Mapas genéticos

Systematic morbidity and mortality inequalities exist in the population of every country, also including those with a high development index (e.g., UK, Netherlands, or Sweden) (Mackenbach, 2012; Mackenbach, 2006). The aim of cancer screening programmes is to decrease mortality rates by detecting cancers at an early stage by providing an early, less invasive treatment intervention (Mauad et al., 2009). However, unequal access to, and quality

of health care including cancer prophylaxis might result in health inequalities (Marmot et al., 2012; Van der Meer and Mackenbach, 1998). The relationship between income inequality and health status has been well established (Chiu, 2003; Damiani et al., 2012). Socio-economic differences may result in unequal access to and uptake of breast and cervical cancer screening especially in countries without population-based cancer screening programmes (Palencia et al., 2010). Additionally, lower levels of education have been typically associated with lower screening uptake (Sabates and Feinstein, 2004). It has been suggested that individuals’ social interactions, place of habitation, and psychosocial characteristics, all have an effect on a patient’s health outcomes (Martikainen et al., 2002; Chiu, 2003). Many of these inequalities, within and between countries, are caused by inequalities in the social conditions in which people live and work (Irwin et al., 2006). These determinants have an impact on patients’ wellbeing. Tackling the underlying causes of poor health and understanding the problem can contribute to improving health and health equity (Feachem, 2000).

There is a growing body of theoretical and empirical work that explores the relationships between health inequalities and place of habitual residence (Mackenbach, 2012, Popay et al., 2003). Often those health differences are discussed in the context of the populations living in different countries, regions or even as being part of different social classes. For example many researchers discussed significant mortality and morbidity health differences between Central/Eastern and Western Europe (Adeyi et al., 1997; Bobak and Marmot, 1996; Carlson, 1998; Pardell et al., 2001; Zatonski and Bhala, 2012) often explaining them by the fact that Central/Eastern Europe was subject to substantial transition from communism to democracy (Adeyi et al., 1997; Wroblewska, 2003). Others noted health variations between regions of the same country, as for example breast cancer incidence varying between women from different socio-economic groups with higher rates among women with lower socio-economic status (Bray et al., 2004). This can be partially related to the fact that those from lower socio- economic groups are more likely not to take up the screening (Bray et al., 2004). For example Doran et al. (2004) pointed towards the widely discussed term of ‘North South’, divide referring to health inequalities between Northern and Southern parts of Britain which they hypothesised was due to differences between social classes and the level of deprivation (Doran et al., 2004). Similarly, the Report of the Nuffield Council on Bioethics (2007) mentioned a

great variation in health risks, health-related behaviours, physical and mental health, and life expectancy between different social groups. The report stated that the lower health related indices have been linked to lower socio-economic status, female gender, being from racial or ethnic minority, living in places with lower degree of urbanisation (Nuffield Council on Bioethics, 2007). Also religious views have been found to influence heath outcomes and health beliefs as for example the level of alcohol or other addictive substances use can depend on persons’ religious views (Nuffield Council on Bioethics, 2007).

It has been noted that inequalities in screening uptake of both programmes can be associated with being from an ethnic minority as these women may have different access to screening, lack of availability of screening advertisements in their language as well as potentially differing frequency of screening recommended by their physicians (Rodriguez et al., 2005; Scanlon et al., 2006; Thomas et al., 2005; Glick et al., 2012; Consedine et al., 2004; Tavafian, 2012). For example a study conducted in the U.S.A. by Consedine et al. (2004) found that women from different ethnic backgrounds in migrant communities have notably different attitudes towards screening. They noted that in particular Eastern European women reported fewer mammograms than other ethnic groups (Consedine et al., 2004). However, ethnicity as a factor for health or health outcome inequalities would not play a significant role in ethnically homogenous societies such as Poland, or many of the other former Soviet bloc states (Vojtěch, 2010). It has been estimated that only 3% of inhabitants of Poland constitute ethnic minorities (EURYDICE, 2012). Only Polish nationals having personal identification number were included in the data analysed in this thesis (please see 3.3 section).

The type of screening programme (opportunistic vs. population based) has been previously found to be associated with differences in health outcomes. For example Palencia et al. (2010) found that most of the breast and cervical cancer inequalities in Europe are found in countries with opportunistic screening rather than population based initiatives (relative inequality indices (RII) for cervical cancer; and RII=3.11, 95% CI 1.78–5.42 for breast cancer) (Palencia et al., 2010). Over the past two decades, WHO created the Commission on Social Determinants of Health (2005-2008) and developed community based initiatives to provide guidance for government to improve patients’ health, health related education and the quality

of the services enhancing the status of women and their role in the health of families (Commission on Social Determinants of Health, 2008; Irwin et al., 2006; Marmot et al., 2012). In order for health screening to be effective and efficient a significant part (>70%) of the population has to participate in it (Mauad et al., 2009; Szewczyk, 2011). Reduction of morbidity and mortality through the uptake of screening programmes requires the constant engagement of professionals involved in the screening and reaching the populations at risk (including women that might live in remote rural locations) (Mauad et al., 2009). Fister and McKee (2005) noted that many citizens of transitional regions such as Poland still remain insufficiently involved in decisions about their health care (Fister and McKee, 2005). Abbott et al. (2006) hypothesised that health risk behaviours tend to be linked with an inclination of patients to rely on the state to care for their health instead of accepting responsibility for their own health decisions (Abbott et al., 2006). For example, European Commission (2012) found that Eastern European patients find themselves discouraged from involvement in their health care and lacking control over it if the physician does not spend (in their opinion) sufficient time on consultation (European Commission, 2012). They also look for more partnered interaction with their health provider and expressed the need to receive more comprehensive information. However, due to the superiority of physician’s experience and knowledge the Eastern European patients are more likely to give high control of their health to their physician and are less aware, than their counterparts from other member states, of the opportunities to take control of their own health (European Commission, 2012).

Patient involvement in their own health care can be as important as good centralised screening systems (Fister and McKee, 2005) and in order to encourage patients to effectively participate in their care by participation in cancer screening many cultural, behavioural and socio- economic factors have to be addressed (Bobak et al., 2000; Fister and McKee, 2005). Understanding the characteristics, needs, beliefs, and perceptions of people living in different communities and with various levels of income is one of the steps to create comprehensive health programmes and policies because perceptions often reflect the attitudes towards health and are an important element of social exclusion or inclusion (Bullock, 1999, Lott, 2002).