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研究生:蔡孟哲
研究生(外文):Meng-CheTsai
論文名稱:青少年健康需求與醫療服務使用之探討
論文名稱(外文):Exploration of adolescent health needs and health service utilization
指導教授:林秀娟林秀娟引用關係林聖翔林聖翔引用關係
指導教授(外文):Shio-Jean LinShio-Jean Lin
學位類別:碩士
校院名稱:國立成功大學
系所名稱:臨床醫學研究所
學門:醫藥衛生學門
學類:醫學學類
論文種類:學術論文
論文出版年:2013
畢業學年度:101
語文別:中文
論文頁數:90
中文關鍵詞:青少年健康照護服務健康需求醫療資源利用健康資訊
外文關鍵詞:Adolescentheath care servicehealth needshealth care utilizationhealth information
相關次數:
  • 被引用被引用:3
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  • 下載下載:94
  • 收藏至我的研究室書目清單書目收藏:1
背景
青少年是重要過渡時期,此時身體、心靈與社會層面的重大改變,可能會影響終身健康狀況,世界衛生組織近來呼籲發展青年親善健康服務,醫療服務設計應當考量在地社會文化,因此傾聽健康照護使用者也就是青少年的心聲,將有助於建立更適切的健康服務。本研究目的乃為調查台灣青少年醫療照護的經驗與期望,同時瞭解他們對於健康議題的看法,以及追蹤觀察青少年健康問題的趨勢變化。
方法
第一部分研究係以深入訪談和問卷調查方式進行。第一階段採立意取樣方式挑選家長與老師進行深入訪談,並且招募學生進行焦點團體訪談,訪談主要試圖了解他們對於青少年健康現況的看法、健康照護的需求、照護服務的使用、以及健康照護的期待,分析方式以三角交叉檢視法分析轉謄後的訪談內容逐字稿,歸納整理質性資料,並融入設計青少年健康需求問卷,俟後進行專家效度審核,邀請健康促進社團學生進行問卷先行信度與效度測試,該社團乃針對本研究而設計,而最終問卷包含43項關於青少年健康需求、健康服務使用、與青少年認為親善醫師或者場所應具備的條件等問題。第二階段以分層群集抽樣方式,挑選出台南市內15所國中與15所高中職,共5050位學生發放問卷,爾後統計分析方式包含:(1)描述性統計與Pearson X2統計分析比較不同人口背景因素的青少年對於健康知識需求、健康資訊來源、使用醫療資源行為等差異;(2)因素分析萃取青少年健康知識需求分類,(3)序列廻歸方法分析青少年健康知識需求程度與自我評估健康狀態的相關決定因子;(4)多變數廻歸方法分析密集使用醫療照顧者的人口背景的特性;(5)無母數分析方法的Wilconxon符號等級檢定比較排序青少年親善醫師或者場所需具備的條件,係採連續性同質比較法,若兩連續項目出現差異,則列入不同等級,續以two-sample Kolmogorov-Smirnov檢定與Kruskal-Wallis檢定比較不同人口背景因素的青少年認為親善醫師或者場所應該具備條件的排序差異。
第二部分研究為全民健康保險資料庫研究。第一階段描述10-21歲青少年於2000-2009年間全民健康保險資源使用的情形與趨勢,藉以了解青少年就醫行為的實際樣貌,以住院疾病申請為例,以2000年健保資料庫中百萬歸人檔、住院檔、與承保檔為研究材料,使用描述性統計分析青少年於不同年齡時期,以及於研究期間不同年代的青少年,住院的比例、住院的原因與住院的科別的差異,統計方法係採描述性統計和趨勢分析。第二階段以腦部外傷與情感性精神病為例,研究對象為於2000-2004年於門診或者住院診斷為腦部外傷且年齡需在10-24歲的病患,以及年齡、性別相配且於同年使用醫療服務者為對照組,至於腦傷前曾被診斷為情感性精神病者則排除在外,最終形成無情感性精神病的研究追蹤世代,應用Cox比例風險回歸分析,計算五年後腦部外傷導致情感性精神病所增加的風險,結果以風險比率表示,並附上95%信賴區間。
結果
於第一部分研究中,質性訪談分析歸納出青少年有多元不同的身體、心理、社會、以及行為相關的健康問題,他們的就醫行為也受到多種不同因素影響,在隨後的問卷研究中,共有5018有效問卷(回覆率99.4%),結果發現受訪學生主要關心的健康議題為身高體重,接著為飲食健康、青春痘、運動與傷害預防,以及課業壓力,經多變數校正後,許多社會人口特性,像是普通高中、近郊學校、以及慢性疾病均與較高健康需求相關,僅有少數青少年因其健康需求使用健康醫療服務,而父母仍為他們健康資訊首選來源,但近年媒體與網路則逐漸受到高中生歡迎成為常使用來源之一,特別是較為敏感的健康問題,如性與行為問題等。學生的自述健康狀態取決於性別、年齡、慢性疾病有無,與家庭關係。密集使用醫療服務者,通常為女性、高職生、有慢性疾病、與自述健康狀況不佳者,其中以後二者最為重要。在台灣僅有四成青少年有常看醫師,其中最常選看小兒科醫師,但比例隨年齡增加而下降,絕大部分青少年需要家長陪同看診,而將近七成選擇附近診所就醫。青少年親善醫 師首重醫師的能力與耐心,而擁有友善熱於幫助的工作人員則是最重要的親善場所特質,有無慢性疾病與自述健康狀況不影響他們對於親善特質的排序。
於第二部分研究中,由全民健康保險資料庫得知青少年住院比率隨年齡增加而增加,但於不同的年代,增加的趨勢有些許不同,近年早期青少年(10-14歲)住院的比率逐漸增加,而晚期青少年(18-21歲)住院的比率則逐漸下降,而青少年住院原因中,高踞前兩位分別是「外傷或者中毒」與「懷孕」相關的診斷,然則這兩者近年有逐漸下降的趨勢。住院科別亦有不同的變化,青少年最常住院的科別於2000年是外科,但近年最常住院的科別則是小兒科,而婦產科的住院比率亦是逐年下降。而在青少年腦部外傷與情感性精神病的相關性分析當中,總共有451位腦部外傷病人(佔總數15023人的2.97%)於五年追蹤期間中被診斷出罹患情感性精神病,相對於1153位年齡與性別配對的對照病人(佔總人數76015人的1.52%)被診斷出罹患情感性精神病,罹病率明顯增加,經調整區域變項、保險類別與共病變項後,發生腦部外傷仍是情感性精神病的重要相關因子,比對照組病人增加2.04倍(95%信賴區間1.82-2.29)的風險。
結論
台灣青少年對於健康需求、健康資訊來源、健康需求與健康服務使用、以及青少年親善服務等表達多種不同的看法,背景文化可能會影響青少年自述健康狀態、健康照護使用、以及對青少年親善醫療服務的偏好,健康照護資源利用隨年齡性別與年代有異,而青少年疾病可能互相影響,加強並促進年輕人健康知識與自我照護能力可能會減緩因青春期問題所帶來不好的健康負擔。
Background
Adolescence is an important transition period, while the physical and psychosocial changes may have an impact on the health status in the later life. The World Health Organization has called for the development of youth-friendly health service. Design of healthcare service should meet the considerations of local societal context. Listening to the voices of healthcare users (i.e. adolescents) may help to create an appropriate health care service. This study is to investigate Taiwanese adolescents’ experience and expectation of health care service, understand their points of view on health concerns, and monitor trends of their health problems.
Methods
Part I: Interview and questionnaire-based survey. The first stage involved a purposive sampling of parents and teachers in in-depth interviews and high school students in focus group discussion. Discussions were mainly to generate key questions upon their ideas on adolescent health concerns, health service utilization, and healthcare expectation. Triangulation method was applied to analyze the word-to-word transcripts of discussions. The results of qualitative study were incorporated into the design of the questionnaire. The final version of questionnaire contained 43 items concerning health needs, health service use, preferences for adolescent-friendly health services. The questions were validated by a panel of experts and pilot-tested for reliability on students enrolled in health-promotion club specifically organized for the study. The second stage involved a stratified cluster sampling of 5050 students from 15 junior and 15 senior high schools in Tainan. Statistics included: (1) descriptive statistics and Pearson X2 test to compare differences in health needs, health information sources, and healthcare-seeking behaviors among different demographic subgroups; (2) factor analysis to extract the main category of adolescent health needs; (3) ordinal logistic regression analysis to identify the determinants of adolescent health needs and self-perceived health status; (4) multinominal logistic regression to analyze sociodemographic characteristics of the frequent healthcare users; (5) nonparametric analysis with Wilconxon sign rank test to compare the ranking of requirement for youth-friendly clinicians and clinical sites if there is comparative homogenous difference in two consecutive rankings; and with two-sample Kolmogorov-Smirnov test and Kruskal-Wallis test to compare differences in preferences for youth-friendly clinicians and clinical sites among different demographic subgroups.
Part II: National Health Insurance Research Database (NHIRD)-based analysis. The first stage was to describe the pattern and trend of use of medical resources during 2000-2009, in order to understand the real-world adolescent healthcare use. Descriptive and trends analyses on the inpatient claims were conducted to compare the rates of hospitalization, causes of admission and specialties of healthcare in adolescents with different age and year. The second stage used traumatic brain injury (TBI) and mood disorder (MD) as examples. Patients aged between 10-24 years who received a major diagnosis of TBI in ambulatory visits or hospitalization during year 2000 to 2004 were recruited along with age- and gender-matched insurants, who had the index use of health service in the same event year. Meanwhile, individuals with history of MD prior to TBI or index use of health service were excluded to create a MD-naïve cohort. Diagnosis of MD in the 5 follow-up years was described. Increased risk was represented by hazard ratios with 95% confidence intervals in Cox proportional hazard regression analysis.
Results
In the Part I, results of the qualitative study summarized a diversity of physical, psychosocial and behavioral health concerns among adolescents. Their healthcare-seeking behaviors were determined by multiple factors. The following questionnaire-based survey received 5018 valid questionnaires, representing a response rate of 99.4%. The leading health concerns among surveyed adolescents were weight and height, followed by dietary health, acne, sports/injury prevention, and academic stress. After multivariate adjustment, several socio-demographic variables, including general high school program, suburban location, and presence of chronic illness, were associated with higher health needs. Only a minor portion of adolescents used healthcare service for health concerns, while parents remained as their primary source of health information. However, mass media and internet gained popularity as frequently-sought sources among senior high school students. The health status of surveyed students was determined by gender, age, presence of chronic illness and family relationship. Frequent users of healthcare were usually those who were female, vocational high school student, with chronic illness and poor perceived health status; the last two factors were more important. Only 40% of Taiwanese adolescents had a regular doctor and pediatricians were most referred to. The adherence declined with age. While the vast majority of students needed parents’ company in a medical visit, nearly 70% usually visited local clinic. In regards of youth-friendly service, competence and patience were highest ranked for clinicians’ characteristics, and friendly and helpful personnel was the most important requirement for clinical sites. Chronic illness and health status did not affect their view on youth-friendliness.
In the part II, the analysis of NHIRD showed that hospitalization rate of adolescents increased with age and varied with different years. While the hospitalization rate of young adolescents (10-14 years) increased with time; that of elder adolescents (18-21 years) decreased. The causes of hospitalization also changed with time. Worthy of attention is that the main causes were “injury or poisoning” and “pregnancy-related” diagnosis. However, the both causes decreased recently in percentage. The major specialty of hospitalization for adolescents was surgery in 2000; and that was pediatrics in 2009. Admission to obstetrics also declined. Correlation analysis of TBI and MD showed that a total of 451/15023 patients with TBI (2.97%) received a diagnosis of MD in the 5-year follow-up period, in comparison to 1153/76015 individuals (1.52%) in the matched control group. After adjusting for geographical location, enrollee category and selected comorbidities, TBI remains a significant predisposing factor with a 2.04-fold (95% CI 1.82-2.29) increased risk of MD.
Conclusion
Taiwanese adolescents expressed diverse views on health needs, preferred sources of health information, disparity between needs and health service use, and expectation on adolescent friendliness. Contextual factors may influence self-perceived health status, health service use, and preferences for adolescent-friendly health service. Healthcare utilization among adolescents varied according to age, gender, and year. Interaction may occur between prevalent diseases in adolescence. Enhancing young people’s health literacy may be able to alleviate adverse health consequences attributed to adolescent problems.
目錄
中文摘要------------------------------------------------------------------------------------------------I
英文摘要----------------------------------------------------------------------------------------------III
致謝----------------------------------------------------------------------------------------------------VI
目錄--------------------------------------------------------------------------------------------------VIII
表目錄-------------------------------------------------------------------------------------------------IX
圖目錄--------------------------------------------------------------------------------------------------X

第一章 緒論------------------------------------------------------------------------------------------1
第一節 研究背景------------------------------------------------------------------------------1
第二節 研究目的------------------------------------------------------------------------------3
第二章 文獻探討------------------------------------------------------------------------------------4
第三章 研究方法與結果討論---------------------------------------------------------------------7
第一節 質性訪談研究------------------------------------------------------------------------7
第二節 量性問卷研究----------------------------------------------------------------------19
第三節 追蹤性資料庫研究----------------------------------------------------------------51
第四節 推論性資料庫研究----------------------------------------------------------------63
第四章 總結----------------------------------------------------------------------------------------72

參考文獻----------------------------------------------------------------------------------------------74
附錄----------------------------------------------------------------------------------------------------81
附錄一 焦點團體訪談大綱 (家長、教師版)--------------------------------------------81
附錄二 焦點團體訪談大綱 (學生版)-----------------------------------------------------82
附錄三 抽樣說明(高中生)-------------------------------------------------------------------83
附錄四 抽樣說明(高職生)-------------------------------------------------------------------84
附錄五 抽樣說明(國中生)-------------------------------------------------------------------85
附錄六 台南地區青少年健康照顧需求狀況調查問卷---------------------------------86
附錄七 研究成果發表列表------------------------------------------------------------------90
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38.Haavet OR, Straand J, Hjortdahl P, Saugstad OD. Do negative life experiences predict the health-care-seeking of adolescents? A study of 10th-year students in Oslo, Norway. J Adolesc Health 2005;37:128-34.
39.Haller DM, Sanci LA, Patton GC, et al. Toward youth friendly services: A survey of young people in primary care. J Gen Intern Med 2007;22:775-81
40.Haller DM, Meynard A, Pejic D, Sredic A, Huseinagic S, Courvoisier DS, Perone N, Sanci LA, Narring F. YFHS-WHO+ Questionnaire: validation of a measure of youth-friendly primary care services. J Adolesc Health 2012;51:422-30
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