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

Abstract

Background: Cervical 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. Methods: Using 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. Results: Our 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. Conclusions: Reducing 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.

Economic Crisis: A Factor for the Delayed Diagnosis of Breast Cancer

“…Furthermore, austerity measures required to limit the financial effects of the crisis have been demonstrated to significantly impact health inequalities [20]. The presence of such inequalities represents a basis for a delayed cancer diagnosis, particularly in individuals with a low education level, without medical insurance coverage, or with low income [22]. These differences in health inequalities during periods of economic crisis may be more prevalent in low-and middle-income countries, where several factors may contribute to accentuate the negative effects of financial disparities [20,22].…”

“…The presence of such inequalities represents a basis for a delayed cancer diagnosis, particularly in individuals with a low education level, without medical insurance coverage, or with low income [22]. These differences in health inequalities during periods of economic crisis may be more prevalent in low-and middle-income countries, where several factors may contribute to accentuate the negative effects of financial disparities [20,22]. As seen in the present study the economic factor determines a significant delay in the moment of diagnosis, recording a more advanced breast cancer stage.…”

“…As previously mentioned, one of the effects of the economic crisis was reflected in an increase in the unemployment rate, with a direct consequence on individual income level. Merino-Ventosa et al have shown that during the economic crisis income-related inequalities have determined a decrease in cervical cancer screening for individuals with a lower income, despite an increase in screening capacity over time [22]. On a more general note, all-cause cancer mortality rates were significantly increased and correlated to unemployment rate in a longitudinal analysis of 75 countries worldwide.…”

“…Cancer mortality, in general, has been shown to increase during periods of economic instability [19,20], the crisis of 2007-2008 is estimated to have generated an added 260,000 cancer-related deaths in The Organization for Economic Cooperation and Development alone [21]. Financial disparity has a significant impact on health inequalities, a condition that has both short and long-term deleterious effects on public health, particularly in at-risk population groups [19,20,22]. Maynou et al have shown in an analysis of the effect of economic crisis on overall mortality and cause-specific mortality in the European Union, that implementation of austerity measures increased health disparities secondary to socioeconomic inequalities [20].…”

Wealth-related inequalities of women’s knowledge of cervical cancer screening and service utilisation in 18 resource-constrained countries: evidence from a pooled decomposition analysis

“…The relationship between health care utilisation and socio-demographic characteristics has been widely addressed in the literature [26][27][28][29][30]. Low levels of knowledge and uptake of CC screening services are linked to low socio-economic status (SES) [23,27,31], poverty and poor economic development at the country level, and inadequate health services, such as limited health facilities, unaffordability of services, poor quality of cytology services and lack of culturally appropriate and acceptable screening methods [3, 8, 20-22, 26, 32-35].…”