Abstract
Background and aimThe public health impact of population-based mammography screening programs depends on high participation rates. Thus, monitoring participation rates, as well as understanding and considering the factors influencing attendance, is important. With the goal to acquire information on the appropriate level of intervention for increasing screening participation our study aimed to (1) examine whether, over and above individual factors, the neighborhood of residence influences a woman’s mammography non-attendance, and (2) evaluate, whether knowing a woman’s neighborhood of residence would be sufficient to predict non-attendance.MethodsWe analyze all women invited to mammography screening in 2005–09, residing in the city of Malmö, Sweden. Information regarding mammography screening attendance was linked to data on area of residence, demographic and socioeconomic characteristics available from Statistics Sweden. The influence of individual and neighborhood factors was assessed by multilevel logistic regression analysis with 29,901 women nested within 212 neighborhoods.ResultsThe prevalence of non-attendance among women was 18.3%. After adjusting for individual characteristics, the prevalence in the 212 neighborhoods was 3.6%. Neighborhood of residence had little influence on non-attendance. The multilevel analysis indicates that 8.4% of the total individual differences in the propensity of non-attendance were at the neighborhood level. However, when adjusting for specific individual characteristics this general contextual effect decreased to 1.8%. This minor effect was explained by the sociodemographic characteristic of the neighborhoods. The discriminatory accuracy of classifying women according to their non-attendance was 0.747 when considering only individual level variables, and 0.760 after including neighborhood level as a random effect.ConclusionOur results suggest that neighborhoods of residence in Malmö, Sweden (as defined by small-area market statistics (SAMS) areas) do not condition women’s participation in population based mammography screening. Thus, interventions should be directed to the whole city and target women with a higher risk of non-attendance.
Highlights
After a gradual introduction throughout Sweden, and following recommendations from the National Board of Health and Welfare [1], a nationwide program for population-based outreach mammography screening for women over the age of 40 or 50 was implemented by 1997 [2]
The multilevel analysis indicates that 8.4% of the total individual differences in the propensity of non-attendance were at the neighborhood level
A previous study of ours conducted in Malmö reported that the intra-neighborhood correlation for non-attendance in the mammography screening program during 1990–93 was only 4.3% and this small general contextual effect of neighborhood decreased substantially when adjusting for individual sociodemographic factors and neighborhood characteristics [4]
Summary
After a gradual introduction throughout Sweden, and following recommendations from the National Board of Health and Welfare [1], a nationwide program for population-based outreach mammography screening for women over the age of 40 or 50 was implemented by 1997 [2]. Over and above individual level factors, a number of previous studies in Europe [8,9,10,11] Japan [12], and North America [13,14,15,16,17,18,19] have investigated geographical area of residence as a potential determinant of mammography attendance Those studies have applied multilevel regression analyses [20,21,22,23] and mainly focused on the analyses of associations between area-level specific contextual variables (characteristics of the area such as socioeconomic deprivation, degree of urbanization, breast cancer incidence and mortality, density of mammography facilities; type of screening program such as population-based/ opportunistic; and other health-care/institutional factors) and individual level mammography attendance. With the goal to acquire information on the appropriate level of intervention for increasing screening participation our study aimed to (1) examine whether, over and above individual factors, the neighborhood of residence influences a woman’s mammography non-attendance, and (2) evaluate, whether knowing a woman’s neighborhood of residence would be sufficient to predict nonattendance
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