學醫院民國82年1月1日至83年6月30日597張死亡診斷書有關死因診斷的形式錯誤及準確度。僅337張(56.5%)死因診斷形式正確；57張(9.6%)只填死亡機轉未填死因；58張(9.7%)填了數個死因但是因果順序不明；55張(9.2%)填入不明確單一死因；90張(15.1%)填入明確單一死因但是表達錯誤。若以是否影響原死因來分類，三分之一的死診形式錯誤會影響原死因的選擇。影響因素有：住院醫師比主治大夫較多錯誤(P=0.011)，內科醫師比非內科醫師較多錯誤(P=0.038)，死者年齡較大者較多錯誤(P=0.001)，死者在本院住院次數小於等於一次者較多錯誤(P=0.002)。以ICD-9基本分類表二位碼評估死因診斷準確度，82%的死因診斷是一致的。以ICD-9三位碼評估死因診斷準確度，72%的死因診斷是一致的。影響因素有：住院醫師比主治大夫較多不一致(P=0.020)，死者年齡較大者較多不一致(P=0.006)，死者在本院住院次數小於等於一次者較多不一致(P=0.026)。對主要死因進行排序，修正復排序與原本排序主要差別為早產低出生體重及意外事故兩個死因。以ICD-9三位碼來比較，惡性腫瘤排序影響不大（kappa值馱0.94），但是對腦血管疾病的排序有相當的影響（kappa值0.34）。原本有25張死因診斷填寫腦中風，回溯病歷資料復廢現其中23個案在病歷上都有明確記錄診斷是腦內出血或腦動脈阻塞。由病歷資料可得知研究樣本中有26個案是損傷或中毒，可是只有七位在死診上有提及外因。譬如研究樣本中有七位是因為跌倒或車禍造成顱內出血在該院接受手術，結果只有一張死因診斷提到外因。四張填腦內出血，兩張填肺炎。一位個案因分娩產後出血化亡，可是在死診上皆未提及，這會造成孕產婦死亡率的低估。本研究結果對編纂教村教育醫師正確填寫死因診新有相當大助益，對死因統計偏差的估計與調整也有所參考。
  Five hundred and ninety-seven death certificates issued by a teaching hospital during January, 1993 and June, 1994 were reviewed. Only 337(56.5%) of them were formatively correct in cause-of-death diagnoses; 57(9.6%) had mechanism (s) of death only; 58(9.7%) wrote multiple causes of death, but the sequences were not clear; 55(9.2%) gave single cause of death, but not specific; 90(15.1%) gave single cause of death, but had error in expression. Residences compared with attending physicians (p=0.011), interalists compared with non-internalists (p=0.038), elder patients compared with younger patients (p=0.001), patients admitted to this hospital once and less than once compared with those admitted more than once (p=0.002) had higher percentage of making formative errors. Using ICD-9 basic table 2-digit coding, 49 1(82%) cause-of-death diagnoses were concordant with evaluaters'. Using ICD-9 3-digit coding, 432(72%) were concordant. Residences compared with attending physicians (p=0.020), elder patients compared with younger patients (p=0.006), patients admitted to this hospital once and less than once compared with those admitted more than once (p=0.026) had higher percentage of invalid. The formative errors and invalidity in cause-of-death diagnoses in this hospital did not change the ranking of leading causes of death except deaths due to premature and low-birth-weight and deaths due to external causes. The ranking of 3-digit malignant tumors had high concordance (kappa=0.94), but did bias the ranking of cerebrovascular diseases (kappa=0.34). 23 of 25 certificates coded stroke as cause of death could be further specified into cerebral infarction or intracerebral hemorrhage. According to the chart review, there were 26 injuries and poisonings, but only 7 of them mentioned external causes in certificates. There was a delivery-related death, but was not mentioned in the certificate. The results of this study could provide useful information for teaching clinicians how to writie correct cause-of-death diagnoses and give some hints in bias-adjusting when using cause-of-death statistics.
• 373 - 381
• 10.6288/CJPH1996-15-04-08

• Link 原著 Original Article
• 台北市立綜合醫院經營績效之評估Performance Evaluation of Taipei City General Hospitals
• 黃月桂、張保隆、李延春
  Yueh-Guey Huang, Pao-Long Chang, Yang-Chun Li
• 績效評估 ； 醫院經營效率 ； 資料包絡分析
  data envelopment analysis ; hospital performance evaluation ; hospital efficiency
• 本研究運用資料包絡分析法（Data Envelopment Analysis；簡稱DEA），針對臺北市衛生局所屬五家市立綜合醫院為研究對象，利用七十九至八十一年三個會計年度的資料，衡量其經營效率。我們將醫院每年的資料當成一個決策單位（Decision Making Unit，簡稱DMU），研究結果顯示：15個DMUs中有9個為相對效率欠佳，其中3個DMUs未能充分利用投入要素而致整體表現未達最佳境界，另有2個其經營規模亦未達最適之經營規模而影響其整體表現，其餘4個DMUs對於資源使用及經營規模皆有缺失，則應同時在技術及規模上作改善或調整，方能達到最佳效率境界。
  This study utilized Data Envelopment Analysis (DEA) to assess the performance of 5 Taipei City General Hospitals from fiscal year 1990 to 1992. A hospital in each year was treated as a decision making unit (DMU) in this study. The study found that 9 out of 15 DMUs were relatively efficient. Three inefficient DMUs were affected by their technical inefficiency; in other words, these DMUs did not utilize their given inputs efficiently. Another 2 inefficient DMUs were due to their scale inefficiency; in other words, these DMUs needed to increase or decrease their operating scale in order to reach relative efficiency. The remaining 4 DMUs needed to improve their input utilization and to adjust their operating scale simultaneously.
• 382 - 390
• 10.6288/CJPH1996-15-04-09

• Link 原著 Original Article
• 乳房自我檢查衛生教育效果評量Effectiveness of Breast-Self-Examination Education
• 張翠珍、盧豐華、吳南宏、 張瑩如、張智仁
  Tsui-Chen Chang, Feng-Hwa Lu, Nan-Hong Wu, Ying-Zu Chang, Chin-Jen Chang
• 乳房自我檢查 ； 衛生教育
  breast self examination ; health education
• 為探討乳房自我檢查衛生教育教學前後婦女執行乳房自我檢查的技巧正確度及與模出乳房腫塊能力的關係，本研究以民國82年4月3日至民國82年7月15日，報名參加國立成功大學醫學院附設醫院家庭醫學部舉辦之乳房自我檢查衛生教育課程者共302位女性為對象。衛生教育是採用海報演講、模型示範及模型腫塊實際體驗等方式，而以問卷填寫及背著肩掛式乳房模型做自我檢查各步驟之動作來評估教學前及教學復六個月學員執行乳房自我檢查技巧的正確度和模出乳房模型腫塊能力之高低。針對157位同時接受教學前及教學六個月復之評量者，結果發現，教學前學員每月定期做乳房自我檢查者僅佔7.7%，且乳房自我檢查各步驟做正確的比率均低於30%。教學復六個月每月定期做者增加為35.7%，而學員各檢查步驟做正確的比率均有顯著提升，大部份步驟做正確的比率均超過60%，除了輕擠乳頭(30.6%)、先輕壓一次再重壓一次(45.9%)、檢查腋下淋巴結(52.2%)及雙手舉高鏡前檢查(54.8%)等步驟較易遺漏外。另外不論是教學前或教學復六個月，學員乳房自我檢查技巧正確度愈高者，模出乳房模型腫塊數目也愈多。經向此教學模式可提升婦女乳房自我檢查技巧的正確度，進而增加模出乳房腫塊之能力，如此將有助於早期發現以無痛性腫塊來表現之早期乳癌，值得作為推廣乳房自我檢查衛生教育之參考。
  This study makes a comparison of women's proficiency in breast self examination and ability to sense breast mass before and after the health education of breast self examination. The objects of this study are 302 females who participated in the breast self examination class provided by the Department of Family Medicine, National Cheng Kung University Hospital from April 3, 1993 to July 15, 1993. The teaching methods adopted in the health education are poster lectures, model demonstration and touching model breast to sense breast mass. Questionnaire and shoulder hanging breast model for testing the correctness of self examination steps are used to evaluate the students' proficiency in breast self examination and ability to sense breast mass before and six months after the class. It is found that before the class, only 7.7% of the students performed monthly breast self examination regularly, of which less than 30% did the self examination in correct steps. Six month after the class, the proporsion of students who performed the examination regularly increased to 35.7% and the proporsion of those who did the examination in correct steps also increased to 60%. However, the steps of squeezing the nipple (30.6%), superficial pressure of fingers and deep pressure of fingers (45%), examining axillary nodes (52.2%) and examining by lifting arms over head in front of mirror (54.8%) are more easily ommitted. Besides, the higher self examination proficiency the students have, the more breast model mass can be sensed notwithstanding before or six months after the class. In conclusion, this study shows that this health education enhances women proficiency in breast self examination and further promotes their ability to sense breast mass. It is helpful to the discovery of early stage breast cancer which appears in the form of painless mass. The results of this study can serve as a reference for the promotion of breast self examination health education.
• 391 - 401
• 10.6288/CJPH1996-15-04-10