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Disparities between persons with and without disabilities in their participation rates in mass screening
Jong-Hyock Park1, Jin-Seok Lee2,4, Jin-Yong Lee2, Jin Gwack3, Jae-Hyun Park1, Yong-Ik Kim2 and Yoon Kim2,4
1 Division of Cancer Policy and Management, National Cancer Control Research Institute, National Cancer Center
2 Department of Health Policy and Management, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea
3 Department of Preventive Medicine, Seoul National University College of Medicine, Jongno-gu, Seoul, South Korea
4 Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, South Korea
Correspondence: Yoon Kim, MD, PhD, Seoul National University College of Medicine, Yeongeon-dong, Jongno-gu, Seoul 110-799, South Korea, tel: +82-2-2072-3124, fax: +82-2-743-2009, e-mail: yoonkim{at}snu.ac.kr
Received April 16, 2008, accepted October 10, 2008
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Abstract |
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Objectives: The purpose of this study was to determine the number of persons with and without disabilities who participated in the National Health Insurance (NHI) chronic disease mass screening programs in South Korea. Methods: The data were obtained from mass screening claims submitted to the NHI and National Disability Registry. Factors affecting the participation rate included demographic variables, socioeconomic status, residential region, and disability type and severity. A multiple logistic regression analysis was used to evaluate the relationship between participation rates and disability type and severity adjusted for confounding factors. Results: The analysis revealed that persons with a disability were less likely to participate in mass screening programs than those without a disability (35.8% vs. 40.2%). Multiple logistic regression analysis indicated that persons with severe disabilities had lower participation rates than those without disabilities [adjusted odds ratio (aOR): 0.64, 95% confidence interval (CI): 0.63–0.64]. In particular, persons with severe disabilities such as limb, brain, visual and internal organ impairment, were less likely to participate in the mass screening programs. However, persons with mild disability had higher participation rates than those without disabilities (1.03, 1.02–1.03). Conclusions: Although the prevalence rates of chronic diseases are higher among persons with disabilities, various types of impairments such as limb, brain, visual and internal organ impairment, hinder participation in mass screening programs for chronic diseases. The reasons for this disparity must be investigated and health policies must be altered to make preventative treatments more accessible to persons with disabilities.
Keywords: equity, mass screening, National Health Insurance, participation rate, persons with disabilities
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Introduction |
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Persons who are disabled at an early age tend to experience chronic health problems earlier than the general population,1 and the prevalence of chronic disease is two to three times higher among individuals with a disability.2 They are particularly vulnerable to conditions such as high blood pressure and cardiovascular disease,3 and secondary functional losses such as strokes.1
Chronic conditions such as hypertension and diabetes mellitus can be effectively prevented and controlled by early detection and intervention. A recent metanalysis showed that blood pressure control was significantly better in patients who had early intervention and adhered to the treatment.4 Therefore, it is important for persons with disabilities to participate in mass screening programs that provide early detection and intervention for chronic diseases.3,5,6
However, individuals with disabilities may be less likely to receive screening because they face greater barriers in accessing primary health care services. They are also less likely to use appropriate health care services1,7,8 or to take advantage of preventive services such as Pap tests, mammograms and prophylactic dental care.3,5,6 While several studies have examined the influence of disability on the use of primary and preventive health care services,1,7–11 few have investigated the impact of disability on participation in mass screening programs for chronic diseases. Furthermore, no studies to date have examined the effect of the type of disability, such as physical, visual, auditory, internal organ and mental disability, on participation in mass screening programs. This study investigated whether persons with disabilities are less likely to participate in mass screening programs and quantified to what extent a disability influences the uptake of screening.
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National Health Insurance mass screening program for chronic disease in South Korea
In South Korea, National Health Insurance (NHI) provides mandatory universal health insurance and offers comprehensive medical care coverage to all South Korean residents. The National Health Insurance Corporation (NHIC) has increased promotion of mass screening programs and provides free mass screening services for NHI beneficiaries who are over 20 years old. This is to ensure the early detection and treatment of chronic degenerative diseases such as hypertension, diabetes, liver diseases and pulmonary tuberculosis. All mass screening claims are recorded in the NHI mass screening database.
The mass screening programs have two phases. The first phase is a medical history and physical examination that includes height, weight, obesity, vision, hearing, blood pressure, chest X-ray, urine tests (glycosuria, proteinuria, haematuria, pH), blood tests (Hb, fasting blood sugar, total cholesterol, AST, ALT, 
-GTP) and an oral cavity checkup. If these examinations reveal a health problem, participants go on to the second phase, which consists of 28 items including tests for tuberculosis (chest X-ray, AFB stain, AFB culture and identification, anti-AFB drug susceptibility test), and diabetes (fasting blood sugar, blood sugar after meal, close examination of both fundus).
Unlike opportunistic screening, NHI mass screening involves testing individuals who visit a designated hospital after receiving an official letter from the government (sent either to their home, or in the case of employees, through their workplace) inviting participation in mass screening for chronic disease. NHI covers 80% of the expenses for NHI mass screening.
Data collection
Data for the years 2002–03 were collected from the NHI database and the National Disability Database (NDD). The NDD includes information on most persons with a disability registered in the National Social Security System. Article 2 of the Welfare of the Korean Disability Act (KDA), amended in 1999, defines a person with a disability as any individual who, as a result of his or her physical or mental capabilities, is unable to secure by him/herself the necessities required for a normal life and/or social functioning.12
Disabilities are classified into 15 groups, and diagnosis is made by the attending medical specialist. The severity of the disability is graded from 1 to 6 (very severe to very mild, respectively) on the basis of functional loss and clinical impairment, as determined by the medical specialist. Diagnostic criteria are specified in the KDA.12 Disabilities are classified roughly into three groups: external physical disability, internal organ disability and mental disability. Most disabilities involve limb impairment (56.0%), followed by visual impairment (10.5%), auditory impairment (8.7%), brain impairment (7.9%), mental retardation (7.8%), mental diseases (3.2%) and lingual impairment (1.0%). In 2003, 1 436 450 persons were classified as disabled, meaning that 27.1 out of 1000 persons in Korea had a disability. This study used NDD data, which are based on a voluntary self-report system for persons with disabilities and linked with NHI mass screening data. Any individual who reports having any of 15 disabilities at any level of severity is coded as a disabled person. The NDD also records social security numbers and information regarding disability characteristics such as disability type and severity.
The NHI mass screening database includes social security numbers, sex, age, average insurance premium per month, area of residence, the disease being screened and the individuals who participated in the screening. The personal identification number used for data linkage was deleted before analysis. This study used data from a secondary source and was not subject to review by the scientific review panel.
Study population
First, a total of 1 436 450 persons with disabilities were selected from the NDD, which was updated from the list of persons with disability who were registered with social welfare services from 1989 to 2003. Another 2 872 900 non-disabled persons were selected from the 23 182 648 individuals listed in the NHI Mass Screening Eligibility database. The two groups were matched by sex, age, area of residence and average insurance premium per month (Won) at a ratio of 1:2, respectively. Second, because once every 2 years the NHIC provides a mass screening service for insured persons older than 20 years and their dependents aged 40 and above, eligible persons were selected based on the NHIC mass screening inclusion criteria (911 315 persons with a disability and 1 855 335 individuals without disabilities). Third, data for 28 783 persons with disabilities and 43 649 without disabilities were deleted due to missing information about sociodemographic variables and disability type. The final study population included 882 532 persons with a disability and 1 811 686 persons without a disability.
Statistical analysis
Participation rates based on mass screening data claims were used as a measure of ability to access the NHI mass screening programs. Participation rates for disabled and non-disabled persons were calculated based on the number of individuals who were screened for chronic disease and the number of individuals invited to participate in the mass screening program. The NHI database provided this information and also distinguished opportunistic screening from mass screening; the calculation used only the mass screening data.
The analysis included measurement of variables that have previously been associated with participation rates in mass screening programs: sex, age, type of medical insurance, insurance contributions per month as a proxy for household income and residential area. The type of disability was coded as ‘total disability’ if study subjects were registered with the National Disability Registry and coded as ‘no disability’ if study subjects were not. An increasing homogenous trend in compliance appeared from scores of 1–6; persons with more severe disabilities were less likely to participate than were those with mild disabilities. Therefore, severity of disability was classified as severe (disability score 1–3) or mild (disability score 4–6).
The affect of disability type and severity on participation in mass screening was determined using the multiple logistic regression model adjusted for confounding variables with the outcome set as a binary variable (i.e. participation = 1, no participation = 0). The differences between disability types and severity were compared for all variables (demographic, insurance contributions per month as a proxy for household income and residential area).13–16 Area of residence was classified as metropolitan cities, cities and rural areas. Economic status was defined by income taking into account household needs associated with household size. The monthly contribution to the NHI for all employees is based on family income, and we were able to obtain actual family income using the insurance rate for the NHI for each employee.
This study is unique in that it examined a range of disabilities and degrees of severity across a wide sample of the Korean population. This approach yielded information that would otherwise be unobtainable. All analyses were performed using SAS 9.1. Statistical significance was defined as two-tailed P 
0.05.
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Characteristics of the study population
A summary of the general characteristics of the groups is shown in table 1. Of the 2 694 218 individuals included in the study, 32.8% (n = 882 532) had a disability. The distributions of sex, age, area of residence and average insurance premium per month were similar between groups.
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The comparison of NHI mass screening participation rates showed that persons with disabilities participated less than those without a disability (35.77% vs. 40.15%, P < 0.001). This finding was consistent across the matched variables tested.
Participation rates as a function of disability type and severity
Participation rates calculated as a function of disability type and severity are shown in tables 2 and 3. Persons with disabilities had lower participation rates compared to those without disabilities, except for those with facial deformity and epilepsy. Furthermore, persons with more severe disabilities had lower participation rates than those with mild disabilities.
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The multiple logistic regression analysis adjusted for other variables (table 4) indicated that disability was associated with lower participation rates [adjusted odds ratio (aOR): 0.87, 95% confidence interval (CI): 0.86–0.87], and that persons with severe disabilities (aOR: 0.64, 95% CI: 0.63–0.64) had lower participation rates than those with a mild disability (aOR: 1.03, 95% CI: 1.02–1.03). Moreover, persons with a mild disability had a higher participation rate than those without disabilities.
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In summary, the multiple logistic regression analysis adjusted for confounding variables showed that persons with limb, brain, visual, internal organ and linguistic impairments, as well as those with mental illness and mental retardation, were less likely to participate in the mass screening programs than people with other types of disabilities, particularly if their symptoms were severe. These values are shown in table 4.
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Discussion |
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The results indicate that persons with severe disabilities are less likely to participate in mass screening programs than those without disabilities. Previous studies have shown that persons with disabilities are more likely to suffer from high blood pressure and other chronic cardiovascular diseases.3 This suggests that chronic diseases are likely to be detected later in persons with disabilities, resulting in delayed intervention and possible secondary functional losses such as stroke, chronic kidney disease and retinopathy.17 Among people with severe physical and communication limitations, the lower participation in mass screening for chronic disease may be related to transportation and social barriers. Some modes of transportation may not be particularly accessible, and unexpected obstacles may make it difficult to get to a clinic or physician's office in time for an appointment. Moreover, even if a medical facility is physically accessible, the examination equipment may not be. For example, many medical practitioners lack the skills to transfer a patient from a wheelchair to an examining table. Both consumers and providers may become frustrated due to missed appointments and the need for rescheduling.1,18 Wheelchair users and individuals with communication impairments have reported that they are often ignored by office staff, who might speak with their attendant rather than make eye contact with the patient.1 Thus, social and transportation barriers can result in severely disabled persons being neglected in the mass screening program, despite their greater need for screening compared to persons with mild or no disabilities.
In contrast, mildly disabled persons are more likely to participate in mass screening programs than those with no disabilities. These higher rates of participation are presumably related to the lack of mobility or communication barriers among this population, relative to persons with severe disabilities. Some studies have reported that persons with disabilities are more likely to receive preventive services.10,19 Chan et al.20 showed that Medicare beneficiaries with mild limitations received preventive health services more frequently than persons without a disability. Iezzoni et al.10 reported that individuals with minor mobility problems were more likely to receive preventive health services than those with major mobility impairments. This phenomenon is probably caused by mild disabilities being linked to more facilitating factors (want and need for health services) than limiting factors (mobility impairments, communication handicaps). Thus, mildly disabled persons (presumably with a high prevalence of chronic disease) face fewer difficulties when accessing or maintaining health services, resulting in relatively higher participation in mass screening.
We found that persons with severe limb, brain or visual impairments were less likely to participate in mass screening than those with other disabilities. According to the KDA classifications, limb disability includes impairment resulting from amputation, motor disturbance, joint disability, limb deformities and spinal cord injuries. Brain disabilities are the result of stroke, brain damage or brain palsy, and visual impairment includes loss of vision or a visual field defect. Severity is determined primarily by the level of impaired mobility. For example, individuals who have a limb or visual impairment but no mobility limitations are considered to have a mild impairment. This may explain why persons with mild disabilities participate more in mass screening programs than those without a disability. Conversely, persons with severe limb or visual impairment inevitably have problems with mobility, and as a result, are less likely to participate in mass screening programs.
Persons with mobility limitations face several barriers when seeking preventative or primary health care. Transportation often presents a problem,9 and Welner et al.21 suggested that equipment found in the typical physician's office, such as the examination table, may be a barrier for individuals with limited mobility (e.g. limb or brain impairment). Despite KDA provisions, physical barriers still exist in primary care offices in Korea.22,23 Similar problems have been reported in other countries with disability laws, such as the USA, UK and Australia.24,25
Difficulties with communication present another barrier that may prevent people with speech, vision or mental disabilities from seeking health care.26 Several studies have reported communication barriers between care providers and people with disabilities.26,27 Communication aids are lacking in many health care settings,26,28 and this may be another reason for poor participation in mass screening programs.27
Patients with mild as well as severe internal organ failure, such as renal, heart, respiratory, liver, intestinal or urinary tract dysfunction, had lower participation rates than the non-disabled controls, despite seeing health care providers on a regular basis. These findings suggest that treatment for chronic disease is often neglected in people with internal organ impairment who are receiving focused treatment for the organ dysfunction.
Finally, persons with auditory impairment, facial deformity and mild epilepsy participated in screening programs more often than those without a disability. This may be explained by this group not having mobility or communication impairments.
Our study had several limitations. First, Medicaid beneficiaries, who account for about 3.1% of all Korean residents, were excluded because the NHI claims database did not provide enough information. Second, we could not control for variables such as knowledge, attitude and beliefs about mass screening, and psychosocial factors that can influence an individual's use of preventative health care services. Further studies using other research methods, such as patient surveys and qualitative interviews, are necessary to examine the impact of these factors on the decision to participate in mass screening programs. Another limitation of this study is that the coverage rate of the National Disability Database is only 77.7% because it is a voluntary self-report system for persons with disabilities. However, it is probable that the registry included most persons with mobility or functional impairment because the government provides various benefits such as income and financial aid for medical services to such persons. Finally, while there may have been some issues with the representativeness of the study subjects, subjects included individuals with every type and severity of disability; therefore, these issues should not have affected the internal validity of the study results.
This study shows that different types of disabilities and the degree of severity influence participation in mass screening for chronic diseases, and these findings have important implications for health care policy. Future studies must be conducted to investigate the reasons that underlie the disparities reported here, and health care policies must be developed to address these issues. For example, the social system should try to provide appropriate, targeted mass screening information and improve accessibility, communication and coordination between health care providers and people with disabilities.6 Our results strongly suggest that the health care and welfare systems need to recognize the importance of accessibility in obtaining preventive services, whether for primary or comorbid conditions. The United Nations Standard Rules on the Equalization of Opportunities for Persons with Disabilities states that primary health care services needed to preserve or improve functioning should be provided to persons with disabilities on a regular basis. Government actions to facilitate communication and make the physical environment more accessible will improve the participation of persons with disabilities in mass screening for chronic disease.
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Korean National Health Insurance Corporation.
Key points
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