title: Changes in geographic variation in the uptake of cervical cancer screening in Taiwan: possible effects of "leadership style factor"?
abstract: OBJECTIVE
  Wennberg proposed the "practice style factor" to explain the large variations in the use of medical care. As a corollary, we propose the "leadership style factor" of the director of the city/county bureau of public health to explain changes in geographic variation in the uptake of cervical cancer screening.
  
  
  METHODS
  We first calculated the triennial Pap smear rates for women aged 30-69 years from 1997 through 2010 for each city/county in Taiwan and the rate difference and rate ratio between the highest and the lowest city/county to illustrate the geographic variation in the uptake of cervical cancer screening. We then created an expert panel to conduct a hypothesis generation process to examine the possible effects of "leadership style factors" in explaining the changes.
  
  
  RESULTS
  The Pap smear rate in Taiwan as a whole was 35% in 1997 and increased to 56% in 2001, and was then stable until 2010 (55%). In 2002, the geographic variation in the Pap smear rate was the smallest, ranging from 49% in Penghu County to 63% in I-lan County, with a rate ratio of 1.28. Unfortunately, the rate ratio increased to 1.49 in 2010, the rate being lowest in Penghu County (42%) and highest in Tainan City (63%). We identified four cities/counties with unique patterns of change in Pap smear rates, which were highly associated with the leadership style of the director of the city/county bureau of public health.
  
  
  CONCLUSIONS
  Despite the launch of an organized cancer screening program in Taiwan, geographic variation in the uptake of cervical cancer screening still exists and has increased during the past decade. The "leadership style factor" of the director of the city/county bureau of public health might play a plausible role in explaining the pattern of change in geographic variation in the use of cervical cancer screening in Taiwan.
authors: Health Promotion Administration, Ministry of Health and Walfare, Taipei, Taiwan; Institute of Public Health, National Yang-Ming University, Taipei, Taiwan.
authors: Shu-Ti
authors: ST
authors: Chiou
authors: NCKU Research Center for Health Data and Institute of Public Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan. Electronic address: robertlu@mail.ncku.edu.tw.
authors: Tsung-Hsueh
authors: TH
authors: Lu
mesh_terms: D000328:Adult; D000368:Aged; D055088:Early Detection of Cancer / Q000706:statistics & numerical data*; D005260:Female; D062306:Geography, Medical; D006801:Humans; D007857:Leadership; D008875:Middle Aged; D065006:Papanicolaou Test / Q000706:statistics & numerical data*; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012041:Regional Medical Programs / Q000458:organization & administration / Q000706:statistics & numerical data; D013624:Taiwan / Q000453:epidemiology; D002583:Uterine Cervical Neoplasms / Q000517:prevention & control*
keywords: Cervical cancer; Population-based organized cancer screening program; Preventive services utilization; Small-area variation; Taiwan