Cervical screening by socio-economic status in Australia

Cervical Cancer Screening Among Immigrant Women Residing in Australia: A Systematic Review

Since the introduction of systematic population-based cervical cancer screening in Australia in 1991, age-standardized incidence of cervical cancer has halved. Given recent advances in human papillomavirus (HPV) vaccination and screening, cervical cancer may be eliminated nationally within 20 years. However, immigrant women are not equitably reached by screening efforts. This study systematically reviewed evidence on cervical cancer screening practices among immigrant women in Australia. A systematic search of MEDLINE, Embase, PubMed, CINAHL, and PsycINFO and gray literature for English language studies published till March 1, 2019, was conducted. Observational and qualitative studies evaluating cervical cancer screening awareness and participation of immigrant women were screened. Of 125 potentially relevant studies, 25 were eligible: 16 quantitative (4 cohort, 12 cross-sectional), 6 qualitative, and 3 mixed-methods studies. Quantitative studies indicated 1% to 16% lower screening rates among migrant women compared with Australian-born women, with participation of South Asian women being significantly lower (odds ratio = 0.54, 95% confidence interval = 0.48-0.61). Qualitative studies illustrated factors affecting women's willingness to participate in screening, including insufficient knowledge, low-risk perception, and unavailability of a female health professionals being key barriers. Future studies should focus on South Asian women, due to recent increase in their immigration.

Disparities in reported psychosocial assessment across public and private maternity settings: a national survey of women in Australia

BACKGROUND

Psychosocial assessment and depression screening is now recommended for all women who are pregnant or have recently given birth in Australia. Existing studies which have examined the extent of participation by women in such population-based programs have been primarily concerned with depression screening rather than a more comprehensive examination of psychosocial assessment, and have not been sufficiently inclusive of the 30% of women whose maternity care is provided in the private sector. Whether there are disparities in equity of access to perinatal psychosocial assessment is also unknown.

METHODS

A sub-sample of women (N = 1804) drawn from the Australian Longitudinal Study on Women's Health participated in the study. Overall rates of assessment across five psychosocial domains (current emotional health; mental health history; current level of support; current drug or alcohol use; experience of domestic violence or abuse), as well as receipt of mental health promotion information, were examined. Log binomial regression was performed to investigate whether there were socio-demographic or health system inequalities among women who are and are not assessed across each domain.

RESULTS

Two-thirds of women (66.8%) reported being asked about their current emotional health in the antenatal period, increasing to 75.6% of women in the postnatal period. Rates decreased markedly for reported assessment of mental health history (52.9% during pregnancy and 41.2% postnatally). Women were least likely to be asked about their experience of domestic violence or abuse in both the antenatal and postnatal periods (in total, 35.7% and 31.8%, respectively).In terms of equity of access to psychosocial assessment, women who gave birth in the public hospital sector were more likely to report being assessed across all domains of assessment in the antenatal period, compared with women who gave birth in the private sector, after adjusting for other significant covariates. State of residence was associated with reported rates of assessment across all domains in both the antenatal and postnatal periods. Women from non-English speaking backgrounds and women with more than one child were less likely to be assessed across various domains.

CONCLUSION

This study provides an important insight into the reported overall penetration of and access to perinatal psychosocial assessment among a sample of women in Australia. Opportunities to minimise the current shortfall in assessment rates, particularly in the private sector, and for ongoing monitoring of assessment activity at a national level are discussed.

Cancer patients' concerns regarding access to cancer care: perceived impact of waiting times along the diagnosis and treatment journey

Waiting times can raise significant concern for cancer patients. This study examined cancer patients' concern levels at each phase of waiting. Demographic, disease and psychosocial characteristics associated with concern at each phase were also assessed. 146 consenting outpatients (n= 146) were recruited from two hospitals in Sydney, Australia. Each completed a touch-screen computer survey, asking them to recall concern experienced regarding waiting times at each treatment phase. Approximately half (52%) reported experiencing concern during at least one treatment phase, while 8.9% reported experiencing concern at every phase. Higher proportions of patients reported concern about waiting times from: deciding to have radiotherapy to commencement of radiotherapy (31%); the first specialist appointment to receiving a cancer diagnosis (28%); and deciding to have chemotherapy to commencement of chemotherapy (28%). Patient groups more likely to report concern were those of lower socio-economic status, born outside Australia, or of younger age. Although a small proportion of patients reported very high levels of concern regarding waiting times, the experience of some concern was prevalent. Opportunities for reducing this concern are discussed. Vulnerable groups, such as younger and socio-economically disadvantaged patients, should be the focus of efforts to reduce waiting times and patient concern levels.

How do we manage patients who become unemployed?

The number of unemployed patients presenting in general practice will increase over the next 12 months. Unemployed patients are likely to present with physical and psychological problems, including insomnia, depression, anxiety and a worsening of cardiovascular risk factors; family members are also likely to be affected. GPs have an important role in early detection and management of these health problems; effective approaches include cognitive behaviour techniques, goal-setting and motivational counselling. Appropriate provision of medical certificates, advocacy and social support help redress the loss of the personal and social "vitamins" of work. While access to psychological services has improved, patients may also need to be referred to social workers, and employment and welfare services. Divisions of General Practice can have an important role in helping to broker access to services and raise awareness of the health effects of unemployment.

Mass media campaign improves cervical screening across all socio-economic groups

Low socio-economic status (SES) has been associated with lower cervical screening rates. Mass media is one known strategy that can increase cervical screening participation. This study sought to determine whether a mass media campaign conducted in Victoria, Australia, in 2005 was effective in encouraging women across all SES groups to screen. Data were obtained from the Victorian Cervical Cytology Registry for each Pap test registered during 2005 and categorized into SES quintiles using the Index of Socio-Economic Advantage/Disadvantage. Negative binomial regression was used to determine the impact of the campaign on the weekly number of Pap tests and whether the media campaign had a differential effect by SES, after adjusting for the number of workdays per week, age group and time since previous test. Cervical screening increased 27% during the campaign period and was equally effective in encouraging screening across all SES groups, including low-SES women. Mass media campaigns can prompt increased rates of cervical screening among all women, not just those from more advantaged areas. Combining media with additional strategies targeted at low-SES women may help lessen the underlying differences in screening rates across SES.

Absent sexual scripts: lesbian and bisexual women's knowledge, attitudes and action regarding safer sex and sexual health information

Despite recent evidence demonstrating that lesbian and bisexual women are at risk of sexually transmitted infections (STIs), there is a common perception that STIs cannot be transmitted between women. This paper reports on a study in which a self-report questionnaire, completed by over 300 lesbian and bisexual women and a comparison group of heterosexual women, was undertaken to determine lesbian and bisexual women's levels of knowledge about the human papillomavirus (HPV) and their attitudes toward the HPV vaccine and cervical smear testing. Alongside this, a series of in-depth interviews with lesbian and bisexual women explored how they perceive their level of HPV risk, the reasons why they do or do not feel at risk and how they manage their sexual health in relation to their lesbian or bisexual identity. The study concludes that lesbians generally feel at low risk for STIs because they are excluded from dominant sexual scripts that inform the negotiation of safer sex practice. Lesbians are unlikely to engage with sexual health promotion targeted toward gay men or heterosexual women, yet lesbian-specific sexual health promotion does not adequately construct an alternate discourse on safer sex that lesbians can relate to their own sexual practice.

Differential impacts of health care in Australia: trend analysis of socioeconomic inequalities in avoidable mortality

BACKGROUND

Recent avoidable mortality trends in Australia suggest that health care has made a substantial contribution to reducing mortality. This study investigates if the benefits of health care have been distributed equally by comparing declines in avoidable with non-avoidable mortality over time by socioeconomic status (SES).

METHODS

We calculated avoidable and non-avoidable mortality rates in Australia by small areas for 1986, 1991, 1997 and 2002. We performed pooled cross-sectional trend analysis of indirectly standardized mortality rates by SES and year, modelling using Poisson regression with over-dispersion. Socioeconomic inequalities were quantified using the relative (RII) and slope (SII) index of inequality.

RESULTS

The annual percentage decline in avoidable mortality at the higher end of the socioeconomic continuum (5.0%; 95% CI: 4.7-5.4%) was larger than at the lower end (3.5%; 3.2-3.8%), with increasing relative inequality between 1986 (RII = 1.54; 1.46-1.63) and 2002 (RII = 2.00; 1.95-2.06), greater than that in non-avoidable mortality (P = 0.036). In absolute terms, avoidable deaths fell annually by 7.4 (6.9-7.8) and 8.4 (7.9-8.9) deaths per 100 000 at the higher and lower end of the spectrum, respectively, with absolute inequality decreasing between 1986 (SII = 97.8; 87.6-107.9) and 2002 (SII = 81.5; 74.6-88.5).

CONCLUSIONS

Health care has contributed to decreasing the absolute SES mortality gap. However, advantaged people have obtained a disproportionate benefit of health care, contributing to widening relative health inequalities. A universal heath care system does not guarantee equality in health-care-related outcomes.

Precancerous changes in the cervix and risk of subsequent preterm birth

OBJECTIVE

The aims of this study were (i) to examine whether women referred for assessment of precancerous changes in the cervix had higher rates of preterm birth compared with those in the general population and (ii) to compare preterm birth rates for treated and untreated women adjusting for possible confounding factors.

DESIGN

Retrospective cohort design.

SETTING

Teaching hospital.

POPULATION

All women referred to the Royal Women's Hospital, Melbourne (1982-2000), who subsequently had a birth recorded on the Victorian Perinatal Data Collection system (n = 5548).

METHODS

Record linkage of hospital dysplasia clinic records and population-based birth records.

MAIN OUTCOME MEASURES

Total preterm delivery (<37 weeks of gestation) and subtypes.

RESULTS

Both treated and untreated women were at a significantly increased risk for preterm birth compared with those in the general population: treated--standardised prevalence ratio (SPR) 2.0, 95% CI 1.8-2.3 and untreated--SPR 1.5, 95% CI 1.4-1.7. Within the cohort, the treated women were significantly more likely to give birth preterm (adjusted OR 1.23, 95% CI 1.01-1.51). An increased risk of preterm birth was also associated with a history of induced or spontaneous abortions, illicit drug use during pregnancy or a major maternal medical condition. Cone biopsy, loop electrosurgical excision procedure and diathermy were associated with preterm birth. After adjusting for possible confounding factors, only diathermy remained significant (adjusted OR 1.72, 95% CI 1.36-2.17). Women treated using laser ablation were not at an increased risk for preterm birth (adjusted OR 1.1, 95% CI 0.8-1.4).

CONCLUSIONS

Diagnosis of precancerous changes in the cervix (regardless of the treatment) was associated with an increased risk of preterm birth. Consideration should be given to the preferential use of ablative treatments.

The role of education in the uptake of preventative health care: the case of cervical screening in Britain

This paper reports findings on the relationship between education and the take-up of screening for cervical cancer, as an example of preventative health-care activity. Theoretically, education can enhance the demand for preventative health services by raising awareness of the importance of undertaking regular health check-ups and may also improve the ways in which individuals understand information regarding periodical tests, communicate with the health practitioner, and interpret results. Furthermore, education enhances the inclusion of individuals in society, improving self-efficacy and confidence. All these factors may increase service uptake. The empirical analysis uses data from the British Household Panel Survey (BHPS) and applies techniques for discrete panel data to estimate the parameters of the model. Results show that adult learning leading to qualifications is statistically associated with an increase in the uptake of screening. The marginal effect indicates that participation in courses leading to qualifications increases the probability of having a smear test between 4.3 and 4.4 percentage points. This estimate is strongly robust to time-invariant selectivity bias in education and the inclusion of income, class, occupation, and parental socio-economic status. These findings enrich existing evidence on the socio-economic determinants of screening for cervical cancer and enable policy makers to better understand barriers to service uptake.

Why worry about awareness in choice problems? Econometric analysis of screening for cervical cancer

The decision to undertake a screening test is conditional upon awareness of screening. From an econometric perspective there is a potential selection problem, if no distinction is made between aware and unaware non-screeners. This paper explores this problem through analysis of the determinants of cervical screening in Australia. Cervical cancer is one of the most preventable and curable forms of cancer. Since 1991 there has been a concerted effort in Australia to recommend and encourage women to have Pap smears every two years. The success of this program can be partly gauged by exploring the determinants of screening for cervical cancer. Using unit record data from the 1995 National Health Survey, an econometric model is developed for whether women have ever screened or not. A proportion of women in the sample contend that they have never heard of a Pap test. The analysis characterizes this group of women and accounts for their presence in the modelling. The paper demonstrates failing to model awareness can result in inconsistent parameter estimates even when the degree of censoring in the sample is relatively small.

Sociodemographic predictors of pap test receipt, currency and knowledge among Australian women

BACKGROUND

Knowledge of sociodemographic variations in cervical cancer screening can help identify population groups at risk of underutilization of cervical cancer procedures and practices. The aim of this research was to examine sociodemographic predictors of receipt, currency (being up-to-date for), and knowledge of Pap test.

METHODS

We used data from the 1995 National Health Survey. A subsample of women was given self-administered questionnaires that included questions about the Pap test. The sample size was 7,572. Using multiple logistic regression, we examined the association of age, marital status, region of residence, country of birth, Index of Relative Socioeconomic Disadvantage (IRSD), and education with Pap test receipt, currency, and knowledge.

RESULTS

Women under 30 and over 49 years of age, those not presently married, those with lower levels of education, and those born in the Middle East or Asia (compared with the Australian/New Zealand-born women) were at a greater risk of not receiving and having no knowledge of Pap test.

CONCLUSIONS

The results of this study suggest that, as part of a comprehensive cancer screening strategy, women who are unlikely to obtain a Pap smear might benefit from targeted interventions to improve adherence to cervical cancer screening programs.