Association of area socioeconomic status and breast, cervical, and colorectal cancer screening: a systematic review

Residential environment and breast cancer incidence and mortality: a systematic review and meta-analysis

BACKGROUND

Factors beyond the individual level such as those characterizing the residential environment may be important to breast cancer outcomes. We provide a systematic review and results of meta-analysis of the published empirical literature on the associations between breast cancer risk and mortality and features of the residential environment.

METHODS

Using PRISMA guidelines, we searched four electronic databases and manually searched the references of selected articles for studies that were published before June 2013. We selected English language articles that presented data on adult breast cancer incidence or mortality in relation to at least one area-based residential (ABR) independent variable.

RESULTS

We reviewed 31 eligible studies, and observed variations in ABR construct definition and measurement, study design, and analytic approach. The most common ABR measures were indicators of socioeconomic status (SES) (e.g., income, education, summary measures of several SES indicators or composite SES). We observed positive associations between breast cancer incidence and urbanization (Pooled RR for urban vs. rural: 1.09. 95% CI: 1.01, 1.19), ABR income (Pooled RR for highest vs. lowest ABR income: 1.17, 95% CI: 1.15, 1.19) and ABR composite SES (Pooled RR for highest vs. lowest ABR composite SES: 1.25, 95% CI: 1.08, 1.44). We did not observe consistent associations between any ABR measures and breast cancer mortality.

CONCLUSIONS

The findings suggest modest positive associations between urbanization and residential area socioeconomic environment and breast cancer incidence. Further studies should address conceptual and methodological gaps in the current publications to enable inference regarding the influence of the residential environment on breast cancer.

The association of social support and education with breast and cervical cancer screening

BACKGROUND

Disparities in breast and cervical cancer screening by socioeconomic status persist in the United States. It has been suggested that social support may facilitate screening, especially among women of low socioeconomic status. However, at present, it is unclear whether social support enables mammogram and Pap test compliance.

PURPOSE

This study examines the association between social support and compliance with mammogram and Pap test screening guidelines, and whether social support provides added value for women of low education.

METHOD

Data were from a countywide 2009-2010 population-based survey, which included records of 2,588 women 40 years and older (mammogram) and 2,123 women 21 to 65 years old (Pap test). Compliance was determined using the guidelines in effect at the time of data collection.

RESULTS

Social support was significantly related to mammogram (adjusted odds ratio = 1.43; 95% confidence interval [1.16, 1.77]) and Pap test (adjusted odds ratio = 1.71; 95% confidence interval [1.27, 2.29]) compliance after controlling for age, race, having a regular health care provider, and insurance status. The interaction between social support and education had a significant effect on Pap test compliance only among women younger than 40; the effect was not significant for mammogram compliance.

CONCLUSION

Social support is associated with breast and cervical cancer screening compliance. The association between education and cancer screening behavior may be moderated by social support; however, results hold only for Pap tests among younger women. Practitioners and researchers should focus on interventions that activate social support networks as they may help increase both breast and cervical cancer screening compliance among women with low educational attainment.

[Breast cancer screening in thirteen French departments]

BACKGROUND

In France, breast cancer screening programme, free of charge for women aged 50-74 years old, coexists with an opportunistic screening and leads to reduction in attendance in the programme. Here, we reported participation in organized and/or opportunistic screening in thirteen French departments.

POPULATION AND METHODS

We analyzed screening data (organized and/or opportunistic) of 622,382 women aged 51-74 years old invited to perform an organized mammography screening session from 2010 to 2011 in the thirteen French departments. The type of mammography screening performed has been reported according to women age, their health insurance scheme, the rurality and the socioeconomic level of their area or residence. We also represented the tertiles of deprivation and participation in mammography screening for each department.

RESULTS

A total of 390,831 (62.8%) women performed a mammography screening (organized and/or opportunistic) after the invitation. These women were mainly aged from 55-69 years old, insured by the general insurance scheme and lived in urban, semi-urban or affluent areas.

CONCLUSION

The participation in mammography screening (organized and opportunistic) in France remains below the target rate of 70% expected by health authorities to reduce breast cancer mortality through screening.

Neighborhood environment and intimate partner violence: a systematic review

Intimate partner violence (IPV) is an important global public health problem, affecting women across the life span and increasing risk for a number of unfavorable health outcomes. Typically conceptualized as a private form of violence, most research has focused on individual-level risk markers. Recently, more scholarly attention has been paid to the role that the residential neighborhood environment may play in influencing the occurrence of IPV. With research accumulating since the 1990s, increasing prominence of the topic, and no comprehensive literature reviews yet undertaken, it is time to take stock of what is known, what remains unknown, and the methods and concepts investigators have considered. In this article, we undertake a comprehensive, systematic review of the literature to date on the relationship between neighborhood environment and IPV, asking, "what is the status of scholarship related to the association between neighborhood environment and IPV occurrence?" Although the literature is young, it is receiving increasing attention from researchers in sociology, public health, criminology, and other fields. Obvious gaps in the literature include limited consideration of nonurban areas, limited theoretical motivation, and limited consideration of the range of potential contributors to environmental effects on IPV--such as built environmental factors or access to services. In addition, explanations of the pathways by which place influences the occurrence of IPV draw mainly from social disorganization theory that was developed in urban settings in the United States and may need to be adapted, especially to be useful in explaining residential environmental correlates of IPV in rural or non-U.S. settings. A more complete theoretical understanding of the relationship between neighborhood environment and IPV, especially considering differences among urban, semiurban, and rural settings and developed and developing country settings, will be necessary to advance research questions and improve policy and intervention responses to reduce the burden of IPV.

Academic vascular unit collaboration with advertising agency yields higher compliance in screening for abdominal aortic aneurysm

To improve compliance with abdominal aortic aneurysm (AAA) screening in low compliance areas, individually tailored invitations were developed in collaboration with a professional advertising agency. Compliance increased in two intervention municipalities from 71.4% in 2010–2012 to 78.1% in 2013 (p = 0.025), and was then higher [odds ratio 1.7; 95% confidence interval 1.1–2.6; p = 0.013] than in two control municipalities in which compliance was unchanged (417/552 [75.5%] in 2010–12 and 122/180 [67.8%] in 2013). Compliance with AAA-screening can be increased by collaboration with a professional advertising agency, albeit at a comparably high cost.

The doctor is just a messenger: beliefs of ultraorthodox Jewish women in regard to breast cancer and screening

Screenings for the early detection of breast cancer greatly improve survival odds. Studies of minority groups have shown lower attendance of screenings; however, these studies seldom focused on religious minorities. This study examines perceptions of cancer and cancer screening among healthy ultraorthodox women in order to gain insight about ways to promote screening. In this qualitative-phenomenological study of two focus groups, three main themes were found: faith in God; the Rabbi as a guide; one's relationship with the community. The study's findings point to the importance of studying the unique needs of members of certain religious groups.

Lifestyle changes for prevention of breast cancer

Breast cancer is the second most common cause of death from cancer among women. Lifestyle changes are shown to be important in the prevention of breast cancer. Diet, physical activity, smoking, alcohol use, and vitamin and mineral use are key factors influencing the risk of breast cancer among women. Because these factors are related to each other, it is difficult to assess their individual roles in breast cancer. Some of these factors are alterable, meaning that women can decrease their risk for breast cancer by changing their behavior. Breast cancer is associated with a high rate of mortality and morbidity among women. Therefore, it is logical to try to find ways to decrease the risk of developing breast cancer. Lifestyle changes seem to be an easy, effective, and economical way to help prevention breast cancer. In women with a confirmed breast cancer diagnosis who are under radiotherapy treatment after undergoing a mastectomy, lifestyle changes are still very important. Some factors, such as smoking cessation and prevention of weight gain, may improve the long-term survival chances of these patients. Therefore, ways to increase women’s knowledge about the role of lifestyle changes in the prevention of breast cancer and in the survival of patients with diagnosed breast cancer should be considered and studied.

Physicians, clinics, and neighborhoods: multiple levels of influence on colorectal cancer screening

BACKGROUND

We (i) described variability in colorectal cancer (CRC) test use across multiple levels, including physician, clinic, and neighborhood; and (ii) compared the performance of novel cross-classified models versus traditional hierarchical models.

METHODS

We examined multilevel variation in CRC test use among patients not up-to-date with screening in a large, urban safety net health system (2011-2012). Outcomes included: (i) fecal occult blood test (FOBT) or (ii) colonoscopy and were ascertained using claims data during a 1-year follow-up. We compared Bayesian (i) cross-classified four-level logistic models nesting patients within separate, nonoverlapping "levels" (physicians, clinics, and census tracts) versus (ii) three hierarchical two-level models using deviance information criterion. Models were adjusted for covariates (patient sociodemographic factors, driving time to clinic, and census tract poverty rate).

RESULTS

Of 3,195 patients, 157 (4.9%) completed FOBT and 292 (9.1%) completed colonoscopy during the study year. Patients attended 19 clinics, saw 177 physicians, and resided in 332 census tracts. Significant variability was observed across all levels in both hierarchical and cross-classified models that was unexplained by measured covariates. For colonoscopy, variance was similar across all levels. For FOBT, physicians, followed by clinics, demonstrated the largest variability. Model fit using cross-classified models was superior or similar to 2-level hierarchical models.

CONCLUSIONS

Significant and substantial variability was observed across neighborhood, physician, and clinic levels in CRC test use, suggesting the importance of factors at each of these levels on CRC testing.

IMPACT

Future multilevel research and intervention should consider the simultaneous influences of multiple levels, including clinic, physician, and neighborhood.

Correlates of colorectal cancer screening among residents of Ohio Appalachia

There is an excess burden of colorectal cancer (CRC) in the Appalachian region of the United States, which could be reduced by increased uptake of CRC screening tests. Thus, we examined correlates of screening among Appalachian residents at average-risk for CRC. Using a population-based sample, we conducted interviews with and obtained medical records of Appalachian Ohio residents 51-75 years between September 2009 and April 2010. Using multivariable logistic regression, we identified correlates of being within CRC screening guidelines by medical records. About half of participants were within CRC screening guidelines. Participants who were older (OR = 1.04, 95 % CI 1.01, 1.07), had higher income ($30,000-$60,000, OR = 1.92, 95 % CI 1.29, 2.86; ≥$60,000, OR = 1.80, 95 % CI 1.19, 2.72), a primary care provider (OR = 4.22, 95 % CI 1.33, 13.39), a recent check-up (OR = 2.37, 95 % CI 1.12, 4.99), had been encouraged to be screened (OR = 1.57, 95 % CI 1.11, 2.22), had been recommended by their doctor to be screened (OR = 6.68, 95 % CI 3.87, 11.52), or asked their doctor to order a screening test (OR = 2.24, 95 % CI 1.36, 3.69) had higher odds of being screened within guidelines in multivariable analysis. Findings suggest that access to and utilization of healthcare services, social influence, and patient-provider communication were the major factors associated with CRC screening. Researchers and healthcare providers should develop and implement strategies targeting these barriers/facilitators to improve CRC screening rates and reduce the CRC burden among residents of Appalachia.

Reducing racial and ethnic disparities in colorectal cancer screening is likely to require more than access to care

Colorectal endoscopy, an effective screening intervention for colorectal cancer, is recommended for people age fifty or older, or earlier for those at higher risk. Rates of colorectal endoscopy are still far below those recommended by the US Preventive Services Task Force. This study examined whether factors such as the supply of gastroenterologists and the proportion of the local population without health insurance coverage were related to the likelihood of having the procedure, and whether these factors explained racial and ethnic differences in colorectal endoscopy. We found evidence that improving access to health care at the county and individual levels through expanded health insurance coverage could improve colorectal endoscopy use but might not be sufficient to reduce racial and ethnic disparities in colorectal cancer screening. Policy action to address these disparities will need to consider other structural and cultural factors that may be inhibiting colorectal cancer screening.

Observer ratings of neighborhoods: comparison of two methods

Background

Although neighborhood characteristics have important relationships with health outcomes, direct observation involves imperfect measurement. The African American Health (AAH) study included two observer neighborhood rating systems (5-item Krause and 18-item AAH Neighborhood Assessment Scale [NAS]), initially fielded at two different waves. Good measurement characteristics were previously shown for both, but there was more rater variability than desired. In 2010 both measures were re-fielded together, with enhanced training and field methods implemented to decrease rater variability while maintaining psychometric properties.

Methods

AAH included a poor inner city and more heterogeneous suburban areas. Four interviewers rated 483 blocks, with 120 randomly-selected blocks rated by two interviewers. We conducted confirmatory factor analysis of scales and tested the Krause (5-20 points), AAH 18-item NAS (0-28 points), and a previous 7-item and new 5-item versions of the NAS (0-17 points, 0-11 points). Retest reliability for items (kappa) and scales (Intraclass Correlation Coefficient [ICC]) were calculated overall and among pre-specified subgroups. Linear regression assessed interviewer effects on total scale scores and assessed concurrent validity on lung and lower body functions. Mismeasurement effects on self-rated health were also assessed.

Results

Scale scores were better in the suburbs than in the inner city. ICC was poor for the Krause scale (ICC=0.19), but improved if the retests occurred within 10 days (ICC=0.49). The 7- and 5-item NAS scales had better ICCs (0.56 and 0.62, respectively), and were higher (0.71 and 0.73) within 10 days. Rater variability for the Kraus and 5- and 7-item NAS scales was 1-3 points (compared to the supervising rater). Concurrent validity was modest, with residents living in worse neighborhood conditions having worse function. Unadjusted estimates were biased towards the null compared with measurement-error corrected estimates.

Conclusions

Enhanced field protocols and rater training did not improve measurement quality. Specifically, retest reliability and interviewer variability remained problematic. Measurement error partially reduced, but did not eliminate concurrent validity, suggesting there are robust associations between neighborhood characteristics and health outcomes. We conclude that the 5-item AAH NAS has sufficient reliability and validity for further use. Additional research on the measurement properties of environmental rating methods is encouraged.

Regional factors associated with participation in the national health screening program: a multilevel analysis using national data

High participation rates are important for maximizing the effects of a health screening program. Previous studies have suggested that individual or regional characteristics have effects on health behaviors. In this study, we investigated the determinants of participation in the National Screening Program for Transitional Ages by simultaneously analyzing individual and area-level factors by multilevel analysis. A total of 1,081,216 subjects, aged 40 and 66 yr and nested in 254 areas, were included. There was a significant variation in participation rates across the areas even after adjusting for individual and area-level variables. Among the individual-level variables, increasing age, sex, higher income, and mild disability grade were associated with a higher participation rate. In urban areas, the 40-yr-old group had higher participation rates than the 66-yr-old group. Deprived areas had significantly high participation rates for both age groups. The number of screening centers per 1,000 inhabitants had no significant effect on participation in the screening program. In conclusion, regional characteristics are associated with participation rates independent of personal features and regional factors have differential effects with respect to age. A multi-dimensional approach is recommended to promote participation in health screening programs.

Improving participation in colorectal cancer screening: targets for action

OBJECTIVE

Our aim was to determine whether physician-related factors influenced patient participation in colorectal cancer (CRC) screening programs and to identify patient characteristics associated with lower participation in order to facilitate the development of targeted actions to improve participation.

METHOD

A retrospective cohort study was conducted in a French department during its first CRC screening campaign from June 2007 to May 2010. Data for 157,766 patients followed by 903 general practitioners (GPs) were analyzed. Patient participation was assessed using multilevel logistic modeling.

RESULTS

The overall participation rate was 30% (95% confidence interval [95% CI], 29.8-30.2) and varied across the 903 GPs from 0% to 75.5% (median, 30; interquartile range, 24-35). Inter-GP variance explained only 5.5% of the participation rate variance. Participation was significantly lower in males (odds ratio [OR], 0.79; 95% CI, 0.78-0.91), the youngest age group (55-59 years, OR, 0.61; 95% CI, 0.58-0.63), and patients living in socioeconomically deprived areas (OR, 0.82; 95% CI, 0.77-0.87).

CONCLUSION

Targeted actions to improve CRC screening participation should focus on patients younger than 60 years, males, and individuals living in deprived areas. Actions to enhance the influence of GPs on patient participation should be directed to the overall population of GPs.

Socioeconomic status and hepatocellular carcinoma in the United States

BACKGROUND

Hepatocellular carcinoma (HCC) has a poor prognosis and, unlike most cancers, HCC incidence and mortality rates are increasing in the United States. While risk is known to vary among different racial and ethnic groups, less is known about the variability of risk within these groups by neighborhood socioeconomic status (SES).

METHODS

HCC cases diagnosed in the Surveillance, Epidemiology and End Results (SEER) 11 cancer registries between 1996 and 2007, and the population of the SEER 11 catchment areas was studied. Analyses were conducted to compare census tract area family poverty, educational attainment, and unemployment by race and ethnicity. A multiple linear regression model, weighted by the number of cases and the number of individuals in each census tract, with adjustment for registry, was used to calculate mean differences in area-level attributes between HCC cases and the population.

RESULTS

HCC cases in most racial/ethnic groups had lower mean neighborhood-level measures of SES than their referent population. An exception was seen among Hispanics. Comparing white cases with cases of other racial groups and to Hispanics, white cases lived in neighborhoods with less family poverty, fewer high-school dropouts, and lower unemployment. Compared with white cases, Asian and Pacific Islander and Hispanic cases lived in neighborhoods with a higher percentage of foreign-born population.

CONCLUSIONS

Low neighborhood-level SES and immigrant status may be associated with greater risk of HCC within specific racial and ethnic groups.

IMPACT

These findings could help to focus control resources for HCC toward the most affected communities.

Socioeconomic factors affecting colorectal, breast and cervical cancer screening in an Asian urban low-income setting at baseline and post-intervention

BACKGROUND

Inequalities in cancer screening are little studied in Asian societies. We determined whether area and individual measures of socio-economic status (SES) affected cancer screening participation in Singapore and prospectively evaluated an access-enhancing community-based intervention.

METHODS

The study population involved all residents aged >40 years in two housing estates comprising of owner-occupied (high-SES area) and rental (low-SES area) flats. From 2009 to 2011, non-adherents to regular screening for colorectal/breast/cervical cancer were offered free convenient screening over six months. Pre- and post-intervention screening rates were compared with McNemar's test. Multi-level logistic regression identified factors of regular screening at baseline; Cox regression analysis identified predictors of screening post-intervention.

RESULTS

Participation was 78.2% (1081/1383). In the low-SES area, 7.7% (33/427), 20.4% (44/216), and 14.3% (46/321) had regular colorectal, cervical and breast cancer screening respectively. Post-intervention, screening rates in the low-SES area rose significantly to 19.0% (81/427), 25.4% (55/216), and 34.3% (74/216) respectively (p<0.001). Area SES was more consistently associated with screening than individual SES at baseline. Post-intervention, for colorectal cancer screening, those with higher education were more likely to attend (p=0.004); for female cancer screening, the higher-income were less likely to attend (p=0.032).

CONCLUSIONS

Access-enhancing community-based interventions improve participation among disadvantaged strata of Asian societies.

Socioeconomic status, severity of disease and level of family members' care in adult surgical intensive care patients: the prospective ECSSTASI study

Background

Low socioeconomic status (SES) is associated with increased mortality from cardiovascular disease, cancer and trauma. However, individual-level prospective data on SES in relation to health outcomes among critically ill patients admitted to intensive care units (ICU) are unavailable.

Methods

In a cohort of 1,006 patients at a 24-bed surgical ICU of an academic tertiary care facility in Germany, we examined levels of SES in relation to disease severity at admission, time period of mechanical ventilation, length of stay and frequency of phone calls and visits by next-of-kin.

Findings

Patients with low SES had higher risk for Sequential Organ Failure Assessment (SOFA) score greater or equal to 5 [multivariate-adjusted odds ratio (OR) 1.49; 95% confidence interval (CI) 0.95–2.33; p = 0.029] and a trend for higher risk for Simplified Acute Physiology Score (SAPS II) greater or equal to 31 (OR 1.28; 95% CI 0.80–2.05; p = 0.086) at admission as compared with patients with high SES. When compared with men with high SES, those with low SES had greater risk for ICU treatment ≥5 days (multivariate-adjusted OR 1.99; 95% CI 1.06–3.74; p = 0.036) and showed a trend for a low number of visits from next-of-kin (<0.5 visits per day) (OR 1.85; 95% CI 0.79–4.30; p = 0.054). In women such associations could not be demonstrated.

Interpretation

Socioeconomic status is inversely related to severity of disease at admission and to length of stay in ICU, and positively associated with the level of care by next-of-kin. Whether relations differ by gender requires further examination.

Awareness and acceptability of human papillomavirus vaccine: an application of the instrumental variables bivariate probit model

Background

Although lower uptake rates of the human papillomavirus (HPV) vaccine among socioeconomically disadvantaged populations have been documented, less is known about the relationships between awareness and acceptability, and other factors affecting HPV vaccine uptake.

The current study aimed to estimate the potential effectiveness of increased HPV vaccine awareness on the acceptability of HPV vaccination in a nationally representative sample of women, using a methodology that controlled for potential non-random selection.

Methods

This study used a population-based sample from the 2007 Health Information National Trends Survey, a cross-sectional study of the US population aged 18 years or older, and focused on the subsample of 742 women who have any female children under the age of 18 years in the household. An instrumental variables bivariate probit model was used to jointly estimate HPV vaccine awareness and acceptability.

Results

The proportion of HPV vaccine acceptability among the previously aware and non-aware groups was 58% and 47%, respectively. Results from the instrumental variables bivariate probit model showed that the estimated marginal effect of awareness on acceptability was 46 percentage points, an effect that was even greater than observed.

Conclusions

Among populations who are not currently aware of the HPV vaccine, the potential impact of raising awareness on acceptability of HPV vaccination is substantial. This finding provides additional support to strengthening public health programs that increase awareness and policy efforts that address barriers to HPV vaccination.

Condicionantes socioeconômicos e geográficos do acesso à mamografia no Brasil, 2003-2008

Este estudo examinou os efeitos de características da população e geográficas na chance de mamografia, no Brasil em 2003 e 2008. A partir do Suplemento Saúde da Pesquisa Nacional por Amostra de Domicílios, foram analisados os padrões de mamografia em mulheres com 25 anos ou mais, por meio de razão de prevalências, e em mulheres com 40 anos ou mais, por meio de regressão logística multivariada, incluindo o local de residência e a distribuição geográfica da oferta. Entre as mulheres com 50-69 anos, 54,6% relataram ter feito mamografia, em 2003, e 71,5%, em 2008. A chance de realização do exame é maior entre as de 50 a 69 anos, aumenta com a renda familiar e escolaridade, dentre as casadas, para as que consultaram médico e têm plano de saúde. Residir em área metropolitana triplica a chance de mamografia. Comparado com a região Norte, residentes das demais regiões têm chances maiores e a distância influencia negativamente a realização do exame. No período, a cobertura aumentou na faixa etária alvo da política nacional, com redução das desigualdades de renda e de escolaridade. A ampliação do acesso parece mais ligada às políticas de aumento de renda e inclusão social, e à ampliação da oferta de exames na rede pública e conveniada, do que ao aumento do número de mamógrafos.

Sociodemographic gradients in breast and cervical cancer screening in Korea: the Korean National Cancer Screening Survey (KNCSS) 2005-2009

Background

Cancer screening rates in Korea for five cancer types have increased steadily since 2002. With regard to the life-time cancer screening rates in 2009 according to cancer sites, the second highest was breast cancer (78.1%) and the third highest was cervical cancer (76.1%). Despite overall increases in the screening rate, disparities in breast and cervical cancer screening, based on sociodemographic characteristics, still exist.

Methods

Data from 4,139 women aged 40 to74 years from the 2005 to 2009 Korea National Cancer Screening Survey were used to analyze the relationship between sociodemographic characteristics and receiving mammograms and Pap smears. The main outcome measures were ever having had a mammogram and ever having had a Pap smear. Using these items of information, we classified women into those who had had both types of screening, only one screening type, and neither screening type. We used logistic regression to investigate relationships between screening history and sociodemographic characteristics of the women.

Results

Being married, having a higher education, a rural residence, and private health insurance were significantly associated with higher rates of breast and cervical cancer screening after adjusting for age and sociodemographic factors. Household income was not significantly associated with mammograms or Pap smears after adjusting for age and sociodemographic factors.

Conclusions

Disparities in breast and cervical cancer screening associated with low sociodemographic status persist in Korea.

Interventions for encouraging sexual behaviours intended to prevent cervical cancer

BACKGROUND

Human papillomavirus (HPV) is the key risk factor for cervical cancer. Continuing high rates of HPV and other sexually transmitted infections (STIs) in young people demonstrate the need for effective behavioural interventions.

OBJECTIVES

To assess the effectiveness of behavioural interventions for young women to encourage safer sexual behaviours to prevent transmission of STIs (including HPV) and cervical cancer.

SEARCH STRATEGY

Systematic literature searches were performed on the following databases: Cochrane Central Register of Controlled Trials (CENTRAL Issue 4, 2009) Cochrane Gynaecological Cancer Review Group (CGCRG) Specialised Register, MEDLINE, EMBASE, CINAHL, PsychINFO, Social Science Citation Index and Trials Register of Promoting Health Interventions (TRoPHI) up to the end of 2009. All references were screened for inclusion against selection criteria.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of behavioural interventions for young women up to the age of 25 years that included, amongst other things, information provision about the transmission and prevention of STIs. Trials had to measure behavioural outcomes (e.g. condom use) and/or biological outcomes (e.g. incidence of STIs, cervical cancer).

DATA COLLECTION AND ANALYSIS

A narrative synthesis was conducted. Meta-analysis was not considered appropriate due to heterogeneity between the interventions and trial populations.

MAIN RESULTS

A total of 5271 references were screened and of these 23 RCTs met the inclusion criteria. Most were conducted in the USA and in health-care clinics (e.g. family planning).The majority of interventions provided information about STIs and taught safer sex skills (e.g. communication), occasionally supplemented with provision of resources (e.g. free sexual health services). They were heterogeneous in duration, contact time, provider, behavioural aims and outcomes. A variety of STIs were addressed including HIV and chlamydia. None of the trials explicitly mentioned HPV or cervical cancer prevention.Statistically significant effects for behavioural outcomes (e.g. increasing condom use) were common, though not universal and varied according to the type of outcome. There were no statistically significant effects of abstaining from or reducing sexual activity. There were few statistically significant effects on biological (STI) outcomes. Considerable uncertainty exists in the risk of bias due to incomplete or ambiguous reporting.

AUTHORS' CONCLUSIONS

Behavioural interventions for young women which aim to promote sexual behaviours protective of STI transmission can be effective, primarily at encouraging condom use. Future evaluations should include a greater focus on HPV and its link to cervical cancer, with long-term follow-up to assess impact on behaviour change, rates of HPV infection and progression to cervical cancer. Studies should use an RCT design where possible with integral process evaluation and cost-effectiveness analysis where appropriate. Given the predominance of USA studies in this systematic review evaluations conducted in other countries would be particularly useful.

Inequalities in participation in an organized national colorectal cancer screening programme: results from the first 2.6 million invitations in England

BACKGROUND

An organized, population-based, colorectal cancer screening programme was initiated in England in 2006 offering biennial faecal occult blood testing (FOBT) to adults aged 60-69 years. Organized screening programmes with no associated financial costs to the individual should minimize barriers to access for lower socio-economic status (SES) groups. However, SES differences in uptake were observed in the pilot centres of the UK programme, so the aim of this analysis was to identify the extent of inequalities in uptake by SES, ethnic diversity, gender and age in the first 28 months of the programme. Design Cross-sectional analysis of colorectal cancer screening uptake data.

METHODS

Between October 2006 and January 2009, over 2.6 million adults aged 60-69 years were mailed a first FOBT kit by the five regional screening hubs. Uptake was defined as return of a test kit within 13 weeks. We used multivariate generalized linear regression to examine variation by area-based socioeconomic deprivation, area-based ethnicity, gender and age.

RESULTS

Uptake was 54%, but showed a gradient across quintiles of deprivation, ranging from 35% in the most deprived quintile to 61% in the least deprived. Multivariate analyses confirmed an independent effect of deprivation, with stronger effects in women and older people. The most ethnically diverse areas also had lower uptake (38%) than other areas (52-58%) independent of SES, age, gender and regional screening hub. Ethnic disparities were more pronounced in men but equivalent across age groups. More women than men returned a kit (56 vs 51%), but there was also an interaction with age, with uptake increasing with age in men (49% at 60-64 years; 53% at 65-69 years) but not women (57 vs 56%).

CONCLUSIONS

Overall uptake rates in this organized screening programme were encouraging, but nonetheless there was low uptake in the most ethnically diverse areas and a striking gradient by SES. Action to promote equality of uptake is needed to avoid widening inequalities in cancer mortality.

[Social inequalities in health from observational studies to intervention: can the patient navigator reduce social inequalities in cancer patients?]

The impact of social factors on healthcare inequality is well-recognized in many industrialized countries and involves a wide range of pathological conditions (cardiovascular disease, cancer, etc.). In general, the poorest indicators of health are observed in socially disadvantaged populations. Beyond this observation is the question of actions taken to prevent the formation of social inequality in healthcare. The purpose of this work was to evaluate the potential contribution of an intervention tool called the "patient navigator", used in English-speaking countries and to determine its feasibility in France.

Trends in socioeconomic disparities in organized and opportunistic gastric cancer screening in Korea (2005-2009)

BACKGROUND

A growth of consensus and increasing activities related to organized cancer screening programs has occurred in Korea since 1999. It is important to assess disparities in the fight against cancer, and it is crucial to identify particular groups that may be experiencing a high burden of cancer-related illness.

METHODS

Data from 8,160 men and women ages >40 years from the 2005 to 2009 Korean National Cancer Screening Survey were used to analyze the relationship between socioeconomic position and receiving upper gastrointestinal series or upper endoscopy within the past 2 years. We used absolute and relative concentration indexes, that is, summary measures of disparity based on both rate differences and rate ratios.

RESULTS

For organized screening, the education disparity declined, but the income disparity index increased, indicating that participation in organized screening was relatively more concentrated among the lower-income groups. For opportunistic screening, income and education disparities increased due to the widening of socioeconomic differences.

CONCLUSIONS

The results of this study suggested progress toward socioeconomic disparity-related goals in organized screening for gastric cancer. However, the income disparity trends in organized screening may change in a manner similar to those in opportunistic screening in the future because of the much faster rate of organized screening uptake by those higher on the socioeconomic scale.

IMPACT

This study addresses the routine monitoring of coverage of screening among different socioeconomic groups and could be used to inform policies to reduce disparity in coverage.

The roles of social domains, behavioral risk, health care resources, and chlamydia in spatial clusters of US cervical cancer mortality: not all the clusters are the same

BACKGROUND

While high-risk geographic clusters of cervical cancer mortality have previously been assessed, factors associated with this geographic patterning have not been well studied. Once these factors are identified, etiologic hypotheses and targeted population-based interventions may be developed and lead to a reduction in geographic disparities in cervical cancer mortality.

METHODS

The authors linked multiple data sets at the county level to assess the effects of social domains, behavioral risk factors, local physician and hospital availability, and Chlamydia trachomatis infection on overall spatial clustering and on individual clusters of cervical cancer mortality rates in 2000-2004 among 3,105 US counties in the 48 states and the District of Columbia.

RESULTS

During the study period, a total of 19,898 cervical cancer deaths occurred in women aged 20 and older. The distributions of county-level characteristics indicated wide ranges in social domains measured by demographics and socioeconomic status, local health care resources, and the rate of chlamydial infection. We found that overall geographic clustering of increased cervical cancer mortality was related to the high proportion of black population, low socioeconomic status, low Papanicolaou test rate, low health care coverage, and the high chlamydia rate; however, unique characteristics existed for each individual cluster, and the Appalachian cluster was not related to a high proportion of black population or to chlamydia rates.

DISCUSSION

This study indicates that local social domains, behavioral risk, and health care sources are associated with geographic disparities in cervical cancer mortality rates. The association between the chlamydia rate and the cervical cancer mortality rate may be confounded by other factors known to be a risk for cervical cancer mortality, such as the infection with human papillomavirus. The findings will help cancer researchers examine etiologic hypotheses and develop tailored, cluster-specific interventions to reduce cervical cancer disparities.

Geographic disparity, area poverty, and human papillomavirus vaccination

BACKGROUND

A human papillomavirus (HPV) vaccine was approved by the Food and Drug Administration for use among women/girls in 2006. Since that time, limited research has examined HPV vaccine uptake among adolescent girls and no studies have examined the role of geographic disparities in HPV vaccination.

PURPOSE

The purpose of this study is to examine geographic disparity in the prevalence of human papillomavirus (HPV) vaccination and to examine individual-, county-, and state-level correlates of vaccination.

METHODS

Three-level random intercept multilevel logistic regression models were fitted to data from girls aged 13-17 years living in six U.S. states using data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) and the 2000 U.S. census.

RESULTS

Data from 1709 girls nested within 274 counties and six states were included. Girls were predominantly white (70.6%) and insured (74.5%). Overall, 34.4% of girls were vaccinated. Significant geographic disparity across states (variance=0.134, SE=0.065) and counties (variance=0.146, SE=0.063) was present, which was partially explained by state and county poverty levels. Independent of individual-level factors, poverty had differing effects at the state and county level: girls in states with higher levels of poverty were less likely whereas girls in counties with higher poverty levels were more likely to be vaccinated. Household income demonstrated a similar pattern to that of county-level poverty: Compared to girls in the highest-income families, girls in the lowest-income families were more likely to be vaccinated.

CONCLUSIONS

The results of this study suggest geographic disparity in HPV vaccination. Although higher state-level poverty is associated with a lower likelihood of vaccination, higher county-level poverty and lower income at the family level is associated with a higher likelihood of vaccination. Research is needed to better understand these disparities and to inform interventions to increase vaccination among all eligible girls.