Socio-economic inequalities in breast and cervical cancer screening practices in Europe: influence of the type of screening program

Abstract

The aim of this study was to describe inequalities in the use of breast and cervical cancer screening services according to educational level in European countries in 2002, and to determine the influence of the type of screening program on the extent of inequality. A cross-sectional study was performed using individual-level data from the WHO World Health Survey (2002) and data regarding the implementation of cancer screening programmes. The study population consisted of women from 22 European countries, aged 25-69 years for cervical cancer screening (n =11 770) and 50-69 years for breast cancer screening (n = 4784). Dependent variables were having had a PAP smear and having had a mammography during the previous 3 years. The main independent variables were socio-economic position (SEP) and the type of screening program in the country. For each country the prevalence of screening was calculated, overall and for each level of education, and indices of relative (RII) and absolute (SII) inequality were computed by educational level. Multilevel logistic regression models were fitted. SEP inequalities in screening were found in countries with opportunistic screening [comparing highest with lowest educational level: RII = 1.28, 95% confidence interval (CI) 1.12-1.48 for cervical cancer; and RII = 3.11, 95% CI 1.78-5.42 for breast cancer] but not in countries with nationwide population-based programmes. Inequalities were also observed in countries with regional screening programs (RII = 1.35, 95% CI 1.10-1.65 for cervical cancer; and RII = 1.58, 95% CI 1.26-1.98 for breast cancer). Inequalities in the use of cancer screening according to SEP are higher in countries without population-based cancer screening programmes. These results highlight the potential benefits of population-based screening programmes.