社經地位與死因之可預防性之相關：全民健保實施前後之比較

The Correlation of Socioeconomic Status and Preventable Causes of Death：A Comparison before and after Implementation of National Health Insurance

陳光華(chen kuang-hua)

指導教授 ： 董和銳

亞洲大學/健康學院/健康產業管理學系健康管理組/碩士(2010年)

摘要

背景：
高死亡率存在於低社經地位者的健康不平等現象長期以來已被眾多研究文獻所証實。雖然過去150年來，人類主要的死亡原因不斷的改變，但社經地位高低對死亡率的影響並不隨著時空轉移而改變。 這種持續存在的健康不平等現象使得研究者思考著高社經地位意味著其擁有比較多的資源如知識、權力、聲望等可以用來避免疾病發生及死亡的風險。 Link and Phelan (1995)提出了社經地位是健康不平等的基本原因(fundamental cause)的理論。若此理論為真，對於預防方式及治療方法了解較少、較不易預防的低可預防性死因而言，其死亡率無法透過資源使用而降低發生率，那麼社經地位與低可預防性死因的關係將不明顯。
目的：
本研究之目的有二。一為以臺灣中老年人調查資料的社經地位高與死亡率的關係來驗證基本原因理論(fundamental cause theory)。其次， 臺灣在1995年實施全民健康保險後，已大幅提高醫療服務的利用與可近性，尤其是在老年族群方面，但社經地位差異所造成的死亡率差距是否也隨之而有改善呢？本研究第二個目的即是希望澄清全民健康保險制度在減少臺灣老年人之死亡率不平等方面所扮演的角色。
方法：
本研究利用國民健康局「臺灣地區中老人保健與生活長期追蹤調查」資料,並連結衛生署全國死亡檔及死因疾病分類碼。並以美國哈佛大學公衛學院流行病學教授所發展之死因可預防性（preventability）量表將所有死因劃分成高可預防性與低可預防性死因。我們用老人的教育程度及收入兩個變項來作為本研究之社經地位指標，檢查其與高可預防性與低可預防性死因的關係強弱，並比較全民健康保險實施前(從1989年到1995年)及全民健康保險實施後(從1996年到2003年)這兩段時期的變化。
結果：
我們發現低教育程度和收入狀況的老人，相較於高教育程度和收入狀況者，比較容易死於高可預防性的死因。而教育程度和收入狀況等社經地位指標與低可預防性死因的關係則顯得微弱或不顯著。此外，高低社經地位老人之間的死亡率差距並未因全民健保之實施而獲得改善。
結論：
本研究中之老人樣本具有全國代表性，研究結果支持基本原因理論。雖然我國自1995年起實行全民健康保險制度，對於臺灣老人已大幅提升了醫療服務之可近性，但對於改善臺灣老人之死亡率不平等之情形，卻仍然沒有幫助。

關鍵字

社經地位 ； 健康不平等 ； 全民健保 ； 可預防性死因 ； 死亡不平等

並列摘要

Background:
Health disparities research has long documented that mortality is higher among the lower socioeconomic status (SES). More important, the effect of SES on mortality has been confirmed with data from time to time and from place to place, despite of the epidemiological transitions of major causes of death over the past 150 years. The persistence of this association has led researchers to contemplate that higher SES actually implies more resources like knowledge, power, prestige, and beneficial connections to avoid risk of disease and death. It has been proposed by Link and Phelan (1995) that SES is actually a fundamental cause of mortality disparities. If so, SES should be less strongly associated with less preventable causes of death (little about prevention and treatment is known), in which resources should be less helpful in prolonging life.
Objective:
The purpose of this study is two folds. The first purpose was to test the fundamental cause theory of SES-mortality association with Taiwanese survey data. Secondly, the launch of the National Health Insurance (NHI) in 1995 has greatly improved the accessibility and utilization of health care services, especially for the elderly population. However, it is not clear if the SES- mortality gap has been narrowed after the NHI. The second purpose of this study was to clarify the role the program has played in reducing mortality disparities among the elderly in Taiwan.
Methods:
Data were taken from the fourth wave of the Survey of Health and Living Status of the Middle Aged and Elderly in Taiwan. After linking the survey data to the Death Certificate File to obtain the International Classification of Disease (ICD) Codes of the deceased survey participants, a classification scheme of the preventability for their causes of death, developed by two physician epidemiologists from the Harvard University, was used to divide the ICD codes into high or low preventability. We then examined the strength of associations between the two SES measures (education and income level) and high-preventable and low-preventable deaths for the before- (from 1989 to 1995) and after-NHI (from 1996 to 2003) periods.
Results:
Our findings indicated that elders having a lower education and income level were more likely to die from high preventable causes of death than those having a higher education and income levels. We also found that the association between SES measures and low-preventable causes of death was weaker or not significant. Moreover, the SES disparities in mortality had not been narrowed after the implementation of the NHI.
Conclusion:
The validity of the fundamental cause theory was supported with a national representative sample of elders in Taiwan. Even though the implementation of the NHI in 1995 has markedly improved the accessibility of health care services for the elderly in Taiwan, however, it did not help reducing the SES-mortality differentials among the elderly in Taiwan.

並列關鍵字

socioeconomic status ； health disparities ； National Health Insurance ； preventable causes of death ； mortality disparities

參考文獻

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