Our findings with respect to health checkup type were associated with a significant difference in PCS and MCS scores among the public servants suggesting that public servants undergoing GPHC had higher PCS scores than are those undergoing SPHC. Furthermore, a declining trend with the increase in number of chronic diseases and scores of HRQoL indicates that as chronic diseases increase, PCS and MCS scores decrease. Similarly, there is a declining trend across GPHC, SPHC and NOHC.
Factors related to utilization of health checkup
We identified that 71.5% of public servants received health checkups, including GPHC and SPHC, this is greater than the report of 64.5% of citizens aged 40–64 who received health checkups from the Ministry of Health and Welfare . The difference may be accounted for by the fact that only public servants received subsidiaries. In terms of middle or higher socio-economic status, literature has indicated a positive relationship between higher income / social class and utilization rates of preventive services [16, 17].
The findings also showed that non-attendees, NOHC, are younger, male, have a lower educational level, unhealthy lifestyle and multiple chronic conditions compared to attendees; this complies with other study results [18–20]. Related factors like job characteristics, those who work in the administration sector, those in non-managerial positions, and shift work will be less likely to receive health checkups. Since the subsidiary for public servants is in accordance with their job grade, this may result in those with managerial positions attending health checkups and those with shift work failing to schedule checkups with health institutes. The reasons for not attending might include lack of awareness or knowledge, misunderstanding the purpose of the health checkup program, unwillingness to use preventive medicine, time constraints, and difficulties with access to general practices, and doubts regarding clinics as appropriate settings [21, 22].
Association between health checkup type and HRQoL
With respect to health checkup type were associated with a significant difference in PCS and MCS scores among the public servants suggesting that those undergoing GPHC had higher PCS scores than are those undergoing SPHC. The mean scores of PCS (51.2) and MCS (43.4) in the present study were varied across different countries, US study (48.6, 53.1), and the Whitehall II cohort study (51.2, 51.1), respectively . The score of PCS tended to similar to the Whitehall II cohort study while MCS was lower in our study, perhaps reflecting intrinsic cultural differences compared to the other two studies. Another reason is that public servants have been exposed to a high workload and job stress due to government organizations downsizing, manpower decreasing and the public demand increasing.
Our study shows that the mean scores of PCS and MCS of different types of health checkup decreased from Model 1 to Model 3 adjusted for demographics, job characteristics and life style as well as health status sequentially, and these factors are all related to HRQoL and health checkups. In model 1 and model 2, perhaps items included in GPHC are related to basic physical examination and laboratory tests, the score of PCS in GPHC are higher than the other groups, while the scores of MCS were lower in the NOHC group. This suggests that people’ with high health consciousness are more likely to have a desire for extensive health check-ups . In addition, self-paid physical checkup programs may complement government-sponsored health screening programs and add value to free or even mild disease screening for health maintenance and help provide good post-checkup care [25–27]. For the SPHC group, the fact that they may already have health problems means they tend to be willing to pay higher out-of-pocket expenses, especially if they have complementary private health insurance . That implies having diseases or good health awareness and perception have an influence to lead people to seek preventive health checkups.
HRQoL in relation to health checkup and number of chronic diseases
That people with multiple chronic conditions correspondingly had worse HRQoL than those with 1 or no chronic condition and that frequent physical distress was more common than frequent mental distress was consistent with previous studies [5, 29]. We found that public servants with more than 1 chronic disease condition who underwent GPHC are significantly more likely to report higher PCS scores than those undergoing SPHC. The pattern was GPHC was higher than SPHC and NOHC in score of PCS across 3 chronic conditions groups. Different subgroups, including those with no chronic disease, those with one chronic disease, and those with 2 or more chronic diseases, might exhibit different health-seeking behavior and health awareness. On the other hand, both PCS and MCS scores have a significant pair difference for each type of health checkup as the number of chronic conditions increases the score decreases and the two comparisons are statistically significant. Based on health utilization theory, periodic physical health checkup was an enabling factor of awareness of some disease and for disease literacy covering the knowledge of disease screening guidelines and risk factors . A study suggests that low HL may affect behaviors necessary for the development of self-management skills . Another consideration is that the specific disease and the diagnosis date were lacking in our data, we may extend our study to investigate the issue. Due to certain chronic diseases having more of an effect on up-to-date screening status than others for different cancers . In some countries, health was an instrumental value exploited as an economic resource not only during periods of well-being but also during illness, by individuals not seeking preventive or timely health care because of the fear of losing their jobs .
Strengths and limitations
This was the first nationwide study of public servants in Taiwan to investigate the association of preventive health checkup profiles with HRQoL, with both mean scores of PCS and MCS. The representative population was selected using PPS and consistent results were validated using both online- and paper-based questionnaires. Our results can aid in the implementation of an intervention program for high-risk groups and consequently be used for follow-up evaluations on the efficacy and effectiveness of the program. However, our study also has several limitations. First, establishing causality was difficult because of the cross-sectional design. Second, complete theoretical factors were not collected for each participant, such as components in the health belief model, self-rated physical factors, and mental outcome in the health utilization model. Third, chronic conditions play a critical role to motivate the seeking of health services as can be noted in Table 3. But the specific diagnosis time and disease need further investigation in future studies. Fourth, we cannot predict if some participants may receive a health checkup program that was covered by an insurance company not an out-of-pocket payment and resulted in the overuse of medical resources. Finally, the differences in preventive health checkup profiles between public servants and the general population encumbers the comparison of PCS and MCS scores.