Urinary incontinence and the association with depression, stress, and self-esteem in older Korean Women.

The objectives were to investigate the prevalence of urinary incontinence (UI) and its relationships with depression, stress, and self-esteem in older Korean women from the Korean Study of Women's Health Related Issues (K-Stori), a nationally representative cross-sectional survey. A total of 3000 women between 65 and 79 years were the final study subjects. We applied multiple linear regression models to analyze associations with depression, stress, and self-esteem levels in relation to UI types. Types of urinary incontinence included stress, urge, and mixed UI. UI affects at least one in two older Korean women (52.2%). The prevalences of SUI, UUI, and MUI were 45.7%, 39.6%, and 33.1%, respectively. UI was found to be adversely associated with depression, stress, and self-esteem: women with UI reported significantly higher levels of depression and stress and lower levels of self-esteem than those without UI. Women with MUI reported significantly greater impairment than the women with SUI or UUI. Our results provide an evidence base for the evaluation of mental health in older women with incontinence. The prioritization of UI detection and the identification of psychological factors may help improve the diagnosis and management of UI and potentially yield significant economic and psychosocial benefits.

The 30-day unplanned readmission rate and hospital volume: a national population-based study in South Korea.

OBJECTIVE: To examine the association between hospital volume and the unplanned 30-day readmission rate as a quality measure. DESIGN: A retrospective cross-sectional study. SETTING: The Korea healthcare system is operated by a single payer under the National Health Insurance Service. PARTICIPANTS: Using national health claims data of the Health Insurance Review and Assessment in South Korea, we examined 1 296 275 adult discharges (≥18 years old) from 90 hospitals (≥500 beds) in the 2013 calendar year. MAIN OUTCOME MEASURES: We analysed the 30-day, unplanned, observed-to-expected standardized readmission rate for hospitals and for five specialty cohorts: medicine, surgery/gynaecology, cardiovascular, cardiorespiratory, and neurology. We assessed the association between hospital volume by tertiles and the 30-day standardized readmission rates with and without adjustment for hospital characteristics. RESULTS: The rate for the lowest-volume hospitals was 6.10 compared with 6.20 for the highest-volume hospitals. We observed the standardized readmission rates did not differ significantly between the lowest- and highest-volume groups, except for the neurology cohort, which remained significant after adjusting for hospital characteristics. CONCLUSIONS: The standardized readmission rates were not associated with hospital volume, except for the neurology cohort, in which the standardized readmission rate was significantly higher in the highest-volume hospitals than in lowest- and intermediate-volume hospitals, which was not consistent with the typical association of greater hospital volume with better outcomes. This association was independent of hospital characteristics. Therefore, the rate of readmissions should be used with caution when gauging the quality of hospital care according to hospital volume.

Patient and hospital factors associated with 30-day unplanned readmission in patients with stroke.

Stroke is frequently associated with readmission; moreover, readmission is regarded as an important indicator of the quality of stroke care. Thus, we investigated factors associated with 30-day readmission in patients with stroke in South Korea. We used claims data from 2013 for stroke (I60-I62) patients (n=44 729) in 94 hospitals and classified unplanned readmission according to the Centers for Medicare and Medicaid guidelines. We used multilevel models to investigate patient (age, gender, type of insurance, admission via emergency room, length of stay, type of stroke, Elixhauser Index Score) and hospital (stroke care quality grade, location of hospital, type of hospital, number of doctors and nurses per 100 beds) factors associated with readmission within 30 days of discharge. Among the 44 729 patients admitted due to stroke, 9.2% (n=4124) were readmitted to hospital and 7.6% (n=3379) had unplanned readmissions. Regarding patient characteristics, medical aid and longer hospital stay were associated with 30-day readmission rate. Among hospital factors, patients admitted to a low-grade hospital or a non-capital area hospital were more likely to be readmitted within 30 days of discharge. We identified patient and hospital factors associated with 30-day readmission among stroke patients. In particular, patients admitted to hospitals with higher quality stroke care showed lower readmission rates.

Undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkship.

BACKGROUND: The purpose of this study was to examine undergraduate medical students' perceptions and intentions regarding patient safety during clinical clerkships. METHODS: Cross-sectional study administered in face-to-face interviews using modified the Medical Student Safety Attitudes and Professionalism Survey (MSSAPS) from three colleges of medicine in Korea. We assessed medical students' perceptions of the cultures ('safety', 'teamwork', and 'error disclosure'), 'behavioural intentions' concerning patient safety issues and 'overall patient safety'. Confirmatory factor analysis and Spearman's correlation analyses was performed. In total, 194(91.9%) of the 211 third-year undergraduate students participated. RESULTS: 78% of medical students reported that the quality of care received by patients was impacted by teamwork during clinical rotations. Regarding error disclosure, positive scores ranged from 10% to 74%. Except for one question asking whether the disclosure of medical errors was an important component of patient safety (74%), the percentages of positive scores for all the other questions were below 20%. 41.2% of medical students have intention to disclose it when they saw a medical error committed by another team member. CONCLUSIONS: Many students had difficulty speaking up about medical errors. Error disclosure guidelines and educational efforts aimed at developing sophisticated communication skills are needed. This study may serve as a reference for other institutions planning patient safety education in their curricula. Assessing student perceptions of safety culture can provide clerkship directors and clinical service chiefs with information that enhances the educational environment and promotes patient safety.

Association between re-admission rate and hospital characteristics for ischemic heart disease.

OBJECTIVE: Hospital re-admission is considered an important marker of patient health outcomes and healthcare system performance. Korea introduced the Korean Diagnosis Procedure Combination (KDPC) for all regional public hospitals in July 2012. This study examined re-admission rates within 30 days to assess whether the hospital payment system is associated with the re-admission rate, focusing on ischemic heart disease. METHODS: A cross-sectional study was conducted using national claims data for 2013. We analyzed data of patients with a major diagnosis of ischemic heart disease who were admitted to general hospitals with more than 500 beds in Korea. Of the eight general hospitals, two that have been operating under the new Korean payment system were public hospitals using the KDPC, and the remaining six were private general hospitals with fee for service (FFS) systems. Multiple logistic regression analysis was used to identify associations between re-admission rate and hospital characteristics. RESULTS: The study analyzed 4,290 cases (889 cases in KDPC and 3,401 cases in FFS). The 30-day unplanned re-admission rate was higher in KDPC than in FFS (7.9% vs 5.6%, respectively). The unplanned re-admission odds ratios of KDPC was 1.74. CONCLUSIONS: KDPC had higher 30-day unplanned re-admissions rates than did FFS.

The Korean Study of Women's Health-Related Issues (K-Stori): Rationale and Study Design.

BACKGROUND: Measures to address gender-specific health issues are essential due to fundamental, biological differences between the sexes. Studies have increasingly stressed the importance of customizing approaches directed at women's health issues according to stages in the female life cycle. In Korea, however, gender-specific studies on issues affecting Korean women in relation to stages in their life cycle are lacking. Accordingly, the Korean Study of Women's Health-Related Issues (K-Stori) was designed to investigate life cycle-specific health issues among women, covering health status, awareness, and risk perceptions. METHODS: K-Stori was conducted as a nationwide cross-sectional survey targeting Korean women aged 14-79 years. Per each stage in the female life cycle (adolescence, childbearing age, pregnancy & postpartum, menopause, and older adult stage), 3000 women (total 15,000) were recruited by stratified multistage random sampling for geographic area based on the 2010 Resident Registration Population in Korea. Specialized questionnaires per each stage (total of five) were developed in consultation with multidisciplinary experts and by reflecting upon current interests into health among the general population of women in Korea. This survey was conducted from April 1 to June 31, 2016, at which time investigators from a professional research agency went door-to-door to recruit residents and conducted in-person interviews. DISCUSSION: The study's findings may help with elucidating health issues and unmet needs specific to each stage in the life cycle of Korean women that have yet to be identified in present surveys.

Socioeconomic Disparities in the Prevalence, Diagnosis, and Control of Hypertension in the Context of a Universal Health Insurance System.

A lower use of preventive intervention in low socioeconomic populations has been described in countries with universal coverage health care systems, but little is known about the possible socioeconomic inequalities in secondary prevention in a universal health insurance system. Data from the 2010-2013 Korea National Health and Nutrition Examination Survey, a nationwide survey, were analyzed. A total of 20,044 subjects older than 30 years of age were included after excluding subjects with missing data. Prevalence ratios were calculated using Poisson regression models with robust variance to explore factors associated with the prevalence, unawareness, and inappropriate control of hypertension. Hypertension prevalence decreased with increasing education and income level. We observed an inverse association between education level and undiagnosed hypertension among women, but not men. Socioeconomic level was not associated with inadequate control of hypertension among men or women. Future interventions should include primary prevention efforts targeted at lower socioeconomic populations to reduce disparities. There is substantial room for improvement in secondary prevention efforts. Monitoring strategies may highlight gaps in the preventive and care services offered to the most vulnerable individuals and encourage governments and practitioners to address these gaps.

Effectiveness of the Korean National Cancer Screening Program in Reducing Gastric Cancer Mortality.

BACKGROUND & AIMS: It is not clear whether screening for gastric cancer by upper endoscopy or upper gastrointestinal (UGI) series examinations (looking at the upper and middle sections of the gastrointestinal tract by imaging techniques) reduces mortality. Nevertheless, the Korean National Cancer Screening Program for gastric cancer was launched in 1999 to screen individuals 40 years and older for gastric cancer using these techniques. We evaluated the effectiveness of these techniques in gastric cancer detection and compared their effects on mortality in the Korean population. METHODS: We performed a nested case-control study using data from the Korean National Cancer Screening Program for gastric cancer since 2002. A total of 16,584,283 Korean men and women, aged 40 years and older, comprised the cancer-free cohort. Case subjects (n = 54,418) were defined as individuals newly diagnosed with gastric cancer from January 2004 through December 2009 and who died before December 2012. Cases were matched with controls (subjects who were alive on the date of death of the corresponding case subject, n = 217,672) for year of entry into the study cohort, age, sex, and socioeconomic status. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained via conditional logistic regression analysis. RESULTS: Compared with subjects who had never been screened, the overall OR for dying from gastric cancer among ever-screened subjects was 0.79 (95% CI, 0.77-0.81). According to screening modality, the ORs of death from gastric cancer were 0.53 (95% CI, 0.51-0.56) for upper endoscopy and 0.98 (95% CI, 0.95-1.01) for UGI series. As the number of endoscopic screening tests performed per subject increased, the ORs of death from gastric cancer decreased: 0.60 (95% CI, 0.57-0.63), 0.32 (95% CI, 0.28-0.37), and 0.19 (95% CI, 0.14-0.26) for once, twice, and 3 or more times, respectively. CONCLUSIONS: Within the Korean National Cancer Screening Program, patients who received an upper endoscopy were less likely to die from gastric cancer; no associations were found for UGI series.

Why Do Some People Choose Opportunistic Rather Than Organized Cancer Screening? The Korean National Health and Nutrition Examination Survey (KNHANES) 2010-2012.

PURPOSE: Although the Korean government has implemented a universal screening program for common cancers, some individuals choose to participate in opportunistic screening programs. Therefore, this study was conducted to identify factors contributing to the selection of organized versus opportunistic screening by the Korean general population. MATERIALS AND METHODS: Data from 11,189 participants aged ≥ 40 yearswho participated in the fifth Korean National Health and Nutrition Examination Survey (2010-2012) were analyzed in this study. RESULTS: A total of 6,843 of the participants (58.6%) underwent cancer screening, of which 6,019 (51.1%) participated in organized and 824 (7.5%) participated in opportunistic screening programs. Being female, older, highly educated, in the upper quartile of income, an ex-smoker, and a light drinker as well as having supplementary private health insurance and more comorbid conditions and engaging in moderate physical activity 1-4 days per week were related to participation in both types of screening programs. Being at least a high school graduate, in the upper quartile for income, and a light drinker, as well as having more comorbid conditions and engaging in moderate physical activities 1-4 days per week had a stronger effect on those undergoing opportunistic than organized screening. CONCLUSION: The results of this study suggest that socioeconomic factors such as education and income, as well as health status factors such as health-related quality of life and number of comorbid conditions and health behaviors such as drinking and engaging in moderate physical activity 1-4 days per week had a stronger influence on participation in an opportunistic than in an organized screening program for cancer.

Exposure to mould allergens and rhinoconjunctivitis in Korean children.

BACKGROUND: Although rhinitis is the most common allergic disease in children, few studies have explored the causal relationships between mould allergens and rhinitis. Thus, this study aimed to identify factors, especially prior exposure to mould allergens, related to rhinitis and rhinoconjunctivitis in Korean children. METHODS: Subjects in this study were 12- to 13-year-old children from 40 national middle schools who were participants of the International Study of Asthma and Allergies in Childhood (ISAAC) study in Korea. A total of 3852 children who completed the ISAAC questionnaire in 2010 and underwent a skin prick test (SPT) and blood test were enrolled in this study. RESULTS: The prevalence of symptoms suggestive of rhinitis or rhinoconjunctivitis in last 12 months was 42.7% and 19.4%, respectively. A parental history of allergies (OR = 2.03, 95% CI = 1.75-2.35; OR = 2.55, 95% CI = 2.13-3.06), visible mould or dampness (OR = 1.28, 95% CI = 1.09-1.51; OR = 1.23, 95% CI = 1.00-1.51), previous exposure to mould allergens (OR = 4.53, 95% CI = 2.32-8.84; OR = 4.98, 95% CI = 2.43-10.20), total IgE levels ≥78 kU/l (OR = 1.44, 95% CI = 1.22-1.69; OR = 1.99, 95% CI = 1.60-2.48) were risk factors for rhinitis and rhinoconjunctivitis. CONCLUSIONS: This study suggested that previous exposure to mould allergens more influenced rhinitis and rhinoconjunctivitis than visible mould or dampness, and that total IgE levels of ≥78 kU/l, which was the criterion suggested in a study of Asian children, were risk factors for rhinitis diseases.

Socioeconomic Disparities in Colorectal Cancer Screening in Korea: A Nationwide Cross-Sectional Study.

Colorectal cancer (CRC) is a common cancer worldwide. The incidence and mortality rates of CRC are higher among lower socioeconomic status (SES) populations. We investigated the association between different indicators of SES and CRC screening rates in Korea. The eligible study population included males and females aged 50 to 74 years who participated in a nationwide cross-sectional survey (2010-2012). The "compliance with recommendation" category was applicable to participants who had undergone a fecal occult blood test (FOBT), double-contrast barium enema, or colonoscopy within 1, 5, or 10 years, respectively. In total, 6221 subjects (51.4% female, 55.6% aged 50 years) were included in the final analysis. Lower household income was significantly negatively related to compliance with screening recommendations (P for trend < 0.01) and marginally significantly related to noncompliance with recommendations (P for trend = 0.07). Older age and poor self-reported health were associated with the screening rate using the FOBT; male sex, older age, higher household income, having supplemental insurance, family history of cancer, and poor self-reported health were associated with a higher screening rate using colonoscopy. Lower household income was associated with a higher screening rate using the FOBT and with a lower screening rate using colonoscopy. To increase the rate of CRC screening using colonoscopy, efforts should be made toward improving the education and promotion of screening to the low household income target population.

The Korean guideline for cervical cancer screening.

The incidence rate of cervical cancer in Korea is still higher than in other developed countries, notwithstanding the national mass-screening program. Furthermore, a new method has been introduced in cervical cancer screening. Therefore, the committee for cervical cancer screening in Korea updated the recommendation statement established in 2002. The new version of the guideline was developed by the committee using evidence-based methods. The committee reviewed the evidence for the benefits and harms of the Papanicolaou test, liquid-based cytology, and human papillomavirus (HPV) testing, and reached conclusions after deliberation. The committee recommends screening for cervical cancer with cytology (Papanicolaou test or liquid-based cytology) every three years in women older than 20 years of age (recommendation A). The cervical cytology combined with HPV test is optionally recommended after taking into consideration individual risk or preference (recommendation C). The current evidence for primary HPV screening is insufficient to assess the benefits and harms of cervical cancer screening (recommendation I). Cervical cancer screening can be terminated at the age of 74 years if more than three consecutive negative cytology reports have been confirmed within 10 years (recommendation D).

Different socioeconomic inequalities exist in terms of the prevention, diagnosis and control of diabetes.

OBJECTIVE: To evaluate socioeconomic disadvantage in prevalence, awareness and control of diabetes in universal coverage healthcare system. METHODS: Data from the fifth KNHNES (2010-12) were analyzed. The sample included 10,208 individuals with diabetes aged ≥30 years. Diabetes was defined by (i) a self-reported previous diagnosis of diabetes made by a physician, (ii) the current use of oral hypoglycaemic agents and/or insulin or (iii) fasting plasma glucose ≥126 mg/dl. Subjects who were first diagnosed by the survey were classified as 'undiagnosed'. Inadequate control was defined as HbA1c ≥6.5%. RESULTS: It was estimated that 26.4% of subjects with diabetes were not aware of their condition and 73.1% of cases of diabetes were not adequately controlled. Inequalities in socioeconomic status were related to the diabetes prevalence in both men and women. Educational level was not predictive of diagnosis or control in men or women, whereas lower household income level was associated with diagnosis in men only. CONCLUSIONS: This widespread lack of awareness and inadequate control underscore the need for intensive efforts in these domains. Monitoring is expected to highlight the gaps in the preventive and care services offered to the most vulnerable individuals and it may induce governments and practitioners to address these issues.

The effect of new drug pricing systems and new reimbursement guidelines on pharmaceutical expenditures and prescribing behavior among hypertensive patients in Korea.

OBJECTIVE: The purpose of this study was to determine the effects of a new drug-pricing system (January 2012) and new prescription and reimbursement guidelines (January 2013) on hypertension-related pharmaceutical expenditures and prescribing behaviors in Korea. METHODS: In all, 11,298 clinics and 2,667,132 patients with hypertension were included in our study. As dependent variables, we used the drug cost per patient, drug cost per prescribed day, number of drugs per prescription, number of prescribed days per visit, number of visits, number of original (vs. generic) drugs prescribed, and the percentage of original drug cost. Clinic characteristics and patients' age and sex were used as independent variables. Multi-level mixed-effect regression models were used. RESULTS: The drug cost per patient decreased by -1446 KRW$ (-7.4%; p<0.001) in Q4 2012 and by -1833 (-9.3%; p<0.001) in Q2 2013 compared with Q4 2011. Number of drugs per prescription decreased significantly. The percentage of original drug cost and the number of original drugs also declined. CONCLUSION: Reforms to the drug pricing policy and the new guidelines may reduce pharmaceutical expenditures without increasing number of drugs per prescription and the number of original drug used. Policy makers should consider the comprehensive effects of implementing new policies on both drug prices and consumption.

Cost-effectiveness of liver cancer screening in adults at high risk for liver cancer in the republic of Korea.

PURPOSE: This study was conducted in order to determine the most cost-effective strategy, in terms of interval and age range, forliver cancer screening in the high-risk population of Korea. MATERIALS AND METHODS: A stochastic modelwas used to simulate the cost-effectiveness ofliver cancer screening by combined ultrasonography and alpha-fetoprotein testing when varying both screening intervals and age ranges. The effectiveness of these screening strategies in the high-risk population was defined as the probability of detecting preclinical liver cancer, and costwas based on the direct cost ofthe screening and confirmative tests. Optimal cost-effectiveness was determined using the incremental cost-effectiveness ratio. RESULTS: Among the 36 alternative strategies, one-year or two-year interval screening for men aged between 50 and 80 years, six-month or one-year interval screening for men aged between 40 and 80 years, and six-month interval screening for men aged between 30 and 80 years were identified as non-dominated strategies. For women, identified non-dominated strategies were: one-year interval screening between age 50 and 65 years, one-year or six-month interval screening between age 50 and 80 years, six-month interval screening between age 40 and 80 years, and six-month interval screening between age 30 and 80 years. CONCLUSION: In Korea, a one-year screening interval for men aged 50 to 80 years would be marginally cost-effective. Further studies should be conducted in order to evaluate effectiveness of liver cancer screening, and compare the cost effectiveness of different liver cancer screening programs with a final outcome indicator such as qualityadjusted life-years or disability-adjusted life-years.

Quality assurance in ultrasound screening for hepatocellular carcinoma using a standardized phantom and standard clinical images: a 3-year national investigation in Korea.

OBJECTIVES: The purpose of this study was to investigate the quality of ultrasound (US) imaging for hepatocellular carcinoma screening. METHODS: The investigation was performed at all medical institutes participating in the National Cancer Screening Program in Korea. For assessment of personnel, we inquired who was performing the US screenings. For phantom image evaluation, the dead zone, vertical and horizontal measurements, axial and lateral resolution, sensitivity, and gray scale/dynamic range were evaluated. For clinical image evaluation, US images of patients were evaluated in terms of the standard images, technical information, overall image quality, appropriateness of depth, foci, annotations, and the presence of any artifacts. RESULTS: Failure rates for phantom and clinical image evaluations at general hospitals, smaller hospitals, and private clinics were 20.9%, 24.5%, 24.1% and 5.5%, and 14.8% and 9.5%, respectively. No statistically significant difference was observed in the failure rates for the phantom images among groups of different years of manufacture. For the clinical image evaluation, the results of radiologists were significantly better than those of other professional groups (P = .0001 and .0004 versus nonradiology physicians and nonphysicians, respectively). The failure rate was also higher when the storage format was analog versus digital (P < .001). CONCLUSIONS: Approximately 20% of US scanners failed the phantom image evaluation. The year of scanner manufacture was not significantly associated with the results of the phantom image evaluation. The quality of the clinical images obtained by radiologists was the best.

Risk of suicidal ideation in diabetes varies by diabetes regimen, diabetes duration, and HbA1c level.

OBJECTIVE: To investigate patient subgroups based on the clinical characteristics of diabetes to evaluate risk factors for suicidal ideation using a large population-based sample in South Korea. METHODS: Data from the Fifth Korea National Health and Nutrition Examination Survey, a cross-sectional, nationally representative survey, were analyzed. The participants were 9159 subjects aged ≥40years. We defined patients with diabetes based on self-reported physician-diagnosed diabetes. We evaluated clinical risk factors for suicidal ideation according to diabetes regimen, diabetes duration, and glycated hemoglobin (HbA1c) level compared with no diabetes. Given the complex sample design and unequal weights, we analyzed weighted percentages and used survey logistic regression. RESULTS: Diabetes per se was not associated with suicidal ideation. However, suicidal ideation was significantly more prevalent among patients who had injected insulin, had a duration of diabetes ≥5years and had HbA1c levels ≥6.5 compared with those without diabetes. Depressive symptoms were the most prominent predictor of suicidal ideation. CONCLUSIONS: Insulin therapy, diabetes of long duration, and unsatisfactory glycemic control were identified as risk factors for suicidal ideation; thus, patients with these characteristics warrant special attention. Our findings suggest the need to integrate efforts to manage emotional distress into diabetes care.

Differential association of socio-economic status with gender- and age-defined suicidal ideation among adult and elderly individuals in South Korea.

South Korea has the highest suicide rate among countries in the Organisation for Economic Co-operation and Development (OECD), with a rising trend that contrasts with the trend in most other OECD countries. This study assessed differential associations of socio-demographic factors with suicidal ideation in South Korea. We used five waves of data from the 2010 Korea National Health and Nutrition Examination Survey. Study subjects included 5803 men and women aged >25 years. We analysed weighted percentages with consideration of the complex survey sample design and unequal weights. Surveylogistic regressions were applied. Protective effects against suicidal ideation were found for higher household income, higher educational attainment, and being married. Functional limitations and depressive symptoms were risk factors for suicidal ideation. However, these significant factors may exert different effects on vulnerability for suicidal ideation among different genders and age groups. Thus, household income was mainly protective for women and subjects aged 25-44 years, and educational attainment was protective for individuals aged >65 years. Our findings suggest the need for extended social protection policies for the less privileged population and special strategies for different groups.

Determinants of suboptimal hepatitis B vaccine uptake among men in the Republic of Korea: where should our efforts be focused: results from cross-sectional study.

BACKGROUND: Liver cancer is the second most-frequent cause of cancer death in Korea. Hepatitis B virus (HBV) infection is a major cause of liver cancer, and this disease is effectively prevented by HBV vaccination. This study was conducted to investigate factors associated with the lack of HBV vaccine uptake in the general adult male population in Korea. METHODS: Data of men who participated in a nationwide cross-sectional interview survey were analyzed. A total of 2,174 men 40 years of age and older were interviewed between 2006 and 2008. None of the participants was infected with HBV or was experiencing sequelae of an HBV infection. RESULTS: Only half (50.4%) of the men received one or more dose of the three-dose series of HBV vaccinations, and 32.5% received all three doses. Compared with men who had completed the vaccination regimen, non-vaccinated men were more likely to lack supplemental medical insurance for cancer (odds ratio = 0.66, 95% confidence interval: 0.52-0.84), have lower incomes (p-trend = 0.010), and be less educated (p-trend = 0.021). Lower education was also more prevalent in the non-vaccinated group compared with the incompletely vaccinated group. Those who had completed the vaccination regimen were likely to be more educated than those in the incompletely vaccinated group (p-trend = 0.044). The most commonly cited reason for not obtaining the HBV vaccine was lack of knowledge regarding the need for the vaccination. The number of men who cited this reason decreased as a function of education. CONCLUSIONS: It is important to develop strategic interventions targeted at less-educated men to increase uptake of a complete three-dose series of HBV vaccinations as a primary approach to preventing liver cancer.