Development of Screening for Common Gynecological Diseases in Chinese Women (2007- 2020)

doi:10.21203/rs.3.rs-3209169/v1

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Development of Screening for Common Gynecological Diseases in Chinese Women (2007- 2020)

https://doi.org/10.21203/rs.3.rs-3209169/v1

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Background: The study aimed to analyze trends in the implementation of common gynecological disease screening in China under the influence of policies.

Methods: An interrupted time series analysis with segmented linear regression was performed using gynecological disease screening data from 2007 to 2020 obtained from the official government statistical website. Statistical analysis focused on two important time points: the relaxation of the family planning policy and the major institutional reforms in the health sector in 2014 and the elevation of the "Healthy China Strategy" as a fundamental national policy in 2017.

Results: Our results indicate an overall increasing trend in the screening rate, increasing from 38% to 86.58%. Prior to the relaxation of the family planning policy and the health sector reforms, the screening rate increased annually by 4.64% (P < 0.0001, CI= [3.06, 6.21]). However, in the first year of policy implementation, there was a 21% decrease (P ＜ 0.0001, CI= [-27.8, -14.2]). The COVID-19 pandemic in early 2020 also partially hindered screening progress, resulting in a decline in the annual growth rate from 10.16% to 4.13%.

Conclusion: Women's health issues are receiving increasing attention, and the rising screening rates for gynecological diseases are due to the joint efforts of various stakeholders, including the government, society, and individuals. However, policy changes and environmental factors can impact the organized implementation of gynecological disease screening. Therefore, it is necessary to establish robust implementation plans and efficient process management to effectively address potential risks.

Common gynecological diseases

Screening

Women's healthcare

Policy

Common gynecological diseases are those affecting the female reproductive organs or breasts, which significantly impact women's health.¹ They mainly include cervical and breast diseases, reproductive tract infections, and other reproductive system diseases. Symptoms often include irregular menstruation, white vaginal discharge, itching of the external genitalia, burning sensation during urination, and groin area swelling. These symptoms cause significant distress and pain in daily life. Severe cases can also affect fertility, and reproductive functions, potentially leading to death.²

Over the past 30 years, significant progress has been made in global women's health, with substantial resources and political attention dedicated to improving maternal health. However, benign gynecological diseases continue to severely impair quality of life for women.³ Gynecological diseases account for approximately 4.5% of the global disease burden, surpassing the incidence and disability caused by other major global health priorities such as maternal health, tuberculosis, malaria, and cardiovascular diseases.⁴

Screening for common gynecological diseases in women helps to identify reproductive tract infections, cervical cancer, breast cancer, and other conditions at an early stage, enabling prompt treatment and improved prognosis. Many countries worldwide have successfully implemented long-term and sustained screening programs for common gynecological diseases, yielding significant results.^5–8 In high-income countries like the United States, cervical and breast cancer mortality rates have declined in recent years due to widespread screening programs. These programs facilitate early detection, diagnosis, and treatment, providing women with increased opportunities to access high-quality gynecological care. However, in resource-poor countries, women often have limited or no access to specialized care.⁹ Additionally, in many countries, deep-rooted gender biases and inequalities result in a lack of prioritization for women's health.^10–12

The Chinese government has consistently focused on early diagnosis and treatment of common gynecological diseases. It explicitly stipulated that the prevention and treatment of common gynecological diseases are an important component of primary healthcare for women and children.¹³ Under the government leadership, China has implemented, organized, and sustained screening programs for common gynecological diseases targeting women. Grassroot healthcare workers collect and report relevant data on annual screening for these diseases to the central authorities. The data mainly comes from public health service programs in China, such as cervical and breast cancer screening, screening for common gynecological diseases, pre-pregnancy health promotion, and premarital medical examinations. Diseases covered include urinary fistula, second-degree or higher uterine prolapse, trichomoniasis, cervicitis, condyloma acuminatum, HIV/AIDS, gonorrhea, cervical cancer, breast cancer, and ovarian cancer.¹⁴

Since the 1950s, China has initiated comprehensive screening programs for common gynecological diseases among women, making significant progress in areas including sexually transmitted infections such as trichomoniasis, uterine prolapse, urinary fistula, menstrual disorders, and cervical cancer.^15–17 In the early 1970s, China implemented the family planning policy, which focused on birth control and encompassed sexual education, preconception counseling and management, prenatal care, infertility treatment, sterilization, and induced abortion services related to reproductive health. During this period, screening for common gynecological diseases was mainly conducted in conjunction with family planning initiatives and carried out by personnel from the family planning department.^18,19

In 2006, the National Health Commission of China emphasized the importance of actively conducting comprehensive screening and treatment programs for common gynecological diseases such as reproductive tract infections, sexually transmitted diseases, cervical cancer, and breast diseases.²⁰ In 2010, the government set a target for China to achieve an 80% coverage rate of screening for common gynecological diseases by 2020.²¹

However, in 2013, China underwent a large-scale government institutional reform by merging the Ministry of Health and the National Population and Family Planning Commission into the National Health and Family Planning Commission (NHFPC).²² The reform aims to strengthen the integration of maternal and child health and family planning technology service resources, and further promote the construction of the maternal and child health service system. Following the reform, the NHFPC carried out a series of maternal and child health and family planning initiatives including improving service networks and enhancing training for professionals in the field.

In early 2014, China officially implemented the "Two-Child Policy," in response to the demographic situation. This policy allowed families with one child only to have a second child, provided the first pregnancy was not a multiple birth.²³ The relaxation of this family planning policy had a significant impact on the screening of common gynecological diseases, shifting the primary focus of the screening work away from contraception and birth control.²⁴ Previously, under the traditional family planning policy, the screening of common gynecological diseases was closely tied to contraception and birth control. The government and medical institutions included the screening of these diseases as part of their family planning services with the aim to help women maintain their health and control their fertility. However, with the implementation of the "Two-Child Policy," the screening of common gynecological diseases was no longer limited to contraception and birth control. Instead, it now focuses more on women's health and disease prevention. Consequently, the goals and priorities of screening for common gynecological diseases have been adjusted following the implementation of the "Two-Child Policy." In addition to addressing contraception and birth control needs, the screening work emphasizes early detection and treatment of gynecological diseases, such as cervical and breast cancer, and endometriosis to improve women's overall health. To achieve these objectives, the government, and medical institutions aim to strengthen women's health promotion and education, and provide more comprehensive screening and treatment services for common gynecological diseases to meet the diverse needs of women.

In 2016, China introduced the "Healthy China 2030" Planning Outline with the aim of achieving high-quality universal health coverage by 2030.²⁵ In 2019, the Chinese government issued the "Healthy China Action (2019–2030)" as a strategic framework for advancing national health.²⁶ The same year witnessed the inclusion of the "Two Cancers" screening program for rural women in the government’s management of essential public health service projects. This inclusion further facilitated the normalization and institutionalization of screening practice for common gynecological diseases among women.²⁷

It is evident that significant policies enacted by China at different stages of development have put forth different requirements for the implementation of screening for common gynecological diseases, ensuring the continuous implementation of such screening initiatives. These policies have also influenced the implementation of screening initiatives to varying degrees (Fig. 1).²⁸ Thus, this study aimed to improve the provision of continuous and stable healthcare services for women. We utilized the gynecological common disease examination data published in the "China Health and Health Statistical Yearbook" from 2007 to 2020. We employed the Interrupted Time Series (ITS) method using segmented linear regression to analyze the changing trends in the gynecological common disease examination work in China under the influence of policy changes. Specifically, we examined the impact of the 2014 relaxation of the family planning policy, the major reforms in the health sector, and the elevation of the "Healthy China Strategy" to a basic national strategy in 2017. This study aimed to review the historical evolution and achievements of gynecological disease screening in China, explore the current challenges and difficulties faced in implementing this work, analyze the possible next steps and priorities, and provide scientific evidence for the Chinese government and other countries for formulating policies related to the prevention and treatment of common gynecological diseases.

Data sources

The data on screening for common gynecological diseases in China from 2002 to 2020 was sourced from the "China Health and Family Planning Statistics Yearbook" from 2003 to 2017, and the "China Health Statistics Yearbook" from 2018 to 2021. It includes information on the year, province, number of individuals eligible for screening, number of individuals screened, screening rate, and prevalence rate of diagnosed gynecological diseases. The survey involved comprehensive investigations, with data collected and summarized by county- and district-level maternal and child health hospitals. The findings were reported at each level and subsequently aggregated and reported to the central level by provincial departments. The national number of individuals screened is the sum of the screening numbers from each province.^13,14,29 The survey covers mainland China and excludes Hong Kong, Macau, Taiwan, and some islands in the South China Sea.

Due to changes in data collection methods, the scope of the data from 2002–2006 was limited to married women under the age of 65 within the local household population. However, after 2007, the survey scope was adjusted to females aged 20–64 in the registered residence population. Considering the impact of the family planning policy and the "Healthy China 2030" strategy, both of which were released after 2007, this study focused on the analysis of data from 2007 to 2020 to examine the changing trends in screening for common gynecological diseases in China under the influence of different policies during different periods.

Data analysis

Excel was used to conduct a trend analysis on the number of common gynecological diseases examined and the examination rate of such diseases in China from 2007 to 2020. The objective was to gain insight into the overall state of common gynecological disease examination in China over the past 14 years. During the data analysis, the number of individuals who should have undergone screening was found to be significantly lower in the years 2008–2010 compared to other years. According to the regulations of the "National Maternal and Child Health Survey System," the number of individuals who should be screened for common gynecological diseases is calculated by dividing the total number of registered women aged 20 to 64 within the statistical year by the screening cycle. Comprehensive screen is required for all registered women aged 20 to 64 within the jurisdiction every three years.²⁹ Therefore, the number of individuals who should be screened for common gynecological diseases each year is obtained by dividing the total population of registered women aged 20 to 64 within the year by 3. Since the number of individuals who should be screened is only related to the actual population size within the year and considering that the population size does not undergo significant changes each year, a correction was made to the number of individuals who should be screened for the years 2008–2010 using the population data from the "Population Statistics Table by Age and Gender" in the "China Statistical Yearbook".

By constructing a segmented regression model, we analyzed the changes in the level and slope of intervention factors. The ITS method was used to build the model: Y_t = β₀ + β₁ time + β₂ intervention + β₃ post.³⁰ In this equation, Y_t represents the observed outcome at the time "t " (specifically, the screening rate of common gynecological diseases in this study). The variable "intervention" is a dummy variable indicating whether the policy has occurred, while "Post" is another time variable representing the period from the policy intervention until the end of the study.

β ₀ represents the constant term in the model, indicating the initial level of the dependent variable, which in this case is the screening rate for common gynecological diseases at the beginning of the study. β₁ represents the slope before the policy intervention, reflecting the existing trend. β₂ captures the difference between the observed outcome when the policy was implemented and the counterfactual outcome that would have occurred if the policy had not been implemented, thereby reflecting the immediate effect of the intervention. β₃ represents the change in slope before and after the policy intervention, reflecting the sustained effect of the intervention.

The Stata software was used to conduct the ITS analysis at two specific time points: 2014, when the family planning policy was relaxed and healthcare sector reform was introduced, and 2017, when the "Healthy China Strategy" became a fundamental national policy. The aim was to observe the impact of policy implementation or major institutional reforms on the routine implementation of screening programs for common gynecological diseases.

The Examination rate for common gynecological diseases showed an increasing trend

The results showed a substantial overall increase in the number of Chinese women undergoing screenings for common gynecological diseases in China from 2007 to 2020. In 2020 alone, a staggering 112.7 million women aged 20–64 participated in screenings for common gynecological diseases, constituting approximately one-fourth of the total female population.

Between 2007 and 2013, the screening rate for common gynecological diseases in China gradually increased from 38–68.67%. However, in 2014, there was a significant decline in the screening rate, followed by a slow recovery in the subsequent years. It was not until 2017 that the screening rate reached the level observed in 2013. From 2017 to 2019, there was a significant acceleration in the rate of increase surpassing 80% in 2019, thus meeting the national target for screening coverage. Although there was a slight decrease in the rate of increase from 2019 to 2020, the screening rate for common gynecological diseases in China had reached 86.58% by the end of 2020. (Fig. 2)

The relaxation of the family planning policy had a negative impact on the screening for common gynecological diseases in China for a certain period

The relaxation of the family planning policy prompted more women of childbearing age who had already given birth to one child and married women who had not yet given birth but planned to have a second child to actively consider and prepare for pregnancy. The data shows that China’s fertility rate slightly increased after the relaxation of the family planning policy.²³ The increased desire for childbirth led women to place more emphasis on their own health and reproductive capacity. Furthermore, the merger of the National Population and Family Planning Commission with the Ministry of Health signified a close integration of family planning efforts with women’s health and reproductive healthcare at the national and policy levels.¹⁸

The institutional reform at the end of 2013 and the relaxation of the family planning policy in 2014 further promoted the implementation of screenings for common gynecological diseases. Using 2014 as the breakpoint, an ITS analysis was performed on the screening rate for common gynecological diseases from 2007 to 2020 to assess the impact of this policy on the screening efforts for common gynecological diseases.

The results revealed that the initial screening rate for common gynecological diseases in China was 43.10%. Prior to the relaxation of the family planning policy in 2014, the screening rate for these diseases increased by 4.64% annually (P < 0.0001, CI = [3.06, 6.21]). However, in the first year of policy implementation, the screening rate declined by 21% (P < 0.0001, CI = [-27.8, -14.2]). This decline corresponds to β₃, indicating that the increase in the screening rate for these diseases has further increased by 0.67 (P = 0.383, CI = [-0.97, 2.31]) compared to the pre-intervention increasing trend of 4.64%. Moreover, the observed annual increase of 5.31% in the screening rate for common gynecological diseases after the policy implementation was not statistically significant since p > 0.1. (Fig. 3, Table 1)

Table 1

ITS Analysis Results of Examination Rate from 2007 to 2020 (Considering 2014 as the Breakpoint)
Independent variables	Coefficient	Standard Error	t	P-value	95% CI
Constant β₀	43.10	2.72	15.85	0.000	37.04	49.15
Secular trend β₁	4.64	0.71	6.57	0.000	3.06	6.21
Change in level β₂	-21.00	3.05	-6.88	0.000	-27.80	-14.20
Change in trend β₃	0.67	0.74	0.91	0.383	-0.97	2.31

Impact of healthy China policy on the examination of common gynecological diseases in China

The Healthy China 2030 plan, released on October 25, 2016, marked the first long-term strategic plan in the health sector at the national level since the establishment of the People’s Republic of China. It serves as a guiding framework for promoting the construction of a healthy China over the next 15 years. The government has implemented a series of basic and major public health service projects to further enhance the women’s health service system. These efforts include improving the coverage and quality of cervical and breast cancer screenings. To assess the impact of the Healthy China policy on the promotion of gynecological disease screenings in China, an ITS analysis was conducted on the gynecological disease screening rates from 2014 to 2020, with the year 2017 as the breakpoint.

The results showed an initial gynecological disease examination rate of 55.70%. Prior to 2017, the examination rate for common gynecological diseases increased annually at a rate of 4.67% (P = 0.005, CI = [2.63, 6.71]). However, since the corresponding coefficients for the level change (β₂) and trend change (β₃) had p > 0.1, no statistically significant evidence was found to suggest a direct causal relationship between the implementation of the Healthy China policy and the changes in the examination rate of common gynecological diseases in China. (Fig. 4, Table 2)

Table 2

ITS Analysis Results of Examination Rates from 2014 to 2020 (Considering 2017 as the Breakpoint)
Independent variables	Coefficient	Standard Error	t	P-value	95% CI
Constant β₀	55.70	0.77	72.32	0.000	53.25	58.15
Secular trend β₁	4.67	0.64	7.29	0.005	2.63	6.71
Change in level β₂	-1.66	1.41	-1.18	0.323	-6.13	2.82
Change in trend β₃	1.99	1.07	1.85	0.161	-1.43	5.40

Impact of COVID-19 on Examination of common gynecological diseases in China

Additionally, this study found that compared to 2019, the examination rate of common gynecological diseases in China slightly increased in 2020, however, the annual growth rate significantly decreased from 10.16–4.13%. Previous research has shown that the outbreak of the COVID-19 pandemic in early 2020 hindered screening progress to some extent, which is confirmed by this study.³¹ However, despite the pandemic’s impact, the implementation of various policies promoting women’s healthcare has contributed to an improvement in the examination rate of common gynecological diseases in China.

Women's health care is increasingly valued

The Chinese government has been committed to improving women’s health, particularly in examining and preventing common gynecological diseases via the implementation of relevant policies and guidelines, strengthening of the public health service system, and providing economic support and subsidies. The government aims to promote the popularization of gynecological disease examinations and improve the quality of these examinations.²⁸ Particularly during a relatively underdeveloped economic growth period, the government attaches great importance to the health issues of impoverished women. Over the past few decades, the Chinese government has achieved significant results through nationwide surveys and treatment activities for women's diseases.³² Thus, the prevalence of diseases that affect women's health, such as uterine prolapse, urinary fistula, sexually transmitted infections, and vaginitis, have been effectively reduced.¹⁵

By conducting surveys and providing treatment for women's diseases, the government can timely identify common gynecological diseases and provide corresponding treatment and prevention measures. Additionally, the government is strengthening public education, enhancing awareness of gynecological diseases, and encouraging regular examinations to detect issues early. These efforts promote comprehensive women's health development and increase the rate of gynecological disease examinations, providing strong support for women's healthcare. Overall, the long-standing commitment of the Chinese government to women's health, along with a range of measures taken, has led to an increasing trend in the rate of gynecological disease examinations. This helps improve quality of life for women, reduces the impact of diseases on their health, and increases survival rate while reflecting the government's concern for and protection of women's rights and well-being.^33–35

The continuous increase in the rate of gynecological disease examinations is also attributed to the attention and support from society. Social and non-profit organizations, and women's health groups actively participate in promoting gynecological disease examinations by conducting promotional activities, providing information and consultation, and assisting in arranging examination services. Additionally, extensive media coverage and information dissemination on social platforms also contribute to raising women's awareness and consciousness about gynecological disease examinations.

The increase in the rate of gynecological disease examinations is also closely related to individuals' health awareness and proactiveness. With the popularization of health education and the improvement of medical services, increasing number of women have realized the importance of early detection and prevention.³⁶ Thus, attention to their health and proactive pursuit of medical services have contributed to the continuous increase in the rate of gynecological disease examinations.

Developing a long-term mechanism for gynecological common disease examination

The relaxation of the family planning policy had a significant negative impact on gynecological disease examination. Within 3–4 years, as the family planning policy gradually and eventually relaxed, the rate of gynecological disease examination experienced a sharp decline due to the dual effects of institutional reforms and policy changes. It was not until 2017 that the rate gradually recovered to the level observed before the implementation of the two-child policy. According to a survey conducted by the China Center for Women and Children's Health in 2017, the merged Family Planning Commission and Ministry of Health lacked dedicated funding support. As a result, some grassroot institutions had to raise funds on their own, which posed great difficulties.³⁷ Additionally, with the policy shift, a series of reproductive health-related services primarily focused on contraception and family planning weakened, leading to a decrease in the gynecological disease examination rate.

However, since 2014, the gynecological disease examination rate in China has shown an increasing trend, indicating that the work has resumed with new responsibilities in the new era. Despite the challenges, the government continues to emphasize women's health and awareness about gynecological disease examinations. Measures have been gradually implemented to ensure the smooth progress of the work.³⁸ These measures include exploring new ways of funding support, strengthening capacity building, training at the grassroot level, and integrating reproductive health services, among others. With increased healthcare investment in China, government policies actively promoting the prevention and treatment of women's health and gynecological disease issued are being effectively implemented at the grassroot level leading to increased attention and screening. Additionally, the three-level, county-township-village, maternal and child health care service network established in China provides a solid foundation for the comprehensive implementation of various public health projects. It also serves as a prerequisite for ensuring the implementation of policies concerning women's health in the remotest areas of China.¹³ The government's efforts have gradually restored the growth of the gynecological disease examination rate, providing better protection for women's health.

Our results revealed that policy changes, institutional reforms, and major public health emergencies, caused temporary difficulties in the screening of gynecological diseases resulting in significant fluctuations in the screening rates. However, this challenge is not unique to China but is faced by several countries worldwide, characterized by declining birth rates and negative population growth which highlights the increasing importance of prioritizing women's health, particularly in protecting their reproductive health.

The successful implementation and management of gynecological disease screening programs requires resilience. Therefore, it is essential for the government to predict and assess the potential negative impacts of policy or environmental changes timely and make adequate preparations to achieve sustainable development. Additionally, active development and utilization of technological means are necessary to adapt to and cope with the continuously changing environmental conditions.^39–41 Maintaining close communication with grassroot service providers and women is also crucial to ensure that their needs and interests are fully considered, and timely adjustments are made during the implementation of the work.

In future, the government needs to comprehensively plan and evaluate the implementation of gynecological disease screening programs, considering potential risks and uncertainties, and formulate corresponding response measures. With enhanced systematic planning of gynecological disease examination and the ability to adapt to the demands of the new era, the gynecological disease examination rate is expected to continue to increase, making a greater contribution to women's health.

The success achieved in screening of common gynecological diseases in China fully demonstrates the necessity and effectiveness of conducting gynecological examinations. This provides successful experiences for women's health work in China and serves as a reference template for global efforts in women's health. However, this study also had certain limitations. Firstly, as a populous country, China exhibits cultural and geographical variations among its provinces, leading to differences in the spectrum of common gynecological diseases and variations in the level of effort and financial investment in gynecological screening across different regions. Secondly, this study only conducted a trend analysis of the overall situation of gynecological disease screening in China, overlooking the differences between different diseases and regions. Therefore, future research should investigate these issues further to provide a more comprehensive analysis and guidance.

In conclusion, the continuous increase in the rate of gynecological disease examinations in China is the result of collaborative efforts from various stakeholders, including the government, society, and individuals. Government policy support and investment, societal attention, and involvement, as well as individual health awareness and proactiveness, have collectively promoted the development and improvement of gynecological disease examination. This sustained upward trend facilitates early issues detection, timely treatment, and overall improvement of women's health.

National Health and Family Planning Commission - NHFPC

Interrupted Time Series - ITS

Ethical Approval and consent to participate

There are no human or animal studies in this manuscript, and no potentially identifiable human images or data is presented in this study.

Consent to Publication

Not applicable

Data Availability statement

The data used in this study were sourced from publicly available data on the Chinese government website, with the official website being http://www.stats.gov.cn/sj/.

For this study, data related to the screening of common gynecological diseases from the "China Health and Family Planning Statistics Yearbook" for the years 2007 to 2020 were extracted, compiled, reviewed, and corrected. If you wish to access the original analytical data used in this study, you may contact the corresponding author with reasonable requests for access.

Conflict of interest

The authors declare that they have no competing interests.

Funding

The Chinese Academy of Medical Sciences (CAMS) Innovation Fund for Medical Sciences—A Strategic Study on Healthy China Development and Health system Reform (2021-I2M-1-046).

Author contribution

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Zixuan Fan, Peihan Wang and Chenyang Pei. The first draft of the manuscript was written by Zixuan Fan and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Development of Screening for Common Gynecological Diseases in Chinese Women (2007- 2020)

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Abstract

Figures

Background

Methods

Data sources

Data analysis

Results

The Examination rate for common gynecological diseases showed an increasing trend

Impact of healthy China policy on the examination of common gynecological diseases in China

Impact of COVID-19 on Examination of common gynecological diseases in China

Discussion

Women's health care is increasingly valued

Developing a long-term mechanism for gynecological common disease examination

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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