Psychosocial Determinants of Socioeconomic Inequalities in Cancer Screening Participation: A Conceptual Framework

Wagner, Christian von; Good, Anna; Whitaker, Katriina L.; Wardle, Jane

doi:10.1093/epirev/mxq018

Cited by 143 publications

(166 citation statements)

References 181 publications

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“…18 Socioeconomic barriers that have been linked to reduced cancer screenings may also contribute to lower osteoporosis screening rates. 19 While we documented significant underuse, our study suggests that DXA screening is also commonly overused, particularly in younger women without osteoporosis risk factors. Several factors may contribute to DXA overuse.…”

Section: Discussionmentioning

confidence: 53%

Underuse and Overuse of Osteoporosis Screening in a Regional Health System: a Retrospective Cohort Study

et al. 2015

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BACKGROUND:The United States Preventive Services Task Force (USPSTF) recommends screening for osteoporosis with dual-energy x-ray absorptiometry (DXA) for women aged ≥ 65 years and younger women with increased risk. BChoosing Wisely^initiatives advise avoiding DXA screening in women younger than 65 years without osteoporosis risk factors. OBJECTIVE: We aimed to determine the extent to which DXA screening is used in accordance with USPSTF recommendations within a regional health system. DESIGN: This was a retrospective longitudinal cohort study within 13 primary care clinics in the Sacramento, CA region. PATIENTS: The study included 50,995 women aged 40-85 years without prior osteoporosis screening, diagnosis, or treatment attending primary care visits from 2006 to 2012, observed for a mean of 4.4 years. MAIN MEASURES: We examined incidence of DXA screening. Covariates included age, race/ethnicity, and osteoporosis risk factors (body mass index<20, glucocorticoid use, secondary osteoporosis, prior high-risk facture, rheumatoid arthritis, alcohol abuse, and current smoking). KEY RESULTS: Among previously unscreened women for whom the USPSTF recommends screening, 7-year cumulative incidence of DXA screening was 58.8 % among women aged 60-64 years with ≥ 1 risk factor (95 % CI: 51.9-65.8 %), 57.8 % for women aged 65-74 years (95 % CI: 55.6-60.0 %), and 42.7 % for women aged ≥ 75 years (95 % CI: 38.7-46.7 %). Among women for whom the USPSTF does not recommend screening, 7-year cumulative incidence was 45.5 % among women aged 50-59 years (95 % CI 44.1-46.9 %) and 58.6 % among women aged 60-64 years without risk factors (95 % CI 55.9-61.4 %). CONCLUSIONS: DXA screening was underused in women at increased fracture risk, including women aged ≥ 65 years. Meanwhile, DXA screening was common among women at low fracture risk, such as younger women without osteoporosis risk factors. Interventions may be needed to augment the value of population screening for osteoporosis.

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Section: Discussionmentioning

confidence: 53%

Underuse and Overuse of Osteoporosis Screening in a Regional Health System: a Retrospective Cohort Study

et al. 2015

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“…This suggests that the apparent pro-rich pattern in screening uptake could be mediated by a number of factors associated with wealth, which we have not measured in our analyses. As we previously reported, it has been speculated that a number of psychosocial factors might mediate the association between low income and screening uptake (von Wagner, Good, et al, 2011).…”

Section: Discussionmentioning

confidence: 88%

“…Because poorer health was concentrated in participants with lower SES, self-reported general health had a high contribution to health inequalities in CRC screening uptake in our sample (10.6% 0.1>p>0.05). Factors such as fatalistic attitudes towards cancer, previous experiences of illhealth, and distrust in the medical system, which are more common in individuals with both poorer health and low SES, have been shown to mediate the association between poor health and lower uptake of CRC screening (von Wagner, Good, et al, 2011). Being sick/disabled was independently associated with lower screening uptake in multivariate models, and contributed to 14% of inequality in uptake of screening, suggesting the plausibility of this hypothesis in our sample.…”

Section: Discussionmentioning

confidence: 99%

“…Previous research also suggests that psychosocial determinants such as pessimistic expectations about future events, low levels of self-efficacy (i.e. a person's belief in their ability to succeed) and lack of social support, which are more frequent in individuals of low SES could explain its association with low CRC screening uptake (von Wagner, Good, Whitaker, & Wardle, 2011). Finally, health status has been suggested as a factor affecting participation in CRC screening, although evidence with respect to the direction of this association is contradictory (Power et al, 2009).…”

Section: Introductionmentioning

confidence: 99%

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Decomposing socio-economic inequality in colorectal cancer screening uptake in England

Solmi

Wagner

Kobayashi

et al. 2015

Social Science & Medicine

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Colorectal cancer (CRC) is the second largest cause of cancer death in the UK. Since 2010, CRC screening based on Faecal Occult Blood testing has been offered by the NHS in England biennially to all persons age 60 to 69 years. Several studies have demonstrated a gradient in uptake using area-level markers of socio-economic status (SES), but few have examined the individual-level contributors to the gradient. We aimed to quantify the extent of SES inequality in CRC screening uptake in England using individual-level data, and to identify individual factors associated with this inequality.We used data from 1,833 participants (aged 61-69) in Wave 5 (collected in years 2010/11) of the English Longitudinal Study of Ageing (ELSA) eligible for having been sent at least one CRC screening invitation. Uptake was defined by self-report of ever having been screened as part of the National Screening Programme. We assessed socio-economic inequality using the corrected concentration index of uptake against SES rank, which was derived by regressing a range of SES markers against net non-pension household wealth. Other demographic and health-related variables were included in the analysis. Factors associated with inequality were measured using concentration index decomposition.There was a significant pro-rich gradient in screening uptake (concentration index: 0.16, 95% CI:0.11-0.22), mostly explained within our model by differences in non-pension wealth (38.7%), partner screening status (15.9%), sickness/disability (13.5%), and health literacy (8.5%).Interventions aimed at reducing inequalities in CRC screening uptake should focus on improving acceptability of screening in populations with low levels of education and literacy barriers.

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“…If socioeconomic deprivation is associated with fewer perceived benefits of and greater perceived barriers to uptake, as it is for cancer screening, then an intervention using the QBE may increase uptake inequality. 56 How might offering an incentive for questionnaire return affect the social patterning of responses to the question-behaviour effect?…”

Section: Financial Incentives To Increase Questionnaire Return Ratesmentioning

confidence: 99%

Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records

McDermott

Wright

Cornelius

et al. 2016

Health Technol Assess

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BackgroundA national programme of health checks to identify risk of cardiovascular disease (CVD) is being rolled out but is encountering difficulties because of low uptake.ObjectiveTo evaluate the effectiveness of an enhanced invitation method using the question–behaviour effect (QBE), with or without the offer of a financial incentive to return the QBE questionnaire, at increasing the uptake of health checks. The research went on to evaluate the reasons for the low uptake of invitations and compare the case mix for invited and opportunistic health checks.DesignThree-arm randomised trial and cohort study.ParticipantsAll participants invited for a health check from 18 general practices. Individual participants were randomised.Interventions(1) Standard health check invitation only; (2) QBE questionnaire followed by a standard invitation; and (3) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by a standard invitation.Main outcome measuresThe primary outcome was completion of the health check within 6 months of invitation. Ap-value of 0.0167 was used for significance. In the cohort study of all health checks completed during the study period, the case mix was compared for participants responding to invitations and those receiving ‘opportunistic’ health checks. Participants were not aware that several types of invitation were in use. The research team were blind to trial arm allocation at outcome data extraction.ResultsIn total, 12,459 participants were included in the trial and health check uptake was evaluated for 12,052 participants for whom outcome data were collected. Health check uptake was as follows: standard invitation, 590 out of 4095 (14.41%); QBE questionnaire, 630 out of 3988 (15.80%); QBE questionnaire and financial incentive, 629 out of 3969 (15.85%). The increase in uptake associated with the QBE questionnaire was 1.43% [95% confidence interval (CI) –0.12% to 2.97%;p = 0.070] and the increase in uptake associated with the QBE questionnaire and offer of financial incentive was 1.52% (95% CI –0.03% to 3.07%;p = 0.054). The difference in uptake associated with the offer of an incentive to return the QBE questionnaire was –0.01% (95% CI –1.59% to 1.58%;p = 0.995). During the study period, 58% of health check cardiovascular risk assessments did not follow a trial invitation. People who received an ‘opportunistic’ health check had greater odds of a ≥ 10% CVD risk than those who received an invited health check (adjusted odds ratio 1.70, 95% CI 1.45 to 1.99;p < 0.001).ConclusionsUptake of a health check following an invitation letter is low and is not increased through an enhanced invitation method using the QBE. The offer of a £5 incentive did not increase the rate of return of the QBE questionnaire. A high proportion of all health checks are performed opportunistically and not in response to a standard invitation letter. Participants receiving opportunistic checks are at higher risk of CVD than those responding to standard invitations. Future research should aim to increase the accessibility of preventative medical interventions to increase uptake. Research should also explore the wider use of electronic health records in delivering efficient trials.Trial registrationCurrent Controlled Trials ISRCTN42856343.FundingThis project was funded by the NIHR Health Technology Assessment programme and will be published in full inHealth Technology Assessment; Vol. 20, No. 84. See the NIHR Journals Library website for further project information.

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Psychosocial Determinants of Socioeconomic Inequalities in Cancer Screening Participation: A Conceptual Framework

Cited by 143 publications

References 181 publications

Underuse and Overuse of Osteoporosis Screening in a Regional Health System: a Retrospective Cohort Study

Underuse and Overuse of Osteoporosis Screening in a Regional Health System: a Retrospective Cohort Study

Decomposing socio-economic inequality in colorectal cancer screening uptake in England

Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records

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