1 Determining Factors for Utilization of Preventive Health Services among Adults with
Disabilities in Taiwan
Pei-Tseng Kung1＃, Wen-Chen Tsai2＃, Ya-Hsin Li3*
1
Department of Healthcare Administration, Asia University, Taichung, Taiwan, R.O.C. E-mail: ptkung@seed.net.tw
2
Department of Health Services Administration, China Medical University, Taichung, Taiwan, R.O.C. E-mail: wtsai@mail.cmu.edu.tw
3
Department of Health Policy and Management, Chung Shan Medical University and Hospital. Taichung, Taiwan, R.O.C. E-mail: yli.tulane@gmail.com
Running Title: The use of adult preventive health services among the disabled
＊
Corresponding author: Ya-Hsin Li, DrPH, Department of Health Policy and
Management, Chung Shan Medical University and Hospital, No.110, Sec.1, Jianguo N. Rd., Taichung City 40201, Taiwan, R.O.C.
TEL: +886-4-24730022 ext: 17172, Fax: + 886-4-22412337
Email: yli.tulane@gmail.com
2
Abstract
Taiwan has provided free health checks for adults since 1995. However, very little previous research has explored the use of preventive health services by
physically and mentally disabled adults. The present study aimed to understand this use of preventive health services and the factors that influence it. Research subjects included disabled people registered in a Ministry of the Interior database in 2008 (a total of 785,746 adults who met the conditions for being physically or mentally disabled and using preventive health services). These data were merged with the Bureau of Health Promotion’s 2006-2008 dataset on preventive health and the 2006-2008 health insurance database published by the National Health Research Institutes. In addition to descriptive and bivariate analysis, the study used logistic regression analysis to investigate the factors that influence the use of adult preventive health services. The results showed that 15.81 % of physically and mentally disabled adults used preventive health services. The rate of use among females was
significantly higher than the rate among males, and rates were higher among residents of relatively less urbanized areas. Usage rates were also universally higher among sufferers of chronic diseases. However, more serious disabilities had lower usage rates. From the logistic regression analysis, we ascertained that the factors that influenced the use of preventive health services were gender, age, level of urbanization, monthly salary, low-income household status, aboriginal status, catastrophic disease/injury status, chronic diseases, type of disability, and severity of the disability. The study’s main conclusion is that although Taiwan’s Department of Health has provided free preventive health services for more than 15 years, the usage rate of this care among the disabled remains low. Demographic features, health status, and type of disability are the main factors influencing the use of preventive healthcare services.
3 1. Introduction
By the end of 2008, the number of physically and mentally disabled persons in Taiwan totaled 1,040,585, or 4.52 % of the total population (Ministry of the Interior, 2009). To advance the health of Taiwan’s public, the Department of Health (DOH) has provided adult preventive health services (in the form of health checks) since 1995. According to the Bureau of Health Promotion (BHP) regulations, the targets of adult preventive health services can be divided into three categories: (1) people aged 40-64 years, who may undergo one health check every three years; (2) people aged 65 years and over, who may undergo one health check each year; and (3) sufferers of poliomyelitis aged 35 and over, who may undergo one health check each year. The services included under “adult preventive health services” are physical examination, health education guidance, blood tests, and urinalysis.
In 2004, the overall rate of use of adult preventive health services among the 40- to 64-year-old category was 42 %, while the rate of use among the 65-year-old and over category was 38 %. The number of people using adult preventive health services increased from 1.21 million in 1999 to 1.63 million in 2006 (DOH, 2008), showing a significant increase in the public use of these services.
The physically and mentally disabled may not be able to express the nature of their medical ailments because of physiological or psychological disabilities. Because visits to the doctor may require more time and difficulty and may be less convenient for them than for the general population, physically and mentally disabled adults may not obtain necessary treatments. Previous studies have indicated that the usage rates for preventive health services among the physically and mentally disabled are lower than the rates among the general population (Ramirez et al., 2005; Tezzoni et al., 2001; Phillips et al., 2000; Shabas, Weinreb, 2003; Kroll, Neri, 2004). Fewer females
4 among the physically and mentally disabled population receive cervical smears or breast screening than their able-bodied counterparts (Jones, Beatty, 2003). The more serious the mental or physical disability, the lower the usage rate of preventive health services (Diab, Johnston, 2004). However, the findings on these rates are
contradictory. Weiet et al.’s (2006) analysis of the 1999-2002 Medical Expenditure Survey (MEPS) found that more physically or mentally disabled females (50.1 %) availed themselves of influenza vaccinations than did their able-bodied counterparts (39.0 %), and more physically or mentally disabled females underwent cholesterol tests (92.6 %) than did their able-bodied counterparts (90.9 %). Ramirez et al. (2005) found that the proportions of the disabled who underwent the prostate-specific antigen test (46.06%), colorectal endoscopy (41.91%), and the fecal occult blood test
(22.52%) were lower than the proportions of their able-bodied counterparts (52.36%, 43.35%, and 23.08%).
Previous research has indicated that the factors that influence whether the public accepts preventive health services include gender (Owens, 2008; Smith, Cokkinides, Eyre, 2007; Bertakis et al., 2000; Green, Pope, 1999), ethnic group (Makuc et al., 1989), educational level (Katz, Hofer, 1994; Dolan-Mullen et al., 1997), and income (Singh et al., 2004; Makuc et al., 1989). Generally speaking, higher income represents a greater probability of using preventive health services, whereas educational level and the probability of using each type of preventive health service are directly proportional to one another. In Taiwan, a study has found that the use of preventive care among women depends on a variety of factors, such as age, marital status, income level, education, and health status (Lin, 2009).
If we integrate the findings of previous research, we find that the use of medical services by the physically and mentally disabled differs from that of the general
5 population. To date, however, most studies have emphasized the use of medical services by the general population, with very little research into the use of preventive healthcare by the disabled. For this reason, the present study focuses on the physically and mentally disabled and explores their use of preventive healthcare and the factors that determine this use. It is hoped that this study might serve as a reference in the formulation of preventive health policy for disadvantaged groups.
2. Materials and methods 2.1. Data source and processing
This study focused its analysis on adults aged 40 and over. The research subjects included physically and mentally disabled persons registered in 2008 in a database of the Ministry of the Interior. Information on these subjects was merged with the preventive health services files of the Bureau of Health Promotion in 2006-2008 and the health insurance medical claims database published by the National Health Research Institutes. The following variables were recorded:
(1) Demographic characteristics: gender, age, aboriginal status, residence, premium-based monthly salary, and low-income household status; (2) health and disability status: catastrophic illness/injury, relevant chronic illnesses (including cancer, endocrine and metabolic diseases, mental disorders, diseases of the nervous system, diseases of the circulatory system, diseases of the respiratory system, diseases of the digestive system, diseases of the genitourinary system, diseases of the
musculoskeletal system and connective tissue, disorders of the eye and adnexa, infectious diseases, congenital anomalies, diseases of the skin and subcutaneous tissue, diseases of the blood and blood-forming organs, and diseases of the ear and mastoid process); (3) classification of disability: type of disability and severity of
6 disability; (4) utilization of preventive health services among the disabled.
2.2. Subjects
According to Taiwan’s Disability Rights Protection Acts, disability can be classified into 18 categories: visual impairment, hearing impairment, balance
impairment, sound or speech impairment, limb impediment, mental retardation, major organ malfunction, facial injury, persistent vegetative state, refractory epilepsy,
dementia, autism, chromosomal abnormalities, congenital metabolic disorders, other congenital defects, multiple disabilities, chronic mental illness, and other disabilities caused by rare diseases recognized by central health authorities. The severity of disability is classified into four categories: very severe, severe, moderate, and mild.
This study included the subjects aged 40 or older and excluded individuals with persistent vegetative state (4,176 persons) who are unsuitable for the use of preventive health services, and individuals suffering from poliomyelitis aged 35-39 years in the analysis. Since those with disability due to poliomyelitis belong to the group of physical disability, they could not be distinguished from those with physical disability in the dataset.A total of 785,746 persons with disabilities were identified as meeting the requirements for preventive health services.
2.3. Statistical analysis
We first used descriptive statistics to understand characteristics of the disabled subject such as gender, age, level of urbanization, type of physical or mental
disability (categorized into 18 types and four levels), educational level, marital status, and aboriginal status. Then we analyzed the disabled persons’ use of adult preventive health services in terms of the numbers of occasions and percentages. We used the 2 test to compare variations in disabled persons’ use of preventive health services. The variables with p<0.05 from the 2
7 and the factors influencing the use of adult preventive health services by the disabled were investigated separately. In the logistic regression analysis, the use of adult preventive health services was the dependent variable. Independent variables included demographic features (gender, age, level of urbanization, premium-based monthly salary, low-income household status, educational level, marital status, aboriginal status, etc.), health status (relevant chronic diseases, catastrophic
disease/injury, etc.), qualifications for physically or mentally disabled status (category of physical or mental disability, level of severity of disability), and the use of other preventive health services. There were eight levels of urbanization, from “areas at the highest level of urbanization” to “areas at the lowest level of urbanization.”
3. Results
3.1 Basic characteristics of the physically and mentally disabled (Table 1)
This study identified 785,746 physically and mentally disabled persons who met the conditions for adult preventive health services, of whom 55.84 % (N=438,766) were males. The largest category included persons 70 years of age and over (37.57%, N=295,198). The largest category for premium-based salary was “dependent
population” (34.33%, N=269,753). Aborigines constituted a mere 1.57 % of the subjects (N=12,348). The largest category in terms of educational level was “elementary school or lower” (51.96%, N=408,271). The largest group for type of physical or mental disability was “limb impediment(s)” (41.90%, N=329,264). The largest category of disability level was “mild disability.”
3.2 The use of preventive health services among the disabled (Table 1)
Of the disabled subjects who met the conditions for the use of adult preventive health services, 15.81 % (N=124,257) used these services. The rate of use among
8 disabled females (16.57%) was slightly higher than the rate among disabled males (15.22%). If we distinguish the usage rates by age, the rate of use was greatest among the 60- to 64-year-old age group (23.72%). If we distinguish the usage rates by level of urbanization, the rate of use was greatest among disabled persons residing in areas at level 8 (18.05%) and lowest among those residing in areas at the highest levels of urbanization. When examining premium-based monthly salary, the highest rate of use was found for those in the category of “NT$30,300-36,300 (New Taiwan Dollars)” (21.69%). The rate of use among aborigines was 23.63 %, slightly higher than the usage rate among the non-aboriginal disabled population (15.69%). If we distinguish usage rates by educational level, the rate of use was greatest among disabled persons educated to the junior high school level (17.48%). When examining marital status, the highest rate of use was found among the unmarried population (16.12%). The highest rate of use was found among those suffering from infectious diseases (20.14%), while the lowest rate of use was among those suffering from cancer (12.15%). Of the
different types of disabilities, the highest rates of use were among those suffering from chronic epilepsy (23.33%) and the mildly disabled (18.26%). The more severe the level of disability, the lower the rate of use was.
3.3 Factors influencing the use of adult preventive health services (Table 2) The study found that age, level of urbanization, premium-based salary, low-income household status, aboriginal status, marital status, catastrophic
injury/disease status, relevant chronic diseases, type of physical or mental disability, and the severity of the disability significantly influenced the use of adult preventive health services among disabled persons (p<0.05). These findings indicate that the probability of using such services among males is 0.88 times higher than the
9 use was highest among the 60- to 64-year-old group, 1.36 times higher than that of the 40- to 44-year-old group (95% C.I.=1.32-1.41). The probability of use was lowest among the 70-year-old and older group, 0.46 times lower than that of the 40- to 44-year-old group (95% C.I.=0.45-0.48). In terms of the level of urbanization, the probability of using adult preventive health services was greatest among those living in level-7 areas, 1.75 times higher than that of those living in level-one areas (95% C.I.=1.70-1.80). For premium-based salary, the probability of use among those at the “NT$30,300-36,300” level was 1.20 times greater than the probability of use for those at the lowest level of “＜NT$15,840” (95% C.I. =1.16-1.24). The probability of use among low-income individuals was 1.42 times greater than among those from non-low-income households (95% C.I. =1.38-1.46). The probability of use among aborigines was 1.18 times higher than that of non-aborigines (95% C.I.=1.13-1.24). The probability of use among those suffering from catastrophic injuries or diseases was 0.79 times lower than the probability of use among those not suffering from such injuries or diseases (95% C.I. =0.77-0.80). For the category of relevant chronic diseases, the probability of use was highest among those suffering from diseases of the digestive system (OR=1.37, 95% C.I.=1.35-1.39), followed by those suffering from endocrine and metabolic diseases (OR=1.34, 95% C.I. =1.32-1.36). In terms of type of disability, compared to those with limb impediments, the probability of use was highest among those with mental disorders (OR= 1.41, 95% C.I.=1.37-1.45). The probability of use was lowest among those suffering from major organ malfunction (OR= 0.76, 95% C.I.=0.74-0.78). Regarding the severity of the disability, the greater the level of severity, the lower the subject’s probability of use. The most severely physically or mentally disabled (OR= 0.61, 95% C.I.= 0.59-0.63) persons showed the lowest probability of using adult preventive health services.
10 4. Discussion
Regarding the use of adult preventive health services by physically or mentally disabled persons, the current study found that the probability of use was significantly greater for females than for males. This is in agreement with the findings of many previous studies, which suggest that the usage rate of preventive health services is higher for females than for males (Owens, 2008; Smith, Cokkinides, Eyre, 2007; Bertakis et al., 2000; Green, Pope, 1999).
Regarding residence areas, the study found that the probability of using adult preventive health services was significantly greater among those living in areas with relatively low levels of urbanization than among those living in areas with the highest levels of urbanization. Generally speaking, the level of urbanization can reflect the availability of medical resources. However, since Taiwan implemented its National Health Insurance program, the accessibility of doctors to the public has significantly improved (Wen et al., 2008), and the public’s usage rate of preventive health services in urban and rural township areas has increased accordingly. Lifestyle and social relationships in suburban or rural areas differ from those in urban areas in Taiwan. Residents of urban areas are more dependent on public media for information than on the word-of-mouth communications common in rural areas. Compared to urban areas, people in rural areas have stronger cohesion and prefer group activities. Therefore, it is very common for people in rural areas to receive preventive health care together. Accordingly, the probability of using medical resources may be higher, significantly increasing the rate of health checks. Furthermore, in recent years, Taiwan has improved mobile medical services in remote areas such as mountains and offshore islands. In these areas, cooperative health care institutions perform mobile medical
11 care, bringing screening vehicles and doctors directly to villages to provide services. Thus, the usage rate of preventive health services is higher among residents of areas with low levels of urbanization than among those in areas with high levels of urbanization.
Regarding premium-based salary, although previous research has indicated that the usage rates and frequency of preventive health services are directly proportionate to income (Makuc et al., 1989), the present study found that subjects whose
premium-based salary was NT$48,200 or above had lower usage rates for adult preventive health services, perhaps because many Taiwanese people of relatively high social and economic status choose to undergo self-paid health checks. Many hospitals provide relatively high-level adult health checks for a fee, which offer more detailed and more diverse health services.
The findings of the current study show that the rate of use among subjects from low-income households was greater than the rate of use among subjects from
non-low-income households. This finding is at odds with previous findings in which higher income indicated a higher usage rate for preventive health services (Chang & Tun, 2008). However, this finding confirms that, since the implementation of the National Health Insurance program, Taiwan has improved the situation in which financial impediments prevented the public from visiting doctors.
This study found significant differences between different marital statuses and the usage rates for preventive health services. There were significantly lower usage rates among subjects who were divorced or whose spouse was deceased than among subjects who were married. This finding is in accordance with the findings of many previous studies on the relationship between marital status and the use of medical services. Studies have indicated that married people attach relatively greater
12 importance to their health and adopt more preventive health or life habits (Goldman et al., 1995; Suarez et al., 1994). Research indicates that married people are more likely than unmarried people to have fixed locations at which they visit the doctor, which influences their behavior in relation to the use of medical services (Doescher et al., 2004).
In terms of health status, the findings of the current study show that the usage rates for preventive health services are significantly higher among those suffering from chronic diseases and those with catastrophic injuries or diseases than among those without catastrophic injuries or diseases, perhaps because people whose chronic disease is induced by their health status and those with catastrophic injuries or
diseases attach more importance to preventive health checks. Research indicates that the usage rates of preventive health services are higher among adults suffering from catastrophic injuries or diseases than among adults in the general population (Nosek & Howland, 1997). Previous studies have found that people with mild and moderate disabilities received more preventive health services than did people without
disabilities (Diab & Johnston, 2004). Regarding the severity of physical or mental disabilities, the more severe a disability is, the lower the usage rate of preventive health services. Previous research has shown that the lowest usage rates for preventive health services are among groups of patients whose diseases are the most severe (Diab & Johnston, 2004; Chan et al., 1999). It is less convenient for patients with relatively serious disabilities to use preventive health services. The planning of health policies should therefore be focused on improving the use of preventive health services among the more severely disabled population. In Taiwan, global budgeting payments were employed to increase health care providers’ willingness to spend time on oral health care for children with severe disabilities and to encourage treatment and care for
13 severely disabled persons (Tsai et al., 2007). A similar financial incentive scheme could be implemented to enhance preventive health services for the disabled and to increase the utilization of these services.
Regarding the type of physical or mental disability, the lowest usage rates for preventive health services were among persons with major organ malfunction and rare diseases. As the data from the Ministry of the Interior show, 63.97 % of physically or mentally disabled persons must visit doctors periodically, and 55.89 % are unable to do so independently. Of the latter group, 68.77 % suffer from rare diseases, and 41.58 % of those with major organ malfunction are unable to visit a doctor independently. Of patients who are unable to visit a doctor independently, 88.12 % are unable to independently complete the registration process, while 48.86 % find it difficult to resolve transportation issues (Summary Report on the Survey of Life Needs among the Physically and Mentally Disabled in Taiwan, 2006). Accordingly, usage rates for preventive health services are relatively low.
In accordance with the findings of the current study, we suggest that the
government should provide more channels to enable physically or mentally disabled persons to avail themselves of adult preventive health services and should increase levels of participation in preventive health services among the physically or mentally disabled through widespread mass media publicity and education by health
institutions. At the same time, remuneration for conducting health checks among the disabled should be improved to increase physicians’ willingness to provide these services.
5. Conclusion
The current study investigated the use of adult preventive health services by physically or mentally disabled persons. The main factors influencing whether the
14 disabled used such services were gender, age, level of urbanization, income,
low-income household status, aboriginal status, marital status, catastrophic
injury/disease status, relevant chronic diseases, type of disability, and level of severity of disability.
For high-risk groups, such as persons of low social and economic status or advanced old age, who may have gone long periods without receiving health checks, we suggest that the public health system or medical institutions implement extensive publicity and related education programs for caregivers of the disabled to ensure that these high-risk groups receive periodic health checks. Medical institutions should encourage doctors to actively question disabled patients during medical appointments and to remind these patients to arrange health checks. Periodically, medical
institutions should track and notify these disabled patients to make return visits in an attempt to facilitate supportive measures for follow-up and treatments. Medical institutions should also improve facilities with obstruction-free spaces and other planning that takes into account the mobility issues and convenience of physically or mentally disabled persons, thereby increasing these patients’ satisfaction with medical visits.
Because the data for this study came from secondary databases, it was not possible to obtain information on some factors, such as individuals’ health behavior and health beliefs. This limitation also affected the variables that could be used.
Acknowledgement
This study was supported by grants (CMU94-099,
NSC98-2410-H-468-015-My2, DOH99-TD-B-111-004) from China Medical University, the National Science Council, and the Department of Health. The
15 preventive health care files were obtained from the Bureau of Health Promotion, Department of Health, in Taiwan. We are also grateful for use of the National Health Insurance Research Database provided by the Department of Health, Taiwan. The interpretations and conclusions contained herein do not represent those of the Bureau of Health Promotion in Taiwan.
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