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

Inequalities in patients' experiences with cancer care: the role of economic and health literacy determinants

BACKGROUND

Patients with fewer socioeconomic and health literacy resources are disadvantaged in their access and use of healthcare, which may give rise to worse experiences with care and thus inequalities in patient experiences. However, only a limited number of studies have examined how socioeconomic and health literacy factors shape inequalities in patients' experiences with cancer care.

OBJECTIVE

To examine whether patients' experiences with cancer care differ according to their economic status and health literacy.

METHODS

Secondary analysis of data on 2789 adult patients diagnosed with cancer from the Swiss Cancer Patient Experiences-2 (SCAPE-2) study, a cross-sectional survey conducted in eight hospitals across Switzerland from September 2021 to February 2022. Regression analysis was applied to examine the independent effect of patients' economic status and health literacy on various outcomes of experiences with cancer care, covering eight different dimensions of patient-centred care, controlling for confounding factors.

RESULTS

Adjusted regression analysis showed that patients with lower economic status reported significantly worse experiences with cancer care in 12 out of 29 specific care experiences, especially in the dimensions of 'respect for patients' preferences' and 'physical comfort' where all items of experiences were associated with economic status. Additionally, lower health literacy was associated with worse patient experiences in 23 specific care experiences. All items in the dimensions of 'respect for patients' preferences', 'physical comfort' and 'emotional support' were associated with health literacy.

DISCUSSION

This study revealed significant inequalities in experiences with cancer care shaped by the economic status and health literacy of patients across different dimensions of patient-centred care. It is essential to address the needs of more disadvantaged patients who face obstacles in their access and use of the healthcare system, not only to mitigate inequalities in cancer care but also to avoid inequalities in health outcomes.

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.

Interventions to Improve Endoscopic Screening Adherence of Cancer in High-Risk Populations: A Scoping Review

Background

Colorectal, and gastric cancers have the second, and fourth mortality rates worldwide, respectively. Endoscopic screening is a crucial diagnostic tool for colorectal, and gastric cancers. Effective interventions can improve adherence to endoscopic screening in high-risk populations, which is important for cancer prevention and mortality reduction. This study aimed to identify interventions that could improve adherence to endoscopic screening for cancer in high-risk populations.

Methods

Combination keywords including colorectal cancer, gastric cancer, screening adherence, and interventions were used to search for articles in PubMed, Web of Science, Cochrane Library, and MEDLINE Complete. The review methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SCR).

Results

A total of 12 articles were included in this review: 9 randomized controlled trials(RCT) and 3 quasi-experimental studies(QEDs). Among the extracted studies, 11 were about colorectal cancer, and 1 was about gastric cancer. Most studies used lecture-based or Information Technology-based health education interventions. Narrative interventions have proven to be novel and effective approaches for promoting adherence to endoscopic screening. Health education interventions included cancer epidemiology, cancer risk factors, warning symptoms, and screening methods.

Conclusion

All interventions involved were effective in increasing individual knowledge of cancer-related endoscopic screening, willingness to undergo screening, and screening behaviors. These findings provide a reference for designing endoscopy-related cancer screening interventions.

Impact of altering the invitation package on screening participation among never-screeners in the Flemish population-based cancer screening programs

BACKGROUND

The total coverage of both the Flemish breast cancer and cervical screening program remain suboptimal, with approximately 63% for both. Of all the women invited to the breast cancer screening program, 14.1% never underwent any type of breast cancer screening (any type of mammogram, ultrasound, or clinical breast examination). For the cervical cancer screening, this proportion of 'never-screeners' is 12.1%. We conducted two randomized controlled trials to assess whether various communication and presentation styles in the invitation package, were effective at motivating women who had never participated to attend.

METHODS

The study population was limited to never-screeners (women who had never participated in the screening program). The RCT embedded in the breast cancer screening consisted of seven intervention arms and one control arm (all of them included a fixed appointment by letter). The RCT embedded in the cervical cancer screening consisted of three intervention arms and two control arms. In both RCTs, several content and style adaptations were made to the invitation letter, information leaflet, and envelope.

RESULTS

None of the intervention arms in either the breast cancer screening or the cervical cancer screening had a statistically significant impact on the participation rate compared to 'usual care' (the regular invitation package used in the screening program).

CONCLUSION

Sending adapted invitation packages to never-screeners, from the Flemish breast and cervical cancer screening program, does not seem to be effective in increasing the proportion of women screened. Innovative methods are needed to motivate never-screeners to be screened.

Socioeconomic disparities in Papanicolaou test utilization in Western Iran

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.

Association of Regular Cervical Cancer Screening with Socioeconomic, COVID-19 Infection and Vaccine Status Among Japanese Population: Cohort Observational Study

Purpose

Among the Organisation for Economic Co-operation and Development countries, Japan has one of the lowest cervical cancer screening coverages. Cancer screening coverage has worsened due to the coronavirus disease of 2019 (COVID-19) pandemic. This study investigated the relationship between socioeconomic background, COVID-19 infection history and vaccine status, and regular cervical cancer screening (CCS) during the two years of the COVID-19 era in Japan.

Patients and Methods

We used data from the Japan COVID-19 and Society Internet Survey, a nationwide, Internet-based, self-report cohort observational study conducted in 2022. The outcome variable was identified by asking whether the participants had undergone CCS within the last two years. Cervical cytology was performed in Japan by brushing the external cervical os. This study used multivariate log-binomial regression models to evaluate inequalities during regular checkups for CCS. Adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) were estimated to incorporate the socioeconomic background variables.

Results

Of the 12,066 participants, 5597 (46.4%) had undergone regular CCS for over two years. The prevalence ratio (PR) of patients who underwent CCS was 0.70 for those in their 20s and 0.78 for those in their 60s, compared to those in their 40s. Socioeconomic inequities were found in the following groups: unemployed/student, unmarried, high school graduate or lower, and household income below 4 million Yen. Our final multivariate analysis revealed that participants who were in their 20s or 60s, had a household income below 4 million Yen, were unmarried, had no annual health check-ups, and were unvaccinated with COVID-19 were at a higher risk of not undergoing CCS.

Conclusion

The relationship between socioeconomic inequality and CCS hesitancy is prevalent among younger participants. The CCS coverage in Japan during the COVID-19 pandemic year (2020-2022) was not low compared with the pre-pandemic era.

Cervical cancer (over-)screening in Europe: Balancing organised and opportunistic programmes

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.

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.

A systematic review of the cost-effectiveness of interventions to increase cervical cancer screening among underserved women in Europe

BACKGROUND

This study aimed to conduct a systematic review of the cost-effectiveness studies of interventions to increase cervical cancer screening uptake rates in underserved women in Europe.

METHODS

A search of Embase, Medline, Global Health, PsychINFO, and NHS Economic Evaluation Database was conducted for studies published between January 2000 and September 2022. Studies were eligible if they analysed the cost-effectiveness of any interventions to improve participation in cervical cancer screening among underserved women of any age eligible to participate in cervical cancer screening in European countries, in any language. Study characteristics and cost-effectiveness results were summarised. Study quality was assessed using the Drummond Checklist, and methodological choices were further compared.

RESULTS

The searches yielded 962 unique studies, with 17 of these (from twelve European countries) meeting the eligibility criteria for data extraction. All studies focused on underscreened women as an overarching group, with no identified studies focusing on specific subgroups of underserved women. Generally, self-HPV testing and reminder interventions were shown to be cost-effective to increase the uptake rates. There was also research showing that addressing access issues and adopting different screening modalities could be economically attractive in some settings, but the current evidence is insufficient due to the limited number of studies.

CONCLUSION

This systematic review has revealed a gap in the literature on the cost-effectiveness of interventions to improve uptake rates of cervical cancer screening through tailored provision for specific groups of underserved women.

Effect of Test History at Ages 50-64 on Later Cervical Cancer Risk: A Population-based Case-control Study

As life expectancy increases, the effectiveness of cervical cancer screening programs needs to be reassessed for the older population. We addressed the effect of test history in and outside organized screening at age 50-64 years on later cervical cancer risk. A case-control study was conducted by deriving 229 cases of 65-79 years old women with invasive cervical cancer in 2010-2019 from the Finnish Cancer Registry. Ten controls were matched for each case by birth year and hospital district. The effect of test uptake and abnormal results in 50-64 year olds on cancer risk was investigated using conditional logistic regression and adjusted for self-selection. Test uptake within the 50-64 years age group showed 75% lower odds of cervical cancer [adjusted OR (aOR) = 0.25; 95% confidence interval (95% CI), 0.18-0.35]. Untested women had 4.9 times higher odds than those tested with normal results (aOR = 4.86; 95% CI, 3.42-6.92). Having at least one abnormal test result increased the odds by 2.5 when compared with only normal results but showed lower odds when compared with untested women. The importance of testing is exhibited by the result showing a reduction of odds of cancer to one-fourth for those tested compared with untested. Similarly, receiving abnormal results was protective of cancer compared with having no tests highlighting the importance of proper follow-up. Therefore, screening history should be considered when further developing cervical cancer screening programs with special interest in non-attenders and those receiving abnormal results at older ages.

Significance

To our knowledge, this is the first study from Finnish data describing the effect of test history on later cervical cancer at older ages. Focusing on the cervical tests taken within the Finnish national screening program and outside it highlights the overall importance of having cervical tests and adds this study into the slowly increasing number of studies considering all cervical testing in Finland.

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.

The Practice and Willingness of Women Towards Opportunistic Screening for Breast and Cervical Cancers in Sichuan Province, China: A Cross-Sectional Study

Purpose

To understand the practices and willingness of Chinese women to undergo opportunistic screening for breast cancer (BC) and cervical cancer (CC).

Patients and Methods

From July to August 2021, a cross-sectional study of 1446 women from six cities in Sichuan Province, China, was conducted. A questionnaire was used to investigate practices, willingness, and barriers to opportunistic screening for BC and CC. Furthermore, potential factors for opportunistic screening willingness were analyzed using the chi-squared test and logistic regression.

Results

During their lifetime, 312 (21.6%) and 388 (26.8%) women had undergone opportunistic screening for BC and CC, respectively. There were 1069 (73.9%) women willing to accept physician-recommended screening during a medical visit, while 835 (57.7%) were willing to have a voluntary screening at a healthcare institution. The main barriers to reluctance to participate in physician-recommended and voluntary screenings were "no symptoms; hence, no need for screening" and "unwillingness or difficulty in paying screening cost". Ethnic minorities, lower education levels, and menopause were inversely associated, whereas awareness of the screening methods and eligibility for screening were positively associated with physician-recommended and voluntary screenings (P < 0.05). Furthermore, awareness of "two-cancers" screening was positively associated with physician-recommended screening (P < 0.05).

Conclusion

BC and CC opportunistic screening rates in Sichuan Province were low. The willingness to undergo physician-recommended screening was high, while that towards individual initiative screening was low. Public health education should be strengthened to increase cancer prevention awareness and knowledge of cancer screening, especially for women with low education, ethnic minorities, and post-menopause, for whom tailored interventions are suggested. In addition, novel ways of sharing screening costs need to be explored.

Barriers and facilitators to cervical cancer screening among under-screened women in Cuenca, Ecuador: the perspectives of women and health professionals

Background

Cervical cancer screening is a cost-effective method responsible for reducing cervical cancer-related mortality by 70% in countries that have achieved high coverage through nationwide screening strategies. However, there are disparities in access to screening. In Ecuador, although cervical cancer is the second most common cancer in women, only 58.4% of women of reproductive age have ever been screened for cervical cancer.

Methodology

A qualitative study was performed to understand the current barriers to screening and to identify strategies that could increase uptake in Azuay province, Ecuador. Seven focus group discussions (FGDs) were conducted with under-screened women and health professionals (HPs). The FGDs were recorded and transcribed. Content analysis was done using the socio-ecological framework to categorize and analyse the data.

Results

Overall, 28 women and 27 HPs participated in the study. The two groups perceived different barriers to cervical cancer screening. The HPs considered barriers to be mainly at the policy level (lack of a structured screening plan; lack of health promotion) and the individual level (lack of risk perception; personal beliefs). The women identified barriers mainly at organizational level, such as long waiting times, lack of access to health centres, and inadequate patient–physician communication. Both groups mentioned facilitators at policy level, such as national campaigns promoting cervical cancer screening, and at community and individual level, including health literacy and women’s empowerment.

Conclusions

The women considered access to health services the main barrier to screening, while the HPs identified a lack of investment in screening programmes and cultural patterns at the community level as major obstacles. To take an integrated approach to cervical cancer prevention, the perspectives of both groups should be taken into account. Additionally, new strategies and technologies, such as self-administered human papillomavirus (HPV) testing and community participation, should be implemented to increase access to cervical cancer screening.

Harms and benefits of cervical cancer screening among non-attenders in Switzerland: The transition towards HPV-based screening

•

We evaluate the expected benefits and harms of cervical cancer screening strategies.

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Primary self-sampling with HPV was associated with a lower cancer incidence and mortality compared to cytology.

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Primary self-sampling with HPV resulted in a reduction of screening and follow-up visits.

•

Primary self-sampling with HPV has a reasonable balance of harms and benefits when performed every 5 years.

Human papillomavirus (HPV) testing is replacing cytological screening for cervical cancer. Our aim was to assess the expected benefits and harms of different cervical screening strategies. This study is sub-analysis of a previous cost-effectiveness study with a target population of unscreened women without cervical cancer aged ≥ 25 years. A recursive decision-tree with one-year cycles was used to model the life-long natural HPV history. Markov cohort simulations were used to assess the expected outcomes from the model. The outcomes of three strategies were compared with the absence of screening: HPV-testing on self-collected vaginal samples (Self-HPV) followed by colposcopy (Self-HPV/colpo), Self-HPV and triage with cytology (Self-HPV/PAP), cytology and triage with HPV (PAP/HPV). All screening strategies resulted in reductions in cancer cases and deaths. Self-HPV strategies were associated with a lower cancer incidence and mortality life-long, not only when performed every 3 years but also when Self-HPV was performed every 5 years vs cytology every 3 years. The gain in life expectancy obtained was 82 days with Self-HPV/colpo, 81 days with Self-HPV/PAP and 75 days with PAP/HPV compared to no screening. The number of lifetime total visits was greater with PAP/HPV compared with the Self-HPV strategies (13.13 vs < 3). The number of conizations remained relatively stable with the change of screening frequency and strategy. Self-HPV may represent a reasonable balance of harms and benefits when performed every 5 years compared to cytology every 3 years. Self-HPV/PAP yielded the most efficient harm to benefit ratio when using colposcopy as a proxy for harms.

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.

Cervical Cancer Prophylaxis—State-of-the-Art and Perspectives

Background: Each year 604,127 new cases of cervical cancer (CC) are diagnosed, and 341,831 individuals die from the disease. It is the fourth most common cancer among women and the fourth most common cause of death from female cancers worldwide. The pathogenesis of CC is associated with human papillomavirus (HPV) infections and consists of several steps involving cell proliferation outside the human body’s control mechanisms. Strategies to prevent CC are based on screening and vaccination. Scope of the Review: The aim of this paper was to collect and analyze the available literature on the issue of CC prevention and the impact of the COVID-19 pandemic on its implementation. For this purpose, PubMed and Google Scholar databases were searched using keywords, such as “cervical cancer”; “HPV”; “prevention”; “prophylaxis”; “vaccination”; “screening” and “COVID-19” in different variations. Only articles published since 2018 were included in the study. Conclusions: Selected European countries have different CC prevention programs funded by national budgets. This translates into observed differences in the risk of death from CC (age-standardized rate Malta = 1.1, Poland = 5.9). COVID-19 pandemic due to disruption of CC screening may exacerbate these differences in the future. To improve the situation, new screening methods, such as p16/Ki67, HPV self-testing, and the use of artificial intelligence in colposcopic assessment, should be disseminated, as well as free HPV vaccination programs implemented in all countries. The search for new solutions is not without significance and entails ultra-sensitive screening tests for risk groups (mRNA E6/E7, SOX1/SOX14), HPV vaccines with shorter dosing schedules, and new therapeutic pathways using nanotheranostics.

Does the socioeconomic status predict health service utilization in persons with enhanced health care needs? Results from a population-based survey in persons with spinal cord lesions from Switzerland

Background

Evidence suggests that the socioeconomic status (SES) affects individuals’ health service utilization. Spinal cord injury is a condition that often leads to physical impairments and enhanced health care needs. It therefore presents an informative and yet under-researched case in point to investigate social inequalities in health service utilization. This study aims to describe associations between SES and health service utilization in adults with spinal cord injury from Switzerland.

Methods

We use cross-sectional data from 1,294 participants of the Swiss Spinal Cord Injury Cohort Study community survey 2017. SES was operationalized with education, household income, perceived financial hardship, subjective status, and granting of supplementary financial benefits. Health service utilization was assessed with information on visits to 13 different health care providers and four health care institutions (inpatient stays, outpatient clinics, emergency departments, specialized spinal cord centers) during the past 12 months. The dichotomized outcomes on service utilization (visited vs. not visited) were regressed on SES indicators, including adjustments for sociodemographics, lesion characteristics, and health status.

Results

Persons with higher SES reported higher likelihood for specialist, dentist, and dental hygienist visits and reported utilizing a larger number of different care providers. Further, specific SES indicators were associated with certain care provider visits (i.e., higher education and subjective status: higher odds for pharmacist visits; higher income: higher odds for natural healer visits; higher subjective status: higher odds for chiropractor visits; supplementary benefit granting: higher odds for general practitioner and home care service visits). We found statistically non-significant trends towards lower likelihood for inpatient stays, outpatient clinic and emergency department visits and enhanced likelihood for specialized spinal cord-center visits in higher SES groups.

Conclusions

This study generally supports the claim that basic health care provision is guaranteed for all patients with spinal cord injury in Switzerland, independently of their SES. However, social inequalities were still observed for the utilization of specific providers, such as oral health care providers. Given that oral health is key for health maintenance in persons with spinal cord injury, specific interventions to enhance regular dental check-ups in lower SES groups are highly recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-022-01693-6.

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.

Revisiting the Effects of Organized Mammography Programs on Inequalities in Breast Screening Uptake: A Multilevel Analysis of Nationwide Data From 1997 to 2017

This study revisits the effects of mammography screening programs on inequalities in breast screening uptake in Switzerland. The progressive introduction of regional mammography programs by 12 out of the 26 Swiss cantons (regions) since 1999 offers an opportunity to perform an ecological quasi-experimental study. We examine absolute income and marital status inequalities in mammography uptake, and whether the cantons' implementation of mammography programs moderate these inequalities, as previous research has devoted little attention to this. We use five waves of the Swiss Health Interview Survey covering the 1997–2017 period and comprising data on 14,267 women aged 50–70. Both up-to-date and ever-screening outcomes are analyzed with multilevel models which assess the mammography programs' within-canton effect. Findings show that higher income women and married women (compared to unmarried women) had significantly higher mammography uptake probabilities. Mammography programs did not moderate absolute income differences in up-to-date screening; however, they were associated with smaller absolute income differences in ever-screening uptake. Mammography programs related to higher screening uptake for married women, more than for unmarried women. In conclusion, we showed absolute income inequalities in mammography uptake which were not revealed by previous studies using relative inequality measures. Mammography programs may have contributed to reducing income inequalities in ever-screening, yet this was not observed for up-to-date screening. This study has implication for preventive health interventions—e.g., cancer screening promotion should pay attention to women's marital status since screening programs may widen the screening gap between married and unmarried women.

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.