Abstract
BackgroundLittle 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. MethodsData 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. ResultsMain 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. ConclusionsOverall, 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.
Highlights
Increasing attention has been paid to macro-contextual and institu tional determinants of health and health inequalities in social science and epidemiology (Beckfield & Krieger, 2009; Brennenstuhl et al, 2012; Muntaner et al, 2011)
We address the following questions and hypotheses: 1. How are welfare social policies and healthcare system characteristics related to cancer screening participation? We hypothesise that more generous welfare provision and decommodifying healthcare system arrangements are associated with higher cancer screening participation
The median odds ratios (MOR) is 1.568 and 2.001 indicating that an individual from a country with high screening uptake had 1.568 (Pap smear) and 2.001 times the odds of screening compared to an individual from a country with low screening uptake, which suggests that country-level factors have less influence on Pap smear than on mammography uptake
Summary
Increasing attention has been paid to macro-contextual and institu tional determinants of health and health inequalities in social science and epidemiology (Beckfield & Krieger, 2009; Brennenstuhl et al, 2012; Muntaner et al, 2011). This ‘institutional turn’ in cross-national studies has drawn attention to macro-level determinants and how these interact with socioeconomic differences in health at the individual level (Beck field et al, 2015) From this standpoint, social policy contexts and healthcare characteristics shape the distribution of resources in a population, and to what extent these resources are important for individuals’ health across different institutional settings. The institutional approach to health and health inequalities stresses the role of policy and institutional arrangements which structure social inequalities and (re)distribute social determinants of population health (Beckfield et al, 2015) In this sense, welfare and healthcare system arrangements have ‘institutional effects’ (Beckfield et al, 2015) which might directly or indirectly affect cancer screening participation, and explain cross-country differences in screening uptake and in equalities. Educa tion, the social inequality measure chosen in this paper, was shown to be a robust measure of socioeconomic position in comparative European analyses (Mackenbach et al, 2008) and to capture the social distribution of a large range of health determinants, as it relates to material, psy chological and social resources (Ross & Wu, 1995)
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