Numerous studies have examined the relationship between socio-economic and demographic factors and the uptake of breast and cervical screening tests, as the characteristics of the screened population may influence the effectiveness and uptake of the screening programme (Lorant et al., 2002; Damiani et al., 2012; Damiani et al., 2011; Wells and Roetzheim, 2007; Garrido-Cumbrera et al., 2010; Palencia et al., 2010). Factors such as: older age (>50 for breast cancer), lower education, lower economic situation (incl. higher level of deprivation) being single or divorced, belonging to ethnic minority or living in a rural location, have been widely discussed as having a positive association with lower uptake of breast and cancer screening (Chiu, 2004; Sutton and Rutherford, 2005; Thomas et al., 2005). The most important determinants of breast and cervical cancer screening uptake are discussed in greater detail in the following sections.
Age
Differences between different age-groups in the uptake of cervical screening have been noted previously (Cancer Research UK, 2011). Young women in their 20s and 30s who decide not to attend cervical screening often report that this is due to unsuitable appointment times or difficulty fitting it around their busy lifestyles, whereas older women aged 50 and over tend to be embarrassed by the procedure (Cancer Research UK - Press release, 2011). Champion (1994) noted that breast screening compliance (1 and 5 year screening) was lower for women aged 50 or over than younger women (<50 years old) (Champion, 1994). Jepson et al. (2000) reported in their review that age was a significant predictor for Pap screening uptake in the
majority of the reviewed publications but the effects of the association in the reviewed studies were conflicting as the screening status and age of the study subjects varied (Jepson et al. 2000). Also a Polish study conducted amongst 109 women attending cost free prophylactic mammography showed such positive correlation (Prażnowska et al., 2010). The breast screening attendance decreased after the age of 55 years old (target screening age in Poland is 50-69) (Prażnowska et al., 2010).
Marital status
Marital status has been found to be associated with the uptake of both breast and cervical screening (Damiani et al., 2012; Sutton and Rutherford, 2005; Macedo et al., 2012; Martin- Lopez et al., 2010; Jelastopulu et al., 2013; Soni, 2007). For example Soni (2007) found that married women (75.6%) were more likely than never married (62.8%) or no longer married (64.1%) to take up mammograms. Also married women (81.3%) were more likely than never married (72.8%) or no-longer married women (67.9%) to receive a breast exam. (Soni, 2007). Later Damiani et al. (2012) confirmed these findings. They reported that married were 1.83 times more likely than single women to uptake regular breast cancer prevention 95% CI=1.56- 2.15). Being married in comparison to not being married was also significantly associated with higher uptake of Pap test (OR=2.41; 95% CI=2.23-2.60) (Damiani et al., 2012). Jelastopulu et al. (2013) found a very similar relationship between marital status and Pap test uptake. Married or partnered women were 2.4 times more likely to than single women to utilise cervical screening (95% CI 1.4-4.1).
Education, employment and income
Various studies across the world show that literacy and health literacy have been found to be linked with the uptake of screening (Day et al., 2010). A positive association of education and occupation with uptake of both breast and cervical screening has been confirmed by many researchers (Damiani et al., 2012; Duport et al., 2008; Hewitt et al., 2004). One of the studies conducted amongst Italian women revealed that higher levels of education and being in employment is related to higher likelihood to undergo a mammogram than being less educated or unemployed (OR=1.77; 95% CI=1.55-2.03, OR=1.63; 95% CI=1.40-1.91 respectively). When comparing women in the highest occupational class with those in the lowest it was
found that there was a significant difference between those groups (OR=1.81; 95% CI=1.63- 2.01). The researchers also found that screening invitees with lower education or lower occupational levels were more likely to attend organised screening programmes than the more advantaged women who also attended those services from their own initiative (Damiani et al., 2012). Similar outcomes of lower uptake of cervical screening were observed amongst Polish women with basic education in comparison with the ones educated to a high school or higher level (20% versus 6% respectively) (Spaczyński et al., 2010). Thirty eight per cent (38%) of the women with highest education indicated that they attended screening only in private health clinics (Spaczyński et al., 2010). Over the years the literacy and education levels in Poland improved. In the mid 20th century over 50% of Polish people were literate (Unesco, 2006), by 1994 reaching 99% and in 2010, 100% (World Bank, 2013). In 2002, 10.4% of women obtained a university degree versus 18.8% in 2011. This resulted in a decrease of numbers of women in each of the remaining educational groups (high school: 35.1% in 2002 vs. 33.7% in 2011; technical: 16.9% in 2002 vs. 15.9% in 2011; complete primary: 31.4% in 2002 vs. 25.0% in 2011; and incomplete primary or lack of formal education: 4.3 % in 2002 vs. 1.7% in 2011) (Central Statistical Office of Poland, 2012b). Today education between ages 7 and 18 years old is compulsory and guaranteed by the Constitution of the Republic of Poland to every citizen. Education delivered in public schools is cost free and with equally accessible to the citizens (EURYDICE, 2012).
Researchers also showed that there is strong association between low income, level of deprivation and lower uptake of screening services (Blanks et al., 2002; Lofters et al., 2011; Champion, 1994). For example in Ontario (Canada) it has been shown that not being in the 35- 49 year age group and living in the neighbourhoods with the lowest income was one of the predictors of low cervical screening uptake (Lofters et al., 2011). Blanks et al. (2002) found that women who attended breast cancer screening in the UK were more likely to live in less deprived areas than those who did not attend it (Blanks et al., 2002). Due to the political and historical background it is difficult to assess the levels of deprivation in Poland. In 2009, there were 17.4% Polish women living in poverty (poverty line: <60% of median equalized income of households) and 15.3% in deep poverty (inability to afford four or more of nine essential needs) (Szarfenberg, 2010). The European Working Conditions Observatory (2010) noted that
the majority of the working poor (people who are below poverty line despite being employed) Poland are aged 40 years or more, and they live in multigenerational households (often two or three generations) (Towalski and Kuźmicz, 2010). It has been stated that working poor are visible in the labour market however they are not present in the social or fiscal policy institutions (Towalski and Kuźmicz, 2010). Towalski and Kuźmicz (2010) also described a study conducted in 2008 by the Centre for Public Opinion Research (CBOS) which indicated that on average, households that were classified as working poor were composed on average of 4.2 people; versus 3.2 in the working non-poor and 2.6 people in the non-working poor. The working poor were the most common amongst two generation (57.7%) and multi-generation households (16.8%), respectively (Centrum Badania Opinii Społecznej (CBOS), 2008; Towalski and Kuźmicz, 2010). The same study has also showed that the working poor have lower financial expectations when compared to all other groups including even those of the non-working poor (CBOS, 2008). Wide spread poverty amongst working Poles makes it challenging to consider employment status a proxy for economic situation. Therefore, the most important proxies for poverty or deprivation in Poland are the household characteristics and self-assessed needs and expectations (Towalski and Kuźmicz, 2010). Considering these facts the data on self-assessed economic status analysed in this thesis were treated as proxy for the level of economic status.
Rural versus urban setting
According to the most recent estimates (2011) 60.2% of Polish people live in the urban areas (61.8% in 2002) (Central Statistical Office of Poland, 2012b). Lower levels of both breast and cervical uptake can be observed especially amongst rural populations (Day et al., 2010; Spaczyński et al., 2010; Jokiel and Bielska-Lasota, 2005). Spaczyński at al. (2010) conducted a survey amongst a convenience sample of 1,625 Polish women (age: 25-59) who visited gynaecology clinics in Poland (for various reasons) and found that more women living in the rural areas (15.2%) than urban (8%) decide not to take up cervical screening (Spaczyński et al., 2010). Another study among Polish women that attended free prophylactic mammography showed that only 10% of the women in the studied sample lived in a rural region (Prażnowska et al., 2010). Even though the evidence for Poland is very limited it is likely that women from rural areas will have a limited access to the screening services.