The importance of socio-economic variables in cancer screening participation: A comparison between population-based and opportunistic screening in the EU-15

Educational inequalities in cervical cancer screening participation in 24 European countries

OBJECTIVES

Cervical cancer screening (CCS) is an important public health measure for early detection of cervical cancer and prevents a large proportion of cervical cancer deaths. However, participation in CCS is relatively low and varies substantially by country and socio-economic position. This study aimed to provide up-to-date participation rates and estimates on educational inequalities in CCS participation in 24 European countries with population-based CCS programmes.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Using data from the European Health Interview Survey (EHIS) conducted in 2019, 80,479 women aged 25-64 years were included in the analyses. First, standardized participation rates and standardized participation rates by educational attainment were calculated for all 24 countries based on each country-specific screening programme organization. Second, a series of generalized logistic models was applied to assess the effect of education on CCS participation.

RESULTS

Screening participation rates ranged from 34.1% among low-educated women in Romania to 97.1% among high-educated women in Finland. We observed that lower-educated women were less likely to attend CCS than their higher-educated counterparts. Largest educational gaps were found in Sweden (odds ratio [OR] = 6.36, 95% confidence interval [CI] = 3.89-10.35) and Poland (odds ratio = 5.80, 95% CI = 4.34-7.75).

CONCLUSION

Population-based screening initiatives have successfully reduced participation differences between women with medium and high educational attainment in some countries; however, persistent disparities still exist between women with low and high levels of education. There is an urgent need to increase participation rates of CCS, especially among lower-educated women.

Lack of social support, gender and colorectal cancer screening participation across Europe: How do screening programmes mitigate the effect of social support for men and women?

This study investigates how a lack of social support differentially affects men and women's colorectal cancer (CRC) screening participation, considering different screening strategies implemented across European countries. Although health sociology has stressed gender differences in social support and its effects on health behaviours, this was overlooked by cancer screening research. Using a data set of 65,961 women and 55,602 men in 31 European countries, we analysed the effect of social support variables on CRC screening uptake. We found that living alone and lower perceived social support were associated with lower screening uptake for both men and women. These effects were, however, stronger among men. Population-based screening programmes mitigated these effects, particularly for women, but not for men living alone. In countries with opportunistic screening programmes, social support variables remained associated with screening uptake. We conclude that cancer screening interventions should pay attention to social support and its gender-differentiated effects.

Uptake and detection rate of colorectal cancer screening with colonoscopy in China: A population-based, prospective cohort study

BACKGROUND

Colorectal cancer is the leading cause of cancer-related death worldwide. Colonoscopy is widely used as a screening test for detecting colorectal cancer in many countries. However, there is little evidence regarding the uptake and diagnostic yields of colonoscopy in population-based screening programs in countries with limited medical resources.

OBJECTIVE

We reported the uptake of colonoscopy and the detection of colorectal lesions and explored related factors based on a colorectal cancer screening program in China.

DESIGN

Individuals aged 45-74 years who were asymptomatic for colorectal cancer and had no history of colorectal cancer were recruited. An established risk score system was used to identify individuals at high risk for colorectal cancer, and they were subsequently recommended for colonoscopy.

SETTING

A population-based, prospective cohort study was implemented in 169 communities, 14 districts of Chongqing, Southwest China.

PARTICIPANTS

A total of 288,150 eligible participants were recruited from November 2013 to June 2021, and 41,315 participants were identified to be at high risk of colorectal cancer.

METHODS

Generalized linear mixed model was used to explore the individual and community structural characteristics associated with uptake of colonoscopy. Additionally, the detection rate of colorectal lesions under colonoscopy screening was also reported, and their associated factors were explored.

RESULTS

7859 subjects underwent colonoscopy, with an uptake rate of 19.02 % (95 % CI 18.64 %-19.40 %). Lower uptake rates were associated with older age, lower education, more physical activity, and structural characteristics, including residing in developing areas (OR 0.73, 95 % CI 0.69-0.78), residing more than 5 km from screening hospital (5-10 km: OR 0.85, 95 % CI 0.79-0.91; >10 km: OR 0.85, 95 % CI 0.80-0.91), and not being exposed to social media publicity (OR 0.63, 95 % CI 0.53-0.75). Overall, 8 colorectal cancers (0.10 %), 423 advanced adenomas (5.38 %), 820 nonadvanced adenomas (10.43 %), and 684 hyperplastic polyps (8.70 %) were detected, with an adenoma detection rate of 15.92 %. Several factors, including older age, male, current smoking and a family history of colorectal cancer, were positively related to colorectal neoplasms.

CONCLUSIONS

The uptake of colonoscopy for colorectal cancer screening was not optimal among a socioeconomically diverse high-risk population. The screening strategy should attempt to ensure equitable access to screening according to regional characteristics, and enhance the uptake of colonoscopy by recommended multifaceted interventions, which focus on individuals with poor compliance, select a closer screening hospital, and strengthen social media publicity at the structural level.

Association between Socioecological Status, Nutrient Intake, and Cancer Screening Behaviors in Adults Aged 40 and Over: Insights from the Eighth Korea National Health and Nutrition Examination Survey (KNHANES, 2019)

Cancer screening is pivotal for early detection and improved survival rates. While socio-ecological factors are known to influence screening uptake, the role of lifestyle, dietary habits, and general health in shaping these decisions remains underexplored. Utilizing the 2019 Korea National Health and Nutrition Examination Survey (KNHANES), this study examined the myriad of factors impacting cancer screening utilization. Data from 274,872 adults aged 40 years or older were scrutinized, highlighting demographics, income, lifestyle behaviors, health-related variables, nutrient intake, and dietary quality. A combination of descriptive statistics and logistic regression helped us ascertain influential determinants. Higher educational attainment and income quartiles were positively correlated with cancer screening rates. Regular walkers, those engaged in moderate physical activity, and individuals with a previous cancer diagnosis were more likely to get screened. High-risk drinkers and smokers were less inclined towards screening. Dietary habits also influenced screening decisions. Notably, participants with healthier eating behaviors, indicated by factors such as regular breakfasts and fewer meals out, were more likely to undergo screening. Additionally, nutrient intake analysis revealed that those who had undergone screening consumed greater quantities of most nutrients, bar a few exceptions. For individuals aged 50-64, nutritional assessment indicators highlighted a higher mean adequacy ratio (MAR) and index of nutritional quality (INQ) value among those who participated in screening, suggesting better nutritional quality. This study elucidates the complex socio-ecological and nutritional landscape influencing cancer screening decisions. The results underscore the importance of a holistic approach, emphasizing lifestyle, dietary habits, and socio-economic considerations. It provides a roadmap for policymakers to craft more inclusive screening programs, ensuring equal access and promoting early detection.

Papanicolaou test in Brazil: analysis of the National Health Survey of 2013 and 2019

OBJECTIVES

To compare the coverage of cervical cancer screening in Brazil in 2013 and 2019, investigating the factors associated with having the test performed and the reasons given for not doing it. Additionally, a comparison is made concerning the time taken to receive the test result in SUS (Sistema Único de Saúde) and in the private health services.

METHODS

Using data from the National Health Survey (Pesquisa Nacional de Saúde - PNS), prevalence rates and corresponding confidence intervals were calculated to determine the frequency of recent cervical cancer screenings among women aged between 25 and 64 years old in Brazil, for both 2013 and 2019. Poisson regression models were employed to compare the prevalence of the outcome according to sociodemographic characteristics. The reasons for not having the test and the time between performing and receiving the result were also analyzed.

RESULTS

The findings revealed an increase in the coverage of preventive cervical cancer exams in Brazil from 78.7% in 2013 to 81.3% in 2019. Additionally, there was a decline in the proportion of women who had never undergone the exam, from 9.7% to 6.1%. Prevalence of test uptake was higher among white women, those with higher levels of education and income, and those residing in the South and Southeast regions of the country. The most commonly cited reasons for not taking the test were the impression it was unnecessary (45% in both 2013 and 2019) and never having been asked to undergo the test (20.6% in 2013 and 14.8% in 2019).

CONCLUSIONS

Despite the high coverage of screening achieved in the country, there is great inequality in access to the test, and a non-negligible number of women are at greater risk of dying from a preventable disease. Efforts must be made to structure an organized screening program that identifies and captures the most vulnerable women.

Functional forms of socio-territorial inequities in breast cancer screening - A French cross-sectional study using hierarchical generalised additive models

To reduce the breast cancer burden, the French National Organised Breast Cancer Screening Programme (FNOBCSP) was implemented in 2004. The recommended participation rate has never been achieved and socio-territorial inequities in participation have been reported on several occasions. We investigated the functional forms and consistency of the relationships between neighbourhood deprivation, travel time to the nearest accredited radiology centre and screening uptake. We used two-level hierarchical generalised additive models in 8 types of territories classified by socio-demographic and economic factors. The first level was 368,201 women aged 50-72 invited to the 2013-2014 screening campaign in metropolitan France. They were nested in 41 départements, the level of organisation of the FNOBCSP. The effect of travel time showed two main patterns: it was either linear (with participation decreasing as travel time increased) or participation first increased with increasing travel time to a peak around 5-15 min and decreased afterward. In nearly all types and départements, the probability of participation decreased linearly with increasing deprivation. Territorial inequities in participation were more context-dependent and complex than social inequities. Inequities in participation represent a loss of opportunity for individuals who already have the worst cancer outcomes. Evidence-based public health policies are needed to increase the effectiveness and equity of breast cancer screening.

Lung Cancer Screening with Low-Dose CT: What We Have Learned in Two Decades of ITALUNG and What Is Yet to Be Addressed

The ITALUNG trial started in 2004 and compared lung cancer (LC) and other-causes mortality in 55-69 years-aged smokers and ex-smokers who were randomized to four annual chest low-dose CT (LDCT) or usual care. ITALUNG showed a lower LC and cardiovascular mortality in the screened subjects after 13 years of follow-up, especially in women, and produced many ancillary studies. They included recruitment results of a population-based mimicking approach, development of software for computer-aided diagnosis (CAD) and lung nodules volumetry, LDCT assessment of pulmonary emphysema and coronary artery calcifications (CAC) and their relevance to long-term mortality, results of a smoking-cessation intervention, assessment of the radiations dose associated with screening LDCT, and the results of biomarkers assays. Moreover, ITALUNG data indicated that screen-detected LCs are mostly already present at baseline LDCT, can present as lung cancer associated with cystic airspaces, and can be multiple. However, several issues of LC screening are still unaddressed. They include the annual vs. biennial pace of LDCT, choice between opportunistic or population-based recruitment. and between uni or multi-centre screening, implementation of CAD-assisted reading, containment of false positive and negative LDCT results, incorporation of emphysema. and CAC quantification in models of personalized LC and mortality risk, validation of ultra-LDCT acquisitions, optimization of the smoking-cessation intervention. and prospective validation of the biomarkers.

The Perception and Awareness of the Public about Cancer and Cancer Screening in the United Arab Emirates, a Population-Based Survey

The United Arab Emirates (UAE) has one of the fastest growing economies in the world, which has resulted in an increase in the detection of noncommunicable diseases such as cancer. Despite its screening and early detection efforts falling short of the target coverage of the intended population, the number of reported cases and deaths in UAE has increased over the years. A few studies have been conducted to understand the hurdles to cancer screening in UAE, mostly focusing on breast and colorectal malignancies. There are no studies or surveys that have addressed the barriers and hurdles to overall cancer screening in UAE's population. Through this is the largest survey to date, we aimed at assessing UAE society's perception of cancer and early screening and detection. The survey was constructed using the SurveyPlanet platform. The survey was then distributed on social media for direct and snowball sampling, including Instagram, WhatsApp, LinkedIn, Meta (Facebook), and Twitter. Interestingly, 71.3% of the respondents reported that they were fine mentioning or discussing cancer, while 28.2% reported that they were not comfortable with it. Moreover, 91.8% of the respondents knew the meaning of the early detection or screening of cancer, while 8.2% did not. The ability of respondents to correctly identify different types of cancer screening varied. This study suggests that regulatory authorities need to raise more awareness about cancer, especially among younger generations, and create screening recommendations and guidelines that should include younger people. Lastly, hospitals, cancer charity organizations, educational institutes, and the media should address target audiences to raise cancer awareness among them.

Adherence to Cervical Cancer Screening Programs in Migrant Populations: A Systematic Review and Meta-Analysis

Organized cervical cancer screening programs to promote the early identification of precancerous lesions have proven to be effective in decreasing the burden associated with cervical cancer, but knowledge regarding screening adherence among migrant women compared to that of native women has not been summarized. A systematic search of the literature on PubMed, Scopus and Embase led to the identification of 772 papers that were published up to July 2022 and reported population-based data regarding adherence to cervical screening. The screening participation rates among migrant women, compared to native women, were pooled using a random-effects meta-analysis. A total of 18 papers were included in the review, with most of them being conducted in Europe (83.3%). Overall, migrants showed a significantly lower participation rate compared to native women (OR for screening adherence: 0.54, 95% CI = 0.42-0.70). This discrepancy was especially evident for migrant women from North Africa and Sub-Saharan Africa (OR = 0.47, 95% CI = 0.35-0.63, and OR = 0.35, 95% CI = 0.24-0.49, respectively). The results of this systematic review emphasize the importance of increasing cervical cancer screening adherence among migrant women. A significant heterogeneity in screening adherence was observed based on the country of origin. Interventions aimed at reducing the disparities in screening participation should specifically consider how to improve the recruitment of migrant women.

Associated factors and global adherence of cervical cancer screening in 2019: a systematic analysis and modelling study

BACKGROUND

Cervical cancer screening is vital for its prevention. Adherence is a crucial indicator that implies the individual willingness to take cervical cancer screening. We aimed to estimate the global and regional adherence rates of cervical cancer screening in 2019 and identify its associated factors among general women.

METHOD

We searched studies in PubMed, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang Database, ProQuest theses database and Google Web, without a lower time limit and until 23 June, 2021. Survey studies were considered eligible if they investigated cervical cancer screening adherence among general women, with data on sample size, the number of adherent subjects, and/or adherence rate. Random-effects were used to pool the odds ratios (ORs) of associated factors of adherence. Using modelling analysis, we estimated 2019 overall and age-specific adherence rates at the global and regional levels in women aged 20-69 years.

RESULTS

Eight thousand two hundred ninety records were identified, and 153 articles were included. Being married (vs not married: OR, 1.34; 95% confidence interval [CI]: 1.23-1.46), higher educational attainment (higher than high school vs less than high school: OR, 1.44; 95% CI: 1.35-1.53), having healthcare (OR, 1.64; 95% CI: 1.43-1.88), former smoking (OR, 1.20; 95% CI: 1.07-1.34), physical activity (OR, 1.19; 95% CI: 1.05-1.36), parity (OR, 1.07; 95% CI: 1.01-1.12), and chronic disease (OR, 1.17; 95% CI: 1.04-1.32) were associated with better adherence, whereas obesity (vs normal: OR, 0.85; 95% CI: 0.74-0.97) and current smoking (vs former/never: OR, 0.64; 95% CI: 0.54-0.76) were associated with worse adherence. In 2019, the adherence was at 33.66% (95% CI: 23.34-39.30%) worldwide, and was higher in high-income countries (HICs) (75.66, 95% CI: 66.74-82.81%) than in low and middle-income countries (LMICs) (24.91, 95% CI: 14.30-30.24%). It varied across regions, the highest in the European region (65.36, 95% CI: 55.40-74.19%), but the lowest in the African region (5.28, 95% CI: 3.43-8.03%).

CONCLUSIONS

Cervical cancer screening adherence remained low globally, exhibiting geographical discrepancy with HICs higher than LMICs. Further implementations of screening programs should comprehensively consider the local economy, social benefits, and demographic structure to adapt delivery for vulnerable or underserved women to boost screening adherence.

Effectiveness of Cervical Testing in and outside a Screening Program-A Case-Control Study

In many countries with organized cervical cancer screening, opportunistic Pap and human papillomavirus (HPV) tests are common. However, little is known about their effectiveness. We examined the effect of testing in and outside the Finnish screening program on the risk of cervical cancer. We conducted a case-control study that involved 1677 cases with invasive cervical cancer that were diagnosed between 2010 and 2019. Five- and three-year test intervals were analyzed across all ages, by age group and by cancer morphology subtype. Conditional logistic regression was used, adjusting for socioeconomic variables. Women undergoing any kind of cervical test had a significantly lowered risk of cervical cancer (adjusted OR = 0.43, 95% CI = 0.38-0.48, tests in five-year intervals). The results were similar, regardless of whether the test had been taken in the screening program or outside of it, or whether the interval was five years or three years. Testing of women at ages 35-64 showed the strongest effects, but moderate preventive effects were seen until age 79. No significant effect was seen below age 30. Tests in and outside the program were effective at the screening target age. However, participation in the program should be encouraged for optimal cost-effectiveness. Preventive effects were also seen above the program target ages.

Strategies for Improving the Utilization of Preventive Care Services: Application of Importance-Performance Gap Analysis Method

The utilization of preventive care services is limited. Previous studies based on communities have looked at many types of barriers to preventive care (i.e., why not do). This study aimed to gain an insight into the key factors and performance gaps (i.e., why do and how to do) of people who attended a regional teaching hospital to undergo health check-ups using a purposive sampling method to recruit people to complete a self-administered questionnaire. Paired sample t-tests and importance-performance gap and regression analyses were performed. The results indicated that the participants' wish to understand their health status, the quality of medical devices and the completeness of items, and process layout planning were the key factors that affect people's health check-up behavior. Promoting the effectiveness of hospital performance may improve the positive cycle of people's health check-up behavior from the community to the hospital. Continuing to promote the knowledge of preventive care services is necessary, and it is very important for people to have a good experience of undergoing health check-ups in the hospital. Important strategies for improving the utilization of preventive care services may include: meeting the person's personalization needs, improving the quality of medical devices and the completeness of items, and having appropriate process layout planning, a detailed interpretation of the results, and further follow-ups in the hospital.

Changes in rate and socioeconomic inequality of cervical cancer screening in northeastern China from 2013 to 2018

Objective

Cervical cancer, the fourth leading cancer diagnosed in women, has brought great attention to cervical cancer screening to eliminate cervical cancer. In this study, we analyzed two waves of provincially representative data from northeastern China's National Health Services Survey (NHSS) in 2013 and 2018, to investigate the temporal changes and socioeconomic inequalities in the cervical cancer screening rate in northeastern China.

Methods

Data from two waves (2013 and 2018) of the NHSS deployed in Jilin Province were analyzed. We included women aged 15-64 years old and considered the occurrence of any cervical screening in the past 12 months to measure the cervical cancer screening rate in correlation with the annual per-capita household income, educational attainment, health insurance, and other socioeconomic characteristics.

Results

A total of 11,616 women aged 15-64 years were eligible for inclusion. Among all participants, 7,069 participants (61.11%) were from rural areas. The rate of cervical cancer screening increased from 2013 to 2018 [odds ratio (OR): 1.06; 95% confidence interval (CI): 1.04-1.09, p < 0.001]. In total, the cervical cancer screening rate was higher among participants who lived in urban areas than rural areas (OR: 1.20; 95% CI: 1.03-1.39, p = 0.020). The rate was also higher among those with the highest household income per capita (OR: 1.30; 95% CI: 1.07-1.56, p = 0.007), with higher educational attainment (p < 0.001), and with health insurance (p < 0.05), respectively. The rate of cervical cancer screening was also significantly associated with parity (OR: 1.62; 95% CI: 1.23-2.41, p = 0.001) and marital status (OR: 1.45; 95% CI: 1.15-1.81, p = 0.001) but not ethnicity (OR: 1.41; 95% CI: 0.95-1.36, p = 0.164).

Conclusion

Cervical cancer screening coverage improved from 2013 to 2018 in northeastern China but remains far below the target 70% screening rate proposed by the World Health Organization. Although rural-urban inequality disappeared over time, other socioeconomic inequalities remained.

Gender inequality and mammography screening: Does living with a partner improve women's mammography uptake?

Macrolevel gender inequality is defined as the unequal distribution of power and resources between men and women shaped by macrolevel social structures and institutions. An emerging line of health research is emphasising its negative consequences on women's health and healthcare access. The present study examines how gender inequality contexts affect women's mammography screening uptake. It adopts a macrosociological and institutionalist approach on preventive healthcare use and compares women who live with a partner with those who do not. This is the first study to test the effect of macrolevel gender inequality on mammography uptake across the 26 Swiss cantons (i.e. regions). The Swiss cantons' autonomy to manage their political and healthcare systems, as provided by the federal system, offers an ideal setting for the comparative analysis of macrolevel factors. Data on 9724 women aged 50-70 from the Swiss Health Interview Survey (waves 2007, 2012 and 2017) is analysed. Multilevel logistic models estimate two canton-level indicators of gender inequality, the gender gaps in time use and full-time employment, and their association with mammography uptake, controlling for women's socioeconomic and demographic characteristics, health status and healthcare use. Cross-level interactions assess how these indicators moderate the mammography uptake of women living with and without a partner. Results show that in cantons with higher gender inequality, women have a lower probability of mammography uptake. Women who live with a partner have a higher mammography uptake than those who do not. However, this advantage is moderated by canton-level gender inequality, namely, women who live with a partner in more gender unequal cantons have a lower mammography uptake than their counterparts who reside in more gender equal cantons. Results support the hypothesis that macrolevel gender inequality moderates women's preventive healthcare uptake, from an institutionalist approach.

Effects of workplace skin cancer screenings on preventive and risk behaviour

Aim

Skin cancer is the most prevalent cancer in western countries and is associated with a high burden of disease. Skin cancer screenings can help detect cancer at an early stage and thus allow for better treatment. We aimed to analyse the impact of workplace skin cancer screenings on prevention behaviour and potential spillover effects on non-participants.

Subject and methods

Participants of workplace skin cancer screenings completed questionnaires at 0, 3 and 12 months on knowledge about and attitudes toward skin cancer and prevention behaviours. Effects over time were compared using McNemar tests. For additional analyses we performed logistic regression analyses.

Results

Of the 998 participants (44.7% women, mean age 43.3 years), 26.7% had never attended a skin cancer screening. The proportion of participants seeking shade for UV protection and the number of visits to dermatologists and general practitioners increased significantly in the year following workplace screening (p < 0.05). Two thirds (66.4%) recommended skin cancer screenings to others and at least 39.2% of them were sure that this recommendation was followed. Characteristics associated with participants’ recommendation for screening included female gender (odds ratio: 1.62), older age (odds ratio: 1.02), and lower education (odds ratio: 1.40).

Conclusion

Workplace screenings can complement routine skin cancer screenings. They inform participants about the existence and benefits of screenings and may have spillover effects for peers. They can also serve as another source of information on prevention and risk behaviours.

Effects of deprivation and age on staging of breast, colon, rectum and prostate cancer in Umbria region, Italy: a multilevel approach

BACKGROUND

Early diagnosis of breast, colon, rectum and prostate cancers improves health outcomes. Low socioeconomic status (SES) is related to advanced stages at diagnosis; inequalities could explain differences in outcomes by age. The influence of SES, age and residence area on staging was explored in the Umbrian population.

METHODS

2001-2010 cases were geo-coded by census tract of residence. Stage distribution or Gleason score were analyzed by multilevel multinomial logistic regression with age and SES as the fixed effects and census tract as the random-effect.

RESULTS

For breast and colorectal cancers, the screening age class was advantaged. For breast, age effect was modulated by deprivation and census tract. In the elderly, the richest were advantaged, the poorest disadvantaged; issues emerged for the young. For colon, age effect is modulated by census tract in early stages and deprivation in late stages. The elderly were disadvantaged; the young and the deprived had more stages IV. About rectum, age effect was modulated by deprivation in the late stages. The elderly were disadvantaged; the young and the deprived presented more stages IV. For prostate, age effect was modulated by deprivation and census tract. The intermediate age class was advantaged, the elderly disadvantaged.

CONCLUSION

Age was not always the determinant of a delayed staging when SES was considered. For breast and colorectal cancers, issues of delayed diagnosis emerged in the young. If the care center was near the residence, the census tract modified the stage at diagnosis. These results are useful to reduce SES barriers by specific programs adapted to the age of the patient and area of residence.

Trajectories and individual determinants of regular cancer screening use over a long period based on data from the French E3N cohort

Despite several incentive policies for cancer screenings over the last two decades, the overall and regular use of cancer screenings remains insufficient in France. While the individual determinants of cancer screening uptake have been fairly well studied, the literature has rarely focused on the regularity of screening uptake, which is key to early cancer detection. We aimed to address this issue by studying cancer screening behaviors over 15 years, emphasizing the regularity and diversity of use. Using data from 40,021 women in the French E3N cohort, we studied the individual trajectories of screenings for breast, colorectal and cervical cancer between 2000 and 2014. We employed optimal matching methods to identify typical behaviors of use for each cancer screening. Then, we determined the associations between the identified behavior screening patterns for the different cancer screenings and, finally, assessed the associated individual determinants with logistical and multinomial models. We found that screening behaviors were fairly stable over time, with few typical screening patterns for each cancer. Overall, once a woman starts screening, she continues, and once she stops, she no longer returns. Cancer screening behaviors appear consistent; in particular, insufficient use of mammography appears to be associated with long-term nonuse of other cancer screenings. Factors associated with low or nonuse of screening are overall common between cancer screenings and are similar to those identified in the literature of screening use at a single point in time. Ultimately, these barriers prevent some women from entering a screening process in the long run, ultimately reinforcing social inequalities in health. Targeting women with insufficient mammography uptake may reach women outside of cancer screening settings more generally and, thus, both increase the overall uptake of cancer screening and reduce social inequalities in cancer screening.

Determinants of Intention to Participate in Breast Cancer Screening among Urban Chinese Women: An Application of the Protection Motivation Theory

Despite the significance of early detection of breast cancer through screening, the screening uptake in China remains relatively low. Protection motivation theory (PMT) suggested by Rogers is one of the theories concerning threat appeal. This study aimed to apply the protection motivation theory (PMT) in predicting breast cancer screening intention. In this cross-sectional study, a sample of Chinese urban women was recruited using the convenient sampling method from five communities in Wuhan. Data were collected using a self-report questionnaire that included demographic variables, knowledge about breast cancer, six PMT subconstructs, and screening intention. We used the structural equation modeling (SEM) to identify the predictor factors associated with screening intention. Of the total sample (n = 412), 86.65% had intention to participate in screening. Our data fit the hypothesized SEM model well (Goodness of fit index (GFI) = 0.91, adjusted GFI (AGFI) = 0.89, comparative fit index (CFI) = 0.91, root mean square error of approximation (RMSEA) = 0.05, standardized root mean residual (SRMR) = 0.06, and Chi-square/df = 2.01). Three PMT subconstructs (perceived severity, response cost, and self-efficacy) were significantly associated with screening intention. Knowledge, social status, and medical history had significantly indirect associations with screening intention through the mediating effect of PMT subconstructs. Considering the utility of PMT, intervention programs might be more effective based on the subconstructs of PMT, especially to improve self-efficacy, perceived severity, and knowledge, reduce response cost, as well as targeting specific demographic groups.

Contextual factors associated with cancer screening uptake: A systematic review of observational studies

We conducted a systematic review of a wide range of contextual factors related to cancer screening uptake that have been studied so far. Studies were identified through PubMed and Web of Science databases. An operational definition of context was proposed, considering as contextual factors: social relations directly aimed at cancer screening, health care provider and facility characteristics, geographical/accessibility measures and aggregated measures at supra-individual level. We included 70 publications on breast, cervical and/or colorectal cancer screening from 42 countries, covering a data period of 24 years. A wide diversity of factors has been investigated in the literature so far. While several of them, as well as many interactions, were robustly associated with screening uptake (family, friends or provider recommendation, provider sex and experience, area-based socio-economic status…), others showed less consistency (ethnicity, urbanicity, travel time, healthcare density …). Screening inequities were not fully explained through adjustment for individual and contextual factors. Context, in its diversity, influences individual screening uptake and lots of contextual inequities in screening are commonly shared worldwide. However, there is a lack of frameworks, standards and definitions that are needed to better understand what context is, how it could modify individual behaviour and the ways of measuring and modifying it.

Socio-Territorial Inequities in the French National Breast Cancer Screening Programme-A Cross-Sectional Multilevel Study

Simple Summary

France implemented a national breast cancer screening programme in 2004, which, despite recommendations, still coexists with opportunistic screening practices. We aimed to study socio-territorial inequities in participation in the 2013–2014 screening campaign, using multilevel models. With a representative sample of 42% of the estimated eligible population, we found that the organized programme does not erase social or territorial inequities in participation. Social inequities, at multiple levels, were found in nearly all départements, whereas territorial inequities seemed more context dependent. The impact of the coexistence with opportunistic screening, beyond any control and evaluation, is adding more risks (over-diagnosis, over-treatment) and leads to underestimating the true coverage of the population, mainly in the wealthiest, therefore leading to an underestimation of the true social gradient in participation. The French breast cancer screening programme needs to evolve to be more efficient in coverage, notably through the reduction of the unfair inequities in participation.

Abstract

Background. France implemented in 2004 the French National Breast Cancer Screening Programme (FNBCSP). Despite national recommendations, this programme coexists with non-negligible opportunistic screening practices. Aim. Analyse socio-territorial inequities in the 2013–2014 FNBCSP campaign in a large sample of the eligible population. Method. Analyses were performed using three-level hierarchical generalized linear model. Level one was a 10% random sample of the eligible population in each département (n = 397,598). For each woman, age and travel time to the nearest accredited radiology centre were computed. These observations were nested within 22,250 residential areas called “Îlots Regroupés pour l’Information Statistique” (IRIS), for which the European Deprivation Index (EDI) is defined. IRIS were nested within 41 départements, for which opportunistic screening rates and gross domestic product based on purchasing power parity were available, deprivation and the number of radiology centres for 100,000 eligible women were computed. Results. Organized screening uptake increased with age (OR_1SD = 1.05 [1.04–1.06]) and decreased with travel time (OR_1SD = 0.94 [0.93–0.95]) and EDI (OR_1SD = 0.84 [0.83–0.85]). Between départements, organized screening uptake decreased with opportunistic screening rate (OR_1SD = 0.84 [0.79–0.87]) and départements deprivation (OR_1SD = 0.91 [0.88–0.96]). Association between EDI and organized screening uptake was weaker as opportunistic screening rates and as département deprivation increased. Heterogeneity in FNBCSP participation decreased between IRIS by 36% and between départements by 82%. Conclusion. FNBCSP does not erase socio-territorial inequities. The population the most at risk of dying from breast cancer is thus the less participating. More efforts are needed to improve equity.

Joint effects of HPV-related knowledge and socio-demographic factors on HPV testing behaviour among females in Shenzhen

BACKGROUND

Limited population-based studies explore the utilization and associated barriers or facilitators to cervical cancer screening in China. We attempted to investigate the associations of socio-demographic factors, HPV specific knowledge with HPV testing behaviour in Shenzhen, China.

METHODS

A citywide cross-sectional survey was conducted from January to June 2015 in Shenzhen city by using a multistage stratified cluster sampling method. Socio-demographic information, awareness and specific knowledge of HPV, practice of HPV testing, and HPV vaccination-related attitude were collected. Multivariate logistic regression model was used to analyse possible associations.

RESULTS

Approximately one third of total 8639 women aged from 30 to 60 years old had ever received HPV testing. Overall, 67.6% of all participants demonstrated low knowledge level of HPV. High HPV knowledge level was significantly associated with HPV testing behaviour (odds ratio: 3.792, 95% confidence interval: 3.400-4.230). The impact of residence and education on testing behaviour only turned to be significant if women had low level of HPV knowledge (P for multiplicative interactions: 0.001 and <0.001, respectively), whereas monthly income exerted promotion effects apparently among those with high knowledge level (P for multiplicative interaction: 0.037).

CONCLUSIONS

Our study revealed gaps in HPV knowledge and screening participation among Chinese women, and provided novel clues that women with high HPV knowledge level would be more appeal to involve in HPV testing behaviour. The influence of HPV-related knowledge on HPV testing also lies in the joint effects with socio-demographic factors, including residence, education and monthly income.

Social inequalities in participation in cancer screening: does the mode of data collection matter? The CONSTANCES cohort

BACKGROUND

Self-reported data are prone to item non-response and misreporting. We investigated to what extent the use of self-reported data for participation in breast (BCS) and cervical cancer screening (CCS) impacted socioeconomic inequalities in cancer screening participation.

METHODS

We used data from a large population-based survey including information on cancer screening from self-reported questionnaire and administrative records (n = 14 122 for BCS, n = 27 120 CCS). For educational level, occupation class and household income per capita, we assessed the accuracy of self-reporting using sensitivity, specificity and both positive and negative predictive value. In addition, we estimated to what extent the use of self-reported data modified the magnitude of socioeconomic differences in BCS and CCS participation with age-adjusted non-screening rate difference, odds ratios and relative indices of inequality.

RESULTS

Although women with a high socioeconomic position were more prone to report a date for BCS and CCS in questionnaires, they were also more prone to over-declare their participation in CCS if they had not undergone a screening test within the recommended time frame. The use of self-reported cancer screening data, when compared with administrative records, did not impact the magnitude of social differences in BCS participation but led to an overestimation of the social differences in CCS participation. This was due to misreporting rather than to item non-response.

CONCLUSIONS

Women's socioeconomic position is associated with missingness and the accuracy of self-reported BCS and CCS participation. Social inequalities in cancer screening participation based on self-reports are likely to be overestimated for CCS.

Population-based mammography screening attendance in Sweden 2017-2018: A cross-sectional register study to assess the impact of sociodemographic factors

Sweden has a population-based mammography screening programme for women aged 40–74. The objective of this study was to examine the association between mammography screening attendance and sociodemographic factors in 15 of Sweden's 21 health care regions. Register-based information was collected on all mammography screening invitations and attendance during 2017 and 2018, and linked to individual-level sociodemographic data from Statistics Sweden. Odds ratios (ORs) and 95% confidence intervals (CIs) for attendance were computed by sociodemographic factor. The study sample included 1.5 million women, aged 40–75, with an overall screening attendance of 81.3%. The lowest odds of attending were found for women living without a partner (OR = 0.52, 95% CI: 0.52–0.53), low-income women (OR = 0.57, 95% CI: 0.56–0.57), and non-Nordic women born in Europe (OR = 0.60, 95% CI: 0.59–0.61). Other groups with lower odds of attending were women whose main source of income was social assistance or benefits (OR = 0.62, 95% CI: 0.62–0.63), those not owning their home (OR = 0.66, 95% CI: 0.66–0.67), and those with low level of education (OR = 0.72, 95% CI: 0.71–0.73). Having multiple of these sociodemographic characteristics further lowered the odds of attending. Although overall mammography screening attendance in Sweden is high, sociodemographic inequalities exist, and efforts should be made to address these. Particular attention should be given to low-income women who live without a partner.

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Mammography screening attendance in Sweden was 81% in 2017–2018.

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Sociodemographic inequalities were found for screening attendance.

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Having multiple low attendance risk factors further decreased the odds of attending.

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Lowest attendance among low-income women who live without a partner.

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.

Never and under cervical cancer screening in Switzerland and Belgium: trends and inequalities

Background

Research on inequalities in cervical cancer screening (CCS) participation has overlooked the distinction between ‘never-’ and ‘under-screeners’ while different socioeconomic and demographic determinants may underlie ‘non-’ and ‘under-’ screening participation. This study examines socioeconomic and demographic inequalities in never and under CCS participation. We compare cross-national prevalence and trends among these two groups in Switzerland and Belgium, two countries with similar opportunistic CCS strategy but different healthcare systems.

Methods

Data on 38,806 women aged 20–70 from the Swiss Health Interview Survey (1992–2012) and 19,019 women aged 25–64 from the Belgian Health Interview Survey (1997–2013), both population-based cross-sectional nationally representative surveys, was analysed. Weighted adjusted prevalence ratios were estimated with multivariate Poisson regressions.

Results

Over the studied period, never screening prevalence was about 15% in both Switzerland and Belgium and under screening prevalence about 14.0%. Socioeconomic gradients were found among both never- and under-screeners. Higher income women had lower never and under screening prevalence in Switzerland and a similar gradient in education was observed in Belgium. Importantly, distinct socioeconomic and demographic determinants were found to underlie never and under screening participation. Never screening was significantly higher among foreign nationals in both countries and this association was not observed in under screening. Never screening prevalence was lower among older age groups, while under screening increased with older age. Over time, age inequalities diminished among never- and under- screeners in Switzerland while educational inequalities increased among never-screeners in Belgium.

Conclusion

Findings revealed that determinants of screening inequalities differed among never- and under-screeners and hence these should be addressed with different public health strategies. Crucially, socioeconomic and demographic inequalities were more pronounced among never-screeners who appeared to face more structural and persistent inequalities. Differences between the two countries should also be noted. The more liberal-type Swiss healthcare systems appeared to shape income-related screening inequalities, while education appeared to be a stronger determinant of never- and under-screening in Belgium.

Differences in cervical test coverage by age, socioeconomic status, ethnic origin and municipality type - A nationwide register-based study

An invitational organized cervical cancer screening together with widely spread opportunistic testing has coexisted for decades in Finland. The aim of this study was to examine the coverage of cervical tests by age, socioeconomic status, ethnicity and municipality type within and outside the organized screening program. We had a cohort of women of whom 1,2 million were in the target age range of screening and residing in Finland in 2010-2014. Data on Pap and/or HPV -tests within and outside the screening program were collected from the Mass Screening Registry, the pathology laboratories and the health insurance reimbursement registry and five-year population coverages of tests were reported. The total test coverage was 86.0%; 95% CI, (85.8-86.1), and was notably lower for those with an unknown socioeconomic status and pensioners (68.8%; 95% CI, (67.9-69.6) and 77.1%; 95% CI, (76.5-77.6), respectively) compared to upper-level employers (89.8%; 95% CI, (89.5-90.2)). Coverage was also lower for non-native speaking women (72.4%; 95% CI, (71.8-73.0)) compared to native speakers (86.9%; 95% CI, (86.7-87.0)) and for women living in urban municipalities (85.5%; 95% CI, (85.3-85.7)) compared to semi-urban (87.4%; 95% CI, (87.0-87.8)). Although overall coverage was high, tests within and outside the program seemed to concentrate on women with presumably good access to health services. Tests outside the program were especially common among young women who are at a low risk of invasive cervical cancer. Efforts should be made to reduce excessive opportunistic testing and to increase attendance at the program among hard-to-reach populations.

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.

Forgone Health and Economic Benefits Associated with Socioeconomic Differences in Organized Cervical Cancer Screening

Objective:

To describe cervical cancer screening participation among women in Taiwan under its population-based screening policy and to estimate the economic burden of disease attributable to avoidable disparities in cervical cancer (CC) screening.

Methods:

We identified a nationally-representative sample of females aged 30 years or above who were eligible for Pap smear testing in Taiwan from 1 January to 31 December 2013. An administrative database with detailed claims of health care utilization under the universal coverage health care system was used. Socioeconomic position of the female subjects was defined using the occupation classification, and two groups were specifically identified: general (O1) and low-income (O5) groups. Differences in screening rate, CC prevalence, and CC-attributable deaths were assessed between the two groups. Economic consequences as a result of screening inequalities were estimated using actual total health care spending (health care expenditure), monetary value per life-year and years of life lost for ill health and screening disparities (health as consumption good), and productivity losses alongside costs of social benefits (health as capital good).

Result:

A total of 301,057 enrolled females aged 30 years and older eligible for screening were identified. Overall, 3-year and 1-year screening rates among all subjects were 0.601 and 0.372, respectively. Impact of observed differences in screening translated to US$59,568 of health care spending in one year, 90.4% of which was specific to hospital admissions. When we viewed health as a consumption good and capital good, the impact of screening disparity on health losses through CC would be equivalent to US$78,095 and US$190,868, respectively.

Conclusion:

Forgone health and economic benefits associated with inequalities in CC screening uptake can be considerable in productive women.

The impact of depression on adherence to organized and opportunistic breast cancer screening

One in five women will experience depression over her lifetime, and one out of eight will develop breast cancer. We evaluated the effect of depression on adherence to mammography in Switzerland, where opportunistic and organized screening programs coexist. We analyzed data from 3206 women aged 50-69 who participated in the Swiss Health Survey 2012. We compared mammographic rates among women with no to mild versus moderate to severe depressive symptoms. The effect of the type of screening on the odds of undertaking a mammography was calculated using multivariable logistic regression analysis. Women with moderate to severe major depressive symptoms were more likely to have had a mammography in the previous 2 years than their nondepressed or less-depressed counterparts (51 vs. 39.2%, respectively, P = 0.005). In the multivariable analysis, women with no to mild major depression living in cantons with an organized screening program had an adjusted odds ratio of 2.7 (95% confidence interval: 2.30-3.17, P < 0.001) of having had a mammography within the past 24 months compared with those living in the regions with an opportunistic screening. The adjusted odds ratio for women with moderate to severe major depression was 4.21 (95% confidence interval: 2.13-8.33, P < 0.001). In Switzerland. adherence to mammographic screening among women with moderate to severe major depression is higher than among women with no or minimal major depressive symptoms. This increased adherence is even more pronounced in regions with organized screening.

Invitation strategies and coverage in the population-based cancer screening programmes in the European Union

The aim of this study was to describe the compliance of the population-based cancer screening programmes in the European Union Member States to the invitation strategies enumerated in the European Guidelines and the impact of such strategies on the invitational coverage. Experts in screening programme monitoring from the respective countries provided data. Coverage by invitation was calculated as the proportion of individuals in the target age range receiving a screening invitation over the total number of annualized eligible population. The invitation strategies of 30 breasts, 25 cervical and 27 colorectal national or regional population-based screening programmes are described. Individual mail invitations are sent by 28 breasts, 20 cervical and 25 colorectal screening programmes. Faecal occult blood test kits are sent by post in 17 of the colorectal cancer screening programmes. The majority of programmes claimed to have a population registry, although some use health insurance data as the database for sending invitations. At least 95% invitation coverage was reached by 16 breast, six cervical and five colorectal screening programmes. Majority of the programmes comply with the invitation strategies enumerated in the European guidelines, although there is still scope for improvements. Coverage by invitation is below the desirable level in many population-based cancer screening programmes in European Union.

A methodology to design a performance management system in preventive care

Background

Preventive care has gained increasing attention in health reforms around the world due to its ability to reduce the burden of disease and to save health costs. Nevertheless, there is a gap in terms of the development of reliable systems to measure and evaluate performance of preventive care in order to support decision-making and increase service outcomes. The aim of this study is to define a methodology for designing a performance management system (PMS) in order to effectively support the planning, control and evaluation of preventive care and to identify the factors that influence such a process.

Methods

The methodology is based on the participatory action research approach, which implies collaboration between researchers and practitioners. The study was articulated in four phases and carried out in an Italian regional healthcare system that was undergoing a major reorganization process.

Results

The findings provide insights into the peculiarities that affect preventive care and highlight two categories of critical factors: general issues regarding the process and specific issues regarding preventive care. The first category includes the importance of interactions between academics, physicians and policy-makers, the impact of workloads and red tape on employee involvement and the increased conservation mechanisms during periods of institutional change. The second category concerns the strong heterogeneity of preventive activities within health organizations, the huge amount of regulations and the incompleteness of information systems.

Conclusion

The development of a PMS for preventive care can best be served by collaborative methods that involve academics, professionals and policy-makers, whose roles and responsibilities must be clearly defined, and by an improvement in transparency and communication within organizations in order to enhance the involvement of different professionals at appropriate times and in appropriate ways. Key recommendations that may improve the maintenance and use of information systems are proposed to policy-makers.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3837-8) contains supplementary material, which is available to authorized users.

The impact of regional screening policies on the diffusion of cancer screening participation in Belgium: time trends in educational inequalities in Flanders and Wallonia

BACKGROUND

We investigate whether the extent of educational inequalities in the use of Pap smears (cervical cancer screening) and mammograms (breast cancer screening) in Belgium has changed over time in accordance with the pattern predicted by diffusion of innovation theory, as well as how the regional cancer screening policies of Flanders and Wallonia influence this pattern.

METHODS

Data were obtained from five successive cross-sectional waves (1997-2001-2004-2008-2013) of the Belgian Health Interview Survey. Final sample sizes consisted of 8988 women aged 25-64 years for cervical cancer screening and 4194 women aged 50-69 years for breast cancer screening. We calculated absolute and relative measures of inequality, more specifically, the slope index of inequality (SII) and the relative index of inequality (RII), and their development over time.

RESULTS

In both Flanders and Wallonia, mammogram use increased greatly between 1997 and 2013, while Pap smear use has remained quite stable over time. Educational inequalities in cervical-cancer screening have been largely persistent over time in both regions. In contrast, educational inequalities in breast cancer screening fluctuated more between 1997 and 2013. Between 1997 and 2001, when the breast cancer screening programme was implemented in Flanders, RII reduced significantly by 45%. Inequality measures did not change significantly in Wallonia, where it is known that most women are screened opportunistically outside the programme.

CONCLUSIONS

By focussing on Belgium, this study demonstrates that regional variations in the support of a national screening programme can result in regional variations in the pattern of diffusion for cancer screening, as well as to the development of inequalities in cancer screening participation. Moreover, the findings demonstrate that high visibility and awareness of the screening programme, as was more the case in Flanders than it was in Wallonia, are required in order to reduce or eliminate educational inequalities in cancer screening participation over time. General practitioners and gynaecologists can play a decisive role in this regard.

Organised population-based programmes and change in socioeconomic inequalities in mammography screening: A 1992-2012 nationwide quasi-experimental study

Organised mammography screening programmes may reduce socioeconomic inequalities in breast cancer screening, but evidence is contradictory. Switzerland has no national organised mammography screening programme, but regional programmes were progressively introduced since 1999, giving the opportunity to conduct a nationwide quasi-experimental study. We examined the evolution of socioeconomic inequalities in mammography screening in Switzerland and if exposure to regional organised programmes reduced socioeconomic inequalities. Data of 10,927 women aged 50 to 70 years old were collected from the Swiss Health Interview Survey, a nationally representative cross-sectional survey repeated 5 times (1992-2012). Socioeconomic characteristics were assessed using education, income, employment status, and occupational class. Adjusted prevalence ratios of up-to-date mammography screening were estimated with Poisson regressions and weighted for sampling strategy and non-participation bias. In the absence of organised screening programmes (1992-1997), prevalence of mammography screening increased by 23% and was associated with tertiary education and working part time. During the period of progressive introduction of regionally organised programmes (2002-2012), prevalence of mammography screening increased by 19% every 5 years and was associated with exposure to regional programmes and with independent/artisan occupations. Tertiary education and working part time were no longer associated. Exposure to organised programmes did not modify socioeconomic inequalities except for employment status: not employed women benefitted more from organised programmes compared to women working full time. In conclusion, socioeconomic inequalities in mammography screening decreased over time but organised programmes did not greatly modify them, except women not employed whose prevalence passed employed women.

What Explains Education Disparities in Screening Mammography in the United States? A Comparison with The Netherlands

Background: In the U.S., less educated women are substantially less likely to receive screening mammography. It is not clear whether this is due to differences in access to screening or in perceptions of breast cancer risks and the effectiveness of screening. We weigh the plausibility of these two explanations by examining how the dependence of mammography on education changes after conditioning on indicators of access and perceptions. We also compare estimates for the U.S. with those for the Netherlands where there is universal access to a publicly financed screening program. Method: Cross-sectional and cross-country comparable individual level data from the American Life Panel (n = 646) and the Netherlands Longitudinal Internet Studies for the Social Sciences (n = 1398) were used to estimate and explain education disparities in screening mammograms given to American and Dutch women aged 40+. The education gradient was estimated using logit models. Controls were sequentially added to detect whether disparities were explained by differences in access or perceptions of risks and effectiveness. Results: In the United States, high school graduates were 11.5 percentage points (95% CI: 1–22 percentage points) less likely than college graduates to receive a screening mammogram in the previous two years. This education gradient was largely explained by differences in income, insurance coverage and receipt of medical advice. It was not explained by educational differences in the perceived risk of breast cancer and the effectiveness of mammography. There were no education disparities in receipt of mammography among Dutch women within the 50–75 age range covered by the national screening program. Conclusion: In the absence of a universal screening program in the U.S., determinants of access—income, insurance coverage and receipt of medical advice—appear to drive the education disparities in screening mammography.

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.

“Taking responsibility for my health”: Health system barriers and women’s attitudes toward cervical cancer screening in Romania and Bulgaria

The study used mixed-methods to illustrate the complexity of the interplay between the contexts in Bulgaria and Romania and women’s attitudes and behaviors related to screening. A secondary analysis of quantitative data from Romanian (n = 1053) and Bulgarian (n = 1099) women and qualitative interviews ( n = 30 Romanian, n = 35 Bulgarian) was performed. Low rates of screening attendance were found in both countries. Regression analysis illustrates that attitudes and social norms significantly predicted intentions and screening behavior in both countries. Thematic analysis revealed that systemic barriers and cultural meanings were relevant to women’s decisions to attend screening or avoid contact with the health-care system.

Factors associated with non-participation in cervical cancer screening - A nationwide study of nearly half a million women in Denmark

Cervical cancer occurs most often in under-screened women. In this nationwide register study, we described differences in sociodemographic characteristics between passive and active non-participants and examined socio-demographic characteristics, reproductive history, and mental and physical health as potential determinants for passive non-participation compared with participation in the Danish cervical cancer screening program. Screening history in women aged 23-49 years invited for cervical cancer screening in 2008-2009 was retrieved from the Danish Pathology Databank with information about dates of invitation and unsubscription. We identified participants (n = 402,984), active non-participants (n = 10,251) and passive non-participants (n = 63,435) within four years following baseline invitation and retrieved data about the study population from high-quality registries. We examined differences in socio-demographic characteristics of passive and active non-participants, and used multiple logistic regression analyses to identify potential determinants of passive non-participation. We found that active and passive non-participants differed in relation to socio-demography. When compared with screening participants, the odds of passive non-participation was increased in women who originated from less developed countries; were unmarried; had basic education or low income; had four or more children; smoked during pregnancy; had multiple induced abortions; or had a history of obesity, intoxicant abuse or schizophrenia or other psychoses. In conclusion, in this nationwide, prospective, population-based study, differences in socio-demographic characteristics between passive and active non-participants were found. Furthermore, sociodemography, reproductive history, and mental and physical health were determinants for passive non-participation. Addressing inequalities in screening attendance may help to further decrease the incidence of and mortality from cervical cancer.

The incremental role of trait emotional intelligence on perceived cervical screening barriers

Researchers have become increasingly interested in investigating the role of the psychological aspects related to the perception of cervical screening barriers. This study investigates the influence of trait EI on perceived cervical screening barriers. Furthermore, this study investigates the incremental validity of trait EI beyond the Big Five, as well as emotion regulation in the perceived barrier towards the Pap test as revealed in a sample of 206 Italian women that were undergoing cervical screening. Results have shown that trait EI is negatively related to cervical screening barriers. Furthermore, trait EI can be considered as a strong incremental predictor of a woman's perception of screening over and above the Big Five, emotion regulation, age, sexual intercourse experience and past Pap test. Detailed information on the study findings and future research directions are discussed.

Participants, Physicians or Programmes: Participants' educational level and initiative in cancer screening

This study is an in-depth examination of at whose initiative (participant, physician or screening programme) individuals participate in cervical, breast and colorectal cancer screening across the EU-28. Special attention is paid to (1) the association with educational attainment and (2) the country's cancer screening strategy (organised, pilot/regional or opportunistic) for each type of cancer screened. Data were obtained from Eurobarometer 66.2 'Health in the European Union' (2006). Final samples consisted of 10,186; 5443 and 9851 individuals for cervical, breast, and colorectal cancer, respectively. Multinomial logistic regressions were performed. Surprisingly, even in countries with organised screening programmes, participation in screenings for cervical, breast and colorectal cancer was most likely to be initiated by the general practitioner (GP) or the participant. In general, GPs were found to play a crucial role in making referrals to screenings, regardless of the country's screening strategy. The results also revealed differences between educational groups with regard to their incentive to participate in cervical and breast cancer screening and, to a lesser extent, in colorectal cancer screening. People with high education are more likely to participate in cancer screening at their own initiative, while people with less education are more likely to participate at the initiative of a physician or a screening programme. Albeit, the results varied according to type of cancer screening and national screening strategy.

Compliance with Breast and Cervical Cancer Screening Programs in Women: Results from a Population-Based Study

Aims and background

Women's adherence to mammography and PAP test screening guidelines is a fundamental topic regarding women's health. The aim of the study was to evaluate the knowledge and compliance to breast and cervical cancer screening programs in women living in three Italian towns, where a public screening program, consisting of free mammography every two years and free PAP test every three years, is ongoing.

Methods

An anonymous survey was mailed to a random sample of women. Eight 120-min focus discussions with groups of women exploring perceptions, knowledge and practices were carried out after analysis of the returned surveys.

Results

Replies were received from 1345 women (response rate, 27%). Almost every woman knew of the screening program, but women's practice of mammography was age-dependent: up to 72% of the women performed it before the age of 50. Conversely, the age of the first PAP test was rather late: up to 70% of the women performed it at over 30 years of age. Women with a lower educational level reported being screened less than those with a higher level. During the group discussions, women's perceptions, knowledge and beliefs regarding cancer and screening, together with aspects of the health care system, appeared to strongly influence the preventive practices. Many women deplored being infrequently instructed by health professionals.

Conclusions

Despite the limitations of the study due to the low response rate, we believe that health professionals should invest on encouraging factors and reduce the deterring factors to optimize screening practices.

Introduction of an organised programme and social inequalities in mammography screening: A 22-year population-based study in Geneva, Switzerland

In developed countries, breast cancer mortality has decreased during the last decades due to, at least partially, the advent of mammography screening. Organised programmes aim, among other objectives, to increase participation and decrease social inequalities in screening access. We aimed to characterise the evolution of socioeconomic disparities in mammography screening before and after the implementation of an organised programme in Geneva, Switzerland. We included 5345 women, aged 50-74years, without past history of breast cancer who participated in the cross-sectional Bus Santé study, between 1992 and 2014. Outcome measures were: 1) never had a mammography (1992-2014) and 2) never had a mammography or not screened in the two years before being surveyed (subgroup analysis, 2007-2014). Educational attainment was divided in three groups (primary, secondary and tertiary) and period in two (before/after introduction of a screening programme in 1999). We calculated measures of relative and absolute change, including the relative (RII) and slope (SII) indices of social inequality adjusted for age and nationality. We compared the prevalence of screening before and after screening programme implementation using Poisson models. The proportion of unscreened women decreased during the study period from 30.5% to 3.6%. Lower educated women were more frequently unscreened (RII=2.39, p<0.001; SII=0.10, p<0.001). Organised screening decreased the proportion of unscreened women independently of education (prevalence ratio_{before vs. after}=4.41, p<0.001), but absolute and relative inequalities persisted (RII=2.11, p=0.01; SII=0.04, p=0.01). Introduction of an organised programme increased women's adherence to mammography screening but did not eliminate social disparities in screening participation.

Inequalities in cervical cancer screening utilisation and results: A comparison between Italian natives and immigrants from disadvantaged countries

Cervical cancer screening underutilisation is documented among immigrants from poor countries and it is associated to an augmented risk for severe lesions. In a cohort of 1,410,364 Italian women and 200,491 immigrants from poor countries differences in screening participation and results were investigated. Participation rate was lower for immigrants than for Italians: 43.98% versus 48.59% (chi(1): p<0.001). This gap increased with age (ptrend<0.0001). Some socio-demographic factors negatively influenced immigrants' participation. Illiteracy (OR=0.75) versus secondary school, being single (OR=0.71) versus attached, first screens (OR=0.67) versus subsequent ones. Although the interaction between educational and professional levels showed that graduated immigrant women conducting an intellectual job have a higher inclination towards screening than their Italian peers (OR=1.43 vs OR=1.04). The Standardised Detection Ratio (SDR) suggested a frequency of severe lesions nearly double among immigrants in first screens (SDR=1.94; 95% CI: 1.82-2.08) and even higher (SDR=2.53; 95% CI: 2.35-2.73) for Central/Eastern Europeans. Multi-component interventions involving both patients and providers offer the greatest potential to increase cervical cancer screening uptake within foreign-born populations. So immigrant-specific interventions are needed for some immigrant groups, like Central/Eastern Europeans who are at higher risk of cervical lesions and, together with Asians and Africans, showed a poor attitude towards cancer prevention.

Breast cancer in the 21st century: from early detection to new therapies

The analysis of the causes that have given rise to a change in tendency in the incidence and mortality rates of breast cancer in the last few decades generates important revelations regarding the role of breast screening, the regular application of adjuvant therapies and the change of risk factors. The benefits of early detection have been accompanied by certain adverse effects, even in terms of an excessive number of prophylactic mastectomies. Recently, several updates have been published on the recommendations in breast cancer screening at an international level. On the other hand, the advances in genomics have made it possible to establish a new molecular classification of breast cancer. Our aim is to present an updated overview of the epidemiological situation of breast cancer, as well as some relevant issues from the point of view of diagnosis, such as molecular classification and different strategies for both population-based and opportunistic 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.

Ethical Hurdles in the Prioritization of Oncology Care

With finite resources, healthcare payers must make difficult choices regarding spending and the ethical distribution of funds. Here, we describe some of the ethical issues surrounding inequity in healthcare in nine major European countries, using cancer care as an example. To identify relevant studies, we conducted a systematic literature search. The results of the literature review suggest that although prevention, access to early diagnosis, and radiotherapy are key factors associated with good outcomes in oncology, public and political attention often focusses on the availability of pharmacological treatments. In some countries this focus may divert funding towards cancer drugs, for example through specific cancer drugs funds, leading to reduced expenditure on other areas of cancer care, including prevention, and potentially on other diseases. In addition, as highly effective, expensive agents are developed, the use of value-based approaches may lead to unacceptable impacts on health budgets, leading to a potential need to re-evaluate current cost-effectiveness thresholds. We anticipate that the question of how to fund new therapies equitably will become even more challenging in the future, with the advent of expensive, innovative, breakthrough treatments in other therapeutic areas.