臺灣博碩士論文加值系統

背景與目的：近半個世紀以來，全球皆在廣泛的探討如何降低兒童死亡率；兒童死亡率能凸顯國家的環境、社會、經濟及醫療服務品質好壞；文獻指出，家庭社經地位與居住地所在地區之社經狀況對兒童死亡率均有相當程度的影響。本研究旨在利用台灣地區出生登記資料連結至死因登記資料分析父母親教育程度與居住所在地區都市化程度對新生兒死亡率、嬰兒死亡率及5歲以下兒童死亡率之影響，並比較個人層級（家庭社經）與區域層級（都市化程度）社經指標兩者對兒童在各年齡期全病因及主要死因別死亡率影響程度之相對大小。
材料與方法：本研究利用1996-2000年台灣地區出生登記資料中共1,501,620位新生兒與1996-2004年死因登記資料進行串聯，以獲得此出生世代5歲以下死亡之相關訊息；接著依都市化程度與父母親教育程度單獨（各區分為高低兩組）或合併分為四組（低都市化且低教育程度（Type I）、低都市化且高教育程度（Type II）、高都市化且低教育程度（Type III）及高都市化且高教育程度（Type IV）進行分析。統計分析包括計算全死因與死因別死亡人數與死因別死亡分率；並以邏輯斯迴歸模式計算父母親教育程度與居住地區都市化程度對新生兒、嬰兒、與5歲以下兒童全死因及病因別死亡之粗勝算比（odds ratio，OR）及調整後勝算比（adjusted odds ratio，AOR）。
結果：本研究發現周產期病態（ICD-9：E760-779）是新生兒死亡、嬰兒死亡及5歲以下兒童死亡的最主要原因，其中Type II樣本者所佔的死亡分率最高；此外，相較於父母親教育程度較高者，較低父母親教育程度之樣本其新生兒期、嬰兒期、及五歲以下兒童之調整後全死因死亡勝算比皆顯著增加，其中以5歲以下兒童之事故傷害（AOR=1.69，95% confidence interval （CI）=1.47-1.94）死亡勝算比最高且達統計顯著意義；而相較於都市化程度較高者，居住於都市化程度較低兒童之全死因死亡勝算比亦顯著增加，而死因別死亡勝算比則是以嬰兒（AOR=1.74，95% CI=1.04-2.94）及5歲以下兒童（AOR=2.06，95% CI=1.44-2.94）呼吸道疾病死亡勝算比較高。樣本分為四組後的分析發現，相較於Type IV組（參考組），Type I組兒童在新生兒期、嬰兒期、與5歲以下兒童之全死因死亡勝算比皆顯著增加，分別為：1.71、1.58及1.60。本研究也發現相較於參考組樣本，Type II樣本之5歲以下兒童周產期病態（AOR=1.40，95% CI=1.24-1.59）、先天性畸形（AOR=1.25，95% CI=1.09-1.44）、呼吸道疾病（AOR=2.18，95% CI=1.08-4.39）、惡性腫瘤（AOR=1.65，95% CI=1.06-2.56）與白血病（AOR=2.78，95% CI=1.34-5.75）等死因之死亡勝算比都顯著增加，且數值大於Type III樣本之相對應死因別勝算比數值。
結論：本研究結果顯示：父母親低教育程度與居住於低都市化程度地區都對兒童於各年齡期之死亡風險有不良的影響，而居住於低都市化地區且父母為低教育程度之兒童其相對死亡風險最高；此外，低都市化且高教育程度組之5歲以下兒童全死因與多種死因死亡勝算比均高於高都市化且低教育程度組織相對應數據，顯示居住環境相關之危險因子對5歲以下兒童死亡之影響大於與父母教育程度之影響；建議衛生單位對於都市化程度較低地區中家庭社經地位也較低之兒童，應提供更多之健康與醫療照護資源，並加強落實兒童安全與健康教育。此外，有鑑於區域層級社經因素較個人層級社經因素對兒童死亡率的影響為大，本研究也建議：對於都市化程度較低地區亦應要訂定有效策略降低疾病之危險因子，並提高醫療照護服務之可近性以增進疾病發生後之預後情形。

Background & Objectives: Over the past half century, worldwide investigations have been conducted in an attempt to reduce the risk of children’s mortality, which can best reflect the quality of environment, social factors, and health care services. Previous studies indicated that both family socioeconomic status (SES) and the socioeconomic class of residential area may pose substantial influences on children’s mortality. The present study linked Taiwan’s birth registry (TBR) to death registry (TDR) to investigate whether or how parent’s educational attainment and urbanization level of residential area may affect neonatal, infant, and under 5 mortalities, and to compare the magnitude of influence posed by socioeconomic status at individual (family) and area levels.
Materials & Methods: A total of 1,501,620 live births were retrieved from TBR between 1996 and 2000, who were then linked to TDR of 1996-2004 to obtain the information concerning mortality under 5 years of age. The study subjects were categorized into groups according to levels of parental education and urbanization, separately (high and low) and jointly (low urbanization/low education (Type I); low urbanization/high education (Type II); high urbanization/low education (Type III); and high urbanization/high education (Type IV). The statistical analyses included calculation of numbers of death from all-causes and certain specific causes as well as calculation of cause-specific proportions of mortality. We then employed logistic regression model to assess the unadjusted odds ratios (ORs) and adjusted ORs (AORs) of neonatal, infant, and under 5 mortalities in relation to parental educational and urbanization levels, separately and jointly.
Results: The study showed that “certain conditions originating in the perinatal period (ICD-9：E760-779) ” was the most common cause of death at various ages, and children with higher educated parents and living in less urbanized areas had the highest proportion mortality rate of perinatal conditions. Additionally, compared to children with higher educated parents, those born to lower educated parents experienced significantly increased risks of neonatal, infant, and under 5 mortalities in which the injury related under 5 mortality was most increased (AOR=1.69, 95% confidence interval (CI)=1.47-1.94). On the other hand, less urbanized areas were also associated with a significantly increased risk of mortality in children, and the respiratory related mortality during infancy (AOR=1.74, 95% CI=1.04-2.94) and under 5 years (AOR=2.06, 95% CI=1.44-2.94) tended to demonstrate the strongest associations with lesser urbanization. When the study subjects were categorized into four groups (reference group: Type IV), we noted that children in Type I group experienced the most increased risks of neonatal, infant, and under 5 mortalities, with an AOR of 1.71, 1.58, and 1.60, respectively. Additionally, compared to the reference group, children in Type II group experienced significantly higher ORs of under 5 mortality from certain conditions originating in the perinatal period (AOR=1.40, 95% CI=1.24-1.59), congenital abnormalities (AOR=1.25, 95% CI=1.09-1.44), respiratory disease (AOR=2.18, 95% CI=1.08-4.39), neoplasm (AOR=1.65, 95% CI=1.06-2.56), and leukemia (AOR=2.78, 95% CI=1.34-5.75). And the above AORs were greater than the corresponding figures for the children in Type III group.
Conclusion: This study demonstrated that lower parental education and living in less urbanized areas were both adversely associated with risk of mortality in children of various ages. Additionally, children of parents with lower educational attainment and from less urbanized areas were at the most increased risk of mortality. Moreover, ORs of all-causes and various cause-specific mortalities were higher in children with higher educated parents but from lower urbanized areas than in those with lower educated parents but living in higher urbanized areas. Such findings were most obvious for under 5 mortality, suggesting that the risk factors associated lesser urbanization posed greater adverse influences on under 5 mortality than the familial socioeconomic related risk factors for mortality. We therefore suggest that health authority should consider provision of more health and medical care resources for children from lower SES families and living in less urbanized areas. Advanced health education and life safety programs should also be provided for those socially deprived children. Moreover, given a greater adverse influence posed by urbanization related factors than by individual family related factors, we also suggest a need of strategies that can effectively reduce the prevalence of disease risk factors and improve disease prognosis through enhancing the accessibility of medical care services in less urbanized areas.

目錄
摘要 I
目錄 VII
表目錄 IX
圖目錄 X
第一章 前言 1
第一節 研究動機 1
第二節 研究目的 4
第二章 文獻探討 5
第一節 個人層級社會經濟地位與死亡率 5
第二節 區域層級社會經濟地位與死亡率 10
第三節 個人層級與區域層級社經地位與死亡率 13
第三章 材料與方法 16
第一節 資料來源 16
第二節 資料處理 17
第三節 研究世代之擷取以及與死亡資料之串聯 19
第四節 資料分析 21
第四章 結果 25
第一節 研究樣本特性 25
第二節 研究樣本於各年齡其死因及死亡人數分布 27
第三節 父母親教育程度與兒童及嬰幼兒全死因及死因別死亡勝算之邏輯斯迴歸分析 29
第四節 居住地區都市化程度與兒童及嬰幼兒全死因及死因別死亡勝算之邏輯斯迴歸分析 30
第五節 合併都市化程度與父母教育程度分組後之邏輯斯迴歸分析 32
第五章 討論 36
第一節 本研究主要發現 36
第二節 個人層級社會經濟地位對兒童死亡率之影響 37
第三節 區域層級社會經濟地位對兒童死亡率之影響 38
第四節 合併個人層級與區域層級社經地位對兒童死亡率之影響 40
第五節 本研究之優點與限制 43
第六節 結論 45
參考文獻 46
附錄 81
附錄一 研究世代變項整理表 81
附錄二 台灣地區359 鄉鎮市區分層研究結果表 85

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