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Geographical and Socioeconomic Differences in Uptake of Pap Test and Mammography in Italy: Results from the National Health Interview Survey

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Geographical and Socioeconomic Differences in Uptake of Pap Test and Mammography in Italy: Results from the National Health Interview Survey Open access Research BMJ Open: first published as 10.1136/bmjopen-2018-021653 on 19 September 2018. Downloaded from Geographical and socioeconomic differences in uptake of Pap test and mammography in Italy: results from the National Health Interview Survey Alessio Petrelli,1 Paolo Giorgi Rossi,2,3 Lisa Francovich,4 Barbara Giordani,5 Anteo Di Napoli,1 Marco Zappa,6 Concetta Mirisola,1 Lidia Gargiulo4 To cite: Petrelli A, Giorgi ABSTRACT Strengths and limitations of this study Rossi P, Francovich L, Objective The Italian National Health Service instituted et al. Geographical and cervical and breast cancer screening programmes in 1999; ► The large amount of information derived from Italian socioeconomic differences the local health authorities have a mandate to implement in uptake of Pap test and National Health Interview Survey allowed us to in- these screening programmes by inviting all women aged mammography in Italy: results vestigate inequities in screening uptake in Italy thor- 25–64 years for a Pap test every 3 years (or for an Human from the National Health oughly for the first time. Papilloma Virus (HPV) test every 5 years) and women aged Interview Survey. BMJ Open ► The joint use of two data sources enabled estimating 50–69 years for a mammography every 2 years. However, 2018;8:e021653. doi:10.1136/ the impact of screening programmes on uptake in the implementation of screening programmes throughout bmjopen-2018-021653 the country, evaluating also the differences between the country is still incomplete. This study aims to: (1) Prepublication history regions and in groups with different socioeconomic ► describe cervical and breast cancer screening uptake and for this paper is available and behavioural characteristics. (2) evaluate geographical and individual socioeconomic online. To view these files, ► It could be difficult for interviewed women to dis- difference in screening uptake. please visit the journal online tinguish how the test was delivered (screening pro- Methods Data both from the Italian National Health (http:// dx. doi. org/10.1136/ gramme or opportunistic) and this potential recall Interview Survey (NHIS) conducted by the National Institute bmjopen-2018-021653). bias could be different by citizenship or between of Statistics in 2012–2013 and from the Italian National educational levels. Received 11 January 2018 Centre for Screening Monitoring (INCSM) were used. The ► The uptake obtained by the public sector, which Revised 14 June 2018 NHIS interviewed a national representative random sample adopts less intensive protocols and longer intervals, Accepted 3 August 2018 of 32 831 women aged 25–64 years and of 16 459 women may be underestimated, looking at the most recent http://bmjopen.bmj.com/ aged 50–69 years. Logistic multilevel models were used test only, because some women undergo tests at to estimate the effect of socioeconomic variables and shorter intervals than recommended. behavioural factors (level 1) on screening uptake. Data on screening invitation coverage at the regional level, taken from INCSM, were used as ecological (level 2) covariates. Results Total 3-year Pap test and 2-year mammography that each European Union Member State uptake were 62.1% and 56.4%, respectively; screening offer screening to its population. In accor- programmes accounted for 1/3 and 1/2 of total test dance with these recommendations, popu- lation-based free screening programmes, uptake, respectively. Strong geographical differences were on 24 September 2018 by guest. Protected copyright. observed. Uptake was associated with high educational with active invitation of the target popula- levels, healthy behaviours, being a former smoker and tion as well as quality assurance and moni- being Italian versus foreign national. Differences in uptake toring activities, are included in the essential between Italian regions were mostly explained by the healthcare services guaranteed by the Italian invitation coverage to screening programmes. National Health Service (NHS). The target Conclusions The uptake of both screening programmes population for cervical screening includes all in Italy is still under acceptable levels. Screening permanent and temporary (when possible) © Author(s) (or their programme implementation has the potential to reduce the health inequalities gap between regions but only if uptake resident women aged 25–64 years, and for employer(s)) 2018. Re-use breast screening, women aged 50–69 years1 2; permitted under CC BY-NC. No increases. commercial re-use. See rights the screening tests used are a Pap test every and permissions. Published by 3 years and mammography every 2 years, in BMJ. accordance with EU Recommendations (see For numbered affiliations see INTRODUCTIOn table 1).3 4 end of article. As cervical and breast cancer screening The introduction of screening programmes Correspondence to programmes have proven effective in in Italy has been slow and characterised by Dr Alessio Petrelli; reducing morbidity and mortality, the Euro- profound geographical differences. The petrelli@ inmp. it pean Commission recommended in 2003 difficulties and delays in organised screening Petrelli A, et al. BMJ Open 2018;8:e021653. doi:10.1136/bmjopen-2018-021653 1 Open access BMJ Open: first published as 10.1136/bmjopen-2018-021653 on 19 September 2018. Downloaded from and make the environment more favourable through Table 1 Characteristics of the Italian organised screening 10 programmes in 2013 modification of reinforcing and enabling factors. In this model, organised programmes are supposed Cervical cancer Breast cancer to be effect modifiers of the association between socio- screening screening economic factors and screening participation, reducing Target age 25–64 50–69* inequalities, because the access to opportunistic Test Pap test† Mammography screening is more probable among affluent people. (double projection) In fact, organised programmes have shown to reduce Interval 3 years 2 years inequality in access, particularly for mammography.11 Proportion of the 70.8% 73.9% Furthermore, studies on the association between healthy target population behaviours and screening uptake have shown inconsistent regularly invited results12; the heterogeneity could be due to the different Participation rate 40.9% 57.0% screening settings, with organised programmes showing no or small differences,13 particularly in colorectal cancer *In two regions, Emilia-Romagna and Piedmont, the target age was screening.14 15 In Italy, the coexistence of opportunistic extended in 2010 to 45–74 years. In these regions, the screening interval is 1 year for women aged 45–49 years. and organised screening and the wide variation among †Since January 2013, the Italian Ministry of Health now regions in the level of organised screening implementa- recommends HPV-DNA test, followed by cytology triage in case of tion makes it possible to study how these two ways of deliv- HPV positivity, with 5-year interval, as an alternative option to Pap ering screening interact with the known determinants of test every 3 years for women ≥30 years. When the interviews were screening uptake. conducted in 2013, only few pilot studies used HPV as primary screening test, accounting for 7.5% and 6.9% of the invited Study objectives are: (1) to describe cervical and breast population in 2012 and 2013, respectively. cancer screening uptake in Italy based on data from the Italian National Health Interview Survey (NHIS) conducted by National Institute of Statistics (Istat) in activation have favoured the spread of opportunistic 2012–2013—we distinguish overall uptake and uptake screening, both by public and private providers.5 Thus, within organised screening programmes; (2) study actual screening coverage and uptake are the result of both geographical and individual socioeconomic differ- organised and opportunistic screening models.6 Organ- ence in screening uptake, and the impact of screening ised public screening programmes include a monitoring programme invitation coverage on these determinants. system to determine exactly how many women are invited and screened in the target population, while opportunistic screening tests are registered in a way that does not allow METHODS Data sources a calculation of test coverage, and some are not registered http://bmjopen.bmj.com/ at all.6 Thus, the only way to have complete information This study is part of epidemiological and political analyses about screening coverage is by interviewing the target of the barriers to implementation of and participation population. The spread of opportunistic testing and the in screening programmes in Italy conducted within the framework of the Green and Kreuter model.9 10 16 progressive implementation of organised screening have The study was conducted based on data from the NHIS, led to a marked increase in test coverage. In 1994, the a population-based cross-sectional survey conducted once-in-a-lifetime Pap test (ages 25–64 years) uptake was every 5 years in Italy by the Istat17 18 and from the Italian 60% and mammography (ages 50–69 years) uptake was National Centre for Screening Monitoring (INCSM). The 44%, virtually all due to opportunistic screening. In 2004, on 24 September 2018 by guest. Protected copyright. 2012–2013 edition of the NHIS collected information both tests had an uptake of 71%, with organised screening 7 about screening coverage and investigated the character- playing a major role, particularly for mammography. istics of women who availed themselves of female cancer Nevertheless,
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