| Summary: | 博士 === 國立陽明大學 === 公共衛生研究所 === 92 === 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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