Wealth-related inequalities of women's knowledge of cervical cancer screening and service utilisation in 18 resource-constrained countries: evidence from a pooled decomposition analysis

Picturing Prevalence and Inequalities in Cancer Screening Attendance to Population-Based Programs in Portugal

INTRODUCTION

Screening is effective in reducing cancer-related morbidity and mortality. The aim of this study was to analyze the level of, and income-related inequalities in, screening attendance, in Portugal for population-based screening programs.

METHODS

Data from the Portuguese Health Interview Survey 2019 was used. Variables included in the analysis were self-reported: mammography, pap smear test, fecal occult blood test. Prevalence and concentration indices were computed at national/regional level. We analyzed: up-to-date screening (within recommended age/interval), under-screening (never or overdue screening), and over-screening (due to frequency higher than recommended or screening outside target group).

RESULTS

Up-to-date screening rates were 81.1%, 72%, and 40%, for breast, cervical and colorectal cancer, respectively. Never-screening was 3.4%, 15.7%, and 39.9%, for breast, cervical, and colorectal cancer, respectively. Over-screening related with frequency was highest for cervical cancer; in breast cancer, over-screening was observed outside recommended age, affecting one third of younger women and one fourth of older women. In these cancers, over-screening was concentrated among women with higher income. Never-screening was concentrated among individuals with lower income for cervical cancer and higher income for colorectal cancer. Beyond the recommended age, 50% of individuals never underwent screening for colorectal cancer and 41% of women never underwent screening for cervical cancer.

CONCLUSION

Overall, screening attendance was high, and inequalities were low in the case of breast cancer screening. The priority for colorectal cancer should be to increase screening attendance.

Socioeconomic inequalities in cervical precancer screening among women in Ethiopia, Malawi, Rwanda, Tanzania, Zambia and Zimbabwe: analysis of Population-Based HIV Impact Assessment surveys

OBJECTIVES

We examined age, residence, education and wealth inequalities and their combinations on cervical precancer screening probabilities for women. We hypothesised that inequalities in screening favoured women who were older, lived in urban areas, were more educated and wealthier.

DESIGN

Cross-sectional study using Population-Based HIV Impact Assessment data.

SETTING

Ethiopia, Malawi, Rwanda, Tanzania, Zambia and Zimbabwe. Differences in screening rates were analysed using multivariable logistic regressions, controlling for age, residence, education and wealth. Inequalities in screening probability were estimated using marginal effects models.

PARTICIPANTS

Women aged 25-49 years, reporting screening.

OUTCOME MEASURES

Self-reported screening rates, and their inequalities in percentage points, with differences of 20%+ defined as high inequality, 5%-20% as medium, 0%-5% as low.

RESULTS

The sample size of participants ranged from 5882 in Ethiopia to 9186 in Tanzania. The screening rates were low in the surveyed countries, ranging from 3.5% (95% CI 3.1% to 4.0%) in Rwanda to 17.1% (95% CI 15.8% to 18.5%) and 17.4% (95% CI 16.1% to 18.8%) in Zambia and Zimbabwe. Inequalities in screening rates were low based on covariates. Combining the inequalities led to significant inequalities in screening probabilities between women living in rural areas aged 25-34 years, with a primary education level, from the lowest wealth quintile, and women living in urban areas aged 35-49 years, with the highest education level, from the highest wealth quintile, ranging from 4.4% in Rwanda to 44.6% in Zimbabwe.

CONCLUSIONS

Cervical precancer screening rates were inequitable and low. No country surveyed achieved one-third of the WHO's target of screening 70% of eligible women by 2030. Combining inequalities led to high inequalities, preventing women who were younger, lived in rural areas, were uneducated, and from the lowest wealth quintile from screening. Governments should include and monitor equity in their cervical precancer screening programmes.

[Faible niveau de dépistage du cancer du col de l'utérus, disparités géographiques et déterminants sociodémographiques du dépistage chez les femmes adultes au Burkina Faso : résultats de la première enquête nationale en population générale]

OBJECTIVE

To explore the level, geographical disparities and sociodemographic determinants of cervical cancer screening uptake among adult women in Burkina Faso by using data from the first national population-based survey.

METHODS

This was a cross-sectional secondary analysis of primary data obtained by the 2013 World Health Organization (WHO) Stepwise Approach to Surveillance survey conducted in Burkina Faso. All 13 Burkinabè regions, with their different rates of urbanization, were surveyed. Lifetime cervical cancer screening uptake was explored. We included 2293 adult women for analyses and performed Student's t, chi-square and Fisher's exact tests, and logistic regression.

RESULTS

Only 6.2% (95% CI: 5.3-7.3) of women had ever been screened for cervical cancer. For two regions ("Centre" and "Hauts-Bassins"), the pooled frequency was 16.6% (95% CI: 13.5-20.1) while in the other eleven regions it was significantly lower, 3.3% (95% CI: 2.5-4.2). In urban and rural areas, the respective frequencies for the screening uptake were 18.5% and 2.8% (p < 0.001), and in educated and un-educated women, frequencies were 27.7% and 3.3% (p < 0.001) respectively. The sociodemographic factors associated with screening uptake were being educated (adjusted odd-ratio [aOR] = 4.3; 95% CI: 2.8-6.7), urban residence (aOR = 3.8, 95% CI: 2.5-5.8) and having an occupation providing income (aOR = 3.1, 95% CI: 1.8-5.4).

CONCLUSION

There was a significantly wide range in screening uptake between Burkina Faso regions, and the overall national as well as the region-specific levels were far below the WHO's target for cervical cancer elimination. Cervical cancer interventions should be tailored specifically for Burkinabè women with different educational levels, and prevention strategies based on community engagement integrating psychosocial considerations could be helpful.

The burden of chronic diseases and patients' preference for healthcare services among adult patients suffering from chronic diseases in Bangladesh

BACKGROUND

Low- and middle-income countries (LMICs) have a disproportionately high burden of chronic diseases, with inequalities in health care access and quality services. This study aimed to assess patients' preferences for healthcare services for chronic disease management among adult patients in Bangladesh.

METHODS

The present analysis was conducted among 10,385 patients suffering from chronic diseases, drawn from the latest Household Income and Expenditure Survey 2016-2017. We used the multinomial logistic regression to investigate the association of chronic comorbid conditions and healthcare service-related factors with patients' preferences for healthcare services.

RESULTS

The top four dimensions of patient preference for healthcare services in order of magnitude were quality of treatment (30.3%), short distance to health facility (27.6%), affordability of health care (21.7%) and availability of doctors (11.0%). Patients with heart disease had a 29% significantly lower preference for healthcare affordability than the quality of healthcare services (relative risk ratio [RRR] = 0.71; 0.56-0.90). Patients who received healthcare services from pharmacies or dispensaries were more likely to prefer a short distance to a health facility (RRR = 6.99; 4.80-9.86) or affordability of healthcare services (RRR = 3.13; 2.25-4.36). Patients with comorbid conditions were more likely to prefer healthcare affordability (RRR = 1.39; 1.15-1.68). In addition, patients who received health care from a public facility had 2.93 times higher preference for the availability of medical doctors (RRR = 2.93; 1.70-5.04) than the quality of treatment in the health facility, when compared with private service providers.

CONCLUSIONS

Patient preferences for healthcare services in chronic disease management were significantly associated with the type of disease and its magnitude and characteristics of healthcare providers. Therefore, to enhance service provision and equitable distribution and uptake of health services, policymakers and public health practitioners should consider patient preferences in designing national strategic frameworks for chronic disease management.

PATIENT OR PUBLIC CONTRIBUTION

Our research team includes four researchers (co-authors) with chronic diseases who have experience of living or working with people suffering from chronic conditions or diseases.

Mirror, mirror on the wall, when are inequalities higher, after all? Analysis of breast and cervical cancer screening in 30 European countries

Screening for breast and cervical cancer is strongly related with a reduction in cancer mortality but previous evidence has found socioeconomic inequalities in screening. Using up-to-date data from the second wave of the European Health Interview Survey (2013-2015), this study aims to analyse income-related inequalities in mammography screening and Pap smear test in 30 European countries. We propose a framework that combines age group and screening interval, identifying situations of due-, under-, and over-screening. Coverage rates, standard and generalised concentration indices are calculated. Overall, pro-rich inequalities in screening persist though there are varied combinations of prevalence of screening attendance and relative inequality across countries. Bulgaria and particularly Romania stand out with low coverage and high inequality. Some Baltic and Mediterranean countries also present less favourable figures on both accounts. In general, there are not marked differences between mammography and Pap smear test, for the recommended situation ('Due-screening'). 'Extreme under-screening' is concentrated among lower income quintiles in basically all countries analysed, for both screenings. These women, who never screened, are at risk of entering the group of 'Lost opportunity', once they reach the upper-limit age of the target group. At the same time, there are signals of 'Over-screening', within target group, due to screening more frequently than recommended. In several countries, 'Over-screening' seems to be concentrated among richer women. This is not only a waste of resources, but it can also cause harms. The inequalities found in 'Extreme under-screening' and 'Over-screening' raise concerns on whether women are making informed choices.

The effect of education based on the theory of planned behavior on the intention of vaccination against human papillomavirus in female students: A controlled educational trial

BACKGROUND

Human papillomavirus (HPV) is the most common sexually transmitted infection and causes more than 90% of cervical cancers. The highest rate of infection occurs between the ages of 18 and 28. This study aimed to determine the effect of education based on the theory of planned behavior (TPB) on the intention of vaccination against HPV in female students.

MATERIALS AND METHODS

This controlled educational trial study was performed on 72 female students aged 18-26 years of Mashhad University of Medical Sciences by random assignment to intervention and control groups. For random assignment in the intervention and control groups, random blocking with four blocks was performed using a random number table with a ratio of 1:1. Data collection tools included demographic questionnaire, awareness about HPV vaccination, and TPB theory constructs. The control group was received the university routine training. The intervention group was received the virtual group training in four sessions, 60-90 min at weekly intervals and with educational content including TPB constructs on HPV vaccination with the method of lecture training, group discussion, questions and answers, and presentation of training package. Questionnaires were completed before, instantly, and 1 month after the educational intervention. Data were analyzed using the Chi-square test, Fisher's exact, t-test, Mann-Whitney test, and Friedman test.

RESULTS

The mean age of students was 18.9 ± 1.1 years. The intervention and control groups were homogeneous in terms of demographic characteristics (P > 0.05). Before the intervention, the mean score of model constructs did not show a statistically significant difference between the two groups (P > 0.05), but after the intervention, in the intervention group, mean scores of attitude, subjective norms, perceived behavioral control, and behavioral intention in the intervention group was significantly higher than the control group (P < 0.001). In the intervention group, the difference in the mean score of HPV vaccination intention instantly (P < 0.001) and 1 month (P < 0.001) after the intervention significantly increased.

CONCLUSION

TPB-based education was effective in increasing attitudes, subjective norms, and perceived behavioral control and the intention to vaccinate against HPV in the female students of Mashhad University of Medical Sciences. Therefore, it is suggested that the present educational intervention be widely used to educate female students.

Explaining socioeconomic inequality in cervical cancer screening uptake in Malawi

Background

Cervical cancer is a prevalent public health concern and is among the leading causes of death among women globally. Malawi has the second highest cervical cancer prevalence and burden in the world. Due to the cervical cancer burden, the Malawi government scaled up national cancer screening services in 2011, which are free for all women. This paper is the first study to examine the socioeconomic inequality in cervical cancer screening uptake using concentration indices, in Malawi. Furthermore, it decomposes the concentration index to examine how each factor contributes to the level of inequality in the uptake of cervical cancer screening.

Methods

The data used in this paper were obtained from the nationally representative Malawi Population HIV Impact Assessment (MPHIA) household survey, which was conducted in 2015. Concentration curves were constructed to explore whether there was any socioeconomic inequality in cervical cancer screening and, if so, its extent. This was complemented by concentration indices that were computed to quantify the magnitude of socioeconomic inequality. A decomposition analysis was then conducted to examine the factors that explained/were associated with greater socioeconomic inequality in cervical cancer screening. The methodology in this paper followed that of previous studies found in the literature and used the wealth index to measure socioeconomic status.

Results

The results showed that the concentration curves lay above the line of equality, implying a pro-rich inequality in cervical cancer screening services. Confirming the results from the concentration curves, the overall concentration index was positive and significant (0.142; %95 CI = 0.127, 0.156; p < 0.01). The magnitude was lower in rural areas (0.075; %95CI = 0.059, 0.090; p < 0.01) than in urban areas (0.195; %95CI = 0.162, 0.228 p < 0.001). After undertaking a decomposition of the concentration index, we found that age, education, rural or urban location, and wealth status account for more than 95% of the socioeconomic inequality in cervical cancer uptake.

Conclusion

Despite the national scale-up of free cancer care at the point of use, cervical cancer screening uptake in Malawi remains pro rich. There is a need to implement parallel demand-side approaches to encourage uptake among poorer groups. These may include self-testing and mobile screening centres, among others.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13750-4.

Perceptions and attitude of women of Luderitz, Namibia on Pap smear and cervical cancer prevention

Background

Cervical cancer is one of the leading malignancies globally and has taken third place in Namibia amongst women aged 15–44 years. Infection with the Human Immunodeficiency Virus (HIV) has been proven to increase women’s susceptibility to developing cervical carcinoma. Sadly, Namibia carries a twin burden of HIV and cervical cancer. Namibians are aware of HIV/AIDS, but remain poorly informed about cervical cancer. Furthermore, among those who are aware of the disease, low utilisation of screening tests have been reported.

Objective

The purpose was to explore perceptions and attitudes held by women about cervical cancer, reasons for low uptake of Pap smear testing amongst those who are aware of the malignancy as well as unearth motivation factors that has fuelled women to go for screening.

Methodology

A descriptive, cross-sectional study was conducted using convenience sampling as a sampling technique. The survey instrument used was a self-administered questionnaire. It consisted of both closed and open ended questions. A total of 136 women were surveyed.

Results and conclusion

The level of awareness for cervical cancer (92.6%) and Pap smear (93.4%) were high. Most were able to identify that Pap smear test is used for screening for pre-cancerous lesions. However, knowledge about the impact of a HIV positive status along with co infection with HPV as the leading causes for progression of invasive cervical carcinoma was not well known. Knowledge about the other risk factors such as multiple sexual partners (39.7%), early sex debut (34.9%) and smoking was poorly demonstrated. This suggests that a high awareness level does not necessarily translate into having a good perception or understanding of a disease. A good attitude towards screening was observed although less than half of the study population reported ever having a test done.

Ghanaian women's knowledge on whether malaria treatment is covered by the national health insurance: A multilevel regression analysis of national data

BACKGROUND

To obviate malaria and other healthcare costs and enhance healthcare utilization, the government of Ghana introduced the National Health Insurance Scheme (NHIS) in 2005. Nonetheless, there is dearth of empirical evidence on Ghanaian women's knowledge about whether malaria treatment is covered by the NHIS or not. The current study, therefore, investigated factors associated with knowledge of malaria treatment with the NHIS among women aged 15-49 in Ghana.

METHODS

The study is a secondary analysis of data from women respondents in the 2014 Ghana Demographic and Health Survey. A total of 2,560 women participated in this study. Descriptive computation of the weighted proportion of women who knew that malaria is covered by NHIS was conducted at 95% confidence interval (CI). A multilevel logistic regression analyses was carried out with Stata's MLwinN package version 3.05. We declared significance at 5% alpha. Findings from the models were reported as adjusted odds ratios (aOR) and credible intervals (CrIs).

RESULTS

In all, 81.0% of Ghanaian women included in the study knew that NHIS covers malaria treatment. Women aged 45-49 had higher odds of knowing that NHIS covers malaria relative to those aged 15-19 age category [aOR=1.5;95%crl=1.2-2.1]. Women with higher education (post-secondary) had higher odds of knowing that NHIS covers malaria treatment compared with women who had no formal education [aOR=1.6;95%Crl=1.2-2.0]. Richest women were more likely to know that NHIS covers malaria treatment compared to the poorest women [aOR=1.3;95%Crl=1.2-1.7]. Women who had subscribed to the NHIS were more likely to report that NHIS covers malaria treatment [aOR=1.5;95%Crl=1.2-1.8]. The study revealed that the variance in the tendency for a woman to be aware that NHIS covers malaria treatment is attributable to 10.8% community level factors.

CONCLUSION

This study has shown that individual, community and regional level factors affect women's knowledge on whether NHIS covers malaria treatment or not. As knowledge that malaria treatment is covered by NHIS may increase use of malaria prevention and treatment services in health facilities, we recommend that the Ghana Health Service intensifies community level education and awareness creation efforts, targeted at women among whom awareness levels are currently low.

The Prevalence and Associated Factors of Cancer Screening Uptake Among a National Population-Based Sample of Adults in Marshall Islands

Background:

The study aimed to estimate the prevalence and associated factors of cancer screening among men and women in the general population in Marshall Islands.

Methods:

The national cross-sectional sub-study population consisted of 2,813 persons aged 21-75 years (Median = 37.4 years) from the “2017/2018 Marshall Islands STEPS survey”. Information about cancer screening uptake included Pap smear or Vaginal Inspection with Acetic Acid (=VIA), clinical breast examination, mammography, faecal occult blood test (FOBT), and colonoscopy.

Results:

The prevalence of past 2 years mammography screening was 21.7% among women aged 50-74 years, past year CBE 15.9% among women aged 40 years and older, past 3 years Pap smear or VIA 32.6% among women 21-65 years, past year FOBT 21.8% among women and 22.3% among men aged 50-75 years, and past 10 years colonoscopy 9.1% among women and 7.3% among men aged 50-75 years. In adjusted logistic regression, cholesterol screening (AOR: 1.91, 95% CI: 1.07-3.41) was associated with past 2 years mammography screening among women aged 50-74 years. Blood pressure screening (AOR: 2.39, 95% CI: 1.71-3.35), glucose screening (AOR: 1.59, 95% CI: 1.13-2.23), dental visit in the past year (AOR: 1.51, 95% CI: 1.17, 1.96), binge drinking (AOR: 1.88, 95% CI: 1.07-3.30), and 2-3 servings of fruit and vegetable consumption a day (AOR: 1.42, 95% CI: 1.03-1.95) were positively and high physical activity (30 days a month) (AOR: 0.56, 95% CI: 0.41-0.76) was negatively associated with Pap smear or VIA screening among women aged 21-65 years. Higher education (AOR: 2.58, 95% CI: 1.02-6.58), and cholesterol screening (AOR: 2.87, 95% CI: 1.48-5.59), were positively and current smoking (AOR: 0.09, 95% CI: 0.01-0.65) was negatively associated with past 10 years colonoscopy uptake among 50-75 year-olds.

Conclusion:

The study showed a low cancer screening uptake, and several factors were identified that can assist in promoting cancer screening in Marshall Islands.