全民健保下之預防醫療照護需求研究:婦女子宮抹片檢查之利用

Abstract

台灣地區自民國八十四年三月開始實行全民健保，並於同年七月起提供三十歲以上婦女每年一次免費抹片檢查，但我國婦女抹片檢查利用率和先進國家相比仍舊偏低。爰此，本論文主要目的，在探討台灣地區婦女在健保制度下抹片篩檢利用度的影響因素，藉由實證分析結果，期能提供政府當局有效提高篩檢率的具體方針和建議，以有效降低婦女子宮頸癌的發生率和死亡率。\n 第二章為理論架構，分別應用Becker(1965)的家庭生產函數和Grossman(1972)的健康需求模型，以建構影響抹片檢查需求的理論模型，並為本論文實證分析的理論基礎。本論文實證分析共分三章，首先利用衛生署國民健康局家庭計畫研究所，分別於民國81年及87年進行的「台灣地區家庭與生育力調查」資料，採用Logit迴歸模型做分析。實證結果發現，抹片檢查接受與否的影響因素在健保實施前後有很大差異，而「南部＊全民健保」及「鄉鎮＊全民健保」的變數對30歲以上婦女亦為顯著正相關；意味健保制度的推行，沖消掉大多數變數的影響效果，使得原本具有影響力的因素變為不顯著，亦即健保政策在婦女抹片防癌使用度的增加有很大貢獻。此外，政府除了對30歲以上女性提供免費檢查給付政策外，亦積極加強衛教宣導工作、建立子宮頸抹片篩檢服務網等工作，使得「全民健保」變數不僅對30歲以上婦女，亦對30歲以下婦女有顯著的正影響力，故建議政府可考慮將篩檢給付擴及至所有已婚女性。 \n 接者，在第四章則利用國家衛生研究院於民國90年所進行的「國民健康訪問調查」資料，應用Bivariate Probit 迴歸模型，並將台灣地區所有316個鄉鎮市分成八個都市化層級，探討都市化程度高低對婦女預防保健利用度之影響。結果發現都市化程度不同，的確造成婦女抹片檢查利用率存在顯著差異，居住在第二至第六個都市化層級的婦女，其接受抹片篩檢的比率明顯較都市化程度最高者低；而第七和第八層級(都市化程度最低)並無顯著較第一層級不願做篩檢。究其原因，乃因政府為均衡不同地區抹片篩檢的可近性，積極鼓勵相關醫療院所加入健保特約醫院，以配合健保給付政策並提供篩檢服務，至民國86年，有超過90%約1500家的醫療院所加入；此外，衛生當局亦在偏遠地區提供巡迴車設站採檢服務，以解決偏遠地區醫療資源不足問題。意味全民健保制度在婦女抹片檢查服務上，已達到提昇偏遠地區醫療服務可近性的貢獻。\n 最後，在第五章我們利用國民健康局於民國91年所進行的「國民健康促進知識、態度與行為調查」資料，應用兩階段最小平方法(2SLS)估計模型，分析健康資訊對抹片檢查的影響程度。應用Kenkel(1990)衡量資訊的方法，將受訪者對子宮頸癌及抹片檢查相關知識的得分加總，以代表婦女健康資訊程度。實證結果發現，健康資訊的確是影響婦女是否接受抹片檢查的重要因素，擁有愈多相關健康資訊的婦女，因愈了解抹片檢查對預防子宮頸癌的重要，故明顯較願意去接受篩檢。因此，政府除了積極全面衛教宣導工作、建立子宮頸抹片篩檢服務網等工作外，也應針對擁有較低健康資訊的婦女多加宣導抹片防癌的重要性，以有效提高我國婦女的篩檢利用率。

The National Health Insurance program provided free annual cervical cancer screening for women aged above 30 years old since July, 1995, just four months after the inauguration of the NHI. Therefore, the purpose of this dissertation is to investigate the demand for Pap-smear utilization among women under NHI program. To explore the factors influencing cervical cancer screening and the empirical results can be of great importance to health policy decisions aimed at reducing the incidence and mortality of cervical cancer.\nIn Chapter 2, we attempt to analyze the theoretical foundations applying the household production function developed by Becker (1965) and Grossman’s (1972) health decision-making model and summarize the literatures through a review of the demand for preventive care services. Three empirical essays will proceed in following three chapters. \nFirst of all, chapter 3 presents data obtained from the 1992 and 1998 surveys on ‘Knowledge, Attitudes and Practice’ administered by Taiwan’s Provincial Institute of Family, performing a logit model. The results show that factors affecting Pap smear test utilization varied significantly before and after NHI, besides, the coefficient of the South＊NHI and village/town＊NHI interaction variable for women above 30 become significant and positive. This indicates that NHI system plays an important contributor on reducing the disparities in utilization of Pap smear tests between different areas. In addition to NHI coverage, other strategies such as strengthening educational activities and establishing a service network for Pap-smear screening are other vital contributors to increase the utilization rate of Pap smear screening for those aged below 30 years under NHI. To further increase the utilization of cervical cancer screening, the insurance coverage could be extended to all married women regardless of age.\nIn chapter 4, we attempt to explore the impact of urbanization level on the use of female preventive services under NHI, using a bivariate probit model and dataset obtained from the 2001 National Health Interview Survey provided by the National Health Research Institutes. All 316 cities/counties in Taiwan was stratified into 8 levels of urbanization. The results showed that urbanization levels have a significant influence on Pap-smear screening. Those living between the second and sixth levels of urbanized regions were significant negative to the cervical cancer screening compared to the highest urbanization level. In order to balance the accessibility of cervical cancer screening between different areas, the health authorities encourage the obstetric, gynecological hospitals and clinics to contract with the government, more than 90%, about 1,500 medical care institutions were under contract until 1997. Besides, government authorities introduced mobile testing stations to provide specimen collection services in the deeper remote regions. As a result, those living in the areas with the 7th level and the 8th level (the lowest level) of urbanization were not less likely to take Pap-smear test. It means that the implementation of NHI has enhanced the accessibility of taking pap-smear test.\n Finally, in chapter 5, the nationwide survey dataset was obtained from the 2002 Health Promotion of Knowledge, Attitudes and Practice (HPKAP) in Taiwan, provided by the Bureau of Health Promotion and two-stage estimation model was adopted to investigate the association of cervical cancer screenings with the healthcare information. The results showed that women’s healthcare information has a significant positive effect on the utilization of cervical cancer screening; that is, the more informed women are, in terms of information and knowledge on cervical cancer screening, the more likely they are to undergo Pap-smear testing. Therefore, it is important for the healthcare authorities to place greater effort into strengthening the knowledge and information on cervical cancer screening and Pap-smear testing, for those who are currently less informed, so as to enhance the overall efficiency of the screening program.