Explaining variations in breast cancer screening across European countries

Socio-economic inequalities in the use of flu vaccination in Europe: a multilevel approach

BACKGROUND

The European-wide statistics show that the use of flu vaccination remains low and the differences between countries are significant, as are those between different population groups within each country. Considerable research has focused on explaining vaccination uptake in relation to socio-economic and demographic characteristics, health promotion and health behavior factors. Nevertheless, few studies have aimed to analyze between-country differences in the use of flu vaccination for the EU population. To address this gap, this study examines the socio-economic inequalities in the use of influenza vaccination for the population aged 15 years and over in all 27 EU Member States and two other non-EU countries (Iceland and Norway).

METHODS

Using data from the third wave of European Health Interview Survey (EHIS) 2019, we employed a multilevel logistic model with a random intercept for country, which allows controlling simultaneously the variations in individuals' characteristics and macro-contextual factors which could influence the use of flu vaccination. In addition, the analysis considers the population stratified into four age groups, namely adolescents, young adults, adults and elderly, to better capture heterogeneities in flu vaccination uptake.

RESULTS

The main findings confirm the existence of socio-economic inequalities between individuals in different age groups, but also of significant variation between European countries, particularly for older people, in the use of influenza vaccination. In this respect, income and education are strong proxy of socio-economic status associated with flu vaccination uptake. Moreover, these disparities within each population group are also explained by area of residence and occupational status. Particularly for the elderly, the differences between individuals in vaccine utilization are also explained by country-level factors, such as the type of healthcare system adopted in each country, public funding, personal health expenditure burden, or the availability of generalist practitioners.

CONCLUSIONS

Overall, our findings reveal that vaccination against seasonal influenza remains a critical public health intervention and bring attention to the relevance of conceiving and implementing context-specific strategies to ensure equitable access to vaccines for all EU citizens.

Investigating Factors Influencing the National Cancer Screening Program among Older Individuals in Republic of Korea-Data from the Korea National Health and Nutrition Examination Survey VIII

This study aims to determine the influencing factors of the participation of older individuals aged 65 years and above in South Korea's National Cancer Screening Program (NCSP) using data from the eighth wave (2019-2021) of the Korea National Health and Nutrition Examination Survey (KNHANES VIII), and discuss potential problems and coping strategies. Variables were selected based on Andersen's healthcare utilization model. "Participation in the NSCP" was considered the dependent variable, with independent variables including sociodemographic characteristics (sex, marital status, residence, education level, income level, economic activity, medical coverage type, and private insurance), health conditions (subjective health status, hypertension, and diabetes), and health behaviors (physical activity, monthly alcohol consumption, and current smoking status). The analysis revealed that higher participation rates correlated with being married, having an education level beyond elementary school, being employed, subscribing to private insurance, perceiving oneself as having average or poor health, engaging in physical activity, and not smoking. Sex, residence, income, medical coverage type, hypertension, diabetes, and monthly alcohol consumption were found to be insignificantly correlated. These findings underscore the importance of tailored promotion and health education for older individuals to boost NCSP participation rates, which could ultimately elevate public health standards.

Mapping evidence on knowledge of breast cancer screening and its uptake among women in Ghana: a scoping review

INTRODUCTION

Female breast cancer is currently the most commonly diagnosed cancer globally with an estimated 2.3 million new cases in 2020. Due to its rising frequency and high mortality rate in both high- and low-income countries, breast cancer has become a global public health issue. This review sought to map literature to present evidence on knowledge of breast cancer screening and its uptake among women in Ghana.

METHODS

Five databases (PubMed, CINAHL, PsycINFO, Web of Science, and EMBASE) were searched to identify relevant published studies between January 2012 and August 2021 on knowledge of breast cancer screening and its uptake among women. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews and the six-stage model by Arksey and O'Malley were used to select and report findings.

RESULTS

Of the 65 articles retrieved, 14 records were included for synthesis. The review revealed varied knowledge levels and practices of breast cancer screening among women across a few regions in Ghana. The knowledge level of women on breast cancer screening was high, especially in breast cancer screening practice. Breast cancer screening practice among women was observed to be low and the most identified barriers were lack of technique to practice breast self-examination, having no breast problem, lack of awareness of breast cancer screening, and not having breast cancer risk. The results further showed that good knowledge of breast cancer screening, higher educational level, increasing age, physician recommendation, and household monthly income were enabling factors for breast cancer screening uptake.

CONCLUSION

This review showed varied discrepancies in breast cancer screening uptake across the regions in Ghana. Despite the benefits of breast cancer screening, the utilization of the screening methods across the regions is very low due to some varied barriers from the different regions. To increase the uptake of breast cancer screening, health workers could employ various strategies such as community education and sensitization on the importance of breast cancer screening.

Cervical cancer screening programs and their context-dependent effect on inequalities in screening uptake: a dynamic interplay between public health policy and welfare state redistribution

BACKGROUND

While organized and opportunistic cervical cancer screening (CCS) programs implemented across the European Union have increased participation rates, barriers to socioeconomically deprived women remain substantial, implying high levels of inequality in CCS uptake.

AIM

This study assesses how the screening strategy (as a score based on the availability of organized population-based CCS programs), accessibility of the healthcare system (as an index of out-of-pocket expenditure as a proportion of total healthcare costs, public health expenditure as a percentage of total GDP, and general practitioner (GP) density per 10'000 inhabitants) and social protection (as a decommodification index), impact education- and income-based inequalities in CCS uptake.

METHODS

A two-level design with 25-64-year-old women (N = 96'883), eligible for Pap smear screening, nested in 28 European countries, was used to analyze data from the European Health Interview Survey's second wave, using multilevel logistic regression modelling.

RESULTS

Clear educational and income gradients in CCS uptake were found, which were smaller in countries with organized CCS programs, higher accessibility of the healthcare system and a higher level of decommodification. Furthermore, three-way interaction terms revealed that these gradients were smaller when organized CCS programs were implemented in countries with better accessibility of the healthcare system or a high level of decommodification.

CONCLUSION

This study indicates that the combination of organized screening and high accessibility of the healthcare system or social protection is essential for having lower levels of inequality in CCS uptake. In such countries, the structural threshold for poorer and lower educated women to engage in CCS is lower. This may be explained by them having a better interaction with their GP, who may convince them of the screening test, lower out-of-pocket payments, and financial support to buffer against a disadvantageous position on the labor market.

Macro-contextual determinants of cancer screening participation and inequalities: A multilevel analysis of 29 European countries

Background

Little attention has been devoted to the role of macro-level determinants in preventive health inequalities, particularly in cancer screening participation. Research has evidenced inequalities in cancer screening uptake yet has mainly focused on the screening programmes’ moderating role at the macro-level. To address this gap, this study examines how welfare provision and healthcare system features modify cancer screening uptake and inequalities across European countries.

Methods

Data from 99 715 (Pap smear) and 54 557 (mammography) women in 29 countries from the European Health Interview Survey (EHIS) 2014 wave and Swiss Health Interview Survey (SHIS) 2012 wave was analysed. We estimated multilevel logistic regression models, including cross-level interactions, to examine whether social protection expenditure in particular policy areas and healthcare system characteristics explained cross-country differences in Pap smear and mammography uptake and inequalities.

Results

Main findings revealed that GP gatekeeping systems were associated with reduced screening uptake likelihood in both Pap smear and mammography, and so were stronger primary care systems in Pap smear, while higher expenditures on old age and survivors were associated with increased mammography uptake. Cross-level interactions showed that in countries with higher expenditures on sickness/healthcare, disability, social exclusion and public health, and a higher number of GPs, educational inequalities in both Pap smear and mammography uptake were smaller, while higher out-of-pocket payments had the opposite effect of increasing inequalities.

Conclusions

Overall, our results show that social protection policies and healthcare system features affect cancer screening participation. We conclude that institutional and policy arrangements interact with individuals’ (educational) resources and, through the (re)distribution of valued goods and resources at the macro level, these arrangements may contribute to enhancing preventive healthcare use and mitigating screening uptake inequalities.

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Welfare provision and healthcare system features affect Pap smear and mammography uptake.

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Social spending and healthcare features moderate inequalities in cancer screening uptake.

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Policymakers should consider macro-level factors for cancer screening strategies and programmes.

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Policies and institutions shape social determinants of preventive healthcare use.

Cost-effectiveness of risk-based breast cancer screening: A systematic review

To analyse published evidence on the economic evaluation of risk-based screening (RBS), a full systematic literature review was conducted. After a quality appraisal, we compared the cost-effectiveness of risk-based strategies (low-risk, medium-risk and high-risk) with no screening and age-based screening. Studies were also analysed for modelling, risk stratification methods, input parameters, data sources and harms and benefits. The 10 modelling papers analysed were based on screening performance of film-based mammography (FBM) (three); digital mammography (DM) and FBM (two); DM alone (three); DM, ultrasound (US) and magnetic resonance imaging (one) and DM and US (one). Seven studies did not include the cost of risk-stratification, and one did not consider the cost of diagnosis. Disutility was incorporated in only six studies (one for screening and five for diagnosis). None of the studies reported disutility of risk-stratification (being considered as high-risk). Risk-stratification methods varied from only breast density (BD) to the combination of familial risk, genetic susceptibility, lifestyle, previous biopsies, Jewish ancestry and reproductive history. Less or no screening in low-risk women and more frequent mammography screening in high-risk women was more cost-effective compared to no screening and age-based screening. High-risk women screened annually yielded a higher mortality rate reduction and more quality-adjusted life years at the expense of higher cost and false positives. RBS can be cost effective compared to the alternatives. However, heterogeneity among risk-stratification methods, input parameters, and weaknesses in the methodologies hinder the derivation of robust conclusions. Therefore, further studies are warranted to assess newer technologies and innovative risk-stratification methods.

COVID-19 Unintended Effects on Breast Cancer in Italy After the Great Lockdown

Italy introduced social distancing measures, which limited the spread of COVID-19; all the non-life-threatening treatments have been temporarily suspended, including screening programs. This decision leads to unintended effects on the ability to detected neoplasia in their first stages. Possible future outcomes of the ability to detect new breast cancer cases based on two alternative scenarios show that the reduction in organized screening activities will limit the ability to detect no <3.43% of the new cases; the economic crisis will reduce voluntary screening, increasing the undetected new cases up to 11.73%. Cases diagnosed with delay will show up in their advanced stage along with unknown effects on mortality and health care costs. Global health care policies should be implemented to counterbalance these adverse effects.

Distribution and predictors associated with the use of breast cancer screening services among women in 14 low-resource countries

BACKGROUND

Breast cancer is one of the leading public health problem globally, especially in low-resource countries (LRCs). Breast cancer screening (BCS) services are an effective strategy for early determining of breast cancer. Hence, it is imperative to understand the utilisation of BCS services and their correlated predictors in LRCs. This study aims to determine the distribution of predictors that significantly influence the utilisation of BCS services among women in LRCs.

METHODS

The present study used data on 140,974 women aged 40 years or over from 14 LRCs. The data came from country Demographic and Health Surveys (DHS) between 2008 and 2016. Multivariate logistic regression analysis was employed to investigate the significant predictors that influence the use of BCS services.

RESULTS

The utilisation of BCS services was 15.41%, varying from 81.10% (95% CI: 76.85-84.73%) in one European country, to 18.61% (95% CI: 18.16 to 19.06%) in Asian countries, 14.30% (95% CI: 13.67-14.96%) in American countries, and 14.29% (95% CI: 13.87-14.74%). Factors that were significantly associated to increase the use of BCS services include a higher level of education (OR = 2.48), advanced age at first birth (> 25 years) (OR = 1.65), female-headed households (OR = 1.65), access to mass media communication (OR = 1.84), health insurance coverage (OR = 1.09), urban residence (OR = 1.20) and highest socio-economic status (OR = 2.01). However, obese women shown a significantly 11% (OR = 0.89) lower use of BSC services compared to health weight women.

CONCLUSION

The utilisation of BCS services is low in many LRCs. The findings of this study will assist policymakers in identifying the factors that influence the use of BCS services. To increase the national BCS rate, more attention should be essential to under-represented clusters; in particular women who have a poor socioeconomic clusters, live in a rural community, have limited access to mass media communication, and are have a low level educational background. These factors highlight the necessity for a new country-specific emphasis of promotional campaigns, health education, and policy targeting these underrepresented groups in LRCs.

Cancer Screening Participation and Gender Stratification in Europe

The current study examines whether the extent of macrolevel gender inequality affects the association between women's educational attainment and their participation in cervical and breast cancer screening and how this relationship is moderated by a country's cancer screening strategy (organized vs. opportunistic). A multilevel design with women (N_cervical = 99,794; N_breast = 55,021) nested in 30 European countries was used to analyze data from the European Health Interview Survey (2013-2015). Results of multilevel logistic regression models demonstrate that higher macrolevel gender inequality is associated with (a) a lower overall likelihood that women have had a mammography and Pap smear and (b) a larger gap in participation between women with low and high levels of education, regardless of a country's screening strategy (i.e., no moderation by a country's screening strategy was found). We conclude that macrolevel gender stratification should not be neglected when designing cancer screening policy.

Age-Specific Breast Density Changes in Taiwanese Women: A Cross-Sectional Study

Breast density is a risk factor for breast cancer. This study explored distribution of mammographic density quantitatively and qualitatively in a wide age range of Taiwanese women. Subjects with negative and benign mammographic findings were included. According to the Breast Imaging Reporting and Data System, the proportion of extremely dense breasts declined from 58.0% in women < 30 years to 1.9% in women > 74 years. More than 80% of mammograms in women < 55 years old were classified as extremely or heterogeneously dense, while the proportion of dense breasts was still high in women aged 60–64 years (59.3%). The absolute dense area of the breast declined from 35.8% in women < 30 years to 18.5% in women > 74 years. The correlation between breast density and age was significant, with and without controlling for the effect of body composition (p < 0.001), implying that the relationship between breast density and age was not wholly related to body composition. In conclusion, the higher breast density in Taiwanese women aged 60–64 years was comparable to that of Western women aged 40–44 years in the literature. This suggests that breast cancer screening using mammography may be more challenging for Asian women than for Western women of the same age.

Males in mammography - A narrative review of the literature

OBJECTIVE

There is a worldwide shortage of radiographers qualified to perform mammography. One solution is the employment of male radiographers. This literature review aims to assess the scope of information available that covers the prospect of males being employed in a breast screening setting. The review specifically focuses on the incidence of males employed as mammographers, training options and client perceptions of males performing breast imaging.

KEY FINDINGS

Some countries employ male mammographers, though this is limited. There is contradictory information regarding the education of male radiography students in mammography. Several studies have indicated that clients of breast screening services would be open to males performing mammographic procedures, while others have reported strong opposition. The client's level of education, marital status and ethnicity affected their perception.

CONCLUSION

The review has shown that the employment of male radiographers in mammography may work better in some countries and in some subgroup of clients than others. The review has also highlighted some of the barriers that needs to be overcome if the widespread inclusion of men in mammography were to be successfully implemented. These include the use of chaperones and providing client choice in the gender of radiographer.

Identifying the barriers to effective breast, cervical and colorectal cancer screening in thirty one European countries using the Barriers to Effective Screening Tool (BEST)

The aim of this study was to identify barriers to effective breast, cervical and colorectal cancer screening programmes throughout the whole of the European region using the Barriers to Effective Screening Tool (BEST). The study was part of the scope of the EU-TOPIA (TOwards imProved screening for breast, cervical and colorectal cancer In All of Europe) project and respondents were European screening organisers, researchers and policymakers taking part in a workshop for the project in Budapest in September 2017. 67 respondents from 31 countries responded to the online survey. The study found that there are many barriers to effective screening throughout the system from identification of the eligible population to ensuring appropriate follow-up and treatment for the three cancers. The most common barriers were opportunistic screening, sub-optimal participation, limited capacity (including trained human resource), inadequate and/or disjointed information technology systems and complex administration procedures. Many of the barriers were reported consistently across different countries. This study identified the barriers that, in general, require further investment of resources.

Increasing breast-cancer screening uptake: A randomized controlled experiment

Early screening increases the likelihood of detecting cancer, thereby improving survival rates. National screening programs have been established in which eligible women receive a letter containing a voucher for a free screening. Even so, mammography use is often considered as remaining too low. We test four behavioral interventions in a large-scale randomized experiment involving 26,495 women. Our main assumption is that, due to biases in decision-making, women may be sensitive to the content and presentation of the invitation letter they receive. None of our treatments had any significant impact on mammography use. Sub-sample analysis suggests that this lack of a significant impact holds also for women invited for the first time and low-income women.

The effects of organized screening programs on the demand for mammography in Switzerland

The objective of this study is to estimate the causal effect of organized mammography screening programs on the proportion of women between 50 and 69 years of age who have ever used mammography. We exploit the gradual implementation of organized screening programs in nine Swiss cantons using a difference-in-difference approach. An analysis of four waves of the Swiss Health Survey shows that 3.5-5.4% points of the 87.9% utilization rate in cantons with screening programs in 2012 can be attributed to these organized programs. This effect indicates that organized programs can motivate women who have never done mammography to initiate screening.

Health beliefs, illness perceptions and determinants of breast screening uptake in Malta: a cross-sectional survey

BACKGROUND

Women's beliefs and representations of breast cancer (BC) and breast screening (BS) are salient predictors for BS practices. This study utilized the health belief model (HBM) and common-sense model (CSM) of illness self-regulation to explore factors associated with BS uptake in Malta and subsequently, to identify the most important predictors to first screening uptake.

METHODS

This cross-sectional survey enrolled Maltese women (n = 404) ages 50 to 60 at the time of their first screening invitation, invited to the National Breast Screening Programme by stratified random sampling, with no personal history of BC. Participants responded to a 121-item questionnaire by telephone between June-September 2015. Data were analyzed using descriptive statistics, chi-square tests and logistic regression.

RESULTS

There is high awareness of BC signs and symptoms among Maltese women (>80% agreement for 7 out of 8 signs), but wide variation about causation (e.g., germ or virus: 38.6% 'agree', 30.7% 'disagree'). 'Fear' was the key reason for non-attendance to first invitation (41%, n = 66) and was statistically significant across all subscale items (p < 0.05). Most items within HBM constructs (perceived barriers; cues to action; self-efficacy) were significantly associated with first invitation to the National Breast Screening Programme, such as fear of result (χ2 = 12.0, p = 0.017) and life problems were considered greater than getting mammography (χ2 = 38.8, p = 0.000). Items within CSM constructs of Illness Representation (BC causes; cyclical cancer timeline; consequences) were also significantly associated, such as BC was considered to be life-changing (χ2 = 18.0, p = 0.000) with serious financial consequences (χ2 = 13.3, p = 0.004). There were no significant associations for socio-demographic or health status variables with uptake, except for family income (χ2 = 9.7, p = 0.047). Logistic regression analyses showed that HBM constructs, in particular perceived barriers, were the strongest predictors of non-attendance to first invitation throughout the analyses (p < 0.05). However, the inclusion of illness representation dimensions improved the model accuracy to predict non-attendance when compared to HBM alone (65% vs 38.8%).

CONCLUSIONS

Interventions should be based on theory including HBM and CSM constructs, and should target first BS uptake and specific barriers to reduce disparities and increase BS uptake in Malta.

Health-related Factors Associated with Adherence to Breast Cancer Screening

Introduction:

In Belgium, an effective preventive program for breast cancer exists but as in many countries to few women participates in the screening. This study aims to describe the factors that affect the participation in the national breast cancer screening program.

Methods:

The participants were aged between 50 and 69 years and were recruited during an exhibition at the Brussels Exhibition Centre. Medical history and health-related parameters of the participants were recorded.

Results:

In total, 350 women aged between 50 and 69 years participated. After adjustment for age and region, 81.5% of the participants had a mammography during the past 2 years. The multivariate analysis confirms the association between not having had a mammography and (a) having an older age (odds ratio [OR]: 0.25–0.87), (b) having diabetes (OR: 0.08–0.80), (c) having a family history of coronary heart disease (OR: 0.16–0.80), (d) not following a cholesterol diet or treatment (OR: 0.10–0.91) and (e) having a higher body mass index (OR: 0.39–0.97). Having had a mammogram was associated with adherence to cervical smear screening (OR: 2.74–11.21).

Conclusions:

Most of these associations are most likely related to socioeconomic status. However, the relationship with diabetes offers opportunities to increase the participation in breast cancer screening programs because these patients have regular contacts with their family physicians.

Differing types of medical prevention appeal to different individuals

We analyze participation in medical prevention with an expected utility model that is sufficiently rich to capture diverging features of different prevention procedures. The predictions of the model are not rejected with data from SHARE. A decrease in individual health decreases participation in breast cancer screening and dental prevention and increases participation in influenza vaccination, cholesterol screening, blood pressure screening, and blood sugar screening. Positive income effects are most pronounced for dental prevention. Increased mortality risk is an important predictor in the model for breast cancer screening, but not for the other procedures. Targeted screening and vaccination programs increase participation.

Patient pathway for breast cancer: turning points and future aspirations

Improved survival from breast cancer can be attributed to a number of advances in the patient pathway from screening to advanced disease. The benefit of population screening has been established with national programs implemented. There has been improvement in the methodology of diagnostic assessment, relating to imaging techniques, methods of obtaining histological evidence and evaluation of lymph node status. Sentinel node biopsy is now routine, as is oncoplastic surgery. New forms and improved adjuvant systemic therapies are being explored. The prognosis of breast cancer can be more reliably evaluated to provide individualized information and to personalize treatments. Developments have also been seen in other areas improving the treatment and care of patients with advanced disease.

Mammography screening in less developed countries

Less developed countries (LDCs) are struggling with an increasing burden of breast cancer. It is important to identify what interventions might be most effective and feasible in reducing overall breast cancer mortality in a resource constrained settings. Mammography screening (MS) utilized in developed countries cannot be equally applied to LDCs. We provide a summary of the status of existing and past MS program attempts in LDCs, and try to determine the prerequisites under which any developing country is ready to benefit from a MS program. We make the case for a “mixed” portfolio of tools to reduce breast cancer mortality with MS reserved only for those sub-populations that meet the criteria. We hope our review will provide a background for policy makers to apply rigorous criteria before attempting to implement costly MS program and before judiciously evaluating additional competed programs in their countries.

Does the Neighborhood Area of Residence Influence Non-Attendance in an Urban Mammography Screening Program? A Multilevel Study in a Swedish City

BACKGROUND AND AIM

The public health impact of population-based mammography screening programs depends on high participation rates. Thus, monitoring participation rates, as well as understanding and considering the factors influencing attendance, is important. With the goal to acquire information on the appropriate level of intervention for increasing screening participation our study aimed to (1) examine whether, over and above individual factors, the neighborhood of residence influences a woman's mammography non-attendance, and (2) evaluate, whether knowing a woman's neighborhood of residence would be sufficient to predict non-attendance.

METHODS

We analyze all women invited to mammography screening in 2005-09, residing in the city of Malmö, Sweden. Information regarding mammography screening attendance was linked to data on area of residence, demographic and socioeconomic characteristics available from Statistics Sweden. The influence of individual and neighborhood factors was assessed by multilevel logistic regression analysis with 29,901 women nested within 212 neighborhoods.

RESULTS

The prevalence of non-attendance among women was 18.3%. After adjusting for individual characteristics, the prevalence in the 212 neighborhoods was 3.6%. Neighborhood of residence had little influence on non-attendance. The multilevel analysis indicates that 8.4% of the total individual differences in the propensity of non-attendance were at the neighborhood level. However, when adjusting for specific individual characteristics this general contextual effect decreased to 1.8%. This minor effect was explained by the sociodemographic characteristic of the neighborhoods. The discriminatory accuracy of classifying women according to their non-attendance was 0.747 when considering only individual level variables, and 0.760 after including neighborhood level as a random effect.

CONCLUSION

Our results suggest that neighborhoods of residence in Malmö, Sweden (as defined by small-area market statistics (SAMS) areas) do not condition women's participation in population based mammography screening. Thus, interventions should be directed to the whole city and target women with a higher risk of non-attendance.

Social disparities in access to breast and cervical cancer screening by women living in Spain

OBJECTIVES

To describe uptake of breast and cervical cancer screening by women living in Spain, analyse the possible associated social and health factors, and compare uptake rates with those obtained in previous surveys.

STUDY DESIGN

Cross-sectional study using data from the 2011 Spanish national health survey.

METHODS

Uptake of breast cancer screening was analysed by asking women aged 40-69 years whether they had undergone mammography in the previous two years. Uptake of cervical cancer screening was analysed by asking women aged 25-65 years whether they had undergone cervical cytology in the previous three years. Independent variables included sociodemographic characteristics, and variables related to health status and lifestyle.

RESULTS

Seventy-two percent of women had undergone mammography in the previous two years. Having private health insurance increased the probability of breast screening uptake four-fold [odds ratio (OR) 3.96, 95% confidence interval (CI) 2.71-5.79], and being an immigrant was a negative predictor for breast screening uptake. Seventy percent of women had undergone cervical cytology in the previous three years. Higher-educated women were more likely to have undergone cervical cancer screening (OR 2.59, 95% CI 1.97-3.40), and obese women and women living in rural areas were less likely to have undergone cervical cancer screening. There have been no relevant improvements in uptake rates of either breast or cervical cancer screening since 2006.

CONCLUSION

Uptake of breast and cervical cancer screening could be improved in Spain, and uptake rates have stagnated over recent years. Social disparities have been detected with regard to access to these screening tests, indicating that it is necessary to continue researching and optimizing prevention programmes in order to improve uptake and reduce these disparities.

Age differences in mammography screening reconsidered: life course trajectories in 13 European countries

BACKGROUND

Breast cancer is the most common cause of cancer mortality among European women. To reduce mortality risk, early detection through mammography screening is recommended from the age of 50 years onwards. Although timely initiation is crucial for cancer prognosis, the temporal dimension has largely been ignored in research. In cross-sectional research designs, it is not clear whether reported age differences reflect 'true' age effects and/or presumed period effects resulting from evolving knowledge and screening programmes.

METHODS

We use longitudinal data from the survey of Health, Ageing and Retirement (SHARELIFE, 2008), which enables to cast light on age differences by providing retrospective information on the age at which women commenced regular mammography screening. Moreover, the cross-national dimension of the SHARE permits framing the results within the context of nationally implemented screening programmes. By means of the Kaplan-Meier procedure, we examine age trajectories for five 10-year birth cohorts in 13 European countries (n = 13 324).

RESULTS

Birth cohorts show very similar age trajectories for each country. Along with the observation that large country differences and country-specific deviations coincide with screening programme characteristics, this suggests strong period effects related to implemented national screening programmes.

CONCLUSION

Age differences in mammography screening generally reflect the period effects of national screening policies. This leaves little room for economic theories about human health capital that leave out the institutional context of preventive health care provision.