臺灣博碩士論文加值系統

依據內政部處理統計遊民資料顯示，官方登記在案的遊民人數大都維持在三、四千人左右。對經濟發展快速、生活水準提升的台灣社會而言，遊民現象是非常令人不解且困惑的社會現象。流浪為生的遊民是極易受傷的，更是容易罹患疾病的高危險群，而遊民健康更是一個容易被忽視的社區衛生與安全問題。而目前遊民的健康問題並無專責機構負責建檔與管理，且遊民的流動性高更不易掌握其健康狀態，常造成醫療中斷或醫療資源的重複利用與浪費。而遊民醫療過程經濟問題是其主要的原因。多數遊民無穩定工作，無固定收入，因此遊民更易在罹患各式各樣疾病後，仍遊走於社會每個角落，成爲疾病的散播者之一。
本研究在探討遊民個人背景、生活習慣、就醫情形與門急診及住院醫療時健保申報醫療費用耗用之情形。研究結果發現，遊民普遍教育程度偏低，未婚居多，經濟來源以打零工為主，屬於長期或慢性遊民人口，相當高比例有菸酒上癮習慣，無每日盥洗者居多，這與顯現在外骯髒、惡臭相符，經常處於挨餓狀態，勢必減弱規律工作時所需的體力及精神，大多獨來獨往無與他人往來。以第六類人口加入全民健康保險，但多無力負擔健保費及就醫之醫療費用，大多於離院後無門診追蹤。門急診就醫及住院治療次數範圍很廣，就醫主診斷以損傷及中毒為最多，顯示流浪在外的生活較易遭受意外傷害或因悲觀情緒而產生自我傷害。就醫診斷個數以2個為最多，顯示遊民就醫時通常非單一診斷，因此治療次數及天數常因疾病所伴隨之合併症或併發症而有所不同。遊民的親人網絡絕大部分因故無伸出援手或無法提供協助，以致在事故發生時無所依靠。
無醫療後續追蹤與不安定的生活型態，更加速遊民身體的衰弱。沒有錢買藥、看病是遊民最大的困難。而遊民的醫療問題並非是單一機構就可以解決的，它需要多面向的合作與支援才有可能成功。本研究期能提供政府部門對未來遊民醫療問題能發展有效之因應對策。

According to the statistics on the homeless people compiled by the Welfare Department of the Internal Affairs Ministry, the number of homeless people who have registered with that agency is around 3-4 thousand. Homeless is a perplexing social phenomenon for Taiwan, whose economy develops and living standard is raised. Homeless people get injured easily due to their unsteady, wandering lives. Moreover, they are in for the prey of diseases. Their health issue is easily neglected and has been a problem with the general community health and safety. Currently, no governmental agency has been held responsible for the health issue with the homeless; the homeless people’s health issue is neither on file nor under management. The issue is exacerbated by their high mobility. The discontinuation of health care or redundancy / waste of health care resources thus has often occurred. Above all, economic condition is the main reason behind the lack of or inappropriate health care for the homeless. Most homeless people have no steady job nor steady income. Therefore, despite the fact that they may have contracted a variety of diseases, they continue living here and there in the society, and become a media for certain contagious diseases.

This thesis focuses on studying the personal background of the homeless, their living habits, their mode of having health care, and the health care expenditure application with respect to regular and emergency intake and hospitalization. This study finds that the homeless generally are with little education, their marital status is single mostly, and their income comes from odd-job mostly. A high percentage of the long-term or chronical homeless people are addicted with alcohol or tobaccos. Most of them do not clean themselves regularly, which corresponds with their dirty appearance, and the accompanying smells. Their regular state of hunger helps weaken their physical stamina and metal strength required for a steady job. The homeless people are used to act alone, without interaction with others. They join Taiwan’s nationwide health care program in the sixth category. However, the homeless cannot afford their health care insurance premiums and co-payments. They also lack follow-up health care most of the time. The homeless tend to use a wide range of hospitals and they repeatedly see the doctor. Their main diagnoses are injuries and being poisoned, reflecting the fact that they are prone to get hurt by accident due to their wandering living style and self-injury due to depression. They are diagnosed with two different injuries / diseases mostly, showing that they probably have other complications which cause a variety of health care processes and days of health care. Further, a majority of the homeless do not have relatives who provide help financially or support them mentally; thus, the homeless usually are rendered helpless when an accident happens or a disease strikes.

No follow-up health care and unsteady living style contribute to the physical weakness of the homeless. As afore-mentioned, lack of money to buy the medicine and to see the doctor is the main difficulty for the homeless. This homeless people health care issue is not resolvable by s single agency; this issue needs cooperation and support from many resources in the society. I hope this study will provide the governmental departments with a clue for their strategy toward resolving this issue in the future.

目錄

中文摘要 ------------------------------------------------------------------------------ Ⅰ
英文摘要 ------------------------------------------------------------------------------ Ⅱ
謝辭 ------------------------------------------------------------------------------ Ⅳ
目錄 ------------------------------------------------------------------------------ Ⅴ
表目錄 ------------------------------------------------------------------------------ Ⅶ圖目錄 ------------------------------------------------------------------------------ Ⅷ
一、緒論 ------------------------------------------------------------------------------ 1
1.1 研究背景 ----------------------------------------------------------------- 1
1.2 研究動機 ----------------------------------------------------------------- 2
1.3 研究目的 ----------------------------------------------------------------- 3
1.4 研究範圍與限制 -------------------------------------------------------- 4
二、文獻探討 ------------------------------------------------------------------------ 5
2.1 遊民定義 ----------------------------------------------------------------- 5
2.2 遊民形成理論與因素 -------------------------------------------------- 10
2.3 遊民結構性分析 -------------------------------------------------------- 11
2.4 遊民身分及人數推估 -------------------------------------------------- 14
2.4.1 遊民身分 --------------------------------------------------------- 14
2.4.2 遊民人數推估 ----------------------------------------------------- 15
2.4.3 遊民令人懼怕的原因 -------------------------------------------- 16
2.5 英美台灣遊民問題與對策 ---------------------------------------------- 17
2.6 社會保險之功能 ---------------------------------------------------------- 20
2.6.1 現行社會保險問題 ----------------------------------------------- 21
2.6.2 我國社會保險問題分析 ----------------------------------------- 22
2.7 全民健康保險起源 ------------------------------------------------------- 25
2.7.1 全民健保組織架構與制度設計 -------------------------------- 26
2.7.2 全民健保實施成果 ----------------------------------------------- 26
2.7.3 實施全民健保後所產生之問題 -------------------------------- 27
2.8 全民健保支付制度 ------------------------------------------------------- 29
2.8.1 總額預算支付制度及優點 -------------------------------------- 30
2.8.2 全民健保制度相關之研究 -------------------------------------- 32
2.9 社經狀況與死亡率之相關研究 ---------------------------------------- 33
2.9.1 可避免死亡疾病的相關研究 --------------------------------- 33
三、研究方法 ----------------------------------------------------------------------- 35
3.1 研究流程 ------------------------------------------------------------------- 35
3.2 研究設計 ------------------------------------------------------------------- 36
3.2.1 研究實施程序----------------------------------------------------- 36
3.2.2 研究歷程 -------------------------------------------------------- 37
3.3 研究方法選擇 ---------------------------------------------------------- 37
3.4 研究樣本設計 ---------------------------------------------------------- 37
四、研究結果與討論----------------------------------------------------------------- 39
五、結論與建議----------------------------------------------------------------------- 74
5.1 研究結論 ------------------------------------------------------------------ 74
5.2 研究建議 ----------------------------------------------------------------- 76
參考文獻 ------------------------------------------------------------------------------- 79

參考文獻
[1]中央健康保險局編，1996，全民健康保險業務手冊，台北：中央健康保險局。
[2]方孝鼎，2001，台灣底層階級研究：以台中市遊民、拾荒者、原住民勞工、外籍勞工為例，東海大學社會學研究所，博士論文。
[3]王偉忠，1998，台灣地區遊民服務網絡的初步分析－以國內的四個機構為例，中正大學社會福利研究所，碩士論文。
[4]王頌華，2002，全民健康保險實施對社經狀況不同地區的國民健康影響之研究－以時間數列分析，國立台北護理學院醫護管理研究所，碩士論文。
[5]石曜堂，2001，全民健保制度的修訂，健康PLUS，1/2合併號，頁18。
[6]內政部，2004，內政部統計年報。
[7]江瑩，2001，從大台北地區之遊民服務網絡探討遊民賦權之可行性，世新大學社會發展研究所，碩士論文。
[8]全國遊民研討會大會手冊，2004，內政部。
[9]李慧玟，1994，遊民與精神疾病，臨床醫學，34卷，4期，頁306-308。
[10]李慧玟等，1994，急診室路倒病患之精神疾病，中華精神醫學，9卷，1期，頁74-80。
[11]林萬億等，1994，遊民問題之調查分析，行政院研究發展考核委員會，台北。
[12]林洸民，2002，新制度主義的迷思：我國全民健康保險制度之分析，東海大學政治學系，碩士論文。
[13]林淑珩，2001，社會經濟階層對健康行為及健康的影響：台灣的實證分析，國立台北大學，未出版之碩士論文。
[14]吳秀琪，1995，底層的社會建構與自我認同－以台北市遊民為例，清華大學社會人類學研究所，碩士論文。
[15]吳瑾嫣，1999，女性遊民研究－家的意義與城市生活經驗，台灣大學建築與城鄉研究所，碩士論文。
[16]高召恩，1995，底層的社會建構與自我認同，清華大學社會人類學研究所，碩士論文。
[17]陳大衛，2000，台灣遊民問題的結構分析，世新大學社會發展研究所，碩士論文。
[18]陳自昌，1995，遊民的社區生活與遊民服務－台北市萬華地區的遊民研究，台灣大學社會學研究所，碩士論文。
[19]許金龍，1996，台北市遊民輔導服務的省思與發展方向，福利社會，58，頁21-33。
[20]郭倩琳，1993，一群被忽略的人－遊民，護理雜誌，40卷，3期，頁75-78。
[21]曾淑芬等，2000，對我國全民健保財務政策的評析與省思，醫院，33卷，4期，頁34-48。
[22]楊志良，2000，健保實施五年之回顧與未來興革之道，中華衛誌，19卷，3期，頁159-160。
[23]楊昱琪，2001，醫院服務支付制度對住院醫療費用之影響，逢甲大學保險學系，碩士論文。
[24]黃玫玲，1995，台北市遊民生活適應問題之研究，台灣大學社會研究所，碩士論文。
[25]詹啟賢，1998，健保多元改革、體制永續發展，政策月刊，35期，頁2-3。
[26]賴美淑，2002，實施全民健康保險前後對病因死亡率變化之研究，行政院衛生署委託計畫DOH90-NH-003。
[27]鄭文輝，1994，從財源規劃探討全民健保財務問題，研考雙週刊，18卷，1期，頁39-50。
[28]鄭麗珍等，2004，遊民問題調查、分析與對策研究，行政院內政部社會司委託研究報告，台北。
[29]簡春安、鄒平儀，1998，社會工作研究法，巨流圖書公司。
[30]Acorn,Sonia,1993,Mental and Physical Health of Homeless Persons Who Use Emergency Shelters in Vsncouver, Hospital and Community Psychiatry,44:9,p854-857。
[31]Anderson, I.,＆Christian,J,2003,Causes of homeless in the UK：A dynamic analysis., Journal of Community ＆ Applied Social Psychology,13：p105-118。
[32]Bachrach, Leona L,1987,Homeless Women: A Context for Health Planning, The Milbank Quarterly 65:3,p371-396。
[33]Barker,R.L,1995,The social work dictionary（3rd ed）,Washington, DC: Nation Association of Social Workers
[34]Buckner, John C., Ellen L.Bassuk & Bonnie T.Zima,1993,Mental Health Issues Affecting Homeless Women: Implications for Intervention, American Journal of Orthopsychiat,63:3,p385-399。
[35]Burt,M..B,1992,Over the Edge, The Growth of Homelessness in the 1980s.New York, NY：Russell sage Foundation Publications。
[36]Clark,M.J,1999,Nursing in the community: Dimensions of community health nursing（3rd ed,p589-610）.Stanford, CT: Appleton & Lange。
[37]Daly, G., 1996, Homeless：Polices, Strategies, and Lives on the Street. London, UK：Rout ledge。
[38]Daly, Gerald, 1991, Health Implication of Homelessness: Report from Three Countries. Journal of Sociology & Social Welfare,17:1,p111-125。
[39]Feinstein,J.S,1993,The relationship between socioeconomic status and health :A review of the literature, Milbank Quarterly,71,2,p279-322。
[40]Feitel, Barbara, Neil Margetson, John Chamas & Clindy Lipman, 1992, Psychosocial Background and Behavioral and Emotional Disorders of Homeless and Runaway Youth, Hospital and Community Psychiatry,43:2,p155-159。
[41]Fischer, Pamela J.& William R.Breakey,1986,Homelessness and Mental Health: An Overview, International Journal of Mental Health,14:4,p6-41。
[42]Fitzpatrick, S. Kemp, p.,＆Klinker,S.,2000,Single homelessness：An overview of research in Britain .Bristol, UK：Policy Press。
[43]Gaubatz, Kathlyn T..,2001,Family homeless in Britain：More than just a housing issue, Journal of Children ＆Poverty,7,1,p3-22。
[44]House, J.S., Kessler, R.C.,& Herzog,A.R,1990,Age,socioeconomic status, and health, Milbank Quarterly ,68(3),p383-411。
[45]Jencks,C..,1994,The Homeless, Cambridge, MA：Harvard University Press。
[46]Jennifer,J.,Kuehn,1991,Homelessness：Interdisciplinary Collection Development Challenge, Collection Building,11,1,p14。
[47]Johnson,A.K.,1995, Homelessness, Encyclopedia of Social Work,19th,P1338-1447,Washington DC：National Association of Social Workers。
[48]Kutza, Eelizabeth A. & Sharon M.Keigher, 1991, The Elderly New Homeless’: An Emerging Population at Risk. Social Work, 36:4, p288-293。
[49]Lamb, H.Richard & Doris M.Lamb,1990,Factor Contributing to Homelessness among the Chronically and Severely Mentally ILL, Hospital and Community Psychiatry,41:3,p301-305。
[50]Linn, Lawrence S., Lillian Gelberg & Leake Barbara, 1990, Substance Abuse and Mentally Health Status of Homeless and 1Domiciled Low-income Users of a Medical Clinic, Hospital and Community Psychiatry,41-3,p306-310。
[51]McDonough,P.,Duncan,G.J.,Williams,D.,&House,J,1997,Income dynamics and adult mortality in the US,1972 through 1989.American Journal of Public Health,87,9,p1476-1483。
[52]North,Carol S.,Elizabeth M.Smith & Edward L.Spitznagel,1993,Is Antisocial Personality a Valid Diagnosis Among the Homeless? ,American Journal of Psychiatry,150:4,p578-583。
[53]O’Connell,M.E.,2001, Responding to homelessness：An overview of US and UK policy interventions, K Journal of Community＆Applied Psyhology,13,p158-170。
[54]O’Flaherty,B,1996,Makingroom:the economic of homeless. Cambridge Mass: Harvard University Press。
[55]Price,Viginia Ann,1989,Characteristics and Needs of Boston Street Youth: One Agency Response, Children and Youth Service Review, 11,p75-90。
[56]Ritchey,Ferris J.,Mark La Gory & Jeffrey Mullis,1991,Gender Difference in Health Risk and Physical Symptoms among the Homeless, Journal of Health and Social Behavior,32,p33-48。
[57]Robertson,Marjorie J. & Michael R.Cousineau,1986,Health Status and Access To Health Service among the Urban Homeless ,American Journal of Public Health,76:5,p561-563。
[58]Rossi,P..,1994,TroublingFamilies,AmericanBehavioralcientist,37,3:p342-395。
[59]Roth,Dee M.A.& Gerald J.Bean,Jr,1986,New Respective on Homelessness: Findings from a Statewide Epidemiological Study, Hospital and Community Psychiatry,37:7,p712-719。
[60]Simonato, L., Balland, T., Bellini, P.,& Winkelmann,R.,1998,Avoidable mortality in Europe 1955-1994:A plea for prevention, Journal of Epidemiology and Community Health, 52,10, p624-630。
[61]Snow, David A. and Leo Anderson,1993,Down on Their Luck: A Study of Homeless Street People, California: University of California Press。
[62]Spradley,B.W, & Allender,J.A,1996,Community health nursing: Concept and practice,4th ed,p552-557.Philadelphia:Lippincott。
[63]Sorlie, P.D., Backlund, E.,& Keller,J.B,1995,US mortality by economic demographic and social characteristics: The national longitudinal mortality study. American Journal of Public Health,85,7,p949-956。
[64]Spradley,B.W, & Allender,J.A,1996,Community health nursing: Concept and practice,4th ed,p552-557.Philadelphia:Lippincott。
[65]Stoner,Medeleina R.,1989,Beyond Shelter: Policy Directions for the Prevention of Homelessness, Social Work Research & Abstracts,25:4,p7-11。
[66]Third, H.,＆Yanetta,A.,2000,Homelessness in Scotland: A summery of research evidence. Edinburgh: Scottish Homes。
[67]Vredevoe,D.L,1992,Risk Factors for Disease in a Homeless Population, Publish Health Nursing,9（4），p263-269。
[68]Weinreb,Linda & John C.Buckner,1993,Homeless Family: Program Responses and Public Policies, American Journal of Orthopsychiat,63:3,p400-409。
[69]Westerling,R,1996,Studies of “avoidable” factors influencing death: A call for explicit criteria, Quality and Safety in Health Care,5,3,p159-165。
[70]Westerling,R., Gullberg, A.,& Rosen ,M,1996, Socioeconomic differences in “avoidable” mortality in Sweden,1986-1990, International Journal of Epidemiology,25,3,p560-567。
[71]Wright,James D.,1990,Poor Health: The Health Status of The Homeless, Journal of Social Issues,46:4,p49-64。