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Socioeconomic disparities in the uptake of breast and cervical cancer screening in Italy: a cross sectional study

  • Gianfranco Damiani1Email author,
  • Bruno Federico2,
  • Danila Basso1,
  • Alessandra Ronconi1,
  • Caterina Bianca Neve Aurora Bianchi1,
  • Gian Marco Anzellotti1,
  • Gabriella Nasi1,
  • Franco Sassi3 and
  • Walter Ricciardi1
BMC Public Health201212:99

DOI: 10.1186/1471-2458-12-99

Received: 1 July 2011

Accepted: 3 February 2012

Published: 3 February 2012

Abstract

Background

Breast and cervical cancer screening are widely recognized as effective preventive procedures in reducing cancer mortality. The aim of this study was to evaluate the impact of socioeconomic disparities in the uptake of female screening in Italy, with a specific focus on different types of screening programs.

Methods

A cross-sectional study was conducted using data from the 2004-2005 national health interview survey. A sample of 15, 486 women aged 50-69 years for mammography and one of 35, 349 women aged 25-64 years for Pap smear were analysed. Logistic regression models were used to estimate the association between socioeconomic factors and female screening utilization.

Results

Education and occupation were positively associated with attendance to both screening. Women with higher levels of education were more likely to have a mammogram than those with a lower level (OR = 1.28; 95% CI = 1.10-1.49). Women of intermediate and high occupational classes were more likely to use breast cancer screening (OR = 1.77; 95% CI = 1.55-2.03, OR = 1.63; 95% CI = 1.40-1.91) compared to unemployed women. Women in the highest occupational class had a higher likelihood of cervical cancer screening compared to those in the lowest class (OR = 1.81; 95% CI = 1.63-2.01). Among women who attended screening, those with lower levels of education and lower occupational classes were more likely than more advantaged women to attend organized screening programs rather than being screened on the basis of their own initiative.

Conclusions

Inequalities in the uptake of female screening widely exist in Italy. Organized screening programs may have an important role in increasing screening attendance and tackling inequalities.

Background

Breast and cervical cancer have both high morbidity and mortality rates in Italy. In 2006, 36, 634 new cases of breast cancer were diagnosed and 11, 476 deaths were registered. In the same year 3, 418 new cases of cervical carcinoma were diagnosed, whereas 351 deaths due to cervical cancer and 2, 404 deaths due to cancer of the uterus not otherwise specified were recorded [1]. This disease burden can be reduced if cases are detected and treated early. Education helps people recognize early signs of cancer and seek prompt medical attention for symptoms, while screening programs, which include mammography for breast cancer, and Pap smear for cervical cancer, allow the early identification of cancer or pre-cancer before signs are recognizable [2].

Screening for breast and cervical cancer are strongly related with a reduction in cancer mortality [3]. Evidence-Based screening plans and European guidelines recommend a mammography every 2 years for women aged 50-69 and Pap test every 3 years for women aged 25-64 [46].

In Italy, in accordance to the National Health Plan, a National Plan for Prevention was developed to promote women's cancer screening. Cervical and breast cancer screening programs, promoted since the 90s, are developed at a regional level and offered free of charge to women of target age groups (25-64 for cervical cancer and 50-69 for breast cancer). Although participation rates generally increased in recent years, they were substantially lower than those recommended by international guidelines. In 2008, participation in organized screening programs was 40% and 55% for cervical cancer and breast cancer, respectively [6]. These figures are substantially lower than those set by the European guidelines of 85% and 70%, respectively [7].

Socioeconomic factors were shown to be strongly related to the use of preventive services [811]. Disparities in the utilization of female screening were widely identified [1113]. Comparative studies on the use of preventive services in Europe showed inequalities in the participation to screening programs, although the size of the inequality varied among countries [14, 15]. Women with lower health literacy are less likely to carry out routine cancer screening [16, 17]. Ethnic minority, old age and low socioeconomic status are all accompanied by a low chance of undergoing cancer screening procedures [18].

In the US characteristics associated with lower rates of Pap test use included low family income and low educational attainment [19]; income and educational level were positively associated with mammography practice in a French population-based study [20].

Recent Italian studies generally focused on the effectiveness of screening programs [21, 22]. Other Italian studies reported significant regional and educational inequalities [17, 23].

This study aims to assess the association between socioeconomic status and the use of female cancer screening. A further objective was to evaluate whether socioeconomic factors are associated with adherence to organised screening programs versus opportunistic ones.

Methods

A cross-sectional study was conducted using data from the National Survey on "Health conditions and health care services use", a five-yearly nationwide survey conducted by the Italian National Centre for Statistics (Istat) in December 2004-March 2005. Data were provided in an anonymised electronic dataset which is publicly available at Istat website [24]. Information was collected through face to face interviews and self-administered questionnaires. This analysis focused on women without self-reported history of cancer.

According to cancer screening guidelines the analysis was conducted on a subgroup of women aged 25-64 years for Pap smear and on a subgroup of women aged 50-69 years for mammography.

The survey contained the following questions: "Have you ever had a mammography/Pap test without having symptoms?"; "In case you had at least one mammography/Pap test, did you have other tests afterwards?"; "In case you had at least one mammography/Pap test, how often did you have the following tests afterwards?".

The frequency of screening practices was considered "appropriate" if women reported having a mammogram every 2 years and a Pap test every 3 years according to European guidelines [5, 6]. For women aged 50-53 we considered as regular prevention having only one mammography, whereas for women aged 25-29 we considered as regular prevention having only one Pap test. With regards to the comparison between organized and opportunistic screening, we defined a dichotomous variable as whether or not a women reported having had Pap test or mammogram on invite of National Health Program at the most recent screening. This second analysis was performed on the subset of women who reported having an appropriate frequency of screening.

Demographic variables, such as age (from 50 to 69 for breast cancer screening and from 25 to 64 for cervical cancer screening), region of residence and marital status were considered as independent variables. Other independent variables considered were Body Mass Index (BMI), smoking status and self-assessed health status, because they were all found to be correlated to the use of female screening [25, 26].

Educational level (primary school or less, secondary school, and high school and over) and occupational class (with the categories high, intermediate, low and non-working) were used as indicators of socioeconomic status. The non-working category included students, those unable to work, those in search of occupation, retired and housewives. In the breast cancer sample housewives were 86.5% of the "non-working" category, while in the cervical cancer sample they were 70.8% of the same category. Occupational class was classified according to the UK National Statistics Socio-economic Classification (NS-SEC) [27]. NS-SEC class was derived using the full derivation method based on the 1990 Standard Operational Classification (SOC) codes combining data on occupation and employment status (whether an employer, self-employed or employee; whether a supervisor, manager).

Descriptive statistics were used to describe the study population. Separate multivariate logistic regression models were developed to examine the relationship between all explanatory variables and the outcomes of interest. For each final model, adjusted odds ratios (OR) and their 95% confidence intervals (CI) were calculated. Sampling weights in all analyses were used, in order to reflect the multistage sampling design of the survey.

Results

Breast cancer screening

Table 1 describes the characteristics of the sample (N = 15, 486). About 43.4% of women lived in Northern Italy and 11, 310 women (73.0%) were married. About 50% of the sample reported a "fair" health status and only 8.5% a "bad" or "very bad" status. Approximately half had less than secondary school education and 38.2% was in the low occupational class. Women who underwent routine breast cancer screening were 47.0% of the sample. Table 2 shows prevalence rates of having regular screening by sample characteristics. Women with the highest level of education attended more frequently breast cancer screening than women with the lowest educational level (57.0% vs. 40.5%). There was a strong positive association between occupational class and attendance to breast cancer screening.
Table 1

Characteristics of the sample*

 

Breast cancer screening

Cervical cancer screening

 

(N = 15, 486)

(N = 35, 349)

 

N

Proportion (%)

N

Proportion (%)

Age groups

    

25-34

  

8746

24.7

35-44

  

10201

28.9

45-54

  

8677

24.5

55-64

  

7725

21.9

50-54

4184

27.0

  

55-59

4299

27.8

  

60-64

3426

22.1

  

65-69

3577

23.1

  

Region of residence

    

North-western Italy

3599

23.2

12383

35.0

North-eastern Italy

3127

20.2

2355

21.5

Central-Italy

2833

18.3

6241

20.2

Southern Italy

4213

27.2

10405

29.4

Italian Islands

1714

11.1

3965

11.2

Marital status

    

Single

1067

6.9

7257

20.5

Married

11310

73.0

23782

67.3

Separated/Divorced

914

5.9

2723

7.7

Widowed

2195

14.2

1587

4.5

Body mass index

    

Normal weight

7564

48.8

22342

63.2

Underweight

305

2.0

1889

5.3

Overweight

5378

34.7

8128

23

Obese

2239

14.5

2990

8.5

Self-assessed health status

    

Good/Very good

6414

41.4

22771

64.4

Fair

7751

50.1

11310

32.0

Bad/Very bad

1321

8.5

1268

3.6

Cigarette smoking status

    

Current

2216

14.3

6474

18.3

Former

2565

16.6

5869

16.6

Never

10705

69.1

23006

65.1

Level of education

    

Primary school or less

7603

49.1

7082

20.1

Secondary school

3900

25.2

11214

31.7

High school and over

3983

25.7

17053

48.2

Occupational class

    

Non-working

4941

31.9

9806

27.8

Low

5915

38.2

11643

32.9

Intermediate

3167

20.5

10223

28.9

High

1463

9.4

3677

10.4

Mammography

    

One every two years

7274

47.0

  

Less than two or none

8212

53.0

  

Pap test

    

One every three years

  

18417

52.1

Less than three or none

  

16932

47.9

*Italian National Health Interview Survey, 2004-2005 [24].

Table 2

Prevalence rates of having regular mammography and Pap test by sample characteristics

 

Women that performed a mammography every two years

Women that performed a Pap test every three years

 

n

%

n

%

Age groups

    

25-34

  

3718

42.5

35-44

  

5482

53.7

45-54

  

5084

58.6

55-64

  

4133

53.5

50-54

2409

57.4

  

55-59

2038

47.6

  

60-64

1478

43.9

  

65-69

1349

38.1

  

Region of residence

    

North-western Italy

1985

56.4

4795

63.1

North-eastern Italy

1959

62.7

5236

73.3

Central-Italy

1507

50.3

3753

60.1

Southern Italy

1308

29.3

3403

32.7

Italian Islands

515

28.1

1230

31.0

Marital status

    

Single

402

38.4

2739

37.7

Married

5608

49.8

13376

56.2

Separated/Divorced

419

46.1

1529

56.2

Widowed

845

38.2

773

48.7

Body mass index

    

Normal weight

3732

49.8

11981

53.6

Underweight

156

50.0

945

50.0

Overweight

2451

45.7

4120

50.7

Obese

935

41.1

1371

45.9

Self-assessed health status

    

Good/Very good

3087

48.7

11540

50.7

Fair

3690

47.5

6279

55.5

Bad/Very bad

497

37.5

598

47.2

Cigarette smoking status

    

Current

1130

44.7

3452

49.0

Former

1407

54.8

3690

63.5

Never

4737

50.2

11275

53.9

Level of education

    

Primary school or less

3052

40.5

3114

44.0

Secondary school

1951

49.5

5632

50.5

High school and over

2271

57.0

9671

56.7

Occupational class

    

Non-working

1800

35.4

3598

63.3

Low

2788

47.9

6142

52.8

Intermediate

1863

59.5

6371

62.3

High

823

57.5

2306

62.7

Results of logistic regression models are shown in Table 3. Age, region of residence, marital status, education and social class were significant predictors of regular breast cancer screening after adjusting for the other covariates. Women of 55 years and older were less likely to have had a mammogram within the clinically recommended 2 year-time period. The likelihood to perform breast cancer screening was lower in central (OR = 0.83; 95% CI = 0.73-0.96) and southern (OR = 0.30; 95% CI = 0.26-0.34) than in northern regions. Married women resulted more likely to have regular prevention (OR = 1.83; 95% CI = 1.56-2.15). Women with a higher level of education were more likely to have a mammogram within the past 2 years than those with a lower level (OR = 1.28; 95% CI = 1.10-1.49). Women of intermediate and high occupational classes were more likely to use screening (OR = 1.77; 95% CI = 1.55-2.03, OR = 1.63; 95% CI = 1.40-1.91) compared to the unemployed ones. Obese women had a lower likelihood to have a mammogram than normal weight ones (OR = 0.87; 95% CI = 0.77-0.98). Significant interactions were found between the highest educated and living in central and Southern Italy: as a result, educational inequalities were largest in Southern Italy and lowest in Central Italy.
Table 3

Odds ratio of having regular prevention by mammography

 

ORs (CI 95%)

Linearized standard errors

p-value

Age groups

   

50-54

1

  

55-59

0.64 (0.57-0.71)

0.04

< 0.001

60-64

0.58 (0.51-0.65)

0.03

< 0.001

65-69

0.47 (0.42-0.53)

0.03

< 0.001

Region of residence

   

North-western Italy

1

  

North-eastern Italy

1.30 (1.16-1.46)

0.08

< 0.001

Central-Italy

0.83 (0.73-0.96)

0.06

< 0.05

Southern Italy

0.30 (0.26-0.34)

0.02

< 0.001

Italian Islands

0.32 (0.27-0.37)

0.02

< 0.001

Marital status

   

Single

1

  

Married

1.83 (1.56-2.15)

0.15

< 0.001

Separated/Divorced

1.15 (0.93-1.43)

0.13

0.206

Widowed

1.32 (1.10-1.60)

0.13

< 0.05

Body mass index

   

Normal weight

1

  

Underweight

0.88 (0.64-1.20)

0.14

0.403

Overweight

1.04 (0.95-1.13)

0.05

0.405

Obese

0.87 (0.77-0.98)

0.05

< 0.05

Self-assessed health status

   

Good/Very good

1

  

Fair

1.17 (1.07-1.27)

0.05

< 0.001

Bad/Very bad

1.01 (0.86-1.17)

0.08

0.957

Cigarette smoking status

   

Never

1

  

Former

1.11 (0.99-1.24)

0.06

0.084

Current

0.95 (0.85-1.06)

0.05

0.361

Level of education

   

Primary school or less

1

  

Secondary school

1.08 (0.97-1.19)

0.05

0.147

High school and over

1.28 (1.10-1.49)

0.10

< 0.001

Occupational class

   

Non-working

1

  

Low

1.23 (1.12-1.36)

0.06

< 0.001

Intermediate

1.77 (1.55-2.03)

0.12

< 0.001

High

1.63 (1.40-1.91)

0.13

< 0.001

Interaction between Region of residence and Level of education

   

North-western Italy*Primary school or less

1

  

Central-Italy*High school and over

0.77 (0.61-0.98)

0.09

< 0.05

Southern Italy*High school and over

1.38 (1.13-1.70)

0.15

< 0.001

Figure 1 shows the ORs of attending an organized mammography screening program versus opportunistic screening by level of education and social class adjusting for age, regional residence, marital status, BMI, smoking status and self-assessed health status. The figure shows that women with lower educational level had a higher likelihood of attending an organized mammography screening program than more educated women (OR = 1.37; 95% CI = 1.12-1.67). In addition, low social class was associated with a greater use of organized screening program (OR = 1.44; 95% CI = 1.15-1.81) compared to a higher class.
https://static-content.springer.com/image/art%3A10.1186%2F1471-2458-12-99/MediaObjects/12889_2011_Article_3897_Fig1_HTML.jpg
Figure 1

Odds Ratio of attending an organized mammography screening program versus opportunistic screening by level of education and social class adjusted for age, regional residence, marital status, BMI, smoking status and self-assessed status.

Cervical cancer screening

Table 1 summarizes the characteristics of the 35, 349 women included in the study. About half of the sample had a high educational level (48.2%), only 10.4% were in the high occupational class, while there were not considerable differences in the percentages of non-working (27.8%), low (32.9%) and intermediate class (28.9%). More than 50% of women had a Pap test within the past 3 years.

A positive educational gradient was found for attendance to cervical cancer screening (Table 2). Attendance ranged from 56.7% among the highest educated to 44.0% among the lowest educated. Women in the low occupational class showed a lower attendance rate compared to the other occupational groups.

Results of logistic regression models are shown in Table 4. Women aged 35-64 years were more likely to undergo screening than women aged 25-34 years. A regional gradient was found in the regular uptake of cervical cancer screening: women living in Southern Italy and main islands, used Pap test less frequently than women living in North Italy with an OR of 0.38 (95% CI = 0.33-0.43) and an OR of 0.30 (95% CI = 0.27-0.34), respectively. Married women had a higher likelihood to have a Pap test (OR = 2.41; 95% CI = 2.23-2.60) than single women. Obese women reported a lower likelihood of cancer screening (OR = 0.77; 95% CI = 0.70-0.85) than normal weight ones. Former smoking status was an important predictor of regular Pap test attendance (OR = 1.36; 95% CI = 1.25-1.47). Women with a high socioeconomic status had a higher likelihood of cervical cancer screening compared to those with a lower status. The ORs were 1.91 (95% CI = 1.72-2.13) for women with a high school level or a higher level and 1.81 (95% CI = 1.63-2.01) for those with a high occupational class. The significant interaction terms in this model imply that higher levels of education in the South are less strongly associated with cervical cancer screening than in the rest of Italy.
Table 4

Odds ratio of having regular prevention by Pap test

 

ORs(CI 95%)

Linearized standard errors

p-value

Age groups

   

25-34

1

  

35-44

1.21 (1.12-1.31)

0.05

< 0.001

45-54

1.62 (1.49-1.77)

0.07

< 0.001

55-64

1.45 (1.32-1.60)

0.07

< 0.001

Region of residence

   

North-western Italy

1

  

North-eastern Italy

1.65 (1.52-1.80)

0.07

< 0.001

Central-Italy

0.87 (0.80-0.95)

0.04

< 0.05

Southern Italy

0.38 (0.33-0.43)

0.03

< 0.001

Italian Islands

0.30 (0.27-0.34)

0.02

< 0.001

Marital status

   

Single

1

  

Married

2.41 (2.23-2.60)

0.09

< 0.001

Separated/Divorced

1.69 (1.50-1.90)

0.10

< 0.001

Widowed

1.78 (1.54-2.07)

0.14

< 0.001

Body mass index

   

Normal weight

1

  

Underweight

0.98 (0.87-1.12)

0.04

0.790

Overweight

0.90 (0.84-0.97)

0.08

< 0.05

Obese

0.77 (0.70-0.85)

0.06

< 0.001

Self-assessed health status

   

Good/Very good

1

  

Fair

1.22 (1.14-1.29)

0.04

< 0.001

Bad/Very bad

1.10 (0.95-1.28)

0.07

0.206

Cigarette smoking status

   

Never

1

  

Former

1.36 (1.25-1.47)

0.10

< 0.001

Current

1.10 (1.03-1.18)

0.05

< 0.05

Level of education

   

Primary school or less

1

  

Secondary school

1.44 (1.31-1.59)

0.05

< 0.001

High school and over

1.91 (1.72-2.13)

0.10

< 0.001

Occupational class

   

Non-working

1

  

Low

1.28 (1.19-1.38)

0.05

< 0.001

Intermediate

1.73 (1.60-1.89)

0.07

< 0.001

High

1.81 (1.63-2.01)

0.10

< 0.001

Interaction between Region of residence and Level of education

   

North-western Italy*Primary school or less

1

  

Southern-Italy*Secondary school

0.78 (0.66-0.91)

0.06

< 0.05

Southern Italy*High school and over

0.83 (0.72-0.96)

0.06

< 0.05

Figure 2 shows the OR of attending an organized cervical cancer screening program versus opportunistic screening by level of education and social class adjusting for age, regional residence, marital status BMI, smoking status and self-assessed health status. The lowest educated women had a higher likelihood of using organized screening than those with a higher educational level (OR = 1.35; 95% CI = 1.17-1.55). Women of lower occupational class had a higher odds of organized screening program attendance compared with women in the highest occupational class (OR = 1.46; 95% CI = 1.27-1.69).
https://static-content.springer.com/image/art%3A10.1186%2F1471-2458-12-99/MediaObjects/12889_2011_Article_3897_Fig2_HTML.jpg
Figure 2

Odds Ratio of attending an organized cervical cancer screening program versus opportunistic screening by level of education and social class adjusted for age, regional residence marital status, BMI, smoking status and self-assessed status.

Discussion

In our study, we investigated inequity in breast and cervical cancer screening among Italian women. Our study suggests the presence of important inequalities in the use of these preventive services: both lower level of education and occupational class are strongly associated with underutilization of screening, despite coverage of most expenses for such preventive services by the Italian National Health System. However, among women who attended screening, those with lower level of education and lower occupational class were more likely to attend organized screening program rather than being screened on the basis of their own initiative.

These findings are consistent with the results of other international studies [8, 13, 2830] reporting that women with lower socioeconomic status are less likely to undergo cancer screening. Sabates and Feinstein investigated the role of education in the uptake of cervical cancer screening in Britain; they found that continuing adult learning has a direct impact on the uptake of preventative screening which is not reduced by income, occupation or social class [31]. Furthermore, Rakowski et al. highlighted the positive influence of education on preventive behaviours [32]. Recently, a study on the use of breast and cervical cancer screening among European countries found that inequalities existed in some countries and were related to the type of screening program [14]. Contextual effects may also be important: it was shown that less educated women living in metropolitan areas with a lower proportion of low-education residents are less likely to undergo cancer screening, compared to women with similar level of education in other metropolitan areas. This may be due to socioeconomic factors or to the lack of culturally appropriate and accessible preventive health care services in the areas in which women live [16]. On the other hand, Achat et al. in 2005 demonstrated the existence of a weak association between socioeconomic status and regularity of mammography among Australian women when preventive programs were available without direct charge [33].

Referring to the relationship between socioeconomic status and adherence to organized screening programs versus opportunistic screening, our results are in line with several studies showing that women who attended an organized breast cancer screening program were more likely to be of a lower socioeconomic status [20, 34]. These studies suggested that screening programs appeared to attract disadvantaged women who did not usually undergo screening. Similarly, a national study reported lower participation in organized screening program in more educated women, which was thought to reflect the greater extent of private purchase of screening outside public services [35]. In their study on the influence of type of screening program on the extent of inequality in some European countries, Palencia et al. reported large inequalities in countries without population-based cancer screening programs [14].

In contrast, other studies reported that organized screening programs assure a generic positive effect on coverage without clearly reducing the social gap [15, 30, 36, 37]. More recently, results from two studies seemed to confirm that it is necessary to give programs longer periods of time since their start in order to observe any impact on inequalities [38, 39].

In our study, we found that the association between socioeconomic status and mammography uptake was stronger for occupational status than for education. Women who do non-working were the most disadvantaged. This finding is similar to the one reported by Zackrisson et al. [40].

Our results show a positive association between female screening and marriage condition similar to other studies [33, 41]. Being unmarried was a stronger predictor for not undergoing screening especially for Pap test. It may be that Pap test was often offered to married women as part of pre or post natal services [28]. In addition, according to Zackrisson et al. marital status could be considered as a proxy for social support [40].

Age was positively correlated to the uptake of Pap test whereas it was negatively correlated with the use of mammography. Conflicting findings are reported in the literature in this regard [4244]. Higher rates found among older women for Pap smear may be due to a lower attention paid to preventive issues among younger generations.

We also considered the influence of BMI and smoking status on the use of preventive services. The role of obesity as a barrier to screening is a fairly recent research topic. This study reveals, as also shown by Datta [45], that women with BMI > 30 had a greater likelihood of non attending screening than women with normal weight. Cohen et al. discussed possible reasons for this association that were not necessarily weight-related, including embarrassment, discomfort and emotional barriers [46]. Results from a meta-analysis showed that obesity was inversely associated with the likelihood of having recently undergone a mammography [25].

In contrast with previous studies, our findings show that cigarettes smokers are not less likely that non smokers to use cancer preventive services [26, 29]. Recently Ortiz et all found similar results, reporting that Pap screening was not associated with smoking status and other unhealthy behaviors [47]. We showed that former smokers tended to have higher attendance to screening than current smokers and people who were never smokers. This may be because former smokers decided to adopt a healthier lifestyle altogether. Similar results are reported by Rakowski et al. [48].

Despite the existence of free cancer prevention programs, the overall proportion of women that undertake regular screening tests is relatively small. Only half of the investigated women have had regular prevention, even though in Italy female screening programs have been existing for more than 10 years.

Deficit in utilization may be due to a lack of trust in the National Health Service and in its initiatives, as a consequence of the wide geographical heterogeneity in implementation of regional programs. Other reasons associated with poor adherence to screening may be the low perception in cancer screening efficacy, the fear of radiation mammography, the anxiety for the result and the fear of cancer.

In order to increase screening uptake rates, Duport et al. suggested that media campaigns should target women who were never screened or not regularly screened, underlying the importance of early diagnosis of breast cancer and the fact that screening is free of charge. On the other hand, benefits in terms of quality of organization about screening programs should be shown to women who underwent opportunistic mammography [20].

Our findings are subject to some limitations. First, there may be an effect of recall bias on self reported information about cancer screening practices: patients frequently tend to over-report their use of Pap test or mammogram and underreport the time lapse since their last screening [43, 49].

Furthermore, several studies found that women's self-reported information varies according to the type of health care providers and to socio-demographic factors [50]. Secondly, useful information on some variables was not included in the survey questionnaire such as number of partners and parity.

A major strength of this study is that data were collected on a large national population-based sample. Furthermore, this sample provided detailed information about health status, socio-demographic characteristics and unhealthy behaviours.

In Italy, the 1998-2000 National Health Plan recommended that cancer screening programs should be introduced in every region [51]. Since 2005 the National Screening Observatory and the National Centre for Disease Control and Prevention have been working in partnership in order to control and support Regions in implementing screening programs.

Identifying reasons for failures of cancer screening is an important public health issue. In order to increase the proportion of women who carry out regular prevention it could be useful to improve the organization of screening services, for example through more flexible hours to meet the needs of women. Furthermore, it is important to involve the primary health sector to enhance and promote the spread of information on the benefits of screening to improve access to health services by increasing women compliance. Knowledge about socioeconomic status is essential for providing equal access to preventive care. Specific interventions at the national, regional and local level have to be designed in order to reduce disparities in screening utilisation by focusing on disadvantaged women. The implementation of organized screening programs may have an important role in increasing screening attendance and tackling socioeconomic inequalities.

Conclusions

Inequalities in the uptake of female screening widely exist in Italy. Organized screening programs may have an important role in increasing screening attendance and tackling inequalities.

Declarations

Acknowledgements

The authors would like to thank Dr. Saverio Tomaiuolo, Department of Health and Sport Sciences, University of Cassino, for his contribution in revising the manuscript.

Authors’ Affiliations

(1)
Department of Public Health, Università Cattolica del Sacro Cuore
(2)
Department of Health and Sport Sciences, Università di Cassino
(3)
Health Division, Directorate for Employment, Labour and Social Affairs, OECD-Organization for economic Cooperation and Development

References

  1. AIRTUM Working Group: Cancer trend (1998-2005). Epidemiol Prev. 2009, 33 (Suppl 1): 1-167. http://www.registri-tumori.it/cms/ (accessed 14 January 2011)Google Scholar
  2. World Health Organization: Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases 2008-2013. 2008, http://www.who.int/entity/nmh/Actionplan-PC-NCD-2008.pdf (accessed 14 January 2011)Google Scholar
  3. Kerlikowske K, Grady D, Rubin SM, Sandrock C, Ernster VL: Efficacy of screening mammography. A meta-analysis. JAMA. 1995, 273 (2): 149-154. 10.1001/jama.1995.03520260071035.View ArticlePubMedGoogle Scholar
  4. American Cancer Society: Cancer Prevention and Early DetectionWorksheet for Women. 2009, http://www.cancer.org/acs/groups/content/@nho/documents/webcontent/acsq-009098.pdf (accessed January 2011)Google Scholar
  5. Perry N, Broeders M, de Wolf C, Törnberg S, Holland R, von Karska L: European guidelines for quality assurance in breast cancer screening and diagnosi. 2006, Luxembourg: European Commission. Office for Official publications of the European Communities, http://ec.europa.eu/health/ph_projects/2002/cancer/fp_cancer_2002_ext_guid_01.pdf (accessed January 2011)Google Scholar
  6. I programmi di screening in Italia 2009. (Screening programs in Italy 2009) Osservatorio Nazionale Screening. http://ons.stage-zadig.it/sites/default/files/allegati/screening_cervice2009.pdf#overlay-context=it/content/i-rapporti-brevi-dell%25E2%2580%2599ons; http://ons.stage-zadig.it/sites/default/files/allegati/screening_mammografia2009.pdf#overlay-context=it/content/i-rapporti-brevi-dell%25E2%2580%2599ons
  7. Arbyn M, Anttila A, Jordan J, Ronco G, Schenk U, Segnan N, et al: European guidelines for quality assurance in cervical cancer screenin. 2008, Luxembourg: European Commission. Office for Official Publications of the European CommunitiesGoogle Scholar
  8. Lorant V, Boland B, Humblet P, Deliège D: Equity in prevention and health care. J Epidemiol Community Health. 2002, 56: 510-516. 10.1136/jech.56.7.510.View ArticlePubMedPubMed CentralGoogle Scholar
  9. Damiani G, Federico B, Bianchi CBNA, Ronconi A, Basso D, Fiorenza S, et al: Socioeconomic status and prevention of cardiovascular disease in Italy: evidence from a national health survey. Eur J Public Health. 2011, 21 (5): 591-596. 10.1093/eurpub/ckq075.View ArticlePubMedGoogle Scholar
  10. Wells KJ, Roetzheim RG: Health disparities in receipt of screening mammography in Latinas: a critical review of recent literature. Cancer Control. 2007, 14 (4): 369-379.PubMedGoogle Scholar
  11. Garrido-Cumbrera M, Borrell C, Palència L, Espelt A, Rodríguez-Sanz M, Pasarín MI, et al: Social class inequalities in the utilization of health care and preventive services in Spain, a country with a national health system. Int J Health Serv. 2010, 40 (3): 525-542. 10.2190/HS.40.3.h.View ArticlePubMedGoogle Scholar
  12. Sassi F, Luft HS, Guadagnoli E: Reducing racial/ethnic disparities in female breast cancer screening rates and stage diagnosis. Am J Public Health. 2006, 96 (12): 2165-2172. 10.2105/AJPH.2005.071761. doi:10.2105/AJPH.2005.07176. [published Online First: 31 October 2006]View ArticlePubMedPubMed CentralGoogle Scholar
  13. Moser K, Patnick J, Beral V: Inequalities in reported use of breast and cervical screening in Great Britain: analysis of cross sectional survey data. BMJ. 2009, 338: b2025-10.1136/bmj.b2025. doi:10.1136/bmj.b2025 [published Online First: 16 June 2009]View ArticlePubMedPubMed CentralGoogle Scholar
  14. Palencia L, Espelt A, Rodriguez-Sanz M, Puigpinòs R, Pons-Vigués M, Pasarìn MI, et al: Socio-economic inequalities in breast and cervical cancer screening practices in Europe: influence of the type of screening program. Int J Epidemiol. 2010, 39 (3): 757-765. 10.1093/ije/dyq003.View ArticlePubMedGoogle Scholar
  15. Stirbu I, Kunst A, Mielck A, Mackenbach JP: Educational inequalities in utilization of preventive services among elderly in Europe. Tackling Health Inequalities. Europe: an integrated approach - EUROTHINE. Final Report. 2007, Rotterdam: Erasmus MC, 483-499. [http://survey.erasmusmc.nl/eurothine]Google Scholar
  16. Coughlin SS, King J, Richards TB, Ekwueme DU: Cervical cancer screening among women in metropolitan areas of the United States by individual-level and area-based measures of socioeconomic status, 2000 to 2002. Cancer Epidemiol Biomarkers Prev. 2006, 15 (11): 2154-2159. 10.1158/1055-9965.EPI-05-0914.View ArticlePubMedGoogle Scholar
  17. Mamo C, Landriscina T, Vannoni F, Costa G: L'Indagine ISTAT e il Piano nazionale della prevenzione. Spunti per la definizione di target. (Italian National Institute of Statistics' survey and Italian National Prevention Plan. Consideration for target definition.). Approfondimenti sull'indagine Multiscopo Istat 2005. 2008, 22 (Suppl 3): 143-160. MonitorGoogle Scholar
  18. Ackerson K, Gretebeck K: Factors influencing cancer screening practices of underserved women. J Am Acad Nurse Pract. 2007, 19 (11): 591-601. 10.1111/j.1745-7599.2007.00268.x.View ArticlePubMedGoogle Scholar
  19. Hewitt M, Devesa SS, Breen N: Cervical cancer screening among U.S. women: analyses of the 2000 National Health Interview Survey. Prev Med. 2004, 39 (2): 270-278. 10.1016/j.ypmed.2004.03.035.View ArticlePubMedGoogle Scholar
  20. Duport N, Ancelle-Park R, Boussac-Zarebska M, Uhry Z, Bloch J: Are breast cancer screening practices associated with sociodemographic status and healthcare access? Analysis of a French cross-sectional study. Eur J Cancer Prev. 2008, 17 (3): 218-224. 10.1097/CEJ.0b013e3282b6fde5.View ArticlePubMedGoogle Scholar
  21. Puliti D, Miccinesi G, Collina N, De Lisi V, Federico M, Ferretti S, et al: Effectiveness of service screening: a case-control study to assess breast cancer mortality reduction. Br J Cancer. 2008, 99 (3): 423-427. 10.1038/sj.bjc.6604532.View ArticlePubMedPubMed CentralGoogle Scholar
  22. Giorgi Rossi P, Chini F, Barca A, Baiocchi D, Federici A, Farchi S, et al: Efficacy of disease management profiles. The mammographicscreening program of Lazio. Tumori. 2008, 94 (3): 297-303.PubMedGoogle Scholar
  23. Bologna E: La prevenzione dei tumori femminili in Italia: il ricorso a Pap test e mammografia. Anni 2004-2005. Istat Statistiche in breve. 2006, 1-12.Google Scholar
  24. Condizioni di salute e ricorso ai servizi sanitari Anni 2004-2005. (Health conditions and use of health services, 2004-2005). [http://www.istat.it/it/archivio/5471]
  25. Maruthur NM, Bolen S, Brancati FL, Clark JM: Obesity and mammography: a systematic review and meta-analysis. J Gen Intern Med. 2009, 24 (5): 665-677. 10.1007/s11606-009-0939-3.View ArticlePubMedPubMed CentralGoogle Scholar
  26. Clark MA, Rakowski W, Ehrich B: Breast and cervical cancer screening: association with personal, spouse's, and combined smoking status. Cancer Epidemiol Biomarkers Prev. 2000, 9 (5): 513-516.PubMedGoogle Scholar
  27. Rose D, Pevalin D: The National Statistics Socio-economic Classification: Genesis and Overvie. 2001, London: Office of National StatisticsGoogle Scholar
  28. Couture MC, Nguyen CT, Alvarado BE, Velasquez LD, Zunzunegui MV: Inequalities in breast and cervical cancer screening among urban Mexican women. Prev Med. 2008, 47 (5): 471-476. 10.1016/j.ypmed.2008.07.005. [published Online First: 15 July 2008]View ArticlePubMedGoogle Scholar
  29. Selvin E, Brett KM: Breast and cervical cancer screening: sociodemographic predictors among White, Black, and Hispanic women. Am J Public Health. 2003, 93 (4): 618-623. 10.2105/AJPH.93.4.618.View ArticlePubMedPubMed CentralGoogle Scholar
  30. Duport N, Ancelle-Park R: Do socio-demographic factors influence mammography use of French women? Analysis of a French cross-sectional survey. Eur J Cancer Prev. 2006, 15 (3): 219-224. 10.1097/01.cej.0000198902.78420.de.View ArticlePubMedGoogle Scholar
  31. Sabates R, Feinstein L: The role of education in the uptake of preventative health care: the case of cervical screening in Britain. Soc Sci Med. 2006, 62 (12): 2998-3010. 10.1016/j.socscimed.2005.11.032. [published Online First: 5 January 2006]View ArticlePubMedGoogle Scholar
  32. Rakowski W, Breen N, Meissner H, Rimer BK, Vernon SW, Clark MA, et al: Prevalence and correlates of repeat mammography among women aged 55-79 in the Year 2000 National Health Interview Survey. Prev Med. 2004, 39 (1): 1-10. 10.1016/j.ypmed.2003.12.032.View ArticlePubMedGoogle Scholar
  33. Achat H, Close G, Taylor R: Who has regular mammograms? Effects of knowledge, beliefs, socioeconomic status, and health-related factors. Prev Med. 2005, 41: 312-320. 10.1016/j.ypmed.2004.11.016.View ArticlePubMedGoogle Scholar
  34. Chamot E, Charvet A, Perneger TV: Overuse of mammography during the first round of an organized breast cancer screening programme. J Eval Clin Pract. 2009, 15 (4): 620-625. 10.1111/j.1365-2753.2008.01062.x.View ArticlePubMedGoogle Scholar
  35. Donato F, Bollani A, Spiazzi R, Soldo M, Pasquale L, Monarca S, et al: Factors associated with non-participation of women in a breast cancer screening programme in a town in northern Italy. J Epidemiol Community Health. 1991, 45: 59-64. 10.1136/jech.45.1.59.View ArticlePubMedPubMed CentralGoogle Scholar
  36. Spadea T, Bellini S, Kunst A, Stirbu I, Costa G: The impact of interventions to improve attendance in female cancer screening among lower socioeconomic groups: a review. Prev Med. 2010, 50 (4): 159-164. 10.1016/j.ypmed.2010.01.007.View ArticlePubMedGoogle Scholar
  37. Anttila A, Ronco G, Clifford G, Bray F, Hakama M, Arbyn M, Weiderpass E: Cervical cancer screening programmes and policies in 18 European countries. Br J Cancer. 2004, 91 (5): 935-941.PubMedPubMed CentralGoogle Scholar
  38. Luengo-Matos S, Polo-Santos M, Saz-Parkinson Z: Mammography use and factors associated with its use after the introduction of breast cancer screening programmes in Spain. Eur J Cancer Prev. 2006, 15 (3): 242-248. 10.1097/01.cej.0000199503.30818.e6.View ArticlePubMedGoogle Scholar
  39. Puddu M, Demarest S, Tafforeau J: Does a national screening programme reduce socioeconomic inequalities in mammography use?. Int J Public Health. 2009, 54 (2): 61-68. 10.1007/s00038-009-8105-6.View ArticlePubMedGoogle Scholar
  40. Zackrisson S, Andersson I, Manjer J, Janson L: Non-attendance in breast cancer screening is associated with unfavourable socio-economic circumstances and advanced carcinoma. Int J Cancer. 2004, 108 (5): 754-760. 10.1002/ijc.11622.View ArticlePubMedGoogle Scholar
  41. Rodríguez MA, Ward LM, Pérez-Stable EJ: Breast and cervical cancer screening: impact of health insurance status, ethnicity, and nativity of Latinas. Ann Fam Med. 2005, 3 (3): 235-241. 10.1370/afm.291.View ArticlePubMedPubMed CentralGoogle Scholar
  42. Sambamoorthi U, McAlpine DD: Racial, ethnic, socioeconomic, and access disparities in the use of preventive services among women. Prev Med. 2003, 37 (5): 475-484. 10.1016/S0091-7435(03)00172-5.View ArticlePubMedGoogle Scholar
  43. Qi V, Phillips SP, Hopman WM: Determinants of a healthy lifestyle and use of preventive screening in Canada. BMC Public Health. 2006, 6: 275-10.1186/1471-2458-6-275.View ArticlePubMedPubMed CentralGoogle Scholar
  44. Coughlin SS, Leadbetter S, Richards T, Sabatino SA: Contextual analysis of breast and cervical cancer screening and factors associated with access among United States women, 2002. Soc Sci Med. 2008, 66 (2): 260-75. 10.1016/j.socscimed.2007.09.009.View ArticlePubMedGoogle Scholar
  45. Datta G, Colditz GA, Kawachi I, Subramanian SV, Palmer JR, Rosenberg L: Individual-, neighborhood-, and state-level socioeconomic predictors of cervical carcinoma screening among U.S. black women. Cancer. 2006, 106 (3): 664-669. 10.1002/cncr.21660.View ArticlePubMedGoogle Scholar
  46. Cohen SS, Palmieri RT, Nyante SJ, Koralek DO, Kim S, Bradshaw P, et al: Obesity and screening for breast, cervical, and colorectal cancer in women. A review. Cancer. 2008, 112 (9): 1892-1904. 10.1002/cncr.23408.View ArticlePubMedGoogle Scholar
  47. Ortiz AP, Hebl S, Serrano R, Fernandez ME, Suárez E, Tortolero-Luna G: Factors associated with cervical cancer screening in Puerto Rico. Prev Chronic Dis. 2010, 7 (3): A58-[Erratum appears in Prev Chronic Dis 2010;7(5)]PubMedPubMed CentralGoogle Scholar
  48. Rakowski W, Clark MA, Ehrich B: Smoking and cancer screening for women ages 42-75: associations in the 1990-1994 National Health Interview Surveys. Prev Med. 1999, 29: 487-495. 10.1006/pmed.1999.0578.View ArticlePubMedGoogle Scholar
  49. Gordon NP, Hiatt RA, Lampert DI: Concordance of self-reported data and medical record audit for six cancer screening procedures. J Natl Cancer Inst. 1993, 85 (7): 566-570. 10.1093/jnci/85.7.566.View ArticlePubMedGoogle Scholar
  50. McPhee SJ, Nguyen TT, Shema SJ, Nguyen B, Somkin C, Vo P, et al: Validation of recall of breast and cervical cancer screening by women in an ethnically diverse population. Prev Med. 2002, 35 (5): 463-473. 10.1006/pmed.2002.1096.View ArticlePubMedGoogle Scholar
  51. Piano Sanitario Nazionale 1998-2000. (Italian National Health Plan 1998-2000). [http://www.salute.gov.it/imgs/C_17_pubblicazioni_947_allegato.pdf]
  52. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/12/99/prepub

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This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/2.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.