"Not Alone in Loneliness": A Qualitative Evaluation of a Program Promoting Social Capital among Lonely Older People in Primary Health Care.

The weekly group-based program "Paths: from loneliness to participation" was conducted face-to-face over 15 sessions by nurses, social workers and volunteers in primary care in Catalonia (Spain) to alleviate loneliness among older people by promoting peer support and participation in community assets. We aimed at exploring participants' experiences of loneliness and participation prior to the program and its perceived benefits. The qualitative design was descriptive-interpretative. Data were collected through three focus groups and 41 interviews applying a semistructured topic guide involving 26 older participants, six professionals and nine volunteers. Participant-observation of all sessions involved the 38 older people who started the program. A thematic content analysis was applied. Older persons with diverse profiles of loneliness and participation explained different degrees of decrease in loneliness, an increase in participation in local community assets, companionship, peer support and friendship, and an empowerment process. Successful cases reported improvements in mental wellbeing and recovering the sense that life was worth living. Loneliness persisted among some widowed participants and vulnerabilities hampered some benefits. Participants, professionals and volunteers reported different degrees of success in older people to alleviate loneliness by enhancing social relationships and activities through complex processes interrelated with health and socioeconomic factors.

[How to measure the migration status of the child and young population? Studies on health and inequalities in health in Europe]. / ¿Cómo medir el estatus migratorio de la población infantil y juvenil? Estudios sobre salud y desigualdades en salud en Europa.

OBJECTIVE: To analyse how the migration status of the child and young population is measured in the scientific literature on health and social inequalities in health in Europe. METHOD: A systematic search of the literature published in Spanish, English and French between 2007 and 2017 in PubMed and Social Sciences Citation Index was carried out. The included studies analysed health and social inequalities in health of a population under 18 years old according to its migration origin in Europe. The variables used to measure the migration status were described. RESULTS: 50 articles were included. Twenty studies analysed perinatal health, eleven mental health, nine dental health, and ten studies other variables. The main variables to define migration status were the country of birth (32 studies), either of the child, the mother, or one of the parents, and sometimes in a complementary way. Less frequent was the use of nationality (15 studies), of the child, or of the parents, especially the mother. Migration status is referred to in very different ways, not always comparable and sometimes the variable used is not clearly explained. CONCLUSIONS: There is a great diversity of ways to measure migration status in the child and young population. A better definition and consensus is needed to improve the temporal and geographical comparability of knowledge in this area, which will help to design public policies aimed at reducing social inequalities in health from childhood.

[Public participation in research projects: ways of creating collective knowledge in health]. / Participación pública en los proyectos de investigación: formas de crear conocimiento colectivo en salud.

Public participation in research projects is an emerging area in Spain and Latin American countries. There are five types of projects according to the degree of involvement that the participants have in the processes: contributory, collaborative, co-created, contractual and independent. In order to promote public participation in health research teams, their practices and competencies need to be redefined. To this end, it may be useful to ask questions in the different phases of the research, as well as to develop strategies that include audiences that have fewer channels of participation in favour of favouring equity in health. This way of doing science allows gathering experience and expertise prioritizing and adapting the research to the needs of the population, which increases its transforming capacity and the social impact of its results.

Coping Strategies and Social Support in a Mobile Phone Chat App Designed to Support Smoking Cessation: Qualitative Analysis.

BACKGROUND: Smoking is one of the most significant factors contributing to low life expectancy, health inequalities, and illness at the worldwide scale. Smoking cessation attempts benefit from social support. Mobile phones have changed the way we communicate through the use of freely available message-oriented apps. Mobile app-based interventions for smoking cessation programs can provide interactive, supportive, and individually tailored interventions. OBJECTIVE: This study aimed to identify emotions, coping strategies, beliefs, values, and cognitive evaluations of smokers who are in the process of quitting, and to analyze online social support provided through the analysis of messages posted to a chat function integrated into a mobile app. METHODS: In this descriptive qualitative study, informants were smokers who participated in the chat of Tobbstop. The technique to generate information was documentary through messages collected from September 2014 through June 2016, specifically designed to support a smoking cessation intervention. A thematic content analysis of the messages applied 2 conceptual models: the Lazarus and Folkman model to assess participant's experiences and perceptions and the Cutrona model to evaluate online social support. RESULTS: During the study period, 11,788 text messages were posted to the chat by 101 users. The most frequent messages offered information and emotional support, and all the basic emotions were reported in the chat. The 3 most frequent coping strategies identified were physical activity, different types of treatment such as nicotine replacement, and humor. Beliefs about quitting smoking included the inevitability of weight gain and the notion that not using any type of medications is better for smoking cessation. Health and family were the values more frequently described, followed by freedom. A smoke-free environment was perceived as important to successful smoking cessation. The social support group that was developed with the app offered mainly emotional and informational support. CONCLUSIONS: Our analysis suggests that a chat integrated into a mobile app focused on supporting smoking cessation provides a useful tool for smokers who are in the process of quitting, by offering social support and a space to share concerns, information, or strategies.

Complex multiple risk intervention to promote healthy behaviours in people between 45 to 75 years attended in primary health care (EIRA study): study protocol for a hybrid trial.

BACKGROUND: Health promotion is a key process of current health systems. Primary Health Care (PHC) is the ideal setting for health promotion but multifaceted barriers make its integration difficult in the usual care. The majority of the adult population engages two or more risk behaviours, that is why a multiple intervention might be more effective and efficient. The primary objectives are to evaluate the effectiveness, the cost-effectiveness and an implementation strategy of a complex multiple risk intervention to promote healthy behaviours in people between 45 to 75 years attended in PHC. METHODS: This study is a cluster randomised controlled hybrid type 2 trial with two parallel groups comparing a complex multiple risk behaviour intervention with usual care. It will be carried out in 26 PHC centres in Spain. The study focuses on people between 45 and 75 years who carry out two or more of the following unhealthy behaviours: tobacco use, low adherence to the Mediterranean dietary pattern or insufficient physical activity level. The intervention is based on the Transtheoretical Model and it will be made by physicians and nurses in the routine care of PHC practices according to the conceptual framework of the "5A's". It will have a maximum duration of 12 months and it will be carried out to three different levels (individual, group and community). Incremental cost per quality-adjusted life year gained measured by the tariffs of the EuroQol-5D questionnaire will be estimated. The implementation strategy is based on the "Consolidated Framework for Implementation Research", a set of discrete implementation strategies and an evaluation framework. DISCUSSION: EIRA study will determine the effectiveness and cost-effectiveness of a complex multiple risk intervention and will provide a better understanding of implementation processes of health promotion interventions in PHC setting. It may contribute to increase knowledge about the individual and structural barriers that affect implementation of these interventions and to quantify the contextual factors that moderate the effectiveness of implementation. TRIAL REGISTRATION: ClinicalTrials.gov , NCT03136211 .Retrospectively registered on May 2, 2017.

Talking to the people that really matter about their participation in pandemic clinical research: A qualitative study in four European countries.

BACKGROUND: Pandemics of new and emerging infectious diseases are unpredictable, recurrent events that rapidly threaten global health and security. We aimed to identify public views regarding provision of information and consent to participate in primary and critical care clinical research during a future influenza-like illness pandemic. METHODS: Descriptive-interpretive qualitative study, using focus groups (n = 10) and semi-structured interviews (n = 16), with 80 members of the public (>18 years) in Belgium, Spain, Poland and the UK. Local qualitative researchers followed a scenario-based topic guide to collect data. Data were transcribed verbatim, translated into English and subject to framework analysis. RESULTS: Public understandings of pandemics were shaped by personal factors (illness during the previous H1N1 pandemic, experience of life-threatening illness) and social factors (historical references, media, public health information). Informants appreciated safeguards provided by ethically robust research procedures, but current enrolment procedures were seen as a barrier. They proposed simplified enrolment processes for higher risk research and consent waiver for certain types of low-risk research. Decision making about research participation was influenced by contextual, research and personal factors. Informants generally either carefully weighed up various approaches to research participation or responded instinctively. They supported the principle of using routinely collected, anonymized clinical biological samples for research without explicit consent, but regarded this as less acceptable if researchers were motivated primarily by commercial gain. CONCLUSIONS: This bottom-up approach to ascertaining public views on pandemic clinical research has identified support for more proportionate research protection procedures for publically funded, low-risk studies.

Smokefree legislation effects on respiratory and sensory disorders: A systematic review and meta-analysis.

AIMS: The aim of this systematic review and meta-analysis is to synthesize the available evidence in scientific papers of smokefree legislation effects on respiratory diseases and sensory and respiratory symptoms (cough, phlegm, red eyes, runny nose) among all populations. MATERIALS AND METHODS: Systematic review and meta-analysis were carried out. A search between January 1995 and February 2015 was performed in PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, and Google Scholar databases. Inclusion criteria were: 1) original scientific studies about smokefree legislation, 2) Data before and after legislation were collected, and 3) Impact on respiratory and sensory outcomes were assessed. Paired reviewers independently carried out the screening of titles and abstracts, data extraction from full-text articles, and methodological quality assessment. RESULTS: A total number of 1606 papers were identified. 50 papers were selected, 26 were related to symptoms (23 concerned workers). Most outcomes presented significant decreases in the percentage of people suffering from them, especially in locations with comprehensive measures and during the immediate post-ban period (within the first six months). Four (50%) of the papers concerning pulmonary function reported some significant improvement in expiratory parameters. Significant decreases were described in 13 of the 17 papers evaluating asthma hospital admissions, and there were fewer significant reductions in chronic obstructive pulmonary disease admissions (range 1-36%) than for asthma (5-31%). Six studies regarding different respiratory diseases showed discrepant results, and four papers about mortality reported significant declines in subgroups. Low bias risk was present in 23 (46%) of the studies. CONCLUSIONS: Smokefree legislation appears to improve respiratory and sensory symptoms at short term in workers (the overall effect being greater in comprehensive smokefree legislation in sensory symptoms) and, to a lesser degree, rates of hospitalization for asthma.

Health-care users, key community informants and primary health care workers' views on health, health promotion, health assets and deficits: qualitative study in seven Spanish regions.

BACKGROUND: Although some articles have analysed the definitions of health and health promotion from the perspective of health-care users and health care professionals, no published studies include the simultaneous participation of health-care users, primary health care professionals and key community informants. Understanding the perception of health and health promotion amongst these different stakeholders is crucial for the design and implementation of successful, equitable and sustainable measures that improve the health and wellbeing of populations. Furthermore, the identification of different health assets and deficits by the different informants will generate new evidence to promote healthy behaviours, improve community health and wellbeing and reduce preventable inequalities. The objective of this study is to explore the concept of health and health promotion and to compare health assets and deficits as identified by health-care users, key community informants and primary health care workers with the ultimate purpose to collect the necessary data for the design and implementation of a successful health promotion intervention. METHODS: A descriptive-interpretive qualitative research was conducted with 276 participants from 14 primary care centres of 7 Spanish regions. Theoretical sampling was used for selection. We organized 11 discussion groups and 2 triangular groups with health-care users; 30 semi-structured interviews with key community informants; and 14 discussion groups with primary health care workers. A thematic content analysis was carried out. RESULTS: Health-care users and key community informants agree that health is a complex, broad, multifactorial concept that encompasses several interrelated dimensions (physical, psychological-emotional, social, occupational, intellectual, spiritual and environmental). The three participants' profiles consider health promotion indispensable despite defining it as complex and vague. In fact, most health-care users admit to having implemented some change to promote their health. The most powerful motivators to change lifestyles are having a disease, fear of becoming ill and taking care of oneself to maintain health. Health-care users believe that the main difficulties are associated with the physical, social, working and family environment, as well as lack of determination and motivation. They also highlight the need for more information. In relation to the assets and deficits of the neighbourhood, each group identifies those closer to their role. CONCLUSIONS: Generally, participants showed a holistic and positive concept of health and a more traditional, individual approach to health promotion. We consider therefore crucial to depart from the model of health services that focuses on the individual and the disease toward a socio-ecological health model that substantially increases the participation of health-care users and emphasizes health promotion, wellbeing and community participation.

Primary care patients' perspectives of barriers and enablers of primary prevention and health promotion-a meta-ethnographic synthesis.

BACKGROUND: Primary care (PC) patients have difficulties in committing to and incorporating primary prevention and health promotion (PP&HP) activities into their long-term care. We aimed to re-interpret, for the first time, qualitative findings regarding factors affecting PC patients' acceptance of PP&HP activities. METHODS AND FINDINGS: A meta-ethnographic synthesis was generated following electronic and manual searches that retrieved 29 articles. Papers were reviewed and translated to produce a re-interpretation of the extracted concepts. The factors affecting PC patients' receptiveness to PP&HP activities were framed in a four-level ecological model (intrapersonal, interpersonal, institutional and environment and society). Intrapersonal factors (patients' beliefs/attitudes, knowledge, skills, self-concept, motivation and resources) were the most numerous, with almost 25 different factors. Public health education to modify erroneous beliefs and values regarding PP&HP could encourage a transition to healthier lifestyles. Health care professionals' abilities to communicate and involve patients in the decision-making process can act as facilitators. Biopsychosocial training (with emphasis on communication skills) for health professionals must start with undergraduates. Increased consultation time, the use of reminders, follow-up visits and tools for communicating risk and motivating patients could be applied at the intrapersonal level. Collaborative care involving other health professionals (nutritionists or psychotherapists) and family and community stakeholders (teachers or gym trainers) was important in developing healthier habits. Patients also cited barriers related to the built environment and socioeconomic difficulties that highlighted the need for policies promoting social justice and equity. Encouraging PP&HP using social marketing strategies and regulating media to control its impact on health were also cited. Only the perspectives of PC patients in the context of chronic conditions were considered thus limiting extrapolation to other contexts. CONCLUSIONS: Several factors affect PP&HP. This must be taken into account when designing PP&HP activities if they are to be successfully implemented and maintained in routine practice.

Perceptions and beliefs of public policymakers in a Southern European city.

INTRODUCTION: Socio-economic inequalities in health are large in urban areas; however, local municipal governments may plan, manage and provide services and policies which can reduce these. The objective of this study was to describe the beliefs and perceptions of public policymakers in a European city, Barcelona. They are the key actors in designing and implementing urban public policies. METHODS: A qualitative research study describing policymakers' beliefs on health inequalities. The study population were twelve policymakers. These were politicians or officers from the city council. Informant profiles were selected using a theoretical sample. Semi-structured individual interviews were performed to collect the data and a thematic content analysis was carried out. RESULTS: Politicians were aware of health inequalities in their city and identified diverse social causes. They viewed reducing inequalities as a priority for the city's government. Officers were less knowledgeable and described less efforts in addressing health inequalities. It was stated by some that reducing inequalities in non-health sectors helped to reduce health inequalities indirectly and there was some collaboration between two sectors. The most frequent barriers encountered when implementing policies were funding and the cities' limited authority. CONCLUSIONS: Officers and policymakers had different levels of awareness and access to information on health and its social determinants. Officers referred to specific causes of health inequalities and policies which related to their sectors and politicians were more familiar with upstream determinants and policies. Some participants explained that policies and programmes needed to be evaluated and very little intersectoral action was said to be carried out. More efforts should be made to provide all policymakers with information on the social determinants of health inequalities. Research on health inequalities and policy should engage with policymakers and promote health as a cross cutting issue in the city council in liaison with the third sector.

Burden of multimorbidity, socioeconomic status and use of health services across stages of life in urban areas: a cross-sectional study.

BACKGROUND: The burden of chronic conditions and multimorbidity is a growing health problem in developed countries. The study aimed to determine the estimated prevalence and patterns of multimorbidity in urban areas of Catalonia, stratified by sex and adult age groups, and to assess whether socioeconomic status and use of primary health care services were associated with multimorbidity. METHODS: A cross-sectional study was conducted in Catalonia. Participants were adults (19+ years) living in urban areas, assigned to 251 primary care teams. MAIN OUTCOME: multimorbidity (≥2 chronic conditions). Other variables: sex (male/female), age (19-24; 25-44; 45-64; 65-79; 80+ years), socioeconomic status (quintiles), number of health care visits during the study. RESULTS: We included 1,356,761 patients; mean age, 47.4 years (SD: 17.8), 51.0% women. Multimorbidity was present in 47.6% (95% CI 47.5-47.7) of the sample, increasing with age in both sexes but significantly higher in women (53.3%) than in men (41.7%). Prevalence of multimorbidity in each quintile of the deprivation index was higher in women than in men (except oldest group). In women, multimorbidity prevalence increased with quintile of the deprivation index. Overall, the median (interquartile range) number of primary care visits was 8 (4-14) in multimorbidity vs 1 (0-4) in non-multimorbidity patients. The most prevalent multimorbidity pattern beyond 45 years of age was uncomplicated hypertension and lipid disorder. Compared with the least deprived group, women in other quintiles of the deprivation index were more likely to have multimorbidity than men until 65 years of age. The odds of multimorbidity increased with number of visits in all strata. CONCLUSIONS: When all chronic conditions were included in the analysis, almost 50% of the adult urban population had multimorbidity. The prevalence of multimorbidity differed by sex, age group and socioeconomic status. Multimorbidity patterns varied by life-stage and sex; however, circulatory-endocrine-metabolic patterns were the most prevalent multimorbidity pattern after 45 years of age. Women younger than 80 years had greater prevalence of multimorbidity than men, and women's multimorbidity prevalence increased as socioeconomic status declined in all age groups. Identifying multimorbidity patterns associated with specific age-related life-stages allows health systems to prioritize and to adapt clinical management efforts by age group.

Health inequalities in European cities: perceptions and beliefs among local policymakers.

OBJECTIVE: To describe the knowledge and beliefs of public policymakers on social inequalities in health and policies to reduce them in cities from different parts of Europe during 2010 and 2011. DESIGN: Phenomenological qualitative study. SETTING: 13 European cities. PARTICIPANTS: 19 elected politicians and officers with a directive status from 13 European cities. MAIN OUTCOME: Policymaker's knowledge and beliefs. RESULTS: Three emerging discourses were identified among the interviewees, depending on the city of the interviewee. Health inequalities were perceived by most policymakers as differences in life-expectancy between population with economic, social and geographical differences. Reducing health inequalities was a priority for the majority of cities which use surveys as sources of information to analyse these. Bureaucracy, funding and population beliefs were the main barriers. CONCLUSIONS: The majority of the interviewed policymakers gave an account of interventions focusing on the immediate determinants and aimed at modifying lifestyles and behaviours in the more disadvantaged classes. More funding should be put towards academic research on effective universal policies, evaluation of their impact and training policymakers and officers on health inequalities in city governments.

Municipal interventions against inequalities in health: The view of their managers.

BACKGROUND: European city councils are increasingly developing interventions against health inequalities. There is little knowledge about how they are perceived. This study describes and analyses good practices and challenges for local interventions on inequalities in health through the narratives of European city managers. METHODS: A qualitative study was conducted. Each participating city (Amsterdam, Barcelona, Cluj-Napoca, Helsinki, Lisbon, London, Madrid, Rotterdam) selected interventions following these criteria: at least 6 months of implementation; an evaluation performed or foreseen; the reduction of health inequalities among their objectives, and only one of the interventions selected could be based on health care. Managers of these local interventions were interviewed following an outline. Eleven individual in-depth interviews describing nine local interventions were obtained. A thematic content analysis was performed. RESULTS: One or more local interventions against health inequalities were identified in each city. Most relied on quantitative data and were linked to national strategies. Few interventions addressed socio-economic determinants. Health care, employment and education were the main determinants addressed. With variable depth, evidence-base, participation and intersectorality were regular components of the interventions. Half of them targeted the city and half some deprived neighbourhoods. Few interventions had been evaluated. Scarcity of funding and sustainability of the projects were the main perceived barriers by the managers. CONCLUSIONS: City intervention managers were familiar with health inequalities and concepts as intersectorality, participation and evidence-based action, but others such as socioeconomic aims, gradient approach, evaluation and sustainability were not so widely applied. Managers' capacities and political leadership in governance for health should be reinforced.

Social and health policies or interventions to tackle health inequalities in European cities: a scoping review.

BACKGROUND: Health inequalities can be tackled with appropriate health and social policies, involving all community groups and governments, from local to global. The objective of this study was to carry out a scoping review on social and health policies or interventions to tackle health inequalities in European cities published in scientific journals. METHODS: Scoping review. The search was done in "PubMed" and the "Sociological Abstracts" database and was limited to articles published between 1995 and 2011. The inclusion criteria were: interventions had to take place in European cities and they had to state the reduction of health inequalities among their objectives. RESULTS: A total of 54 papers were included, of which 35.2% used an experimental design, and 74.1% were carried out in the United Kingdom. The whole city was the setting in 27.8% of them and 44.4% were based on promoting healthy behaviours. Adults and children were the most frequent target population and half of the interventions had a universal approach and the other half a selective one. Half of the interventions were evaluated and showed positive results. CONCLUSIONS: Although health behaviours are not the main determinants of health inequalities, the majority of the selected documents were based on evaluations of interventions focusing on them.

Comparison of health policy documents of European cities: are they oriented to reduce inequalities in health?

Health policies are specified in documents that contain values, objectives, strategies, and interventions to be implemented. The objective of our study was to analyse health policy documents of six European cities and one county council published around 2010 to determine (i) how cities conceptualize health inequalities, and (ii) what strategies are proposed to reduce them. We performed a qualitative document analysis. We selected Health or Health Inequalities policy documents and analysed the following aspects: general characteristics of the document, inclusion and definition of health inequalities, promotion of good governance and participation, number of objectives, and evaluation. We also described specific objectives. Rotterdam, London, and Stockholm use a conceptual framework. Two of them define health inequalities as a social gradient. Intersectoral action, participation, and evaluation are included in most documents. Interventions focus mainly on the socioeconomic context.

Knowledge, attitude and perceptions of breast cancer screening among native and immigrant women in Barcelona, Spain.

OBJECTIVE: Inequalities between immigrant and native populations in terms of access and use of health services have been described. The objective is to compare knowledge, attitudes, vulnerabilities, benefits and barriers related to breast cancer (BC) and screening mammography among women from different countries resident in Barcelona. METHODS: A cross-sectional survey carried out in Barcelona in 2009. The study population consisted of female residents in Barcelona between 45 and 69 years of age; participants were Spanish nationals or immigrants from low-income countries. 960 participants were asked 72 questions, mainly with Likert responses. The dependent variables were five quantitative scales: (1) knowledge of BC and early detection, (2) attitude towards health and BC, (3) vulnerability to BC, (4) barriers to mammography, (5) benefits of mammography. The independent variables were country of origin, social class, setting, cohabitation, age, mammography use, length of residence and fluency of the language. Analyses compared scale scores stratified by the independent variables. Multivariable linear regression models were fitted to determine the relationship between the scales and the independent variables. RESULTS: We observed inequalities according to country of origin on all scales after adjustment for independent variables. Chinese women presented the greatest differences with respect to native women, followed by Maghrebi and Filipino women. Inequalities exist on the vulnerability and barriers scales according to social class and urban/rural setting, and on the attitude scale according to social class. CONCLUSIONS: Country of origin, social class and urban/rural setting are key contributors to inequality in these scales.

Preventive control of breast and cervical cancer in immigrant and native women in Spain: the role of country of origin and social class.

The study describes the periodic use of cervical and breast cancer screening by women residing in Spain, according to their country of origin, and analyzes whether the observed associations are modified by social class. A cross-sectional design was used, with the study population consisting of women residing in Spain in 2006, ages 25-65 years (N = 10,093) and 40-69 years (N = 6674) in the cervical and breast cancer screening groups, respectively. The information source was Spain's National Health Survey of 2006. The dependent variables were: undergoing periodic cervical cancer screening (every 5 years or less) and breast cancer screening (every 2 years or less). The independent variables were: country of origin, social class, health care coverage, cohabitation, and age. A descriptive analysis was carried out, and robust Poisson regression models were fitted. Women from low-income countries underwent fewer periodic screening exams for cervical cancer and breast cancer. Independent of country of origin, women from the manual classes underwent fewer screening exams than those from the non-manual classes. In the 50-69 years age group, it was mainly women from the manual classes from low-income countries who underwent fewer periodic mammograms. Having only public health care coverage and not cohabiting with a partner were also associated with lower prevalences of use.

Evolution of inequalities in breast and cervical cancer screening in Barcelona: population surveys 1992, 2001, and 2006.

OBJECTIVE: To describe and compare breast and cervical cancer screening among women in Barcelona in 1992, 2001, and 2006 by social class, age, and screening approach. METHODS: This was a study of trends based on analysis of Barcelona health interview surveys for the years 1992 (n=5,003), 2001 (n=10,030), and 2006 (n=6,050). Dependent variables were having regular mammographies (at least every 2 years) and having regular cytologic testing (at least every 3 years). Independent variables were age, social class, and survey year. A descriptive analysis was carried out. To compare prevalence in terms of social class and the years studied, we calculated prevalence differences (PD) and prevalence ratios (PR) by fitting robust Poisson regression models. RESULTS: In 1992, women aged 40?49 had more regular mammographies than those aged 50?69, with social class inequalities in both age groups. Having cervical cancer screening was more common than having breast cancer screening, with prevalence varying from 46.4% in the low social classes to 59.2% in the high classes. In 2001, breast cancer screening had risen, particularly in women aged 50?69, a tendency that had stabilized by 2006. Inequalities diminished over the period, more markedly in women aged 50?69; PRs of 1.22 and 1.58, respectively, for high and middle social classes with respect to the lowest class in 1992 fell to PRs of 1.07 and 1.08, respectively, in 2006. In the case of cervical cancer screening, inequalities also diminished but not to the same extent. CONCLUSIONS: Preventive screening for breast and cervical cancer has increased, and the population screening program for breast cancer among women aged 50?69 years appears to contribute more than opportunistic screening for cervical cancer in reducing social class inequalities.

Socio-economic inequalities in breast and cervical cancer screening practices in Europe: influence of the type of screening program.

BACKGROUND: The aim of this study was to describe inequalities in the use of breast and cervical cancer screening services according to educational level in European countries in 2002, and to determine the influence of the type of screening program on the extent of inequality. METHODS: A cross-sectional study was performed using individual-level data from the WHO World Health Survey (2002) and data regarding the implementation of cancer screening programmes. The study population consisted of women from 22 European countries, aged 25-69 years for cervical cancer screening (n =11 770) and 50-69 years for breast cancer screening (n = 4784). Dependent variables were having had a PAP smear and having had a mammography during the previous 3 years. The main independent variables were socio-economic position (SEP) and the type of screening program in the country. For each country the prevalence of screening was calculated, overall and for each level of education, and indices of relative (RII) and absolute (SII) inequality were computed by educational level. Multilevel logistic regression models were fitted. RESULTS: SEP inequalities in screening were found in countries with opportunistic screening [comparing highest with lowest educational level: RII = 1.28, 95% confidence interval (CI) 1.12-1.48 for cervical cancer; and RII = 3.11, 95% CI 1.78-5.42 for breast cancer] but not in countries with nationwide population-based programmes. Inequalities were also observed in countries with regional screening programs (RII = 1.35, 95% CI 1.10-1.65 for cervical cancer; and RII = 1.58, 95% CI 1.26-1.98 for breast cancer). CONCLUSIONS: Inequalities in the use of cancer screening according to SEP are higher in countries without population-based cancer screening programmes. These results highlight the potential benefits of population-based screening programmes.