Medical Care-seeking Patterns Among Women with Diagnoses Associated with Menstrual Syndromes: A Longitudinal Population-based Study

Background: This study aimed to explore women’s tendency to seek Traditional Chinese Medicine and/or Western Medicine when newly diagnosed with menstrual syndromes, and to identify factors associated with their medical care-seeking behavior. Methods: Women aged 15 to 50 years with newly diagnosed menstrual syndromes were selected from Taiwan’s 2005 National Health Insurance Database. Follow-up was divided into 10 time-periods (1-6, 7-12, 13-18, 19-24, 25-30, 31-36, 37-42, 43-48, 49-54 and 55-60 months) after patients’ rst visits for obstetric/gynecologic care. Patients’ tendency for medical care utilization was estimated using Poisson regression. Unadjusted and adjusted relative risks and their 95 % condence intervals were calculated. Results: The number of Traditional Chinese Medicine utilization was 0.69, and Western Medicine utilization was 1.75 within six months after the rst menstrual syndrome diagnosis. The tendency for Traditional Chinese Medicine utilization increased as follow-up time increased after controlling for potential confounders, while Western medicine utilization decreased gradually as follow-up time increased. Women’s age, economic status, infertility, value of prevention, baby delivery and Obstetric/ Gynecologic inpatient histories were signicantly associated with their medical care-seeking behavior. Conclusions: Traditional Chinese Medicine and Western Medicine medical care-seeking patterns are signicantly different among women with diagnoses associated with menstrual syndromes. Related factors affecting Medical care-seeking behavior have been explored in this study.

Women who experience menstrual syndromes will seek medical care. Medical care-seeking behavior has been de ned as any action undertaken by individuals who perceive themselves to have a health problem and tend to nd an appropriate remedy [2,9]. The health belief model [10][11][12] proposes that healthcareseeking behavior is in uenced by certain factors, including perceived susceptibility (subjective assessment of risk of developing a health problem), perceived severity (subjective assessment the potential consequences of disease), bene ts (the value or e cacy of engaging in a health-promoting behavior to decrease risk of disease), barriers (such as inconvenience, expense, danger, access and discomfort), cue to action (the stimulus needed to trigger the decision-making process to accept a recommended health action), and self-e cacy (con dence in one's ability to effect change in outcomes).
All of the above factors are affected by demographic, psychosocial and structural variables.
Traditional Chinese Medicine (TCM) has a long history in the treatment of menstrual syndromes. The World Health Organization (WHO) recognizes TCM as a legitimate medical system, and lists it in the 11th revision of the WHO International Classi cation of Diseases (ICD). This has helped the popularity of TCM to grow rapidly among people who are seeking alternative healthcare remedies rather than relying on Western Medicine (WM) alone. The combined use of TCM and WM, called pluralistic medical utilization, is a common practice for women with menstrual syndromes in Taiwan. However, research on the utilization of TCM and WM by women with menstrual syndromes is seldom reported, especially longitudinal population-based study is comparatively limited. The present study aimed to investigate medical care-seeking patterns among women with newly diagnosed conditions associated with menstrual syndromes and to identify determining factors associated with their medical care-seeking behaviors. Results of this study may not only help to meet women's healthcare needs, but also contribute to reduce inappropriate medical care use.

Data Source
The National Health Insurance (NHI) program was initiated in Taiwan in 1995 and now covers nearly all Taiwan citizens. The Bureau of NHI has released all claims data in electronic form to researchers under the National Health Insurance Research Database project (NHIRD). A representative cohort database comprising data of 1 million people in 2005 was randomly selected by the National Health Research Institute (NHRI) for scienti c purposes from all bene ciaries. The NHRI reported no signi cant differences in age, gender, or health care costs between the representative group and all bene ciaries under the NHI program. For this study, we obtained the complete WM and TCM claim datasets from the NHIRD. The datasets contained the patients' medical visit les, including dates, medical care facilities and specialties, patients' genders, dates of birth, and the four major diagnoses coded in the International Classi cation of Disease, 9th Revision, Clinical Modi cation (ICD-9-CM) format.

Study Cohort and Group Identi cation
Patient selection included all women diagnosed with menstrual syndromes in 2005 that were coded according to the ICD-9-CM. The included categories were as follows: leiomyoma of uterus (ICD-9-CM codes 218), endometriosis (ICD-9-CM codes 617), symptoms associated with female genital organs (ICD-9-CM codes 625, except for 625.6), menstruation disorders and other abnormal bleeding from female genital tract (ICD-9-CM codes 626). All medical visit information was tracked back to 2004 to con rm that these subjects were new patients. Because women may experience menstrual symptoms during their entire reproductive life cycle, women were selected within the age range 15-50 years (risk exposure). Women's rst visits to obstetricians/gynecologists/TCM in 2005 were extracted for further analysis.
Medical utilization patterns for obstetric/gynecologic (Ob/Gyn) care/TCM were also followed for 5 years after their rst visits. Figure 1 shows the patient selection process used in this study.

Study Design and Statistical Analysis
Categorical variables are presented as percentages, continuous variables as mean ± standard deviation (SD). Multivariate Poisson regression analysis was used to evaluate the tendency for use of TCM or WM obstetric/gynecologic outpatient visits. Follow-up periods were divided into 10 time-periods after rst visits for obstetric or gynecologic/TCM healthcare services (1-6, 7-12, 13-18, 19-24, 25-30, 31-36, 37-42, 43-48, 49-54 and 55-60 months). The outpatient visits were calculated for TCM or WM within each time period. The descriptive variables included TCM or WM outpatient visits, age (15-39, 40-50), residence (urban or rural), insurance premium (proxy of economic status), infertility (Yes, No), baby delivery (Yes, No), Ob/Gyn inpatient (Yes, No) and health prevention practices (Yes, No). Monthly insurance premiums were divided into four levels as follows: Fixed premium and dependents (requiring social welfare support, no stable salary); lower income (less than 20,000 New Taiwan Dollars [NTD] per month); middle income (20,000-39,999 NTD per month); and higher income (40,000 NTD or greater per month). Implementation of health preventive measures, such as health exam, Pap smear, or mammography, represents patient's value of prevention.
Most descriptive variables were considered as time dependent, except for patient residence and insurance premium (measured at baseline); that is, their values were assessed by each time-period, and the dynamic effect of these time-dependent variables on response variables was estimated. The unadjusted and adjusted relative risk (RR) and 95% con dence interval (CI) were calculated. All tests were 2-sided and P values < 0.05 were considered statistically signi cant. Statistical analyses and data management were performed using SAS 9.4 software (SAS Institute Inc., Cary, NC).

Patients' characteristics
A total of 47,097 women newly diagnosed with menstrual syndromes were included in this study. Patients' demographic and clinical characteristics are summarized in Table 1. Patients' mean age was 32.22 ± 9.15 years. About three-fourths of patients were aged 15-39 years, and 81% lived in urban areas.
Nearly 53% of patients have no stable salary or belong to low income group. Infertility was reported by 760 (1.61%) patients, 199 (0.42%) reported baby delivery, 977 (2.07%) patients were shown as Ob/Gyn inpatients. 4681 (9.94%) patients implementation of health preventive measures.  Table 2 indicate that the number of TCM utilization was 0.69, and WM utilization was 1.75 within six months after the rst menstrual syndrome diagnosis. After half a year (7-12 months), only less than 30% of the patients are still follow-up, but their TCM utilization was increased to 0.75, and WM utilization was decreased to 1.60. The observed mean outpatient visits showed an upward trend for TCM and a downward trend for WM (Table 2). Factors affecting tendency for TCM utilization Multivariate Poisson regression analysis revealed that the tendency for TCM utilization increased as the follow-up time increased after controlling for potential confounders (Table 3). Younger women (aged 15-39 years), higher economic status, infertility women, and patients who were hospitalized for obstetrics and gynecology were factors that signi cantly increases the tendency for seeking TCM outpatient services (all p < 0.05). Women with preventive health care value, and women who have baby delivery tend to reduce the use of traditional Chinese medicine. Factors affecting tendency for WM utilization Contrary to TCM, the use of WM outpatient services gradually decreased with as follow-up time increased (Table 4). Women with preventive health care value, infertility, and Ob/Gyn inpatient status were more inclined to seek WM outpatient services (all p < 0.05). Patients with higher economic status or have baby delivery history were tend to reduce the use of WM outpatient services (all p < 0.05).

Discussion
Results of the present study revealed that the tendency of TCM utilization increased as the follow-up time increased, whereas the tendency of WM utilization decreased gradually as follow-up time increased.
Women's age, economic status, infertility, baby delivery, Ob/Gyn inpatient history and value of prevention were signi cantly associated with their medical care-seeking behavior.
We found that TCM utilization was only 0.69 and WM utilization was 1.75 within six months after the rst menstrual syndrome diagnosis. Unlike some other disease symptoms, symptoms of menstrual discomfort occur frequently and periodically. For women who suffer menstrual discomfort every month, the frequency of related medical utilization is very low. Previous study revealed that most women suffer from menstrual discomfort but only a few will seek medical care [13,14]. Participants in another study indicated that patient viewed seeking professional treatment was needed only if they felt the pain was too intense and unbearable [15]. It is reasonable to conclude that patients start looking for medical services when symptoms are more severe or unbearable [16].

TCM is widely used in Taiwan and other Asian countries. As part of Complementary and Alternative
Medicine, TCM, like western medicine, is a scienti c system with complete theory [17]. For better treatment results, the concept of TCM suggests the importance of constitutional adjustments, which will take a long time. Once patients accept the concept of TCM treatment, they will continue to return to the clinic for treatment, and the number of times is often more than at the initial starting point. TCM is usually used frequently by patients who would like to decrease recurrent symptoms and relieve the uncomfortable side effects of treatment [18]. On the contrary, the WM approach put more emphasis on immediate effect that may relieve symptoms quickly. However, menstrual syndromes may recur repeatedly, and patients' expectations may be frustrated, so the number of clinical visits tended to decrease compared with the initial starting point. The author believes that this is the reason why the trend of TCM and WM utilization show an inverted pattern.
In terms of personal characteristics, women of younger ages (15-39 years old), those who have higher economic status, tend to use TCM clinics. The ndings of this study are not consistent with those of previous studies. One previous study suggested that medical care-seeking is not associated with age [19]. In addition, older people are more likely to use TCM as their main form of care. However, with the recognition of Chinese medicine by WHO, younger people began to pay attention to the bene ts of TCM for improving overall health status and conditioning the body, and they are more likely to actively seek ways to improve their well-being by curing the root of the problem. Therefore, more and more young people choose TCM as their main form of care. Another possible explanation is that older women already have more experience dealing with the menstrual syndromes. Instead of using TCM, they might use other alternative therapy or food remedies to solve these discomforts.
According to TCM, many ways of treatment are available to deal with symptoms, including medications, acupuncture, infrared rays, and so on. Although the NHI program covers TCM and makes these services affordable to all enrollees, many items are still not reimbursable by NHI. As a result, out-of-pocket items of complementary healthcare have become obstacles for low-income patients. The present study revealed that higher economic status was associated with TCM use, which is consistent with the ndings of previous research [20].
Longitudinal data (60-months) from the present study revealed that women with medical history of infertility or who were ever hospitalized due to obstetrical/gynecologic disorders would likely use more clinical outpatient services of both TCM and WM. Because both TCM and WM clinical outpatient services are covered by NHI, we reasonably suggested that these women increased outpatient follow-up once they had been diagnosed with the documented medical history. Previous study also indicated that the extension of NHI bene ts coverage led to an increase in the utilization of outpatient services across all income groups among patients [21].
On the other hand, the utilization of health preventive services, such as screening tests, had different effects on the use of TCM and WM outpatient services. Women receiving screening tests such as cervical Pap smears and mammography, were less likely to use TCM outpatient services, and were more likely to use WM outpatient services. Previous studies found that patients who underwent gynecological cancer screening were more likely to experience symptom discomfort and would therefore visit outpatient clinics for treatment [13]. In addition, the use of preventive healthcare is a category of WM. Therefore, women who performed these health prevention practices are basically more likely to agree with and therefore seek WM healthcare services.
The present study also found that women who have baby delivery history were tend to reduce the use of outpatient services. After the birth, the uterus and cervix are enlarged, the uterus no longer contracts excessively. When menstruation comes, the menstrual blood is discharged smoothly, and the discomfort of menstrual syndromes may be relieved.

Strengths and limitations
There are both strengths and limitations to the current study. An important strength of the study is that it used data from a comprehensive, national and high-quality database, which minimized discrepancies and biased studies. In addition, the use of longitudinal data allowed us to conduct long-term research and make it possible to explore the changes in long-term trends. Nevertheless, the present study has several limitations. Although the NHIRD is a large and trusted source of patient data, all analyses are retrospective, which does not rule out selection bias nor allow inference of cause. Also, certain patient data were not known, such as the use of Chinese herbal remedies obtained directly from TCM pharmacies with or without prescriptions from licensed TCM physicians. The study also did not include medical visits that were not covered by the NHI program. Thus, the frequency of outpatient utilization may have been underestimated. In addition, patients may have used both TCM and WM, or used WM rst and then changed to TCM, and these patterns could not be differentiated.

Conclusions
TCM and WM medical care-seeking patterns differed signi cantly among women with diagnoses associated with menstrual syndromes. An upward trend was observed for TCM and a downward trend for WM. Medical care-seeking behavior is in uenced by age, economic status, infertility, value of prevention, baby delivery and Ob/Gyn inpatient histories. Findings of the present study contribute to increase understanding of patients' medical care-seeking behavior and help to develop appropriate policies to meet their healthcare needs effectively and to reduce inappropriate medical care use.

List Of Abbreviations
Traditional Chinese Medicine (TCM); World Health Organization (WHO); Study owchart