臺灣博碩士論文加值系統

目的：由於國人高度的中醫醫療使用率，使得臺灣地區存在著中、西醫並行的醫療特色。然而，過去針對醫護人員的相關研究，多著墨於西醫師職業族群的健康狀態或其特殊疾病發生與死亡之情形，同身為醫師族群之中醫師卻鮮少受到關注。中醫師由於時常實施針灸治療，頻繁的操作可能使其針扎意外發生的風險增加，且臺灣屬高肝炎帶原地區，因此可能加重中醫師因施行針灸而感染肝炎的風險；此外特殊的職業特性、健康的生活、飲食方式與豐富的健康知識，亦皆可能進一步造成其子代出生性別比與國人之間的差異。因此，本研究之目的為探討中醫師職業族群之肝炎發生率與子代出生性別比之特性。

方法：利用衛生署中醫師證照登記資料庫，獲得領有中醫師執照之中醫師世代，排除1985年前年滿85歲及未滿25歲之族群後，與內政部出生登記資料串聯獲得1985年至2003年中醫師子代之出生資料，進一步將資料區分為父親中醫師，母親中醫師，以及雙親皆中醫師三組，並分析子代出生性別比與國人出生性別比之差異。此外，另選取中部某教學醫院針灸科病人與一般中醫科病人資料為對照組後串聯疾病管制局肝炎通報系統，獲得中醫師與兩對照組之急性肝炎與慢性肝炎發生資料，並同時分析比較三組肝炎發生率之差異。

結果：本研究之中醫師族群總人數為6951人，其中男性中醫師佔5642人（81.2%），女性中醫師佔1309人（18.8%），平均年齡為48.04± 13.45歲；針灸科病人共23317人，平均年齡為44.93± 19.43歲；一般中醫科病人共17036人，平均年齡為44.86± 19.84歲。急性B型肝炎與C型肝炎部分，中醫師較兩對照組都有較高的相對風險（RR1= 6.94, p= 0.147；RR1= 2.09, p= 0.627）；進一步分析兩對照組之差異則呈現，無接受針灸治療之一般中醫科病人有較高的急性肝炎發生率（IR=2.93×10-4, p= 0.221）。在慢性肝炎部分則呈現，中醫師有最低之慢性肝炎發生率（IR= 11.51×10-4），其次為針灸科病人（IR= 26.16×10-4），而一般中醫科病人則有最高的肝炎發生率（IR= 39.92×10-4）。中醫師世代與內政部出生登記資料串聯後共獲得6567筆子代出生登記資料，包含出生男嬰3464人及女嬰3103人，總出生性別比為110.63
，相較於國人有較高的子代出生性別比（中醫師SR= 110.63 vs. 國人SR= 108.89, p= 0.31）。進一步分析各組中醫師與國人之差異則呈現，父親中醫師、母親中醫師，以及雙親皆中醫師者在出生胎次、胎別、父母親教育程度、父母親生育年齡、出生胎兒體重與母親妊娠週數等變項上達統計上顯著性之差異（p＜0.05）。多變項邏輯斯迴歸結果發現，雙親皆中醫師者相較國人的出生男嬰比例多出1.07倍（p= 0.51）。此外，在父親中醫師組與母親中醫師組相較於國人皆有大於1的男嬰勝算比（OR=1.01, p= 0.70； OR=1.06, p= 0.49），在出生體重方面則呈現，體重介於2500-3000克及小於2500克者相較於體重介於3000-3500克者，有較低的出生男嬰勝算比（OR=0.64, p＜0.0001；OR=0.74, p＜0.0001），體重大於3500克者則有較高的男嬰勝算比（OR=1.43, p＜0.0001）。而隨著胎次增加，父親中醫師與國人出生性別比亦有增加的趨勢。

結論：本研究結果呈現，相較於針灸科病人以及一般中醫科病人，中醫師有較高的急性肝炎發生率以及較低的慢性肝炎發生率，一般中醫科病人急性或慢性肝炎發生率皆較針灸科病人為高，可能是近年來廣泛使用拋棄式針對針灸科病人的保護作用所致，而B型肝炎疫苗施打計畫也可能提供良好的保護成效。此外，本研究中醫師有略高於於國人的子代出生性別比，而隨著父母親生育年齡的增加亦有增高的趨勢。在出生體重方面，較低出生體重者之性別比亦較低，表示在低出生體重嬰兒中有較高的女嬰出生比例。此外，本研究也觀察到，隨著胎次的增加，子代出生性別比有隨之上升的趨勢，顯示出隨著胎次漸增，可能會增加父母親的性別選擇行為，建議未來應進一步深入探討。

Objectives：Because physicians’ health status is critical to the quality of care, most previous studies reported health problems of physicians of Western medicine, but paid inadequate attention to the potential health problems of Chinese medicine physicians who also cared a large number of patients in many Asia societies. No data so far have been reported regarding the health problems associated with Chinese medicine physicians (CMP). Chinese medicine physicians used acupuncture to treat patients, and will increase risk of needlestick and sharps injuries (NSI), also increased risk of infecting hepatitis due to practice acupuncture among Chinese medicine physician. Besides, Chinese medicine physicians’ special occupational characteristic may cause the difference of secondary sex ratio between and general population. Hence, this study aimed to investigate the incident rate of hepatitis and the secondary sex ratio among Chinese medicine physicians in Taiwan.

Method：Based on the medical personnel register system with the Taiwan Department of Health, we have since 1985 established a cohort of 7677 physicians in Chinese medicine between 25 years and 85 years of age. The birth records were obtained by linking to the 1985-2003 Birth Register System of Ministry of the Interior. We divided into three groups (father is Chinese medicine physicians, mother is Chinese medicine physician, and parents are Chinese medicine physician) and compared with general population. In analysis incident rate of hepatitis, the reference data of acupuncture patients and general Chinese medicine patients acquired from a medical university hospital in central Taiwan. The data of hepatitis were obtained from Hepatitis Register System of Centers of Disease Control.
Result：There were 6,951 Chinese medicine physicians in our study, including 5,642(81.2%) males and 1,309(18.8%) females, mean age were 48.04± 13.45 years old. 23,317 acupuncture patients in the study , mean age were 44.93± 19.43 years old, and 17,036 general Chinese medicine patients, mean age were 44.86± 19.84 years old. In acute hepatitis B and C, the Chinese medicine physicians showed higher rates than two controls (RR1= 6.94, p= 0.147；RR1= 2.09, p= 0.627). Moreover, the incidence rate of acute hepatitis of general Chinese medicine patients was higher than acupuncture patients (IR=2.93×10-4, p=0.221). In chronic hepatitis, CMP showed the lowest incidence rate (IR=11.51×10-4), but general Chinese medicine patients showed the highest (IR=39.92×10-4). We gained 6,567 eligible live births, including 3,464 male infants and 3,103 female infants. The crude secondary sex ratio of CMP was slight higher than general population (SR= 110.63 vs. SR=108.89, p=0.31). The analysis of difference between three group and general population was showed significantly in birth order, parity, education level of parents, delivery age of parents, birth weight, and gestational age (p＜0.05). We used general population as reference group in logistic regression, the odds ratio of male birth was 1.07 among parents were CMP (p= 0.51). Compared with baseline group, the ORs of CMP groups were more than 1 (OR=1.01, p=0.70；OR=1.06, p= 0.49). Compared with birth weight between 3000-3500g, there were significantly lower OR in birth weight between 2500- 3000g and below 2500g (OR=0.64, p＜0.0001；OR=0.74, p＜0.0001), but significantly higher in birth weight above 3500g (OR=1.43, p＜0.0001). Additionally, secondary sex ratio was increase with birth order in general population and father is CMP.

Conclusion： Compared with two controls, CMP showed higher incidence of acute hepatitis and lower incidence of chronic hepatitis. The hepatitis incidence rates of general Chinese medicine patients were also higher than acupuncture patients. We inference that disposable needle use and National hepatitis B vaccination program may provide protect effects. In our study, the secondary sex ratios among CMP were higher than general population, while parents delivery age were increased. At the same time, we observed that sex ratio were low in lower birth weight. Besides, we also noticed secondary sex ratios were increasing by birth order, means people might have sexual selection behavior, it is also worthwhile to further investigate the sexual selection behavior.

總目錄
致謝 I
中文摘要 III
Abstract VI
總目錄 IX
表目錄 XI
圖目錄 XI
第一章 前言 1
第一節 研究緣起 1
第二節 研究目的 3
第三節 研究架構 4
第二章 文獻探討 5
第一節 臺灣地區傳統中醫利用 5
第二節 醫師之針扎傷害與肝炎 6
第三節 臺灣地區針灸治療之利用與肝炎傳播之風險 8
第四節 出生性別比意義與趨勢 10
第五節 出生性別比影響因子 11
一、種族與國家政策 11
二、年齡 11
三、父母親社經地位 12
四、心理壓力事件 13
五、生產因素：胎次、懷孕所需時間、妊娠週數、出生體重 14
六、特殊環境與職業物質暴露 15
七、其他因子 16
第六節 中醫師與子代出生性別比 16
第三章 材料與方法 20
第一節 研究族群之選取 20
第二節 肝炎資料 20
第三節 出生登記資料 21
第四節 統計方法 21
第五節 研究流程 23
第四章 結果 24
第一節 中醫師族群基本描述 24
第二節 肝炎發生率 24
第三節 子代出生性別比 26
第五章 討論 31
第一節 肝炎發生率 31
一、急性肝炎 31
二、慢性肝炎 31
三、影響針灸利用之因素-年齡、性別 33
四、臺灣B型肝炎疫苗政策 35
第二節 子代出生性別比 37
一、醫療取得與產前照顧 37
二、高社經地位與母親營養 38
三、健康行為與居住環境 39
四、傳統中醫治療與不孕症 40
五、生殖危害與出生性別比 41
六、出生胎次與性別選擇 42
七、父母親年齡與出生性別比 43
八、妊娠週數、出生體重與出生性別比 44
第六章 結論與建議 48
第一節 結論 48
第二節 建議 49
第七章 參考文獻 50

表目錄
表一 出生性別相關因子文獻整理 65
表一 出生性別相關因子文獻整理（續） 66
表二 中醫師世代基本特性描述 67
表三 針灸科病人與一般中醫科病人就診人次與人數分佈 68
表四 針灸科病人與一般中醫科病人之五年就診次數分佈 68
表五 中醫師與兩組對照病人之基本人口統計學變項分佈 69
表六 中醫師及對照組之急性肝炎發生率與相對危險性比較 70
表七 扣除疫苗世代後中醫師及對照組之急性肝炎發生率與相對危險性比較 71
表八 中醫師及對照組之慢性肝炎發生率與相對危險性比較 72
表九 扣除疫苗世代後中醫師及對照組之慢性肝炎發生率與相對危險性比較 73
表十 以邏輯斯迴歸分析對象就診次數與肝炎發生率之關係 74
表十一 中醫師子代出生基本變項分佈 75
表十二 中醫師各組子代出生基本變項分佈 76
表十二 中醫師各組子代出生基本變項分佈（續） 77
表十三 中醫師子代出生基本變項之性別比分 78
表十四 中醫師各組子代出生基本變項之性別比分 79
表十四 中醫師各組子代出生基本變項之性別比分佈（續） 80
表十五 中醫師各組子代出生出生體重分佈（續） 82
表十六 中醫師各組子代妊娠週數分佈 83
表十六 中醫師各組子代妊娠週數分佈（續） 84
表十七 單變項邏輯斯迴歸分析出生男嬰之勝算比 85
表十八 多變項邏輯斯迴歸分析出生男嬰之勝算比 86
表十九 單變項線性迴歸分析出生體重 87
表二十 單變項線性迴歸分析妊娠週數 88
表二十一 各年代中醫師子代出生性別比與國人之比較 89
表二十二 各月份與季節中醫師子代出生性別比與國人之比較 90

圖目錄
圖一 各年代中醫師子代與國人性別比差值趨勢圖 91
圖二 不同季節中醫師子代與國人性別比差值趨勢圖 92
圖三 各胎次中醫師子代與國人性別比差值趨勢圖 93

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