Inequalities In Cervical Cancer Screening Research Articles

Coverage and Socioeconomic Inequalities in Cervical Cancer Screening in Low- and Middle-Income Countries Between 2010 and 2019.

Cervical cancer screening is vital in addressing the global burden of cervical cancer. In this study, we describe the coverage and socioeconomic inequalities in the coverage of cervical cancer screening in low- and middle-income countries (LMICs). We analyzed data from the women's recode files of the Demographic and Health Surveys conducted in LMICs from 2010 to 2019 with variables on cervical cancer screening. We included women 21 years or older and determined the proportion of women who were screened for cervical cancer by age categories, wealth quintile, type of place of residence, level of education, and marital status. Socioeconomic inequality was measured using the concentration index (CIX) and the slope index of inequality (SII). A total of 269,506 women from 20 surveys in 16 countries were included in the survey. Generally, there was a low coverage of screening, with lower rates among women age 21-24 years, living in rural areas, in the poorest wealth quintile, with no formal education, and who have never been in union with or lived with a man. The CIX and SII values for screening for cervical cancer were positive (pro-rich) for all the countries except Tajikistan in 2012 where they were negative (pro-poor). The coverage of cervical cancer screening was low in LMICs with variations by the quintile of wealth (pro-rich) and type of place of residence (pro-urban). To achieve the desired impact of cervical cancer screening services in LMICs, the coverage of cervical cancer screening programs must include women irrespective of the type of place and wealth quintiles.

Intersecting Upstream Factors: Inequities in Cervical Cancer Screening in Malawi

Sub-Saharan African countries like Malawi have been experiencing a rapid increase in cervical cancer incidence and mortality. Cervical cancer screening services are essential for reducing cancer incidence and associated fatalities. Previous attempts to understand the determinants of cervical cancer testing have predominantly focused on the independent influence of residence and socioeconomic status on the utilization of screening services. This has limited our understanding of intersectional sources of inequities in healthcare usage. Guided by an intersectionality framework, we used data from the 2015 to 2016 Malawi Population-Based HIV Impact Assessment Project (n = 11,313) to examine the intersecting effects of women’s residence and socioeconomic status on cervical cancer screening tests. We found residential and socioeconomic inequalities in cervical cancer screening in Malawi. Respondents’ levels of education and household wealth had a statistically significant effect on the use of both lifetime and past-3-years cervical cancer screens. Further results showed a significantly greater influence of household wealth among rural than among urban Malawian women in both lifetime and past-3-years cervical cancer screens. Conversely, a significantly lower influence of education in rural compared to urban areas in lifetime cervical cancer screening was observed. Our study highlights the need to consider the residential context’s role in modifying socioeconomic inequalities in cervical cancer screening among women. Such structural considerations are necessary to increase cervical cancer screening and health and well-being among women in the global south.

Racial/ethnic inequalities in cervical cancer screening in the United States: An outcome reclassification to better inform interventions and benchmarks

In the United states (U.S.), prevailing understanding suggests significant racial/ethnic inequalities in cervical cancer screening exist. However, recent findings elsewhere in North America indicate the magnitude of these inequalities depend on the way screening is defined: lifetime screening versus up-to-date screening. As those who have never been screened are most at risk for invasive cancer, an improved understanding of inequalities in this outcome is necessary to better inform interventions.To describe racial/ethnic inequalities in 1) never screening and 2) not being up-to-date with screening among women who have been screened at least once in their lifetime, three years (2014–2016) of the U.S. Behavioral Risk Factor Surveillance Survey were utilized to estimate cervical cancer screening prevalence ratios via Poisson regression (N = 123,070). The sample was limited to women age 21 to 65 years.Women from racial/ethnic minority groups were more likely to never have been screened in comparison to White women, particularly women of Asian descent (Prevalence Ratio (PR) = 3.8, 95% CI = 3.3–4.3). However, among women who had been screened at least once in their lifetime, an inverse association was observed between being a member of a racial/ethnic minority group and not being up-to-date with screening (e.g. PRasian vs white = 0.7, 95% CI = 0.6–0.9).Physicians and public health institutions concerned with monitoring racial/ethnic inequalities should consider adding lifetime screening as a primary benchmark, as this outcome implies different intervention targets to address inequalities and the differential burden of cervical cancer.

Acceptability of human papillomavirus (HPV) self-sampling among never- and under-screened Indigenous and other minority women: a randomised three-arm community trial in Aotearoa New Zealand.

BackgroundInternationally, self-sampling for human papillomavirus (HPV) has been shown to increase participation in cervical-cancer screening. In Aotearoa New Zealand, there are long-standing ethnic inequalities in cervical-cancer screening, incidence, and mortality, particularly for indigenous Māori women, as well as Pacific and Asian women.MethodsWe invited never- and markedly under-screened (≥5 years overdue) 30-69-year-old Māori, Pacific, and Asian women to participate in an open-label, three-arm, community-based, randomised controlled trial, with a nested sub-study. We aimed to assess whether two specific invitation methods for self-sampling improved screening participation over usual care among the least medically served populations. Women were individually randomised 3:3:1 to: clinic-based self-sampling (CLINIC – invited to take a self-sample at their usual general practice); home-based self-sampling (HOME – mailed a kit and invited to take a self-sample at home); and usual care (USUAL – invited to attend a clinic for collection of a standard cytology sample). Neither participants nor research staff could be blinded to the intervention. In a subset of general practices, women who did not participate within three months of invitation were opportunistically invited to take a self-sample, either next time they attended a clinic or by mail.FindingsWe randomised 3,553 women: 1,574 to CLINIC, 1,467 to HOME, and 512 to USUAL. Participation was highest in HOME (14.6% among Māori, 8.8% among Pacific, and 18.5% among Asian) with CLINIC (7.0%, 5.3% and 6.9%, respectively) and USUAL (2.0%, 1.7% and 4.5%, respectively) being lower. In fully adjusted models, participation was statistically significantly more likely in HOME than USUAL: Māori OR=9.7, (95%CI 3.0-31.5); Pacific OR=6.0 (1.8-19.5); and Asian OR=5.1 (2.4-10.9). There were no adverse outcomes reported. After three months, 2,780 non-responding women were invited to participate in a non-randomised, opportunistic, follow-on substudy. After 6 months,192 (6.9%) additional women had taken a self-sample.InterpretationUsing recruitment methods that mimic usual practice, we provide critical evidence that self-sampling increases screening among the groups of women (never and under-screened) who experience the most barriers in Aotearoa New Zealand, although the absolute level of participation through this population approach was modest. Follow-up for most women was routine but a small proportion required intensive support.Trial registrationANZCTR Identifier: ACTRN12618000367246 (date registered 12/3/2018) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371741&isReview=true; UTN: U1111-1189-0531FundingHealth Research Council of New Zealand (HRC 16/405)Protocolhttp://publichealth.massey.ac.nz/assets/Uploads/Study-protocol-V2.1Self-sampling-for-HPV-screening-a-community-trial.pdf

Socioeconomic inequalities in women\u2019s access to health care: has Ecuadorian health reform been successful?

BackgroundOver the last 12 years, Ecuador has implemented comprehensive health sector reform to ensure equitable access to health care services according to need. While there have been important achievements in terms of health care coverage, the effects of these reforms on socioeconomic inequalities in health care have not been analysed. The present study assesses whether the health care reforms implemented in the decade between 2007 and 2017 have contributed to reducing the socioeconomic inequalities in women’s health care access.MethodsThe present study was based on two waves (2006 and 2014) of the Living Standards Measurement Survey conducted in Ecuador. Data from women of reproductive age (15 to 49 years) were analysed to evaluate health care coverage across three indicators: skilled birth attendance, cervical cancer screening, and the use of modern contraceptives. Absolute risk differences were calculated between the heath care indicators and the socioeconomic variables using binomial regression analysis for each time period. The Slope Index of Inequality (SII) was also calculated for each socioeconomic variable and period. A multiplicative interaction term between the socioeconomic variables and period was included to assess the changes in socioeconomic inequalities in health care over time.ResultsAccess to health care increased in the three studied outcomes during the health sector reform. Significant reductions in inequality in skilled birth attendance were observed in all socioeconomic variables except in the occupational class. Cervical cancer screening inequalities increased according to education and occupation, but decreased by wealth. Only a poorer education was observed for modern contraceptive use.ConclusionsWhile most socioeconomic inequalities in skilled birth attendance decreased during the reform period, this was not the case for inequalities in cervical cancer screening or the use of modern contraceptives. Further studies are needed to address the social determinants of these health inequalities.

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

BackgroundResearch on inequalities in cervical cancer screening (CCS) participation has overlooked the distinction between ‘never-’ and ‘under-screeners’ while different socioeconomic and demographic determinants may underlie ‘non-’ and ‘under-’ screening participation. This study examines socioeconomic and demographic inequalities in never and under CCS participation. We compare cross-national prevalence and trends among these two groups in Switzerland and Belgium, two countries with similar opportunistic CCS strategy but different healthcare systems.MethodsData on 38,806 women aged 20–70 from the Swiss Health Interview Survey (1992–2012) and 19,019 women aged 25–64 from the Belgian Health Interview Survey (1997–2013), both population-based cross-sectional nationally representative surveys, was analysed. Weighted adjusted prevalence ratios were estimated with multivariate Poisson regressions.ResultsOver the studied period, never screening prevalence was about 15% in both Switzerland and Belgium and under screening prevalence about 14.0%. Socioeconomic gradients were found among both never- and under-screeners. Higher income women had lower never and under screening prevalence in Switzerland and a similar gradient in education was observed in Belgium. Importantly, distinct socioeconomic and demographic determinants were found to underlie never and under screening participation. Never screening was significantly higher among foreign nationals in both countries and this association was not observed in under screening. Never screening prevalence was lower among older age groups, while under screening increased with older age. Over time, age inequalities diminished among never- and under- screeners in Switzerland while educational inequalities increased among never-screeners in Belgium.ConclusionFindings revealed that determinants of screening inequalities differed among never- and under-screeners and hence these should be addressed with different public health strategies. Crucially, socioeconomic and demographic inequalities were more pronounced among never-screeners who appeared to face more structural and persistent inequalities. Differences between the two countries should also be noted. The more liberal-type Swiss healthcare systems appeared to shape income-related screening inequalities, while education appeared to be a stronger determinant of never- and under-screening in Belgium.

Social inequalities in cervical cancer screening: a discrete choice experiment among French general practitioners and gynaecologists

BackgroundCervical cancer screening is effective in reducing mortality due to uterine cervical cancer (UCC). However, inequalities in participation in UCC screening exist, especially according to age and social status. Considering the current situation in France regarding the ongoing organized UCC screening campaign, we aimed to assess general practitioners’ (GPs) and gynaecologists’ preferences for actions designed to reduce screening inequalities.MethodsFrench physicians’ preferences to UCC screening modalities was assessed using a discrete choice experiment. A national cross-sectional questionnaire was sent between September and October 2014 to 500 randomly selected physicians, and numerically to all targeted physicians working in the French region Midi-Pyrénées. Practitioners were offered 11 binary choices of organized screening scenarios in order to reduce inequalities in UCC screening participation. Each scenario was based on five attributes corresponding to five ways to enhance participation in UCC screening while reducing screening inequalities.ResultsAmong the 123 respondents included, practitioners voted for additional interventions targeting non-screened women overall (p < 0.05), including centralized invitations sent from a central authority and involving the mentioned attending physician, or providing attending physicians with the lists of unscreened women among their patients. However, they rejected the specific targeting of women over 50 years old (p < 0.01) or living in deprived areas (p < 0.05). Only GPs were in favour of allowing nurses to perform Pap smears, but both GPs and gynaecologists rejected self-collected oncogenic papillomavirus testing.ConclusionsFrench practitioners tended to value the traditional principle of universalism. As well as rejecting self-collected oncogenic papillomavirus testing, their reluctance to support the principle of proportionate universalism relying on additional interventions addressing differences in socioeconomic status needs further evaluation. As these two concepts have already been recommended as secondary development leads for the French national organized screening campaign currently being implemented, the adherence of practitioners and the adaptation of these concepts are necessary conditions for reducing inequalities in health care.

Changes in income-related inequalities in cervical cancer screening during the Spanish economic crisis: a decomposition analysis

BackgroundCervical cancer is one of the most prevalent cancers, but it may be prevented by early detection. Social inequalities in the use of cytology testing have been identified in the literature. However, the degree of income-related inequality has not been quantified and determinants of inequality changes during the economic crisis remain unknown.MethodsUsing the Spanish National Health Surveys (2006–07 / 2011–12), we analyzed how income-related inequalities in the use of cervical cancer screening for women aged 25–64 changed across the economic crisis. We used corrected concentration indices (CCI) which were further decomposed in order to compute the contribution of the explanatory variables. An Oaxaca-type approach was employed to investigate the origin of changes over time.ResultsOur final sample consisted of 10,743 observations in 2006–07 and 6587 in 2011–12. Despite the higher prevalence of screening over time (from 73.9 to 77.9%), pro-rich inequality significantly increased (from CCI = 0.1726 to CCI = 0.1880, p < 0.001). Income was the main determinant of inequality in cervical screening, although its contribution decreased over time, as well as the contribution of the type of health insurance, mainly due to changes in elasticity. Other factors, such as nationality or the educational level, seem to have played an important role in the increase of pro-rich inequality of cytology testing.ConclusionsReducing cervical screening inequalities would require actions focused on most vulnerable groups such as migrants, low income and low educated population. The implementation of population-based screening programs would also help to cope with income-related inequalities in cytology testing.

The impact of regional screening policies on the diffusion of cancer screening participation in Belgium: time trends in educational inequalities in Flanders and Wallonia

BackgroundWe investigate whether the extent of educational inequalities in the use of Pap smears (cervical cancer screening) and mammograms (breast cancer screening) in Belgium has changed over time in accordance with the pattern predicted by diffusion of innovation theory, as well as how the regional cancer screening policies of Flanders and Wallonia influence this pattern.MethodsData were obtained from five successive cross-sectional waves (1997–2001–2004-2008-2013) of the Belgian Health Interview Survey. Final sample sizes consisted of 8988 women aged 25–64 years for cervical cancer screening and 4194 women aged 50–69 years for breast cancer screening. We calculated absolute and relative measures of inequality, more specifically, the slope index of inequality (SII) and the relative index of inequality (RII), and their development over time.ResultsIn both Flanders and Wallonia, mammogram use increased greatly between 1997 and 2013, while Pap smear use has remained quite stable over time. Educational inequalities in cervical-cancer screening have been largely persistent over time in both regions. In contrast, educational inequalities in breast cancer screening fluctuated more between 1997 and 2013. Between 1997 and 2001, when the breast cancer screening programme was implemented in Flanders, RII reduced significantly by 45%. Inequality measures did not change significantly in Wallonia, where it is known that most women are screened opportunistically outside the programme.ConclusionsBy focussing on Belgium, this study demonstrates that regional variations in the support of a national screening programme can result in regional variations in the pattern of diffusion for cancer screening, as well as to the development of inequalities in cancer screening participation. Moreover, the findings demonstrate that high visibility and awareness of the screening programme, as was more the case in Flanders than it was in Wallonia, are required in order to reduce or eliminate educational inequalities in cancer screening participation over time. General practitioners and gynaecologists can play a decisive role in this regard.

The next Sub Saharan African epidemic? A case study of the determinants of cervical cancer knowledge and screening in Kenya

Early cervical cancer screening has been shown to be beneficial in reducing cervical cancer related deaths. Despite the benefits of early cervical cancer screening, uptake remains limited, with wide disparities in access and uptake in most developing countries. As part of a larger study, this paper uses a socio-ecological framework to explain the determinants of cervical cancer knowledge and screening among women of reproductive age (15–49 years) in Kenya. We conducted a multilevel analysis of cervical cancer knowledge (n = 11,138) and screening (n = 10,333) using the 2014 Kenya Demographic and Health Survey (KDHS). Results show regional disparities in cancer knowledge and the utilization of cervical cancer screening services; regions with high wealth inequality (OR = 0.70, 95% CI [0.56–0.87]) emerged as vulnerable regions where women were less likely to screen for cervical cancer. Gender equity, health insurance coverage and education level significantly predicted cervical cancer screening rates. Results further revealed regional as well as rural-urban wealth inequalities in cervical cancer screening. We argue that given that Kenyan women are highly exposed to human papilloma virus (HPV) due to the legacy of human immunodeficiency virus (HIV) in the country, cervical cancer may be the next epidemic if integrated measures are not adopted to increase cervical cancer knowledge and overcome the barriers to utilizing early screening services. The paper concludes with policy recommendations and directions for future research.

Cervical cancer screening in Switzerland: cross-sectional trends (1992-2012) in social inequalities.

Background: Incidence and mortality of cervical cancer declined thanks to Pap smear screening. However cervical cancer screening (CCS) inequalities are documented, including in high income countries. This population-based study aims to assess the importance and 20-year trends of CCS inequalities in Switzerland, where healthcare costs and medical coverage are among the highest in the world. Methods: We analyzed data from five waves of the population-based Swiss Health Interview Survey (SHIS) covering the period 1992–2012. Multivariable Poisson regression were used to estimate weighted prevalence ratios (PR) of CCS and 95% Confidence Intervals (CI) adjusting for socio-economic, socio-demographic characteristics, family status, health status, and use of healthcare. Results: The study included 32’651 women aged between 20 and 70 years old. Between 1992 and 2012, rates of CCS over the past 3 years fluctuated between 71.7 and 79.6% (adjusted P < 0.001). Lower CCS was observed among women with low education, low income, those having limited emotional support, who were non-Swiss, single, older, living in non-metropolitan area or in the French-speaking region, overweight. Over the analyzed period, differences in CCS across age groups diminished while rates among women who visited a GP over the previous year, versus those who did not, increased. Conclusions: While important changes occurred in screening recommendations and in social circumstances of the targeted population, CCS rates remained fairly stable in Switzerland between 1992 and 2012. At the same time, inequalities in CCS persisted over that period.

Inequalities in cervical cancer screening for women with or without a regular consulting in primary care for gynaecological health, in Paris, France

ObjectivesTo describe the individual characteristics associated with the absence of cervical smear (CCST); to investigate the role of residential neighbourhood, particularly practitioner density; and to explore changes in individual and contextual determinants after taking regular consulting in primary care for gynaecological health (RCGH) into account. MethodsData: 1843 adult women from the SIRS survey conducted in 2005 in the Paris metropolitan area. Multilevel logistic regressions analysed factors associated with never-screening. Results10% of the women had never undergone CCST. Being single, less educated, of foreign origin, with no children, and without health insurance, having never worked, having never undergone a serious health problem and/or having nobody in their circle with cancer were associated with no CCST. Once adjusted on individual characteristics, living in a middle- (OR=1.95; IC=1.05–3.62) or in a lower-class neighbourhood (OR=2.31; IC=1.26–4.25) was associated with increased risks of never-screening, but neighbourhood physician density was not. Interactions were found between socioeconomic status and RCGH. Individual- and neighbourhood-level associations with CCST were different for women with or without an RCGH. ConclusionThis study analysed individual and contextual inequalities in CCST practice in the Paris metropolitan area. To benefit from an RCGH did not seem to reduce all the social inequalities in CCST practice.

Do social inequalities in cervical cancer screening persist among patients who use primary care? The Paris Prevention in General Practice survey

Objective Social inequalities in cervical cancer screening may be related to either lack of access to care or inadequate delivery of preventive care by providers. We sought to characterize social inequalities among women consulting general practitioners with a wide range of social position indicators. Methods In 2005–06, 59 randomly recruited general practitioners from the Paris metropolitan area enrolled every woman aged 50–69 years seen during a two-week period. Cervical cancer screening status (overdue if the last cervical cancer screening had been more than 3 years earlier) was analyzed for 858 women in a logistic mixed model that considered: occupational class (in 5 levels, based on last occupation), education, income, characteristics related to family, housing, neighborhood, household wealth (social allocations, perceived financial difficulties in 4 levels, income tax), employment status, supplementary health insurance, and social network (4 levels). Results The rate of overdue patients did not vary between general practitioners (21%). social position indicators associated with overdue status (odds ratio between 2 adjacent decreasing social levels) were occupational class (1.20, 95% CI: 1.03–1.41), social network (1.52, 95% CI: 1.18–1.94), financial difficulties (1.42, 95% CI: 1.07–1.88), neighborhood safety (2.15, 95% CI: 1.10–4.20), and allocations (3.34, 95% CI: 1.12–9.96). Conclusions Even among women visiting general practitioners we observed marked social inequalities that persist above and beyond occupational class.

Inequalities in cervical cancer screening in Eastern Europe: perspectives from Bulgaria and Romania

The incidence of cervical cancer in Eastern Europe has been on the rise, in contrast to the reduction in incidence in most countries of Western Europe. The objectives of the paper are to delineate the inequalities in cervical cancer screening in Romania and Bulgaria and identify explanations for these inequalities. Representative samples of women - 1,099 in Bulgaria and 1,053 in Romania, were interviewed through a structured questionnaire. We found multiple dimensions of inequalities in cervical cancer prevalence and prevention, including disparities in comparison to other countries, disparities due to socioeconomic status, education, residency and ethnicity, as well as differential barriers faced by women in access to screening and in relationships with providers. We identified mediators of the effects of socio-economic status on screening history. The study concludes that the effect of SES on screening is mediated mainly by the structural barriers in accessing the healthcare system, as well as women's perceptions of the multiple costs of the smear. These conclusions are relevant to the development of national screening programs and health promotion in the two countries.