The use of Pap smear and its influencing factors among women with disabilities

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The use of Pap smear and its inﬂuencing factors among women with disabilities in Taiwan

Kuang-Hua Huang

^a

, Wen-Chen Tsai

^a,1

, Pei-Tseng Kung

^b,1,

*

aDepartmentofHealthServicesAdministration,ChinaMedicalUniversity,Taichung40402,Taiwan,ROC

bDepartmentofHealthcareAdministration,AsiaUniversity,Taichung41354,Taiwan,ROC

1. Introduction

CervicalcancerisaprevalenttypeofcanceramongTaiwanesewomen,andcanbeeffectivelycuredifdiagnosedearly.

From1995,theNationalHealthInsurance(NHI)inTaiwanhasofferedonefreePapsmearannuallyforwomenaged30or ARTICLE INFO

Articlehistory:

Received12September2011 Accepted15September2011 Availableonline18November2011

Keywords:

Disability Papsmear Disabledwomen Preventivehealthservice Severityofdisability

ABSTRACT

CervicalcancerisaprevalentcanceramongTaiwanesewomen,andcanbeeffectivelycuredif diagnosedearly.Therefore,cervicalcancerisworthyofpreventivehealthscreening.Dueto physicalandpsychologicalbarriers,patientswithdisabilitymaybeunabletoexpresstheir physicalcomplaintsaccurately,thusreducingtheiraccesstohealthcare;somemaynoteven receiveproperpreventivehealthcareormedicaltreatment.Thisstudyinvestigatesthe utilizationofPapsmearamongwomenwithdisabilityinTaiwananditsinﬂuencingfactors.

Withwomenaged30andoverasthestudysubjects,thisretrospectivecohortstudyis conductedbasedonthedatabaseoftheMinistryoftheInterior,Taiwan,2008,combinedwith informationgatheredbetween2006and2008regardingpreventivehealthcareandhealth insurancemedicalclaimsdatafromtheBureaufHealthPromotionandtheNationalHealth ResearchInstitutes,respectively.ThefrequencyofPapsmearsandthepercentagedifferences ofeachvariableareexaminedusingthe2teststocheckforstatisticalsigniﬁcance.Finally, logisticregressionanalysisisusedtoexaminethefactorsinﬂuencingtheuseofPapsmears.

Theresultsrevealedthatamongdisabledwomenaged30andover,theuseofPapsmearswas 7.71%in2008.Disabledwomenwiththefollowingcharacteristicshadloweruselevels regardingPapsmears:greaterage,residinginareasofhigherurbanization,lowerincome, lowereducationlevels,unmarried,notdiagnosedwithcancer,diagnosedwithdiabetes,and with severe disability levels. Disabled women with hearing impairments or mental retardationwerepossessedofthehighestandlowestprobabilitiesofusingPapsmear, respectively.Therecommendationsofthisstudyinclude:(1)providephysicianswitha varyingpricingschemeandincentivesforPapsmearbasedonthetypeorseverityof disability;(2)proactivelyencouragegynecologistandobstetricianstoconductregularand convenientPapsmearondisabledwomen;and(3)targetdisabledwomeninlowusage groups,andimprovetheirknowledgeofPapsmear.

ß2011ElsevierLtd.Allrightsreserved.

* Correspondingauthorat:DepartmentofHealthcareAdministration,AsiaUniversity,500,LioufengRd.,Wufeng,Taichung41354,Taiwan,ROC.

Tel.:+886423323456x1929;fax:+886422028895.

E-mailaddress:ptkung@seed.net.tw(P.-T.Kung).

1Authorswithequalcontributions.

ContentslistsavailableatSciVerseScienceDirect

Research in Developmental Disabilities

0891-4222/$–seefrontmatterß2011ElsevierLtd.Allrightsreserved.

doi:10.1016/j.ridd.2011.09.016

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older,effectivelypromotingscreeningrates(Huang,Chi,Chang,&Chou,1999;Wang&Lin,1996).However,thepublic’suse ofpreventivehealthservicesremainsfarlessthanideal.In2009,thescreeningrateofPapsmearwasaslowas29.7%(Bureau ofHealthPromotion,2010).

Topromotehealth,preventsecondaryconditions,andreducedifferencesofmedicalcareutilizationbetweenthepatients withandwithoutdisability,HealthyPeople2010oftheUnitedStatesincludeddisabledpeopleinnationalhealthobjectives (USDepartmentofHealthandHumanServices,1997).In2008,astudyusingtheBehavioralRiskFactorSurveillanceSystem (BRFSS)discoveredthattheuseofPapsmearamongdisabledwomen(78.9%)wassigniﬁcantlylowerthanthosewomen withoutdisability(83.4%)(Armour,Thierry,&Wolf,2009).However,aBritishstudyindicatedthatwheelchair-dependent womenwithinjuredspinalcordshadhigherPapsmearscreeningratescomparedtonon-disabledwomen(Graham,Savic,&

Gardner,1998).Thisisduetodifferentpopulationsorotherfactorsremainstobeclariﬁed.Nevertheless,disabilityindeed canaffecttheuseofPapsmear.

Duetophysicalandpsychologicalbarriers,patientswithdisabilitymaybeunabletoexpresstheirphysicalcomplaints accurately,thusreducingtheiraccesstohealthcare.Thelongertimerequiredandotherobstaclesencounteredfrequently hinderthemfromreceivingtimelyandappropriatetreatmentsandhealthcare.Studiesindicatedthatwhenwewould developapopulation-basedcancerscreeninginterventionplan,populationswiththelowesttestingrateshouldbeﬁrst identiﬁed,andappropriatecancerscreeninginformationshouldbeprovidedtothesepopulations(Selvin&Brett,2003).

Subsequently,throughapublichealthinformationsystem,thedisparitiesinprevalenceofcancercanbefurtherunderstood andeliminated(Koh,Judge,Ferrer,&Gershman,2005).Thisstudyusesthenationwidedatasetstoinvestigatetheutilization ofPapsmearamong womenwithdisabilityinTaiwananditsinﬂuencingfactors.Theresultscanhopefullyserve asa referenceforthehealthauthoritieswhenestablishingpreventivehealthcareservicepoliciestargetingdisabledpeople,with eliminatinghealthinequalitiesastheultimategoal.

2. Materialsandmethods 2.1. Datasourceandprocessing

Selectingdisabledwomenaged30andolderasthesubjects,thisretrospectivecohortstudywasconductedbasedonthe databaseofMinistryoftheInterior,Taiwan,2008,andcombinedwithinformationgatheredbetween2006and2008on preventivehealthcareandhealthinsurancemedicalclaimsdatafromtheBureauofHealthPromotionandtheNational HealthResearchInstitutes,respectively.Thevariablesrecordedinclude:(1)demographiccharacteristics:age,maritalstatus, educationlevel,urbanizationlevelofresidentarea,premium-basedmonthlysalary,andaboriginalstatus;(2)healthstatus:

catastrophicillness/injury,relevantchronicillnesses(includingcanceranddiabetes);(3)classiﬁcationofdisability:typeof disability,severityofdisability;and(4)useofPapsmearsasapreventivehealthservice.

2.2. Subjects

Accordingtothe‘‘DisabilityRightsProtectionAct’’ofTaiwan,disabilitycanbeclassiﬁedinto18categories,namelyvisual impairment,hearingimpairment,balanceimpairment,soundorspeechimpairment,physicaldisability,mentalretardation, majororganmalfunction,facialinjury,persistentvegetativestate,refractoryepilepsy,dementia,autism, chromosomal abnormalities,congenitalmetabolicdisorders,othercongenitaldefects,multipledisabilities,chronicmentalillness,and otherdisabilitiescausedbyrarediseasesrecognizedbycentralhealthauthorities.Severityofdisabilityisclassiﬁedinto4 categories:verysevere,severe,moderate,andmild.

Table1providesanexampleoftheselectioncriteria.Atotalof396,194women(30yearsold)withdisabilitiesmetthe requirementforPapsmearservices.Participantswiththedisabilityofapersistentvegetativestate(1955individuals),allof whomdidnotundergoPapsmeartesting,weredeemedunsuitabletobesubjectsand,thus,wereexcludedfromthisstudy.

Becausethecategoriesofautism(22individuals)andcongenitalmetabolicdisorders(43individuals)hadsmallsamplesizes, thisstudygroupsthemintothecategoryof‘‘others.’’

2.3. Statisticalanalysis

AlldatawereanalyzedusingSASversion9.1.Thisstudyﬁrstconductsadescriptiveanalysisoftheidentiﬁedvariables.

ThefrequencyofPapsmeartestinganddifferencesinthepercentageofeachvariableareexaminedusingthe

x

²teststo checkforstatisticalsigniﬁcance.Finally,multivariatelogisticregressionanalysisisusedtoexaminethefactorsinﬂuencing theuseofPapsmear.

3. Results

Atotalof394,329disabledwomenwerequaliﬁedtoreceiveafreePapsmear,andthoseagedbetween70and79years constitutethelargestgroup(20.42%).Nearlyhalfoftheparticipantswereresidinginareasoflevel1–3urbanizationformthe largestgroup(47.49%).Amajorityofpremium-basedmonthlysalaryaredependentpopulation(39.22%).Approximately 1.57%ofdisabledwomenhadanaboriginalstatus.Intermsofeducationallevels,elementaryorlowereducationlevelsmade

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upthelargestgroup(56.77%).Amongtheparticipants,32.15%hadcatastrophicillness/injury,andthosesufferingfrom cancerordiabetesmellitus(DM)constituted5.87%and22.93%,respectively.Asforthetypeofdisability,themajorityofthe participantshadphysicaldisabilities(37.89%),followedbymajororganmalfunction(12.55%).Regardingtheseverityof disability,mostoftheparticipantswerecategorizedinthemildgroup(32.21%)(seeTable2).

ThePapsmearusagerateamongdisabledwomenwas7.71%,whichissigniﬁcantlylowerthanthe28.8%usagerateof womenaged30andoverin2008(BureauofHealthPromotion,2010).TheusagerateofPapsmearwasthehighestamong disabledwomenaged40–49years(11.64%)andtheusageratedecreasedastheparticipant’sageincreased.Individuals residinginareaswithurbanizationlevelsof8hadthehighestscreeningrates(8.27%),whilethoseresidinginareaswith urbanizationoflevelonehadthelowestusage(6.87%).

Participantswithapremium-basedmonthlysalaryofNT$38,200–45,800(NewTaiwanDollars)hadthehighestusage rate(13.45%)insteadofsubjectswiththehighestpremium-basedmonthlysalaryofNT$48,200–57,800(11.72%).Aboriginal participantshadausagerateof9.05%,whichisslightlyhigherthantherateofnon-aboriginals(7.72%).Whencategorizedby educationallevel,disabledwomenwithseniorhigh(orvocational)schooldiplomashadthehighesttestingrates,whereas thosewitheducationlevelsofelementaryschoolorlesshadthelowesttestingrates(6.47%).Asformaritalstatus,married disabledwomenhadahigherusagerate(8.59%)comparedtothesinglewomenwithdisability(5.0%).Participantswith catastrophicillnesseshadausagerateof8.47%,whichisslightlyhigherthantherateofthosewithoutcatastrophicillness (7.40%).Similarly,thosewithcancerhadausagerateof9.45%,whichishigherthanthatofthosewithoutcancer(7.63%).

However,thesufferersofdiabeteshadausagerateof6.46%,whichislessthanthosewithoutdiabetes(8.12%).Amongthe differentcategoriesofimpairment,disabledwomenwithfacialinjurieshadthehighestusage(12.73%),followedbythose withrefractoryepilepsy(12.31%),whiledementiahadthelowestusagerate(3.50%).Thosewithmilddisabilitiesshowa greaterusage(10.19%)comparedtothosewithhigherseverityofdisability.Anegativerelationshipbetweenseverityof disabilityandusagewasobserved(Table2).

InTable3,oddsratios(ORs)and95%confidenceinterval(CI)wereestimatedusinglogisticregressionmodelstoexamine theinfluencingfactorsontheusageofPapsmear.Age,urbanizationlevel,premium-basedsalary,educationlevel,marital status,existenceofcancer,existenceofdiabetes,typeofdisability,andseverityofdisabilityallsignificantlyinfluencedPap smearuse(p<0.05).

TheprobabilityofusingPapsmeardecreasedwithage.TheprobabilityofPapsmearusageamongaged80orolder displayed0.15timeslessthanthatofthoseaged30–39years(95%CI:0.14–0.16).Disabledwomenresidinginareaswith urbanizationlevelsof8hadthehigherprobabilityofusecomparedtothoseresidinginareawithlevel1(OR=1.14;95%CI:

1.07–1.21).Furthermore,thosewithpremium-basedmonthlysalaryofNT$38,200–45,800hadthehighestprobabilityof use,with1.56timesgreaterthanthatofthosewithmonthlysalaryof<NT$15,840(95%CI:1.46–1.67).Forthosewitha premium-basedmonthlysalarylessthanNT$45,800,theprobabilityofuseroseassalaryincreased,whereassubjectsinthe categoryof NT$48,200–57,800had slightlylowerprobabilityof use.In addition,disabledwomenwithseniorhigh(or vocational)schooleducationsigniﬁcantlyhadthehighestprobabilityofusecomparedtothosewhohadanelementary schooleducationorless(OR=1.13;95%CI:1.09–1.18).Marriedparticipantsdisplayeda2.33-timeshigherprobabilityofuse thansinglesubjectsdid(95%CI:2.22–2.45).

The probability of use for those with catastrophic illness/injury did not signiﬁcantly differ from those without catastrophicillness/injury(p>0.05).Participantswithcancerhadahigherprobabilityofuse(OR=1.20;95%CI:1.13–1.27), whereasparticipantswithdiabetesdisplayedalowerprobability(OR=0.95;95%CI:0.92–0.98).

ThelikelihoodofusingPapsmearvariedwiththetypesofdisability.Participantswithmentalretardationorbalance impairmentdisplayedthelowestprobabilitiesofusecomparedtothosewithphysicaldisabilities(OR=0.64;95%CI:0.60–

0.69;OR=0.78;95%CI:0.62–0.98,respectively).Theprobabilityofuseamongsubjectswithhearingimpairmentsormajor organmalfunctionwas1.38and1.31timeshigherthanthatamongthosewithphysicaldisabilities,respectively.Onthe Table1

Studysubjectsselectioncriteria.

Age Birthdate ObservedperiodforusingPapsmear

30yearsold(onceperyear) 1978/01/01 2008/01/01–2008/12/31

1977/12/31 2007/12/31–2008/12/30

...

1977/01/02 2007/01/02–2008/01/01

1976/12/31 2007/12/31–2008/12/30

...

1976/01/02 2007/01/02–2008/01/01

1975/12/31 2007/12/31–2008/12/30

...

1975/01/02 2007/01/02–2008/01/01

... ... ...

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Table2

Chi-squareanalysisofPapsmearuseamongwomenwithdisabilitiesduring2007–2008.

Variables Total Use Non-use x²

N=394,239 % n1=30,518 % n2=363,721 % p-Value

Gender –

Female 394,239 100.00 30,518 7.74 363,721 92.26

Age <.001^*

30–39years 37,247 9.45 3434 9.22 33,813 90.78

40–49years 65,625 16.65 7636 11.64 57,989 88.36

50–59years 76,307 19.36 8285 10.86 68,022 89.14

60–69years 68,758 17.44 6320 9.19 62,438 90.81

70–79years 80,505 20.42 3672 4.56 76,833 95.44

380years 65,797 16.69 1171 1.78 64,626 98.22

Urbanizationlevel <.001^*

Level1 46,812 11.87 3218 6.87 43,594 93.13

Level2 81,819 20.75 6600 8.07 75,219 91.93

Level3 58,616 14.87 4658 7.95 53,958 92.05

Level4 33,589 8.52 2627 7.82 30,962 92.18

Level5 58,634 14.87 4620 7.88 54,014 92.12

Level6 43,723 11.09 3272 7.48 40,451 92.52

Level7 46,718 11.85 3512 7.52 43,206 92.48

Level8 24,328 6.17 2011 8.27 22,317 91.73

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

Dependentpopulation 154,613 39.22 9188 5.94 145,425 94.06

<15,840 80,064 20.31 5337 6.67 74,727 93.33

16,500– 22,800 118,703 30.11 10,653 8.97 108,050 91.03

24,000–28,800 15,123 3.84 1950 12.89 13,173 87.11

30,300–36,300 12,436 3.15 1669 13.42 10,767 86.58

38,200–45,800 9367 2.38 1260 13.45 8107 86.55

48,200–57,800 3933 1.00 461 11.72 3472 88.28

Aboriginalstatus <.001^*

Yes 6186 1.57 560 9.05 5626 90.95

No 388,053 98.43 29,958 7.72 358,095 92.28

Educationlevel <.001^*

Elementaryschoolandunder 223,821 56.77 14,475 6.47 209,346 93.53

Juniorhighschool 45,308 11.49 4657 10.28 40,651 89.72

Seniorhigh/vocationalschool 50,793 12.88 5535 10.90 45,258 89.10

Juniorcollege/universityandabove 22,352 5.67 2202 9.85 20,150 90.15

Unknown 51,965 13.18 3649 7.02 48,316 92.98

Maritalstatus <.001^*

Married 216,540 54.93 18,610 8.59 197,930 91.41

Unmarried 42,902 10.88 2146 5.00 40,756 95.00

Divorcedandwidowed 23,510 5.96 1762 7.49 21,748 92.51

Unknown 111,287 28.23 8000 7.19 103,287 92.81

Catastrophicillness/injury <.001^*

Yes 126,754 32.15 10,735 8.47 116,019 91.53

No 267,485 67.85 19,783 7.40 247,702 92.60

Relevantchronicillnesses

Cancer <.001^*

Yes 23,134 5.87 2187 9.45 20,947 90.55

No 371,105 94.13 28,331 7.63 342,774 92.37

Diabetesmellitus <.001^*

Yes 90,650 22.99 5853 6.46 84,797 93.54

No 303,589 77.01 24,665 8.12 278,924 91.88

Typeofdisability <.001^*

Physicaldisability 149,373 37.89 11,501 7.70 137,872 92.30

Majororganmalfunction 49,493 12.55 4038 8.16 45,455 91.84

Chronicmentalillness 48,333 12.26 5339 11.05 42,994 88.95

Hearingimpairment 43,217 10.96 3841 8.89 39,376 91.11

Multipledisabilities 36,051 9.14 1738 4.82 34,313 95.18

Visualimpairment 25,112 6.37 1887 7.51 23,225 92.49

Mentalretardation 18,204 4.62 880 4.83 17,324 95.17

Dementia 17,633 4.47 618 3.50 17,015 96.50

Soundorspeechimpairment 2939 0.75 279 9.49 2660 90.51

Balanceimpairment 1245 0.32 80 6.43 1165 93.57

Refractoryepilepsy 1243 0.32 153 12.31 1090 87.69

Facialinjury 888 0.23 113 12.73 775 87.27

Rarediseases 244 0.06 29 11.89 215 88.11

Congenitaldefects 106 0.03 9 8.49 97 91.51

Chromosomalabnormalities 93 0.02 7 7.53 86 92.47

Others 65 0.02 6 9.23 59 90.77

Severityofdisability <.001^*

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Table2(Continued)

Variables Total Use Non-use x²

N=394,239 % n1=30,518 % n2=363,721 % p-Value

Mild 138,830 35.21 14,147 10.19 124,683 89.81

Moderate 130,112 33.00 10,056 7.73 120,056 92.27

Severe 74,526 18.90 3537 4.75 70,989 95.25

Verysevere 50,771 12.88 2778 5.47 47,993 94.53

* p<0.05.

Table3

LogisticregressionmodelsforPapsmearuseamongwomenwithdisabilitiesduring2007–2008.

Variables UnadjustedOR 95%CI p-Value AdjustedOR 95%CI p-Value

Age

30–39years – – – – – – – –

40–49years 1.30 1.24 1.35 <.001^* 1.04 1.00 1.09 0.082

50–59years 1.20 1.15 1.25 <.001^* 0.92 0.87 0.96 0.000^*

60–69years 1.00 0.95 1.04 0.881 0.79 0.75 0.83 <.001^*

70–79years 0.47 0.45 0.49 <.001^* 0.38 0.35 0.40 <.001^*

380years 0.18 0.17 0.19 <.001^* 0.15 0.14 0.16 <.001^*

Urbanizationlevel

Level1 – – – – – – – –

Level2 1.19 1.14 1.24 <.001^* 1.00 0.95 1.04 0.881

Level3 1.17 1.12 1.23 <.001^* 1.00 0.96 1.05 0.906

Level4 1.15 1.09 1.21 <.001^* 0.97 0.92 1.03 0.347

Level5 1.16 1.11 1.21 <.001^* 1.01 0.96 1.06 0.694

Level6 1.10 1.04 1.15 0.000^* 1.00 0.94 1.05 0.877

Level7 1.10 1.05 1.16 0.000^* 1.03 0.98 1.09 0.218

Level8 1.22 1.15 1.29 <.001^* 1.14 1.07 1.21 <.001^*

Premium-basedmonthlysalary(NT$)

<15,840 – – – – – – – –

Dependentpopulation 0.89 0.85 0.92 <.001^* 1.07 1.03 1.12 0.001^*

16,500–22,800 1.38 1.33 1.43 <.001^* 1.35 1.30 1.41 <.001^*

24,000–28,800 2.07 1.96 2.19 <.001^* 1.43 1.34 1.51 <.001^*

30,300–36,300 2.17 2.05 2.30 <.001^* 1.50 1.41 1.60 <.001^*

38,200–45,800 2.18 2.04 2.32 <.001^* 1.56 1.46 1.67 <.001^*

48,200–57,800 1.86 1.68 2.06 <.001^* 1.33 1.20 1.48 <.001^*

Aboriginalstatus

No – – – – – – – –

Yes 1.19 1.09 1.30 0.000^* 1.03 0.94 1.13 0.522

Educationlevel

Elementaryschoolandunder – – – – – – – –

Juniorhighschool 1.66 1.60 1.72 <.001^* 1.10 1.06 1.15 <.001^*

Seniorhigh/vocationalschool 1.77 1.71 1.83 <.001^* 1.13 1.09 1.18 <.001^*

Juniorcollege/universityandabove 1.58 1.51 1.66 <.001^* 1.08 1.03 1.14 0.004^*

Unknown 1.09 1.05 1.13 <.001^* 1.03 0.99 1.07 0.153

Maritalstatus

Unmarried – – – – – – – –

Married 1.79 1.71 1.87 <.001^* 2.33 2.22 2.45 <.001^*

Divorcedandwidowed 1.54 1.44 1.64 <.001^* 2.21 2.07 2.37 <.001^*

Unknown 1.47 1.40 1.55 <.001^* 1.90 1.80 2.00 <.001^*

Catastrophicillness/injury

Yes – – – – – – – –

No 1.16 1.13 1.19 <.001^* 1.02 0.98 1.06 0.301

Relevantchronicillnesses Cancer

No – – – – – – – –

Yes 1.26 1.21 1.32 <.001^* 1.20 1.13 1.27 <.001^*

DiabetesMellitus

No – – – – – – – –

Yes 0.78 0.76 0.80 <.001^* 0.95 0.92 0.98 0.003^*

Typeofdisability

Physicaldisability – – – – – – – –

Visualimpairment 0.97 0.93 1.03 0.308 1.24 1.18 1.31 <.001^*

Hearingimpairment 1.17 1.13 1.22 <.001^* 1.38 1.32 1.43 <.001^*

Soundorspeechimpairment 1.26 1.11 1.42 0.000^* 1.04 0.92 1.18 0.542

Mentalretardation 0.61 0.57 0.65 <.001^* 0.64 0.60 0.69 <.001^*

Multipledisabilities 0.61 0.58 0.64 <.001^* 1.07 1.01 1.13 0.024^*

Majororganmalfunction 1.07 1.03 1.11 0.001^* 1.31 1.25 1.37 <.001^*

Facialinjury 1.75 1.43 2.13 <.001^* 1.17 0.96 1.43 0.126

Dementia 0.44 0.40 0.47 <.001^* 1.08 0.99 1.17 0.092

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contrary,theprobabilityofusewaslowestamongthosewithmentalretardation,0.64timeslowerthanthatofthosewith physicaldisabilities(95%CI:0.60–0.69).Whencategorizedaccordingtoseverityofdisability,subjectswithhigherseverity signiﬁcantlydisplayedlowerusagerates.Thus,disabledwomenwithveryseveredisabilitieshadthelowestprobabilityof useincomparisontothosewithmilddisabilities(OR=0.51;95%CI:0.48–0.54)(seeTable3).

4. Discussion

ThisstudydiscoveredthattheuseofPapsmearsinhealthpreventiondecreasedastheparticipant’sageincreased.These resultsareconsistentwithmanypreviousstudies(Chang,Hsiung,Chen,Yen,&Chen,2007;Huangetal.,1999;Rodrı´guez, Ward,&Pe´rez-Stable,2005;Wang&Lin,1996).Regardingresidingarea,theusageprobabilityofsubjectsresidinginareasof lowerurbanizationwassigniﬁcantlyhigherthanthoseresidinginareaswithhigherurbanization.Thisresultisidenticalto anotherstudyconductedinTaiwan(Chenetal.,2009).Generally,urbanizationreﬂectstheaccessibilityofmedicalresources.

AfterimplementationoftheNationalHealthInsuranceinTaiwan,theaccessibilityofmedicalcarehaseffectivelyimproved.

Therefore,theusagesofPapsmearhaveincreasedamongthefemalepopulation(Huangetal.,1999;Lin,Chen,Liu,&Lin, 2008). This effectis especially evident inareas of low urbanization.Because theaccessibilityof medical resourcesis enhanced,Papsmearusageratesareimprovedonalargerscale.Inaddition,thelifestyleofruraltownshipsandremoteareas allowstheeffectivespreadofhealthpoliciesandhealthpromotionactivitiesbythehealthauthorities.Publichealthofﬁces andstationsinruraltownshipsacrossTaiwanareactivelyinvolvedinpromotingcancerscreeningactivities,andfrequently cooperatewithdistricthospitalsandclinicstolaunchmobilemedicalcare,subsequentlycontributingtohigherusage.

Besides,sincetheimplementationof‘‘theProgramofImprovingMedicalServiceUtilizationinMountainousRegionsand OutlyingIslands’’in1999,theaccessibilityofmedicalcareinremoteareashasbeenproactivelyimprovedthroughthe IntegrativeDeliverySystem(IDS)programinTaiwan.Inthisprogram,Papsmearwasasigniﬁcantindicatorofprogram effectiveness(Chenetal.,2007;Tan,Tseng,Chang,Lin,&Hsiao,2005).Inordertoachievetheprogramgoals,mobilePap smear screening vehicles visited remote areas to service entire villages, increasing the usage of Pap smear in low- urbanizationregionstohigherthanthatofotherareas.TheseresultsindicatethatNationalHealthInsurance,mobilemedical services,and IDSprogramsarehighlyeffectivefor improvinghealth careandpreventive service,andbalancing inter- regionalmedicalresourcedistribution.

Disabledwomenwitha premium-basedmonthlysalaryoverNT$15,840(includingdependentpopulations) showed higherPapsmearusageratesthanthoseintheNT$15,840categorydid. Thisis consistentwithprevious studyresults indicatingthattheusageratesandfrequencyofpreventivehealthcarewasdirectproportionaltoincome(Hewitt,Devesa,&

Breen,2004;Rodrı´guezetal.,2005).Papsmearusageratesinaboriginalsubjectsweresignificantlyhigherthanthoseinnon- aboriginalsubjects.Thisprovedthatfinancialbarrierstohealthcarewereeffectivelyovercomeafterimplementationofthe NationalHealth Insurance. Among people witha lower socioeconomic status, such as aboriginals,the effects on the utilizationofpreventivehealthcarewasevenmoresignificant.However,Lantz,WeigersandHouse(1997)believedthat incomedidnot directlydeterminePapsmearscreeningbehaviors,buttogetherwithotherfactorsexertedan indirect influence.Therefore,inadditiontoovercomingfinancialbarriers,otherinfluencingbarriersshouldalsobeeliminatedto improvePapsmearscreening.

Thisstudyrevealedthatthelowerthesubject’seducationallevel,thelowertheusageofPapsmearwas.Thisresultis consistentwiththosefrompreviousstudies(Changetal.,2007;Huangetal.,1999;Linetal.,2008;Wang&Lin,1996).Since educationoftencorrelateswithsocioeconomicstatus,lowersocioeconomicgroupsmayhaveinadequateknowledgeon preventivehealthcare,contributingtolimiteduseofPapsmear.

SingledisabledwomenhadlowerPapsmearusagerates,whichisinaccordancewithnumerouspreviousstudies(Chang etal.,2007;Hewittetal.,2004;Lantzetal.,1997;Rodrı´guezetal.,2005).ItislikelythatTaiwaneseandAsianpeoplepossess relativelyconservativeattitudestowardsexandknowledgeofsexualorganscomparedtothepublicinWesterncountries, resultingintheunmarrieddisabledwomentobereluctanttoreceivesuchpreventivehealthservices.

Disabledwomenwithcatastrophicillness/injuryandcancerhadsigniﬁcantlyhigherusageratesofPapsmear.Thereisa likelihoodthatdisabledpeoplewithcatastrophicillness/injuryandcancermustreceivemedicalservicesregularly.Previous Table3(Continued)

Variables UnadjustedOR 95%CI p-Value AdjustedOR 95%CI p-Value

Chromosomalabnormalities 0.98 0.45 2.11 0.950 0.97 0.44 2.10 0.931

Congenitaldefects 1.11 0.56 2.20 0.760 0.87 0.44 1.74 0.697

Chronicmentalillness 1.49 1.44 1.54 <.001^* 1.26 1.20 1.32 <.001^*

Balanceimpairment 0.82 0.66 1.03 0.094 0.78 0.62 0.98 0.036^*

Refractoryepilepsy 1.68 1.42 2.00 <.001^* 1.00 0.84 1.19 0.987

Rarediseases 1.62 1.10 2.38 0.015^* 1.19 0.80 1.76 0.390

Others 1.22 0.53 2.82 0.644 1.16 0.50 2.72 0.727

Severityofdisability

Mild – – – – – – – –

Moderate 0.74 0.72 0.76 <.001^* 0.79 0.76 0.81 <.001^*

Severe 0.44 0.42 0.46 <.001^* 0.56 0.54 0.59 <.001^*

Verysevere 0.51 0.49 0.53 <.001^* 0.51 0.48 0.54 <.001^*

*p<0.05.

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studiesindicatedthatpatientswithregularmedicalattentionhadrelativelyhigherusageofpreventivehealthcare(Hewitt etal.,2004;Lantzetal.,1997).Thisisprobablybecausethosedisabledwomenreceivingregularmedicalserviceshavemore opportunitiestoberemindedorsuggestedtoreceivepreventivehealthcareservices.

On theside, disabledwomenhadlowerusageratesof Papsmear.Thiswasprobablybecausepatients mustlieon examinationtablestoundergoPapsmears,whichcanbeextremelydifﬁcultforcertaindisabledwomen(Welner,1998).

Moreover,thepublicandphysiciansmayalsoconsiderdisabledwomentobelesspronetocervicalcancerasaresultofalack oforscarcesexualintercourse(Diab&Johnston,2004;Welner,1998).Thesemisconceptionswerepossiblyamajorcauseof lowerusageofPapsmearindisabledwomen.Amongthe16typesofdisabilities,patientswithhearingimpairment,major organmalfunction,chronicmentalillness,andvisualimpairmentexhibitedhigherusageofPapsmear,whereasdisabled womenwithmentalretardationandbalanceimpairmenthadlowerusage.Itseemsmostlikelythatthetypesofdisabilities described intheformerhavelessimpacton anindividualmarriageand sexlife,whichpossiblyleadstosuchresults.

Furthermore,theseresultsmayalsobeassociatedwiththeseverityofdisability;however,thisrequiresfurtherveriﬁcation.

SubjectswithhigherdisabilityseveritydemonstratedlowerPapsmearusagerates,whichisconsistentwithnumerous previousstudies(Armouretal.,2009;Chengetal.,2001;Chevarley,Thierry,Gill,Ryerson,&Nosek,2006;Diab&Johnston, 2004; Iezzoni,McCarthy,Davis, Harris-David,&O’Day,2001;Ramirez,Farmer,Grant,&Papachristou,2005; Reynolds, Stanistreet,&Elton,2008;Wei,Findley,&Sambamoorthi,2006).Thosewithhigherdisabilityseverityalsohadalower accessibilitytomedical care,inevitablyresultingin extremelylowusageof Papsmearamong thosewithverysevere disability.

5. Conclusions

ThisstudydeterminedthatthePapsmearusagerateamongdisabledwomenis7.71%,whichissigniﬁcantlylowerthan the28.8%usagerateamongTaiwanesewomenaged30andolderin2008.AmongthefactorsinﬂuencingPapsmearusage rates,subjectswiththefollowingcharacteristicshavelowerusagerates:greaterage,residinginareasofhigherurbanization, lowerincome,lowereducationlevels,unmarried,notsufferingfromcancer, diagnosedwithdiabetes,andwithsevere disabilitylevels.Amongthe16typesofdisabilities,patientswithahearingimpairment,majororganmalfunction,chronic mentalillness,multipledisabilities,andvisualimpairmentdemonstratedhigherusageofPapsmear,whereasdisabled womenwithmentalretardationandbalanceimpairmenthadthelowerusage.

Inbrief,theresultsindicatethatdisabledwomenwhoareamongtheminoritypopulationregardingsocialstatusdisplay lowPapsmearusagerates.Therecommendationsofthisstudyinclude:(1)Providephysicianswithavaryingpricingscheme andincentivesforPapsmearbasedonthetypeorseverityofwomenwithdisability;(2)proactivelyencouragegynecologist and obstetricianstoconduct regularand convenientPap smearon disabled women,especially targetingthe relevant inﬂuencingfactorsofutilizationofpreventivehealthcare;and(3)targetdisabledwomeninlowusagegroups,andimprove theirknowledgeofPapsmear.ThesesuggestionswillhopefullyhelpeliminatetheobstaclesanddisparitiesofPapsmear usageamongdisabledwomen.

Acknowledgments

ThestudywasgratefulforthefundingfromtheChinaMedicalUniversity,AsiaUniversity,andDepartmentofHealth, Taiwan(GrantNos.:CMU99-ASIA-18andDOH-TD-B-111-004).ThisstudyisbasedinpartondatafromtheNationalHealth Insurance ResearchDatabase providedbytheBureauof NationalHealthInsurance,and publishedbyNationalHealth ResearchInstitutes.TheinterpretationandconclusionscontainedhereindonotrepresentthoseofBureauofNationalHealth Insurance,DepartmentofHealth,orNationalHealthResearchInstitutes.

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