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研究生:蔡淑鈴
研究生(外文):Shu-ling Tsai
論文名稱:醫療利用、死亡與失業:在經濟不景氣下之實証研究
論文名稱(外文):Medical Care Utilization, Mortality and Unemployment in Economic Recession
指導教授:藍忠孚藍忠孚引用關係
指導教授(外文):Chung-Fu Lan
學位類別:博士
校院名稱:國立陽明大學
系所名稱:公共衛生研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2004
畢業學年度:92
語文別:中文
論文頁數:123
中文關鍵詞:失業每人年醫療利用差異中之差異法死亡率Cox hazard function企業規模
外文關鍵詞:unemploymentmedical utilizationdifference in difference methodmortalityCox hazard functionfirm size
相關次數:
  • 被引用被引用:19
  • 點閱點閱:684
  • 評分評分:
  • 下載下載:196
  • 收藏至我的研究室書目清單書目收藏:8
台灣過去30年來失業率一向低平,總在3﹪以下,自1999年起台灣面臨自光復以來最嚴重之經濟衰退,失業率一路攀高至2001年之5.0﹪,成長2倍以上,依據中華經濟研究院之預測,台灣將真正進入高失業率之時代。
失業對健康之影響則呈現多面向,亦為相當複雜之問題,對個人而言,失業是一種壓力事件或狀態,可能影響個人之健康。台灣失業者因有失業保險,基本經濟生活得以維持;因有全民健康保險,醫療權益不致受影響。歐美工業化國家過去已歷經長期高失業率對其社會之衝擊,早有大量有關失業對健康之實証研究文獻;台灣由於過去長期處於低失業率狀態,故迄今未對失業對健康之問題加以重視。近年台灣之高失業率已引起國內各界對失業問題高度重視,本文之目的即在利用台灣失業保險與全民健康保險下之完整資料庫,進一步實証台灣失業所帶來之健康問題,共區分三大部份加以探討,第一部份為失業與醫療利用,第二部份為失業與死亡;第三部份為企業規模、失業與死亡,以上實証結果可為台灣面對未來高失業率時代,全民健保、醫療政策與勞工政策等制定之參考。
第一部份:失業與醫療利用
過去之研究顯示失業與醫療利用之關係同時存在健康效應(health effect)與所得效應(income effect),但迄今尚無定論,在台灣迄今亦無失業與醫療利用相關之實証研究。目標:本研究之目的在了解台灣在全民健康保險制度下,失業對醫療利用上之影響,並針對特定疾病醫療利用之影響加以分析。方法:本研究為有對照組之世代研究,定義之失業為2001年非志願性失業者共92,562人為研究對象,並選取同時期之在職者共92,443人為對照組,觀察期間為每人失業前後各一人年,以差異中之差異法(difference in difference method)與廣義估計方程式(Generalized Estimation Equation )測量。結果:研究結果顯示失業後一年西醫整體門診醫療利用變化呈下降情形,主要受呼吸道感染之醫療利用下降之影響;精神疾病之醫療利用有明顯上升之情形;另三種心血管疾病之醫療利用則在失業後無明顯影響。結論:失業對醫療利用之影響,在不同疾病上確有可能受所得降低與健康衝擊之不同程度之影響。本研究只檢驗失業對醫療利用之短期(一年)影響,至長期影響尚待後續之追蹤與監測。
第二部份:失業與死亡率
失業及其後續影響是嚴重經濟衰退危機時最被關注之社會問題。過去許多失業與死亡之研究結論均指出,失業者在控制可能之干擾因素後,仍較有工作者有較高之死亡風險,但台灣迄今尚無探討失業與死亡之相關之實証研究。目標:本研究之目的在以台灣為例,探討失業與死亡之相關,並就其對性別與原因別之死亡風險加以分析。方法:本研究設計為以個人為觀察單位且有對照組之世代研究,觀察單位為個人,研究對象為2001年非自願性失業者共92,563人,對照組為自失業者失業時所屬投保單位在職者共單1,230,000人中,經比對年齡、性別、投保金額、企業規模、與居住地都市化程度等變項,以次數比對技術隨機抽樣而得92,599人。觀察期間由2001年1月至2002年12月,在控制個人特質與影響健康選擇之干擾因素後,採Cox proportional hazard model計算hazard ratio(HR)(或稱adjusted relative ratio)加以測量。結果:在控制相關干擾因素後,失業者較有業者有顯著較高之死亡之風險,RR值為1.99(95%CI:1.60-2.48),男性RR值為2.07(95%CI:1.59-2.70),女性為1.81(95%CI:1.22-2.69),均達統計上顯著之差異;在性別原因別之分析上,男性失業者在心血管疾病、消化系統疾病、其它疾病(除癌症、心血管疾病與消化性疾病之外的疾病)與其它外因(除自殺之外之其它外因)有顯著較高之死亡風險,RR值介於2.21至3.37間;癌症未達顯著差異(P=0.095);自殺一項因死亡數有限(n=15),未達統計上顯著差異;在失業女性方面,則因死亡人數較低,故僅其它疾病一項之死亡風險顯著較高,其它疾病均未達統計上顯著差異。結論:失業是死亡之重要風險預測因子,尤其反應在男性之癌症、心血管疾病、消化系統疾病、其它疾病、其它外因與女性之其它疾病之死亡。本實証研究因只觀察台灣非志願性失業後一年之死亡風險,長期之影響仍待後續之追蹤研究。
第三部份:企業規模、失業與死亡率
現有文獻已提出大企業有較高之就業安全,但大企業員工一旦面對被解雇,則其所受之衝擊與壓力,會對健康造成影響,其間所帶來之就業不安全會大於小企業員工。但迄今尚無以經濟衰退為背景,研究大小企業失業者因就業安全程度不同對健康衝擊。目標:本研究之目的即在台灣嚴重經濟衰退為例,以企業規模為就業安全之代理變項(proxy),探討企業規模、失業與死亡之相關研究。方法:本研究設計為以個人為觀察單位且有對照組之世代研究,觀察單位為個人,研究對象為2001年失業組與對照組共185,162人,年齡介於15-64歲之間,觀察期間由2001年1月至2002年12月,在控制個人特質與影響健康選擇之干擾因素後,採Cox proportional hazard model計算hazard ratio(HR)(或稱adjusted relative ratio),並以Interaction effect 以控制組別與企業規模之交互作用。統計上顯著差異採P<0.05之標準。結果:在控制個人特質與失業前之健康狀態後,大企業失業組死亡風險為對照組之2.64倍(95%CI:1.94-3.59),小企業為1.43倍(95%CI:1.04-1.96),兩者均達統計上顯著之差異;進一步控制組別與企業規模之交互作用後(即扣除大小企業對照組死亡風險差距之固定影響),大小企業失業組死亡風險之差距為1.87倍(95%CI:1.21-2.91),亦達統計上顯著之差異,顯示大企業失業者較小企業失業者有明顯較高之死亡風險。結論:大企業勞工面對就業安全轉變程度大及失業之雙重衝擊,本研究提供很強之証據證明,在經濟衰退下,企業規模可為就業安全轉變之代理變項,用以預測大小企業失業勞工之死亡風險,此結果亦符合就業不安全與失業為健康之危險因子之理論。未來政策上對即將失業者及已失業者之社會支持、心理輔導與就業機會等均是重要之課題,並應強調大企業對解雇員工之責任。
Part 1: Unemployment and Medical Care Utilization
Previous research has shown that exposure to unemployment could have either health effect or income effect on medical care utilization.
Objective: This study examines to distinguish health effect from income effect by studying total and five disease-specific medical care utilizations before and after exposure to involuntary unemployment under the National Health Insurance Program in Taiwan.
Methods: A experimental study design with control group and fixed effect model were used. Two groups of people were observed from 1999 to 2002: (1) the involuntary unemployment group (n=92,562), and (2) the control group (n=92,443). The unit of observation was person-year. In order to obtain more precise estimates and control for possible confounders, the difference-in-difference (DD) method and generalized estimation equation (GEE) approach were conducted.
Results: Decreases in both ambulatory and inpatient services utilizations were observed after unemployment. In terms of disease-specific utilization, 3 important findings are identified: (1) a decrease in utilization for common cold detected after unemployment exhibits a strong income effect of unemployment on minor diseases; (2) has no significant change in utilization for three cardiovascular diseases found after unemployment; (3) an increase in utilization identified for mental diseases after unemployment implies a significant health effect from exposure to unemployment. Conclusion: Income and health effects of unemployment on medical care utilization vary among types of diseases. One study limitation is that we only examines the short-term(one year) effects of unemployment on medical care utilization, so it is important for future study to further investigate possible long-term effects of unemployment on utilization.
Part II: Unemployment and Mortality in Taiwan
Background: Unemployment, and its consequences, is always of great concern during economic downturns. However, no empirical study has investigated the effect of unemployment on mortality in Taiwan.
Objective: The aim of this study was to investigate the effect of unemployment on mortality in Taiwan - an environment with a high unemployment rate in 2001.
Method: The study design was a cohort study with a control group. Each unit of observation was a subject, within the study population. The unemployed group included 92,563 involuntarily unemployed individuals in 2001. Those in the control group (n=92,599) were randomly selected from 1,230,000 employees, and matched with those in the unemployed group, by age, sex, income, firm size and urbanization, using a frequency matching mechanism. All subjects were followed during the period from January 2001 to December 2002. The adjusted hazard ratio was estimated using the Cox Proportional Hazards Model.
Result: After adjusting for other factors, it was found that those who were unemployed (HR=1.99, 95%CI: 1.60, 2.48), had a higher risk of mortality than those who were employed. The gender specific adjusted hazard ratios for the unemployment of men and women were 2.07 (95%CI: 1.59-2.70) and 1.82(95%CI: 1.22-2.69), respectively. Unemployed men had a significantly higher mortality risk for cardiovascular disease, digestive system diseases, all other diseases (except for cancer, digestive system and cardiovascular diseases) and other external causes (not including suicide) than men who were employed. Unemployed women had a significantly higher mortality risk, only for other diseases, than women who were employed.
Conclusion: Unemployment is one important risk factor for mortality in Taiwan. However, since the study population was followed only within two years of becoming unemployed, the long-term impact of unemployment on mortality still remains to be explored.
Part III: Firm Size, Unemployment and Mortality
It is well documented that job security is higher in larger firms. However, many speculate that as employees of larger firms tend to have a better job security, once they are laid off, they may face a more dramatic change in life and suffer worse health consequences than those of smaller firms. However, none has empirically studied how the relationship between unemployment and health vary by level of job security. Objectives: This study aimed to examine the relationship between job security, unemployment, and mortality using firm size as a proxy of job security.
Methods: We performed a cohort study among 185,162 men and women, 15-64 years old, in Taiwan in 2001. This sample was followed from January 2001 to December 2002 on mortality. The mortality in relation to firm size and unemployment was analyzed using the multivariate Cox hazard model.
Results: After adjusting for possible confounding factors, the laid off employees of larger and small firms had 2.64 times (95%CI: 1.94-3.59) and 1.43 times (95%CI: 1.04-1.96) higher mortality rates than those who are still employed, respectively. The mortality risk of unemployment on previous large firm employees was significantly higher than small firm employees (RR=1.87, 95%CI: 1.21-2.91). Conclusion: The study not only confirms previous finding of significant relationship between unemployment and health, but also shows that the relationship between unemployment and health was particularly strong among employees who are laid off by larger firms. The results warrant more public attentions on the unemployed, especially those who are laid off by larger firms.
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