臺灣博碩士論文加值系統

子宮頸癌一直是台灣地區女性好發的癌症之一，也是所有女性癌症中最容易早期發現且治癒效果佳的疾病，因此是最適合進行篩檢的疾病之一。由於子宮頸抹片篩檢是需要長時間定期的追蹤，在全民健保實施有了全面性的給付後，是否提高了民眾接受篩檢的比例及減少子宮頸侵襲癌的發生？所以本研究目的是為了解自全民健保實施前後，影響此母群體接受篩檢的原因及成果。
本研究國立台灣大學公共衛生學院自1991年起，對台灣地區七個鄉鎮，30-64歲38,035位已婚婦女邀請參加子宮頸癌早期篩檢計畫，並結合全民健保婦女子宮頸抹片檢查資料檔、衛生署癌症登記檔及死亡檔，追蹤為期十年之篩檢相關資料。其中健保後有65.07%婦女曾做過一次抹片篩檢，遠高於1991年前的不及30.0%。最後選取符合研究資格並實際受訪的10,780人為樣本，其中健保後至少每三年定期篩檢者佔53%，並以邏輯斯回歸、存活分析推論之。
研究結果發現影響十年中10,338位子宮未切除且存活婦女，在全民健保後定期接受子宮頸抹片篩檢的原因，包括年齡較高、教育程度及收入較低、健保前無保險、加入計畫案到健保前無定期篩檢之婦女，較不定期接受篩檢。而進入計畫案前曾有篩檢過或曾因婦科疾病就醫、加入計畫案到健保前有定期篩檢及曾子宮頸抹片或攝影為陽性者，較會定期接受篩檢。
由10,780位十年內找出切片確診陽性的426人中，定期接受篩檢對於抹片篩檢成果較佳，其摘要如下：進入研究計畫前一年（含）內，有做過子宮頸抹片篩檢者（38.26％），之後定期至少每三年篩檢切片確診為侵襲癌的機會較高度病變低（十年追蹤期間log-rank p=0.0246）。而不管過去有無做過抹片，之後有定期篩檢切片得病的機會都較無定期者低（p<0.05）。十年內有定期至少每兩年篩檢者，切片得低、高度病變的機會較不定期（無至少每三年篩檢）者低（p均<0.0001）。不定期篩檢者切片高度病變發生的機會高於低度病變（p <0.0001）。每年定期篩檢之成果與每兩年及每三年定期篩檢之成果均未達統計上的顯著差異（p > 0.2），但若能進一步鼓勵有高危險因子之婦女，每年定期抹片篩檢，則可提早發現低度病變，而使得侵襲癌不易發生，並能有效節省醫療資源。

In Taiwan, although cervical cancer is one of female common cancer diseases, it is the easiest to detect early and therefore treat effectively by the cervical Papnicolaou (Pap) smear test. The national health insurance had performed free service for the Pap smear screening test since July 1995 to establish the need of long-term regular follow up of cervical pre-cancerous diseases. Dose this effort really increase women’s medical utilization and decrease the occurrence of cervical invasive cancer？Therefore, the purpose of this study is to evaluate utilization factors and effects of universal health insurance on cervical Pap smear test in Taiwan.
This study invited 38,035 married women who aged 30-64 years old lived in seven communities of Taiwan for free cervical Pap smear test. Database sources were form the cervical cancer research plan conducted by the college of Public Health, National Taiwan University since 1991, and were further linked to the national files of the cervical Pap smear tests, cancer registry, and death from the department of health. There was 24,749 women (65.07%) who had at least one cervical Pap smear test after June 1995, much higher than that prior to 1991 ( <30 % ). The final sample was 10,780 women who met all our research criteria and actually responded to fill the questionnaires. After ten-year follow up, 5,709 women had regular within-three-year Pap smear screening test, and logistic regression analysis and survival statistical analysis were performed.
For the 10,338 survival women without hysterectomy, low utilization factors of regular Pap smear test after the national health insurance were on the woman who had older age, low education level, poor income, no insurance and irregular Pap smear test prior to the national health insurance. On the other hand, high utilization factors are on the women who had ever had the cervical Pap smear test or gynecological dieases prior to study entry, Pap smear test/cervicgraphy positive finding or regular Pap smear test prior to July 1995.
For 426 women who had cervical intraepithelial neoplasia (CIN) or cervical invasive cancer among 10,780 women confirmed by biopsy during 1991-2001, the results of regular Pap smear test were better than irregular one as summarized in the following contents. Having the Pap smear test within one year prior to study entry (38.26%), the chance of occurrence in cervical invasive cancer is lower than CIN2/3 for subsequently regular within-three-year Pap smear screening test (log-rank p=0.0246). Regardless of past history of the cervical Pap smear test, the occurrence of CIN and invasive cancer on regular within-three-year Pap smear test was lower than that of irregular one (p<0.05). During ten-year follow up period, regular within-two-year Pap smear test on the CIN occurrence was lower than that of irregular one (beyond three years). The occurrence of CIN2/3 on irregular (beyond three years) was higher than that of CIN1 (p <0.0001). Although there was no statistically significant difference among the results of regular one-year, two-year, and three-year Pap smear test (p>0.2), the women in high risk group of developing cervical cancer are encouraged to have regular one-year Pap smear test in order to detect CIN early for avoiding cervical invasive cancer, and therefore saving medical costs effectively.

目錄
頁數
誌謝 I
國立台北護理學院醫護管理學系碩士論文中文摘要 II
ABSTRACT (英文摘要) IV
目錄 VII
表目次………………………………………………………………………………..IX
圖目次 XI
第一章 緒論 1
第一節 研究背景及動機 1
第二節 研究目的 3
第三節 研究重要性 4
第二章 文獻探討 6
第一節 子宮頸癌與子宮頸抹片篩檢 6
第二節 影響婦女接受篩檢的原因 8
第三節 子宮頸篩檢間隔及定期篩檢 11
第四節 子宮頸抹片篩檢與子宮頸癌發生率、死亡率之下降 17
第三章 研究架構 19
第一節 概念性架構 19
第二節 概念性及操作性定義 20
第三節 研究假設 23
第四章 研究方法與設計 24
第一節 研究對象 24
第二節 資料處理 25
第三節 研究設計與資料分析 26
第五章 研究結果與結論 31
第一節 樣本描述 31
第二節 影響定期篩檢之因素 33
第三節 篩檢成果 42
第四節 假說檢定 59
第六章 討論與建議 60
第一節 研究摘要 60
第二節 研究推論 60
第三節 研究限制 65
第四節 未來研究方向與建議 65
參考文獻 66
中文部分 66
英文部分 68
附錄
附錄一 依實際接受第一次訪視的資料來計算樣本數 73
附錄二 健保1995年6月後每年、每兩年及每三年定期接受篩檢之1991/02-1992/12基線資料個別因素 75
表目次
頁數
表一 影響子宮頸抹片篩檢因素之相關研究……………………………………10
表二 各國篩檢計畫之實行情況…………………………………………………15
表三 原計畫案人數之計算…….…………………………………………………25
表四 樣本數計算…….……………………………………………………………26
表五 健保1995年6月後至2001年7月篩檢平均天數及日數（n=10,780人） ………………………………………………………………………….……….31
表六 樣本、受邀參加篩檢、及全國之婦女各年齡層人數百分比…….……….32
表七 健保1995年6月後至2001年12月篩檢次數 (n=10,780人)…………….32
表八 健保前後不同定義之定期篩檢人數分配（n＝10,780）……..…………….35
表九 健保1995年6月後每年定期接受篩檢之1991/02-1992/12基線資料聯合因素（Multivariable Logistic Regression）R2＝0.3109………………………………36
表十 健保1995年6月後每兩年定期接受篩檢之1991/02-1992/12基線資料聯合因素（Multivariable Logistic Regression）R2＝0.4811…….………………………..38
表十一 健保1995年6月後每三年定期接受篩檢之1991/02-1992/12基線資料聯合因素（Multivariable Logistic Regression）R2＝0.5681…………………………..40
表十二 健保前後（1991/02-2001/12）定期篩檢定義與篩檢出疾病嚴重度之人數與比例………………………………………………………………………………..46
表十三 健保前後（1991/02-2001/12）定期篩檢定義與切片結果嚴重度之人數與比例…………………………………………………………………………………..47
表十四 過去是否接受篩檢與篩檢出疾病嚴重度之人數與比例 ……………..48
表十五 過去是否接受篩檢與切片結果嚴重度之人數與比例…………………..48
表十六 各抹片結果與其定期篩檢不同定義每兩組比較之 log-rank p值….…..49
表十七 各切片結果與其定期篩檢不同定義每兩組比較之 log-rank p值……..50
表十八 過去是否接受篩檢與各抹片結果及其是否每三年定期篩檢每兩組比較之 log-rank p值……..……………………………………………………………….51
表十九 過去是否接受篩檢與各切片結果及其否每三年定期篩檢每兩組比較之 log-rank p值………..………………………………………………………………..52
圖目次
頁數
圖一：影響定期子宮頸抹片篩檢之因素及成果。 19
圖二：437人中篩檢間隔與其抹片結果為陽性的分析圖。 53
圖三：211人中篩檢間隔與其抹片結果為CIN1的分析圖。 53
圖四：190人中篩檢間隔與其抹片結果為CIN2/3的分析圖。 54
圖五：36人中篩檢間隔與其抹片結果為侵襲癌的分析圖。 54
圖六：426人中篩檢間隔與其切片結果為陽性的分析圖。 55
圖七：284人中篩檢間隔與其切片結果為CIN1的分析圖。 55
圖八：124人中篩檢間隔與其切片結果為CIN2/3的分析圖。 56
圖九：18人中篩檢間隔與其切片結果為侵襲癌的分析圖。 56
圖十：277人進計畫案前一年（含）內沒有做過抹片者至少每三年定期篩檢的抹片結果分析圖。 57
圖十一：160人進計畫案前一年（含）內有做過抹片者是否每三年定期篩檢的抹片結果分析圖。 57
圖十二：263人進計畫案前一年（含）內沒有做過抹片者是否每三年定期篩檢的切片結果分析圖。 58
圖十三：163人進計畫案前一年（含）內有做過抹片者是否每三年定期篩檢的切片結果分析圖。 58

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