Factors related to hysterectomy in women with physical and mobility disabilities

Factors related to hysterectomy in women with physical and mobility disabilities

Lan-Ping Lin

, Molly Hsieh

, Si-Fan Chen

, Chia-Ling Wu

, Shang-Wei Hsu

, Jin-Ding Lin

*

aSchoolofPublicHealth,NationalDefenseMedicalCenter,161,Min-ChunERd,Sec.6,Nei-Hu,Taipei,Taiwan

bCenterforGeneralEducation,NationalDefenseMedicalCenter,Taipei,Taiwan

cResearchCenterforIntellectualDisabilitiesTaiwan,Chung-HuaFoundationforPersonswithIntellectualDisabilities,NewTaipeiCity,Taiwan

dGraduateInstituteofHealthcareAdministration,AsiaUniversity,Taichung,Taiwan

eDepartmentofPublicHealth,ChinaMedicalUniversity,Taichung,Taiwan

1. Introduction

Hysterectomyisasurgicalproceduretoremovetheuterinebody(i.e.,partialhysterectomy)ortheuterinebodyand cervix(i.e.,totalhysterectomy)(NationalCancerInstitute,2010).Hysterectomiesarethesecondmostcommontypeof majorsurgeryperformedonwomenofchildbearingage.Hysterectomymaybeconductedtotreatmanyconditionsthat affecttheuterus,suchasuterinefibroids,endometriosis,pelvicsupportproblems,abnormaluterinebleeding,cancerand chronicpelvicpain(TheAmericanCollegeofObstetriciansandGynecologists,2010).

Hysterectomyprevalencerateshavevariedindifferentstudies(Borman,McKenna,&Findlay,1986;Bower,Schreiner, Sternfeld,&Lewis,2009;CentersforDiseaseControl,1992;Dickeretal.,1982;Palmer,Rao,Adams-Campbell,&Rosenberg, 1999;Pokras&Hufnagel,1988;Zhangetal.,2005),andhysterectomyprevalencemaycorrelatewithhealthcareprovider ARTICLE INFO

Articlehistory:

Received31December2011 Accepted3January2012 Availableonline21February2012

Keywords:

Hysterectomy Cervicalcancer Reproductivehealth

Physicalandmobilitydisability

ABSTRACT

Thispaperaimstoidentifyself-reportdataforhysterectomyprevalenceandtoexploreits correlatedfactorsamongwomenwithphysicalandmobilitydisabilitiesinTaiwan.This paperwaspartofalargerstudy,‘‘SurveyonPreventiveHealthUtilizationsofPeoplewith PhysicalandMobilityDisabilityinTaiwan’’,whichisacross-sectionalsurveyconductedin 2009.Werecruited502womenaged315yearswhowereofficiallyregisteredashaving physicalandmobilitydisabilities.Theresultsshowthat11.3%ofwomenwithphysicaland mobilitydisabilitiesacceptedhysterectomysurgeryandthathysterectomyprevalence wasincreasingbyage:7%(45–49years),9.7%(50–54years),26.3%(55–59years),31%(60–

64years)and17.6%(365years).Multilevellogisticregressionanalysesrevealedthatbeing 350yearsorolder(OR=4.65,95%CI=1.79–12.064),havinghadcervicalcancer(OR=17.2, 95%CI=3.5–84.47)andnothavingaPapsmeartestwithinthelast3years(OR=2.79,95%

CI=1.194–6.561) were more likely to accept a hysterectomy operation than their counterparts.Thisstudysuggeststhatfuturestudiesshouldanalyzehospital dataand assesseslong-termchangestounderstandanarea’shysterectomyprofileandcorrelated factorsforthesetypesofvulnerablepopulations.

ß2012ElsevierLtd.Allrightsreserved.

*Correspondingauthorat:SchoolofPublicHealth,NationalDefenseMedicalCenter,161,Min-ChunERd,Sec.6,Nei-Hu,Taipei,Taiwan.

Tel.:+886287923100x18447;fax:+886287923147.

E-mailaddress:a530706@ndmctsgh.edu.tw(J.-D.Lin).

1 Equallycontributedtothispaper.

ContentslistsavailableatSciVerseScienceDirect

Research in Developmental Disabilities

0891-4222/$–seefrontmatterß2012ElsevierLtd.Allrightsreserved.

doi:10.1016/j.ridd.2012.01.002

variables and a number of clinical or non-clinical characteristics of women, such as age, race, disease condition, socioeconomicstatus,geographicdiversity(Boweretal.,2009;Boyd,Novetsky,&Curtin,2010;Kjerulff,Guzinski,etal., 1993;Kjerulff,Langenberg,&Guzinkis,1993;Palmeretal.,1999;Rogo-Guptaetal.,2010;Santow&Bracher,1992;Zhang etal.,2005).

Hysterectomycausesmanyphysical,emotionalandsexualsideeffectsforwomen,andthesurgerycarriesagreatmedical carecostintermsofriskofcomplicationsandproductivityloss,anditalsodiminishesqualityoflifeduringtherecovery period(TheAmericanCollegeofObstetriciansandGynecologists,2010).Manywomenwithdisabilitiesareunderservedor vulnerable in many disadvantaged circumstances(Hughes,2006), and theyoften experience a number of barriersin receivingreproductivehealthservicesfromtheirhealthcaresystem(Friedman&Shepeard,2007;Lin,Chen,Lin,&Sung, 2011;Linetal.,2010;Lin,Lin,Chu,&Lin,2011;Lin,Lin,Hsu,etal.,2011;Yenetal.,2011).Oman,Reed,andFerrara(1999) found that incident physical disability wascorrelated with prevalent chronic illnesses, poor vision, obesity, physical inactivity,poormemory,fewersocialactivitiesandhigherdepressionscores.Manystudieshavealsoreportedthatwomen withphysicaldisabilitiesmayusepreventivehealthmeasureslessthanwomenwithoutdisabilities(Becker,Stuifbergen,&

Tinkle,1997;Chengetal.,2001;Kroll,Jones,Kehn,&Neri,2006).Consequently,thesewomenmayriskseriousreproductive healthproblemssuchascervicalcancer.Thepresentpaperaimstocollectself-reportdataabouthysterectomyprevalence andtoexploreitscorrelatedfactorsamongwomenwithphysicalandmobilitydisabilitiesinTaiwan.

2. Methods

AccordingtoArticle3ofthePhysicallyandMentallyDisabledCitizensProtectionAct(1980)ofTaiwan,disabledpeople areconsideredindividualswhoseabilitiestoparticipateinsocietyandengageinproductiveactivitiesarerestrictedorwho cannotadequatelyservesocialrolesduetophysicalormentallimitations.Afteranassessmentprocess,disabledindividuals enrollinanationaldisabilityregistrysystemthatisregulatedbythegovernmentagencyinchargeofhealthandsocial welfare.PhysicalandmobilitydisabilityisoneofsixteentypesofdisabilitiesinthisAct,andindividualswithphysicaland mobilitydisabilitiesincludeupperandlowerlimbs,spinalcordimpairmentsandothernervoussystemimpairments.

Thepresentpaperwaspartofa largerstudy‘‘SurveyonPreventiveHealthUtilizationsofPeoplewithPhysicaland MobilityDisabilityinTaiwan’’,whichisacross-sectionalsurveyconductedin2009.Astructuredquestionnairewasmailed towomenaged315yearswhowerealsoofficiallyregisteredashavingphysicalandmobilitydisabilitiesinTaipeiCounty, Taiwan.Thesurveyincludedquestionsaboutdemographiccharacteristics,self-reportedhealthexperienceandreproductive healthcareusebywomenwithphysicalandmobilitydisabilities.Thestudysamplecharacteristicshavebeendescribedin detailbyourpreviousreports,includinginformationaboutthesample’sexperiencesofreproductivehealthcareusesuchas Papsmearsandcervicalcancervaccineacceptability(Lin,Chen,etal.,2011;Yenetal.,2011).Inthisanalysis,werecruited 502womenwhocouldprovidedataonhysterectomiestoexamineitsprevalenceandcorrelatedfactors.WeusedSPSS18.0 toanalyzethedataandemployeda rangeofstatisticalmethods(e.g.,chi-squaredtests).Multilevellogistic regression methods,oddsratio(OR)and95%confidenceinterval(CI)allwereusedtoexaminethecorrelatedfactorstohysterectomies inwomenwithphysicalandmobilitydisabilitiesinthestudy.

3. Results

Thestudyshowedthat11.3%ofwomenwithphysicalandmobilitydisabilitieshadhysterectomysurgery(Fig.1).Table1 showedthatacrosstheagedistributionamonghysterectomycases,thesurgeryrateincreasedsignificantlyinaccordance withage.Thehysterectomyprevalenceineachagegroupwasasfollows:7%(45–49years),9.7%(50–54years),26.3%(55–59 years),31%(60–64years)and17.6%(365years).

Table 2 shows the relation between hysterectomy prevalence and participants’ demographic characteristics with bivariateChi-squaredtests.Wefoundthatstudyparticipantswhowereolder(p<0.001),hadlowereducationallevels (p=0.004),hadspinalcordimpairment(p<0.001),hadmultipledisabilities(p<0.001)andreportedapoorhousehold

11.3

88.7

0 10 20 30 40 50 60 70 80 90 100

Nohysterectomy Hysterectomy

%

Fig.1.Hysterectomyprevalenceforwomenwithphysicalandmobilitydisabilities(N=502).

economic situation (p=0.006) were statistically more likely to have had a hysterectomy than their counterparts.

Hysterectomywasnotsignificantlycorrelatedwithmaritalstatus,upper/lowerlimborothernervoussystemimpairments, anddisabilitylevel.

Weanalyzedtherelationbetweenhysterectomyprevalenceandparticipants’healthexperiences(Table3).Ourresults showedthatwomenwhohavehadcervicalcancer(p<0.001)andhavenothadaPapsmeartestwithinthelast3years (p=0.018)weremorelikelytohavehadahysterectomythantheircounterparts.Otherfactorssuchastuballigation,Pap smears(i.e.,everhad,regularlyhaveorhadaPapsmearwithinthelastyear),understandingofandsatisfactorylevelwith Papsmear,andfamiliarity withPapsmear resourceswerenot statisticallycorrelatedwithhysterectomyrates among womenwithphysicalandmobilitydisabilitiesinourstudy.

Weconductedmultilevellogisticregressionanalysestoaccountforpossiblefactorsofhysterectomyprevalenceamong women with physical and mobility disabilities (Table 4). With model 1 analyzing predisposing factors which affect hysterectomyprevalence,theresultsshowthatwomenaged350yearsweremorelikelytohavereceivedahysterectomy thanwomenyoungerthan50years(OR=3.69,95%CI=1.54–8.82).Model2consideredpredisposingandenablingfactorsfor hysterectomyprevalence,andwefoundthathouseholdincomewasnotcorrelatedwithwomen’soperations.Model3uses dataconcerninga needforhysterectomysurgery,andtheresultsshowedthatwomenaged350years (OR=4.65,95%

CI=1.79–12.064),whohavehadcervicalcancer(OR=17.2,95%CI=3.5–84.47),andwhohavenothadaPapsmeartestinthe last3years(OR=2.79,95%CI=1.194–6.561)weremorelikelytohavehadahysterectomyoperationthantheircounterparts.

Table1

Ageandhysterectomyratesforwomenwithphysicalandmobilitydisabilities(N=482).^a

Age(years) N HysterectomyN(%) NohysterectomyN(%)

<30 30 0(0) 30(100)

30–34 20 1(5.0) 19(95.0)

35–39 22 1(4.5) 21(95.5)

40–44 45 0(0) 45(100)

45–49 115 8(7.0) 107(93.0)

50–54 113 11(9.7) 102(90.3)

55–59 57 15(26.3) 42(73.7)

60–64 29 9(31.0) 20(69.0)

365 51 9(17.6) 42(82.4)

aMissingdata:20.

Table2

RelationsbetweenhysterectomyanddemographiccharacteristicsofwomenwithphysicalandmobilitydisabilitiesusingChi-squaredtests.

Variable Nohysterectomy(%) Hysterectomy(%) x² pvalue

Age(N=482) 17.765 <0.001

<50 241(94.5) 14(5.5)

350 187(82.4) 40(17.6)

Maritalstatus(N=501) 0.322 0.571

Married 368(88.5) 48(11.5)

Unmarried 77(90.6) 8(9.4)

Educationlevel(N=500) 8.291 0.004

Juniorhighschoolandless 192(84.6) 35(15.4)

Seniorhighschoolandmore 253(92.7) 20(7.3)

Upperlimb(N=502) 0.978 0.323

Yes 146(90.7) 15(9.3)

No 299(87.7) 42(12.3)

Lowerlimb(N=501) 0.167 0.682

Yes 323(89.0) 40(11.0)

No 121(87.7) 17(12.3)

Spinalcordimpairment(N=501) 15.482 <0.001

Yes 40(72.7) 15(27.3)

No 404(90.6) 42(9.4)

Othernervoussystemimpairments(N=501) 1.076 0.300

Yes 30(83.3) 6(16.7)

No 414(89.0) 51(11.0)

Multipledisabilities(N=460) 12.458 <0.001

Yes 51(77.3) 15(22.7)

No 361(91.6) 33(8.4)

Disabilitylevel(N=502) 3.815 0.148

Mild 246(90.1) 27(9.9)

Moderate 146(89.6) 17(10.4)

Severeandprofound 54(81.8) 12(18.2)

Householdeconomicsituation(N=491) 7.628 0.006

Good(surplus) 191(93.6) 13(6.4)

Poor(deficit) 246(85.7) 41(14.3)

Table3

RelationsbetweenhysterectomyandhealthexperiencesofwomenwithphysicalandmobilitydisabilitiesusingChi-squaredtests.

Variable Nohysterectomy(%) Hysterectomy(%) x² pvalue

Tuballigation(N=485) 5.549 0.019

Yes 114(85.7) 19(14.3)

No 326(92.6) 26(7.4)

Cervicalcancer(N=500) 40.858 <0.001

Yes 8(44.4) 10(55.6)

No 440(91.3) 42(8.7)

HaseverhadaPapsmear(N=501) 2.287 0.130

Yes 323(90.0) 36(10.0)

No 121(85.2) 21(14.8)

HashadaPapsmearwithinthe1year(N=482) 1.341 0.247

Yes 180(91.4) 17(8.6)

No 251(88.1) 34(11.9)

HashadaPapsmearwithinthelast3years(N=454) 5.553 0.018

Yes 221(92.9) 17(7.1)

No 186(86.1) 30(13.9)

HashadaPapsmearregularly(N=484) 0.559 0.455

Yes 122(90.4) 13(9.6)

No 307(88.0) 42(12.0)

LevelofsatisfactionwiththePapsmearexperience(N=356) 0.181 0.671

Low 84(91.3) 8(8.7)

High 237(89.8) 27(10.2)

UnderstandingregardingPapsmear(N=503) 2.979 0.084

Low 133(85.3) 23(14.7)

High 314(90.5) 33(9.5)

LeveloffamiliaritywithPapsmearrelatedresources(N=490) 0.189 0.664

Low 131(89.7) 15(10.3)

High 304(88.4) 40(11.6)

Table4

Factorscorrelatedwithhysterectomyprevalenceamongpeoplewithphysicalandmobilitydisabilitiesusingmultilevellogisticregressionanalyses (N=460).

Variable ModelI ModelII ModelIII

OR(95%CI) OR(95%CI) OR(95%CI)

Predisposingfactors Age

<50 1 1 1

350 3.69(1.54–8.82)^* 3.78(1.58–9.04)^* 4.65(1.79–12.06)^*

Educationlevel

Juniorhighschoolorless 1 1 1

Seniorhighschoolormore 0.86(0.38–1.91) 1.0(0.43–2.19) 1.25(0.53–2.95)

Spinalcordimpairment

No 1 1 1

Yes 1.39(0.44–4.44) 1.46(0.46–4.7) 1.80(0.55–5.91)

Multipledisabilities

No 1 1 1

Yes 1.51(0.56–4.04) 1.43(0.53–3.84) 1.47(0.53–4.07)

Enablingfactors

Householdeconomicsituation

Good(surplus) 1 1

Poor(deficit) 0.57(0.24–1.32) 0.57(0.24–1.38)

Needfactors Tuballigation

No 1

Yes 1.16(0.48–2.78)

Cervicalcancer

No 1

Yes 17.2(3.5–84.47)^*

HashadaPapsmearwithinthelast3years

Yes 1

No 2.79(1.19–6.56)^*

* pvalue<0.05.

4. Discussion

Thepresentpaperanalyzesself-reportdataofhysterectomyprevalenceandexplorescorrelatedfactorsamongwomen withphysicalandmobilitydisabilitiesinTaiwan.Ourstudyisoneofthefirsttopresentdatadescribinghysterectomy prevalenceofwomenwithaphysicaldisability.Wefoundthat11.3%ofwomenwithphysicalandmobilitydisabilitieshad hysterectomiesandthatprevalenceincreasedsignificantlywithwomen’sage.Ourfindingsforhysterectomyprevalence werehigherthanwhathasbeenfoundforthegeneralpopulationinastudyconductedbyChang,Chang,Ku,andHu(1995), whichindicatedthathysterectomyrateswerebetween6.4%and10.1%forwomenaged40–60years.Chang,Mao,andHu (1996)showedthattheprevalenceofhysterectomiesinfourcommunitiesrangedfrom6.1%to10.0%inTaiwan.However, incomparisontoWesternstudies,womenwithphysicalandmobilitydisabilitiesseemtohavelowerhysterectomyrates thantheircounterparts.IntheUS,hysterectomieshavebeenoneofthemostfrequentlyperformedinpatientsurgeries sincethe1960s,withanestimated33%ofwomenundergoingahysterectomybytheageof60(CentersforDiseaseControl, 1992).Palmeret al. (1999)foundthattheprevalenceof hysterectomyincreasedfrom 1.9%to38.9%amongAfrican American women aged 30–34 years and45–49 years, respectively. Zhang et al. (2005) investigated hysterectomy prevalenceamongAmericanIndianwomen,findingthathysterectomyprevalencerangedfrom24%to34%acrossdifferent agegroups.Prevalenceofhysterectomywas22.2%inIreland,andoperationagepeakedbetween45and49years(Ong, Codd,Coughlan,&O’Herlihy,2000).InNewZealand,Dharmalingam,Pool,andDickson(2000)analyzedanationaldataset ofwomenaged20–59years,andtheyfoundthatwomenaged35–54yearsunderwenthysterectomiesata3-foldincreased rate than women younger than 35 years, and approximately one-quarter of the women aged 50–54 had had hysterectomies.

With Skeaet al. (2004) analyzing women’s perceptions of the decision-making process regarding theeusing of hysterectomyforbenignmenstrualproblems,researchersfoundthatalmostallwomen(97%)reportedsatisfactionwith theirdecisions.However, somewomenhadresidualdoubts regardingtheappropriatenessof hysterectomy.Overall, approximately16%ofwomenwhohaveundergoneahysterectomyhadthesurgeryforreasonsthatwerejudgedtobe clinicallyinappropriate.Onlyonestudyhasshownsignificantlymorehysterectomieswhichhavebeenratedclinically inappropriate,ascomparedwiththegroupmeaningeneralpopulation(Bernsteinetal.,1993).InTaiwan,Chao,Tseng, Su, and Chien (2005) examined the rate of inappropriate hysterectomies, and they found that 74.2% of patients underwenthysterectomyforappropriatereasons,5.6%fordebatablereasonsand20.2%forinappropriatereasons.These studiessuggestthatgynecologistsandphysicianorganizationsshouldtakeactiontoimprovetheappropriateuseof hysterectomy.

Ourstudyreportsthatparticipant factorssuchasolder age,having cervicalcancer, andnothaving a Papsmear testwithinthelast3yearsare relatedtolowerhysterectomy prevalence.InWesternliterature, Zhangetal.(2005) foundthatgeographicarea,priorpregnancylosses,highereducationalattainment,andreduceduseofone’slanguage wereassociatedwithincreasedhysterectomyprevalenceamongAmericanIndianwomen.Boweretal.(2009)evaluated theassociationbetween raceandhysterectomy prevalencein a population-basedcohortofUS women,findingthat blackwomendemonstratedgreateroddsofhysterectomy comparedtowhitewomen(OR=3.52).BrettandHiggins (2003)alsorevealedthatHispanicwomenundergofewerhysterectomiesthannon-HispanicWhitewomen,implying thathysterectomywaspositivelyassociatedwithculturalnorms.Therefore,Palmeretal.(1999)suggestedthatthere may be nonmedicalfactors which could be modified to reduce the rate of hysterectomy among African-American women.

Among other socioeconomic factors associated with hysterectomy prevalence, many studies report that higher educationallevel,occupationalattainmentandfamilyincomearestrongpredictorsofhysterectomyandaresignificantly associatedwithlowerratesofhysterectomyoperations(Dharmalingametal.,2000;Marks&Shinberg,1997).Hartowand Barbieri(1999)foundthatlesseducatedwomenwereapproximatelyfourtimesmorelikelytohavehadahysterectomythan more educated women. A possible explanation is that less educated women may delay seeking health services for gynecologicproblems,whichultimatelymayresultinneedingahysterectomylateron.Palmeretal.(1999)foundthat premenopausalhysterectomieswerestronglyassociatedwithgeographicregionofresidence,anearliermaternalageatfirst birth,ahistoryofuterinefibroidsandahistoryofendometriosis.Hysterectomywasonlyweaklyassociatedwithwomen’s numberofbirthsandageatmenarche,anditwasnotassociatedwithhistoryoftuballigation.

Therearemanylimitationsthatneedtobeaddressedforthisstudy.Ourcross-sectionalsurveywasnotdesignedto determinethecausalrelationshipbetweenpersonaldemographiccharacteristicsandhysterectomy.Second,self-reportsof hysterectomy may underestimate the prevalence of women with physical and mobility disabilities who have had hysterectomiesduetoculturalfactorsinTaiwan.Finally,wedidnotcontrolforhealthproviders,whichmayaffectthe acceptabilityofhysterectomy.Wesuggestthatthefuturestudiesshouldanalyzehospitaldataandassesslong-termchanges tobetterunderstandthehysterectomyprofileanditscorrelatedfactorsforthisvulnerablepopulationofwomen.

Acknowledgments

WeacknowledgethefinancialsupportfromtheBureauofHealthPromotion,DepartmentofHealth,RepublicofChinaof thisstudy(GrantNo.98-10002A).Wealsothankthewomenwhoparticipatedinthisstudy.

References

Becker,H.,Stuifbergen,A.,&Tinkle,M.(1997).Reproductivehealthcareexperiencesofwomenwithphysicaldisabilities:Aqualitativestudy.ArchivesofPhysical andMedicalRehabilitation,78,S26–S33.

Bernstein,S.J.,McGlynn,E.A.,Siu,A.L.,Roth,C.P.,Sherwood,M.J.,Keesey,J.W.,etal.(1993).Theappropriatenessofhysterectomy:Acomparisonofcareinseven healthplans.TheJournaloftheAmericanMedicalAssociation,269,2398–2402.

Borman,B.,McKenna,S.,&Findlay,J.(1986).HysterectomiesinNewZealand.TheNewZealandMedicalJournal,99,470.

Bower,J.K.,Schreiner,P.J.,Sternfeld,B.,&Lewis,C.E.(2009).Black–whitedifferencesinhysterectomyprevalence:TheCARDIAstudy.AmericanJournalofPublic Health,99,300–307.

Boyd,L.R.,Novetsky,A.P.,&Curtin,J.P.(2010).Effectofsurgicalvolumeonrouteofhysterectomyandshort-termmorbidity.Obstetrics&Gynecology,116,909–

915.

Brett,K.M.,&Higgins,J.A.(2003).HysterectomyprevalencebyHispanicethnicity:Evidencefromanationalsurvey.AmericanJournalofPublicHealth,93,307–312.

CentersforDiseaseControl.(1992).Hysterectomyprevalenceanddeathratesforcervicalcancer–UnitedStates,1965–1988.Morbidity&MortalityWeeklyReport, 41,17–20.

Chang,C.,Chang,C.H.,Ku,S.F.,&Hu,Y.H.(1995).ApreliminarystudyonhysterectomyrateinTaiwan.ChineseJournalofPublicHealth,14,487–493.

Chang,C.,Mao,C.L.,&Hu,Y.H.(1996).PrevalenceofhysterectomyofChinesewomeninTaiwan.InternationalJournalofGynecology&Obstetrics,52,73–74.

Chao,Y.M.,Tseng,T.C.,Su,C.H.,&Chien,L.Y.(2005).AppropriatenessofhysterectomyinTaiwan.JournaloftheFormosanMedicalAssociation,104,107–112.

Cheng,E.,Myers,L.,Wolf,S.,Shatin,D.,Cui,X.P.,Ellison,G.,etal.(2001).Mobilityimpairmentsanduseofpreventiveservicesinwomenwithmultiplesclerosis:

Observationalstudy.BritishMedicalJournal,323,968–969.

Dharmalingam,A.,Pool,I.,&Dickson,J.(2000).BiosocialdeterminantsofhysterectomyinNewZealand.AmericanJournalofPublicHealth,90,1455–1458.

Dicker,R.C.,Scally,M.J.,Greenspan,J.R.,Layde,P.M.,Ory,H.W.,Maze,J.M.,etal.(1982).Hysterectomyamongwomenofreproductiveage:TrendsintheUnited States,1970–1978.TheJournaloftheAmericanMedicalAssociation,248,323–327.

Friedman,A.L.,&Shepeard,H.(2007).Exploringtheknowledge,attitudes,beliefs,andcommunicationpreferencesofthegeneralpublicregardingHPV:Findings fromCDCfocusgroupresearchandimplicationsforpractice.HealthEducation&Behavior,34,471–485.

Hartow,B.L.,&Barbieri,R.L.(1999).Influenceofeducationonriskofhysterectomybeforeage45years.AmericanJournalofEpidemiology,150,843–847.

Hughes,R.B.(2006).Introductiontothethemeissueonwomenanddisabilities.Women’sHealthIssues,16,283–285.

Kjerulff,K.H.,Guzinski,G.M.,Langenberg,P.W.,Stolley,P.D.,Moye,N.E.,&Kazandjian,V.A.(1993).Hysterectomyandrace.Obstetrics&Gynecology,82,757–764.

Kjerulff,K.,Langenberg,P.,&Guzinkis,G.(1993).ThesocioeconomiccorrelatesofhysterectomiesintheUnitedStates.AmericanJournalofPublicHealth,83,106–

108.

Kroll,T.,Jones,G.C.,Kehn,M.,&Neri,M.T.(2006).Barriersandstrategiesaffectingtheutilisationofprimarypreventiveservicesforpeoplewithphysical disabilities:Aqualitativeinquiry.HealthandSocialCareintheCommunity,14,284–293.

Lin,J.D.,Chen,S.F.,Lin,L.P.,&Sung,C.L.(2011).Self-reportsofPapsmearscreeninginwomenwithphysicaldisabilities.ResearchinDevelopmentalDisabilities,32, 456–461.

Lin,J.D.,Sung,C.L.,Lin,L.P.,Liu,T.W.,Lin,P.Y.,Chen,L.M.,etal.(2010).PerceptionandexperienceofprimarycarephysiciansonPapsmearscreeningforwomen withintellectualdisabilities:Apreliminaryfindings.ResearchinDevelopmentalDisabilities,31,440–445.

Lin,L.P.,Lin,P.Y.,Chu,C.,&Lin,J.D.(2011).Predictorsofcaregiversupportivebehaviorstowardsreproductivehealthcareforwomenwithintellectualdisabilities.

ResearchinDevelopmentalDisabilities,32,824–829.

Lin,L.P.,Lin,P.Y.,Hsu,S.W.,Loh,C.H.,Lin,J.D., Lai,C.I.,etal.(2011).Caregiverperceptionofreproductivehealthrecognitionandservicesforwomenwith intellectualdisabilitieswhoarecaringinwelfareinstitutions.BMCPublicHealth,11,59.

Marks,N.F.,&Shinberg,D.S.(1997).Socioeconomicdifferencesinhysterectomy:TheWisconsinlongitudinalstudy.AmericanJournalofPublicHealth,87,1507–

1514.

NationalCancerInstitute.(2010).NCIThesaurus,2010_02D<http://ncit.nci.nih.gov/ncitbrowser>Accessed09.04.11.

Oman,D.,Reed,D.,&Ferrara,A.(1999).Doelderlywomenhavemorephysicaldisabilitythanmendo?AmericanJournalofEpidemiology,150,834–842.

Ong,S.,Codd,M.B.,Coughlan,M.,&O’Herlihy,C.(2000).PrevalenceofhysterectomyinIreland.InternationalJournalofGynecology&Obstetrics,69,243–247.

Palmer,J.R.,Rao,R.S.,Adams-Campbell,L.L.,&Rosenberg,L.(1999).CorrelatesofhysterectomyamongAfrican-Americanwomen.AmericanJournalof Epidemiology,150,1309–1315.

PhysicallyandMentallyDisabledCitizensProtectionAct.(1980).Thewholeenactedtextof26articlespromulgatedbyPresidentOrderTai-Tung(1)-Yi-TzuNo.3028 June2,1980.

Pokras,R.,&Hufnagel,V.G.(1988).HysterectomyintheUnitedStates1965–1984.AmericanJournalofPublicHealth,78,852–853.

Rogo-Gupta,L.J.,Lewin,S.N.,Kim,J.H.,Burke,W.M.,Sun,X.,Herzog,T.J.,etal.(2010).Theeffectofsurgeonvolumeonoutcomesandresourceuseforvaginal hysterectomy.Obstetrics&Gynecology,116,1341–1347.

Santow,G.,&Bracher,M.(1992).CorrelatesofhysterectomyinAustralia.SocialSciences&Medicine,34,929–942.

Skea,Z.,Harry,S.,Bhattacharya,S.,Entwistle,V.,Williams,B.,MacLennan,G.,etal.(2004).Women’sperceptionsofdecision-makingabouthysterectomy.BJOG:An InternationalJournalofObstetricsandGynaecology,111,133–142.

TheAmericanCollegeofObstetriciansandGynecologists.(2010).Hysterectomy–Patienteducationpamphlet.Washington,DC:ACOG.<http://www.acog.org/

publications/patient_education/bp008.cfm>Accessed09.04.11.

Yen,C.F.,Chen,S.F.,Lin,L.P.,Hsu,S.W.,Chang,M.J., Wu,C.L.,etal.(2011).Theacceptabilityofhumanpapillomavirus(HPV)vaccinationamongwomenwith physicaldisabilities.ResearchinDevelopmentalDisabilities,32,2020–2026.

Zhang,Y.,Lee,E.T.,Cowan,L.D.,North,K.E.,Wild,R.A.,&Howard,B.V.(2005).HysterectomyprevalenceandcardiovasculardiseaseriskfactorsinAmerican Indianwomen.Maturitas,52,328–336.