Determining factors for utilization of preventive health services among adults with disabilities in Taiwan
Pei-Tseng Kung
a,1, Wen-Chen Tsai
b,1, Ya-Hsin Li
c,*
aDepartmentofHealthcareAdministration,AsiaUniversity,Taichung,Taiwan,ROC
bDepartmentofHealthServicesAdministration,ChinaMedicalUniversity,Taichung,Taiwan,ROC
cDepartmentofHealthPolicyandManagement,ChungShanMedicalUniversityandHospital,Taichung,Taiwan,ROC
1. Introduction
Bytheendof2008,thenumberofphysicallyandmentallydisabledpersonsinTaiwantotaled1,040,585,or4.52%ofthe totalpopulation(MinistryoftheInterior,2009).ToadvancethehealthofTaiwan’spublic,theDepartmentofHealth(DOH) hasprovidedadultpreventivehealthservices(intheformofhealthchecks)since1995.AccordingtotheBureauofHealth ARTICLE INFO
Articlehistory:
Received29August2011
Receivedinrevisedform8September2011 Accepted8September2011
Availableonline11October2011
Keywords:
Thedisabled Disability
Adultpreventivehealthservice Healthchecks
ABSTRACT
Taiwanhasprovidedfreehealthchecksforadultssince1995.However,verylittleprevious researchhasexploredtheuseofpreventivehealthservicesbyphysicallyandmentally disabledadults.Thepresentstudyaimedtounderstandthisuseofpreventivehealth servicesandthefactorsthatinfluenceit.Researchparticipantsincludeddisabledpeople registeredinaMinistryoftheInteriordatabasein2008(atotalof785,746adultswhomet theconditionsforbeingphysically ormentallydisabled andusingpreventive health services).ThesedataweremergedwiththeBureauofHealthPromotion’s2006–2008 datasetonpreventivehealthandthe2006–2008healthinsurancedatabasepublishedby theNationalHealthResearchInstitutes.Inadditiontodescriptiveandbivariateanalysis, thestudyusedlogisticregressionanalysistoinvestigatethefactorsthatinfluencetheuse ofadultpreventivehealthservices.Theresultsshowedthat15.81%ofphysicallyand mentallydisabledadultsusedpreventivehealthservices.Therateofuseamongfemales was significantly higher than the rate among males, and rates were higher among residentsof relativelylessurbanized areas.Usagerates werealso universallyhigher amongsufferersofchronicdiseases.However,moreseriousdisabilitieshadlowerusage rates.Fromthelogisticregressionanalysis,weascertainedthatthefactorsthatinfluenced theuseofpreventivehealthservicesweregender,age,levelofurbanization,monthly salary,low-incomehouseholdstatus,aboriginalstatus,catastrophicdisease/injurystatus, chronicdiseases, type of disability, and severity of the disability. The study’s main conclusionisthatalthoughTaiwan’sDepartmentofHealthhasprovidedfreepreventive healthservicesformorethan15years,theusagerateofthiscareamongthedisabled remainslow.Demographicfeatures, healthstatus,andtypeofdisabilityarethemain factorsinfluencingtheuseofpreventivehealthcareservices.
ß2011ElsevierLtd.Allrightsreserved.
* Correspondingauthorat:DepartmentofHealthPolicyandManagement,ChungShanMedicalUniversityandHospital,No.110,Sec.1,JianguoN.Rd., TaichungCity40201,Taiwan,ROC.Tel.:+886424730022x17172;fax:+886422412337.
E-mailaddress:yli.tulane@gmail.com(Y.-H.Li).
1Authorwithequalcontribution.
ContentslistsavailableatSciVerseScienceDirect
Research in Developmental Disabilities
0891-4222/$–seefrontmatterß2011ElsevierLtd.Allrightsreserved.
doi:10.1016/j.ridd.2011.09.006
Promotion(BHP)regulations,thetargetsofadultpreventivehealthservicescanbedividedintothreecategories:(1)people aged40–64years,whomayundergoonehealthcheckevery3years;(2)peopleaged65yearsandover,whomayundergo onehealthcheckeachyear;and(3)sufferersofpoliomyelitisaged35andover,whomayundergoonehealthcheckeach year.Theservicesincludedunder‘‘adultpreventivehealthservices’’arephysicalexamination,healtheducationguidance, bloodtests,andurinalysis.
In2004,theoverallrateofuseofadultpreventivehealthservicesamongthe40-to64-year-oldcategorywas42%,while therateofuseamongthe65-year-oldandovercategorywas38%.Thenumberofpeopleusingadultpreventivehealth servicesincreasedfrom1.21millionin1999to1.63millionin2006(DOH,2008),showingasignificantincreaseinthepublic useoftheseservices.
Thephysicallyand mentally disabledmay notbeable toexpress thenatureof their medical ailmentsbecauseof physiologicalorpsychologicaldisabilities.Becausevisitstothedoctormayrequiremoretimeanddifficultyandmaybeless convenientforthemthanforthegeneralpopulation,physicallyandmentallydisabledadultsmaynotobtainnecessary treatments.Previousstudieshaveindicatedthattheusageratesforpreventivehealthservicesamongthephysicallyand mentallydisabledarelowerthantheratesamongthegeneralpopulation(Phillips,Meyer,&Aday,2000;Ramirez,Farmer, Grant,&Papachristou,2005; Shabas&Weinreb,2003; Tezzoni,McCarthy,Davis,Harris-David, &O’Day,2001). Fewer femalesamongthephysicallyandmentallydisabledpopulationreceivecervicalsmearsorbreastscreeningthantheirable- bodiedcounterparts(Jones&Beatty,2003).Themoreseriousthementalorphysicaldisability,thelowertheusagerateof preventivehealthservices(Diab&Johnston,2004).However,thefindingsontheseratesarecontradictory.Wei,Findley,&
Sambamoorthi(2006) analysis of the 1999–2002 Medical Expenditure Survey (MEPS) found that more physically or mentallydisabledfemales(50.1%)availedthemselvesofinfluenzavaccinationsthandidtheirable-bodiedcounterparts (39.0%),andmorephysicallyormentallydisabledfemalesunderwentcholesteroltests(92.6%)thandidtheirable-bodied counterparts(90.9%).Ramirezetal.(2005)foundthattheproportionsofthedisabledwhounderwenttheprostate-specific antigen test (46.06%), colorectal endoscopy (41.91%), and the fecal occult blood test (22.52%) were lower than the proportionsoftheirable-bodiedcounterparts(52.36%,43.35%,and23.08%).
Previousresearchhasindicatedthatthefactorsthatinfluencewhetherthepublicacceptspreventivehealthservices includegender(Bertakis,Azari,Helms,Callahan,&Robbins,2000;Green&Pope,1999;Owens,2008;Smith,Cokkinides,&
Eyre,2007),ethnicgroup(Makuc,Freid,&Kleinman,1989),educationallevel(DolanMullenetal.,1997),andincome(Makuc etal.,1989).Generallyspeaking,higherincomerepresentsagreaterprobabilityofusingpreventivehealthservices,whereas educationallevelandtheprobabilityofusingeachtypeofpreventivehealthservicearedirectlyproportionaltooneanother.
InTaiwan,astudyhasfoundthattheuseofpreventivecareamongwomendependsonavarietyoffactors,suchasage, maritalstatus,incomelevel,education,andhealthstatus(Lin,Ma,Yang,Chang,&Yeh,2009).
Ifweintegratethefindingsofpreviousresearch,wefindthattheuseofmedicalservicesbythephysicallyandmentally disableddiffersfromthatofthegeneralpopulation.Todate,however,moststudieshaveemphasizedtheuseofmedical servicesbythegeneralpopulation,withverylittleresearchintotheuseofpreventivehealthcarebythedisabled.Forthis reason,thepresentstudyfocusesonthephysicallyandmentallydisabledandexplorestheiruseofpreventivehealthcare andthefactorsthatdeterminethisuse.Itishopedthatthisstudymightserveasareferenceintheformulationofpreventive healthpolicyfordisadvantagedgroups.
2. Materialsandmethods 2.1. Datasourceandprocessing
Thisstudyfocuseditsanalysisonadultsaged40andover.Theresearchparticipantsincludedphysicallyandmentally disabledpersonsregisteredin2008inadatabaseoftheMinistryoftheInterior.Informationontheseparticipantswas mergedwiththepreventivehealthservicesfilesoftheBureauofHealthPromotionin2006–2008andthehealthinsurance medicalclaimsdatabasepublishedbytheNationalHealthResearchInstitutes.Thefollowingvariableswererecorded.
(1)Demographiccharacteristics:gender,age,aboriginalstatus,residence, premium-basedmonthlysalary,and low- incomehouseholdstatus;(2)healthanddisabilitystatus:catastrophicillness/injury,relevantchronicillnesses(including cancer,endocrineandmetabolicdiseases,mentaldisorders,diseasesofthenervoussystem, diseasesofthecirculatory system,diseasesoftherespiratorysystem,diseasesofthedigestivesystem,diseasesofthegenitourinarysystem,diseasesof the musculoskeletal system and connective tissue, disorders of the eye and adnexa, infectious diseases, congenital anomalies,diseasesoftheskinandsubcutaneoustissue,diseasesofthebloodandblood-formingorgans,anddiseasesofthe earand mastoidprocess); (3)classification ofdisability:type ofdisability and severityof disability;(4) utilizationof preventivehealthservicesamongthedisabled.
2.2. Participants
AccordingtoTaiwan’sDisabilityRightsProtectionActs,disabilitycanbeclassifiedinto18categories:visualimpairment, hearingimpairment,balanceimpairment,soundorspeechimpairment,limbimpediment,mentalretardation,majororgan malfunction,facialinjury,persistentvegetativestate,refractoryepilepsy,dementia,autism,chromosomalabnormalities, congenitalmetabolicdisorders,othercongenitaldefects,multipledisabilities,chronicmentalillness,andotherdisabilities
causedbyrarediseasesrecognizedbycentralhealthauthorities.Theseverityofdisabilityisclassifiedintofourcategories:
verysevere,severe,moderate,andmild.
Thisstudyincludedtheparticipantsaged40orolderandexcludedindividualswithpersistentvegetativestate(4176 persons)whoareunsuitablefortheuseofpreventivehealthservices,andindividualssufferingfrompoliomyelitisaged35–
39yearsintheanalysis.Sincethosewithdisabilityduetopoliomyelitisbelongtothegroupofphysicaldisability,theycould notbedistinguishedfromthosewithphysicaldisabilityinthedataset.Atotalof785,746personswithdisabilitieswere identifiedasmeetingtherequirementsforpreventivehealthservices.
2.3. Statisticalanalysis
Wefirstuseddescriptivestatisticstounderstandcharacteristicsofthedisabledsubjectsuchasgender,age,levelof urbanization,typeofphysicalormentaldisability(categorizedinto18typesandfourlevels),educationallevel,marital status,andaboriginalstatus.Thenweanalyzedthedisabledpersons’useofadultpreventivehealthservicesintermsofthe numbersofoccasionsandpercentages.Weusedthe
x
2testtocomparevariationsindisabledpersons’useofpreventive healthservices.Thevariableswithp<0.05fromthex
2testweresubmittedtoalogisticregressionanalysis,andthefactors influencingtheuseofadultpreventivehealthservicesbythedisabledwereinvestigatedseparately.Inthelogisticregression analysis, the use of adult preventive health services was the dependent variable. Independent variables included demographicfeatures(gender,age,levelofurbanization,premium-basedmonthlysalary,low-incomehouseholdstatus, educationallevel,maritalstatus,aboriginalstatus,etc.),healthstatus(relevantchronicdiseases,catastrophicdisease/injury, etc.),qualificationsforphysicallyormentallydisabledstatus(categoryofphysicalormentaldisability,levelofseverityof disability),andtheuseofotherpreventivehealthservices.Therewereeightlevelsofurbanization,from‘‘areasatthehighest levelofurbanization’’to‘‘areasatthelowestlevelofurbanization.’’3. Results
3.1. Basiccharacteristicsofthephysicallyandmentallydisabled(Table1)
Thisstudyidentified785,746physicallyandmentallydisabledpersonswhomettheconditionsforadultpreventive healthservices,ofwhom55.84%(N=438,766)weremales.Thelargestcategoryincludedpersons70yearsofageandover (37.57%,N=295,198).Thelargestcategoryforpremium-basedsalarywas‘‘dependentpopulation’’(34.33%,N=269,753).
Aboriginesconstitutedamere1.57%oftheparticipants(N=12,348).Thelargestcategoryintermsofeducationallevelwas
‘‘elementaryschoolorlower’’(51.96%,N=408,271).Thelargestgroupfortypeofphysicalormentaldisabilitywas‘‘limb impediment(s)’’(41.90%,N=329,264).Thelargestcategoryofdisabilitylevelwas‘‘milddisability.’’
3.2. Theuseofpreventivehealthservicesamongthedisabled(Table1)
Of the disabled participants who met the conditions for the use of adult preventive health services, 15.81%
(N=124,257)usedtheseservices.Therateofuseamongdisabledfemales(16.57%)wasslightlyhigherthan therate amongdisabledmales(15.22%).Ifwedistinguishtheusageratesbyage,therateofusewasgreatestamongthe60-to64- year-oldagegroup(23.72%).Ifwedistinguishtheusageratesbylevelofurbanization,therateofusewasgreatestamong disabledpersonsresidinginareasatlevel8(18.05%)andlowestamongthoseresidinginareasatthehighestlevelsof urbanization.Whenexaminingpremium-basedmonthlysalary,thehighestrateofusewasfoundforthoseinthecategory of‘‘NT$30,300–36,300(NewTaiwanDollars)’’(21.69%).Therateofuseamongaborigineswas23.63%,slightlyhigherthan theusagerateamongthenon-aboriginaldisabledpopulation(15.69%).Ifwedistinguishusageratesbyeducationallevel, therateofusewasgreatestamongdisabledpersonseducatedtothejuniorhighschoollevel(17.48%).Whenexamining maritalstatus,thehighestrateofusewasfoundamongtheunmarriedpopulation(16.12%).Thehighestrateofusewas foundamongthosesufferingfrominfectiousdiseases(20.14%),whilethelowestrateofusewasamongthosesuffering fromcancer(12.15%).Ofthedifferenttypesofdisabilities,thehighestratesofusewereamongthosesufferingfrom chronicepilepsy(23.33%)andthemildlydisabled(18.26%).Themoreseverethelevelofdisability,thelowertherateof usewas.
3.3. Factorsinfluencingtheuseofadultpreventivehealthservices(Table2)
Thestudyfoundthatage,levelofurbanization,premium-basedsalary,low-incomehouseholdstatus,aboriginalstatus, maritalstatus,catastrophicinjury/diseasestatus,relevantchronicdiseases,typeofphysicalormentaldisability,andthe severity ofthe disability significantly influenced theuse ofadult preventive health servicesamong disabled persons (p<0.05).Thesefindingsindicatethattheprobabilityofusingsuchservicesamongmalesis0.88timeslowerthanthe probabilityamongfemales(95%CI=0.87–0.89).Intermsofage,theprobabilityofusewashighestamongthe60-to64-year- oldgroup,1.36timeshigherthanthatofthe40-to44-year-oldgroup(95%CI=1.32–1.41).Theprobabilityofusewaslowest amongthe70-year-oldandoldergroup,0.46timeslowerthanthatofthe40-to44-year-oldgroup(95%CI=0.45–0.48).In termsofthelevelofurbanization,theprobabilityofusingadultpreventivehealthserviceswasgreatestamongthoseliving
Table1
Useofadultpreventivehealthservicesamongthephysicallyormentallydisabled:basiccharacteristicsandbivariateanalysis.
Variablename N=78,5746 % Used Didnotuse x2
n1=12,4257 % n2=66,1489 % p-Value
Overallrateofuse 15.81
Gender <.0001
Female 346,980 44.16 57,482 16.57 289,498 83.43
Male 438,766 55.84 66,775 15.22 371,991 84.78
Age <.0001
40–44years 47,697 6.07 7788 16.33 39,909 83.67
45–49years 97,739 12.44 17,431 17.83 80,308 82.17
50–54years 98,149 12.49 19,342 19.71 78,807 80.29
55–59years 92,266 11.74 19,713 21.37 72,553 78.63
60–64years 73,209 9.32 17,364 23.72 55,845 76.28
65–69years 81,488 10.37 9837 12.07 71,651 87.93
=70years 295,198 37.57 32,782 11.11 262,416 88.89
Levelofurbanizationa <.0001
Levelone 89,779 11.43 10,088 11.24 79,691 88.76
Leveltwo 159,934 20.35 24,213 15.14 135,721 84.86
Levelthree 115,598 14.71 18,276 15.81 97,322 84.19
Levelfour 67,412 8.58 10,480 15.55 56,932 84.45
Levelfive 117,954 15.01 20,279 17.19 97,675 82.81
Levelsix 89,506 11.39 15,368 17.17 74,138 82.83
Levelseven 96,002 12.22 16,608 17.3 79,394 82.7
Leveleight 49,561 6.31 8945 18.05 40,616 81.95
Insuredamount <.0001
Dependentpopulation 269,753 34.33 34,158 12.66 235,595 87.34
<15,840 189,394 24.1 31,399 16.58 157,995 83.42
16,500–22,800 228,759 29.11 39,745 17.37 189,014 82.63
24,000–28,800 29,930 3.81 6273 20.96 23,657 79.04
30,300–36,300 26,302 3.35 5706 21.69 20,596 78.31
38,200–45,800 25,722 3.27 4976 19.35 20,746 80.65
48,200–57,800 5331 0.68 766 14.37 4565 85.63
60,800–72,800 6223 0.79 782 12.57 5441 87.43
76,500–87,600 4332 0.55 452 10.43 3880 0.59
Low-incomehousehold <.0001
Yes 36,185 4.61 8623 23.83 27,562 76.17
No 749,561 95.39 115,634 15.43 633,927 84.57
Aborigine <.0001
Yes 12,348 1.57 2918 23.63 9430 76.37
No 773,398 98.43 121,339 15.69 652,059 84.31
Educationallevel <.0001
Elementaryschoolandunder 408,271 51.96 63,187 15.48 345,084 84.52
Juniorhighschool 107,247 13.65 18,750 17.48 88,497 82.52
Senior(vocational)highschool 107,688 13.71 17,850 16.58 89,838 83.42
Juniorcollegeanduniversity orabove
59,140 7.53 8665 14.65 50,475 85.35
Unclear 103,400 13.16 15,805 15.29 87,595 84.71
Maritalstatus <.0001
Married 453,659 57.74 73,109 16.12 380,550 83.88
Unmarried 82,473 10.5 13,795 16.73 68,678 83.27
Divorcedorwidowed 34,998 4.45 5560 15.89 29,438 84.11
Unclear 214,616 27.31 31,793 14.81 182,823 85.19
Catastrophicinjuryordisease <.0001
Yes 220,873 28.11 31,884 14.44 188,989 85.56
No 564,873 71.89 92,373 16.35 472,500 83.65
Relevantdiseases
Cancer <.0001
Yes 55,086 7.01 6693 12.15 48,393 87.85
No 730,660 92.99 117,564 16.09 613,096 83.91
Endocrineandmetabolicdisease <.0001
Yes 337,660 42.97 64,308 19.05 273,352 80.95
No 448,086 57.03 59,949 13.38 388,137 86.62
Mentalillness <.0001
Yes 263,994 33.6 51,368 19.46 212,626 80.54
No 521,752 66.4 72,889 13.97 448,863 86.03
Diseaseofthenervoussystem <.0001
Yes 167,171 21.28 29815 17.84 137,356 82.16
No 618,575 78.72 94,442 15.27 524,133 84.73
Diseaseofthecirculatorysystem <.0001
Yes 448,886 57.13 77,083 17.17 371,803 82.83
No 336,860 42.87 47,174 14 289,686 86
inlevel-7areas,1.75timeshigherthanthatofthoselivinginlevel-oneareas(95%CI=1.70–1.80).Forpremium-basedsalary, theprobabilityofuseamongthoseatthe‘‘NT$30,300–36,300’’levelwas1.20timesgreaterthantheprobabilityofusefor thoseatthelowestlevelof‘‘NT$15,840’’(95%CI=1.16–1.24).Theprobabilityofuseamonglow-incomeindividualswas1.42 times greaterthan among those fromnon-low-incomehouseholds (95%CI=1.38–1.46). The probability ofuseamong aborigineswas1.18timeshigherthanthat ofnon-aborigines(95%CI=1.13–1.24).Theprobabilityofuseamong those sufferingfromcatastrophicinjuriesordiseaseswas0.79timeslowerthantheprobabilityofuseamongthosenotsuffering fromsuchinjuriesordiseases(95%CI=0.77–0.80).Forthecategoryofrelevantchronicdiseases,theprobabilityofusewas highest amongthose sufferingfromdiseasesof thedigestive system(OR=1.37,95%CI=1.35–1.39), followedby those sufferingfromendocrineandmetabolicdiseases(OR=1.34,95%CI=1.32–1.36).Intermsoftypeofdisability,comparedto those with limb impediments, the probability of use was highest among those with mental disorders (OR=1.41, Table1(Continued)
Variablename N=78,5746 % Used Didnotuse x2
n1=12,4257 % n2=66,1489 % p-Value
Diseaseoftherespiratorysystem <.0001
Yes 215,826 27.47 41,490 19.22 174,336 80.78
No 569,920 72.53 82,767 14.52 487,153 85.48
Diseaseofthedigestivesystem <.0001
Yes 327,257 41.65 64,739 19.78 262,518 80.22
No 458,489 58.35 59,518 12.98 398,971 87.02
Diseaseoftheurinarysystem <.0001
Yes 85,923 10.94 10,660 12.41 75,263 87.59
No 699,823 89.06 113,597 16.23 586,226 83.77
Diseaseoftheskeletalandmuscular systemandconnectivetissue
<.0001
Yes 334,626 42.59 64,647 19.32 269,979 80.68
No 451,120 57.41 59,610 13.21 391,510 86.79
Diseaseoftheeyesandauxiliaryorgans <.0001
Yes 115,684 14.72 20,025 17.31 95,659 82.69
No 670,062 85.28 104,232 15.56 565,830 84.44
Infectiousdiseases <.0001
Yes 48,748 6.2 9818 20.14 38,930 79.86
No 736,998 93.8 114,439 15.53 622,559 84.47
Congenitalmalformation <.0001
Yes 19,562 2.49 3602 18.41 15,960 81.59
No 766,184 97.51 120,655 15.75 645,529 84.25
Skinandsubcutaneoustissuedisorders <.0001
Yes 109,881 13.98 21,816 19.85 88,065 80.15
No 675,865 86.02 102,441 15.16 573,424 84.84
Diseasesofthebloodandblood-formingorgans <.0001
Yes 53,402 6.8 9566 17.91 43,836 82.09
No 732,344 93.2 114,691 15.66 617,653 84.34
Diseasesoftheearandmastoidprocess <.0001
Yes 85,013 10.82 16,864 19.84 68,149 80.16
No 700,733 89.18 107,393 15.33 593,340 84.67
Typeofphysicalormentaldisability <.0001
Limbimpediment 329,264 41.9 53,913 16.37 275,351 83.63
Hearingimpediment 101,289 12.89 17,271 17.05 84,018 82.95
Majororganmalfunction 100,308 12.77 10,243 10.21 90,065 89.79
Multipleimpediments 74,008 9.42 10,645 14.38 63,363 85.62
Mentalillness 65,588 8.35 14,636 22.32 50,952 77.68
Visualimpairment 47,812 6.08 7728 16.16 40,084 83.84
Dementia 29,937 3.81 3864 12.91 26,073 87.09
Mentalretardation 21,042 2.68 3503 16.65 17,539 83.35
Speechimpediment 8899 1.13 1225 13.77 7674 86.23
Impairedbalance 2752 0.35 391 14.21 2361 85.79
Facialdisfigurement 2710 0.34 386 14.24 2324 85.76
Refractoryepilepsy 1573 0.2 367 23.33 1206 76.67
Rarediseases 282 0.04 44 15.6 238 84.4
Congenitaldefect 176 0.02 25 14.2 151 85.8
Otherb 106 0.01 16 15.09 90 84.91
Levelofseverityofphysicalormentalillness <.0001
Mild 288,794 36.75 52,739 18.26 236,055 81.74
Moderate 261,874 33.33 41,356 15.79 220,518 84.21
Severe 145,469 18.51 21,721 14.93 123,748 85.07
Verysevere 89,609 11.4 8441 9.42 81,168 90.58
aLevelone:themosturbanizedareas.
bOther:includesautism,chromosomalabnormalities,congenitalmetabolicdisorders.
Table2
Factorsinfluencingthedisabledtouseadultpreventivehealthservices:logisticregressionanalysis.
Variablename Unadjustedmodel Adjustedmodel
OR 95%CI p-Value OR 95%CI p-Value
Gender
Female – – – – – – – –
Male 0.9 0.89 0.92 <.001 0.88 0.87 0.89 <.001
Age
40–44years – – – – – – – –
45–49years 1.11 1.08 1.15 <.001 1.09 1.06 1.12 <.001
50–54years 1.26 1.22 1.3 <.001 1.19 1.15 1.23 <.001
55–59years 1.39 1.35 1.43 <.001 1.24 1.21 1.28 <.001
60–64years 1.59 1.55 1.64 <.001 1.36 1.32 1.41 <.001
65–69years 0.7 0.68 0.73 <.001 0.55 0.53 0.57 <.001
=70years 0.64 0.62 0.66 <.001 0.46 0.45 0.48 <.001
Levelofurbanizationa
Levelone – – – – – – –
Leveltwo 1.41 1.43 1.5 <.001 1.47 1.43 1.51 <.001
Levelthree 1.48 1.45 1.52 <.001 1.56 1.51 1.6 <.001
Levelfour 1.45 1.41 1.5 <.001 1.49 1.44 1.53 <.001
Levelfive 1.64 1.6 1.68 <.001 1.73 1.68 1.77 <.001
Levelsix 1.64 1.59 1.68 <.001 1.72 1.67 1.77 <.001
Levelseven 1.65 1.61 1.7 <.001 1.75 1.7 1.8 <.001
Leveleight 1.74 1.69 1.79 <.001 1.67 1.61 1.72 <.001
Insuredamount
<15,840 – – – – – –
Dependentpopulation 0.73 0.72 0.74 <.001 0.91 0.89 0.92 <.001
16,500–22,800 1.06 1.04 1.08 <.001 1.09 1.07 1.11 <.001
24,000–28,800 1.33 1.29 1.38 <.001 1.16 1.13 1.2 <.001
30,300–36,300 1.39 1.35 1.44 <.001 1.2 1.16 1.24 <.001
38,200–45,800 1.21 1.17 1.25 <.001 1.07 1.03 1.11 <.001
48,200–57,800 0.84 0.78 0.91 <.001 0.85 0.78 0.92 <.001
60,800–72,800 0.72 0.67 0.78 <.001 0.76 0.7 0.82 <.001
76,500–87,600 0.59 0.53 0.65 <.001 0.62 0.56 0.69 <.001
Low-incomehousehold
No – – – – – – –
Yes 1.72 1.67 1.76 <.001 1.42 1.38 1.46 <.001
Aborigine
No – – – – – – – –
Yes 1.66 1.6 1.73 <.001 1.18 1.13 1.24 <.001
Educationallevel
Elementaryschoolandunder – – – – – – – –
Juniorhighschool 1.16 1.14 1.18 <.001 1 0.98 1.02 0.788
Senior(vocational)highschool 1.09 1.07 1.071 <.001 0.98 0.96 1 0.071
Juniorcollegeanduniversityorabove 0.94 0.92 0.96 <.001 0.98 0.96 1.01 0.248
Unclear 0.99 0.97 1 0.128 1.02 0.99 1.04 0.16
Maritalstatus
Unmarried – – – – – –
Married 0.96 0.94 0.98 <.001 1.04 1.02 1.07 0.000
Divorcedorwidowed 0.94 0.981 0.97 0.000 1.01 0.98 1.05 0.461
Unclear 0.87 0.85 0.89 <.001 0.91 0.89 0.93 <.001
Catastrophicinjuryordisease
No – – – – – – – –
Yes 0.86 0.85 0.88 <.001 0.79 0.77 0.8 <.001
SufferingfromaRelevantdiseases
Cancer 0.72 0.7 0.74 <.001 0.96 0.93 0.99 0.014
Endocrineandmetabolicdisease 1.52 1.521 1.54 <.001 1.34 1.32 1.36 <.001
Mentalillness 1.49 1.47 1.51 <.001 1.2 1.18 1.22 <.001
Diseaseofthenervoussystem 1.21 1.19 1.22 <.001 0.98 0.96 0.99 0.005
Diseaseofthecirculatorysystem 1.27 1.26 1.29 <.001 1.271 1.19 1.23 <.001
Diseaseoftherespiratorysystem 1.4 1.38 1.42 <.001 1.23 1.21 1.24 <.001
Diseaseofthedigestivesystem 1.65 1.63 1.67 <.001 1.37 1.35 1.39 <.001
Diseaseoftheurinarysystem 0.73 0.72 0.75 <.001 0.81 0.79 0.83 <.001
Diseaseoftheskeletalandmuscular systemandconnectivetissue
1.57 1.55 1.59 <.001 1.3 1.28 1.32 <.001
Diseaseoftheeyesandauxiliaryorgans 1.14 1.12 1.16 <.001 1.02 1 1.04 0.028
Infectiousdiseases 1.37 1.34 1.4 <.001 1.16 1.13 1.19 <.001
Congenitalmalformation 1.21 1.16 1.25 <.001 1.01 0.97 1.05 0.66
Skinandsubcutaneoustissuedisorders 1.39 1.37 1.41 <.001 1.2 1.17 1.22 <.001
Diseasesofthebloodandblood-formingorgans 1.18 1.15 1.2 <.001 1.12 1.1 1.15 <.001
Diseasesoftheearandmastoidprocess 1.37 1.34 1.39 <.001 1.08 1.06 1.1 <.001
Typeofphysicalormentaldisability
95%CI=1.37–1.45).Theprobabilityofusewaslowestamongthosesufferingfrommajororganmalfunction(OR=0.76, 95%CI=0.74–0.78). Regarding theseverity of the disability, the greater the level of severity, thelower the subject’s probabilityofuse.Themostseverelyphysicallyormentallydisabled(OR=0.61,95%CI=0.59–0.63)personsshowedthe lowestprobabilityofusingadultpreventivehealthservices.
4. Discussion
Regardingtheuseofadultpreventivehealthservicesbyphysicallyormentallydisabledpersons,thecurrentstudyfound thattheprobabilityofusewassignificantlygreaterforfemalesthanformales.Thisisinagreementwiththefindingsofmany previous studies,whichsuggest thattheusagerateofpreventivehealth servicesishigherfor femalesthan formales (Bertakisetal.,2000;Green&Pope,1999;Owens,2008;Smithetal.,2007).
Regardingresidenceareas,thestudyfoundthattheprobabilityofusingadultpreventivehealthserviceswassignificantly greateramongthoselivinginareaswithrelativelylowlevelsofurbanizationthanamongthoselivinginareaswiththe highestlevelsofurbanization.Generallyspeaking,thelevelofurbanizationcanreflecttheavailabilityofmedicalresources.
However,sinceTaiwanimplementeditsNationalHealthInsuranceprogram,theaccessibilityofdoctorstothepublichas significantlyimproved(Wen,Tsai,&Chung,2008),andthepublic’susagerateofpreventivehealthservicesinurbanand ruraltownshipareashasincreasedaccordingly.Lifestyleandsocialrelationshipsinsuburbanorruralareasdifferfromthose inurbanareasinTaiwan.Residentsofurbanareasaremoredependentonpublicmediaforinformationthanontheword-of- mouthcommunicationscommoninruralareas.Comparedtourbanareas,peopleinruralareashavestrongercohesionand prefergroupactivities.Therefore,itisverycommonforpeopleinruralareastoreceivepreventivehealthcaretogether.
Accordingly,theprobabilityofusingmedicalresourcesmaybehigher,significantlyincreasingtherateofhealthchecks.
Furthermore,inrecentyears,Taiwanhasimprovedmobilemedicalservicesinremoteareassuchasmountainsandoffshore islands.Intheseareas,cooperativehealthcareinstitutionsperformmobilemedicalcare,bringingscreeningvehiclesand doctorsdirectlytovillagestoprovideservices.Thus,theusagerateofpreventivehealthservicesishigheramongresidentsof areaswithlowlevelsofurbanizationthanamongthoseinareaswithhighlevelsofurbanization.
Regarding premium-based salary, althoughprevious researchhasindicated that the usagerates and frequencyof preventive health services are directly proportionate to income (Makuc et al., 1989), the present study found that participantswhose premium-basedsalary wasNT$48,200or abovehad lowerusageratesfor adultpreventivehealth services,perhapsbecausemanyTaiwanesepeopleofrelativelyhighsocialandeconomicstatuschoosetoundergoself-paid healthchecks.Manyhospitalsproviderelativelyhigh-leveladulthealthchecksforafee,whichoffermoredetailedandmore diversehealthservices.
Thefindingsofthecurrentstudyshowthattherateofuseamongparticipantsfromlow-incomehouseholdswasgreater thantherateofuseamongparticipantsfromnon-low-incomehouseholds.Thisfindingisatoddswithpreviousfindingsin whichhigherincomeindicatedahigherusagerateforpreventivehealthservices(Chang&Tun,2008).However,thisfinding confirmsthat,sincetheimplementationoftheNationalHealthInsuranceprogram,Taiwanhasimprovedthesituationin whichfinancialimpedimentspreventedthepublicfromvisitingdoctors.
Table2(Continued)
Variablename Unadjustedmodel Adjustedmodel
OR 95%CI p-Value OR 95%CI p-Value
Limbimpediment – – – – – –
Visualimpairment 0.99 0.96 1.01 0.245 1.12 1.09 1.16 <.001
Hearingimpediment 1.05 1.03 1.07 <.001 1.22 1.19 1.24 <.001
Speechimpediment 0.82 0.77 0.87 <.001 0.94 0.88 1 0.036
Mentalretardation 1.02 0.98 1.06 0.298 1.1 1.06 1.15 <.001
Multipleimpediments 0.86 0.84 0.88 <.001 1.1 1.08 1.13 <.001
Majororganmalfunction 0.58 0.57 0.59 <.001 0.76 0.74 0.78 <.001
Facialdisfigurement 0.85 0.76 0.95 0.003 0.9 0.8 1 0.059
Dementia 0.76 0.73 0.78 <.001 1.13 1.08 1.17 <.001
Congenitaldefect 0.85 0.55 1.29 0.437 0.79 0.51 1.22 0.283
Mentalillness 1.47 1.44 1.5 <.001 1.471 1.37 1.45 <.001
Impairedbalance 0.85 0.76 0.94 0.002 0.77 0.69 0.86 <.001
Chronicepilepsy 1.55 1.38 1.75 <.001 1.17 1.04 1.32 0.010
Rarediseases 0.94 0.68 1.3 0.727 1 0.72 1.39 0.999
Otherb 0.91 0.53 1.55 0.722 0.89 0.52 1.52 0.661
Levelofseverityofphysical ormentalillness
Mild – – – – – – – –
Moderate 0.84 0.83 0.85 <.001 0.84 0.82 0.85 <.001
Severe 0.79 0.77 0.8 <.001 0.85 0.83 0.87 <.001
Verysevere 0.47 0.45 0.48 <.001 0.61 0.59 0.63 <.001
aLevelone:themosturbanizedareas.
bOther:includesautism,chromosomalabnormalities,congenitalmetabolicdisorders.
Thisstudyfoundsignificantdifferencesbetweendifferentmaritalstatusesandtheusageratesforpreventivehealth services.Thereweresignificantlylowerusageratesamongparticipantswhoweredivorcedorwhosespousewasdeceased thanamongparticipantswhoweremarried.Thisfindingisinaccordancewiththefindingsofmanypreviousstudiesonthe relationshipbetweenmaritalstatusandtheuseofmedicalservices.Studieshaveindicatedthatmarriedpeopleattach relativelygreaterimportancetotheirhealthandadoptmorepreventivehealthorlifehabits(Goldmana,Korenmanb,&
Weinstein,1995;Suarez,Lloyd,Weiss,Rainblot,&Pulley,1994).Researchindicatesthatmarriedpeoplearemorelikelythan unmarriedpeopletohavefixedlocationsatwhichtheyvisitthedoctor,whichinfluencestheirbehaviorinrelationtotheuse ofmedicalservices(Doescheretal.,2004).
Intermsofhealthstatus,thefindingsofthecurrentstudyshowthattheusageratesforpreventivehealthservicesare significantlyhigheramongthosesufferingfromchronicdiseasesandthosewithcatastrophicinjuries ordiseasesthan amongthosewithoutcatastrophicinjuriesordiseases,perhapsbecausepeoplewhosechronicdiseaseisinducedbytheir healthstatusandthosewithcatastrophicinjuriesordiseasesattachmoreimportancetopreventivehealthchecks.Previous studieshavefoundthatpeoplewithmildandmoderatedisabilitiesreceivedmorepreventivehealthservicesthandidpeople withoutdisabilities(Diab&Johnston,2004).Regardingtheseverityofphysicalormentaldisabilities,themoreseverea disabilityis,thelowertheusagerateofpreventivehealthservices.Previousresearchhasshownthatthelowestusagerates forpreventivehealthservicesareamonggroupsofpatientswhosediseasesarethemostsevere(Diab&Johnston,2004).Itis lessconvenientforpatientswithrelativelyseriousdisabilitiestousepreventivehealthservices.Theplanningofhealth policiesshouldthereforebefocusedonimprovingtheuseofpreventivehealthservicesamongthemoreseverelydisabled population.InTaiwan,globalbudgetingpaymentswereemployedtoincreasehealthcareproviders’willingnesstospend timeonoralhealthcareforchildrenwithseveredisabilitiesandtoencouragetreatmentandcareforseverelydisabled persons(Tsaietal.,2007).Asimilarfinancialincentiveschemecouldbeimplementedtoenhancepreventivehealthservices forthedisabledandtoincreasetheutilizationoftheseservices.
Regardingthetypeofphysicalormentaldisability,thelowestusageratesforpreventivehealthserviceswereamong personswithmajororganmalfunctionandrarediseases.AsthedatafromtheMinistryoftheInteriorshow,63.97%of physicallyormentallydisabledpersonsmustvisitdoctorsperiodically,and55.89%areunabletodosoindependently.Ofthe lattergroup,68.77%sufferfromrarediseases,and41.58%ofthosewithmajororganmalfunctionareunabletovisitadoctor independently.Ofpatientswhoareunabletovisitadoctorindependently,88.12%areunabletoindependentlycompletethe registrationprocess,while48.86%finditdifficulttoresolvetransportationissues(SummaryReportontheSurveyofLife NeedsamongthePhysicallyandMentallyDisabledinTaiwan,2006).Accordingly,usageratesforpreventivehealthservices arerelativelylow.
Inaccordancewiththefindingsofthecurrentstudy,wesuggestthatthegovernmentshouldprovidemorechannelsto enablephysicallyormentallydisabledpersonstoavailthemselvesofadultpreventivehealthservicesandshouldincrease levelsofparticipationinpreventivehealthservicesamongthephysicallyormentallydisabledthroughwidespreadmass mediapublicityandeducationbyhealthinstitutions.Atthesametime,remunerationforconductinghealthchecksamong thedisabledshouldbeimprovedtoincreasephysicians’willingnesstoprovidetheseservices.
5. Conclusion
Thecurrentstudyinvestigatedtheuseofadultpreventivehealthservicesbyphysicallyormentallydisabledpersons.The mainfactorsinfluencingwhetherthedisabledusedsuchservicesweregender,age,levelofurbanization,income,low- incomehouseholdstatus,aboriginalstatus,maritalstatus,catastrophicinjury/diseasestatus,relevantchronicdiseases,type ofdisability,andlevelofseverityofdisability.
Forhigh-riskgroups,suchaspersonsoflowsocialandeconomicstatusoradvancedoldage,whomayhavegonelong periodswithoutreceivinghealth checks, wesuggest thatthepublichealth systemormedical institutionsimplement extensivepublicityandrelatededucationprogramsforcaregiversofthedisabledtoensurethatthesehigh-riskgroups receiveperiodichealthchecks.Medicalinstitutionsshouldencouragedoctorstoactivelyquestiondisabledpatientsduring medicalappointmentsandtoremindthesepatientstoarrangehealthchecks.Periodically,medicalinstitutionsshouldtrack andnotifythesedisabledpatientstomakereturnvisitsinanattempttofacilitatesupportivemeasuresforfollow-upand treatments.Medicalinstitutionsshouldalsoimprovefacilitieswithobstruction-freespacesandotherplanningthattakes intoaccountthemobilityissues andconvenienceof physicallyormentallydisabledpersons,thereby increasingthese patients’satisfactionwithmedicalvisits.
Becausethedataforthisstudycamefromsecondarydatabases,itwasnotpossibletoobtaininformationonsomefactors, suchasindividuals’healthbehaviorandhealthbeliefs.Thislimitationalsoaffectedthevariablesthatcouldbeused.
Acknowledgements
Thisstudywassupported bygrants(CMU94-099,NSC98-2410-H-468-015-MY2,DOH99-TD-B-111-004)fromChina MedicalUniversity,theNationalScienceCouncil,andtheDepartmentofHealth.Thepreventive healthcarefileswere obtainedfromtheBureauofHealthPromotion,DepartmentofHealth,inTaiwan.WearealsogratefulforuseoftheNational HealthInsuranceResearchDatabaseprovidedbytheDepartmentofHealth,Taiwan.Theinterpretationsandconclusions containedhereindonotrepresentthoseoftheBureauofHealthPromotioninTaiwan.
