| Summary: | 博士 === 國立陽明大學 === 公共衛生研究所 === 97 === Background.
Cervix cancer is the second most common cancer among women worldwide. According to the statistics from WHO (World Health Organization), an estimated 493,000(age-standardize incidence 16.2 per 100,000) new cases and 274,000(age-standardize mortality 9.0 per 100,000) deaths in the year 2002. From the 2002 annually cancer registry report, cervical cancer is the most common cancer among women (age-standardize incidence 17.2 per 100,000), and fifth greatest mortality in female cancer (age-standardize mortality 7.8 per 100,000) in Taiwan. It had been proof that organized population-based screening program can be cost-effective in decreasing morbidity and mortality of cervical cancer.
Taiwan implemented a universal and comprehensive National Health Insurance program in March 1995. The program stared to provide several preventive services including cervical cancer screening, in July 1995. A free annual Pap smear test is offered to women aged 30 and above. Although the screening rate had been increased after the implementation of national health insurance program (32% vs. 18%) in Taiwan. Compared to the data from western countries, the screening rates were 70%~80%. Furthermore, compared to the data from the US Healthy People 2010, the target-screening rate is 80%. Taiwan’s cervical cancer screening rate is quite lower than that in the worldwide.
Factors related with the uptake of Pap smear test included cognition, health believe, information, health status, area of residence, health insurance, age, income, education, married, ever had a Pap test. However, little is known about physicians’ personal practice of having the recommended Pap smear test and the relationship between the level of disability and regular Pap smear testing among women.
Objective.
（1） To compare the practice of having the recommended Pap smear test every three years among female physicians, female relatives of physicians, and general women of similar socio-economic background.
（2） To investigate the relationship between the level of disability and regular Pap smear testing among women in Taiwan and explore how this relationship may vary with the various levels of physician availability.
Methods.
This population-based cohort study followed a total of 5,815,781 alive women who were age 30 years and over, were not diagnosed with cervical cancer prior to January 2001, and were enrolled in the NHI program in Taiwan in the year 2001. This study cohort was followed and observed for their utilization of the Pap smear test between January 2001 and December 2003. Six national registries in Taiwan (the NHI claims data, the NHI enrollment files, the Medical Personnel Registry, the NHI major disease file, the Household Registry, and the Death Certificate Registry) were used.
According to the recommendation of the U.S. Preventive Services Task Force (USPSTF), we dichotomized the outcome variable into “having at least one Pap smear test during the three-year study period” or “not.” This study includes control variables such as age, socio-economic status (SES), ethnic status, major disease status, and physical disability status, geographic location of residence and physician availability.
In the first part of this study, we compared the practice of having the recommended Pap smear test every three years among female physicians, female relatives of physicians, and general women of similar socio-economic background. A total of 5,815,781 women from Taiwan were followed. Among this study cohort, there were 1,950 female physicians, 27,441 female physician relatives.
In the second part of this study, we investigated the relationship between the level of disability and regular Pap smear testing among women in Taiwan. A total of 5,469,581 women from Taiwan were followed. And 184,701 individuals were women with disability. Gynecologist-obstetrician/general practitioner to female population ratio was used as an indicator of physician availability.
Simple and Multiple logistical regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (CI).
Results.
After adjusting for age, ethnic status, physical disability status, and place of residence, of those women whose monthly insurable income was greater than $NT 40,000, female physicians (OR 0.54, 95% CI: 0.50- 060) were the least likely to have undergone at least one Pap smear test during the three-year study period. The physicians’ relatives (OR 0.90, 95% CI: 0.87- 0.92) were also significantly less likely to take routine pap smear tests compared to general women with equivalent socio-economic background.
After adjusting for age, SES, racial group, residence area and physician availability, women with severe disability (OR=0.38; 95% CI: 0.38, 0.39) were the least likely to undergo Pap smear testing. Women with moderate disability (OR=0.59; 95% CI: 0.58, 0.60) and mild disability (OR=0.88; 95% CI: 0.86, 0.89) were also significantly less likely to undertake a routine test than women without disability. Women residing in the areas with the greatest physician availability (OR=0.93; 95% CI:0.93,0.94) were significantly less likely to receive a Pap test than those in the areas with the lowest level of resource availability. The disparity in routine screening between women with and without disability remained across the different levels of physician availability.
Conclusions.
The female physician is a major player in disease prevention with advanced knowledge of the benefits associated with the Pap smear test, but may not adhere any better to the recommendations than the general population.
In Taiwan, women with disability are at a higher risk of lower compliance than women without disability. The gap between women with and without disability persisted across different levels of physician availability.
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