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精神疾患患者の受診率の性差に関する国際比較研究

崎谷(石川), 華子 東京大学 DOI:10.15083/0002002369

2021.10.13

概要

これまでに精神疾患の重要性、さらに治療の有効性が示されているにもかかわらず、その治療の需要はいまだに満たされておらず、精神疾患の受診率は低いままである。一般的に男性よりも女性の方が精神疾患による受診行動を取りやすいことが知られているが、この性差の強さは国によって大きく異なる。また、精神科専門医療機関、一般医療機関などの治療セクターに着目した場合、女性は男性よりも一般医療機関を受診する傾向があるのに対して、女性は男性よりも精神科専門医療機関への受診をしにくい傾向にあるとの報告が多い。

 このような精神疾患の受診行動の男女差に対する説明の一つとして、これまでに伝統的な社会的性役割や男女の社会格差が挙げられている。伝統的男性性は自立や強さを意味し、男性における症状の否定、スティグマへの恐れ、治療への否定的な態度や受診行動の抑制につながると考えられている。しかし、特に専門的医療に着目した場合には、伝統的性役割が逆の影響を与える可能性もある。これまでに、社会経済的ポジションが低い人が専門的医療を受けにくいことが報告されており、男女の社会格差が大きい国では女性が精神科専門医にアクセスしにくいという可能性が考えられる。また、それ以外の国レベルの要因(国の所得水準、経済的・人的な精神保健資源など)も受診率に影響すると報告されており、これらの要因が受診行動の性差にも関与している可能性が考えられる。例えば、発展途上国において精神科医数が少ないことで、専門医療機関へのアクセスの格差が増大するのではないかという仮説が考えられる。本研究では、国の所得水準、男女格差、精神保健資源などの国レベルでの要因と医療機関全体、および治療セクターごとの受診行動と性差との関連について、地域疫学研究のデータを用いて国際比較研究を行った。

 具体的な仮説は以下のようである。
1. 低所得国では精神科専門医療機関への受診率が男性とくらべて女性で低くなる。
2. 雇用や経済における男女の社会格差が大きい国では、精神科専門医療機関への受診率が男性とくらべて女性で低くなる。
3. それぞれの国内の人的・経済的な精神保健資源が乏しいことが、医療機関、特に精神科専門医療機関への女性の受診しにくさの拡大と関連する。

 本研究では、精神疾患に関する国際疫学共同研究である世界精神保健調査に含まれる、25カ国における28調査のデータを利用して国際比較研究を行なった。精神疾患を過去12ヶ月間に経験した合計16, 744人が解析の対象となった。治療セクターを精神保健専門医療機関、一般医療機関に分け、いずれかの医療機関」を、精神保健専門医療機関または一般医療機関への受診とした。過去12ヶ月間における各治療セクターおよびいずれかの医療機関への受診行動の有無を目的変数とし、個人の社会人口学的変数(性別(ref:女性)、世帯収入、年齢、婚姻状況、学歴、疾患の重症度)を説明変数として、多変量ロジスティック回帰分析に投入した。この多変量ロジスティック回帰分析により、社会人口学的変数を調整した上での、女性と比較した男性の相対受診確率(オッズ比)を推定した。この解析で得られた相対受診確率を用いて、マルチレベルモデルにより、調査参加国全体、および国の所得カテゴリー別(低・低中所得国、高中所得国、高所得国)の、女性に対する男性の相対受診確率を示す統合オッズ比を推定した。さらに、国レベルの指標(国の所得カテゴリー、Gender Inequality Index(GII)、国民医療費、精神科医数、看護師数)と男性の相対受診確率との関連をマルチレベルモデルにより推定した。

 それぞれの調査の特徴として、医療機関全体への受診率は特に低・低中所得国で低く(5-16%)、高所得国で高かった(20-49%)。精神保健専門医療機関への受診率は低・低中所得国で低く(2-10%)、中高所得国で3-16%、高所得国で9-28%、一般医療機関への受診率は低・低中所得国で4-11%、中高所得国で6-17%、高所得国で10-38%と、医療機関の中では一般医療機関が主要な受診先である国が多い傾向が見られた。

 全調査を統合した結果、男性の相対受診確率を示す統合オッズ比は、精神保健専門医療機関で1.26(95% CI, 0.92-1.71)、一般医療機関で0.66(95% CI, 0.51-0.84)、いずれかの医療機関で0.75(95% CI, 0.67-0.84)で、男性は女性よりも一般医療機関、いずれかの医療機関への受診が有意に少なかった。国の所得カテゴリー別で統合した場合も、この性差のパターンには大きな違いはなかった。

 精神保健専門医療機関について、各調査における、女性と比較した男性の相対受診確率(回帰係数)を目的変数としたマルチレベルモデルの結果、2変量解析では国の所得水準、GII、国民医療費が男性の相対受診確率と有意に関連していた。調査全体を統合すると有意ではないが男性の方が精神保健専門医療機関を受診しやすい傾向にあったが(統合オッズ比1.26)、高中所得国および高所得国では、低・低中所得国と比べて男性の相対受診確率が有意に低下し(b=-1.89, t=-2.98, およびb=-1.73, t=-3.18, いずれもp<0.01)、これは先進国に比べて発展途上国で男性と比べた女性の精神保健専門医療機関への受診確率が低いことを示唆する。また、GIIが高いほど(男女格差が大きい国ほど)女性と比べた男性の精神保健専門医療機関への相対受診確率が有意に増加し(b=3.72, t=3.06, p<0.01)、GDPにしめる国民医療費の割合が多いほど女性と比べた男性の相対受診確率が有意に減少した(b=-0.23, t=-2.40, p<0.05)。国の所得水準を調整した後も、GIIと男性の相対受診確率との関連は有意であった(b=6.13, t=3.02, p<0.01)。

 一般医療機関について、各調査における女性と比較した男性の相対受診確率(回帰係数)を目的変数としたマルチレベルモデルの結果からは、有意な関連のある国レベルの指標は認められなかった。

 いずれかの医療機関について、各調査における女性と比較した男性の相対受診行動(回帰係数)を目的変数としたメタ回帰分析の結果、2変量解析では、国の所得水準が高くなると女性と比べた男性の受診確率が減少する傾向にあったが、有意ではなかった(高中所得国でb=-0.25, t=-1, 17, p=0.25および高所得国でb=-0.31, t=-1.70, p=0.10)。また、国民医療費が増えると男性の受診傾向が減少する傾向があったが、有意ではなかった(b=-0.034, t=-1.82, p=0.08)。国の所得水準を調整後は、国レベルの指標との間に有意な関連は認めなかった。

 本研究は、25カ国合計28地域において精神疾患の経験者における受診行動の性差についての国際比較を行い、特に国の所得水準、精神保健資源、GIIといった国レベルの指標との関連を検討した最初の研究である。今回検討した25カ国を平均すると、いずれかの医療機関、特に一般医療機関については、女性は男性よりも受診しやすいことが示され、このパターンは国の所得水準とは有意な関連を示さなかった。一方で精神保健専門医療機関については、低・中所得国では高所得国に比べて有意に男性が女性より受診しやすかった。また、性別による社会的格差の大きい国でも男性の方が精神保健専門医療機関を受診しやすい可能性が示された。

 一般に低所得国の方が高所得国よりも性別格差が大きい傾向にあると言われており、今回の結果においても低所得国において男女の間の社会格差が大きいことが女性の精神保健専門医療機関の受診を抑制している、という可能性を示唆する。この可能性は本研究でみられたGIIと精神保健専門医療機関の性差との関連からも示唆される。

 本研究では、女性の方が男性よりも精神疾患のためにいずれかの医療機関、特に一般医療機関を受診しやすい傾向を認めた。これは先行研究と同様の結果であるが、女性の受診しやすさは一般医療機関で明確に見られることを明らかにした点が本研究のユニークな点である。精神疾患治療におけるそれぞれの治療セクターの役割を考えると、専門的治療は重度の患者、一般医療機関での治療はプライマリケアの一部として重症度の低い患者が受けると考えられる。そのため、女性が男性よりも一般医療機関への受診行動が多いことで、発展途上国において専門的治療を受けにくいことを補えるのかどうかははっきりしない。今回の研究では先進国、発展途上国問わず、特に男性の受診率を改善する必要性を確認しただけでなく、女性において専門医療へのアクセスが少ないという問題があることを示した。特に発展途上国のような精神保健資源のとぼしい国で女性における治療を改善するためには、プライマリケアにおいて投薬を含む基本的な治療を行えるよう整備し、プライマリケアの医療機関を含む、コミュニティーにおけるサービスにも予算を配分することが重要であることが示唆される。

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