The assessment of the likelihood of mammography usage with relevant factors among women with disabilities
Pei-Tseng Kung
a,1, Wen-Chen Tsai
b,1, Shang-Jyh Chiou
a,*
aDepartmentofHealthcareAdministration,AsiaUniversity,500,LioufengRoad,Wufeng,TaichungCity41354,Taiwan,ROC
bDepartmentofHealthServicesAdministration,ChinaMedicalUniversity,No.91,Hsueh-ShihRoad,Taichung,Taiwan40402,Taiwan,ROC
1. Introduction
Breastcanceristhemostcommontypeofcancerandamajorthreatforallwomen,includingwomenwithdisabilities.
Comparedwithothercancers,earlydetectionofbreastcanceriscurrentlyrecognizedasthemosteffectiveresponsetothis threatandtheoptimalapproachtoprovideapromisingprognosis.AccordingtoCentersforDiseaseControlandPrevention (CDC),76.2%ofwomenintheU.S.aged40orolderreportedhavingamammogramwithinthepasttwoyearsin2008, whereaswomenwithdisabilitieshavealowerrate(Armour,Thierry,&Wolf,2009;CDC,2008a)andtendtobescreenedfor cancerssignificantlylessfrequently(Wei,Findley,&Sambamoorthi,2006).Nonetheless,nodatasupportsthehypothesis thatdisabledwomenarediagnosedatmoreadvancedstagesofdiseases(Caban,Nosek,Graves,Esteva,&McNeese,2002).
ARTICLE INFO
Articlehistory:
Received29August2011
Receivedinrevisedform30August2011 Accepted30August2011
Availableonline4October2011
Keywords:
Disability Mammography Breastcancer Womenwithdisability Preventionhealthcare
ABSTRACT
Researchthatidentifiesthedeterminantsoflowmammographyuseamongdisabledpeople is scant. This study examines the determining factors related to the low usage of mammographyamongwomenwithdisabilities.Toidentifythebarriersthatpreventwomen with disabilities from participating in mammographyscreening can help authorities conceivefeasiblyusefulstrategiesforavoidingworsesuffering.Withwomenagedbetween 50and69assubjects,thisstudywasconductedusingthedatabaseofMinistryoftheInterior, Taiwan,in2008,coupledwithinformationgatheredbetween2006and2008onpreventive healthcareandmedicalclaimdatafromtheBureauofHealthPromotionandtheNational HealthResearchInstitutes,respectively.Thisstudyexaminedthefactorsdeterminingthe useofmammographywithlogisticregressionanalysis.Only8.49%ofthedisabledwomen usedmammographies.Whenwomenwithdisabilitieswereinhigherincomelevel,they weremorelikelytousemammographyforbreastcancerscreening.Similarfindingswere foundforeducationlevels.Moreover,subjectswithamoresevereformofdisabilitywereless likelytousemammographywithORsof0.84,0.63,and0.52.Disabledwomenwithmajor organmalfunction,chronicmentalillness,ormentalretardationhadahigherlikelihoodto usemammographyservices,whereaswomenwithmultipledisabilitieshadthelowest likelihoodofusage.Thosewithexperienceusingotherpreventiveservicesshowed1.9times to 7.54 times (95% CI: 1.82–1.98, 7.15–7.95, respectively) increased likelihood of mammographyusage.Insummary,mammographyusageisrelativelydifferentfordisabled andnondisabledpopulations.Tomitigatethedisparities,wecanusecommunityhealthcare institutionsorpublichealthnursesandsocialworkerstoproviderelatedpreventivehealth servicesthroughcommunityeventstoimplementintegratedcancerscreeningservices.
ß2011ElsevierLtd.Allrightsreserved.
*Correspondingauthor.Tel.:+886+042332345620038.
E-mailaddress:chiou@asia.edu.tw(S.-J.Chiou).
1 Theseauthorscontributedequallytothiswork.
ContentslistsavailableatSciVerseScienceDirect
Research in Developmental Disabilities
0891-4222/$–seefrontmatterß2011ElsevierLtd.Allrightsreserved.
doi:10.1016/j.ridd.2011.08.032
Mostimportantly,womenwithdisabilitiessufferthesameriskofbeingdiagnosedwithbreastcancer(Hogg&Tuffrey- Wijne,2008),butareinvulnerablesituationsinwhichtheycannotalwayshaveaccesstoadequatescreeningservices.
InTaiwan,accordingtotheBureauofHealthPromotionsurvey,therewere6593breastcancercases(incidenceratewas 49/100,000)in2005,and1552ofthesepatientsdied(Chang,Kuo,&Wang,2008).Theusageofmammographyinwomen between50and69yearsoldwithintheprevioustwoyearsinTaiwanandtheU.S.were12%and70%,respectively(Breen etal.,2007;CDC,2008b).Thefive-yearsurvivalrateofbreastcancerpatientsinTaiwanislowerthanthatintheU.S.(80%vs.
89%,respectively)(Howladeretal.,2010),whichispossiblyduetothelowerscreeningrate(Lin&Effken,2010).Forhealth authorities, therelevant factorsofthebarrierstomammographyarefundamental todevelopusefulstrategies forthe promotionofpreventiveservicesinthenearfuture.
Regardingmammographyusageforcertainpopulations,particularlyinwomenwithdisabilities,anumberofstudies have indicatedthat lowratesof breastcancer screeningmaybeattributedtothevariousriskfactorssuchasobesity (Kerlikowskeetal.,2008),lessphysicalactivity(Irwinetal.,2007),ordelayeddiagnosis,whichcomewithbarrierstoobtain preventivescreening.Womenwithdisabilitieshavereportedbarrierstoobtainmammograms(Barr,Giannotti,VanHoof, Mongoven,&Curry,2008).Thebarrierscanbedividedintothreemajorparts:environment;attitude;andcommunication.
Certainobstacles,forexample,comefromfacilities,clinicians,healthworkers,andself-consensus(Llewellyn,Balandin, Poulos,&McCarthy,2011).Somewomenwithdisabilitiesattributeobstaclestosituationssuchasdifficultywithpositioning whileobtainingamammogram,difficultytoarrangeappointments,oralackofaccess(Schuur,Shah,Wu,Forman,&Gross, 2009).Inaddition,theproviders’knowledgeandattitudesalsoinfluencethebreastcancerscreeningofdisabledwomen.
Furthermore,womenwithdisabilitiesmaynotadequatelyexpressdiscomfortbecauseoftheirphysicalorpsychological restrictions.Theytakelongerandhavehigherdifficultywithexplanationscomparedtothenormalpopulation.TheCDCalso foundthathealthpromotionalmessagesandmaterialsreflectingtheuniqueneedsofthedisabledarelacking.Therefore, differenttypesofdisabilitiessuchasmentalretardation(Havercamp,Scandlin,&Roth,2004;Wilkinson,Deis,Bowen,&
Bokhour,2011)orphysicallimitations(Nosek&Howland,1997)delaytreatmentormakeitdifficulttoreceiveadequate services,placingthedisabledpersonatgreaterrisk.Consequently,womenwithdisabilitiesarelesslikelytoreceiveteststhat candiscovercancerandotherhealthproblems,andtheyoftenavoidroutinehealthexams.
Accordingtoextantresearch(Diab&Johnston,2004),increasedseverityofadisabilitylowersthepreventionservicesused.
Furthermore,disparitiesinscreeningratesamongwomenwithdisabilitiesmaycontributetolargertumorsduringbreast cancerdiagnosis.AlthoughmammographyscreeningiswidelyappliedforbreastcancerinWesterncountries,onlyasmall proportion of the population hasthe experiencein Asian countries.Research that identifies the determinants of low mammographyuseisscantamongthispopulation.Thisstudyexaminesthedeterminingfactorsrelatedtothe usageof mammography among women with disabilities. Identifying the barriers that prevent women with disabilities from participatinginmammographyscreeningcanhelpauthoritiesconceivefeasiblyusefulstrategiesforavoidingworsesuffering.
2. Materialsandmethods 2.1. Datasourceandprocessing
Withwomenagedbetween50and69assubjects,thisstudywasconductedusingthedatabaseofMinistryoftheInterior, ExecutiveYuan,R.O.C.,2008,coupledwithinformationgatheredbetween2007and2008onpreventivehealthcarefromthe BureauofHealthPromotionandmedicalclaimdatafromtheNationalHealthInsuranceResearchDatasetpublishedbythe NationalHealthResearchInstitutes.
Previousstudieshavemostlyadoptedthesurveymethodorrandomizedtrialstoinvestigatetherelationshipbetween womenwithdisabilitiesandmammographyusage.Therespectiverolesofhealthstatus,comorbidity,andlevelofdisability inthereceptionofmammographyscreening,orreasonsfordifferencesintheuseofmammographyaccordingtodisability status,areunclear.Thisstudyusedauniqueandhigh-qualitydatabasetodeterminetherelevantfactorsassociatedwith mammographyamongwomenwithdisabilities.
Therecordedvariablesincludedthefollowing:(1)demographiccharacteristics:age,urbanizationlevelofresidentarea, premium-based monthlysalary,low incomestatus, education,maritalstatus, and aboriginalstatus; (2)health status:
catastrophicillness/injury,andrelevantchronicillnessessuchascanceranddiabetes;(3)classificationofdisability:typeof disabilityandseverityofdisability;(4)utilizationofotherpreventivehealthservices:usageofpapsmearandutilizationof adultpreventivehealthservices;and(5)mammographystatus:usageofmammography.
2.2. Subjects
Accordingtothe‘DisabilityRightsProtectionActs’ofTaiwan,disabilitywasclassifiedinto18categories,namelyvisual impairment,hearingimpairment,balanceimpairment,soundorspeechimpairment,physicaldisability,mentalretardation, majororganmalfunction,facialinjury, persistentvegetativestate,refractoryepilepsy, dementia,autism,chromosomal abnormalities,congenitalmetabolicdisorders,othercongenitaldefects,multipledisabilities,chronicmentalillness,and otherdisabilitiescausedbyrarediseasesrecognizedbycentralhealthauthorities.Severityofdisabilitywasclassifiedinto fourgroups:verysevere;severe;moderate;andmild.AccordingtotheregulationoftheBureauofHealthPromotion,women whoseageisbetween50and69couldreceiveonefreemammogramscreeningeverytwoyears.Thestudypopulationwitha P.-T.Kungetal./ResearchinDevelopmentalDisabilities33(2012)136–143 137
persistentvegetativestate(627individuals)wasunsuitableforthisstudy,andthus,wasexcluded.Basedonthedatabaseof theMinistryoftheInteriorin2008,136,600womenagedbetween50and69withdisabilitieswereincludedinthisstudyto investigatetheirmammographyusefrom2007to2008.
2.3. Statisticalanalysis
AlldatawereanalyzedwithSAS,version9.1.Thisstudyfirstinvolvedadescriptiveanalysisoftherelativevariables.
Accordingtotheuseofmammography,thedifferenceinpercentageofeachvariablewouldbeexaminedusingan
x
2testto checkforstatisticalsignificance.Multivariatelogisticregressionanalysiswassubsequentlyusedtoexaminetheinfluencing factorson theusageofmammography.Theindependentvariablesincludeddemographiccharacteristics,healthstatus, classificationofdisability,andtheutilizationofotherpreventivehealthservicesforthesubjects.3. Results
Inthis study,136,600 casesfollowedthedefinitionof disability,includingthemammographyusagegroup(8.49%, n=11,603)andthenon-usagegroup(91.51%,124,997).Apparently,themajorityofwomenwithdisabilitiesdidnotuse
Table1
CharacteristicsofStudySubjectsinuseofmammographyduring2007–2008.
Variables N=136,600 % Used Non-use x2
n1=11,603 % n2=124,997 % p-Value
Gender –
Female 136,600 100.00 11,603 8.49 124,997 91.51
Age <.001*
50–59 67,859 49.68 6040 8.90 61,819 91.10
60–69 68,741 50.32 5563 8.09 63,178 91.91
Urbanization <.001*
Level1 15,395 11.27 1212 7.87 14,183 92.13
Level2 30,090 22.03 2140 7.11 27,950 92.89
Level3 20,992 15.37 1779 8.47 19,213 91.53
Level4 12,426 9.10 996 8.02 11,430 91.98
Level5 20,549 15.04 1861 9.06 18,688 90.94
Level6 14,546 10.65 1311 9.01 13,235 90.99
Level7 14,915 10.92 1472 9.87 13,443 90.13
Level8 7687 5.63 832 10.82 6855 89.18
Premium-basedmonthlysalary(NT$) <.001*
Dependent 53,942 39.49 3894 7.22 50,048 92.78
<15,840 25,269 18.50 1438 5.69 23,831 94.31
16,500–22,800 36,873 26.99 3797 10.30 33,076 89.70
24,000–28,800 7325 5.36 851 11.62 6474 88.38
30,300–36,300 6709 4.91 806 12.01 5903 87.99
38,200–45,800 5384 3.94 699 12.98 4685 87.02
48,200–57,800 1098 0.80 118 10.75 980 89.25
Low-income <.001*
Yes 4392 3.22 203 4.62 4189 95.38
No 132,208 96.78 11,400 8.62 120,808 91.38
Aboriginal 0.204
Yes 2275 1.67 210 9.23 2065 90.77
No 134,325 98.33 11,393 8.48 122,932 91.52
Education <.001*
Elementaryorunder 86,429 63.27 6888 7.97 79,541 92.03
JuniorHigh 12,546 9.18 1220 9.72 11,326 90.28
SeniorHigh 13,298 9.73 1386 10.42 11,912 89.58
College 6183 4.53 688 11.13 5495 88.87
Unknown 18,144 13.28 1421 7.83 16,723 92.17
Marriage <.001*
Married 82,775 60.60 7692 9.29 75,083 90.71
Single 8686 6.36 497 5.72 8189 94.28
Divorceorwidow 7931 5.81 584 7.36 7347 92.64
Unknown 37,208 27.24 2830 7.61 34,378 92.39
Otherpreventivehealthservices
Papsmear <.001*
Yes 56,430 41.31 9848 17.45 46,582 82.55
No 80,170 58.69 1755 2.19 78,415 97.81
Adults’PreventiveCareService <.001*
Yes 36,659 26.84 5605 15.29 31,054 84.71
No 99,941 73.16 5998 6.00 93,943 94.00
*p<0.05.
mammography for breast cancer screening within the previous two years during 2007–2008. Table 1 displays the characteristicscomparing thetwo groups.Regardingtheagestructure, theyoungergrouphasa higherproportionof mammographyusage.Mostsubjectsinbothgroupsweredependentmembers,married,withelementaryeducationor under,notoflowincomestatus,oraboriginal.Mostpredicatorsweresignificantbetweentheusagegroupandnon-usage group,exceptforthoseofaboriginalstatus.Furthermore,intheusagegroup,certainproportionsofthecaseshadalsoused otherpreventivehealthservicessuchasPapsmearsandadultpreventivecareservices(85%and48%,respectively),while thosefiguresinthenon-usedgroupdwindledsignificantly,to37%and25%,respectively.
InTable2,weshowthehealthstatuscomparisonsofthetwogroups.Overone-thirdsufferedfromcatastrophicillness, and nearly 30%had diabetes,while thepercentage ofcancer population didnot surpass10%. Regardingthetypesof disabilities,approximately40%comprisedphysicaldisabilities,andapproximately70%werecataloguedasdisabilitiesof moderateormildseverity.Mostpredicators,exceptfortherelevantchronicdiseaseincancer,weresignificantbetweenthe usagegroupandthenon-usagegroup,irrespectiveofcancer.
Finally,inthelogisticregressionmodelshowninTable3,wedisplaythelikelihoodofusageofmammographywiththe determiningfactors.Regardingurbanization(from1to8),thelowernumbersignifiedahigherurbanization.However,no significantdifferencewaspresentamongurbanizationlevels,exceptforthesecondlevel.Forthemonthlysalary,exceptfor thegroupwith48,200–57,800NewTaiwandollars(NT$),thelikelihoodofmammographyusageincreasedwiththeincome levels,withoddsratios(ORs)from1.10to1.50,comparedtothosewithmonthlysalariesofNT$<15,840.Thismeansthat whenwomenwithdisabilitieswereinthehigherincomelevel,theyweremorelikelytousemammographyforbreastcancer screening.However,whentheirmonthlyincomesreachedthehighestlevelofNT$48,200–57,800,theuseofmammography wasreduced.Inaddition,similarfindingswerefoundfortheireducationlevel.Thosewhohadahighereducationlevel (juniorhigh,seniorhigh,andcollege)showedanincreasedlikelihoodofmammographyusagecomparedtothosewithan elementaryschoolorunderlevelofeducation,withORsof1.27,1.44,and1.66,respectively.
Concerningcomorbidity and theseverityof disability,women insuchsituations showedadecreased likelihoodof mammographyusage.Disabledwomensufferingfromanytypeofcancerordiabeteswouldhavealowerlikelihoodof mammographyusage.Moreover,subjectswithamoresevereformofdisabilitywerelesslikelytousemammography,with ORsof0.84,0.63,and0.52,respectively,comparedtothemildgroupofdisabilities.However,differenttypesofdisabilities hadmixedeffectsontheusageofmammography.Comparedtophysicaldisabilities,some,suchasmajororganmalfunction, chronicmentalillness,ormentalretardation,hadahigherlikelihoodtousemammographyservices,whereasothers,suchas thosewithmultipledisabilities,hadadecreasedlikelihoodofmammographyusage.Mostimportantly,thosewithmore
Table2
Chi-squareanalysisoftheusageofmammographyinwomenwithdisabilityduring2007–2008(heathstatus).
Variables N=136,600 % Used Non-used x2
n1=11,603 % n2=124,997 % p-Value
Catastrophicillness <.001*
Yes 47,995 35.14 3398 7.08 44,597 92.92
No 88,605 64.86 8205 9.26 80,400 90.74
Relevantchronicdisease
Cancer 0.544
Yes 9737 7.13 811 8.33 8926 91.67
No 126,863 92.87 10,792 8.51 116,071 91.49
Diabetes <.001*
Yes 36,995 27.08 2697 7.29 34,298 92.71
No 99,605 72.92 8906 8.94 90,699 91.06
Typeofdisability <.001*
Physicaldisability 53,294 39.01 4953 9.29 48,341 90.71
Majororganmalfunction 22,728 16.64 1494 6.57 21,234 93.43
Chronicmentalillness 17,243 12.62 1515 8.79 15,728 91.21
Hearingimpairment 14,761 10.81 1718 11.64 13,043 88.36
Multipledisability 10,549 7.72 518 4.91 10,031 95.09
Visualimpairment 9058 6.63 845 9.33 8213 90.67
Mentalretardation 4370 3.20 189 4.32 4181 95.68
Dementia 2282 1.67 153 6.70 2129 93.30
Soundorspeechimpairment 1063 0.78 92 8.65 971 91.35
Balanceimpairment 531 0.39 46 8.66 485 91.34
Facialinjury 298 0.22 38 12.75 260 87.25
Refractoryepilepsy 298 0.22 33 11.07 265 88.93
Others 125 0.09 9 7.20 116 92.80
Severityofdisability <.001*
Mild 51,800 37.92 6097 11.77 45,703 88.23
Moderate 43,131 31.57 3604 8.36 39,527 91.64
Severe 21,443 15.70 1109 5.17 20,334 94.83
Verysevere 20,226 14.81 793 3.92 19,433 96.08
*p<0.05.
P.-T.Kungetal./ResearchinDevelopmentalDisabilities33(2012)136–143 139
Table3
Theresultsoflogisticregressionmodelforthemammographyusage.
Variable Unadjustedmodel Adjustedmodel
OR 95%CI p-Value OR 95%CI p-Value
Age
50–59 – – – – – – – –
60–69 0.90 0.87 0.94 <.001* 1.00 0.96 1.05 0.883
Urbanization
Level1 – – – – – – – –
Level2 0.90 0.83 0.96 0.003* 0.87 0.80 0.94 <.001*
Level3 1.08 1.00 1.17 0.039* 1.01 0.93 1.10 0.825
Level4 1.02 0.93 1.11 0.662 0.96 0.87 1.06 0.397
Level5 1.17 1.08 1.26 <.001* 1.01 0.93 1.10 0.755
Level6 1.16 1.07 1.26 0.000* 0.96 0.88 1.06 0.421
Level7 1.28 1.18 1.39 <.001* 0.99 0.90 1.08 0.792
Level8 1.42 1.30 1.56 <.001* 0.98 0.88 1.09 0.732
Premium-basedmonthlysalary(NT$)
<15,840 – – – – – – – –
Dependent 1.29 1.21 1.37 <.001* 1.10 1.02 1.18 0.011*
16,500–22,800 1.90 1.79 2.03 <.001* 1.27 1.18 1.37 <.001*
24,000–28,800 2.18 1.99 2.38 <.001* 1.40 1.27 1.55 <.001*
30,300–36,300 2.26 2.07 2.48 <.001* 1.36 1.23 1.51 <.001*
38,200–45,800 2.47 2.25 2.72 <.001* 1.50 1.35 1.67 <.001*
48,200–57,800 2.00 1.64 2.43 <.001* 1.17 0.95 1.46 0.143
Low-incomehousehold
No – – – – – – – –
Yes 0.51 0.45 0.59 <.001* 0.88 0.75 1.03 0.102
Aboriginal
No – – – – – – – –
Yes 1.10 0.95 1.27 0.204 0.92 0.79 1.07 0.291
Education
Elementaryorunder – – – – – – – –
JuniorHigh 1.24 1.17 1.33 <.001* 1.27 1.18 1.36 <.001*
SeniorHigh 1.34 1.27 1.43 <.001* 1.42 1.32 1.52 <.001*
College 1.45 1.33 1.57 <.001* 1.66 1.51 1.83 <.001*
Unknown 0.98 0.93 1.04 0.533 1.06 1.00 1.13 0.063
Marriage
Married – – – – – – – –
Single 1.69 1.54 1.85 <.001* 1.05 0.95 1.16 0.374
Divorceorwidow 1.31 1.16 1.48 <.001* 1.00 0.88 1.15 0.961
Unknown 1.36 1.23 1.50 <.001* 0.99 0.89 1.10 0.882
Catastrophicillness
Yes – – – – – – – –
No 0.75 0.72 0.78 <.001* 0.97 0.91 1.04 0.429
Comorbidity
Cancer 0.98 0.91 1.05 0.548 0.87 0.79 0.95 0.003*
Diabetes 0.80 0.77 0.84 <.001* 0.91 0.87 0.96 0.000*
Typeofdisability
Physicaldisability – – – – – – – –
Majororganmalfunction 1.00 0.93 1.08 0.916 1.10 1.02 1.20 0.021*
Chronicmentalillness 1.29 1.21 1.36 <.001* 1.13 1.06 1.20 0.000*
Hearingimpairment 0.93 0.75 1.15 0.477 1.01 0.81 1.27 0.932
Multipledisability 0.44 0.38 0.51 <.001* 0.84 0.72 0.99 0.031*
Visualimpairment 0.50 0.46 0.55 <.001* 1.00 0.90 1.11 0.981
Mentalretardation 0.69 0.65 0.73 <.001* 1.08 1.00 1.17 0.043*
Dementia 1.43 1.01 2.01 0.042* 1.19 0.83 1.71 0.352
Soundorspeechimpairment 0.70 0.59 0.83 <.001* 0.85 0.72 1.02 0.076
Balanceimpairment 0.94 0.89 1.00 0.045* 1.06 0.98 1.15 0.169
Facialinjury 0.93 0.68 1.25 0.618 1.01 0.73 1.39 0.974
Refractoryepilepsy 1.22 0.85 1.75 0.292 0.87 0.60 1.27 0.474
Others 0.76 0.38 1.49 0.422 0.84 0.41 1.70 0.618
Severityofdisability
Mild – – – – – – – –
Moderate 0.68 0.65 0.71 <.001* 0.84 0.80 0.88 <.001*
Severe 0.41 0.38 0.44 <.001* 0.63 0.58 0.68 <.001*
Verysevere 0.31 0.28 0.33 <.001* 0.52 0.46 0.57 <.001*
Otherpreventivehealthservices Papsmear
No – – – – – – – –
Yes 9.45 8.97 9.95 <.001* 7.54 7.15 7.95 <.001*
Adults’preventivehealthservice
No – – – – – – – –
Yes 2.83 2.72 2.94 <.001* 1.90 1.82 1.98 <.001*
*p<0.05.
experienceusingotherpreventiveservices,suchaspapsmearsoradultpreventivecareservices,showed1.9timesto7.54 times(95%CI:7.15–7.95,1.82–1.98,respectively)increasedlikelihoodofmammographyusage.
4. Discussion
Womenwithdisabilities,accordingtopreviousstudies, havehigherbreastcancermortalityrates (McCarthyet al.,2006),and thereisanassociationbetweendisabilityandscreening(Schootman&Jeffe,2003).Thereasonswhywomenwithdisabilitiesdo notparticipateinbreastcancerscreeningwithmammographymightnotbesurprising,andarerevealedfromagovernment report,suchasaccesstoinformation,communication,accesstomammographymachines,themammographyprocedure, attitudestowardpreventivehealthcare,lackofphysicianreferral,andsoon(Barretal.,2008;USDeptofHealth&Human Services,2009).Toadvocatethebenefitofmammographyfordisabledwomen,somespecificpoliciesinpublichealthcould addressthisissue.Governmentorhospitalscanoffer trainingand educate healthcareprovidersonthesensitivityandawareness ofdisabilityissues(Schopp,Sanford,Hagglund,Gay,&Coatney,2002;Truesdale-Kennedy,Taggart,&McIlfatrick,2011).
In this study, thehigher income group, thehigher education level group, and those with experience using other preventiveservicesshowedanincreasedlikelihoodofmammographyusage,whereasthosewithcomorbiditiessuchas cancer ordiabetesand thosein aseverestateof disabilityshoweddecreasedlikelihoodof mammographyusage.The disabledwomenareinanespeciallyvulnerablesituationbecausetheyaresignificantlylesslikelytoengageinroutine mammographyscreeningpractices.
Generally,ahighernumberofwomenaged65yearsoroldercitedobstaclestousingmammographycomparedtothatof youngerwomen(Yankaskasetal.,2010).However,inthisstudy,agewasnotsignificant.Thismaybeattributedtothe nationalhealthinsurance(NHI)inTaiwan,whichreducesthefinancialbarrierstousehealthcareservices.Inaddition,local healthauthoritiesprovidemobilebreastcancerscreeningservicesandintegratedcancerscreeningservices,therebyeasing thebarrierofaccess.Regardingurbanization,itdoesnotseemtomarkedly influencetheuseofmammography.These servicesreducetheobstaclesforpopulationsinsomeremoteareas,especiallyforwomenwithdisabilities.
Frompriorstudies,themostimportantfactoraffectingusageofmammographyissuggestedbyphysicians(Lerman, Rimer,Trock,Balshem,&Engstrom,1990),andTsaiandKung(2010)alsoindicatedthatpatientswithhighereducation, higherhouseholdincome,andregularphysiciancounselingtendtohaveabetterunderstandingofpreventionservices.Our findingswereconsistentwiththoseofpreviousstudies.Womenwithhigherincome,aswellasahighereducationlevel, showedanincreasedlikelihoodofusingmammographyservices.Oneexplanationisthatwomenwithhigherincomeor educationlevelhaveanincreasedsenseofself-awareness.Anotherreasoncouldbethattheymaybemorelikelytopayfor thebreastcancerscreeningontheirown,comparedwiththoseinlowerincomelevel.Anumberofpeoplewithhigher incomeconductedmammographyscreeningsintheircomprehensivephysicalexamination,andpaidforitontheirown insteadofbygovernment.ThisisthereasonwhysubjectswithahighermonthlyincomeofNT$48,200–57,800reducedthe useofmammographyscreeningofferedbythegovernment.
Forthelowsocioeconomicgroupandtheelderpopulationwhomighthavenotreceivedpreventiveservicesforalong timeperiod,publichealthauthoritiesshouldadoptmoreaggressivestrategiestoreachsuchpopulationsbecausetheymay requiremoretimetoadjustorneedmorebudget;thesestrategiesmayberequiredtoprovideinformationortoimprove accessibility.Inaddition,toincreasetheknowledge,attitude,andperception(KAP)level,thegovernmentshouldinvest moreresourcesinhealthpromotionandeducationforthedisabledandtheircaregivers.
Womenwithmultipledisabilitieshavebeenreportedtoexperienceallproblemsatahigherratethanwomenwitha singledisabilityornodisabilities(Clarketal.,2009;Yankaskasetal.,2010).Moreover,ahigherseverityleveldecreasesthe likelihoodofmammographyusage.Womenwithdisabilitieswhohadonetypeofcancershowalowerlikelihoodofusing mammographybecausetheymightthinkthattheyalreadyhadonetypeofcarcinoma,andtheydonottendtothinkthat theyshouldbothertoconsideranother.Apparently,whenpatients’ situations donot improveorareworsening,their situationsbecomeanobstacletoobtainadequatepreventiveservices.
Womenwithphysicaldisabilitiesmayhavedifficultiesinaccessingcaresites(Poulos,Balandin,Llewellyn,McCarthy,&
Dark,2011);alackoftransportation,inadequateappointmenttimes,nonadjustableequipment,communicationissues,and fearsofexaminationandofbeingtouchedbystrangersallcontributetothemoptingtonotseekhelp.Differenttypesof disabilitiesmightaffectawoman’streatmentoptions,preferences,andchoices(Iezzonietal.,2008).Physicaldisabilitiesare noteasilyaccommodatedbymammographyscanners,reducingthelikelihoodofhavingamammogram(Sullivanetal., 2003).Thisstudyreaches thesameconclusion.However,weshouldacknowledgethatwomenwithdisabilitiesstayin institutionsforlongtimeperiods,andmedicalutilization,includingmammographyusage,maybemisstated.Publichealth authoritiesmustdevelopdifferentstrategiesfordifferenttypesofdisabilitiesdependingonthetypeandseveritylevel.The intellectually disabled, for example,may requirereading help when adequateliteracy is necessary,or for requesting accommodationswhenschedulingappointmentsorduringexams.
Not surprisingly, the group with experiences using other preventive services showed an increased likelihood of mammogramusage.Forpreventiveservices,moretimeandcostsarerequiredfordisabledpeople(Tsai,Kung,Chiang,&
Chang, 2007). Therefore, the reimbursement system should reflect these differences to provide more incentives for physiciansandhospitals.
Thisstudyhasseverallimitations.Becauseofusingasecondarydatabase,someinformationsuchashealthbehavior couldnotbeobtained.AnotherimportantlimitationisthatthisstudyusedtheNHIdatabaseinsteadofsurveydata.Wewere P.-T.Kungetal./ResearchinDevelopmentalDisabilities33(2012)136–143 141
unabletoobtaininformationonthecognitivehealthsituation.Informationrelatedtohealthbeliefsorhealthknowledge, whichmayaffectpatients’usageofmammography,especiallyinwomenwithdisabilities,isnotvalidinthisstudy.
5. Conclusions
Currently,Taiwanisimplementingapilotstudyofmammographyforwomenagedbetween40and49.However,thereis lessofafocusonmammographyusageforwomenwithdisabilities.Weshouldunderstandtherelevantfactorstoprovide thecomprehensivestrategies topromotemammographyusage.Healthauthorities shouldregardtheexisting services systemandconsiderthefindingsfromthisstudytorecognizethosewhoareatrisk.Therefore,weshouldimproveclinical preventiveservicesandprovidemoreaggressiveandcomprehensivestrategiestohelpthespecificgroupsofwomenreceive theseimportantservices.Frompreviousstudies,medicalutilizationisrelativelydifferentforthedisabledandnondisabled populations.Tomitigatethedisparities,wecanusecommunityhealthcareinstitutions,orpublichealthnursestocall, interview, or providerelated preventive health servicesthrough community events, toimplement integrated cancer screeningservices.Inaddition,socialworkersmayprovideotheropportunitiestoimprovetheusageofmammographyfor womenwithdisabilitiesstayingininstitutions.
Acknowledgements
ThisstudywassupportedbyBureauofHealthPromotion,DepartmentofHealth(Grantno.9805006A)andDepartmentof HealthClinicalTrialandResearchCenterforExcellence(DOH99-TD-B-111-004)andChinaMedicalUniversityandAsia University(Grantno.CMU98-13),basedondatafromtheNationalHealthInsuranceResearchDatabaseprovidedbyNational HealthResearchInstitute.Thepreventivehealth carefileswereprovidedbyBureauofHealthPromotion,thedisabled personsfileprovidedbyMinistryoftheInteriorinTaiwan.Theinterpretationsandconclusionscontainedhereindonot representthoseoftheBureauofHealthPromotion,NationalHealthResearchInstitutesorMinistryoftheInteriorinTaiwan.
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