University of Macau / Faculty of Education

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台灣地區自民國八十四年三月開始實行全民健保，並於同年七月起提供三十歲以上婦女每年一次免費抹片檢查，但我國婦女抹片檢查利用率和先進國家相比仍舊偏低。爰此，本論文主要目的，在探討台灣地區婦女在健保制度下抹片篩檢利用度的影響因素，藉由實證分析結果，期能提供政府當局有效提高篩檢率的具體方針和建議，以有效降低婦女子宮頸癌的發生率和死亡率。 第二章為理論架構，分別應用Becker(1965)的家庭生產函數和Grossman(1972)的健康需求模型，以建構影響抹片檢查需求的理論模型，並為本論文實證分析的理論基礎。本論文實證分析共分三章，首先利用衛生署國民健康局家庭計畫研究所，分別於民國81年及87年進行的「台灣地區家庭與生育力調查」資料，採用Logit迴歸模型做分析。實證結果發現，抹片檢查接受與否的影響因素在健保實施前後有很大差異，而「南部＊全民健保」及「鄉鎮＊全民健保」的變數對30歲以上婦女亦為顯著正相關；意味健保制度的推行，沖消掉大多數變數的影響效果，使得原本具有影響力的因素變為不顯著，亦即健保政策在婦女抹片防癌使用度的增加有很大貢獻。此外，政府除了對30歲以上女性提供免費檢查給付政策外，亦積極加強衛教宣導工作、建立子宮頸抹片篩檢服務網等工作，使得「全民健保」變數不僅對30歲以上婦女，亦對30歲以下婦女有顯著的正影響力，故建議政府可考慮將篩檢給付擴及至所有已婚女性。 接者，在第四章則利用國家衛生研究院於民國90年所進行的「國民健康訪問調查」資料，應用Bivariate Probit 迴歸模型，並將台灣地區所有316個鄉鎮市分成八個都市化層級，探討都市化程度高低對婦女預防保健利用度之影響。結果發現都市化程度不同，的確造成婦女抹片檢查利用率存在顯著差異，居住在第二至第六個都市化層級的婦女，其接受抹片篩檢的比率明顯較都市化程度最高者低；而第七和第八層級(都市化程度最低)並無顯著較第一層級不願做篩檢。究其原因，乃因政府為均衡不同地區抹片篩檢的可近性，積極鼓勵相關醫療院所加入健保特約醫院，以配合健保給付政策並提供篩檢服務，至民國86年，有超過90%約1500家的醫療院所加入；此外，衛生當局亦在偏遠地區提供巡迴車設站採檢服務，以解決偏遠地區醫療資源不足問題。意味全民健保制度在婦女抹片檢查服務上，已達到提昇偏遠地區醫療服務可近性的貢獻。 最後，在第五章我們利用國民健康局於民國91年所進行的「國民健康促進知識、態度與行為調查」資料，應用兩階段最小平方法(2SLS)估計模型，分析健康資訊對抹片檢查的影響程度。應用Kenkel(1990)衡量資訊的方法，將受訪者對子宮頸癌及抹片檢查相關知識的得分加總，以代表婦女健康資訊程度。實證結果發現，健康資訊的確是影響婦女是否接受抹片檢查的重要因素，擁有愈多相關健康資訊的婦女，因愈了解抹片檢查對預防子宮頸癌的重要，故明顯較願意去接受篩檢。因此，政府除了積極全面衛教宣導工作、建立子宮頸抹片篩檢服務網等工作外，也應針對擁有較低健康資訊的婦女多加宣導抹片防癌的重要性，以有效提高我國婦女的篩檢利用率。 / The National Health Insurance program provided free annual cervical cancer screening for women aged above 30 years old since July, 1995, just four months after the inauguration of the NHI. Therefore, the purpose of this dissertation is to investigate the demand for Pap-smear utilization among women under NHI program. To explore the factors influencing cervical cancer screening and the empirical results can be of great importance to health policy decisions aimed at reducing the incidence and mortality of cervical cancer. In Chapter 2, we attempt to analyze the theoretical foundations applying the household production function developed by Becker (1965) and Grossman’s (1972) health decision-making model and summarize the literatures through a review of the demand for preventive care services. Three empirical essays will proceed in following three chapters. First of all, chapter 3 presents data obtained from the 1992 and 1998 surveys on ‘Knowledge, Attitudes and Practice’ administered by Taiwan’s Provincial Institute of Family, performing a logit model. The results show that factors affecting Pap smear test utilization varied significantly before and after NHI, besides, the coefficient of the South＊NHI and village/town＊NHI interaction variable for women above 30 become significant and positive. This indicates that NHI system plays an important contributor on reducing the disparities in utilization of Pap smear tests between different areas. In addition to NHI coverage, other strategies such as strengthening educational activities and establishing a service network for Pap-smear screening are other vital contributors to increase the utilization rate of Pap smear screening for those aged below 30 years under NHI. To further increase the utilization of cervical cancer screening, the insurance coverage could be extended to all married women regardless of age. In chapter 4, we attempt to explore the impact of urbanization level on the use of female preventive services under NHI, using a bivariate probit model and dataset obtained from the 2001 National Health Interview Survey provided by the National Health Research Institutes. All 316 cities/counties in Taiwan was stratified into 8 levels of urbanization. The results showed that urbanization levels have a significant influence on Pap-smear screening. Those living between the second and sixth levels of urbanized regions were significant negative to the cervical cancer screening compared to the highest urbanization level. In order to balance the accessibility of cervical cancer screening between different areas, the health authorities encourage the obstetric, gynecological hospitals and clinics to contract with the government, more than 90%, about 1,500 medical care institutions were under contract until 1997. Besides, government authorities introduced mobile testing stations to provide specimen collection services in the deeper remote regions. As a result, those living in the areas with the 7th level and the 8th level (the lowest level) of urbanization were not less likely to take Pap-smear test. It means that the implementation of NHI has enhanced the accessibility of taking pap-smear test. Finally, in chapter 5, the nationwide survey dataset was obtained from the 2002 Health Promotion of Knowledge, Attitudes and Practice (HPKAP) in Taiwan, provided by the Bureau of Health Promotion and two-stage estimation model was adopted to investigate the association of cervical cancer screenings with the healthcare information. The results showed that women’s healthcare information has a significant positive effect on the utilization of cervical cancer screening; that is, the more informed women are, in terms of information and knowledge on cervical cancer screening, the more likely they are to undergo Pap-smear testing. Therefore, it is important for the healthcare authorities to place greater effort into strengthening the knowledge and information on cervical cancer screening and Pap-smear testing, for those who are currently less informed, so as to enhance the overall efficiency of the screening program.

我國全民健康保險政策是屬於社會保險，早期在推行健保時決策模式是傾向國家主義，然而隨著民主化時代的來臨，人民權利意識抬頭，各種利害關係團體相應而生，因此民主治理變成重要的課題。在重要政策參與中各個利害關係人皆希望能夠被納入決策。我國目前健保政策體制內的參與管道最主要為費用協定委員會及監理委員會，主要監督及決定健保預算分配，這兩會在2013年整併為健保會。不論整併前後，委員會基本上是以統合主義的精神運作，邀進行決議，最大的優點在於能夠藉由與多方政策利害關係人的溝通，凝聚社會共識。然而哪些團體能夠代表參與政府制定決策的過程，參與的代表能否充分表達團體的意見？因此代表性正是統合主義中最具爭議的，故如何找出遴選團體的標準是刻不容緩的。 　　本文嘗試以社會統合主義的觀點，套用在健保會運作上。然而社會統合主義要運作的良好，基本上必須要在水平及垂直方面的機制建構完善，垂直層面必須要各級組織匯集各級團體的意見，並由代表進入水平的平臺進行協商；而在水平溝通平臺上也需要各方代表皆能有平等及有效的決策。本文最主要了解的是垂直面的整合情形，亦即這些被派入健保會的政策利害關係團體代表是否有充分的被賦權，在會中討論的結果能否充分落實，因此要衡量團體內部本身的治理。本文欲透過專家座談建構組織內部運作的指標，建構指標測量健保會內部實際運作情況，對於好的健保會參與組織建構初探性的評估。希望未來能夠作為健保會遴選組織進入委員會的參考依據。 / National Health Insurance (NHI) policy is a part of social insurance in Taiwan. In the early stages of the program, the pattern of decision-making tended to be based on a Statist model, but as Taiwan democratizes, citizens and various interest groups have become increasingly aware of their rights. Therefore, the democratic governance of National Health Insurance policy has also become an important issue, as stakeholder groups all hope to be included in the NHI’s decision making process. In Taiwan, the two main participation channels within the system are the Medical Expenditure Negotiation Committee and the Supervisory Committee. The main missions of these two committees are to control health care costs and to allocate medical resources. In 2013, these two committees were merged to form a single National Health Insurance Committee. Whichever their merger status is, the committees basically function according to the principles of Corporatism, whereby peak-level organizations are invited to take part of the committee’s decision-making processes. The biggest advantage of the merger is that the committee would be able to achieve social cohe-sion and consensus through its direct communication with various policy stakeholder groups. But the problem with this arrangement is the following: Which groups can participate in the government’s decision-making process? Can the representatives fully express the views of their respective groups inside the committee? Therefore, the question of representation is the most controversial issue in Corporatist theory, and it is imperative to develop the proper criteria by which major interest or corporatist groups are selected. This study attempts to observe the National Health Insurance Committee from the perspective of social corporatism. For social corporatism to function well in society, basically both its horizontal and vertical mechanisms have to work perfectly. Vertically, groups must be able to amass and integrate the views of their sub-organizations at all levels; horizontally, the group’s representatives must all have equal capacity to make effective decisions. This paper will focus on understanding the vertical dimension of social corporatism, which means asking the following questions: Can/do the representatives fully and adequately represent their group? And whether the outcomes discussed at the committee meetings are fully implemented? To answer these questions it is thereby necessary to measure the internal governance of the groups themselves. This paper will examine various internal operating indicators developed through experts’ panel discussions, with the primary objective of determining good committee participation measures. It is hoped that the construction of these internal governance indicators will serve as the criteria by which future corporatist groups or stakeholder organizations are selected into the National Health Insurance Committee

長久以來，憂鬱情緒一直是自然科學與社會科學界關注的重要議題，而其中女性較男性憂鬱的現象也受到重視。雖然自然科學界的研究一再指出健康行為對減輕憂鬱情緒的幫助，但並不是每個人都有機會擁有健康的生活型態。尤其在性別方面，性別間的健康行為差異是否能解釋兩性的憂鬱情緒落差即是本研究的課題。本文將透過檢驗暴露差異性以及脆弱差異性假設，了解性別間的憂鬱情緒落差是如何由本身脆弱差異性，以及兩性暴露的風險不同所造成。本研究使用「台灣社會變遷基本調查計畫」在2005年以及2010年的資料，以吸菸、喝酒、運動，三個健康行為作為健康生活型態的指標，對此問題進行分析。研究結果發現，健康生活型態對台灣民眾的憂鬱情緒有影響，吸菸有增加憂鬱情緒的效果，而運動則有減輕憂鬱情緒的效果。將吸菸、喝酒加入模型後，性別落差會增加，而運動的加入則有助於降低性別落差，支持暴露差異性假設。在性別上，吸菸對於男性有顯著增加憂鬱情緒的效果，對女性則無；而運動對於女性降低憂鬱情緒的效果則較大。然而，兩指標的性別差異並沒有達到統計上的顯著水準，因此只能部分支持脆弱差異性假設。希望本文的研究結果有助於了解兩性間的憂鬱情緒落差，並提供憂鬱情緒的影響機制更完整的圖像。 / Gender differences in distress has been well documented in literatures. However, it is unclear about the effect of health lifestyles on gender disadvantage in mental health. To explain the gender gap in distress, there are two hypotheses: differential exposure hypothesis and differential vulnerability hypothesis. In this study, the data are from Taiwanese Social Change Survey conducted in 2005 and 2010. The three indices I choose are the frequency of smoking, drinking, and exercising. The two main findings are: (1) Smoking deteriorates distress while exercising ameliorates it. Also, adding smoking and drinking into the predicting model increases the gender gap in distress, whereas adding exercising decreases the gap. These findings support the differential exposure hypothesis; (2) the effect of smoking is significant for men but not for women. However, the effect of exercising is more important to women. Although the gender differences in smoking and exercising effects are not significant, the findings support the differential vulnerability hypothesis partially.

本研究旨在建構並驗證私立高中職學校校長分布式領導、學校組織健康與學校效能之模式，並比較不同教師背景變項及學校背景變項的差異，依據研究所得結論，分別對教育主管行政機關、私立高中職董事會、私立高中職學校及後續研究者提出建議，以做為推展校長分布式領導，促進學校組織健康，及提升學校效能之參考。 本研究使用問卷調查法，以單因子變異數分析、皮爾森積差相關、多元迴歸、結構方程模式等統計方法，探討私立高中職學校校長分布式領導、學校組織健康與學校效能之關係及模式驗證。經由文獻的蒐集與探討，提出本研究的研究架構和路徑關係模式圖。研究對象為北北基私立高中職學校600位教師；研究工具為研究者自編之私立高中職學校校長分布式領導、學校組織健康與學校效能關係之調查問卷。 透過統計分析與討論，本研究獲得以下結論： 一、私立高中職學校教師覺知校長分布式領導、學校組織健康與學校效能之現況屬中高程度。 二、私立高中職學校部分教師在人員背景變項與學校背景變項對校長分布式領導、學校組織健康與學校效能的覺知具有顯著差異。 三、私立高中職學校校長分布式領導、學校組織健康與學校效能三者間具有正向關聯性。 四、私立高中職學校校長分布式領導、學校組織健康對學校效能均具有正向預測力。 五、本研究所建構之私立高中職學校校長分布式領導、學校組織健康與學校效能之結構方程模式具有良好適配度。 / The study aims to construct and examine the model of principals’ distributed leadership, school health, and effectiveness in private senior and vocational high schools, and compare differences in variances of teachers’ background and schools’ background. The outcomes and suggestions provide substantial references for educational authorities and administrations, the board of directors in private senior and vocational high schools, private senior and vocational high schools, and future researchers to promote principals’ distributed leadership, school health, and school effectiveness. This study adopted questionnaire survey and statistical methods such as one-way ANOVA, Pearson Product-Moment Correlations Coefficient, Multiple Regression Analysis, and Structural Equation Modeling (SEM) to explore the association and model of principals’ distributed leadership, school health, and school effectiveness in private senior and vocational high schools. The framework of research and the path analysis module diagram were constructed on the basis of literature reviews. The subjects of the study included 600 teachers teaching in private senior and vocational high schools in Taipei, New Taipei, and Keelung. The research tool of survey questionnaire was created by the researcher, containing constructs of distributed leadership, school health, and school effectiveness. Based on data analysis and discussions, the conclusions are as follows: 1. Participating teachers perceived that the principals’ distributed leadership, school health, and school effectiveness presented a middle to high level. 2. For some participating teachers, there are significant differences between the two variables of teachers’ background and schools’ background on the perceived principals’ distributed leadership, school health, and school effectiveness. 3. There is a positive correlation between the variables of principals’ distributed leadership, school health, and school effectiveness. 4. Both principals’ distributed leadership and school health show a positive prediction power to school effectiveness. 5. The SEM constructed for the principals’ distributed leadership, school health, and school effectiveness showed a goodness of fit.

本研究主要在探討台灣壽險業健康保險損失率之影響因素。首先，了解健康險損失率是否因為壽險公司規模不同而有顯著差異。再者，將壽險公司依主要專注之通路類型分為三類，包括業務員通路、經代通路以及其他通路，而觀察通路對於健康險損失率的影響情形。最後，藉由個體變數與總體變數之分析，期望以其他不同的角度協助保險公司未來對於損失率的風險控制。 研究結果發現： (一)當壽險公司之資產規模不同時，對於健康險損失率有顯著差異上的影響。大型壽險公司的平均健康險損失率顯著高於小型壽險公司之健康險平均損失率。 (二)壽險公司行銷通路的注重程度不同，確實會使健康保險損失率產生顯著的差異。研究結果發現其他通路運用程度越高的壽險公司，其健康險損失率顯著比使用經代人通路和業務員通路的壽險公司之損失率低。 (三)本研究發現健康險損失率受到總體因素的影響，一般而言比壽險公司個體因素的影響微弱。個體因素確實會顯著影響壽險公司健康險損失率，而且壽險公司不同的規模型態，其主要影響健康險損失率的因素亦會有所不同。 / This study examines the factors that influence the loss ratio of health insurance policies for life insurance companies in Taiwan. First, this thesis intends to investigate whether there are significant differences in loss ratios among insurers due to firm size. Secondly, the impact of marketing channels on health insurance loss ratio is analyzed where the distribution systems mainly used by insurers are divided into three categories: employee sales, agent/broker channel, and others. Finally, this study conducts regression analyses on the health insurance loss ratio with firm-specific and macroeconomic variables to help insurers in controlling risks in the future. The empirical results are shown as follows. 1.The loss ratios of health insurance vary significantly with firm size. The loss ratio of large insurance companies is significantly higher than that of small insurances companies. 2.Distribution system has a significant impact on the loss ratio of health insurance. When the insurer relies more on other channels, instead of employee sales and agent/broker, the insurer will have lower loss ratio. 3.The impact of macroeconomic variables on the loss ratio of health insurance is less than that of firm-specific variables. Additionally, the influential variables for loss ratio may be different between insurers of large and small sizes.

国立情報学研究所で電子化したコンテンツを使用している。

我國每十年進行一次人口普查，以取得國人經常活動地區的資訊，作為中央及地方政府政策規劃的參考。然而，十年一次的人口普查無法即時反映各地區人口特質及其活動，隨著普查完訪率逐年下降、個人資料保護法意識抬頭等趨勢，普查的涵蓋率及其資料品質愈加受到質疑，近年各國思考以其他資料蒐集方式取代傳統普查。我國實施全民健康保險制度已逾20年，民眾納保率超過99%，因此本文以全民健保資料庫為研究素材，透過個人就醫行為探討國人經常活動地區，透過剖析各種疾病的就醫行為，可作為政府評估醫療資源規劃的參考。 本文以全民健保資料庫為依據，探討我國國民選擇醫療地點的特性，作為經常活動地區（或是常住地）的輔助參考。過去研究大多利用上呼吸道感染（俗稱感冒）作為估計常住地的依據，但每年平均只有接近70%國人會因感冒而就醫，其中青壯年、老年人因感冒而就醫的比例明顯較低，以此作為常住地的估計基礎恐有涵蓋率不足之虞。本文依據健保資料庫中的2005年百萬人抽樣檔，包括就醫門診處方及治療明細檔(CD)、承保資料檔(ID)等資料，比較數種常住地判斷的參考準則（包括感冒就醫），分析各方法所觀察到資料的特性及限制，評估以這些準則作為判斷常住地的可行性。 結論：本文提出除了感冒就醫之外的三種常住地推估準則，分別為：因為感冒或是消化就醫、單次健保補助金額較低、基層院所就醫。以樣本涵蓋率量而言，三種準則都能改善感冒就醫涵蓋率的不足，其中以單次金額與基層院所就醫的樣本數增加最多。另外，如果與所有門診資料、普查資料的人口資料比較，發現單次金額與基層院所就醫推估的人口年齡結構最為接近，但單次金額的縣市（地區）結構與普查資料的差異較大。 限制：受限於青壯年人口就醫率較低，本文提出的幾種常住地判斷準則在20歲至44歲的涵蓋率仍然偏低，建議未來研究可經由權數調整修正樣本的年齡等人口結構及比例，或是仰賴就醫以外的紀錄推估，但須考量資料串連及品質等問題。 / Many countries conduct population census every 10 years to acquire the information of population structure and its trend, but the information is not likely to updated since the 10-years period is usually too long. Moreover, the low response rate of questionnaire and the enforcement of Personal Information Protection Act further jeopardize the population census and many question its data quality. Thus, quite a lot of countries are seeking alternatives for collecting the information of de jure population, replacing the regular population census. In this study, we explore the possibility of using the data from National Health Insurance (NHI) Research Database for acquiring the information of de jure population in Taiwan. Taiwan started the NHI in 1995 and more than 99% of Taiwan population are covered. Since the medical accessibility created by the NHI, Taiwan’s people tend to visit medical institutions near to where they live, when they have minor diseases. Past studies showed that the upper respiratory tract infection (or cold) is a popular choice of minor diseases. We will evaluate if the cold is a good candidate and propose alternative criteria for the definition of minor diseases. We found that the proportion of populations with upper respiratory tract infection is about 70% and it is age dependent, with the elderly the lowest. On contrary, the records of smaller amounts and the records of physician clinics (or general practice clinics) can cover more than 90% population, much better than the records of upper respiratory tract infection. The records of digestive system diseases and upper respiratory tract infection can also increase the coverage of elderly population. We recommend using the medical records of smaller amounts to acquire the de jure population.