台灣弱勢族群健康狀況研究

The Health Related Studies in Disadvantaged People of Taiwan

林慶豐(Ching-Feng Lin)

指導教授 ： 王榮德

國立臺灣大學/公共衛生學院/職業醫學與工業衛生研究所/博士(2008年)

https://doi.org/10.6342/NTU.2008.02249

摘要

台灣的弱勢族群包含原住民、獨居老人、監獄受刑人等族群，因著他們在社會及經濟上的弱勢，常常反映他們有較低的社會地位及較差的健康條件。
一般而言除了原住民菸、酒、檳榔之習慣除了部分與原住民習俗及文化有關外，其使用率偏高已是不爭的事實，但如何防治及降低其使用率，實有其執行上的困難；此外，原住民之慢性肝病也是十大死因中重要原因。衛生署為了提昇原住民健康及增進原住民健康照護及疾病篩檢與防治，特別將原住民菸、酒、檳榔習慣性使用之防治列為研究重點，台灣肝病列為十大死因這幾年來一直是居高不下，除了病毒性肝炎外，菸、酒、檳榔亦是造成慢性肝病的重要危險因子，據許多相關研究原住民的慢性肝病盛行率較非原住民嚴重，為了瞭解原住民慢性肝病及肝功能異常之情形，我們結合衛生署桃園醫院於民國九十至九十一年承做健康保險局於桃園縣復興鄉的原住民醫療整合計劃(IDS、integrated delivery system)，針對桃園縣復興鄉18歲以上居民，實施肝病篩檢工作，調查民眾嚼食檳榔的情形，也透過流行病學研究瞭解慢性肝病之危險因子與嚼食檳榔造成的影響，最後將此研究結果提供衛生單位作為原住民健康政策之參考。我們發現在桃園復興鄉18歲以上共3,010位民眾（2,063名原住民與947名非原住民）的B型及C型肝炎的帶原率分別是21.2 % 及 2.9 %, 肝功能ALT異常佔16.5 %，AST異常佔15.1 %，GGT 異常佔22.4 %；在複回歸分析發現同時感染B型及C型肝炎造成ALT及AST肝功能異常高出沒有被感染者的4.2 倍及3.8倍。 而飲酒、男性、嚼食檳榔、吸菸及具原住民身分者其ALT及AST肝功能較為異常；而在分析 1,382 名民眾之肝臟超音波發現有41名(3.0%)為肝硬化，而這些肝硬化也與飲酒、男性、嚼食檳榔、吸菸及具原住民身分者有關。
另外，本研究將對台灣原住民社區檳榔嚼食率、吸菸率和飲酒率及其成癮之各種因素及戒斷行為進行調查，於民國九十一年七月起，針對台灣地區30個山地鄉及18個平地鄉原住民社區進行家庭訪視，完成標準式問卷調查。研究設計乃以抽樣調查方式，採分層抽樣調查法，抽樣機率以等比等幾抽樣方式對台灣地區30個山地鄉及18個平地鄉原住民社區進行調查，調查對象為十八歲以上之原住民社區約一萬位民眾，標準式問卷內容涵蓋：統一菸、酒、檳榔之使用定義及其使用狀況；一般基本人口學資料；相關健康危害之認知程度及其物質濫用之態度、行為現況。本次之研究能找出戒斷意願及戒斷行為或阻礙「習慣且持續物質濫用者」無法戒斷成功之原因，參考戒斷成功者之經驗，提供有效戒食計劃與落實步驟，以達到協助大多數已習慣且持續嚼食者戒食物質濫用成功之目標。我們發現在7144位原住民的研究他們檳榔嚼食率為46.1%，而這些嚼食檳榔習慣與肥胖非常有關係，為非肥胖的1.61倍；嚼食檳榔習慣與同時飲酒及吸煙非常有關；我們也發現檳榔嚼食者的檳榔戒斷率為7.6%，而這些人當中無飲酒習慣者具有更高的戒斷率。
此外，監獄受刑人也是一群被社會忽略及權益上的弱勢族群，他們當中除了因犯罪原因判刑而入監，也有因觸犯煙毒條例之故入監，在許多研究中，監獄受刑人的B型肝炎盛行率也是非常高，這個族群也是因許多不當的健康行為造成他們的健康問題，為了瞭解他們B型肝炎盛行率及其危害因子，我們對全國22個監獄及其15,880個受刑人進行調查，在目前台灣受刑人尚無全民健保的基本健康權利外，除了要照顧監獄受刑人的健康外，也要提出其B型肝炎的危險因子及預防之道。我捫的研究發現，在15,007受刑人的B型肝炎帶原率為21.7 %. 他們輸血、靜脈毒癮及刺青的比率都超過20%以上，B型肝炎的感染在單一危險因子中以靜脈毒癮最高OR為1.54，而同時接觸輸血、靜脈毒癮及刺青的危險因子中其OR高達為2.76。
最後，在研究這些原住民及受刑人等弱勢族群的健康情形及相關危險因子後，我們也提出對照顧原住民及監獄受人的政策與建議，期能提出改善方案，減少他們健康的差異與縮短健康差距，提升他們的健康水準與品質。

關鍵字

弱勢族群 ； 原住民 ； 監獄受刑 ； 檳榔 ； 乙型肝炎帶原

並列摘要

From the viewpoint of sociology, the disadvantaged and minority of a society refers to a group of people, who are relatively weak sociologically and economically. In Taiwan, the disadvantaged group includes aboriginal people, lonely-living aged people and prison inmates, because they are weak sociologically and economically , which reflect that they always have inferior social status and poor health conditions.
Generally speaking, the aboriginal people always have higher rate of cigarette smoking, alcohol drinking and betel quid chewing, but how to control and reduce the using rate, it is very hard in implementation. Besides chronic liver disease is one of the ten leading causes of death among the aboriginal people. The Department of Health, with the objectives to improve the health condition of the aboriginal people, and to screen and control of disease, pays special attention to the study on the control of cigarette smoking, alcohol drinking and betel quid chewing among the aboriginal people; Liver disease is one of the ten leading causes of death in Taiwan, besides hepatitis virus infection, cigarette smoking, alcohol drinking and betel quid chewing are the risk factors leading to chronic liver disease, according to related studies which showed that the prevalence of chronic liver disease among the aboriginal people is more serious than that among the non-aboriginal people. In order to understand the chronic liver disease and the abnormal function of liver among the aboriginal people, we joined Taoyuan Hospital of the Department of Health took charge of the IDS（Integrated Delivery System）program, which was supported by National Health Insurance, that project started from 2001 to 2002 and the study area was in the aboriginal communities of the Fu-shing Township of Taoyuan County , people over the age of 18 in the Fu-shing Township received the screenings of liver disease, the situation of betel quid chewing among the aboriginal people was also studied, to investigate the risk factors leading to chronic liver disease through epidemiological study, and the effect of betel quid on such disease, finally the result of the study would provide useful information to health organizations to form health policy for the aboriginal people. Our finding as follow: There were 2,063 Atayal Aboriginal and 947 non-Aboriginal in this study. The result showed overall prevalence rates for hepatitis B surface antigen (HBsAg) and hepatitis C virus (HCV) were 21.2 % and 2.9 %, respectively. There were 16.5 %, 15.1 % and 22.4 % subjects with abnormal alanine aminotransferase (ALT), aspartate aminotransferase (AST), and gamma glutamyl transpeptidase (GGT), accordingly. Multiple logistic regression analysis showed that combined infections with HBV and HCV presented with the highest risks with OR of 4.2 and 3.8, respectively for elevation of ALT and AST; followed by alcohol (1.7 and 3.1), male gender (1.7 and 1.6), betel quid (1.5 and 1.3), smoking (1.4 and 1.8), and aboriginal (1.4 and 1.3). Among 1,382 subjects consenting to abdominal ultrasonography, 41(3.0%) were found to have liver cirrhosis with the same factors associated with higher risks.
Therefore, our further study conducted such investigations as the prevalence of cigarette smoking, alcohol drinking and betel quid chewing, and their relative risk factors and quitting behavior. This study was initiated in July of 2002, it covered 30 aboriginal townships in the mountain and 18 plan aboriginal townships, this study conducted interviews and completed standard questionnaires. The experimental design was based on stratified sampling method and probability stratified sampling method, there were about 10,000 aboriginal people over 18 years old in 30 townships in the mountain and 18 townships on the plain were interviewed in this study ; the standard questionnaires included: unified definitions on the use of tobacco, alcohol and betel quid and the conditions of using them ; general demographical information; related understanding on health hazard, the attitude and behavior status towards abusing them. This study found out the quitting intention , quitting behavior or retarding factors which resulted in unsuccessful quitting , the experience of successful quitting , all of the information would provide useful information in the formation of quitting plan and implementation procedures , in order to help those people to quit the habit of chewing areca nut. Our finding as follow: The prevalence of betel quid chewers was 46.1%. Betel quid chewing was closely associated with obesity (OR=1.61; 95% CI: 1.40-1.85). Betel quid chewers were most likely to use alcohol and cigarettes together. Quit rate of betel quid chewers was 7.6%. Betel quid chewers who did not drink alcohol were more likely to quit (OR=1.89; 95% CI: 1.43-2.50). Alcohol use is a significant factor related to cessation of betel quid chewing, but smoking is not.
Besides, prison inmates are the high risk group of hepatitis B, especially those narcotic addicts with past history of using the same syringe and tattoo, they are easily to get infected, therefore, we must find out the hazardous factor and relevant preventive measures. A total of 15,007 prisoners were surveyed. The response rate was 92.6 %. The result showed an overall prevalence rate for HBsAg was 21.7 %. 3333 subjects (22.2%) with a history of blood transfusion (BT), 3071 subjects (20.5%) with a history of intravenous drug abuse (IVDA), and 6908 tattooed prisoners (46.0%) showed positivity of HBsAg. IVDA appeared to be the strongest risk factor among the three with an adjusted odds ratio (aOR) of 1.54(95 % C.I. 1.27-1.86), which was followed by tattoo 1.40 (95 % C.I. 1.23-1.55) and blood transfusion 1.27(95 % C.I. 1.05-1.61). A combination of three factors significantly increased the aOR to 2.76(95 % C.I. 2.20-3.47), followed by BT and IVDA (aOR =1.72), BT and tattoo (aOR =1.69), and IVDA and tattoo (aOR=1.41). The overall prevalence rate for positive VDRL tests was 1.0 % and there was no significant association between its positivity and any one of the three major determinants of horizontal transmission.

並列關鍵字

Disadvantaged people ； Aboriginal ； prisoner ； betel quid ； HBsAg carrier

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