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Altová A, Kulhánová I, Reisser K, Netrdová P, Brož J, Eikemo TA, Balaj M, Lustigová M. Educational inequalities in cervical cancer screening participation in 24 European countries. Public Health 2024; 233:1-7. [PMID: 38805834 DOI: 10.1016/j.puhe.2024.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/10/2024] [Accepted: 04/25/2024] [Indexed: 05/30/2024]
Abstract
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.
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Affiliation(s)
- A Altová
- Department of Demography and Geodemography, Faculty of Science, Charles University, Albertov 6, Praha 2, 12800, Czech Republic.
| | - I Kulhánová
- Department of Demography and Geodemography, Faculty of Science, Charles University, Albertov 6, Praha 2, 12800, Czech Republic; Department of Social Geography and Regional Development, Faculty of Science, Charles University, Albertov 6, Praha 2, 12800, Czech Republic
| | - K Reisser
- Faculty of Medicine, Leipzig University, Liebigstraße, 04103, Leipzig, Germany; Faculty of Health, Medicine, and Life Sciences, Maastricht University, Minderbroedersberg 4-6, 6211 LK Maastricht, the Netherlands
| | - P Netrdová
- Department of Social Geography and Regional Development, Faculty of Science, Charles University, Albertov 6, Praha 2, 12800, Czech Republic
| | - J Brož
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, V Úvalu 84, Praha 5, 150 06, Czech Republic
| | - T A Eikemo
- Global Health Inequalities Research (CHAIN), Department of Sociology and Political Science, Norwegian University of Science and Technology, Edvard Bulls veg 17049 Trondheim, Norway
| | - M Balaj
- Global Health Inequalities Research (CHAIN), Department of Sociology and Political Science, Norwegian University of Science and Technology, Edvard Bulls veg 17049 Trondheim, Norway
| | - M Lustigová
- Department of Social Geography and Regional Development, Faculty of Science, Charles University, Albertov 6, Praha 2, 12800, Czech Republic; National Institute of Public Health, Šrobárova 49/48, Praha 10, 100 00, Czech Republic
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Safari-Faramani B, Safari-Faramani R, Najafi F, Zavareh DK, Karyani AK, Darbandi M. Socioeconomic disparities in Papanicolaou test utilization in Western Iran. BMC Public Health 2024; 24:471. [PMID: 38355473 PMCID: PMC10868049 DOI: 10.1186/s12889-024-17927-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 01/30/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Cervical cancer remains the fourth most frequently diagnosed cancer among women, and its impact is particularly significant in women residing in less developed countries. This study aims to assess socioeconomic inequality in using Papanicolaou tests, commonly known as Pap tests, which are crucial for detecting cervical cancer. The research also seeks to decompose this inequality, identifying its contributing factors. This investigation is conducted within a sizable population-based study focused on the Kurdish population, with an additional examination of potential variations between urban and rural areas. METHOD The study utilized baseline data from the Ravansar Non-Communicable Disease Cohort Study (RaNCD), involving 3,074 ever-married women aged 35-65. Asset data was employed to determine socioeconomic status (SES), and Principal Component Analysis was applied. The uptake of Papanicolaou tests was assessed for inequality using the Concentration Index (Cn). Additionally, decomposition analysis was conducted to identify and understand the factors contributing to socioeconomic inequality. RESULTS The study found that overall, 86% of women reported having undergone cervical cancer screening at least once in their lifetime. The Concentration Index (Cn) for the total population was 0.21 (p < 0.0001), indicating a higher concentration of Papanicolaou test uptake among wealthier groups. In urban areas, the Cn was 0.34 (p < 0.0001), reflecting a significant concentration among the rich. However, in rural areas, the Cn was -0.10 (p = 0.3006), suggesting no significant socioeconomic inequality. Factors such as socioeconomic status (SES), education, and age contributed to reducing inequality, explaining 62.7%, 36.0%, and 1.7% of the observed inequality, respectively. Interestingly, place of residence had a negative influence on inequality. CONCLUSION The uptake of Papanicolaou tests varies across different socioeconomic status levels, with a higher concentration among wealthier groups. The results enable health policymakers and researchers to tailor health intervention toward increasing public awareness, especially among women with lower levels of education women in economically deprived groups.
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Affiliation(s)
- Bahare Safari-Faramani
- Students Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Roya Safari-Faramani
- Social Development and Health Promotion Research Center, Research Institute for Health, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Farid Najafi
- Social Development and Health Promotion Research Center, Research Institute for Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Davoud Khorasani Zavareh
- Department of Health in Emergencies and Disasters, Workplace Health Promotion Research Center (WHPRC), School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Neurobiology, Care Sciences and Society (NVS), H1, Division of Family Medicine and Primary Care, Huddinge, Sweden
| | - Ali Kazemi Karyani
- Research Center for Environmental Determinants of Health (RCEDH), Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mitra Darbandi
- Research Center for Environmental Determinants of Health (RCEDH), Health Institute, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Wearn A, Shepherd L. Determinants of routine cervical screening participation in underserved women: a qualitative systematic review. Psychol Health 2024; 39:145-170. [PMID: 35296200 DOI: 10.1080/08870446.2022.2050230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 03/02/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Routine, population-wide cervical screening programmes reduce cervical cancer incidence and mortality. However, socioeconomically deprived communities and ethnic minority groups typically have lower uptake in comparison to the general population and thus are described as 'underserved.' A systematic qualitative literature review was conducted to identify relevant determinants of participation for these groups. METHODS Online databases were searched for relevant literature from countries with well-established, call-recall screening programmes. Overall, 24 articles were eligible for inclusion. Data was synthesized via Framework synthesis. Dahlgren & Whitehead's social model of health was used as a broad a priori coding framework. RESULTS Participation was influenced by determinants at multiple levels. Overall, patient-provider relationships and peer support facilitated engagement. Cultural disparities, past healthcare experience and practical barriers hindered service access and exacerbated negative thoughts, feelings and attitudes towards participation. Complex interrelationships between determinants suggest barriers have a cumulative effect on screening participation. CONCLUSIONS These findings present a framework of psychosocial determinants of cervical screening uptake in underserved women and emphasise the role of policy makers and practitioners in reducing structural barriers to screening services. Additional work, exploring the experience of those living within socioeconomically disadvantaged areas, is needed to strengthen understanding in this area.
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Affiliation(s)
- Angela Wearn
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - Lee Shepherd
- Department of Psychology, Northumbria University, Northumberland Building, Newcastle Upon Tyne, UK
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Mulcahy Symmons S, Leavy P, Heavey L, Mason Mohan C, Drury A, De Brún A. How is equity captured for colorectal, breast and cervical cancer incidence and screening in the Republic of Ireland: A review. Prev Med Rep 2023; 36:102405. [PMID: 37753379 PMCID: PMC10518567 DOI: 10.1016/j.pmedr.2023.102405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 09/06/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
Introduction Organised screening reduces the incidence and late-stage diagnosis of cancer. However, participation in screening is not consistent across populations. Variations can be measured using demographic factors on place of residence, race/ethnicity, occupation, gender/sex, religion, education, socio-economic position (SEP), and social capital (PROGRESS-Plus stratifiers). The Republic of Ireland has screening programmes for colorectal, breast, and cervical cancer but assessment of screening participation and cancer incidence is inconsistent. The review aimed to evaluate the use of stratifiers in breast, cervical and colorectal cancer incidence and screening literature, and assess variations in incidence and screening participation across subgroups in Ireland. Methods PubMed was searched systematically and grey literature was identified via Google, Google Scholar, Lenus (Irish Health Research repository), and The Irish Longitudinal Study of Aging (TILDA) in June 2022. Studies were included if they captured stratifiers alongside incidence or screening participation data of the three cancers. Results Thirty-six studies and reports were included. Place of residence, SEP, sex, and age were most frequently captured. Incidence and screening participation varied by age, place of residence, SEP, and sex. Discussion PROGRESS-Plus is a useful equity lens to review health literature. Cancer incidence and screening participation studies lacked a comprehensive equity lens resulting in difficulties in identifying inequities and non-attenders. Place of residence, SEP and ethnicity should be prioritised in monitoring inequities. Integrating unique health identifiers should improve monitoring and enable evidence-based population-specific interventions to promote screening. Collaboration with community organisations would support engagement with vulnerable populations when data is limited.
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Affiliation(s)
- Sophie Mulcahy Symmons
- School of Nursing, Midwifery and Health Systems, University College Dublin, Ireland
- UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Ireland
| | - Paul Leavy
- Centre for Health Policy and Management, School of Medicine, Trinty College Dublin, Ireland
| | - Laura Heavey
- Department of Public Health Medicine, National Screening Service, King’s Inn House, 200 Parnell Street, Dublin 1, Ireland
| | - Caroline Mason Mohan
- Department of Public Health Medicine, National Screening Service, King’s Inn House, 200 Parnell Street, Dublin 1, Ireland
| | - Amanda Drury
- School of Nursing, Psychotherapy and Community Health, Dublin City University, Glasnevin, Dublin 9, Ireland
| | - Aoife De Brún
- School of Nursing, Midwifery and Health Systems, University College Dublin, Ireland
- UCD Centre for Interdisciplinary Research, Education, and Innovation in Health Systems (UCD IRIS), School of Nursing, Midwifery and Health Systems, University College Dublin, Ireland
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De Prez V, Jolidon V, Cullati S, Burton-Jeangros C, Bracke P. Cervical cancer (over-)screening in Europe: Balancing organised and opportunistic programmes. Scand J Public Health 2023; 51:1239-1247. [PMID: 36016469 DOI: 10.1177/14034948221118215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS Cervical cancer (CC) over-screening has been understudied in Europe, yet is relevant for approaching inequalities in screening uptake. Focusing on countries' screening strategies (opportunistic systems versus organised programmes), we assess in which contexts CC over-screening is more prevalent, and which women are more likely to have engaged in cervical cancer screening (CCS) within the past year. METHODS A two-level (multilevel) design among screening women (N = 80,761) nested in 31 European countries was used to analyse data from the second wave (2013-2015) of the European Health Interview Survey. We focused on over-screening, defined as screening more frequently than the three-yearly screening interval prescribed in the European guidelines - that is, having screened within the past year. RESULTS Higher levels of over-screening were observed in opportunistic systems compared to systems with organised programmes. In opportunistic systems, women with a higher socioeconomic position had a higher likelihood of being screened within the past year than their socioeconomic counterparts. Moreover, these differences diminished under organised programmes. CONCLUSIONS Contexts with organised CCS programmes are more efficiently reducing over-screening, and enforcing the European guidelines. We suggest that the physician-patient relationship is an essential pathway for explaining socioeconomic differences in CC (over-)screening and for future interventions.
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Affiliation(s)
| | - Vladimir Jolidon
- Institute of Sociological Research, Geneva School of Social Sciences, University of Geneva, Switzerland
| | - Stéphane Cullati
- Institute of Sociological Research, Geneva School of Social Sciences, University of Geneva, Switzerland
- Population Health Laboratory, Department of Community Health, Faculty of Science and Medicine, University of Fribourg, Switzerland
| | - Claudine Burton-Jeangros
- Institute of Sociological Research, Geneva School of Social Sciences, University of Geneva, Switzerland
| | - Piet Bracke
- Department of Sociology, Ghent University, Belgium
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Zapata-Moya AR, Freese J, Bracke P. Mechanism substitution in preventive innovations: Dissecting the reproduction of health inequalities in the United States. Soc Sci Med 2023; 337:116262. [PMID: 37898013 DOI: 10.1016/j.socscimed.2023.116262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 09/18/2023] [Accepted: 09/21/2023] [Indexed: 10/30/2023]
Abstract
In the last three decades, numerous studies in different countries have corroborated the main postulates of the Fundamental Cause Theory (FCT), providing evidence showing how health inequalities are reproduced as society increases its capacity to control disease and/or avoid its consequences through preventive innovations. However, documenting the reproductive logic proposed by the theory requires the development of a dynamic analytical approach to consider socioeconomic disparities in the incorporation of multiple preventive innovations over time, which could act as mediating mechanisms of the durable relationship between socioeconomic status and health/mortality. This study draws on data from different waves of the National Health Interview Survey and the National Health and Nutrition Examination Survey to analyze the diffusion processes of various innovations in the U.S. The results of the study show that educational inequalities emerge, are amplified, and are reduced by the continuous diffusion of preventive innovations, supporting the meta-hypothesis of substitution of mediating mechanisms according to the interconnections of FCT and Diffusion of Innovation Theory.
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Affiliation(s)
- Angel R Zapata-Moya
- Universidad Pablo de Olavide, Department of Anthropology, Basic Psychology and Public Health, Seville, Spain; Centre for Sociology and Urban Policies - The Urban Governance Lab, Universidad Pablo de Olavide, Seville, Spain.
| | - Jeremy Freese
- Stanford University, Department of Sociology, United States.
| | - Piet Bracke
- Ghent University, Department of Sociology, Health and Demographic Research, Ghent, Belgium.
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Chipanta D, Kapambwe S, Nyondo-Mipando AL, Pascoe M, Amo-Agyei S, Bohlius J, Estill J, Keiser O. Socioeconomic inequalities in cervical precancer screening among women in Ethiopia, Malawi, Rwanda, Tanzania, Zambia and Zimbabwe: analysis of Population-Based HIV Impact Assessment surveys. BMJ Open 2023; 13:e067948. [PMID: 37339830 PMCID: PMC10314495 DOI: 10.1136/bmjopen-2022-067948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 05/30/2023] [Indexed: 06/22/2023] Open
Abstract
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.
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Affiliation(s)
- David Chipanta
- ERA, UNAIDS, Geneve, Switzerland
- Faculty of Medicine, University of Geneva, Geneve, Switzerland
| | | | | | | | - Silas Amo-Agyei
- Department of Economics, University of Lausanne, Lausanne, Switzerland
| | - Julia Bohlius
- Swiss Tropical and Public Health Institute, University of Bern, Basel, Switzerland
| | - Janne Estill
- Faculty of Medicine, University of Geneva, Geneve, Switzerland
| | - Olivia Keiser
- Faculty of Medicine, University of Geneva, Geneve, Switzerland
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8
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Greenley R, Bell S, Rigby S, Legood R, Kirkby V, McKee M. Factors influencing the participation of groups identified as underserved in cervical cancer screening in Europe: a scoping review of the literature. Front Public Health 2023; 11:1144674. [PMID: 37304105 PMCID: PMC10247980 DOI: 10.3389/fpubh.2023.1144674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/28/2023] [Indexed: 06/13/2023] Open
Abstract
Background Cervical cancer is a preventable and inequitably distributed disease. Screening plays a vital role in prevention, but many women face barriers to participation. The aims of this scoping review, undertaken to inform the co-design of interventions to equitably increase screening uptake, were to: (1) identify barriers and facilitators to cervical cancer screening for underserved populations, and (2) identify and describe the effectiveness of interventions aimed at improving participation in cervical cancer screening among underserved groups in Europe. Methods Qualitative, quantitative, and mixed methods studies focusing on barriers and facilitators to cervical screening participation and interventions to improve uptake undertaken in Europe and published after 2000 were included. Four electronic databases were searched to identify relevant papers. Titles and abstracts were screened, full text reviewed, and key findings extracted. Data were extracted and analyzed according to different health system strata: system-wide (macro), service specific (meso) and individual/community specific (micro). Within these categories, themes were identified, and the population groups impacted were recorded. All findings are presented in accordance with (PRISMA) guidelines. Results 33 studies on barriers and facilitators and eight intervention studies met the inclusion criteria. Collectively, the findings of these studies presented a wide array of screening uptake barriers, facilitators, and interventions, predominantly related to screening service and individual/community factors. However, although diverse, certain core themes around information provision, prompts for participation and the need for inclusive spaces were apparent. Implementation of screening programs should focus on: (1) reducing identifiable barriers, (2) increasing public awareness, and (3) providing patient reminders and measures to promote engagement by healthcare providers. Conclusion There are many barriers to uptake of cervical cancer screening and this review, nested within a larger study, will inform work to devise a solution alongside groups identified in three European countries.
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Affiliation(s)
- Rachel Greenley
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sadie Bell
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Samuel Rigby
- Department of Health Services, Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rosa Legood
- Centre for Global Chronic Conditions, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Victoria Kirkby
- Department of Health Services, Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Martin McKee
- Department of Health Services, Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Vaccarella S, Georges D, Bray F, Ginsburg O, Charvat H, Martikainen P, Brønnum-Hansen H, Deboosere P, Bopp M, Leinsalu M, Artnik B, Lorenzoni V, De Vries E, Marmot M, Vineis P, Mackenbach J, Nusselder W. Socioeconomic inequalities in cancer mortality between and within countries in Europe: a population-based study. THE LANCET REGIONAL HEALTH. EUROPE 2023; 25:100551. [PMID: 36818237 PMCID: PMC9929598 DOI: 10.1016/j.lanepe.2022.100551] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 11/29/2022]
Abstract
Background Reducing socioeconomic inequalities in cancer is a priority for the public health agenda. A systematic assessment and benchmarking of socioeconomic inequalities in cancer across many countries and over time in Europe is not yet available. Methods Census-linked, whole-of-population cancer-specific mortality data by socioeconomic position, as measured by education level, and sex were collected, harmonized, analysed, and compared across 18 countries during 1990-2015, in adults aged 40-79. We computed absolute and relative educational inequalities; temporal trends using estimated-annual-percentage-changes; the share of cancer mortality linked to educational inequalities. Findings Everywhere in Europe, lower-educated individuals have higher mortality rates for nearly all cancer-types relative to their more highly-educated counterparts, particularly for tobacco/infection-related cancers [relative risk of lung cancer mortality for lower- versus higher-educated = 2.4 (95% confidence intervals: 2.1-2.8) among men; = 1.8 (95% confidence intervals: 1.5-2.1) among women]. However, the magnitude of inequalities varies greatly by country and over time, predominantly due to differences in cancer mortality among lower-educated groups, as for many cancer-types higher-educated have more similar (and lower) rates, irrespective of the country. Inequalities were generally greater in Baltic/Central/East-Europe and smaller in South-Europe, although among women large and rising inequalities were found in North-Europe (relative risk of all cancer mortality for lower- versus higher-educated ≥1.4 in Denmark, Norway, Sweden, Finland and the England/Wales). Among men, rate differences (per 100,000 person-years) in total-cancer mortality for lower-vs-higher-educated groups ranged from 110 (Sweden) to 559 (Czech Republic); among women from approximately null (Slovenia, Italy, Spain) to 176 (Denmark). Lung cancer was the largest contributor to inequalities in total-cancer mortality (between-country range: men, 29-61%; women, 10-56%). 32% of cancer deaths in men and 16% in women (but up to 46% and 24%, respectively in Baltic/Central/East-Europe) were associated with educational inequalities. Interpretation Cancer mortality in Europe is largely driven by levels and trends of cancer mortality rates in lower-education groups. Even Nordic-countries, with a long-established tradition of equitable welfare and social justice policies, witness increases in cancer inequalities among women. These results call for a systematic measurement, monitoring and action upon the remarkable socioeconomic inequalities in cancer existing in Europe. Funding This study was done as part of the LIFEPATH project, which has received financial support from the European Commission (Horizon 2020 grant number 633666), and the DEMETRIQ project, which received support from the European Commission (grant numbers FP7-CP-FP and 278511). SV and WN were supported by the French Institut National du Cancer (INCa) (Grant number 2018-116). PM was supported by the Academy of Finland (#308247, # 345219) and the European Research Council under the European Union's Horizon 2020 research and innovation programme (grant agreement No 101019329). The work by Mall Leinsalu was supported by the Estonian Research Council (grant PRG722).
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Affiliation(s)
- Salvatore Vaccarella
- Cancer Surveillance Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Damien Georges
- Early Detection, Prevention, and Infections Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Freddie Bray
- Cancer Surveillance Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Ophira Ginsburg
- Cancer Surveillance Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
- Center for Global Health, U.S. National Cancer Institute Maryland, USA
| | - Hadrien Charvat
- Cancer Surveillance Branch, International Agency for Research on Cancer (IARC/WHO), Lyon, France
| | - Pekka Martikainen
- Population Research Unit, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
- Max Planck Institute for Demographic Research, Rostock, Germany
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden
| | - Henrik Brønnum-Hansen
- Section for Social Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Patrick Deboosere
- Department of Sociology, Interface Demography, Vrije Universiteit Brussel, 1050 Brussels, Belgium
| | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Mall Leinsalu
- Stockholm Centre for Health and Social Change, Södertörn University, 141 89, Huddinge, Sweden
- Department of Epidemiology and Biostatistics, National Institute for Health Development, Tallinn, Estonia
| | - Barbara Artnik
- Chair of Public Health, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Esther De Vries
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Pontificia Universidad Bogota, Bogota, Colombia
| | - Michael Marmot
- Department of Epidemiology and Public Health, University College London Institute of Health Equity, London, England
| | - Paolo Vineis
- School of Public Health, Imperial College, St Mary's Campus, London, England
| | - Johan Mackenbach
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, Netherlands
| | - Wilma Nusselder
- Department of Public Health, Erasmus MC, PO Box 2040, 3000 CA Rotterdam, Netherlands
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Ammitzbøll G, Levinsen AKG, Kjær TK, Ebbestad FE, Horsbøl TA, Saltbæk L, Badre-Esfahani SK, Joensen A, Kjeldsted E, Halgren Olsen M, Dalton SO. Socioeconomic inequality in cancer in the Nordic countries. A systematic review. Acta Oncol 2022; 61:1317-1331. [DOI: 10.1080/0284186x.2022.2143278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Gunn Ammitzbøll
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark
- Danish Research Center for Equality in Cancer (COMPAS), Department of Clinical Oncology & Palliative Care, Zealand University Hospital, Næstved, Denmark
| | | | - Trille Kristina Kjær
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Freja Ejlebæk Ebbestad
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Trine Allerslev Horsbøl
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Lena Saltbæk
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Næstved, Denmark
| | - Sara Koed Badre-Esfahani
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Public Health Programmes, Randers Regional Hospital, Randers, Denmark
| | - Andrea Joensen
- Section of Epidemiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Eva Kjeldsted
- Danish Research Center for Equality in Cancer (COMPAS), Department of Clinical Oncology & Palliative Care, Zealand University Hospital, Næstved, Denmark
| | - Maja Halgren Olsen
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark
| | - Susanne Oksbjerg Dalton
- Survivorship and Inequality in Cancer, Danish Cancer Society Research Center, Copenhagen, Denmark
- Danish Research Center for Equality in Cancer (COMPAS), Department of Clinical Oncology & Palliative Care, Zealand University Hospital, Næstved, Denmark
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11
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Quintal C, Antunes M. Mirror, mirror on the wall, when are inequalities higher, after all? Analysis of breast and cervical cancer screening in 30 European countries. Soc Sci Med 2022; 312:115371. [PMID: 36137367 DOI: 10.1016/j.socscimed.2022.115371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 07/01/2022] [Accepted: 09/11/2022] [Indexed: 10/31/2022]
Abstract
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.
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Affiliation(s)
- Carlota Quintal
- University of Coimbra, CeBER, Faculty of Economics, Portugal; CEISUC, Portugal.
| | - Micaela Antunes
- University of Coimbra, CeBER, Faculty of Economics, Portugal.
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12
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Audiger C, Bovagnet T, Bardes J, Abihsera G, Nicolet J, Deghaye M, Bochaton A, Menvielle G. Social Inequalities in Participation in Cervical Cancer Screening in a Metropolitan Area Implementing a Pilot Organised Screening Programme (Paris Region, France). Int J Public Health 2022; 67:1604562. [PMID: 35859669 PMCID: PMC9289096 DOI: 10.3389/ijph.2022.1604562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 05/30/2022] [Indexed: 12/02/2022] Open
Abstract
Objectives: We aimed to examine social inequalities in participation in cervical cancer screening (CCS) in a metropolitan area by implementing a pilot organised screening programme. The pilot programme consisted of sending invitations to women who did not perform a pap smear within the past 3 years, managing interventions to reach vulnerable women, training healthcare professionals, and organising follow-ups of abnormal pap smears. Methods: We studied participation in CCS between January 2014 and December 2016 among 241,257 women aged 25-63 years old. To assess relative inequalities, Odds Ratios were computed using multilevel logistic regression. To assess absolute inequalities, the CCS coverage and the rate difference were calculated. Inequalities were computed by age and neighbourhood characteristics (social deprivation and proportion of single women). Results: Disparities in participation in CCS were observed by age and social deprivation. For overall screening compared to opportunistic screening, disparities by age were larger (OR25-35_vs._55-64 = 2.13 [2.08-2.19] compared to 2.02 [1.96-2.07]), but disparities by social deprivation were decreased (OR10%_most_vs._10%_least_deprived = 2.09 [1.90-2.30] compared to 2.22 [2.02-2.44]). Conclusion: Disparities in CCS participation remain despite the organised programme. To reduce these inequalities, free screening should be proposed and evaluated.
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Affiliation(s)
- Céline Audiger
- Le Centre Régional de Coordination des Dépistages des Cancers-CRCDC, Paris, France
- Sorbonne Université, INSERM, Institut Pierre Louis d’épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Thomas Bovagnet
- Sorbonne Université, INSERM, Institut Pierre Louis d’épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - Julia Bardes
- Le Centre Régional de Coordination des Dépistages des Cancers-CRCDC, Paris, France
| | - Gaëlle Abihsera
- Le Centre Régional de Coordination des Dépistages des Cancers-CRCDC, Paris, France
| | - Jérôme Nicolet
- Le Centre Régional de Coordination des Dépistages des Cancers-CRCDC, Paris, France
| | - Michel Deghaye
- Le Centre Régional de Coordination des Dépistages des Cancers-CRCDC, Paris, France
| | - Audrey Bochaton
- Université Paris Nanterre, UMR CNRS 7533 LADYSS, Nanterre, France
| | - Gwenn Menvielle
- Sorbonne Université, INSERM, Institut Pierre Louis d’épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
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13
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Trends and Determinants in Uptake of Cervical Cancer Screening in Spain: An Analysis of National Surveys from 2017 and 2020. Cancers (Basel) 2022; 14:cancers14102481. [PMID: 35626086 PMCID: PMC9140061 DOI: 10.3390/cancers14102481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 11/22/2022] Open
Abstract
Cervical cancer rates have declined in industrialized nations as a result of cytology screening programs. However, there are still sizeable differences in screening adherence in Spain. This study aimed to identify the prevalence of cervical cancer screening among women in Spain, to analyze trends in that prevalence from 2017 and 2020 and to identify socio-demographic, health, and lifestyle factors related with adherence to this screening test. We conducted a cross-sectional study of 13,619 women aged 25−65 who participated in the 2017 Spanish National Health Survey and the 2020 European Health Survey for Spain. We used logistic regression to examine the relationship between socio-demographic, health and lifestyle factors and cervical cancer adherence. The prevalence of adherence was 73.18%. Additionally, there was a significant decrease in cervical cancer screening uptake from 2017 and 2020 among women aged 25−44 years (2017: 77.80%, 2020: 75.20%, p = 0.02), but an increase in the age group of 45−65 years (2017: 68.93%, 2020: 72.39%, p < 0.01) and in foreigners (2017: 64.29%, 2020: 72.29%, p < 0.01). Screening for cervical cancer is related with age, educational level, social class, insurance status, visits to the family doctor, alcohol consumption and free time physical exercise.
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