運用Andersen模式探討家庭社經地位及地區差異與兒童健康照護服務利用的關聯：2017年國民健康訪問調查

Abstract

目的： 實施兒童預防保健服務不只改善兒童健康，且降低死亡率，但這項服務的利用在家庭社會經濟地位及地區之間存在不平等；過去有關健康照護服務利用差異的研究多著重於成人，兒童健康照護服務相關研究相對不足。因此，本研究使用2017年國民健康訪問調查檔12歲以下問卷，並運用Andersen健康服務利用行為模式，分析與台灣地區兒童利用健康照護服務有關聯之家庭社會經濟因素。此外，針對兒童流感疫苗的接種，分析縣市別健康政策的差異與其對兒童疫苗接種利用之關聯。 方法： 本研究以SAS 9.4軟體進行羅吉斯迴歸分析以及負二項式迴歸分析，首先，探討12歲以下兒童過去一年間是否曾接種預防注射及其他健康照護服務利用與家庭社會經濟地位的關聯，家庭社會經濟地位包含現居住地、父母婚姻狀況、雙親國籍、雙親教育程度、家戶收入。控制變項包括年齡、性別、居住安排(家中同住人數)、有無加入健保、自評健康狀態、相比同齡兒童之健康狀態、視力狀況、氣喘、重大傷病，接續利用內容分析法，分析縣市別健康政策與兒童預防注射服務利用之關聯。 結果： 研究結果顯示，樣本中61.84%的兒童過去一年有接種流感疫苗，其中與父母婚姻狀況為已婚相比，父母婚姻狀況為離婚、或是與雙親同住相比，僅跟父親同住、或是與家戶收入7萬以上者相比，家戶收入未滿3萬，均與接種流感疫苗顯著正相關。而樣本中18.72%的兒童過去一年有使用過急診，與臺北業務組相比，健保分區為北區業務組以及中區業務組與急診顯著負相關。樣本中8.06%的兒童過去一年有住院過，與臺北業務組相比，健保分區為北區業務組與住院顯著負相關。樣本中71.21%的兒童過去一年有使用牙醫門診，與父母婚姻狀況為已婚相比，父母婚姻狀況為未婚、相較於父母最高學歷較高，父母最高教育程度較低、相較於母親國籍本國籍，母親國籍為非本國籍、相較於家戶收入7萬以上，家戶收入較低與牙醫門診存在負相關。樣本中40.64%的兒童過去一個月有利用西醫門診，母親國籍為非本國籍(相較於母親國籍本國籍)、健保分區為東區業務組(與臺北業務組相比)，均與西醫門診利用存在負相關。樣本中5.10%的兒童過去一個月有使用中醫門診，而相較於臺北業務組，健保分區為中區業務組與中醫門診利用較低存在負相關。樣本中57.20%的兒童過去一年有利用眼科門診，與父母婚姻狀況為已婚進行比較，父母婚姻狀況為其他、或是相較於父母最高學歷為大專以上，父母最高教育程度較低、或是相較於臺北業務組，健保分區為東區業務組與眼科門診存在負相關。過去一年牙醫門診次數平均為0.88次，相較於父母最高學歷為大專以上，父母最高教育程度較低、或是相較於臺北業務組，健保分區為北區業務組的兒童，均與牙醫門診利用次數存在負相關。過去一年西醫門診次數平均為1.88次，家庭社會經濟地位與西醫門診次數存在負相關。此外，縣市別健康政策與兒童接種流感疫苗之相關性並未達到統計上顯著，不過質性研究結果發現健康政策的實施方式依縣市而有些微差異。 結論 整體而言，家庭社會經濟地位較低與牙醫門診利用、西醫門診利用、眼科門診利用存在負相關，不過，家庭社會經濟地位較低與流感疫苗接種存在正相關；急診、住院以及中醫門診利用存在地區差異，相較於臺北業務組，北區業務組的兒童，均與急診、住院存在負相關；中區業務組則與中醫門診利用存在正相關。理解預防保健服務以及其他健康照護服務的利用情形，並瞭解利用服務的因素以及障礙，將有助於政府制定相關健康政策，優先針對重要因素擬定策略。

Objective : The implementation of preventive healthcare services among children improves their health and reduces the mortality rates. However, there exists inequality in the healthcare utilization among family socioeconomic status and geographic. Previous studies have focused on healthcare service utilization of adults, with less research focused on pediatric health care services. Therefore, this study uses data from the 2017 National Health Interview Survey (NHIS) for children aged 12 and below to determine the associations between family socioeconomic status and children’s healthcare services utilization in Taiwan. Additionally, the study examines the differences in county-level influenza immunization policies; furthermore, this study analyzes the association between influenza immunization policies of children’s residing counties and the odds of their receiving annual flu vaccination. Methods： National Health Interview Survey (NHIS) in 2017 was analysed. Logistic regression models and negative binomial models were analyzed to explore the association of family socioeconomic status and healthcare services utilization. Family socioeconomic status included residing county, marital status of parents, parents' nationality, parents' education level, and household income . Covariables included age, gender, number of household members, health insurance, self-rated health status, health status compared to peers, vision condition, asthma, and illnesses. Content analysis is used to analyze the associations between the variation of county-level influenza immunization policies and the utilization of children’s annual flu vaccination. All data analyses were performed with SAS 9.4. Results： The results showed that 61.84% of children in the sample received influenza vaccination in the past year. Social and economic factors significantly associated with higher odds of receiving flu vaccination among children in the past year included the following:parents were divorced (compare to children whose parents' marital status is married), residing solely with the father (compare to children living with parents), household income below 30,000 NTD (compare to those with household income ≧70,000 NTD).Further, 18.72% of children in the sample had an ED visit in the past year; being in the Northern Division or Central Division of the National Health Insurance (compared to Taipei Division) was associated with lower odds of emergency room visits. There were 8.06% of children in the sample with at least one hospitalization stay in the past year, with children in the Northern Division of the National Health Insurance Administration (compared to Taipei Division) associated with a lower odds of hospitalization. There were 71.21% of children in the sample visited dental clinics in the past year. Children whose parents were unmarried(compare to parents' marital status as married), whose parents had lower levels of education(compared to parental education as college or above), mother's non-native citizenship (compare to mother's citizenship is native), or with lower household income (compare to those with household income ≧70,000 NTD), were all associated with lower odds of dental clinic visits. There were 40.64% of children in the sample with at least a physician office visit in the past month. Mother's non-native citizenship (compare to mother's citizenship is native) or residing in Eastern Division of the National Health Insurance Administration(compared to Taipei Division) were associated with a lower odds of having a physician office visit. There were 5.10% of children in the sample with a least one vist to a traditional Chinese medicine clinic within the past month, and residing in Central Division of the National Health Insurance Administration (compared to Taipei Division) is associated with a lower odds of utilizing traditional Chinese medicine clinics. There were 57.20% of children in the sample with a least one vist to an ophthalmology specialist in the previous year and whose parents’ marital status is others (compare to children’s parents’ is married), whose parents had lower levels of education(compared to parental education as college or above), or residing in the Eastern Division of the National Health Insurance Administration(compared to Taipei Division) were associated with a lower odds of having at leat one time of ophthalmology specialists visits. The average frequency of dental visits within the past year was 0.88 times, and children with parents education levels is lower(compared to parental education as college or above) or residing in the Northern Division of the National Health Insurance Administration (compared to Taipei Division) was associated with lower frequencyof dental visits. The average frequency of general physician visits within the past year was 1.88 times. Generally, children with lower family socioeconomic status was associated with lower frequency of general physician visits. Furthermore, the correlation between county-level influenza immunization policies and the utilization of children’s annual flu vaccination had no statistical significance. However, qualitative research findings revealed slight variations in the implementation of influenza immunization policies among counties. Conclusion: In general, there is a negative assocation between lower family socioeconomic status and dental outpatient services, general medical outpatient services, and ophthalmology outpatient services but there is a positive assocation between lower family socioeconomic status and the utilization of influenza vaccination. Regional variations exist in the utilization of emergency department services, hospitalization, and traditional Chinese medicine outpatient services. Compared to the children in the Taipei Division, children in the Northern Division were associated with higher utilization of emergency department services and hospitalization. Gaining insights into the utilization patterns of preventive healthcare services and other types of healthcare services, along with understanding how family socioeconomic status affecting utilization of healthcare services, can significantly contribute to future health policy-making. This knowledge enables the prioritization of strategies targeting critical family socioeconomic factors in order to effectively address healthcare needs.