Lower utilization of cervical cancer screening by nurses in Taiwan: A nationwide
population-based study

Shiu-Dong Chung

a

,

b

,

c

, Stefani Pfeiffer

d

, Herng-Ching Lin

c

,

⁎

a

Division of Urology, Department of Surgery, Far Eastern Memorial Hospital, Ban Ciao, Taipei, Taiwan

b

Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan

c

School of Health Care Administration, Taipei Medical University, Taipei, Taiwan

d

Department of History, Rutgers University, New Brunswick, NJ, USA

a b s t r a c t

a r t i c l e i n f o

Available online 8 May 2011

Keywords:
Nurses
Preventive health services
Papanicolaou smear

Objective. Using a nationwide population-based database in Taiwan, this study compares use of Pap smear

testing by nurses and the general population.

Method. We compared 1093 practicing female nurses and 5465 randomly selected female patients from

the 2006 National Health Insurance (NHI) database to evaluate the likelihood of receiving at least one Pap
smear during a three-year period.

Results. We found that 48.9% of the nurses and 56.2% of comparison subjects received a Pap test from 2004

to 2006 in Taiwan. Regression analysis showed that practicing female nurses were less likely to receive a Pap
smear compared with the general population (OR = 0.42, 95% CI = 0.35

–0.50, pb0.001), after adjusting for

monthly incomes, number of ob/gyn ambulatory care visits, urbanization level and the geographic location of
the communities where subjects resided.

Conclusion. Nurses were less likely to undergo cervical screening than the general population, despite ease

of access and a national health insurance system providing universal coverage to residents of Taiwan. Efforts
to raise the Pap screening rate among nurses may require addressing unique cultural and occupational
concerns.

© 2011 Elsevier Inc. All rights reserved.

Introduction

The Papanicolaou (Pap) smear is an effective measure for reducing

cervical cancer incidence and mortality (

Taylor et al., 2006

). Many

researchers believe raising public awareness of cervical cancer and
Pap testing increases use of screening services (

Aboyeji et al., 2004;

Idestrom et al., 2002; Lartey et al., 2003

). Therefore, health pro-

fessionals, especially nurses, have been studied to determine whether
these informed consumers showed better adherence to screening
recommendations than the general population (

Berry, 2006

). How-

ever, hardly any studies have compared cervical cancer screening
rates among nurses and the general population. Only one nationwide
survey has been conducted;

Ratner and Sawatzky (2009)

reported

that nurses in Canada were more likely than other employed female
postsecondary graduates to have ever had a Pap smear (97.4% vs.
91.0%).

Our study compared the rate of Pap smear testing among nurses

and the general population in Taiwan using a nationwide population-
based dataset (Longitudinal Health Insurance Database 2005

(LHID2005)). Taiwan initiated its National Health Insurance (NHI)
program in 1995. The LHID2005, which contains original claims data
for 1,000,000 subjects, is a representative database systematically
selected from the 2005 Registry of Bene

ficiaries under the NHI

program. The NHI program provides free annual cervical cancer
screening to women age 30 and older. Therefore, all cervical cancer
screenings for these 1,000,000 subjects were recorded in the
LHID2005. This longitudinal dataset allows researchers to avoid
potential measurement bias seen in survey research.

Methods

Our study included a study and a comparison group. We identi

fied 4216

female nurses from the 2006 Registry of Medical Personnel of the LHID2005.
We excluded 1232 nurses who did not practice during the period 2004

–2006.

In addition, we excluded nurses under age 30 (n = 1822), since the NHI
program only provides free annual cervical cancer screening to women
30 years and older. We also excluded patients over age 59 (n = 10) because
few nurses were still practicing at that age. Furthermore, nurses diagnosed
with cervical cancer prior to 2006 were excluded (n = 59). Ultimately, the
study group contained 1093 practicing female nurses.

We selected the comparison group from the 2006 Registry of Bene

ficiaries

of the LHID2005, excluding subjects who were nurses or who were diagnosed
with cervical cancer from 1996 to 2006. We also limited the selected subjects

Preventive Medicine 53 (2011) 82

–84

⁎ Corresponding author at: School of Health Care Administration, Taipei Medical

University, 250 Wu-Hsing St., Taipei 110, Taiwan. Fax: + 886 2 2378 9788.

E-mail address:

[e-mail]

(H.-C. Lin).

0091-7435/$

– see front matter © 2011 Elsevier Inc. All rights reserved.

doi:

10.1016/j.ypmed.2011.05.002

Contents lists available at

ScienceDirect

Preventive Medicine

j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y p m e d

to those between ages 30 and 59. We then randomly extracted 5465 age-
matched subjects (

five for every nurse in the study group, ages 30–39, 40–49

and 50

–59) as the comparison group. Finally, we had a total of 6558 subjects

for analysis.

The dependent variable was whether or not a woman received at least

one Pap smear under the NHI during the three-year period (from January
2004 to December 2006). Under the NHI program, physicians and hospitals
apply for reimbursement after providing cervical cancer screening, so Pap test
use can be reliably identi

fied from the medical claims data.

We also took potential confounding factors into consideration in the

regression modeling. These included subject's age, monthly income, level of
urbanization and the geographic location of the community where the subject
resided, and the number of ob/gyn ambulatory care visits (excluding visits for
Pap tests) during the period in question. We selected these variables based on
prior studies (

Ratner and Sawatzky, 2009

) and the information available in the

LHID2005.

All analyses were performed with the SAS statistical package. We used

conditional multivariate logistic regression analysis conditioned on age to
evaluate the likelihood of women in the study and comparison groups
receiving at least one Pap smear test during the three-year period (2004

–

2006).

Results

Of the sampled patients, 3605 (55.0%) received Pap tests during

2004

–2006, 534 from the study group (48.9% of the practicing female

nurses) and 3071 from the comparison group (56.2% of comparison
subjects).

Table 1

shows that nurses were more likely to have monthly

incomes

≥NT$50,001, reside in more urbanized communities and in

the southern part of Taiwan, and have a higher number of ob/gyn
ambulatory care visits than the comparison group (all p

b0.001).

Table 2

illustrates the crude and adjusted odds ratios (ORs) for

receiving Pap smear tests by group. Conditional logistic regression
analysis (conditioned on age) showed that practicing female nurses
were less likely to receive a Pap smear during the three-year period
compared with comparison group patients (OR = 0.42, 95% CI = 0.35

–

0.50, p

b0.001), after adjusting for monthly income, urbanization

level, the geographic location of the community in which they resided,
and number of ob/gyn ambulatory care visits.

Discussion

We found that even with the NHI program, nurses were signi

ficantly

less likely to receive Pap testing (OR = 0.42) compared to the general
population, after adjusting for potential confounders. Our

finding is not

consistent with

Ratner and Sawatzky's (2009)

study in Canada which

reported that nurses were more likely to have had a Pap smear than
other employed female postsecondary graduates. This disparity could
result from country-level differences in healthcare education and policy,
or a combination of cultural and occupational issues which affect nurses'
willingness to receive cervical cancer screening.

The lower rates of Pap testing among Taiwan nurses suggest a

wide gap between personal knowledge and use of the Pap test. One
study by

Udigwe (2006)

found that knowledge of cervical cancer

screening services was high among female nurses in Nigeria, even
while Pap test use was low. Studies by

Gharoro and Ikeanyi (2006)

and by

Dim et al. (2009)

likewise reported that a large number of

female health workers in Nigeria were aware Pap tests were available
to them, yet screening rates were abysmally poor. There have been no
comparable studies on Taiwan nurses to date.

Another plausible explanation, however, could be that despite the

advantages health workers have in accessing healthcare, psychosocial
barriers may discourage them from seeking Pap tests. Concerns might
include resistance to playing the patient role, the uniquely vulnerable
position required for Pap smears, embarrassment about exposing
their bodies to colleagues, and concerns about con

fidentiality of

results (

Frank et al., 1998; Stoudemire and Rhoads, 1983

). If testing is

performed in the institution where they are employed, these could

Table 1
Demographic characteristics of practicing female nurses and comparison group
patients and rate of Pap testing from 2004 to 2006 in relation to demographic
characteristics of the sampled patients in Taiwan (n = 6558).

Variable

Nurses
(n = 1093)

Comparison
group
(n = 5465)

p
Value

Receiving
Pap test
from
January
2004 to
December
2006

Total
no.

Column
%

Total
no.

Column
%

Total
no.

Row
%

Age

1.000

30

–39

340

31.1

1700

31.1

1014

49.7

40

–49

505

46.2

2525

46.2

1738

57.4

50

–59

248

22.7

1240

22.7

853

57.3

Monthly income

b0.001

NT$

≤30,000

324

29.6

1809

33.1

2557

55.0

NT$30,001

–50,000

566

51.8

3066

56.1

714

53.3

≥NT$50,001

203

18.6

590

10.8

334

58.6

Number of ob/gyn

ambulatory care
visits, 2004

–2006

b0.001

0

287

26.3

1857

34.0

228

10.6

1

–5

382

35.0

1872

34.3

1612

71.5

6

–10

148

13.5

766

14.0

753

82.4

N10

276

25.2

970

17.8

1012

81.2

Urbanization level

0.009

1 (most urbanized)

405

34.6

1954

33.4

1185

53.7

2

388

33.1

1764

30.1

1106

54.8

3

141

12.0

880

15.0

518

54.4

4

149

12.7

705

12.0

454

57.3

5 (least urbanized)

89

7.6

557

9.5

342

58.2

Geographic region

b0.001

Northern

497

45.5

2693

49.3

1739

54.5

Central

247

22.5

1256

23.0

836

55.6

Southern

311

28.5

1412

25.8

940

54.6

Eastern

38

3.5

104

1.9

90

63.4

Note: NT = New Taiwan.

Table 2
Unadjusted and adjusted odds ratios of Pap smear testing for practicing female nurses
and comparison patients in Taiwan (n = 6558).

Variable

Crude odds ratio(95%
Con

fidence Interval)

Adjusted odds ratio(95%
Con

fidence Interval)

Practicing female nurse

Yes

0.75 (0.66

–0.85)

0.42 (0.35

–0.50)

No

1.00

1.00

Monthly income

NT$

≤30,000

1.00

1.00

NT$30,001

–50,000

0.93 (0.83

–1.05)

0.98 (0.87

–1.30)

≥NT$50,001

1.14 (0.96

–1.36)

1.76 (1.35

–2.29)

Number of ob/gyn ambulatory

care visits, 2004

–2006

0

1.00

1.00

1

–5

21.76 (18.50

–25.58)

24.64 (20.74

–29.26)

6

–10

40.08 (33.19

–50.84)

47.59 (37.90

–59.74)

N10

38.76 (31.93

–47.04)

48.68 (39.47

–60.04)

Urbanization level

1 (most urbanized)

1.00

1.00

2

1.06 (0.94

–1.19)

1.08 (0.92

–1.28)

3

1.02 (0.88

–1.19)

1.08 (0.88

–1.33)

4

1.17 (1.01

–1.37)

1.44 (1.13

–1.82)

5 (least urbanized)

1.25 (1.05

–1.50)

1.63 (1.26

–2.12)

Geographic region

Northern

1.00

1.00

Central

1.07 (0.95

–1.20)

0.96 (0.81

–1.15)

Southern

0.99 (0.88

–1.11)

1.08 (0.92

–1.28)

Eastern

1.33 (0.96

–1.84)

1.91 (1.20

–3.08)

Note: NT = New Taiwan.

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S.-D. Chung et al. / Preventive Medicine 53 (2011) 82

–84

affect their day-to-day work. Further studies are recommended to
assess knowledge, beliefs and concerns about cervical cancer
screening among Taiwan nurses.

We found that the rate of cervical cancer screening for the overall

female population in Taiwan ages 30 to 60 was only 52.9% in 2006. That
is lower than some western countries (for example, 78% in the US and
80% in Austria) (

Gakidou et al., 2008

). Prior studies have identi

fied

possible factors contributing to under-utilization of Pap screening
among Chinese women, including lack of knowledge, low perceived
risk, discomfort, embarrassment, lack of health awareness and cultural
beliefs about sexuality (

Seow et al., 1995; Yi, 1998

). Policy makers are

challenged to devise innovative interventions addressing psychosocial
factors that in

fluence screening among Asian women.

This study suffers from some limitations. Because we used a claims

database, we were unable to include some potential confounders in
the regression model, such as highest educational level attained,
knowledge about the Pap, sexual activity, marital status and family
history of cervical cancer.

Conclusions

Although nurses know about cervical cancer screening, they were

less likely to receive screening than the general population. Intervention
programs addressing reluctance to receive cervical cancer screening are
needed to increase Pap smear testing among nurses.

Con

flict of interest statement

None.

Acknowledgments

This study is based in part on data from the National Health

Insurance Research Database provided by the Bureau of National
Health Insurance, Department of Health, Taiwan and managed by the
National Health Research Institutes. The interpretations and conclu-
sions contained herein do not represent those of the Bureau of

National Health Insurance, Department of Health, or the National
Health Research Institutes.

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