Disparities in the Use of Preventive Health Care among Children with Disabilities in Taiwan

Disparities in the use of preventive health care among children with disabilities in Taiwan

Wen-Chen Tsai

, Pei-Tseng Kung

, Jong-Yi Wang

*

aDepartmentofHealthServicesAdministration,ChinaMedicalUniversity,Taichung,Taiwan,ROC

bDepartmentofHealthcareAdministration,AsiaUniversity,Taichung,Taiwan,ROC

1. Introduction

EliminatingdisparitiesinhealthcarereceivedbypersonswithdisabilitiesisanoverarchinggoalofHealthyPeople2010 (CentersforDiseaseControl&Prevention,2000).However,individualswithdisabilitieshavebeenreportedtohaveunmet healthneedsandexperienceddifficultyinaccessinghealthcare(Hagglund,Clark,Conforti,&Shigaki,1999;Houtrow,Kim, Chen,&Newacheck,2007;Lishner,Richardson,Levine,&Patrick,1996)butstilldesirehealthpromotioninterventions (Warms,1987).Lackofdiseasepreventionandhealthpromotionamongpeoplewithdisabilitiesisbelievedtoincreasethe ARTICLE INFO

Articlehistory:

Received21September2011 Accepted22September2011 Availableonline26November2011

Keywords:

Disability Children

Preventivehealthcare Disparity

Healthserviceutilization

ABSTRACT

Childrenwithdisabilitiesfacemorebarriersaccessingpreventivehealthservices.Prior researchhasdocumenteddisparitiesinthereceiptoftheseservices.However,mostare limitedtospecifictypesofdisabilityorcare.Thisstudyinvestigatesdisparitiesintheuse ofpreventivehealthcareamongchildrenwithdisabilitiesinTaiwan.Threenationwide databasesfromtheMinistryoftheInterior,BureauofHealthPromotion,andNational HealthResearchInstituteswerelinkedtogatherrelatedinformationbetween2006and 2008.Atotalof8572childrenwithdisabilitiesaged1–7yearswereincludedinthisstudy.

Multivariate logistic regression analysis was conducted to adjust for covariates.

Nationally,only37.58%ofchildrenwithdisabilitiesreceivedpreventivehealthcarein 2008.Childrenwithsevereandveryseveredisabilitieswerelesslikelytousepreventive carethanthosewithmildseverity.Childrenwithdisabilitiesfromthelowestincome familywerelesslikelytohavepreventivecarethanotherincomegroups.Urbanization wasstronglyassociatedwiththereceiptofpreventivehealthcare.However,surprisingly, urbanchildrenwithdisabilitieswerelesslikelytoreceivepreventivecarethanallothers.

Underuniversalhealthinsurancecoverage,theoverallusageofpreventivehealthcareis stilllowamongchildrenwithdisabilities.Thestudyalsoidentifiedseveraldisparitiesin their usage. Potential factors affecting the lack of use deserve additional research.

Policymakersshouldtargetlowsocioeconomicbracketsandfostereducationaboutthe importanceofpreventivecare.Mobilehealthservicesshouldbecontinuallyprovidedin thoseareasinneed.Capitationreimbursementandotherincentivesshouldbeconsidered inimprovingtheutilizationamongchildrenwithdisabilities.

ß2011ElsevierLtd.Allrightsreserved.

*Correspondingauthorat:DepartmentofHealthServicesAdministration,ChinaMedicalUniversity,No.91Hsueh-ShihRoad,Taichung40402,Taiwan, ROC.Tel.:+886422053366x6313;fax:+886422075385.

E-mailaddress:ericwang@mail.cmu.edu.tw(J.-Y.Wang).

1 Theseauthorscontributedequallytothiswork.

ContentslistsavailableatSciVerseScienceDirect

Research in Developmental Disabilities

0891-4222/$–seefrontmatterß2011ElsevierLtd.Allrightsreserved.

doi:10.1016/j.ridd.2011.09.020

incidenceof‘‘medical,social,emotional,family,orcommunityproblems’’amongthesedisadvantagedindividuals(Centers forDiseaseControl&Prevention,2000).Inaddition,indebateoverwhetherpreventivehealthservicesrepresentaneffective investment,recentempiricalevidencesuggestedthatgreateruseofclinicalpreventiveservicesintheUnitedStatescould avoidthelossofmorethantwomillionlife-yearsannually(Maciosek,Coffield,Flottemesch,Edwards,&Solberg,2010).Thus, preventivehealthservicescanbeeffectiveinreducingsubsequentmedicalexpendituresandpromotinghealthforvarious agegroupsanddiseases(Gandjour,2009;Macnab,Rozmus,Benton,&Gagnon,2008;Malach&Baumol,2009;Va´zquez, Garciflan,Rioboo,&Bratos,2002).Preventivehealthcareisthecornerstoneofwell-childcareforbothhealthychildrenand childrenwithspecialhealthcareneeds(Houtrowetal.,2007),yetpastresearchershavedocumentedevidentdisparitiesin usage(USDepartmentofHealth&HumanServices,2000).Disparitiesinaccesstopreventivehealthservicereflectdifference infamilyincome,gender,race/ethnicity,urban/ruralresidence,levelofdisability,andparentaleducation(Chanetal.,1999;

Diab&Johnston,2004;Iezzoni,McCarthy,Davis,&Siebens,2000;Liu,Probst,Martin,Wang,&Salinas,2007).Failureto receivepreventivecarewasmorecommonamongchildrenfromlowincomefamily,ofminoritybyraceorresidence,with higherlevelofdisability,andwhoseparentsreceivelessthancollegeeducation(Asamoaetal.,2004).

Theimprovementofaccesstohealthcareforchildrenwithdisabilityhasbecomeafocusinpreventivemedicine.Dueto physicalandpsychologicalbarriers,childrenwithdisabilitiesmightnotbeabletocommunicatetheirphysicalcomplaints accurately,whichmay,inturn,reducetheiraccesstocareandutilizationofpreventiveservices(Diab&Johnston,2004;Lin, Yen,&Wu,2005;Weng,Kung,Tsai,Chiang,&Chiu,2011).Besides,careforthesechildrenaredynamic,andhealthcare providers find their energies consumed by time-intensive disability-related issues (Ayyangar, 2002). Diminishing the barriersonbothreceiversandprovidersmayleadtoincreasedequalityandutilization.

Previousstudiesregardingpreventivehealthcareamongchildrenwithdisabilitiesarelimitedtospecifictypeofdisability orcare(Diab&Johnston,2004;Liuetal.,2007;Wengetal.,2011).Inordertoeffectivelyimprovethehealthofchildrenwith disabilities,itisnecessarytoconductalarge-scaledinvestigationoftheutilizationofpreventiveservicesacrossalldiseases anddisabilities.Duetoadearthofnationalstudiesonsuchutilization,thepresentstudywasaimedataddressingdisparities intheuseofallpreventivehealthcareamongTaiwanesechildrenwithdisabilitiesandidentifyassociatedfactorsbyusing nationallyrepresentativedata.Giventhatpreviousresearchpertainstoeitheraspecifickindofdisabilityorhealthservice, thisstudyexpectstoaddnewunderstandingtotherelativedomains.

2. Materialsandmethods 2.1. Datasourceandprocessing

ThepresentresearchwasconductedbasedonthenationallyadministrativedatabasefromtheMinistryoftheInterior, Taiwan,2008,coupledwithinformationgatheredbetween2006and2008onpreventivehealthcareandhealthinsurance medicalclaimsfromtheBureauofHealthPromotionandtheNationalHealthResearchInstitutes,respectively.Thevariables include:(1)demographiccharacteristics:gender,age,aboriginalstatus;(2)healthanddisabilitystatus:catastrophicillness/

injury, relevant chronicillnesses (includingcancer and 14 comprehensive categoriesof diseases); (3) classificationof disability:typeofdisability,severityofdisability;(4)theutilizationofchildren’spreventivehealthservices.Beingpivotalin influencingthechildren’shealthcareutilization,parentalvariablesincludingsex,age,residence,premium-basedmonthly salary,andlow-incomehouseholdstatuswerealsoacquired.

2.2. Subjects

According tothe‘DisabilityRightsProtectionActs’ofTaiwan,disabilitycanbeclassifiedinto18categories,namely mentalretardation,multipledisabilities,physicaldisability,autism,majororganmalfunction,hearingimpairment,soundor speechimpairment,chromosomalabnormalities,visualimpairment,congenitaldefects,metabolicabnormalities,refractory epilepsy,facialinjury,balanceimpairment,persistentvegetativestate,dementia,otherchronicmentalillness,andother disabilities causedby rarediseases recognizedby thehealthauthorities. Amongallcategories ofdisability, persistent vegetativestate,dementia,andchronicmentalillnesswereexcludedfromthepresentanalysisduetoverysmallsample sizesandconstantlynoutilization.Severityofdisabilityisclassifiedinto4groups:mild,moderate,severe,andverysevere.A totalof8572childrenwithdisabilitiesundertheageof7wereincluded,andthatistheexactnumberofthisvulnerable populationnationwide.

Thefreepreventivehealthservicesconsistofphysicalexaminationsandhealtheducations.Allchildrenagedunder7 yearsareeligiblefortheservices,withlimitationsontheyearlyfrequencyofusevaryingbyage:4timesforchildrenaged underoneyear,2timesfortheageof1–2,andonetimeforthoseagedbetween2and7years.

2.3. Statisticalanalysis

AlldatawereanalyzedwiththeSASversion9.2. Thisstudyfirstlyincludeda descriptiveanalysisof theidentified variables. Percentages of each variable and mean difference in their frequency of use wereexamined for statistical significanceusingthet-test,one-wayANOVA,and

x

Table1

Chi-squareanalysisoftheuseofpreventivehealthservicesinchildrenwithdisabilitiesduring2006–2008.

Variables N=8572 % Use Non-use x²

n1=3221 % n2=5351 % p-Value

Totalpercent 37.58 62.42

Gender 0.559

Female 3190 37.21 1186 37.18 2004 62.82

Male 5382 62.79 2035 37.81 3347 62.19

Age <.001^*

<1years 515 6.01 280 54.37 235 45.63

1–2years 905 10.56 535 59.12 370 40.88

2–3years 1472 17.17 573 38.93 899 61.07

3–4years 2038 23.78 461 22.62 1577 77.38

4–7years 3642 42.49 1372 37.67 2270 62.33

Aboriginalstatus 0.169

Aboriginal 132 1.54 42 31.82 90 68.18

Non-aboriginal 8440 98.46 3179 37.67 5261 62.33

Catastrophicillness/injury <.001^*

Yes 3217 37.53 1120 34.82 2097 65.18

No 5355 62.47 2101 39.23 3254 60.77

Relevantchronicillnesses

Cancer 0.036^*

Yes 48 0.56 11 22.92 37 77.08

No 8524 99.44 3210 37.66 5314 62.34

Endocrineandmetabolicdisorder 0.898

Yes 584 6.81 218 37.33 366 62.67

No 7988 93.19 3003 37.59 4985 62.41

Mentaldisorder 0.257

Yes 4182 48.79 1546 36.97 2636 63.03

No 4390 51.21 1675 38.15 2715 61.85

Diseasesofthenervoussystem 0.002^*

Yes 2193 25.58 764 34.84 1429 65.16

No 6379 74.42 2457 38.52 3922 61.48

Diseasesofthecirculatorysystem <.001^*

Yes 495 5.77 146 29.49 349 70.51

No 8077 94.23 3075 38.07 5002 61.93

Diseasesoftherespiratorysystem 0.171

Yes 2700 31.50 986 36.52 1714 63.48

No 5872 68.50 2235 38.06 3637 61.94

Diseasesofthedigestivesystem 0.049^*

Yes 2051 23.93 733 35.74 1318 64.26

No 6521 76.07 2488 38.15 4033 61.85

Diseasesofthegenitourinarysystem 0.578

Yes 92 1.07 32 34.78 60 65.22

No 8480 98.93 3189 37.61 5291 62.39

Diseasesofthemusculoskeletalsystem andconnectivetissue

0.369

Yes 447 5.21 159 35.57 288 64.43

No 8125 94.79 3062 37.69 5063 62.31

Disordersoftheeyeandadnexa 0.561

Yes 521 6.08 202 38.77 319 61.23

No 8051 93.92 3019 37.50 5032 62.50

Infectiousdisease 0.873

Yes 79 0.92 29 36.71 50 63.29

No 8493 99.08 3192 37.58 5301 62.42

Congenitalanomalies 0.664

Yes 2964 34.58 1123 37.89 1841 62.11

No 5608 65.42 2098 37.41 3510 62.59

Diseasesofskinandsubcutaneoustissue 0.760

Yes 1344 15.68 510 37.95 834 62.05

No 7228 84.32 2711 37.51 4517 62.49

Diseasesofbloodandblood-formingorgans 0.408

Yes 355 4.14 126 35.49 229 64.51

No 8217 95.86 3095 37.67 5122 62.33

Diseasesoftheearandmastoidprocess 0.672

Yes 730 8.52 269 36.85 461 63.15

No 7842 91.48 2952 37.64 4890 62.36

Typeofdisability <.001^*

Mentalretardation 2049 23.90 756 36.90 1293 63.10

Multipledisabilities 1613 18.82 508 31.49 1105 68.51

Physicaldisability 1156 13.49 495 42.82 661 57.18

Autism 1155 13.47 421 36.45 734 63.55

3. Results

Onlyslightlyoveronethirdofdisabledchildrenwererecordedashavingusedpreventivehealthcare(37.58%,Table1)in thepastoneyear.Theuseofpreventivehealthcarewasthelowestamongchildrenagedbetween3and4(22.62%),andthe percentageofusenearlydecreasedwithage.Thepercentageofuseamongthosewithcatastrophicillnesswas34.82%, whichissignificantlylowerthanthosewithout(39.23%).Amongtherelevantchronicillnessessignificantlyassociated withuse,childrenwithcancershowedthelowestusage(22.92%).Amongalldifferenttypesofdisability,childrenwith multipledisabilitiesreportedthelowestusage(31.49%)whilebalanceimpairmentwasthehighest(46.15%).Thosewith verysevere disabilitiesexhibitedthelowestusage(22.66%)comparedtootherlevelsofdisability,whichdisplayeda negativerelationshipbetweenseverityofdisabilityandusage.Amongtheparentcharacteristics,theuseofpreventivecare waslowestinchildrenwhoseparentswereaged341years(34.19%)comparedtootheragegroups.Thoseresidinginareas gradedthehighestlevel1,ofurbanizationreportedthelowestusage(28.08%).Also,thoseparentswithpremium-based monthlysalaryofNT$76,500–87,600(NewTaiwanDollar,NT$)showedthelowestutilization(31.29%),followedbythose parentswithpremium-basedmonthlysalaryof<NT$15,840(33.55%).

Intermsofthemeanfrequencyinuseofpreventivehealthcare,childrenwithdisabilityagedbetween3and4yearswas significantly lower than otheragegroups (p<0.001, Table 2), showingalmost negative correlationbetween ageand frequencyofuse.Theaveragefrequencyofuseamongchildrenwithcatastrophicillnesses(0.39)wassignificantlylower Table1(Continued)

Variables N=8572 % Use Non-use x²

n1=3221 % n2=5351 % p-Value

Majororganmalfunction 642 7.49 222 34.58 420 65.42

Hearingimpairment 599 6.99 274 45.74 325 54.26

Soundorspeechimpairment 439 5.12 186 42.37 253 57.63

Chromosomalabnormalities 353 4.12 146 41.36 207 58.64

Rarediseases 216 2.52 74 34.26 142 65.74

Visualimpairment 143 1.67 55 38.46 88 61.54

Congenitaldefects 72 0.84 33 45.83 39 54.17

Metabolicabnormalities 42 0.49 17 40.48 25 59.52

Refractoryepilepsy 42 0.49 16 38.10 26 61.90

Facialinjury 38 0.44 12 31.58 26 68.42

Balanceimpairment 13 0.15 6 46.15 7 53.85

Severityofdisability <.001^*

Mild 3290 38.38 1303 39.60 1987 60.40

Moderate 2834 33.06 1096 38.67 1738 61.33

Severe 1764 20.58 667 37.81 1097 62.19

Verysevere 684 7.98 155 22.66 529 77.34

Parents’characteristics

Sex 0.249

Female 3411 39.79 1307 38.32 2104 61.68

Male 5161 60.21 1914 37.09 3247 62.91

Age 0.004^*

230years 2119 24.72 829 39.12 1290 60.88

31–40years 4739 55.28 1806 38.11 2933 61.89

341years 1714 20.00 586 34.19 1128 65.81

Urbanizationlevel <.001^*

Highest:Level1 1054 12.30 296 28.08 758 71.92

Level2 2182 25.45 807 36.98 1375 63.02

Level3 1420 16.57 538 37.89 882 62.11

Level4 828 9.66 314 37.92 514 62.08

Level5 1209 14.10 500 41.36 709 58.64

Level6 817 9.53 339 41.49 478 58.51

Level7 734 8.56 291 39.65 443 60.35

Lowest:Level8 328 3.83 136 41.46 192 58.54

Premium-basedmonthlysalary(NT$) <.001^*

<15,840 1869 21.80 627 33.55 1242 66.45

16,500–22,800 3488 40.69 1390 39.85 2098 60.15

24,000–28,800 670 7.82 246 36.72 424 63.28

30,300–36,300 734 8.56 297 40.46 437 59.54

38,200–45,800 812 9.47 309 38.05 503 61.95

48,200–57,800 570 6.65 209 36.67 361 63.33

60,800–72,800 266 3.10 92 34.59 174 65.41

76,500–87,600 163 1.90 51 31.29 112 68.71

Low-incomehousehold 0.002^*

Yes 412 4.81 125 30.34 287 69.66

No 8160 95.19 3096 37.94 5064 62.06

* p<0.05.

Table2

Meandifferenceintheuseofpreventivehealthservicesamongchildrenwithdisabilitiesduring2006–2008.

Variables N=8572 Mean SD p-Value(t-testorF-test)

Gender 0.371

Female 3190 0.45 0.66

Male 5382 0.43 0.62

Age <.001^*

<1years 515 1.12 1.26

1–2years 905 0.85 0.80

2–3years 1472 0.39 0.49

3–4years 2038 0.23 0.42

4–7years 3642 0.38 0.48

Aboriginalstatus 0.065

Aboriginal 132 0.35 0.55

Non-aboriginal 8440 0.44 0.64

Catastrophicillness/injury <.001^*

Yes 3217 0.39 0.59

No 5355 0.47 0.66

Relevantchronicillnesses

Cancer 0.010^*

Yes 48 0.25 0.48

No 8524 0.44 0.64

Endocrineandmetabolicdisorder 0.870

Yes 584 0.43 0.62

No 7988 0.44 0.64

Mentaldisorder <.001^*

Yes 4182 0.40 0.57

No 4390 0.47 0.69

Diseasesofthenervoussystem 0.008^*

Yes 2193 0.41 0.62

No 6379 0.45 0.64

Diseasesofthecirculatorysystem <.001^*

Yes 495 0.35 0.59

No 8077 0.44 0.64

Diseasesoftherespiratorysystem <.001^*

Yes 2700 0.39 0.55

No 5872 0.46 0.67

Diseasesofthedigestivesystem 0.015^*

Yes 2051 0.41 0.61

No 6521 0.45 0.64

Diseasesofthegenitourinarysystem 0.712

Yes 92 0.41 0.63

No 8480 0.44 0.63

Diseasesofthemusculoskeletalsystemandconnectivetissue 0.085

Yes 447 0.39 0.57

No 8125 0.44 0.64

Disordersoftheeyeandadnexa 0.155

Yes 521 0.48 0.71

No 8051 0.43 0.63

Infectiousdisease 0.321

Yes 79 0.38 0.51

No 8493 0.44 0.64

Congenitalanomalies 0.007^*

Yes 2964 0.46 0.68

No 5608 0.42 0.61

Diseasesofskinandsubcutaneoustissue 0.477

Yes 1344 0.45 0.65

No 7228 0.44 0.63

Diseasesofbloodandblood-formingorgans 0.593

Yes 355 0.42 0.64

No 8217 0.44 0.63

Diseasesoftheearandmastoidprocess 0.074

Yes 730 0.40 0.56

No 7842 0.44 0.64

Typeofdisability <.001^*

Mentalretardation 2049 0.38 0.51

Multipledisabilities 1613 0.36 0.58

Physicaldisability 1156 0.57 0.79

Autism 1155 0.39 0.54

Majororganmalfunction 642 0.40 0.64

Hearingimpairment 599 0.60 0.79

Soundorspeechimpairment 439 0.44 0.54

Chromosomalabnormalities 353 0.57 0.78

thanthosewithoutsuchillnesses(p<0.001).Theuseofpreventivehealthcarewasloweramongthosewithcancer,mental disorders,nervoussystemdiseases,circulatorysystemdiseases,respiratorysystemdiseases,digestivesystemdiseases,and congenitalanomalies(allps<0.05).Amongthedifferenttypesofdisability,childrenwithmultipledisabilitiesshowedthe lowestmeanfrequencyofuse(0.36),whilehearingimpairmentreportedthehighest(0.60).Theaverageusageofthosewith severedisability(0.47)wassignificantlyhigherthanotherseveritygroups(p<0.001)whilethemeanusageofthe‘very severe’groupwasrankedthelowest(0.26).Utilizationwassignificantlylower(p<0.001)amongchildrenwhoseparentsare aged341years(0.36).Residentsinareasoflevel1urbanizationhadasignificantlylowermeanfrequencyofuse(0.35)than residents ofotherlevels(p<0.001). Theaverage frequencyofuseamong thoseparentswho hadthepremium-based monthlysalaryofNT$76,500–87,600wasaslowas0.36.

Withallothervariablesheldequal,adjustedlogisticregressionanalysisyieldedtoaresultthattheoddsofusedecreased withageinamannerparallelingthefindingsshowninTables1and2.Higheroddsofreceiptofpreventivehealthcarewere significantly associated with children with mental disorder, hearing impairment, and sound or speech impairment (OR=1.20,1,27,1,33,respectively,Table3),whilelowersoddswereassociatedwiththosewithcirculatorysystemdiseases andrarediseases(OR=0.69,0.71,respectively).Differencesinoddswerefoundsignificantamongtheseverityofdisability, inwhich‘verysevere’hadthelowestoddsofuse(OR=0.43;95%CI:0.34–0.54),whichechoeswiththeresultsintheprevious levelsofanalysis.Theoddsofuseamongchildrenwhoseparentswereaged341yearsweremarkedlylower(OR=0.84;95%

CI:0.72–0.99)thanthosewhoseparentswereaged230years.Thedisparitieswereexacerbatedamongtheurbanization levelsofresidence;comparedwiththehighesturbanizationlevel,childrenresidinginareasofallotherlowerurbanization levelsweresignificantlymorelikelytousepreventivehealthcare(allORs>1).Asmightnotbeanticipated,theoddsofuse increasedalmostlinearlywiththedecreaseofurbanizationlevel(p<.001).Amarkeddifferencewasalsopresentacross levels of income; those with premium-based monthly salary of NT$16,500–22,800 and NT$30,300–36,300 showed significantlyhigheroddsofuse(OR=1.22,1.28,respectively),demonstratingastronglinkbetweenparentalincomeanduse ofpreventivecareinchildrenwithdisability.

Table2(Continued)

Variables N=8572 Mean SD p-Value(t-testorF-test)

Rarediseases 216 0.44 0.69

Visualimpairment 143 0.48 0.73

Congenitaldefects 72 0.57 0.69

Metabolicabnormalities 42 0.48 0.63

Refractoryepilepsy 42 0.45 0.63

Facialinjury 38 0.37 0.59

Balanceimpairment 13 0.46 0.52

Severityofdisability <.001^*

Mild 3290 0.45 0.62

Moderate 2834 0.45 0.63

Severe 1764 0.47 0.69

Verysevere 684 0.26 0.52

Parents’characteristics

Sex 0.381

Female 3411 0.44 0.63

Male 5161 0.43 0.63

Age <.001^*

230years 2119 0.47 0.67

31–40years 4739 0.45 0.65

341years 1714 0.36 0.53

Urbanizationlevel <.001^*

Highest:Level1 1054 0.35 0.64

Level2 2182 0.42 0.62

Level3 1420 0.44 0.63

Level4 828 0.45 0.66

Level5 1209 0.47 0.63

Level6 817 0.50 0.70

Level7 734 0.45 0.60

Lowest:Level8 328 0.47 0.62

Premium-basedmonthlysalary(NT$) <.001^*

<15,840 1869 0.37 0.56

16,500–22,800 3488 0.47 0.65

24,000–28,800 670 0.44 0.67

30,300–36,300 734 0.48 0.65

38,200–45,800 812 0.46 0.67

48,200–57,800 570 0.43 0.64

60,800–72,800 266 0.39 0.61

76,500–87,600 163 0.36 0.60

Low-incomehousehold <.001^*

Yes 412 0.31 0.48

No 8160 0.44 0.64

* p<0.05.

Table3

Logisticregressionmodelsfortheuseofpreventivehealthservicesinchildrenwithdisabilitiesduring2006–2008.

Variables Bivariatemodel Multivariatemodel

CrudeOR 95%CI p-Value AdjustedOR 95%CI p-Value

Gender

Female – – – – – – – –

Male 1.03 0.94 1.13 0.559 1.04 0.95 1.15 0.384

Age

<1years – – – – – – – –

1–2years 1.21 0.98 1.51 0.082 1.16 0.93 1.46 0.188

2–3years 0.54 0.44 0.66 <.001^* 0.47 0.38 0.59 <.001^*

3–4years 0.25 0.20 0.30 <.001^* 0.20 0.16 0.25 <.001^*

4–7years 0.51 0.42 0.61 <.001^* 0.43 0.34 0.53 <.001^*

Aboriginalstatus

Non-aboriginal – – – – – – – –

Aboriginal 0.77 0.53 1.12 0.170 0.74 0.50 1.10 0.131

Catastrophicillness/injury

No – – – – – – – –

Yes 0.83 0.76 0.91 <.001^* 1.09 0.96 1.23 0.184

Relevantchronicillnesses

Cancer 0.49 0.25 0.97 0.040^* 0.58 0.29 1.19 0.139

Endocrineandmetabolicdisorder 0.99 0.83 1.18 0.899 1.10 0.91 1.33 0.324

Mentaldisorder 0.95 0.87 1.04 0.257 1.20 1.08 1.34 0.001^*

Diseasesofthenervoussystem 0.85 0.77 0.94 0.002^* 0.97 0.86 1.11 0.690

Diseasesofthecirculatorysystem 0.68 0.56 0.83 <.001^* 0.69 0.56 0.86 0.001^*

Diseasesoftherespiratorysystem 0.94 0.85 1.03 0.172 1.08 0.97 1.20 0.148

Diseasesofthedigestivesystem 0.90 0.81 1.00 0.049^* 0.99 0.89 1.12 0.922

Diseasesofthegenitourinarysystem 0.89 0.58 1.36 0.578 0.98 0.62 1.55 0.937

Diseasesofthemusculoskeletalsystem andconnectivetissue

0.91 0.75 1.11 0.369 1.04 0.84 1.28 0.741

Disordersoftheeyeandadnexa 1.06 0.88 1.27 0.559 1.20 0.98 1.47 0.071

Infectiousdisease 0.96 0.61 1.53 0.874 1.05 0.64 1.71 0.852

Congenitalanomalies 1.02 0.93 1.12 0.664 1.04 0.92 1.17 0.514

Diseasesofskinandsubcutaneoustissue 1.02 0.90 1.15 0.760 1.05 0.92 1.20 0.443

Diseasesofbloodandblood-formingorgans 0.91 0.73 1.14 0.408 1.01 0.79 1.28 0.938

Diseasesoftheearandmastoidprocess 0.97 0.83 1.13 0.673 1.08 0.91 1.28 0.398

Typeofdisability

Physicaldisability – – – – – – – –

Visualimpairment 0.84 0.58 1.19 0.320 1.04 0.71 1.54 0.837

Hearingimpairment 1.13 0.92 1.37 0.242 1.27 1.01 1.59 0.043^*

Soundorspeechimpairment 0.98 0.79 1.23 0.871 1.33 1.04 1.70 0.023^*

Mentalretardation 0.78 0.67 0.90 0.001^* 1.01 0.85 1.21 0.878

Multipledisabilities 0.61 0.53 0.72 <.001^* 0.91 0.76 1.09 0.304

Majororganmalfunction 0.71 0.58 0.86 0.001^* 0.80 0.63 1.02 0.066

Facialinjury 0.62 0.31 1.23 0.172 0.69 0.33 1.44 0.323

Autism 0.77 0.65 0.91 0.002^* 1.05 0.85 1.28 0.674

Chromosomalabnormalities 0.94 0.74 1.20 0.627 1.01 0.76 1.33 0.971

Metabolicabnormalities 0.91 0.49 1.70 0.763 1.08 0.56 2.09 0.821

Congenitaldefects 1.13 0.70 1.82 0.617 1.25 0.75 2.09 0.394

Balanceimpairment 1.15 0.38 3.43 0.809 1.96 0.60 6.44 0.269

Refractoryepilepsy 0.82 0.44 1.55 0.544 0.85 0.44 1.67 0.644

Rarediseases 0.70 0.51 0.94 0.020^* 0.71 0.51 0.98 0.040^*

Severityofdisability

Mild – – – – – – – –

Moderate 0.96 0.87 1.07 0.457 0.97 0.87 1.09 0.591

Severe 0.93 0.82 1.04 0.213 0.82 0.71 0.95 0.009^*

Verysevere 0.45 0.37 0.54 <.001^* 0.43 0.34 0.54 <.001^*

Parents’characteristics Sex

Female – – – – – – – –

Male 0.95 0.87 1.04 0.249 0.97 0.88 1.07 0.596

Age

230years – – – – – – – –

31–40years 0.96 0.86 1.06 0.426 0.93 0.82 1.05 0.230

341years 0.81 0.71 0.92 0.002^* 0.84 0.72 0.99 0.032^*

Urbanizationlevel

Highest:Level1 – – – – – – – –

Level2 1.50 1.28 1.76 <.001^* 1.58 1.33 1.87 <.001^*

Level3 1.56 1.32 1.86 <.001^* 1.62 1.35 1.95 <.001^*

Level4 1.56 1.29 1.90 <.001^* 1.64 1.33 2.01 <.001^*

Level5 1.81 1.51 2.15 <.001^* 1.90 1.57 2.31 <.001^*

Level6 1.82 1.50 2.20 <.001^* 1.96 1.59 2.41 <.001^*

Acrossalllevelsandtypesofanalysis,thefollowingvariablesshowedrobustdifferencesofuseamongchildrenwith disabilities:age,relevantchronicillness,typeandseverityofdisability,parentalage,urbanizationlevel,andfamilyincome.

4. Discussion

Despitethefactthatsince1995,theDepartmentofHealthinTaiwanhasprovidedfreepreventivecaretochildrenwith disabilities,37.58%ofutilizationrateremainsnotablylowcomparedwith87.5%ofchildrenwithand73.1%ofchildren withoutspecialhealthcareneedsreceivinghealthscreening,whichwasreportedinpreviousstudy(Houtrowetal.,2007),as wellaswith78.64%ofthegeneralchildreninTaiwan(Tsai&Kung,2010).Lackofpreventivecareamongchildrenwith disabilitiesindicatesatremendousneedtoimprovetheusageinTaiwan.

Consistentwithmostbutnotallpriorresearch,thisstudyfounddisparities,althoughnotveryextensive,intheuseof preventivehealthcareamongTaiwanesedisabledchildrenbychildren’sage,healthstatus,typeandseverityofdisabilities, parents’age,urbanizationlevel,andincome.Amongchildrencharacteristics,childrenwithhigherage,withdiseasesofthe circulatorysystemandrarediseases,andwithgreaterseverityofdisabilitywerelesslikelytotakeadvantageofpreventive healthcare.Someofthesefindingsmirrorpreviousstudiesintherelevantfields(Chi,Momany,Kuthy,Chalmers,&Damiano, 2010;Diab&Johnston,2004;Liuetal.,2007;Wengetal.,2011).

Thisstudydemonstrates thatgender, aboriginalstatus,and catastrophicillness arenotclosely associatedwiththe utilization ofpreventivehealth careamong childrenwithdisabilities.Given thatchildren withdisabilitiesencompass greaterfunctionallimitationandrequiremorediversehealthcarecomparedtochildrenwithoutdisabilities(Jeng,Wang, Cher,Lin,&Jeng,2009),thesefactorsstillarenotstronglyassociatedwithdifferencesinthereceiptofcare.Nevertheless, severityofdisabilityisanimportantpredictortopreventivehealthcareutilization,whichisconsistentwiththefindings among Americanchildren withdisabilities byDiab and Johnston(2004).Thehealth status andmedical needsamong childrenwithdisabilitiesinevitablyleadtochallengesinaccessingpreventivehealthservices.Ashealthisworsenedby increasedseverityofdisability,theneedfortherapeuticmedicalcarebecomesdemanding.Such needfor caremainly revolvesaroundtherecoveryofdailyfunction,thus,lackingtheurgencyforpreventivehealthservices.Thisphenomenonof attitudinalobstaclebyseverityofdisabilitymightbeexacerbatedbyprovisionobstaclesandtransportationandmobility barriers(Diab&Johnston,2004;Probst,Laditka,Wang,&Johnson,2007;Wengetal.,2011),discouragingtheirwillingnessto usepreventivehealthservices.Therefore,theplanningofpreventivehealthservicesshouldfocusontheusagepromotion amongchildrenwithdisabilityofhigherseverity.Inordertoincreasethewillingnessofdentisttoprovideoralcarefor peoplewithseveredisability,theglobalbudgetreimbursementwasemployedtopromoteoralhealthforthosewith‘severe’

and‘verysevere’disabilityinTaiwan(Tsai,Kung,Chiang,&Chang,2007).Hence,asafinancialincentive,theincreased subsidy of primary carefor children withdisability shouldbe implemented and couldequally encourage theuseof preventivehealthservicesamongthevulnerablepopulation.

Inregardtoparentalcharacteristics,thisstudydidnotfindgenderdifferencesintheuseofpreventivehealthcareamong parentsofchildrenwithdisabilities.However,parentalagewasfoundsignificant.Thefactofamajorityoftheparentsaged between30and40yearsissupportedbyapreviousworkreportingtheaverageage36.3ofprimarycaregiversofpreschool childrenwithdisabilities(Linetal.,2005).Amongalltheassociatedfactors,urbanizationlevelexhibitedmanifestdisparities intheserviceutilization.Thenoteworthyfindingthatchildrenresidinginurbanareas(levels1)tendedtonotusemaybe contrarytoseveralexistingdocumentsthatsuggestlowutilizationinruralareascouldbeattributabletopooraccesstocare (Chietal.,2010;Liuetal.,2007;Torres,Bellinger,Probst,Harun,&Johnson,2007).However,thissomewhatsurprising findingmightactuallyrevealedthedesirableeffectsofimprovedaccesstocarebytheimplementationoftheNationalHealth InsuranceandbymobilehealthservicesofwhichtravellingvehiclesforscreeningandvaccinatingfundedbythePlanof MedicalNetworkhavedirectlypenetratedtheremoteareas(DepartmentofHealth,2009).Nevertheless,under-invested Table3(Continued)

Variables Bivariatemodel Multivariatemodel

CrudeOR 95%CI p-Value AdjustedOR 95%CI p-Value

Level7 1.68 1.38 2.05 <.001^* 1.83 1.48 2.27 <.001^*

Lowest:Level8 1.81 1.40 2.35 <.001^* 2.13 1.61 2.82 <.001^*

Premium-basedmonthlysalary(NT$)

<15,840 – – – – – – – –

16,500–22,800 1.31 1.17 1.48 <.001^* 1.22 1.07 1.39 0.004^*

24,000–28,800 1.15 0.96 1.38 0.139 1.06 0.86 1.29 0.600

30,300–36,300 1.35 1.13 1.61 0.001^* 1.28 1.05 1.55 0.013^*

38,200–45,800 1.22 1.03 1.44 0.025^* 1.18 0.98 1.43 0.087

48,200–57,800 1.15 0.94 1.40 0.170 1.13 0.91 1.40 0.270

60,800–72,800 1.05 0.80 1.37 0.737 1.11 0.83 1.49 0.469

76,500–87,600 0.90 0.64 1.27 0.558 1.07 0.74 1.55 0.731

Low-incomehousehold

No – – – – – – – –

Yes 0.71 0.58 0.88 0.002^* 0.83 0.64 1.08 0.170

* p<0.05.

medicalresources,barrierstotransportation,insufficientuseofhealthinformationmightstillcompoundaccessproblems amongthedisabledchildreninruralareas(Probstetal.,2007;Wang,Probst,Stoskopf,Sanders,&McTigue,2011;Wengetal., 2011).Thus,homeandcommunityvisitsshouldbecontinuallygiventofamiliesofchildrenwithseveredisabilitiesandwith transportationbarriers,evennotinruralareas.Therelatedauthoritiesshouldcontinuetoaddressandendeavortoeliminate thisdisparitybyresourcereallocationthroughchannelingthepotentiallysurplusinvestmenttothoseinneed.Moreof effectiveincentivesinmotivatingmedicalprofessionalstoserveinremoteareas,includingincreasedfinancialpaymentand doubledseniority (Department of Health, 2010), should befurther strengthenedin area in need. Besides,continuing educationonthenecessityofhealthservicesfordiseasepreventiontargetedto‘urban’residentswithdisabilitiesandtheir familyshouldalsobelistedinthepublicpolicyagenda.Thelevelofpremium-basedmonthlysalaryindicativeofhousehold income demonstrated thedisparity in theutilization. Familieswithgood financial and socioeconomic status tendto emphasizeonpreventivehealth,presentinggreaterabilityinensuringthehealthofdisabledchildren(Inkelas,Raghavan, Larson,Kuo,&Ortega,2007;Linetal.,2005).However,thecurrentanalysisonlyindicatedfeweruseinchildrenfromlowest incomefamiliesanddidnotsupporthigherusefromtoplevelincome.Apossibleexplanationisthatthebasicallyfreeof chargepreventivecaremightnotoffertorichestchildrenwhoseparentsmaybeinclinedtochoosetheirchildrenout-of- packetpreventiveservicesnotprovidedbytheNationalHealthInsurance.Therefore,topromotetheuse,disparityinuseby familyincomerequirespreventiveservicesplannerstocommunicateclosely withtheinsuredacrossdifferentlevelsof incomeandmeritsfurtherresearchonneedassessmentinaculturallyfitway.

Timeandphysicalconstraintsarecommonlycitedbyprimarycaregiversasthemajorfactorsaffectingtheactualuseof preventive health care. Adequate knowledge among primary caregivers positively impact on children’s health and development(Hudsonetal.,2003).Onthecontrary,inadequateknowledgeonpreventivecaremayleadtolimiteduse,so effective parental supports and education aimed at lower socioeconomic groups should be formulated by health policymakersintheattempttoincreaseitsuse.

Thisstudyaddstotheexistingliteraturein several substantiveways. Inaddition totheutilization rateandmean frequencydescribed,theresultshighlightanoveralldeficitinthereceiptofpreventivecarenationwideandalsoidentified somedisparitieswithinthepopulationofchildrenwithdisabilities.Furthermore,thisstudyspeculatesaprotectiveeffectfor thegeographicallyvulnerablegroupswithrespecttothenationalhealthinsurancecoverageandhealthsystemmeasures (DepartmentofHealth,2010;Liuetal.,2007).Aimingatshorteningdiscrepancybetweenrural/urbanmedicalresource allocations,theauthoritieshavelauncheddifferentstagesofthePlanofMedicalNetworksince1985.Basedonthecurrent analysis,increasesinuseofpreventiveservicesremainpromisingspecificallyin theremoteareas.Regardlessofother associated factors,eliminatingeconomic and geographical disparitiesin preventive care requiresadditional efforts in removingbothfinancialandculturalbarrierstoitsdeliveryandutilization.

Limitationsofthepresentstudystemfromtheadministrativedatabasesusedandthestudynature.First,thedatabases didnotincorporateinformationregardinglevelofeducationandknowledgeonpreventivecareamongthesubjects’parents.

Failuretoincludetherelatedfactorscouldattenuatetheresults.Second,althoughthisstudyobservedthesubjectsatleast oneyear,theanalysiscouldnotascertainacausaleffect.Instead,onlytheassociationscanbeinferred.

5. Conclusion

TaiwanhasimplementedtheNationalHealthInsurancesince1995.Undertheuniversalcoverage,however,disparitiesin theuseofpreventivehealthcareamongchildrenwithdisabilitywerestillfoundbychildrenandparentaldemographics, healthstatus,typeandseverityofdisability.Ofalltheassociatedfactors,urbanizationlevelismostevident.Withmuchroom forimprovingtheutilization,older,poorerchildrenwithdisabilityandolderparentsshouldbetargeted.Futureresearch wouldbenefitfromfinelyadjustingforthereimbursementandhealthsystemvariablesinevaluatingdisparitiesinreceiptof preventivecare.Limitedmedicalresourceonpreventivecarejustifiesthenecessityofitseffectiveinvestmentinespecially thoseinneed.Theauthoritiesshouldtacklethedisparitiesusingastrategicframework,whichinvolvesspecialhealthand supportneededassessmentsinculturallyappropriateways,adifferentialsubsidysetfordifferentseverityofdisability, redirectingmedical resourcestounderservedareasthroughmobilehealthservicesandincentives,andeducating low incomegroups,toincreasetheaccessibilityanduse.SincetheauthoritieshavepartiallylaunchedtheSystemofFamily Physicianreimbursedbycapitationintheselectedclinicsorhospitals(DepartmentofHealth,2011),thedisability-specific schemeofcapitationreimbursementbyageandbyseveritymightbealsoconsideredinthetimelypursuitofanextensive useofpreventivehealthservicesamongchildrenwithdisability.

Acknowledgements

ThecurrentstudywassupportedbyBureauofHealthPromotion, DepartmentofHealth(grantNo. 9805006A)and Department of Health Clinical Trial and Research Center for Excellence (DOH99-TD-B-111-004) and China Medical UniversityandAsiaUniversity(grantNo.CMU97-325),basedondatafromtheNationalHealthInsuranceResearchDatabase providedby NationalHealth Research Institutes. Thepreventive health carefiles wereprovidedby Bureauof Health Promotion,thedisabledpersonsfileprovidedbyMinistryoftheInteriorinTaiwan.Theinterpretationsandconclusions containedhereindonotrepresentthoseoftheBureauofHealthPromotion,NationalHealthResearchInstitutesorMinistry oftheInteriorinTaiwan.