Psychosocial determinants of socioeconomic inequalities in cancer screening participation: a conceptual framework

Reducing inequities in colorectal cancer screening in North America

Colorectal cancer (CRC) is an important cause of mortality and morbidity in North America. Screening using a fecal occult blood test, flexible sigmoidoscopy, or colonoscopy reduces CRC mortality through the detection and treatment of precancerous polyps and early stage CRC. Although CRC screening participation has increased in recent years, large inequities still exist. Minorities, new immigrants, and those with lower levels of education or income are much less likely to be screened. This review provides an overview of the commonly used tests for CRC screening, disparities in CRC screening, and promising methods at the individual, provider, and system levels to reduce these disparities. Overall, to achieve high CRC participation rates and reduce the burden of CRC in the population, a multi-faceted approach that uses strategies at all levels to reduce CRC screening disparities is urgently required.

Smokers' risk perception, socioeconomic status and source of information on cancer

BACKGROUND

In many countries, the decline in smoking prevalence has coincided with a growing concentration of smoking among people with lower socioeconomic status (SES). This concentration may reflect the social differentiation of risk perceptions. We investigated the factors associated with risk perception and fear of cancer, paying particular attention to SES indicators and health information seeking.

METHODOLOGY

A cross-sectional telephone survey conducted in France in 2010 (including 826 current smokers aged 18-75) assessing how smokers perceive the risk of smoking-related cancer in terms of daily consumption and duration thresholds.

RESULTS

Among current smokers, 38% considered that smoking can cause cancer only for a daily consumption higher than their own consumption, and an additional 22% stated that tobacco-related cancer risk only becomes high for a longer smoking duration than their personal one. Predictors of such risk perceptions included low SES, material deprivation and mentioning either the internet or their relatives as one's main source of information on cancer. The same characteristics were also predictive of personal fear of tobacco-related cancer.

CONCLUSION

Our results illustrate the challenges faced by prevention campaigns in the internet society, as information found on the web may fuel smokers' risk denial. Anti-tobacco policies should tailor interventions to people with low SES, who may be especially impervious to standard prevention campaigns because of material deprivation, and they should also address and challenge smokers' risk denial beliefs.

Enhanced invitation methods to increase uptake of NHS health checks: study protocol for a randomized controlled trial

BACKGROUND

NHS Health Checks is a new program for primary prevention of heart disease, stroke, diabetes, chronic kidney disease, and vascular dementia in adults aged 40 to 74 years in England. Individuals without existing cardiovascular disease or diabetes are invited for a Health Check every 5 years. Uptake among those invited is lower than anticipated.

METHOD

The project is a three-arm randomized controlled trial to test the hypothesis that enhanced invitation methods, using the Question-Behaviour Effect (QBE), will increase uptake of NHS Health Checks compared with a standard invitation. Participants comprise individuals eligible for an NHS Health Check registered in two London boroughs. Participants are randomized into one of three arms. Group A receives the standard NHS Health Check invitation letter, information sheet, and reminder letter at 12 weeks for nonattenders. Group B receives a QBE questionnaire 1 week before receiving the standard invitation, information sheet, and reminder letter where appropriate. Group C is the same as Group B, but participants are offered a £5 retail voucher if they return the questionnaire. Participants are randomized in equal proportions, stratified by general practice. The primary outcome is uptake of NHS Health Checks 6 months after invitation from electronic health records. We will estimate the incremental health service cost per additional completed Health Check for trial groups B and C versus trial arm A, as well as evaluating the impact of the QBE questionnaire, and questionnaire plus voucher, on the socioeconomic inequality in uptake of Health Checks.The trial includes a nested comparison of two methods for implementing allocation, one implemented manually at general practices and the other implemented automatically through the information systems used to generate invitations for the Health Check.

DISCUSSION

The research will provide evidence on whether asking individuals to complete a preliminary questionnaire, by using the QBE, is effective in increasing uptake of Health Checks and whether an incentive alters questionnaire return rates as well as uptake of Health Checks. The trial interventions can be readily translated into routine service delivery if they are shown to be cost-effective.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN42856343. Date registered: 21.03.2013.

Cancer awareness and socio-economic position: results from a population-based study in Denmark

Background

Differences in cancer awareness between individuals may explain variations in healthcare seeking behaviour and ultimately also variations in cancer survival. It is therefore important to examine cancer awareness and to investigate possible differences in cancer awareness among specific population subgroups. The aim of this study is to assess awareness of cancer symptoms, risk factors and perceived 5-year survival from bowel, breast, ovarian, and lung cancer in a Danish population sample and to analyse the association between these factors and socio-economic position indicators.

Methods

A population-based telephone survey was carried out among 1,000 respondents aged 30–49 years and 2,000 respondents aged 50 years and older using the Awareness and Beliefs about Cancer measure. Information on socio-economic position was obtained by data linkage through Statistics Denmark. Prevalence ratios were used to determine the association between socio-economic position and cancer awareness.

Results

A strong socio-economic gradient in cancer awareness was found. People with a low educational level and a low household income were more likely to have a lower awareness of cancer symptoms, cancer risk factors and the growing risk of cancer with age. Furthermore, men and people outside the labour force tended to be less aware of these factors than women and people within the labour force. However, women were more likely than men to lack awareness of the relationship between age and cancer risk. No clear associations were found between socio-economic position and lack of awareness of 5-year survival from bowel, breast, ovarian, and lung cancers.

Conclusions

As cancer awareness has shown to be positively associated with cancer-related behaviour, e.g. healthcare seeking, consideration must be given to tackle inequalities in cancer awareness and to address this issue in future public health strategies, which should be targeted at and tailored to the intended recipient groups.

Cancer survival among First Nations people of Ontario, Canada (1968-2007)

We aimed to compare cancer survival in Ontario First Nations people to that in other Ontarians for five major cancer types: colorectal, lung, cervix, breast and prostate. A list of registered or "Status" Indians in Ontario was used to create a cohort of over 140,000 Ontario First Nations people. Cancers diagnosed in cohort members between 1968 and 2001 were identified from the Ontario Cancer Registry, with follow-up for death until December 31st, 2007. Flexible parametric modeling of the hazard function was used to compare the survival experience of the cohort to that of other Ontarians. We considered changes in survival from the first half of the time period (1968-1991) to the second half (1992-2001). For other Ontarians, survival had improved over time for every cancer site. For the First Nations cohort, survival improved only for breast and prostate cancers; it either declined or remained unchanged for the other cancers. For cancers diagnosed in 1992 or later, all-cause and cause-specific survival was significantly poorer for First Nations people diagnosed with breast, prostate, cervical, colorectal (male and female) and male lung cancers as compared to their non-First Nations peers. For female lung cancer, First Nations women appeared to have poorer survival; however, the result was not statistically significant. Ontario's First Nations population experiences poorer cancer survival when compared to other Ontarians and strategies to reduce these inequalities must be developed and implemented.

Perceived barriers to mammography among underserved women in a Breast Health Center Outreach Program

BACKGROUND

To investigate perceived barriers to mammography among underserved women, we asked participants in the Siteman Cancer Center Mammography Outreach Registry-developed in 2006 to evaluate mobile mammography's effectiveness among the underserved-why they believed women did not get mammograms.

METHODS

The responses of approximately 9,000 registrants were analyzed using multivariable logistic regression. We report adjusted odds ratios (OR) and 95% confidence intervals (CI) significant at 2-tailed P values less than .05.

RESULTS

Fears of cost (40%), mammogram-related pain (13%), and bad news (13%) were the most commonly reported barriers. Having insurance was associated with not perceiving cost as a barrier (OR .44, 95% CI .40 to .49), but with perceiving fear of both mammogram-related pain (OR 1.39, 95% CI 1.21 to 1.60) and receiving bad news (OR 1.38, 95% CI 1.19 to 1.60) as barriers.

CONCLUSION

Despite free services, underserved women continue to report experiential and psychological obstacles to mammography, suggesting the need for more targeted education and outreach in this population.

Understanding the role of embarrassment in gynaecological screening: a qualitative study from the ASPIRE cervical cancer screening project in Uganda

OBJECTIVE

To define embarrassment and develop an understanding of the role of embarrassment in relation to cervical cancer screening and self-collected human papillomavirus (HPV) DNA testing in Uganda.

DESIGN

Cross-sectional, qualitative study using semistructured one-to-one interviews and focus groups.

PARTICIPANTS

6 key-informant health workers and 16 local women, purposively sampled. Key informant inclusion criteria: Ugandan members of the project team. Focus group inclusion criteria: woman age 30-69 years, Luganda or Swahili speaking, living or working in the target Ugandan community.

EXCLUSION CRITERIA

unwillingness to sign informed consent.

SETTING

Primary and tertiary low-resource setting in Kampala, Uganda.

RESULTS

In Luganda, embarrassment relating to cervical cancer is described in two forms. 'Community embarrassment' describes discomfort based on how a person may be perceived by others. 'Personal embarrassment' relates to shyness or discomfort with her own genitalia. Community embarrassment was described in themes relating to place of study recruitment, amount of privacy in dwellings, personal relationship with health workers, handling of the vaginal swab and misunderstanding of HPV self-collection as HIV testing. Themes of personal embarrassment related to lack of knowledge, age and novelty of the self-collection swab. Overall, embarrassment was a barrier to screening at the outset and diminished over time through education and knowledge. Fatalism regarding cervical cancer diagnosis, worry about results and stigma associated with a cervical cancer diagnosis were other psychosocial barriers described. Overcoming psychosocial barriers to screening can include peer-to-peer education, drama and media campaigns.

CONCLUSIONS

Embarrassment and other psychosocial barriers may play a large role at the onset of a screening programme, but over time as education and knowledge increase, and the social norms around screening evolve, its role diminishes. The role of peer-to-peer education and community authorities on healthcare cannot be overlooked and can have a major impact in overcoming psychosocial and social barriers to screening.

Daily hassles' role in health seeking behavior among low-income populations

OBJECTIVES

To adapt a daily hassles measure for a low-income population and assess the relationship between hassles and health seeking behavior.

METHODS

The mixed methods approach used cognitive interviews (N = 23) to inform an adapted measure of daily hassles. The adapted scale was then tested via surveys (N = 144) in community health centers; multivariate logistic regression models were used to assess relationships among variables.

RESULTS

Hassle concerning having enough money for emergencies (76.5%) and worrying about personal health (68.8%) were among the most common. Increased health-related hassles were associated with an increased likelihood to delay needed care.

CONCLUSIONS

Findings suggest daily hassles are unique among low-income populations and should be considered in health behavior interventions.

Benefits and barriers to participation in colorectal cancer screening: a protocol for a systematic review and synthesis of qualitative studies

INTRODUCTION

Colorectal cancer (CRC) poses a serious health problem worldwide. While screening is effective in reducing CRC mortality, participation in screening tests is generally suboptimal and social inequities in participation are frequently reported. The goal of this review is to synthesise factors that influence an individual's decision to participate in CRC screening, and to explore how those factors vary by sex, ethnicity and socioeconomic status.

DATA SOURCES

A primary search of Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, EMBASE, PsycINFO, and a secondary search of grey literature and articles taken from references of included articles (from inception to July 2013).

DESIGN

A systematic review and Meta-study synthesis of qualitative studies that address perceived benefits and barriers to participation in CRC screening tests among adults 50 years of age or older.

REVIEW METHODS

The two-staged Meta-study methodology by Paterson will be used to conduct this review. In stage 1, similarities/differences, patterns and themes will be identified across three levels of analysis while preserving the context of original studies. In stage 2, synthesis will extend beyond the analysis to generate new theory of the phenomenon through a process called Meta-synthesis.

DISCUSSION

This review offers to generate a framework to better understand benefits and barriers that affect decision-making to participate in CRC screening among different sectors of the population. This framework will be a relevant tool for policy makers in framing educational materials, for patient-centered communication, and for researchers interested in the science of equity. This review is registered in PROSPERO (registration number: CRD42013005025).

The development and testing of a brief ('gist-based') supplementary colorectal cancer screening information leaflet

OBJECTIVE

To design and user-test a 'gist-based' colorectal cancer screening information leaflet, which promotes comprehension of the screening offer.

METHODS

Twenty-eight individuals approaching screening age were recruited from organisations in deprived areas of England. Using a between-subjects design, we tested iterations of a newly-designed gist-based information leaflet. Participants read the leaflet and answered 8 'true' or 'false' comprehension statements. For the leaflet to be considered fit-for-purpose, all statements had to be answered correctly by at least 80% of participants in each round. Alterations were made if this threshold was not met and additional rounds of testing were undertaken.

RESULTS

At round 1, answers to 2/8 statements did not meet the threshold. After changes, answers in round 2 did not reach the threshold for 1/8 statements. In round 3, all answers were adequate and the leaflet was deemed fit-for-purpose. Qualitative data offered solutions such as language and layout changes which led to improved comprehension of the leaflet.

CONCLUSION

User-testing substantially improved the design and subsequent comprehensibility of a theory-driven gist-based colorectal cancer screening information leaflet.

PRACTICAL IMPLICATIONS

This leaflet will be evaluated as part of a large national randomised controlled trial designed to reduce socioeconomic inequalities in colorectal cancer screening participation.

Socio-economic differences in healthcare access from a welfare system perspective, Italy: 2007-2010

Inequalities between poorer and wealthier people in accessing healthcare services have been widely studied, but the mechanisms generating them are still to be fully understood. Among these, there is still a lack of evidence of relationships between health prevention/health promotion policies, welfare systems and social differences. We analysed 68 201 females from the PASSI Italian surveillance system for the years 2007-2010. The prevalence of women undergoing Pap testing was used as an example of access to preventive services. An odds ratio gradient was found with regard to different welfare system clusters: the probability of undergoing a screening test is higher for more advanced welfare systems. A strong association was found between having received a letter from the local health unit and having undergone the screening test. Significant differences still exist between high- and low-income women and their access to Italian preventive public services. As we expected, social determinants play an important role in health disparities, as these are also strongly influenced by typologies of welfare systems and by health policies.

How do people interpret information about colorectal cancer screening: observations from a think-aloud study

Background

The English NHS Bowel Cancer Screening Programme biennially invites individuals aged 60–74 to participate in screening. The booklet, ‘Bowel Cancer Screening: The Facts' accompanies this invitation. Its primary aim is to inform potential participants about the aims, advantages and disadvantages of colorectal cancer screening.

Objective

To provide detailed commentary on how individuals process the information contained within ‘The Facts’ booklet.

Design, setting and participants

This study comprised of 18 interviews with individuals aged 45–60 and used a ‘think‐aloud’ paradigm in which participants read aloud the booklet. Participant utterances (verbal statements made in response to researcher‐led prompts) were transcribed and analysed using a combination of content and thematic analysis.

Results

A total of 776 coded utterances were analysed (mean = 43.1 per person; range = 8–95). While overall comprehension was satisfactory, several problem areas were identified such as the use of complex unfamiliar terminology and the presentation of numerical information. Specific sections such as colonoscopy risk information evoked negative emotional responses. Participants made several suggestions for ways in which comprehension might be improved.

Conclusion

Public perceptions of the NHS Bowel Cancer Screening Programme information materials indicated that specific aspects of the booklet were difficult to process. These materials may be an appropriate target to improve public understanding of the aims, benefits and disadvantages of colorectal cancer screening. These findings will contribute to a broader NIHR‐funded project that aims to design a supplementary ‘gist‐based’ information leaflet suitable for low literacy populations.

Factors Associated With Cancer Family History Communication Between African American Men and Their Relatives

African American men bear a disproportionately high burden from cancer in the U.S. The American Cancer Society reports that for all cancer sites combined, African American men are 32% more likely to die than white men (American Cancer Society, 2011). Having a family history of cancer elevates an individual's risk for the disease and should inform decision-making around the use of specific cancer screening tests as well as earlier onset and frequency of cancer screening. Adult African American men who attended an annual hospital-based community health fair in the Midwest which targeted minority men, were approached to complete a paper-based survey. Participants were asked "have you ever talked with any of your relatives about your family history of cancer (about any members of your family who have been diagnosed with cancer)?" Predictors were evaluated using bivariate analysis and logistic regression; they included socio-demographic, health access, health behavior, health status, and communication variables. Participants were 558 African American men with a mean age of 54 years old. African American men were most likely to have ever discussed their family history of cancer with a relative if they had specific knowledge of their family history of cancer and if they had ever talked to a physician about their family history of cancer. For African American men with a familial predisposition to cancer, further examination of barriers and facilitators to discussion with relatives, specifically those related to health access and knowledge, is warranted.

Differences in cancer awareness and beliefs between Australia, Canada, Denmark, Norway, Sweden and the UK (the International Cancer Benchmarking Partnership): do they contribute to differences in cancer survival?

BACKGROUND

There are wide international differences in 1-year cancer survival. The UK and Denmark perform poorly compared with other high-income countries with similar health care systems: Australia, Canada and Sweden have good cancer survival rates, Norway intermediate survival rates. The objective of this study was to examine the pattern of differences in cancer awareness and beliefs across these countries to identify where these might contribute to the pattern of survival.

METHODS

We carried out a population-based telephone interview survey of 19079 men and women aged ≥ 50 years in Australia, Canada, Denmark, Norway, Sweden and the UK using the Awareness and Beliefs about Cancer measure.

RESULTS

Awareness that the risk of cancer increased with age was lower in the UK (14%), Canada (13%) and Australia (16%) but was higher in Denmark (25%), Norway (29%) and Sweden (38%). Symptom awareness was no lower in the UK and Denmark than other countries. Perceived barriers to symptomatic presentation were highest in the UK, in particular being worried about wasting the doctor's time (UK 34%; Canada 21%; Australia 14%; Denmark 12%; Norway 11%; Sweden 9%).

CONCLUSION

The UK had low awareness of age-related risk and the highest perceived barriers to symptomatic presentation, but symptom awareness in the UK did not differ from other countries. Denmark had higher awareness of age-related risk and few perceived barriers to symptomatic presentation. This suggests that other factors must be involved in explaining Denmark's poor survival rates. In the UK, interventions that address barriers to prompt presentation in primary care should be developed and evaluated.

The Jade Goody Effect: whose cervical screening decisions were influenced by her story?

OBJECTIVES

In 2009 more women attended cervical screening in England and Wales than in the previous year. Described as the 'Jade Goody Effect' this was attributed to the death from cervical cancer of a UK celebrity. The present study aimed to establish which sociodemographic characteristics were associated with being influenced by Jade Goody's story.

METHODS

Data were collected as part of a Taylor Nelson Sofres (TNS) omnibus survey using random location sampling. Women in England aged 26-64 years were asked to report whether they felt Jade Goody's story had influenced their decisions about cervical screening over the 18 months between her death and the time of the survey.

RESULTS

Data from 890 participants was included in analysis. Over a third of women felt Goody's story had influenced their decisions about cervical screening (40%). Younger women (aged 26-35 years) were more likely to have been influenced by Goody's story than older women (56-64 year olds). There was also evidence of socioeconomic variation with women from lower socioeconomic class groups and those with fewer educational qualifications more likely to say they had been influenced by Goody's story.

CONCLUSIONS

The 'Jade Goody Effect', as acknowledged by women themselves, was more pronounced among young women and influenced screening decisions more markedly among those from lower socioeconomic backgrounds. Narrative communication may be an effective way to encourage attendance at cervical cancer screening and reach groups of the population that are difficult to reach using traditional intervention methods.

Identifying specific non-attending groups in breast cancer screening--population-based registry study of participation and socio-demography

Background

A population-based breast cancer screening programme was implemented in the Central Denmark Region in 2008–09. The objective of this registry-based study was to examine the association between socio-demographic characteristics and screening participation and to examine whether the group of non-participants can be regarded as a homogeneous group of women.

Method

Participation status was obtained from a regional database for all women invited to the first screening round in the Central Denmark Region in 2008–2009 (n=149,234). Participation data was linked to registries containing socio-demographic information. Distance to screening site was calculated using ArcGIS. Participation was divided into ‘participants’ and ‘non-participants’, and non-participants were further stratified into ‘active non-participants’ and ‘passive non-participants’ based on whether the woman called and cancelled her participation or was a ‘no-show’.

Results

The screening participation rate was 78.9%. In multivariate analyses, non-participation was associated with older age, immigrant status, low OECD-adjusted household income, high and low level education compared with middle level education, unemployment, being unmarried, distance to screening site >20 km, being a tenant and no access to a vehicle. Active and passive non-participants comprised two distinct groups with different socio-demographic characteristics, with passive non-participants being more socially deprived compared with active non-participants.

Conclusion

Non-participation was associated with low social status e.g. low income, unemployment, no access to vehicle and status as tenant. Non-participants were also more likely than participants to be older, single, and of non-Danish origin. Compared to active non-participants, passive non-participants were characterized by e.g. lower income and lower educational level. Different interventions might be warranted to increase participation in the two non-participant groups.

The Lay Public's Understanding and Perception of Dementia in a Developed Asian Nation

Background

Early detection of dementia aims to improve treatment outcomes. However, poor perception and understanding of dementia are significant barriers. We aim to investigate the public's perception of dementia and identify variables associated with the different profiles of public perception.

Methods

A custom-designed questionnaire was used to assess laypersons’ knowledge and perception of dementia during a health fair at a public hospital in Singapore, a developed Asian nation. Out of a sample of 370 subjects, 32 declined to participate (response rate = 91.4%). Latent class analysis (LCA) was used to identify meaningful subgroups of subjects from significant associations with multiple indicators of dementia awareness. Multinomial logistic regression was performed exploring variables associated with each of the subgroups derived from LCA.

Results

The majority of the study participants were female (66.9%), 65 years or older (71.1%), and ethnic Chinese (88.1%). LCA classified the study participants into 3 subgroups: Class 1 (good knowledge, good attitude), Class 2 (good knowledge, poor attitude), and Class 3 (poor knowledge, poor attitude), in proportions of 14.28, 63.83, and 21.88%, respectively. Compared to other classes, participants with good knowledge and good attitude towards dementia (Class 1) were more likely to know someone with dementia and understand the effects of the disease, be married, live in private housing, receive higher monthly income, and not profess belief in Buddhism, Taoism, or Hinduism.

Conclusion

Our results show that the public in Singapore may not be ready for screening initiatives and early dementia diagnosis. Education efforts should be targeted at lower socioeconomic groups, singles, and those of certain oriental religions.

Non-participation in population-based disease prevention programs in general practice

BACKGROUND

The number of people with a chronic disease will strongly increase in the next decades. Therefore, prevention of disease becomes increasingly important. The aim of this systematic review was to identify factors that negatively influence participation in population-based disease prevention programs in General Practice and to establish whether the program type is related to non-participation levels.

METHODS

We conducted a systematic review in Pubmed, EMBASE, CINAHL and PsycINFO, covering 2000 through July 6th 2012, to identify publications including information about characteristics of non-participants or reasons for non-participation in population-based disease prevention programs in General Practice.

RESULTS

A total of 24 original studies met our criteria, seven of which focused on vaccination, eleven on screening aimed at early detection of disease, and six on screening aimed at identifying high risk of a disease, targeting a variety of diseases and conditions. Lack of personal relevance of the program, younger age, higher social deprivation and former non-participation were related to actual non-participation. No differences were found in non-participation levels or factors related to non-participation between the three program types. The large variation in non-participation levels within the program types may be partly due to differences in recruitment strategies, with more active, personalized strategies resulting in higher participation levels compared to an invitation letter.

CONCLUSIONS

There is still much to be gained by tailoring strategies to improve participation in those who are less likely to do so, namely younger individuals, those living in a deprived area and former non-participants. Participation may increase by applying more active recruitment strategies.

Non-participation in population-based disease prevention programs in general practice

Background

The number of people with a chronic disease will strongly increase in the next decades. Therefore, prevention of disease becomes increasingly important. The aim of this systematic review was to identify factors that negatively influence participation in population-based disease prevention programs in General Practice and to establish whether the program type is related to non-participation levels.

Methods

We conducted a systematic review in Pubmed, EMBASE, CINAHL and PsycINFO, covering 2000 through July 6th 2012, to identify publications including information about characteristics of non-participants or reasons for non-participation in population-based disease prevention programs in General Practice.

Results

A total of 24 original studies met our criteria, seven of which focused on vaccination, eleven on screening aimed at early detection of disease, and six on screening aimed at identifying high risk of a disease, targeting a variety of diseases and conditions. Lack of personal relevance of the program, younger age, higher social deprivation and former non-participation were related to actual non-participation. No differences were found in non-participation levels or factors related to non-participation between the three program types. The large variation in non-participation levels within the program types may be partly due to differences in recruitment strategies, with more active, personalized strategies resulting in higher participation levels compared to an invitation letter.

Conclusions

There is still much to be gained by tailoring strategies to improve participation in those who are less likely to do so, namely younger individuals, those living in a deprived area and former non-participants. Participation may increase by applying more active recruitment strategies.

Attachment and barriers to cervical screening

The present study explored the role of attachment insecurity in cervical screening behaviors and barriers in a sample of 257 female undergraduates. Information on attachment dimensions as well as attachment style was collected. Attachment anxiety and attachment avoidance were associated with decreased likelihood of having participated in cervical screening and positively associated with screening barriers. Screening barriers were elevated among individuals with insecure attachment styles (preoccupied, fearful, and dismissing), and dismissing participants were less likely to have engaged in screening compared to secure participants. Our findings demonstrate that attachment insecurity may be a risk factor for inadequate cervical screening and screening barriers.

Is the high-risk strategy to prevent cardiovascular disease equitable? A pharmacoepidemiological cohort study

BACKGROUND

Statins are increasingly prescribed to prevent cardiovascular disease (CVD) in asymptomatic individuals. Yet, it is unknown whether those at higher CVD risk - i.e. individuals in lower socio-economic position (SEP) - are adequately reached by this high-risk strategy. We aimed to examine whether the Danish implementation of the strategy to prevent cardiovascular disease (CVD) by initiating statin (HMG-CoA reductase inhibitor) therapy in high-risk individuals is equitable across socioeconomic groups.

METHODS

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

Applying individual-level nationwide register information on socio-demographics, dispensed prescription drugs and hospital discharges, all Danish citizens aged 20+ without previous register-markers of CVD, diabetes or statin therapy were followed during 2002-2006 for first occurrence of myocardial infarction (MI) and a dispensed statin prescription (N = 3.3 mill).

MAIN OUTCOME MEASURES

Stratified by gender, 5-year age-groups and socioeconomic position (SEP), incidence of MI was applied as a proxy for statin need. Need-standardized statin incidence rates were calculated, applying MI incidence rate ratios (IRR) as need-weights to adjust for unequal needs across SEP.Horizontal equity in initiating statin therapy was tested by means of Poisson regression analysis. Applying the need-standardized statin parameters and the lowest SEP-group as reference, a need-standardized statin IRR > 1 translates into horizontal inequity favouring the higher SEP-groups.

RESULTS

MI incidence decreased with increasing SEP without a parallel trend in incidence of statin therapy. According to the regression analyses, the need-standardized statin incidence increased in men aged 40-64 by 17%, IRR 1.17 (95% CI: 1.14-1.19) with each increase in income quintile. In women the proportion was 23%, IRR 1.23 (1.16-1.29). An analogous pattern was seen applying education as SEP indicator and among subjects aged 65-84.

CONCLUSION

The high-risk strategy to prevent CVD by initiating statin therapy seems to be inequitable, reaching primarily high-risk subjects in lower risk SEP-groups.

Diabetes self-management in patients with low health literacy: ordering findings from literature in a health literacy framework

OBJECTIVE

To review studies on the association between health literacy (HL), diabetes self-management and possible mediating variables.

METHODS

We systematically searched for empirical studies in PubMed. Findings were ordered by a HL framework that outlines routes between HL, sociocognitive determinants and health actions.

RESULTS

Of the 11 relevant studies, three reported a significant positive association between HL and specific diabetes self-management domains. Ten studies investigated the association between HL and knowledge (n=8), beliefs (n=2), self-efficacy (n=3) and/or social support (n=1). Significant associations were found between HL and knowledge (n=6), self-efficacy (n=1) and social support (n=1). Of the three studies evaluating the effect of these sociocognitive variables on diabetes self-management, only one found proof for a mediating variable (social support) in the pathway between HL and self-management.

CONCLUSION

There is only limited evidence for a significant association between HL and diabetes self-management, and for the mediating role of sociocognitive variables in this pathway.

PRACTICE IMPLICATIONS

Longitudinal studies, including HL, diabetes self-management and potential mediators, are needed to substantiate possible associations between these variables. Such research is essential to enable evidence-based development of interventions to increase adequate and sustainable self-management in diabetic patients with low HL.

Comunicação entre os profissionais de saúde e o idoso: uma revisão da investigação

A investigação empírica tem demonstrado consistentemente que a qualidade da comunicação entre os profissionais com responsabilidade de prestação de cuidados de saúde e os idosos assume-se como uma das principais variáveis explicativas do processo de saúde-doença, da recuperação e da optimização da saúde dos idosos. Partindo de uma perspectiva biopsicossocial da saúde, o presente artigo teórico tem como objectivo apresentar de uma forma sistemática os principais conclusões da investigação recente sobre o tema. Globalmente, os estudos têm demonstrado que o tom amistoso, cortesia, o encorajamento, a empatia e a construção de uma parceria no processo terapêutico por parte dos profissionais estão relacionados com a percepção de qualidade dos cuidados por parte dos idosos. No final do artigo serão discutidos estes resultados, sendo apresentadas sugestões para a investigação futura , bem como possíveis implicações para a Gerontologia.

Cancer fatalism: deterring early presentation and increasing social inequalities?

BACKGROUND

Fatalistic beliefs about cancer have been implicated in low uptake of screening and delay in presentation particularly in low socioeconomic status (SES) groups, but no studies have systematically evaluated interrelationships between SES, fatalism, and early detection behaviors. We explored whether (i) fatalism is associated with negative attitudes toward early detection, (ii) lower SES groups are more fatalistic, and (iii) SES differences in fatalism partly explain SES differences in attitudes toward early detection.

METHODS

In a population-representative sample of adults in Britain using computer-based interviews in the home setting, respondents (N = 2,018) answered two questions to index fatalism (expectations of cancer survival and cure) and two items on early detection attitudes (the perceived value of early detection and fear of symptom reporting). SES was indexed with a social grade classification.

RESULTS

Fatalism was associated with being less positive about early detection (β = -0.40, P < 0.001) and more fearful about seeking help for a suspicious symptom (β = 0.24, P < 0.001). Lower SES groups were more fatalistic (β = -0.21, P < 0.001). Path analyses suggest that SES differences in fatalism might explain SES differences in attitudes about early detection.

CONCLUSIONS

In this population sample, SES differences in fatalism partly explained SES differences in the perceived value of early detection and fear of symptom presentation.

IMPACT

Fatalistic beliefs about cancer should be targeted to promote early presentation of cancer and this may be particularly important for lower SES groups.

Overview of screening: where we are and where we may be headed

This volume of Epidemiologic Reviews continues a discussion about screening within the evidence community that has been going on for many years. From various perspectives, the authors of these reviews consider the benefits and harms of screening for multiple conditions; the balance between benefits and harms (and costs) is often not clear. With few exceptions, the contribution of screening to improving the health of the public is small, yet it has become a popular and growing form of prevention. It may be that we are learning that the magnitude of benefit from screening is less than we hoped, and the harms may be greater than we thought. Perhaps we should not think of screening as our primary prevention strategy but rather use screening to make a real, but limited contribution to population health for a few conditions. We might target screening to smaller subpopulations with the highest potential benefit and the lowest potential harm. The payoff for population health could be greater if we shifted some resources we now devote to screening to developing, testing, and implementing alternative approaches to preventing the important threats to population health. There needs to be a wider discussion about these issues with the public.

Responses to procedural information about colorectal cancer screening using faecal occult blood testing: the role of consideration of future consequences

BACKGROUND

Colorectal cancer (CRC) screening participation is low despite its effectiveness in reducing CRC mortality. Identifying benefits and barriers requires consideration of specific characteristics of screening modalities. AIMS AND RESEARCH QUESTIONS: To monitor the impact of providing information about CRC screening via faecal occult blood testing (FOBt) on intentions to participate. To investigate moderation by individual differences in consideration of future consequences (CFC).

DESIGN, SETTING AND PARTICIPANTS

A total of 211 healthy adults (aged 45-59) with no experience of CRC screening were presented with eight consecutive statements about FOBt-based screening in a web survey. Participants completed measures of i) intention (after each statement), ii) CFC and iii) the importance of screening practicalities (e.g. unpleasantness of completing the test) and benefits (e.g. early detection of cancer).

RESULTS

An 8 (information)×2 (CFC) mixed ancova showed that intentions varied across the eight statements. (P<0.001): increasing after information about FOBt being completed at home (P<0.001) before subsequently decreasing after information about the requirement to collect faecal samples (P<0.001) in a plastic tub (P<0.01) on three occasions (P<0.01) with the low CFC group generally being less inclined to complete the test (P<0.01). Two between-group anovas demonstrated that the low CFC group attributed greater importance to practicalities of screening than the high CFC group while the opposite was found for the importance of benefits (both P's<0.001).

CONCLUSION

Deconstructing FOBt-based screening pointed to specific benefits and barriers which can advance research into public preferences of screening and educational materials.