乳癌及大腸癌篩檢不平等評估－反轉公平假說之檢視

Assessing inequalities in breast and colorectal cancer screening-testing the inverse equity hypothesis

10.6288/TJPH.201802_37(1).106059

李佳綺(Chiach i Bonnie Lee)；李妙純(Miaw-Chwen Lee)

癌症篩檢 ； Erreygers校正集中指數 ； 相對不平等指數 ； 反轉公平假說 ； cancer screening ； Erreygers corrected concentration index ； relative inequality index ； inverse equity hypothesis

台灣公共衛生雜誌

37卷1期（2018 / 02 / 15）

50 - 62

繁體中文

目標：本研究探討乳癌及大腸癌篩檢利用之收入不平等，以及不平等與篩檢率之關係。方法：本研究資料取自2001、2005、2009、2013年國民健康訪問調查，估計45或50歲至69歲乳癌及大腸癌篩檢之與均等家戶收入關連之Erreygers集中指數（ECI）、相對不平等指數（RII）及影響不平等因素解析。結果：乳房攝影及糞便潛血篩檢率自2001年之9.2%及10.1%分別上升至2013年之46.1%及41.3%；並呈現收入愈高篩檢率愈高的現象。2001年最高收入群體之乳房攝影使用率比最低收入群體多達近一倍（RII=0.984），但到2013年下降為多5.7%（RII=0.057）。最高收入群體之糞便潛血檢查率比最低收入群體多40-60%（RII=0.377~0.634）。除了2013年乳房攝影外，兩項篩檢之使用亦都集中於高收入群體（乳房攝影ECI=0.060~0.150；糞便潛血檢查ECI=0.036~0.104）。免費政策實施前（2001、2005及2009年）收入都是影響篩檢不平等的重要因素，但免費政策實施後（2013年）教育程度為最重要因素。結論：與「反轉公平假說」一致，當篩檢率上升時，不同收入群體篩檢率差異愈小。提升篩檢率可縮減篩檢之社會不平等，有助於緩和健康不平等。

Objectives: This study analyzed income-related inequalities in breast and colorectal cancer screening in Taiwan and the relationship between inequality and screening rate. Methods: We used data from the 2001, 2005, 2009, and 2013 National Health Interview Surveys. The Erreygers concentration indices (ECI) and relative inequality indices (RII) were calculated and ECIs were decomposed. Results: In 2001, 9.2% of participants reported undergoing mammography and 10.1% reported having a fecal occult blood test (FOBT) within the previous year. Those screening rates within the previous two years increased by 46.1% and 41.3% respectively in 2013 and showed income gradients. In 2001, mammography use by the highest-income group was nearly double that of the lowest-income group (RII=0.984), while that difference in 2013 fell by 5.7% (RII=0.057). Compared with the lowest-income group, the highest income group received 40- 60% more screening for FOBT (RII=0.377 to 0.634). Except for mammography in 2013, both mammography and FOBT were concentrated in the higher income group (ECI=0.06-0.15 for mammography; ECI=0.036-0.104 for FOBT). Before the national cancer screening programs in 2001, 2005 and 2009, income was the most important contributor to inequalities in the screening rate, while education accounted for the greatest contribution in 2013. Conclusions: Consistent with the ＂inverse equity hypothesis,＂ income-related inequalities in cancer screening decreased with higher screening rates. Therefore, an increased screening rate facilitates the reduction in inequality in cancer screening and addresses health inequalities.

1. Health Promotion Board, Singapore (HPB). Healthy workplace ecosystem. Available at: https://www.hpb.gov.sg/workplace/healthy-workplace-ecosystem.2017/04/21. Accessed April 21, 2017.
2. 台北市衛生局：「台北市健康促進績優團體成果發表」，另類健康「互聯網+」 攜手拚健康。http://tcgwww.taipei.gov.tw/ct.asp?xItem=243768039&ctNode=80553&mp=10904M。引用2017/05/30。Department of Health, Taipei City Government. Achievements of the Taipei City Health Promotion Merit Group: alternative health “Internet+”, working together to promote health. Available at: http://tcgwww.taipei.gov.tw/ct.asp?xItem=243768039&ctNode=80553&mp=10904M. Accessed May 30, 2017. [In Chinese]
3. 衛生福利部國民健康署：中華民國103年度(103年1月1日至103年12月31日)菸害防制及衛生保健基金附屬單位決算分決算(非營業部分)(審定本)。2014。https://www.hpa.gov.tw/File/Attach/7112/File_7184.pdf。引用2017/06/07。Health Promotion Administration, Ministry of Health and Welfare, R.O.C. (Taiwan). 2014 final account of the Taiwan Tobacco Control & Health Care Funds subsidiary agencies (non-business part) (the trial version). Available at: https://www.hpa.gov.tw/File/Attach/7112/File_7184.pdf. Accessed June 7, 2017. [In Chinese].
4. Aurélio Peres, M,Simara Fernandes, L,Glazer Peres, K(2004).Inequality of water fluoridation in Southern Brazil -the inverse equity hypothesis revisited.Soc Sci Med,58,1181-9.
5. Bíró, A(2013).Discount rates and the education gradient in mammography in the UK.Health Econ,22,1021-36.
6. Buron, A,Auge, JM,Sala, M(2017).Association between socioeconomic deprivation and colorectal cancer screening outcomes: low uptake rates among the most and least deprived people.PLoS One,12,e0179864.
7. Carrieri, V,Wuebker, A(2013).Assessing inequalities in preventive care use in Europe.Health Policy,113,247-57.
8. Chen, TH,Yen, AM,Fann, JC(2017).Clarifying the debate on population-based screening for breast cancer with mammography: a systematic review of randomized controlled trials on mammography with Bayesian meta-analysis and causal model.Medicine,96,e5684.
9. Chiou, ST,Wu, CY,Hurng, BS,Lu, TH(2014).Changes in the magnitude of social inequality in the uptake of cervical cancer screening in Taiwan, a country implementing a population-based organized screening program.Int J Equity Health,13,4.
10. Chiu, HM,Chen, SL,Yen, AM(2015).Effectiveness of fecal immunochemical testing in reducing colorectal cancer mortality from the One Million Taiwanese Screening Program.Cancer,121,3221-9.
11. Chou, CK,Chen, SL,Yen, AM(2016).Outreach and inreach organized service screening programs for colorectal cancer.PLoS One,11,e0155276.
12. Costa-Font, J,Hernández-Quevedo, C,Jiménez-Rubio, D(2014).Income inequalities in unhealthy life styles in England and Spain.Econ Hum Biol,13,66-75.
13. Cullerton, K,Gallegos, D,Ashley, E(2016).Cancer screening education: can it change knowledge and attitudes among culturally and linguistically diverse communities in Queensland, Australia?.Health Promot J Austr,27,140-7.
14. Damiani, G,Basso, D,Acampora, A(2015).The impact of level of education on adherence to breast and cervical cancer screening: evidence from a systematic review and meta-analysis.Prev Med,81,281-9.
15. Deandrea, S,Molina-Barceló, A,Uluturk, A(2016).Presence, characteristics and equity of access to breast cancer screening programmes in 27 European countries in 2010 and 2014. Results from an international survey.Prev Med,91,250-63.
16. Devaux, M(2015).Income-related inequalities and inequities in health care services utilisation in 18 selected OECD countries.Eur J Health Econ,16,21-33.
17. Erreygers, G(2009).Correcting the concentration index.J Health Econ,28,504-15.
18. Erreygers, G,Van Ourti, T(2011).Measuring socioeconomic inequality in health, health care and health financing by means of rank-dependent indices: a recipe for good practice.J Health Econ,30,685-94.
19. Guillaume, E,Launay, L,Dejardin, O(2017).Could mobile mammography reduce social and geographic inequalities in breast cancer screening participation?.Prev Med,100,84-8.
20. Hahm, MI,Park, EC,Choi, KS,Lee, HY,Park, JH,Park, S(2011).Inequalities in adoption of cancer screening from a diffusion of innovation perspective: identification of late adopters.Cancer Epidemiol,35,90-6.
21. Halpern, MT,Ward, EM,Pavluck, AL,Schrag, NM,Bian, J,Chen, AY(2008).Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis.Lancet Oncol,9,222-31.
22. Hargreaves, JR,Davey, C,White, RG(2013).Does the 'inverse equity hypothesis' explain how both poverty and wealth can be associated with HIV prevalence in sub-Saharan Africa?.J Epidemiol Community Health,67,526-9.
23. Johns, LE,Coleman, DA,Swerdlow, AJ,Moss, SM(2017).Effect of population breast screening on breast cancer mortality up to 2005 in England and Wales: an individual-level cohort study.Br J Cancer,116,246-52.
24. Kalager, M,Zelen, M,Langmark, F,Adami, HO(2010).Effect of screening mammography on breast-cancer mortality in Norway.New Engl J Med,363,1203-10.
25. Kim, S,Hwang, J(2016).Assessment of trends in socioeconomic inequalities in cancer screening services in Korea, 1998-2012.Int J Equity Health,15,30.
26. Kim, S,Kwon, S,Subramanian, SV(2015).Has the National Cancer Screening Program reduced income inequalities in screening attendance in South Korea?.Cancer Causes Control,26,1617-25.
27. Lee, JT,Huang, Z,Basu, S,Millett, C(2015).The inverse equity hypothesis: does it apply to coverage of cancer screening in middle-income countries?.J Epidemiol Community Health,69,149-55.
28. Lee, MC,Jones, AM(2007).Understanding differences in income-related health inequality between geographic regions in Taiwan using the SF-36.Health Policy,83,186-95.
29. Link, BG,Phelan, J(1995).Social conditionsas fundamental causes of disease.J Health Soc Behav,Spec,80-94.
30. Liss, DT,Baker, DW(2014).Understanding current racial/ethnic disparities in colorectal cancer screening in the United States.Am J Prev Med,46,228-36.
31. Lowrie, R,Mcconnachie, A,Williamson, AE(2017).Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data.BMC Med,15,77.
32. Martin, J,Halm, EA,Tiro, JA(2017).Reasons for lack of diagnostic colonoscopy after positive result on fecal immunochemical test in a safety-net health system.Am J Med,130,93.e1-7.
33. Menvielle, G,Richard, JB,Ringa, V,Dray-Spira, R,Beck, F(2014).To what extent is women's economic situation associated with cancer screening uptake when nationwide screening exists? A study of breast and cervical cancer screening in France in 2010.Cancer Causes Control,25,977-83.
34. Moreno-Betancur, M,Latouche, A,Menvielle, G,Kunst, AE,Rey, G(2015).Relative index of inequality and slope index of inequality: a structured regression framework for estimation.Epidemiology,26,518-27.
35. Newey, WK,West, KD(1994).Automatic lag selection in covariance matrix estimation.Rev Econ Stud,61,631-53.
36. O'Donnell, O,O'Neill, S,Van Ourti, T,Walsh, B(2016).conindex: estimation of concentration indices.Stata J,16,112-38.
37. O'Donnell, OA,Wagstaff, A(2008).Analyzing Health Equity Using Household Survey Data: A Guide to Techniques and Their Implementation.Washington, DC:The World Bank.
38. Orbell, S,Szczepura, A,Weller, D,Gumber, A,Hagger, MS(2017).South Asian ethnicity, socioeconomic status, and psychological mediators of faecal occult blood colorectal screening participation: a prospective test of a process model.Health Psychol,36,1161-72.
39. Pacelli, B,Carretta, E,Spadea, T(2014).Does breast cancer screening level health inequalities out? A populationbased study in an Italian region.Eur J Public Health,24,280-5.
40. Palencia, L,Espelt, A,Rodriguez-Sanz, M(2010).Socioeconomic inequalities in breast and cervical cancer screening practices in Europe: influence of the type of screening program.Int J Epidemiol,39,757-65.
41. Peipins, LA,Soman, A,Berkowitz, Z,White, MC(2012).The lack of paid sick leave as a barrier to cancer screening and medical care-seeking: results from the National Health Interview Survey.BMC Public Health,12,520.
42. Peretti-Watel, P,Fressard, L,Bocquier, A,Verger, P(2016).Perceptions of cancer risk factors and socioeconomic status. A French study.Prev Med Rep,3,171-6.
43. Puliti, D,Miccinesi, G,Manneschi, G(2012).Does an organised screening programme reduce the inequalities in breast cancer survival?.Ann Oncol,23,319-23.
44. Ridde, V,Agier, I,Jahn, A(2015).The impact of user fee removal policies on household out-of-pocket spending: evidence against the inverse equity hypothesis from a population based study in Burkina Faso.Eur J Health Econ,16,55-64.
45. Solmi, F,Von Wagner, C,Kobayashi, LC,Raine, R,Wardle, J,Morris, S(2015).Decomposing socio-economic inequality in colorectal cancer screening uptake in England.Soc Sci Med,134,76-86.
46. Vallet, F,Guillaume, E,Dejardin, O(2016).Influence of a screening navigation program on social inequalities in health beliefs about colorectal cancer screening.J Health Psychol,21,1700-10.
47. Victora, CG,Vaughan, JD,Barros, FC,Silva, AC,Tomasi, E(2000).Explaining trends in inequality: evidence from Brazil child health studies.Lancet,356,1093-8.
48. von Wagner, C,Good, A,Whitaker, KL,Wardle, J(2011).Psychosocial determinants of socioeconomic inequalities in cancer screening participation: a conceptual framework.Epidemiol Rev,33,135-47.
49. Walsh, B,Silles, M,O'Neill, C(2012).The role of private medical insurance in socio-economic inequalities in cancer screening uptake in Ireland.Health Econ,21,1250-6.
50. Ward, E,Halpern, M,Schrag, N(2008).Association of insurance with cancer care utilization and outcomes.CA Cancer J Clin,58,9-31.
51. Ward, PR,Javanparast, S,Ah Matt, M(2011).Equity of colorectal cancer screening: cross-sectional analysis of National Bowel Cancer Screening Program data for South Australia.Aust N Z J Public Health,35,61-5.
52. Wardle, J,McCaffery, K,Nadel, M,Atkin, W(2004).Socioeconomic differences in cancer screening participation: comparing cognitive and psychosocial explanations.Soc Sci Med,59,249-61.
53. Yang, S,Platt, RW,Dahhou, M,Kramer, MS(2014).Do population-based interventions widen or narrow socioeconomic inequalities? The case of breastfeeding promotion.Int J Epidemiol,43,1284-92.
54. 衛生福利部國民健康署(2016)。2016國民健康署年報。台北=Taipei:衛生福利部國民健康署=Health Promotion Administration, Ministry of Health and Welfare, R.O.C. (Taiwan)。
55. 衛生福利部國民健康署(2010)。2010-2015國民健康署年報。台北=Taipei:衛生福利部國民健康署=Health Promotion Administration, Ministry of Health and Welfare, R.O.C. (Taiwan)。
56. 賴金英、賴金梅、陳秋媛、辜美安(2012)。台灣中老年女性未接受乳房攝影篩檢之因子。護理雜誌，59，60-70。