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
] 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
]. 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
]. 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
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
]. 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 [42
]. 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
]. 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
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.