Breast Screening Uptake Research Articles

Can Pharmacists Fill the Primary Care Provider Gap in Recommending Breast Screening?

Background and context: BreastScreen Victoria (BSV) provides free breast screening to women aged 40+, targeting women aged 50-74. The program reduces breast cancer deaths by up to 28%. Primary care is important in improving uptake of breast screening. In particular, a recommendation from a health professional is a strong influencer. Many general practitioners (GPs) recommend screening, however, it is important to expand recruitment to other health professionals given many women do not visit a GP regularly. Community pharmacists and pharmacy staff may be a trusted source of health information, and are potentially an underutilized opportunity to promote breast screening to women. Based on this gap, BSV developed a three month pharmacy-based screening awareness campaign that was trialed in community pharmacies throughout 2017/18. The campaign is based on a UK community pharmacy model that was shown to successfully increase public awareness about cancer screening. Aim: BSV aims to diversify the types of health professionals that recommend screening to reach women who do not visit a GP regularly. The aim of the pharmacy-based breast screening awareness campaign is to: • build capacity of pharmacy staff to deliver breast screening messages to their communities • increase awareness of breast screening in women aged 50-74 • increase awareness of breast screening among family and friends of women Strategy/Tactics: BSV's pharmacy-based breast screening awareness campaign was trialed in 4 community pharmacies in 2017. Each pharmacy received a grant of up to $1550 which enabled them to: • allow pharmacy staff to attend training to increase their knowledge of breast screening and the campaign • display BreastScreen collateral throughout the store to provide information and prompt queries • initiate conversations and answer questions about breast screening • monitor campaign activity via a number of methods Outcomes: • Posttraining, 100% of staff were confident in promoting breast screening to customers • Staff across 4 pharmacies had 638 conversations about breast screening with customers (average 160/pharmacy). The majority were with women in the target age group • Most pharmacies suggested shortening the campaign to 2 months • All pharmacies said the funding was a critical motivator to participation • All pharmacies stated that the campaign was worthwhile, and allowed them to participate in health promotion Two additional trials are scheduled to test a reduced campaign duration and funding model. Results will be available later in 2018 What was learned: • Many women do not visit their GP regularly • Community pharmacists and pharmacy staff are an underutilized opportunity to promote breast screening • Delivering cancer screening messages through community pharmacies is an effective way to reach women aged 50-74 • Pharmacy funding and training are critical in enabling pharmacies to deliver a breast screening awareness campaign

Using Record Linkage to Examine the Impact of Poor Mental Health on Breast Screening Uptake

BackgroundThe UK National Breast Screening Programme is estimated to reduce breast cancer mortality by 20%. To maximise the benefits of the programme, we first need to understand the underlying factors contributing to variations in screening uptake. One potentially significant factor which may contribute to these gradients in screening uptake is poor mental health.
 ObjectivesThe objectives of this study were to examine the impact of poor mental health on breast screening uptake, and whether this explained any of the previously observed socio-demographic gradients in screening uptake.
 MethodsBreast screening records were obtained from the National Breast Screening System (NBSS) and were subsequently linked to 2011 Census data within the Northern Ireland Longitudinal Study (NILS). The NILS encompasses 28\% of Census data. This was then linked to psychotropic prescribing information from the Enhanced Prescribing Database (EPD), to produce a de-identified research dataset containing 57,328 women.
 FindingsWomen with self-reported poor mental health were over 20% less likely to attend screening compared to their counterparts who didn't have poor mental health. Using psychotropic prescribing information as a proxy for the presence of mental illness yielded similar results, with those taking anxiolytics, antipsychotics or hypnotics in the three months before screening invitation significantly less likely to attend than those who were not.
 ConclusionWomen with poor mental health were significantly less likely to attend breast screening. However, poor mental health did not explain any of the previously determined socio-demographic gradients in screening uptake.

Influences on Polish migrants' breast screening uptake in Lothian, Scotland

ObjectivesEthnic minorities are known to have low uptake of cancer screening programmes and Polish populations to have low breast screening uptake. Breast screening uptake by women in Poland and Polish migrants to Scotland is low. We interviewed Polish women living in Lothian, Scotland, about their attitudes to breast screening. Study design and methodTelephone interviews were held with a sample of 11 Polish women registered with Lothian general practices and invited for breast screening in 2013 or 2014. Interviews were between November 2014 and February 2015 and were held in Polish then translated, transcribed and analysed thematically. ResultsWomen interviewed (mean age 58 years) had lived in Scotland for an average of 7.5 years. Seven had undergone breast screening in both Poland and Scotland, three in only Scotland and one in Poland alone. Respondents usually used Scottish and Polish health systems and screening programmes in parallel. Convenience and familiarity shaped screening choices with written information neither accessed nor answering key questions e.g. about coordination between programmes. ConclusionPolish women living in Scotland have difficulties in accessing screening there and often use both Polish and Scottish system. Language issues, misunderstandings about screening and different health cultures are key barriers. Combined information in Polish about all cancer screening programmes could help address low uptake.

Health beliefs, illness perceptions and determinants of breast screening uptake in Malta: a cross-sectional survey

BackgroundWomen’s beliefs and representations of breast cancer (BC) and breast screening (BS) are salient predictors for BS practices. This study utilized the health belief model (HBM) and common-sense model (CSM) of illness self-regulation to explore factors associated with BS uptake in Malta and subsequently, to identify the most important predictors to first screening uptake.MethodsThis cross-sectional survey enrolled Maltese women (n = 404) ages 50 to 60 at the time of their first screening invitation, invited to the National Breast Screening Programme by stratified random sampling, with no personal history of BC. Participants responded to a 121-item questionnaire by telephone between June–September 2015. Data were analyzed using descriptive statistics, chi-square tests and logistic regression.ResultsThere is high awareness of BC signs and symptoms among Maltese women (>80% agreement for 7 out of 8 signs), but wide variation about causation (e.g., germ or virus: 38.6% ‘agree’, 30.7% ‘disagree’). ‘Fear’ was the key reason for non-attendance to first invitation (41%, n = 66) and was statistically significant across all subscale items (p < 0.05). Most items within HBM constructs (perceived barriers; cues to action; self-efficacy) were significantly associated with first invitation to the National Breast Screening Programme, such as fear of result (χ2 = 12.0, p = 0.017) and life problems were considered greater than getting mammography (χ2 = 38.8, p = 0.000). Items within CSM constructs of Illness Representation (BC causes; cyclical cancer timeline; consequences) were also significantly associated, such as BC was considered to be life-changing (χ2 = 18.0, p = 0.000) with serious financial consequences (χ2 = 13.3, p = 0.004). There were no significant associations for socio-demographic or health status variables with uptake, except for family income (χ2 = 9.7, p = 0.047). Logistic regression analyses showed that HBM constructs, in particular perceived barriers, were the strongest predictors of non-attendance to first invitation throughout the analyses (p < 0.05). However, the inclusion of illness representation dimensions improved the model accuracy to predict non-attendance when compared to HBM alone (65% vs 38.8%).ConclusionsInterventions should be based on theory including HBM and CSM constructs, and should target first BS uptake and specific barriers to reduce disparities and increase BS uptake in Malta.

The impact of breast cancer awareness interventions on breast screening uptake among women in the United Kingdom: A systematic review.

The impact of breast screening awareness campaigns on mammography attendance among British women was explored. British Nursing Index, Medline, PsycINFO, Embase and Cumulative Index to Nursing and Allied Health were searched between October 2012 and February 2013. Searches identified research on breast cancer awareness interventions and breast self-examination. In total, 867 articles were identified and 14 met criteria for review. Breast cancer awareness interventions were found to increase the uptake of breast self-examination behaviours and increase the likelihood of breast cancer screening attendance. Predicting the impact of these interventions on survivability and general morbidity/mortality outcomes remains a challenge due to a shortage of suitably evaluated campaigns.

Cervical and breast cancer screening uptake among women with serious mental illness: a data linkage study.

BackgroundBreast and cancer screening uptake has been found to be lower among women with serious mental illness (SMI). This study aims to corroborate these findings in the UK and to identify variation in screening uptake by illness/treatment factors, and primary care consultation frequency.MethodsLinked population-based primary and secondary care data from the London borough of Lambeth (UK) were used to compare breast and cervical screening receipt among linked eligible SMI patients (n = 625 and n = 1393), to those without SMI known only to primary care (n = 106,554 and n = 25,385) using logistic regression models adjusted first for socio-demographic factors and second, additionally for primary care consultation frequency.ResultsEligible SMI patients were less likely to have received breast (adjusted odds ratio (OR) 0.69, 95 % confidence interval (CI), 0.57 - 0.84, p < 0.001) or cervical screening (adjusted OR 0.72, CI: 0.60 - 0.85, p < 0.001). Schizophrenia diagnosis, depot injectable antipsychotic prescription, and illness severity and risk were associated with the lowest odds of uptake of breast (adjusted ORs 0.46 to 0.59, all p < 0.001) and cervical screening (adjusted ORs 0.48 - 0.65, all p < 0.001). Adjustments for consultation frequency further reduced effect sizes for all subgroups of SMI patient, in particular for cervical screening.ConclusionsWomen with SMI are less likely to receive breast and cervical cancer screening than comparable women without SMI. Higher primary care consultation rates among SMI patients is likely a mediating factor between SMI status and uptake, particularly for cervical screening - a service organised in primary care. To tackle health disparities linked to SMI, efforts at increasing screening uptake are key and should be targeted at women with other markers of illness severity or risk, beyond SMI status alone.

Effectiveness of timed and non-timed second appointments in improving uptake in breast cancer screening.

ObjectivesTo estimate the effect on breast screening uptake of delayed, targeted, second timed appointments in women who did not take up an initial breast cancer screening appointment offer.MethodsNon-attending women received a four-month delayed second timed appointment following non-response to the initial invitation and the normal open invitation sent to non-attenders. A comparison group was sent a four-month delayed additional open invitation.ResultsResponse to the second timed appointments (percentage of re-invited women eventually attending in this episode) was 20%, corresponding to an estimated increase on total uptake of 6%. Response was highest in women who had previously attended screens. Response in the women offered an additional delayed open invitation was 7.5%, corresponding to an estimated 2.3% increase in overall uptake.ConclusionsSecond timed appointments were almost three times as effective as additional open invitation. They should be targeted at women most likely to attend. A randomized study of second timed appointments versus open invitations should be conducted.

Determinants of breast cancer screening uptake in Kurdish women of Iran.

Background: Recently, a national breast cancer screening program has been introduced in Iran.The aim of this study was to examine the determinants of breast cancer screening uptake among Kurdish women, in order to identify those characteristics that may be potentially associated with the screening uptake. Methods: Through a cross sectional study, in 2014, a random sample of 561 women aged 40 years and older without the history of breast cancer and identified with Kurdish background in Baneh county, Iran, were recruited and interviewed by two trained interviewers. Data were collected using a valid and reliable researcher made questionnaire. Univariate and multivariate logistic regression models with self-reported screening history as the dependent variable were used to estimate the odds ratios (ORs) with 95% of CI. Results: The mean age of women was 43.64 (SD = 5.17). The participation rate in the mammography program was 16.8% (95% CI: 13.7-19.8%). The lowest level of participation was found among women aged 60 and older (OR = 0.30, 95% CI: 0.14-0.69), illiterate (OR = 0.63,95% CI: 0.40-0.99) and post-menopausal (OR = 0.56, 95% CI: 0.35-0.91) women. Conclusion: It was found that the level of breast screening uptake was low among Kurdish women compared to those reported in the previous studies. Designing participation enhancing interventions with a specific focus on older, illiterate and post-menopausal women are recommended.

Breast screening uptake in Polish women in Scotland

We describe the uptake of breast screening in Polish women living in the Lothian region of Scotland 2010-13.This was done by matching Scottish Breast Screening Programme uptake data to Polish and other ethnicity (determined using OnoMAP). We calculated uptake rate in Polish women and compared this with the uptake in all other women. In 2010-13 553 Polish women were invited for screening in Lothian and 258 attended giving an uptake of 46.7% (compared with 70.7% for all other women). Breast screening levels in Polish women are considerably lower than for other women. While other ethnic minorities also have lower uptake, the dynamics and explanations of this may be different for Polish women. This low uptake in Lothian and the reasons for it are likely to be similar throughout the United Kingdom. These reasons, including the potential influence of the breast screening programme in Poland, require further investigation.

A randomised trial of the effect of postal reminders on attendance for breast screening.

Background:Some women make an informed choice not to attend breast screening, whereas others may have forgotten about the appointment. We report on a randomised trial that investigates whether a reminder letter affects attendance.Methods:Women scheduled for a breast screening appointment were randomised to either receive a reminder letter a few days before their breast screening appointment in addition to the standard invitation letter (intervention) or not (control). The primary outcome was attendance within 30 days of the first offered appointment. Secondary outcomes were attendance within 90 and 180 days.Results:In all, 11 383 (49.9%) women were randomised to the intervention and 11 445 (50.1%) to the control. In the intervention arm, 7759 (68.2%) attended within 30 days of the first offered appointment compared with 7349 (64.2%) in the control arm. This difference was significant (P<0.001). The odds ratio (OR) (95% confidence interval) for the primary end point was 1.19 (1.13–1.26). This was not significantly affected by age, socioeconomic status or type of screen (prevalent or incident). Secondary endpoint analyses supported these results. Results did differ, however, between the different centres studied.Conclusions:This study found that postal reminders increase breast screening uptake, and could be practicable to implement in the NHS Breast Screening Programme.

Awareness of breast cancer and barriers to breast screening uptake in Bangladesh: A population based survey

ObjectivesTo investigate the awareness of breast cancer (BCa) and BCa screening amongst women at midlife in Bangladesh. MethodsA nationally representative cross-sectional survey of women aged 30–59 years was conducted in 7 districts of the 7 divisions in Bangladesh, using a multistage cluster sampling technique. The factors associated with the awareness of BCa and breast assessment of asymptomatic women were investigated separately, using multivariable logistic regression. ResultsOf the 1590 participants, mean age 42.3 (±8.0) years, 81.9% had ever heard of BCa and 64.2% of any methods of BCa screening, respectively. Awareness of BCa was associated with being aged 40–49 years (adjusted OR 2.04, 95% CI 1.46–2.84), aged 49–59 years (1.96, 1.32–2.91), being overweight (1.46, 1.07–2.01) and obesity (1.62, 1.01–2.62), while inversely associated with rural dwelling (0.37, 0.22–0.61), primary education (0.44, 0.27–0.70), having no education (0.23, 0.14–0.36) and parity (0.62, 0.44–0.87). Of the 750 women who were aware of clinical breast examination (CBE) or mammography, reasons provided for not undergoing screening included that they had no symptoms (92%) and that they did not know screening was needed (40%). 8% of women reported CBE. Women with no education were less likely to have undergone CBE (0.38, 0.141.04; p=0.059). ConclusionLack of understanding of the assessment of asymptomatic women is the key obstacle to BCa screening uptake in Bangladesh. Health education programs, especially BCa awareness programs, have the potential to increase BCa awareness and down-staging of the disease.

Impact of index of multiple deprivation and ethnicity on breast screening uptake in the North West of England

The aim was to investigate the impact of index of multiple deprivation (IMD) and ethnicity on breast cancer screening uptake in the North West of England.

A population-based study of ethnicity and breast cancer stage at diagnosis in Ontario.

Breast cancer stage at diagnosis is an important predictor of survival. Our goal was to compare breast cancer stage at diagnosis (by American Joint Committee on Cancer criteria) in Chinese and South Asian women with stage at diagnosis in the remaining general population in Ontario. We used the Ontario population-based cancer registry to identify all women diagnosed with breast cancer during 2005-2010, and we applied a validated surname algorithm to identify South Asian and Chinese women. We used logistic regression to compare, for Chinese or South Asian women and for the remaining general population, the frequency of diagnoses at stage ii compared with stage i and stages ii-iv compared with stage i. The registry search identified 1304 Chinese women, 705 South Asian women, and 39,287 women in the remaining general population. The Chinese and South Asian populations were younger than the remaining population (mean: 54, 57, and 61 years respectively). Adjusted for age, South Asian women were more often diagnosed with breast cancer at stage ii than at stage i [odds ratio (or): 1.28; 95% confidence interval (ci): 1.08 to 1.51] or at stages ii-iv than at stage i (or: 1.27; 95% ci: 1.08 to 1.48); Chinese women were less likely to be diagnosed at stage ii than at stage i (or: 0.82; 95% ci: 0.72 to 0.92) or at stages ii-iv than at stage i (or: 0.73; 95% ci: 0.65 to 0.82). Breast cancers were diagnosed at a later stage in South Asian women and at an earlier stage in Chinese women than in the remaining population. A more detailed analysis of ethnocultural factors influencing breast screening uptake, retention, and care-seeking behavior might be needed to help inform and evaluate tailored health promotion activities.

Social disparities in access to breast and cervical cancer screening by women living in Spain

ObjectivesTo describe uptake of breast and cervical cancer screening by women living in Spain, analyse the possible associated social and health factors, and compare uptake rates with those obtained in previous surveys. Study designCross-sectional study using data from the 2011 Spanish national health survey. MethodsUptake of breast cancer screening was analysed by asking women aged 40–69 years whether they had undergone mammography in the previous two years. Uptake of cervical cancer screening was analysed by asking women aged 25–65 years whether they had undergone cervical cytology in the previous three years. Independent variables included sociodemographic characteristics, and variables related to health status and lifestyle. ResultsSeventy-two percent of women had undergone mammography in the previous two years. Having private health insurance increased the probability of breast screening uptake four-fold [odds ratio (OR) 3.96, 95% confidence interval (CI) 2.71–5.79], and being an immigrant was a negative predictor for breast screening uptake. Seventy percent of women had undergone cervical cytology in the previous three years. Higher-educated women were more likely to have undergone cervical cancer screening (OR 2.59, 95% CI 1.97–3.40), and obese women and women living in rural areas were less likely to have undergone cervical cancer screening. There have been no relevant improvements in uptake rates of either breast or cervical cancer screening since 2006. ConclusionUptake of breast and cervical cancer screening could be improved in Spain, and uptake rates have stagnated over recent years. Social disparities have been detected with regard to access to these screening tests, indicating that it is necessary to continue researching and optimizing prevention programmes in order to improve uptake and reduce these disparities.

Text-message reminders increase uptake of routine breast screening appointments: a randomised controlled trial in a hard-to-reach population.

Background:There is a need for interventions to promote uptake of breast screening throughout Europe.Methods:We performed a single-blind randomised controlled trial to test whether text-message reminders were effective. Two thousand two hundred and forty women receiving their first breast screening invitation were included in the study and randomly assigned in a 1 : 1 ratio to receive either a normal invitation only (n=1118) or a normal invitation plus a text-message reminder 48 h before their appointment (n=1122).Findings:In the intention-to-treat analysis, uptake of breast screening was 59.1% among women in the normal invitation group and 64.4% in the text-message reminder group (χ2=6.47, odds ratio (OR): 1.26, 95% confidence intervals (CI): 1.05–1.48, P=0.01). Of the 1122 women assigned to the text-message reminder group, only 456 (41%) had a mobile number recorded by their GP and were thereby sent a text. In the per-protocol analysis, uptake by those in the control group who had a mobile number recorded on the GP system was 59.77% and by those in the intervention group who were sent a reminder 71.7% (χ2=14.12, OR=1.71, 95% CI=1.29–2.26, P<0.01).Interpretation:Sending women a text-message reminder before their first routine breast screening appointment significantly increased attendance. This information can be used to allocate resources efficiently to improve uptake without exacerbating social inequalities.

Uptake of breast screening and associated factors among Hong Kong women aged ≥50 years: a population-based survey

ObjectiveTo examine the uptake of breast screening and its associated factors among Hong Kong Chinese women aged ≥50 years. Study designCross-sectional population-based survey. MethodsA sample of Hong Kong Chinese women was recruited through telephone random-digit dialling. The survey consisted of six sections: perceived health status, use of complementary medicine, uptake of breast screening, perceived susceptibility to cancer, family history of cancer and demographic data. The factors associated with uptake of breast screening were analysed using logistic regression analysis. ResultsIn total, 1002 women completed the (anonymous) telephone survey. The mean age was 63.5 (standard deviation 10.6) years. The uptake rate of breast screening among Hong Kong Chinese women aged ≥50 years was 34%. The primary reasons for undertaking breast screening were as part of a regular medical check-up (74%), prompted by local signs and symptoms (11%) and a physician's recommendation (7%). Higher educational level, married or cohabiting, family history of cancer, frequent use of complementary therapies, regular visits to a doctor or Chinese herbalist, and the recommendation of a health professional were all independently and significantly associated with increased odds of having had a mammogram. ConclusionsThis study provides community-based evidence of the need for public health policy to promote broader use of mammography services among this target population, with emphasis on the active involvement of health care professionals, through the development and implementation of appropriate evidence-based and resource-sensitive strategies.

Are text message reminders an effective intervention to improve uptake of breast screening? A randomised controlled trial

BackgroundBreast cancer is a major public health concern in the UK, one accounting for 16% of all cancer incidences and 7% of all cancer deaths. Fortunately, the natural history of this malignancy can be beneficially changed through the early detection and treatment of benign and malignant breast disease, which have been enabled by mammographic screening techniques. However, the success of screening programmes depends on their ability to attract the at-risk population, as well as the analytical specificity and sensitivity of the screening test itself. The NHS Breast Screening Programme attracts about three-quarters of the invited population each year. In 2010, all but one region reported a triennial coverage of more than 75%; London was the exception, reporting a regional coverage of 69%. London consistently fails to meet the national target. Missed appointments are a primary cause of inefficiency in health-care delivery, with adverse clinical implications for the non-attending patient and substantial monetary costs to the health service. To ensure the future success of the breast screening programme, development of strategies to improve uptake of hard-to-reach patients is imperative. Research has shown that receiving an appointment reminder by text message has been successful in reducing non-attendance in other areas of health care; the same might be true for breast screening. Our primary aim was to establish whether text message reminders can significantly improve the uptake of breast screening by women on an intention-to-treat basis in the London Borough of Hillingdon. Our secondary aim was to assess whether text message reminders are an effective intervention for improvement of uptake of breast screening by hard-to-reach patients such as women living in deprived areas and women of black and minority ethnic groups. MethodsWe undertook a single-blind, randomised controlled trial to assess the effectiveness of sending a text message appointment reminder 48 h before a patient's first breast screening appointment to improve uptake of the programme by prevalent women aged 47–53 years in the London Borough of Hillingdon. 1640 women without a history of breast screening, implant, or bilateral mastectomy were included in the study and randomly assigned (1:1) to either the control (n=833) or intervention (n=807) group. Women in the control group were invited to screening but received no reminder for their appointment, whereas women in the intervention group received a text message reminder 48 h in advance. All women received an information letter about the study with their invitation from the West of London Breast Screening Service. Patients were not told whether they would be receiving a text message reminder or not. iPlato Patient Care Messaging was used to deliver text message reminders. This trial is registered with ClinicalTrials.gov, NCT01977599. FindingsWomen in the text message reminder group were significantly more likely (odds ratio 1·32, 95% CI 1·12–1·53; p=0·0092) to attend their first breast screening appointment (69% uptake) than women in the control group (63% uptake). Of the 807 women assigned to the text message reminder group, only 316 (39%) had a valid mobile telephone number recorded on the GP Clinical System and were subsequently able to receive a text message reminder. Of the 316 patients who did receive a text message reminder, 252 (80%) attended breast screening. No adverse events were reported. These are preliminary data of an ongoing trial expected to be completed in September, 2013. Full results including deprivation and ethnic origin data will be available for the conference. InterpretationReceipt of a text message reminder 48 h before a scheduled breast screening appointment significantly improves uptake. To ensure that the benefits of text message reminders are achieved, work is needed to improve patient mobile records. FundingResearch funded by Imperial College Healthcare Charity.

How can realist synthesis methods contribute to building the evidence base for action on ethnic health inequalities? A narrative assessment

BackgroundEthnic health inequalities have long been recorded in Britain. Although socioeconomic deprivation and discrimination are important underlying factors, differential benefit from public health and health-care interventions contribute to these inequalities. Progress is hampered by a scarcity of evidence on what works, creating uncertainty about how to design and deliver interventions so as to mitigate disadvantage. Understanding the links between ethnicity, health care, and health presents substantial challenges in ethnic categorisation, comparability across diversity, elucidating causal pathways, and dangers of stereotyping and stigmatisation. Furthermore, sociologically driven research examining links between ethnicity and health remains largely descriptive. Therefore, that standard systematic reviews and national guidance generally produce limited recommendations for intervention in this area is not surprising. We need more sophisticated and critical approaches to evidence synthesis. We examine the potential of realist synthesis, a theory-driven approach to reviewing research evidence on complex social interventions that aims to show why and under what conditions particular interventions do or do not work. The approach is flexible and iterative, seeking to explicate underlying interventional theories and operational contexts, and often engaging policy or practice decision makers in the process. Such syntheses thereby produce theoretical claims alongside summaries of empirical evidence. MethodsWe undertook a narrative assessment of selected existing studies that used realist synthesis. Starting with a synthesis we had done previously on interventions to enhance minority ethnic women's breast-screening uptake, plus the wider literature on research practice in ethnicity and health, we developed a thematic framework, identifying potential strengths and weaknesses of the approach conceptually and operationally. We then undertook a pragmatic search to identify at least four studies that addressed ethnicity and health and used realist synthesis. The intention was not to be exhaustive, but to include sufficient studies to identify important common issues. The thematic framework loosely guided our exploration of how the realist synthesis performed across the studies and identified strengths and weaknesses. FindingsHow the realist synthesis approach was used across studies varied, in part suggesting different interpretations of the method itself, but also showing pragmatic decisions in the face of available material. In particular, researchers sometimes struggled to elucidate underlying interventional theories and found disappointing detail on context in many studies. Nevertheless, the approach had important potential benefits. For instance, the process of unpacking interventions to understand their logic meant that taken-for-granted understandings of the causes of ethnic inequality were explicitly examined. Similarly, the focus on identifying mechanisms usefully diverted attention away from fixed ethnic categories (and worries about their comparability) towards more general processes of exclusion and inclusion. The method's explicit consideration of context was helpful in overcoming the tendency to view the contingent nature of ethnic identity as an obstacle to synthesis. Also, more generally, the inclusion of diverse published work to identify and confirm emerging theory produced richer or unanticipated findings, or both. The resulting insights thereby had the potential to shift policy and practice intended to reduce inequalities in useful new directions. InterpretationRealist synthesis holds promise for improvement of the evidence base informing action on ethnic health inequalities. The pros and cons identified deserve attention by researchers undertaking syntheses or primary research, as well as by policy makers and practitioners who seek evidence to inform interventional strategies. Our findings are based on limited experience and, as further realist syntheses appear, revisiting and comparing these methods with others that are in development in this area, such as qualitative meta-synthesis, will be useful. FundingSS is a Senior Research Fellow funded by the NIHR School for Public Health Research.

Inequalities in uptake of breast cancer screening in Spain: analysis of a cross-sectional national survey

Breast cancer remains a public health problem worldwide. Early detection through mammography practice has been shown to be effective in improving survival among women. Nevertheless, it is necessary to have high participation in mammography screening to achieve that goal. The aim of this study is to estimate the adherence to recommended preventive practices for breast cancer (mammography) in Spain and to identify predictors of uptake according to sociodemographic variables, health related variables and lifestyles. This is a descriptive cross-sectional study based on data from the European Health Interview Survey for Spain. Breast cancer screening included self-reported mammography in the last two years. The age target range was 40-69 years (n = 5771). The following independent variables were analysed: sociodemographic (marital status, educational level, monthly income, and nationality), visit to a general practitioner, chronic conditions and lifestyles. Predictors of mammography adherence were explored using multivariate logistic regression. The screening coverage in the target population was 67.7% (95% CI: 66.2-69.1). Mammography uptake was positively associated with being married, higher educational and income levels, Spanish nationality, having visited a general practitioner in the previous four weeks and suffering from musculoskeletal disease. Otherwise, the youngest age group studied (40-49 years) and obesity was associated with lower adherence to mammography. Compliance with mammography practice in Spain is acceptable to achieve the goal of reducing mortality from breast cancer among women. However significant inequalities in uptake of breast screening in Spain were found. Future campaigns must aim to improve participation especially among women with disadvantaged socio-economic situations and immigrants.

Creating awareness and facilitating cervical and breast cancer screening uptake through the use of a Community Health Worker: a pilot intervention study

In South Africa, cervical cancer is the most common female cancer followed by breast cancer. Despite the high incidence of these cancers, population-based screening is limited to cervical screening available at primary health clinics. Cervical screening uptake is, however, low. In 2009 a new cancer prevention initiative was launched in a specific resource poor community in Tshwane, South Africa. The low cervical screening uptake as well as a potentially low breast screening uptake could have resulted in the failure of this initiative. The purpose of the study was to develop and pilot test an intervention to address this risk. A Community Health Worker was trained and tasked to raise awareness of cervical and breast cancer and motivate women to take up screening. The intervention was assessed in terms of three outcomes: screening uptake, awareness and the value of the Community Health Worker. Despite the fact that the Community Health Worker's role was valued, screening uptake was disappointing and the level of awareness remained low. Unfortunately this intervention failed and once again we are left with the challenge of improving screening uptake.