跳到主要內容

臺灣博碩士論文加值系統

(44.200.140.218) 您好!臺灣時間:2024/07/26 01:35
字體大小: 字級放大   字級縮小   預設字形  
回查詢結果 :::

詳目顯示

: 
twitterline
研究生:曾圓惠
研究生(外文):Yuan-Hui Tseng
論文名稱:偏鄉居民的中醫定期義診利用情形與就醫脈絡初探:以台坂村為例
論文名稱(外文):Utilization and context of a long-term voluntary traditional Chinese medical service in the remote village of Taiban
指導教授:許中華許中華引用關係曾育慧曾育慧引用關係
指導教授(外文):Chung-Hua HsuMayeesha Yu-Hwei Tseng
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:傳統醫藥研究所
學門:醫藥衛生學門
學類:藥學學類
論文種類:學術論文
論文出版年:2020
畢業學年度:108
語文別:中文
論文頁數:96
中文關鍵詞:中醫義診偏鄉醫療社會生態學模式
外文關鍵詞:Traditional Chinese medicineMedical service tripsRural healthSocial ecological model
相關次數:
  • 被引用被引用:0
  • 點閱點閱:213
  • 評分評分:
  • 下載下載:14
  • 收藏至我的研究室書目清單書目收藏:0
  山區偏鄉由於交通不便、人口稀少且分散,醫療資源普遍缺乏,還有多種其他面向的因素也同樣可能導致就醫過程的困難。中醫具有驗、便、廉、效等特性,診法使用望、聞、問、切等四診,治法使用一砭、二針、三灸、四藥、五按蹺,機動性極高,適合移動性醫療服務。由臺北市立聯合醫院中醫中心與社團法人中華芸生會共同舉辦的中醫免費門診服務,自2015年11月起在台東縣達仁鄉台坂村提供醫療服務迄今。本研究分析義診病患就診病歷,呈現開辦以來之利用情形,同時透過質性研究搜集山區偏鄉居民使用基層醫療和中醫義診的經驗,探索山區偏鄉病患使用中醫義診之因素。質性研究運用社會生態學模型作為理論架構,透過參與式觀察和深度訪談的資料搜集方式,以及中華芸生會志工日誌內容,探討偏鄉民眾對當地醫療服務的利用狀況與促進前往中醫義診看病之動機。

  分析病歷有關服務利用的面向,研究期間從2015年11月至2019年2月,服務病患共335名,累計共1848人次。有半數以上的病患年齡分布在五十至七十歲。累計病患當中,來自無中醫鄉(達仁鄉、大武鄉、金鋒鄉、鹿野鄉、瑪家鄉、恆春鎮)者占47%。每年台坂村平均有11%~13%(3年平均值)的人口使用義診服務;平均每人就醫 0.53-0.57次(3年平均值)。病患回診情形,每人平均就醫1.04-2.05次(3年平均值)。不同年齡的病患,就診次數具顯著差異;且當病患愈傾向於使用傷科,回診次數愈高。

  研究也發現,山區偏鄉病患在求醫的選擇過程中,會受到社會經濟、勞動職業傷害等影響,在就醫與工作兩相權衡之下,通常會偏向於選擇維持溫飽,以減少因為生病或看病而造成收入損失;而在職場中無法避免的高負荷機械式動作,經常迫使病痛反覆發作。在醫療資源的安排上,距離方便性與時段方便性,構成病患能否前往看病的主因;而治療項目的種類多寡,也成為吸引病患就醫的因素。雖義診團隊屬自願服務,無法維持固定醫師,但相較當地巡迴中醫固定醫師,義診能提供不同科別的選擇,而不僅限於單獨醫師專長。研究結果也呈現出病患如何透過當地的社交網絡,來幫自己尋求義診醫治;促成病患前往義診看病的個人因素,包括:個人經驗對中醫的認知與信任、使用者依賴的中醫特點、病患對醫生看病態度的感知。

  本研究透過社會科學研究方法,發現義診的存在提供中醫醫療的可近性,且中醫醫療的形式與內涵能符合在地生態,使得當地民眾對於中醫的接受度亦高,有利於滿足偏鄉居民部分的醫療需求。
Due to inconvenient transportation, sparse and scattered population, insufficient medical resources and other socioeconomic factors, those living in mountainous areas face multiple barriers when they seek medical intervention. In this context, traditional Chinese medicine (TCM) has several strengths to address the needs of this community. Since November 2015, a voluntary TCM camp jointly organized by the Traditional Chinese Medicine Center of the Taipei City Hospital and a non-governmental organization Yuensen Convention has been providing care in a predominantly Paiwan tribe Taiban Village, Daren Township, Taitung County. The study analyzed the medical records of TCM camp to understand different aspects of the service utilization. Furthermore, qualitative research methods were used to provide an overall picture of lives and health in the village, and explore the patient motivation, perception and experience of using the TCM service. The social ecological model provided the theoretical insight and framework to interpret and combine both quantitative and qualitative data.

Between November 2015 and February 2019 there were 335 patients with a total number of 1,848 visits. More than half of the patients aged between 50 and 70 years. Among the patients, 47% came from 6 townships without TCM facilities in Taitung County and Pingtung County. In Taiban Village alone, 11% to 13% of the population visited the TCM camp, with each person paying 0.53-0.57 visits per year (3-year average). Of all patients, the average number of visits was 1.04-2.05 (3-year average) per person. Patients in different age groups showed significant differences in the number of visits. The more patients visited due to physical injuries, the higher the number of revisits.

Utilization of TCM service among patients was affected by socioeconomic factors. Patients usually had to weigh between seeking medical care and work, and eventually chose the latter to save money or avoid loss of income. Those whose jobs involved a lot of physical labor suffered from recurring health problems. In the aspect of resources, the timing and location constituted the main reasons why patients used the TCM service; the variety of services was another factor that patients found TCM useful. The voluntary TCM camp had a different mix of physicians each time, but was relatively diverse comparing with the existing TCM arrangement provided by the government. The study also shows how patients helped themselves to seek TCM service through local social networks. Finally, the study summarizes individual factors facilitating utilization of the TCM service, including trust as a result of previously personal experience, specific characteristics of TCM which attracted patients, and perception of health care providers' attitude and dedication.

This study shows that provision and arrangement of the voluntary, regular TCM service enhanced availability of and accessibility to TCM in the remote village of Taiban. The high acceptance of TCM among the local people reflected the ability of TCM to suit the local context and satisfy some of the unmet needs.
誌謝..................................II
摘要..................................i
Abstract................................iii
目錄..................................vi
表目錄.................................viii
圖目錄.................................viii
第一章 緒論 ..............................1
第一節 研究背景與重要性 ........................1
第二節 研究目的與問題 .........................3
第二章 文獻回顧 ............................4
第一節 原住民的健康不平等 .......................4
第二節 中醫於山區偏鄉實行之特性 ....................7
第三節 義診的現況及核心議題 ......................8
第四節 社會生態學模式理論 .......................10
第三章 研究方法與設計 .........................13
第一節 義診團隊組成 ..........................13
第二節 研究方法 ............................14
一、 病歷研究之執行 ..........................15
二、 參與式觀察、深度訪談與志工日誌剖析 ................16
第三節 研究倫理 ............................23
第四章 研究結果 ............................24
第一節 中醫義診服務利用情況與就診特性 .................24
一、 研究對象來源地區及社會人口學特質 .................24
二、 中醫義診服務利用情況 .......................29
三、 研究對象社會人口學特質對義診療法之使用情況 ............34
四、 就診人次之科別分布 ........................35
五、 回診特性之相關性分析 .......................38
第二節 義診就醫因素之社會生態學架構 ..................41
一、 研究場域概觀 ...........................41
二、 當地醫療現況 ...........................43
三、 影響就醫選擇之社會脈絡因素 ....................49
四、 醫療資源可近性 ..........................54
五、 社交網絡 .............................62
六、 個人因素 .............................63
第五章 討論 ..............................71
一、 義診利用之個人因素與台坂地區對中醫的高接納性 ...........71
二、 義診治療成效以及社交網絡的漣漪 ..................72
三、 義診提升無中醫鄉的中醫醫療可近性 .................73
四、 職業性質對傷科的需求 .......................74
五、 社經條件對就醫之影響 .......................76
六、 中醫義診服務的角色與重要性 ....................77
第六章 結論與建議 ...........................78
參考文獻 ...............................81
附錄一 訪談大綱 ............................89
一、 病人訪談大綱 ...........................89
二、 志工訪談大綱 ...........................90
附錄二 核准公文及義診團隊志工名單 ...................92
一、 人體研究倫理審查委員會核准函 ...................92
二、 原住民族委員會核准函 .......................93
三、 臺東縣衛生局核准函 ........................94
四、 歷年義診團隊志工名單 .......................96

表目錄
表 1受訪病患基本資料 ..........................21
表 2 受訪志工基本資料..........................22
表 3 義診病歷社會人口學特質與就診資料..................26
表 4 義診病歷人口來源地區分布......................28
表 5 義診服務利用情況(所有病患、來自無中醫鄉病患、來自台坂村病患)...31
表 6 義診服務利用率(有就醫者平均就醫次數)...............32
表 7 義診病歷社會人口學特質對療法的使用狀況...............34
表 8 中醫義診病患就診科別人次及百分比..................35
表 9 義診病歷性別對就診次數之相關性...................37
表 10 義診病歷年齡對就診次數之相關性 ..................37
表 11 義診病歷就診科別對就診次數高低之相關性 ..............39
表 12 受訪病患利用台坂村周邊醫療單位基本資訊 ..............43


圖目錄
圖 1 義診病歷人口來源地區分布 ......................29
圖 2 義診服務利用率 ...........................33
圖 3 義診病歷就診人次科別百分比分布趨勢 .................36
圖 4 義診病歷年齡與平均就診次數散佈圖 ..................38
圖 5 義診病歷不同就診次數之年齡與人數分布圖 ...............38
圖 6 達仁鄉台坂村與周邊村落 .......................40
圖 7 台坂村排灣族部落 ..........................41
圖 8 台坂國小–臺灣體操選手搖籃 .....................41
圖 9 部落地圖 ..............................44
圖 10 促進居民前往中醫義診看病之動機 ..................47
Adler, N. E., & Newman, K. (2002). Socioeconomic disparities in health: pathways and policies. Health affairs, 21(2), 60-76.

Agency for Healthcare Research and Quality. (2017). National Healthcare Disparities Report. https://www.ahrq.gov/sites/default/files/wysiwyg/research/findings/nhqrdr/2017qdrappb.pdf.

Andersson, L. M., Schierenbeck, I., Strumpher, J., Krantz, G., Topper, K., Backman, G., ... & Van Rooyen, D. (2013). Help-seeking behaviour, barriers to care and experiences of care among persons with depression in Eastern Cape, South Africa. Journal of affective disorders, 151(2), 439-448.

Arcury, T. A., Gesler, W. M., Preisser, J. S., Sherman, J., Spencer, J., & Perin, J. (2005). The effects of geography and spatial behavior on health care utilization among the residents of a rural region. Health services research, 40(1), 135-156.

Belgrave, F. Z., & Brevard, J. (2016). African American boys. Springer-Verlag New York.

Benach J, Muntaner C. (2007). Precarious employment and health: developing ia research agenda. Journal of Epidemiology and Community Health, 61(4),276-7.

Benach, J., Benavides, F. G., Platt, S., Diez-Roux, A., & Muntaner, C. (2000). The health-damaging potential of new types of flexible employment: a challenge for public health researchers. American Journal of Public Health, 90(8), 1316.

Blouin C, Chopra M, van der Hoeven R. . (2007). Trade and Social Determinants of Health. Lancet, 373(9662), 502-7.

Bromfenbrennner, U., & Bronfenbrenner, U. (1979). Ecology of human development: Ex-periments by nature and design.

Bronfenbrenner, U. (1992). Ecological systems theory. Jessica Kingsley Publishers.

Buck D. . (2014). Local action on health inequalities: Understanding the economics of investments in the social de-terminants of health. London: Public Health England/UCL Institute of Health Equity.

Campbell, K. E., Marsden, P. V., Hurlbert, J. S. (1986). Social resources and socioeconomic sta-tus. Social Networks 8, 97-117.

Chen, Y.(2003). Pain experience: A sociocultural analysis of the aborigines in Hualien, Taiwan.

Commission on the Social Determinants of Health. (2008). Closing the gap in a generation: health equity through action on th social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization.

Cook, A. F., & Hoas, H. (2001). Voices from the margins: a context for developing bioeth-ics-related resources in rural areas.

DeCamp, M. (2007). Scrutinizing global short-term medical outreach. Hastings Center Re-port, 21-23.

Farmer, J., Iversen, L., Campbell, N. C., Guest, C., Chesson, R., Deans, G., & MacDonald, J. (2006). Rural/urban differences in accounts of patients’ initial decisions to consult primary care. Health & place, 12(2), 210-221.

Green, T., Green, H., Scandlyn, J., & Kestler, A. (2009). Perceptions of short-term medical volunteer work: a qualitative study in Guatemala. Globalization and health, 5(1), 4.

Greene, J. C., Caracelli, V. J., & Graham, W. F. (1989). Toward a conceptual framework for mixed-method evaluation designs. Educational evaluation and policy analysis, 11(3), 255-274.

Hamoudi A, Sachs J. (1999). Economic Consequences of Healh Status: A Review of the Evience. Massachusetts: Center for International Development at Harvard University.

Härkönen, U. (2001). The Bronfenbrenner ecological systems theory of human develop-ment.

Hart, J. T. (1971). The inverse care law. The Lancet, 297(7696), 405-412.

Hege, A., Ball, L., Christiana, R. W., Wallace, C., Hubbard, C., Truesdale, D., ... & Fleming, H. (2018). Social Determinants of Health and the Effects on Quality of Life and Well-being in 2 Rural Appalachia Communities: The Community Members' Perspective and Implica-tions for Health Disparities. Family & community health, 41(4), 244-254.

Jiang, W. Y. (2005). Therapeutic wisdom in traditional Chinese medicine: a perspective from modern science. Trends in pharmacological sciences, 26(11), 558-563.

Kawachi, I. (2000). Income inequality and health. Social epidemiology, 76, 94.

Keji, C., & Hao, X. U. (2003). The integration of traditional Chinese medicine and Western medicine. European Review, 11(2), 225-235.

Koplan, J. P., Bond, T. C., Merson, M. H., Reddy, K. S., Rodriguez, M. H., Sewankambo, N. K., & Wasserheit, J. N. (2009). Towards a common definition of global health. The Lan-cet, 373(9679), 1993-1995.

Lutfiyya, M. N., McCullough, J. E., Saman, D. M., Lemieux, A., Hendrickson, S., McGrath, C. A., ... & Lipsky, M. S. (2013). Rural/urban differences in health services defi-cits among US adults with arthritis: A population-based study. Journal of Nursing Educa-tion and Practice, 3(11), 43.

Martiniuk, A. L., Adunuri, N., Negin, J., Tracey, P., Fontecha, C., & Caldwell, P. (2012). Primary care provision by volunteer medical brigades in Honduras: a health record review of more than 2,500 patients over three years. International Journal of Health Services, 42(4), 739-753.

McLaughlin, M. M., Simonson, L., Zou, X., Ling, L., & Tucker, J. D. (2015). African mi-grant patients’ trust in Chinese physicians: a social ecological approach to understanding pa-tient-physician trust. PloS one, 10(5), e0123255.

Osler, M. (1993). Social class and health behaviour in Danish adults: a longitudinal study. Public health, 107(4), 251-260.

Ozgediz, D. (2009). Voluntarism and the global unmet need for surgery. Archives of Surgery, 144(3), 289-292.

Shanafelt, T. D., & Noseworthy, J. H. (2017, January). Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. In Mayo Clinic Proceedings (Vol. 92, No. 1, pp. 129-146). Elsevier.

Shoemaker, C. A. (2010, August). Using a social-ecological model in development of treatment programs that target behavior change. In X International People-Plant Symposium on Digging Deeper: Approaches to Research in Horticultural Therapy and Therapeutic 954 (pp. 77-82).

Singh, G. K., & Siahpush, M. (2014). Widening rural–urban disparities in life expectancy, US, 1969–2009. American journal of preventive medicine, 46(2), e19-e29.

Snyder, L. (2012). American College of Physicians ethics manual. Annals of Internal Medi-cine, 156(1_Part_2), 73-104.

Stokols, D. (1992). Establishing and maintaining healthy environments: toward a social ecology of health promotion. American psychologist, 47(1), 6.

Sykes, K. J. (2014). Short-term medical service trips: a systematic review of the evidence. American journal of public health, 104(7), e38-e48.

Tashakkori, A., & Teddlie, C. (Eds.). (2010). Sage handbook of mixed methods in social & behavioral research. sage. ISO 690

United Nations. (1948). The Universal Declaration of Human Rights. https://www.ohchr.org/EN/UDHR/Documents/UDHR_Translations/eng.pdf.

United Nations. (2007). United Nations Declaration on the Rights of Indigenous Peoples. https://www.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html.

Vu, M. T., Johnson, T. R., Francois, R., & Simms-Cendan, J. (2014). Sustained impact of short-term international medical mission trips: Resident perspectives. Medical teacher, 36(12), 1057-1063.

Whitehead, M. (1991). The concepts and principles of equity and health. Health promotion international, 6(3), 217-228.

Wilkinson, R., & Pickett, K. (2009). The spirit level: Why more equal societies almost always do better. Allen Lane. ISBN, 1846140396, 352.

World Health Organization. (1947). The constitution of the world health organization. WHO chronicle, 1, 29. http://www.who.int/governance/eb/who_constitution_en.pdf.

World Health Organization. (2003). The World Health Report 2003. Chapter7. https://www.who.int/whr/2003/en/Chapter7.pdf.

中央健保署,2015,原住民納保概況。http://www.nhi.gov.tw/resource/Webdata/Attach_4866_1_work9408.pdf。

中央健保署,2019,健康保險資料開放服務:全國原住民納保分布。http://data.gov.tw/?q=principle。

中華芸生會,2020,達仁中醫義診。https://www.facebook.com/darenyijen/。

內政部,2018,我國生命表。https://www.moi.gov.tw/stat/node.aspx?sn=4883。

行政院主計總處,2020,總預算案之重點分析。http://www.dgbas.gov.tw/public/data/dgbas01/109/109Btab/109%E8%82%86.pdf。

吳珍梅、江侞砡,2013,攜子入監幼兒其親子對話之參與式觀察研究,兒童與教育研究 (8)。頁1-45。

吳燕和,1993,台東太麻里溪流域的東排灣人,中央研究院民族學研究所。

呂宗學,2010,消弭健康不平等的相關政策─歐洲國家經驗,醫療品質雜誌 4。20-3。

宋曜廷、潘佩妤,2010,混合方法研究在教育研究的應用,教育科學研究期刊。

林佳縈,2011,從醫病關係發展探究其信任的危機—以關懷關係重構。

林進川,2003,原住民地區實施醫療給付效益提昇計畫之探討-以屏東縣春日鄉為例,高雄醫學大學公共衛生學研究所碩士在職專班學位論文。頁1-161。

邱煜智,2005,原住民健康狀況差異之研究—依都市化程度探討,臺北醫學大學公共衛生學系暨研究所學位論文。1-0。

金玠縈、詹永兆、胡文龍、黃蘭媖、巫雲光、何永成、洪裕強,2016,臺灣中醫偏遠地區巡迴醫療病患就診特性與服務滿意度研究,中醫藥雜誌 27(2)。f1-12。

施純全,2006,實施無中醫鄉巡迴醫療服務計畫之探討,中醫藥年報 24(5)。頁47-156。

原住民族委員會,2020,原住民族重大政策。https://www.apc.gov.tw/portal/docList.html?CID=F6F47C22D1435F95。

張淑美,2010,臺灣臺中-元宵新社義診,中醫樂服務,人醫心傳-慈濟醫療人文月刊(74)。頁54-55。

張朝琴,2008,貧窮與健康-社經地位與原住民族健康問題探析,嘉義大學通識學報 (6)。頁461-486。

張雅雯,2014,社經地位軌跡與中老年人健康之關係,中正大學社會福利學系學位論文。頁1-78。

莊明貞、陳怡如(譯),2006,質性研究導論(原作者:Glesne, C.)。臺北市:高等教育。

莊豔妃、宋惠娟、林麗萍,2005,偏遠礦區老人健康狀況及健康醫療資源使用之調查研究,慈濟護理雜誌 4(1)。頁34-41。

許敏靖,2003,臺灣北部都會區原住民醫療資源利用情形及其相關因素分析研究─ 以汐止花東新村等社區為例。

郭淑珍、丁志音,2008,嚼檳榔計程車司機的健康生活型態:社會脈絡觀點的初探,臺灣公共衛生雜誌 27(1)。頁67-80。

郭淑珍、陳怡君,2017,求醫行為與社會網絡:以乳癌病患為例,人文社會與醫療學刊 (4)。頁67-97。

陳怡懋,2003,花蓮縣原住民病患疼痛經驗之社會文化意含相關性探討,花蓮市:慈濟大學原住民健康研究所。

陳雪芬、曾雅梅,2017,社區志工對服務獨居老人意願之影響因素探討-應用社會生態學模式,福祉科技與服務管理學刊 5(3)。

黃博裕、吳清源、洪裕強、黃升騰、鄧雪妹、高照為、蔡明諺,2015,南臺灣偏遠地區中醫醫療服務滿意度及病患就診特性之研究,J Chin Med, 26(1)。頁33-44。

黃詩敏,2014,在成長經濟中,都會與偏鄉醫療保健支出不均對健康壽命之影響,慈濟醫學雜誌 10(3)。頁201-209。

達仁鄉公所,2019,戶數人口數統計。https://tmh.taitung.gov.tw/files/11-1002-329.php。

臺灣醫學會,2016,偏鄉醫療健保給付政策。http://www.fma.org.tw/2016lecture/P-1.html。

劉千嘉,2016,遷徙與區域醫療資源對原住民健康不平等之影響,Social Policy 20(1)。

劉玉娟,2008,臺灣原住民族社經地位與健康的關係,國立臺灣大學公共衛生政策與管理研究所碩士論文。

衛生福利部,2018a,107年度全民健康保險中醫門診總額醫療資源不足地區改善方案。http://www.twtm.tw/userfiles/upload/151566288112877.pdf。

衛生福利部,2018b,107年度全民健康保險西醫門診總額醫療資源不足地區改善方案。https://www.nhi.gov.tw/DL.aspx?sitessn=292&u=LzAwMS9VcGxvYWQvMjkyL3JlbGZpbGUvMC8yNzI5NC8xMDflubTluqblhajmsJHlgaXlurfkv53pmqropb%2FphqvphqvnmYLos4fmupDkuI3otrPlnLDljYDmlLnlloTmlrnmoYgucGRm&n=MTA35bm05bqm5YWo5rCR5YGl5bq35L%2Bd6Zqq6KW%2F6Yar6Yar55mC6LOH5rqQ5LiN6Laz5Zyw5Y2A5pS55ZaE5pa55qGILnBkZg%3D%3D&ico%20=.pdf。

衛生福利部,2018c,臺灣健康不平等報告。https://www.hpa.gov.tw/Pages/ashx/File.ashx?FilePath=~/File/Attach/8689/File_8331.pdf。

衛生福利部,2019a,全民健康保險山地離島地區醫療給付效益提昇計畫。https://www.nhi.gov.tw/Content_List.aspx?n=747734D9BD70A038&topn=787128DAD5F71B1A。

衛生福利部,2019b,原鄉健康不平等改善策略行動計畫。https://www.mohw.gov.tw/dl-47858-783619e0-a2fd-489b-92af-f848f906729b.html。

衛生福利部,2019c,醫療機構現況及醫院醫療服務量統計。https://dep.mohw.gov.tw/DOS/np-1864-113.html。

謝承運、陳方佩、曾元卜、吳大鵬、龔彥穎,2016,老年常見疾患之針灸治療,臺灣老年醫學暨老年學雜誌 11(2)。頁79-88。
連結至畢業學校之論文網頁點我開啟連結
註: 此連結為研究生畢業學校所提供,不一定有電子全文可供下載,若連結有誤,請點選上方之〝勘誤回報〞功能,我們會盡快修正,謝謝!
QRCODE
 
 
 
 
 
                                                                                                                                                                                                                                                                                                                                                                                                               
第一頁 上一頁 下一頁 最後一頁 top