To compare the Pap test use rate between women with intellectual disabilities and women without disabilities, we conducted further analysis. We matched women with intellectual disabilities with women without disabilities in the general population at a ratio of 1:5 by using age as the variable. Women with intellectual disabilities (N = 13,271, mean age 44.99 years ± 11.36) exhibited a significantly lower Pap test use rate (6.14%) than did (26.78%) women without disabilities (N = 66,355, mean age 45.15 ± 11.41).
The factors significantly associated with Pap smear test use identified in this study were similar to those identified in a previous study conducted by Huang et al. , who examined all disabled women aged over 30 years. In this study, which included women with intellectual disabilities, we observed that aboriginal women exhibited significantly higher Pap smear test use than did non-aboriginal women. This is because most aboriginal people live in rural areas, and the Pap smear test is provided through mobile medical care in rural areas. The mobile medical care program regularly travels through rural areas and government strongly encourages rural residents to use the free preventive medical services. We observed that physical disability was the most common type of disability (37.89%) . Women with intellectual disabilities who underwent the Pap smear test had easier access to mobile medical care than did women with physical disabilities.
The results of this study conform to those of previous research, which contend that Pap smear test use reduces with increases in age [20–22]. Regarding residence, Pap smear test use rate among people residing in areas with lowest urbanized (i.e., Level 8 of urbanization) was significantly higher compared to that for people living in regions with most urbanized (i.e., Level 1). This finding was consistent with that reported by Chen et al. . Furthermore; this phenomenon resulted from the implementation of NHI in 1995, before which studies showed that the use of Pap smear tests in urban regions exceed that in rural areas . Lin et al.  further verified this point by comparing the Pap smear test usage of Taiwanese women before and after the implementation of NHI in 1995. In addition, Taiwan implemented the Integrative Delivery System (IDS) program in 1999. The primary function of the IDS program was to improve the medical accessibility of rural areas, thereby enhancing the health care acquisition of residents in these areas. The cervical cancer screening rate was among the primary criteria for assessing project effectiveness , thereby increasing the use of Pap smear tests in rural areas [21, 23, 25].
Regarding economic aspects, the Pap smear test usage rate among women with intellectual disabilities rose with increases in their premium-based monthly salary, exhibiting a positive correlation. The usage rate for people with a premium-based salary of > NT$15,840 (including the dependent population) was higher than that for users with monthly salary of < NT$15,840. This result was consistent with that reported in a U.S. study (2010), which contended that disabled persons with high incomes exhibit greater Pap smear test usage . The usage rate among the aboriginal population exceeded that of the non- aboriginal population (OR = 1.73, 95% CI =1.08-2.76). Despite the overall middle-to-low income of the aboriginal population (which may reduce utilization rate), their Pap smear test usage rate was greater compared to the non- aboriginal population because the Taiwanese government has made considerable efforts to reduce the gaps in income and health care between urbanized and rural areas. A great proportion of aboriginal people reside in rural areas, and the medical vehicles that provide Pap smear tests regularly visit these areas to offer health care services, thereby improving the Pap smear test usage rate among aboriginal women. The Pap smear test usage rate of the married population was substantially greater than that of the unmarried population, which is consistent with the findings reported in previous studies [6, 22, 27]. This phenomenon may be because of the common misconception held by the public and physicians that unmarried people do not or seldom engage in sexual activity and, thus, are less susceptible to cervical cancer. In addition, Asian women generally possess more conservative concepts compared to Western women, and tend to believe in maintaining virginity until marriage . Consequently, women in Asia are less likely to accept this type of preventative health care before being sexually active. Thus, the Pap smear test usage rate for the unmarried population is substantially lower than that for the married population.
Persons with DM exhibited a higher odds of Pap smear test use compared to that for people without DM (OR = 1.41, 95% CI = 1.14-1.74). Pandey et al.  found that DM increases cancer risks. Specifically, type 1 DM directly affects cervical cancer. Whether DM patients are more likely to receive Pap smear tests for this reason requires further investigation. In addition, DM patients must undergo regular health checks; therefore, they have more contact with paramedics and are more likely to receive Pap smear tests following the advice or information provided by paramedics. Regarding the severity of disability, the usage rate of mildly disabled people was substantial, which conforms to the findings of a study conducted in 2010 on women with intellectual disabilities . For primary care givers or paramedics, communication difficulties may occur when administering Pap smear tests to women with severe intellectual disabilities. Furthermore, substantial time and manpower are required for this process; thus, the provision of preventative health care to severely disabled women is extremely difficult.
We provide the following recommendations: (a) The knowledge of the Pap smear test of women with intellectual disabilities who exhibit a low usage rate and that of these women’s primary care givers must be enhanced. Insufficient relevant knowledge is a factor associated with women neglecting to undergo Pap smear tests . McAvoy and Raza  indicated that individual interviews and family viewing of educational videos are the most effective methods for enhancing knowledge of Asian women regarding Pap smear test. (b) Rewards proportional to the disability severity of patients should be provided to physicians as an incentive increasing physicians’ willingness to assist women with intellectual disabilities in undergoing Pap smear tests. Lennox et al.  stated that providing health care to disabled people involves considerable difficulties (e.g., communication difficulties, poor compliance, examination difficulties, and excessive time consumption); therefore, payment increases may be a practical and effective solution for enhancing the quality of health care provided by physicians. (c) Female physicians should be encouraged to receive service training to provide health care to specific patient groups, thereby increasing the opportunities of women with intellectual disabilities to receive Pap smear tests administered by female physicians. Fylan  determined that women do not undergo Pap smear tests because of concerns regarding awkwardness, pain, and fear. A previous study indicated that, overall, women prefer to undergo Pap smear tests administered by a female physician and that being administered the test by a female physician increases their willingness to undergo Pap smear tests .
This study referenced numerous databases to investigate the Pap smear test usage of women with intellectual disabilities based on data from 2008. However, the referenced databases did not include information regarding the participants’ health beliefs and lifestyles. Therefore, this study is limited by the difficulty of further analysis. In addition, data obtained from the NHI Research Database has inherent limitations; specifically, the premium-based monthly salary does not completely reflect the real salaries or income of the women with disabilities.