Small-area spatio-temporal analyses of participation rates in the mammography screening program in the city of Dortmund (NW Germany)

Abstract

BackgroundThe population-based mammography screening program (MSP) was implemented by the end of 2005 in Germany, and all women between 50 and 69 years are actively invited to a free biennial screening examination. However, despite the expected benefits, the overall participation rates range only between 50 and 55 %. There is also increasing evidence that belonging to a vulnerable population, such as ethnic minorities or low income groups, is associated with a decreased likelihood of participating in screening programs. This study aimed to analyze in more detail the intra-urban variation of MSP uptake at the neighborhood level (i.e. statistical districts) for the city of Dortmund in northwest Germany and to identify demographic and socioeconomic risk factors that contribute to non-response to screening invitations.MethodsThe numbers of participants by statistical district were aggregated over the three periods 2007/2008, 2009/2010, and 2011/2012. Participation rates were calculated as numbers of participants per female resident population averaged over each 2-year period. Bayesian hierarchical spatial models extended with a temporal and spatio-temporal interaction effect were used to analyze the participation rates applying integrated nested Laplace approximations (INLA). The model included explanatory covariates taken from the atlas of social structure of Dortmund.ResultsGenerally, participation rates rose for all districts over the time periods. However, participation was persistently lowest in the inner city of Dortmund. Multivariable regression analysis showed that migrant status and long-term unemployment were associated with significant increases of non-attendance in the MSP.ConclusionLow income groups and immigrant populations are clustered in the inner city of Dortmund and the observed spatial pattern of persistently low participation in the city center is likely linked to the underlying socioeconomic gradient. This corresponds with the findings of the ecological regression analysis manifesting socioeconomically deprived neighborhoods as risk factors for low attendance in the MSP. Spatio-temporal surveillance of participation in cancer screening programs may be used to identify spatial inequalities in screening uptake and plan spatially focused interventions.

Spatial distribution of mammography adherence in a Swiss urban population and its association with socioeconomic status

“…Our results show that geographical clusters of mammography adherence can be identified in an urban setting like Geneva, Switzerland. While similar clusters have been previously reported in other circumstances using ecological data [18-19,7,20], we report it for the first time using data at the individual level by considering geographic space as a continuum rather than according to predefined administrative units.…”

“…Previous ecological studies, such as Lemke et al, have suggested that clustering was due to low-income and immigrant populations inhabiting neighbourhoods with low mammography adherence [19]. Ecological studies are prone to the ecological fallacy with conclusions about individuals being drawn from group-level analyses; they are based on the mean behaviour of each group and are thereby unable to assess within-group variation.…”

Spatial distribution of mammography adherence in a Swiss urban population and its association with socioeconomic status

“…Our results show that geographical clusters of mammography adherence can be identified in an urban setting like Geneva, Switzerland. While similar clusters have been previously reported in other circumstances using ecological data, we report it for the first time using data at the individual level by considering geographic space as a continuum rather than according to predefined administrative units.…”

“…Previous ecological studies, such as Lemke et al, have suggested that clustering was due to low‐income and immigrant populations inhabiting neighborhoods with low mammography adherence . Ecological studies are prone to the ecological fallacy with conclusions about individuals being drawn from group‐level analyses; they are based on the mean behavior of each group and are thereby unable to assess within‐group variation.…”

The breast cancer paradox: A systematic review of the association between area-level deprivation and breast cancer screening uptake in Europe

“…1 (with further details in Appendix C). In total, 13 unique primary studies (representing 14 articles) from seven countries were included in the review: England (n = 4, from 5 articles) [ [23] , [24] , [25] , [26] , [27] ], France (n = 3) [ 19 , 28 , 29 ], Germany (n = 1) [ 30 ], Italy (n = 1) [ 31 ], Sweden (n = 1) [ 18 ], the Netherlands (n = 1) [ 17 ] and Turkey (n = 2) [ 32 , 33 ]. All countries ran screening programmes, although it is acknowledged that, in Turkey, breast cancer screening is still performed primarily on an opportunistic basis [ 32 , 33 ].…”