Sociodemographic characteristics and health-related factors affecting the use of Pap smear screening among women with mental disabilities in Taiwan

Full title:

Sociodemographic characteristics and health-related factors affecting the use of Pap smear screening among women with mental disabilities in Taiwan

Short title:

Pap smear screening among mental disabilities

Suh-May Yen

Pei-Tseng Kung

Wen-Chen Tsai

1. Department of Health Services Administration, China Medical University, Taichung, Taiwan, R.O.C.

2. Department of Chinese Medicine, Nantou Hospital, Nantou, Taiwan, R.O.C.

3. Department of Healthcare Administration, Asia University, Taichung, Taiwan, R.O.C.

Suh-May Yen: suhmayyen@yahoo.com.tw Pei-Tseng Kung: ptkung@asia.edu.tw Wen-Chen Tsai: wtsai@mail.cmu.edu.tw

#

Authors had equal contribution to this work.

*Correspondence author：Professor Wen-Chen Tsai, Dr.PH

Address：No. 91 Hsueh-Shih Road, Taichung, Taiwan 40402, R.O.C

Tel：886-4-22073070

Fax：886-4-22028895

E-mail: wtsai@mail.cmu.edu.tw

Abstract

Objectives: This study examined the use of the Pap cervical cancer screening test

among women with mental disabilities in Taiwan and analyzed related factors.

Methods: Data were obtained from three national databases in Taiwan: the 2008 database of physically and mentally disabled persons from the Ministry of the Interior, 2007–2008 Pap smear test data from the Health Promotion Administration, and claims data from the National Health Insurance Research Database. The study subjects included 49,642 Taiwanese women aged 30 years with mental disabilities. Besides descriptive and bivariate analyses, logistic regression analysis was also performed to

examine factors affecting Pap smear use.

Results: In 2007–2008, Taiwanese women with mental disabilities had a Pap screening rate of 11.05%. Age, income, education, marital status, catastrophic illness/injury, relevant chronic illnesses, and severity of disability were identified as factors affecting their Pap smear use. Age and severity of disability were negatively correlated with Pap screening, with the odds of screening being 0.37 times as high in 70-year-olds as in 30–39-year-olds and 0.49 times as high for very severe disability as for mild disability.

Income was positively correlated with Pap screening. Being married (OR=2.55) or

divorced or widowed (OR=2.40) relative to being unmarried, and having a catastrophic

illness/injury (OR=1.13), cancer (OR=1.47), or diabetes (OR=1.25), were associated

with greater odds of screening.

Conclusions: In Taiwan, women with mental disabilities receive Pap smears at a far lower rate than women in general.

Key Words : mental disability; Pap smear Test; Screening test; Cancer prevention

Introduction

Cervical cancer is among the top ten most common cancers in women worldwide,

with over 85% of the cases occurring in developing countries

. The Pap smear test for

cervical cancer screening has been recognized as a highly effective preventive measure,

and its systematic use has reduced cervical cancer mortality by an estimated 70% in

developed countries

. In Taiwan, the National Health Insurance program has provided

free annual Pap screening to women 30 years and older since 1995, and has successfully reduced the age-adjusted annual mortality rate for cervical cancer from 10.5 to 3.9 per 100,000 population from 1996 to 2012

. A similar downward trend has been observed in other countries. In Canada, cervical cancer mortality decreased from 13.5 to 2.2 per 100,000 populations per year from 1952 to 2006

; in England and Wales, cervical cancer mortality fell by 4.6% per year between 1988 and 2001

. Previous studies in Taiwan found the use of the Pap screening service to be affected by such factors as women’s age, income, health status, area of residence

, marital status, education level,

7

, and severity of disability, if present

. The Pap smear screening rate in Taiwan in

2008 was 28.8% for women general

.

According to the World Health Organization’s World Mental Health surveys, the

12-month prevalence of mental illness ranged from 7.1% (China) to 27.0% (United

States)

. Studies showed that people with mental illness died on average 10 to 15 years

earlier than the general population

, had a greater disease burden than those without

mental illness

, and were less likely to use preventive health care services within

recommended time frames

. Although the incidence of cancer among psychiatric

patients was no higher than that in the general population, their mortality from cancer was found to be 30% higher

. Kisely et al. reported in 2013 that psychiatric patients were more likely to have metastases at the time of their cancer diagnosis and tended to receive less radiotherapy and chemotherapy for their cancers

, thus making cancer

screening and detection especially important for individuals with mental illness.

A Canadian study found that women with psychosis were significantly less likely to have had a Pap test in the previous three years (47.1%) than women without

psychosis (73.7%)

. In contrast, a 2012 study in the United States found that women with psychosis, bipolar disorder or mania, or depression were significantly more likely than women without such disorders to receive cervical cancer screening (OR, 1.46–

1.78)

. Few studies have examined the use of cervical cancer screening by women with

mental illness in Asian countries including Taiwan.

In 2012, a total of 119,514 people were living with mental disabilities in Taiwan,

of whom 49.2% were men and 50.8% were women, amounting to 0.51% of Taiwan’s

population. The aim of this study was to examine the use of the Pap smear test by

Taiwanese women with mental disabilities and analyze factors affecting the women’s

Pap test use.

Methods

Data source and participants

The study population consisted of 49,642 women aged 30 years and older who were registered as having mental disabilities in Taiwan’s Ministry of the Interior’s 2008 database of physically and mentally disabled persons. Mental disabilities included schizophrenia, affective disorders, delusional disorders, senile and presenile mental disorders, other organic mental disorders, other nonorganic mental disorders, and

childhood-onset mental disorders.

Analyses used the secondary data set and were performed with the latest data

available from three national databases in Taiwan: 2007–2008 Pap smear test data from

the Health Promotion Administration, claims data from the National Health Insurance

Research Database, and the 2008 database of physically and mentally disabled

persons from the Ministry of the Interior. Patient data from different databases were

linked through patients’ national identification card numbers and then stripped of

unique personal identifiers and encrypted in order to protect patient privacy.

The National Health Insurance program was implemented in Taiwan in 1995. The National Health Insurance Research Database (NHIRD) has been used extensively in many published studies in Taiwan

. Since the data sets were released for academic research purposes only by the government, and the identities of all study participants were scrambled, this study was exempt from informed content. This study was

approved by the ethics committee of China Medical University and Hospital (IRB No.

CMU-REC-101-012).

Description of variables

The independent variables examined included the following: demographic

characteristics (age, marital status, and education level), economic status (premium-

based monthly salary), residential environment (urbanization level of area of residence,

from the most urbanized, or level 1, to the least, or level 8), health status (presence or

absence of catastrophic illness/injury or of relevant chronic illnesses), and severity of

disability (very severe, severe, moderate, or mild). The dependent variable analyzed was

use of the Pap smear test during 2007–2008.

Economic status was measured by premium-based monthly salary, which is an individual’s monthly income for the purpose of determining the health insurance premium under Taiwan’s National Health Insurance system. Patients who were not employed were categorized as dependents, as they were typically parents, spouses, or children of income-earning individuals. The severity of mental disability was assessed by nationally recognized psychiatrists and categorized as very severe (completely dependent on caretakers or requiring close supervision), severe (requiring supervision), moderate (capable of self-care and other activities of daily living with partial

supervision), and mild (capable of self-care and other activities of daily living without

need for supervision).

Statistical analysis

Data analysis was performed with the SAS statistical software package, version

9.2. For descriptive statistics, percentages of Pap smear use are presented for the

categories of each variable. Associations between Pap smear use and other variables

were analyzed with the χ

test. Logistic regression analysis was performed to determine

the factors that affected Pap smear use. P-values less than 0.05 were regarded as

statistically significant.

Results

Use of Pap smear screening by women with mental disabilities

We included as study subjects Taiwanese women who were 30 years of age and were registered as having mental disabilities in 2008. After cases with erroneous or missing data were excluded, a study sample of 48,333 women remained. We examined the basic characteristics of the women and analyzed the characteristics’ bivariate associations with the women’s use of the Pap smear test in 2007–2008. As presented in Table 1, the results show that 5,339 of the women with mental disabilities had Pap smear tests during 2007–2008, corresponding to a screening rate of 11.05%. The screening rate varied with the urbanization level of the area of residence, with a higher rate being observed for the least urbanized areas (13.05% for level 8, remote areas, vs.

9.57% for level 1, most urbanized areas) (Table 1).

Factors affecting Pap smear use by women with mental disabilities

We performed logistic regression analysis to identify factors that influenced the use of the Pap smear test by women with mental disabilities. Our results, presented in Table 2, show that the women’s use of Pap screening was significantly affected by age, premium-based monthly salary, education level, marital status, whether catastrophic illness/injury was present, whether relevant chronic illnesses were present, and severity of disability. The use of Pap screening decreased with increasing age and severity of disability and was thus negatively correlated with these two variables. Those in the 70- year age group were 0.37 times as likely (95% CI, 0.31–0.46) as those in the 30–39-year age group to be screened; those with very severe disability, 0.49 times as likely (95%

CI, 0.35–0.68) as those with mild disability.

With respect to economic status, the use of Pap screening increased with

increasing premium-based monthly salary, with the odds of screening being the highest for the NT$30,300–36,300 and NT$38,200–45,800 categories, corresponding,

respectively, to 1.74 times (95% CI, 1.47–2.06) and 1.63 times (95% CI, 1.32–2.00) the

odds for the reference category, <NT$15,840. The odds of screening also varied with

education level, with junior high school education being associated with the highest

odds, or 1.10 times that for elementary school education and under (95% CI, 1.01–

1.21). With respect to marital status, married and divorced or widowed women with mental disabilities were, respectively, 2.55 times (95% CI, 2.32–2.81) and 2.40 times (95% CI, 2.10–2.73) as likely to receive Pap screening as their unmarried counterparts.

Also, greater use of Pap screening was observed among those with catastrophic illness or injury (OR, 1.13; 95% CI, 1.03–1.24) than among those without it, as well as for those with a relevant chronic illness (cancer or diabetes mellitus; 1.47 or 1.25 times, respectively) relative to those without the respective illness.

Discussion

In this study, we found that in 2008, the rate of Pap smear screening in Taiwan

was 11.05% for women with mental disabilities, versus 28.8% for women in general

.

This is in line with Tilbrook, Polsky, and Lofters’s 2010 finding

that women with

psychosis were approximately 5-fold less likely to receive Pap screening than women

without the condition. In agreement with previous studies

our results also show

that the rate of Pap smear use declined with age.

With regard to residential environment, a study conducted in Taiwan observed a significantly higher rate of Pap screening among women residing in remote areas (urbanization level 8) than in the most urbanized areas (level 1)

, which is in agreement with our present results for women with mental disabilities (Table 1). Before 1995, living in urbanized areas was associated with greater use of Pap screening among Taiwanese women

; the trend was reversed after the implementation of National Health Insurance in Taiwan in 1995, with remote areas showing a higher Pap screening rate than more urbanized areas

. In addition, to promote access to health care services in Taiwan’s mountainous areas and outlying islands, the Integrated Delivery System (IDS) program was initiated in 1999, in which participating hospitals send out medical

personnel to those remote areas to provide fixed-site or mobile health care services such

as specialty, emergency, and overnight medical care. Patients treated under the IDS

program may be referred to larger hospitals for follow-up treatment

. Cervical cancer

screening rate is one of the evaluation criteria for the program’s effectiveness

. Thus, it

is likely that the combined implementation of National Health Insurance and the IDS

program has greatly improved the utilization of Pap smear tests in remote regions

and led to a more equitable distribution of health care resources in Taiwan.

With respect to financial status, we found that Pap screening use by women with mental disabilities was positively correlated with premium-based monthly salary, consistent with a 2010 study in the United States that showed higher odds of Pap smear use for higher-income women with disabilities relative to their lower-income

counterparts

. Although past research has suggested limited financial means to be a

major reason for not undergoing cancer screening

, Pap screening is available free of

charge in Taiwan and therefore does not pose a financial barrier for low-income

individuals. It is possible that the lower health literacy of lower socioeconomic groups

is responsible for their more limited use of Pap screening services, similar to the finding

of a 2013 Australian study that individuals of lower socioeconomic status had more

lifestyle or behavioral risk factors for cancer

. Previous studies have also found a

higher rate of Pap screening among married than unmarried women

which is in

agreement with our present results (Table 2). Besides the accepted fact that unmarried

women who lack sexual activity have a lower likelihood of cervical cancer, the

conservative attitude of many Asian women, including the value they place on

premarital virginity

, likely makes them more reluctant to undergo Pap smear tests,

contributing to a lower Pap screening rate among unmarried women.

As reviewed in a 2011 report, type 1 diabetes is associated with increased risk of cervical cancer

. As a result, health care providers may make more effort to ensure that their diabetic patients receive cervical cancer screening. Also, people with catastrophic illness or injury or relevant illnesses such as cancer and diabetes have regular contact with medical personnel and are thus more likely to be recommended screening tests.

These reasons help explain the higher rates of Pap screening in these groups of patients, which we observed in our present study. As for severity of disability, we found Pap screening use to be negatively correlated with the severity of mental disability, with those having mild disability being more likely to be screened, in accord with previous studies

. The greater cognitive impairment of patients with more severe mental disability may lower their motivation for undergoing screening, and these patients’

greater difficulty in communicating with caretakers and medical personnel may further

reinforce their passive attitude toward preventive services.

Limitations

In this study, the use of Pap smear screening by women with mental disabilities in Taiwan was investigated by analyzing data from secondary databases. The premium- based monthly salary, used as a proxy for economic status, does not represent an individual’s entire income. Also, the databases did not include information on the study participants’ health beliefs and lifestyle, and whether the participants were living in institutions could not be ascertained, limiting further analysis in this study.

Conclusion

This study shows that women with mental disabilities receive far less Pap smear screening than women in general. In Taiwan, the rate of Pap screening for women with mental disabilities (11.05%) differed 2.6-fold from that for women in general (28.8%).

Age 70 years, lower income, college/university or higher education, unmarried status,

absence of catastrophic illness/injury, absence of cancer or diabetes, and more severe

disability are factors that contribute to lower screening rates among mentally ill women

in Taiwan. Our results may help inform future public health policies for improving Pap

screening utilization by women with mental disabilities.

List of abbreviations CI: Confidence interval;

IDS: Integrated Delivery System NT$: New Taiwan Dollar;

OR: Odds Ratio;

SAS: Statistics Analysis System;

Funding

This study was supported by grants (CMU100-ASIA-10) from China Medical

University and Asia University, and grants (No.9805006A) from the Health Promotion Administration.

Competing interests

The author(s) declare that they have no competing interests.

Authors’ contributions

WCT and PTK conducted the study design. SMY and LTC drafted the manuscript. PTK

and SMY conducted the statistical analysis. WCT was the supervisor of the study and revised the manuscript critically for important intellectual content. All authors read and approved the manuscript.

Acknowledgements

The preventive health care files were obtained from the Health Promotion

Administration, Ministry of Health and Welfare, Taiwan. We are also grateful for use of the National Health Insurance Research Database provided by the Ministry of Health and Welfare, Taiwan. The interpretations and conclusions contained herein do not represent those of the Health Promotion Administration in Taiwan.

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Table 1 Use of Pap smear among women with mental disability: basic characteristics and bivariate analysis.

Variable Total Use Did not use χ

N=48333 % n

=5339 % n

=42994 % p-value

Gender -

Female 48333 100.00 5339 11.05 42994 88.95

Age <0.001*

30–39 years 10718 22.18 1171 10.93 9547 89.07

40–49 years 16111 33.33 1969 12.22 14142 87.78

50–59 years 13259 27.43 1509 11.38 11750 88.62

60–69 years 5513 11.41 554 10.05 4959 89.95

70 years 2732 5.65 136 4.98 2596 95.02

Urbanization level 0.002*

Level 1 7245 14.99 693 9.57 6552 90.43

Level 2 11579 23.96 1302 11.24 10277 88.76

Level 3 7886 16.32 869 11.02 7017 88.98

Level 3 4096 8.47 446 10.89 3650 89.11

Level 5 6651 13.76 782 11.76 5869 88.24

Level 6 4594 9.50 499 10.86 4095 89.14

Level 7 4366 9.03 498 11.41 3868 88.59

Level 8 1916 3.96 250 13.05 1666 86.95

Premium-based monthly salary (NT$) <0.001*

Dependent population 13100 27.10 1395 10.65 11705 89.35

＜15,840 19707 40.77 1785 9.06 17922 90.94

16,500–22,800 11741 24.29 1554 13.24 10187 86.76

24,000–28,800 1768 3.66 275 15.55 1493 84.45

30,300–36,300 1211 2.51 204 16.85 1007 83.15

38,200–45,800 806 1.67 126 15.63 680 84.37

Education level <0.001*

Elementary school and under 14274 29.53 1489 10.43 12785 89.57

Table 1 (Continued)

Variable Total Use Did not use χ

N=48333 % n

=5339 % n

=42994 % p-value

Junior high school 9352 19.35 1150 12.30 8202 87.70

Senior high/vocational school 14212 29.40 1631 11.48 12581 88.52 Junior college/university and above 5851 12.11 549 9.38 5302 90.62

Unknown 4644 9.61 520 11.20 4124 88.80

Marital status <0.001*

Married 19334 40.00 2668 13.80 16666 86.20

Unmarried 11552 23.90 676 5.85 10876 94.15

Divorced and widowed 3534 7.31 468 13.24 3066 86.76

Unknown 13913 28.79 1527 10.98 12386 89.02

Catastrophic illness/injury 0.818

Yes 43301 89.59 4788 11.06 38513 88.94

No 5032 10.41 551 10.95 4481 89.05

Relevant chronic illnesses

Cancer <0.001*

Yes 1139 2.36 182 15.98 957 84.02

No 47194 97.64 5157 10.93 42037 89.07

Diabetes mellitus <0.001*

Yes 6785 14.04 867 12.78 5918 87.22

No 41548 85.96 4472 10.76 37076 89.24

Severity of disability <0.001*

Mild 12714 26.31 1871 14.72 10843 85.28

Moderate 26677 55.19 2885 10.81 23792 89.19

Severe 8252 17.07 544 6.59 7708 93.41

Very severe 690 1.43 39 5.65 651 94.35

*p<0.05

Table 2 Logistic regression models for Pap smear use among women with mental disability.

Variable Unadjusted model Adjusted model

OR 95% CI p-value OR 95% CI p-value Age

30–39 years - - - - - -

40–49 years 1.14 1.05 1.23 0.001* 0.95 0.87 1.02 0.169 50–59 years 1.05 0.97 1.14 0.266 0.82 0.75 0.90 <0.001*

60–69 years 0.91 0.82 1.01 0.086 0.73 0.65 0.82 <0.001*

70 years 0.43 0.36 0.51 <0.001* 0.37 0.31 0.46 <0.001*

Urbanization level

Level 1 - - - - - - - -

Level 2 1.20 1.09 1.32 <0.001* 1.02 0.92 1.13 0.676

Level 3 1.17 1.05 1.30 0.003* 1.00 0.89 1.11 0.954

Level 3 1.16 1.02 1.31 0.024* 0.98 0.86 1.12 0.773

Level 5 1.26 1.13 1.40 <0.001* 1.06 0.94 1.18 0.337

Level 6 1.15 1.02 1.30 0.022* 0.97 0.85 1.10 0.610

Level 7 1.22 1.08 1.38 0.002* 1.00 0.88 1.13 0.945

Level 8 1.42 1.22 1.66 <0.001* 1.11 0.95 1.31 0.197 Premium-based monthly salary (NT$)

<15,840 - - - - - - - -

Dependent population 1.20 1.11 1.29 <0.001* 1.21 1.11 1.33 <0.001*

16,500–22,800 1.53 1.43 1.65 <0.001* 1.48 1.35 1.61 <0.001*

24,000–28,800 1.85 1.61 2.12 <0.001* 1.62 1.40 1.88 <0.001*

30,300–36,300 2.03 1.74 2.38 <0.001* 1.74 1.47 2.06 <0.001*

38,200–45,800 1.86 1.53 2.26 <0.001* 1.63 1.32 2.00 <0.001*

Education level

Elementary school and under - - - - - - - -

Junior high school 1.20 1.11 1.31 <0.001* 1.10 1.01 1.21 0.035*

Senior high/vocational school 1.11 1.03 1.20 0.005* 1.09 1.00 1.19 0.049*

Junior college/university and above 0.89 0.80 0.99 0.025* 0.98 0.87 1.09 0.666 Unknown 1.08 0.97 1.20 0.141 1.08 0.97 1.21 0.177 Marital status

Unmarried - - - - - - - -

Married 2.58 2.36 2.81 <0.001* 2.55 2.32 2.81 <0.001*

Divorced and widowed 2.46 2.17 2.78 <0.001* 2.40 2.10 2.73 <0.001*

Table 2 (Continued)

Variable Unadjusted model Adjusted model

OR 95% CI p-value OR 95% CI p-value Unknown 1.98 1.81 2.18 <0.001* 1.94 1.76 2.14 <0.001*

Catastrophic illness/injury

No - - - - - - - -

Yes 1.01 0.92 1.11 0.818 1.13 1.03 1.24 0.013*

Relevant chronic illnesses

Cancer 1.55 1.32 1.82 <0.001* 1.47 1.24 1.73 <0.001*

Diabetes mellitus 1.22 1.12 1.31 <0.001* 1.25 1.15 1.36 <0.001*

Severity of disability

Mild - - - - - - - -

Moderate 0.70 0.66 0.75 <0.001* 0.75 0.70 0.80 <0.001*

Severe 0.41 0.37 0.45 <0.001* 0.50 0.45 0.56 <0.001*

Very severe 0.35 0.25 0.48 <0.001* 0.49 0.35 0.68 <0.001*

*p<0.05