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題名：臺北市遊民心血管疾病與傳染病之盛行率與風險因子評估研究
作者：陳靜琳
作者(外文)：CHEN,CHING-LIN
校院名稱：輔仁大學
系所名稱：商學研究所博士班
指導教授：陳銘芷
劉志光
學位類別：博士
出版日期：2021
主題關鍵詞：遊民；慢性病；傳染病；高血壓；高血糖；高血脂；代謝症侯群；肥胖；homeless adults；chronic diseases；infectious diseases；hypertension；hyperglycemia；hyperlipidemia；metabolic syndrome；obesity
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遊民被定義為缺乏足夠的生活資源、安全、和情感健康的無住所群體。據2019年耶魯大學的全球在線統計報告指出，全世界約有1.5億遊民，約佔世界人口的2%。同期統計數據顯示，美國約有567,715名遊民，歐洲至少有70萬遊民。這些數據代表COVID-19危機之前遊民數量狀態。2020年COVID-19大流行造成失業、貧困和糧食危機導致全球遊民人數增加。根據臺灣衛生福利部統計處2019年資料顯示臺灣遊民人數約為3040人，主要分佈於北市都會區，臺北市遊民人數約821人，佔全臺灣遊民人口的27%，為遊民最多的縣市。遊民是社會即存現象，是反映社區未能提供基本安全的標誌。遊民的醫療健保問題為當前世界各國重要的公共衛生與社會問題。在臺灣，遊民的健康問題多且複雜，遊民健康問題常因缺乏固定住所、藥物濫用與酒精成癮、社會福利身份限制、缺乏社會支持網絡、取得醫療保健機會少等因素，致遊民群體易患高血壓、糖尿病、肝病、等慢性疾病，並易感各類傳染病，且助長傳播。
研究採橫斷面研究(Cross-sectional Study)設計，樣本收集於2016年至2018年，由醫院醫療團隊與臺北市社會局萬華社服中心合作，以臺北市各遊民輔導機構之遊民為調查對象，進行基本資料收集、人體測量、與生活問卷填寫，並由醫檢師執行血壓測量與血液生化採檢，收集相關研究資料。調查共採集865筆遊民資料，扣除重複參與者資料後為682筆資料。經資料處理，篩選獲得652筆有效樣本數據。研究計畫經過臺北市立聯合醫院人體試驗委員會審查通過(案號：TCHIRB-10805021-E)。本研究使用R軟體(R版本3.6.3)進行臺北市遊民各項疾病之盛行率分析及患病危險因子分析，通過描述性統計、差異性檢定，羅吉斯迴歸與校正的勝算比分析，以探討人口學因子、肥胖指標、生活習慣等各種因素與疾病風險的關聯。並進一步以多元適應性雲形迴歸(Multivariate Adaptive Regression Splines，MARS)方法結合羅吉斯迴歸分析，細緻探索最適當之模型以解釋因子變數與疾病之關聯性，並以最適解釋變數建立風險因子區間解釋模式。
本研究探討臺北市遊民族群之人口統計因子，人體測量之肥胖表徵（整體肥胖與腹部肥胖）、生活形態因子、與心血管疾病標誌(高血壓、高血脂、高血糖)、肝炎(A型肝炎、B型肝炎、C型肝炎)、愛滋病與梅毒等疾病之間的關聯性，發現幾項重要結論：(1)臺灣臺北市遊民三高盛行率顯著高於臺灣一般民眾。(2)臺北市遊民肥胖盛行率普遍高於一般民眾，尤其以女性遊民腹部肥胖狀況更為盛行；不同於世界其他地區之遊民肥胖盛行率較低於當地一般民眾。(3)相比西方國家之遊民群體，臺北市遊民的吸菸與飲酒率相對較低，尤其是女性遊民。(4)通過羅吉斯迴歸整合MARS分析模式，本研究身高比為標記的腹部肥胖是臺北市遊民高血壓與高血脂症的關鍵危險因素；女性遊民的腹部肥胖、高膽固醇血症與高血脂盛行率均顯著高於男性遊民。(5)離婚、分居或喪偶的遊民更易患代謝症候群與感染梅毒。推測臺北市遊民腹部肥胖、血脂異常、婚姻狀況不佳三者之間存在重要之潛在關聯。本研究將相關結果與臺灣一般民眾以及外國遊民群體進行比較。希望可提供醫學臨床參考與管理啟示。 
Homeless people is defined as people without customary access to a conventional residence that lack sufficient living resources, safety, and emotional health. According to the global online statistics report of Yale University in 2019, there are about 150 million homeless people in the world, accounting for about 2% of the world’s population. There were approximately 567,715 homeless people in the United States, and at least 700,000 homeless people in Europe before COVID-19 crisis. After the pandemic in 2020, the homeless population is growing up due to unemployment, poverty and food crisis. According to the statistics from the Ministry of Health and Welfare of Taiwan in 2019, the number of homeless people in Taiwan is around 3040 mainly in the metropolitan area of north Taiwan. The number of homeless people in Taipei is about 821, accounting for 27% of the total homeless population in Taiwan. It is the county with the most homeless people. The homelessness is an existing phenomenon in society, which reflects the failure of the community to provide basic safety. The health problem of the homeless people is an important public health and social problem in countries all over the world. In Taiwan, the health problems of the homeless are numerous and complex. The prevalent health problems in the homeless people include hypertension, diabetes, chronic liver disease, and other infectious disease which contributed to factors including lack of fixed residence, drug abuse, alcohol dependence, restriction of social welfare, lack of social support network, and lack of medical care.
This cross-sectional study collected data from 2016 to 2018 by the collaboration of Taipei City Hospital and Wanhua Social Service Center of the Taipei City Social Bureau. The survey for the homeless people was conducted in various homeless counseling organizations in Taipei City. Basic data and anthropometric measurements would be collected from participants. They were also asked to fill in life questionnaires. The medical examiners would perform blood pressure measurement and blood biochemical tests to collect relevant data. A total of 865 homeless people were recruited to this survey, and 183 repeated participants were deleted from our data. After data processing, 652 valid sample data were obtained through surveys. The research plan was reviewed and approved by the Human Testing Committee of Taipei United Hospital (Case No: TCHIRB-10805021-E). In this study, R software (R version 3.6.3) was used to analyze the prevalence rate and risk factors of infectious diseases among the residents of Taipei City. Through descriptive statistics, difference test, logistic regression and adjusted odds ratio analysis, In order to explore demographic factors, obesity indicators, living habits (and use multiple adaptive spline curves, MARS) methods combined with Logistic regression analysis, carefully explore the most appropriate model to explain the correlation between factor variables and diseases, and use the most appropriate Interpret the variables to establish a risk factor interval interpretation model
The study found (1)The prevalence of hypertension, hyperglycemia, and hyperlipidemia among the homeless adults in Taipei is significantly higher than that of the general population in Taiwan. (2) The prevalence of obesity among the homeless adults in Taipei is generally higher than that of the general population, especially the abdominal obesity of female homeless is more prevalent.(3) Compared with the homeless in Western countries, the smoking and drinking rates of the homeless in Taipei City are relatively low, especially the female. (4)Through logistic regression integrated with MARS, we found that abdominal obesity marked by waist-to-height ratio is a key risk factor for hypertension and hyperlipidemia; the prevalence of abdominal obesity, total cholesterol level, and hyperlipidemia among female homeless is significantly higher than that of male homeless. (5)The homeless who are divorced, separated or widowed are more likely to suffer from metabolic syndrome and syphilis. It is speculated that there is an important potential correlation between abdominal obesity, dyslipidemia, and unsatisfactory marital status among homeless people in Taipei. This study explores the risk factors of various chronic and infectious diseases of the homeless, and can provide relevant government agencies with health management recommendations. 
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