Macro-contextual determinants of cancer screening participation and inequalities: A multilevel analysis of 29 European countries
Open accessAbstract
BACKGROUND: Little attention has been devoted to the role of macro-level determinants in preventive health inequalities, particularly in cancer screening participation. Research has evidenced inequalities in cancer screening uptake yet has mainly focused on the screening programmes' moderating role at the macro-level. To address this gap, this study examines how welfare provision and healthcare system features modify cancer screening uptake and inequalities across European countries. METHODS: Data from 99 715 (Pap smear) and 54 557 (mammography) women in 29 countries from the European Health Interview Survey (EHIS) 2014 wave and Swiss Health Interview Survey (SHIS) 2012 wave was analysed. We estimated multilevel logistic regression models, including cross-level interactions, to examine whether social protection expenditure in particular policy areas and healthcare system characteristics explained cross-country differences in Pap smear and mammography uptake and inequalities. RESULTS: Main findings revealed that GP gatekeeping systems were associated with reduced screening uptake likelihood in both Pap smear and mammography, and so were stronger primary care systems in Pap smear, while higher expenditures on old age and survivors were associated with increased mammography uptake. Cross-level interactions showed that in countries with higher expenditures on sickness/healthcare, disability, social exclusion and public health, and a higher number of GPs, educational inequalities in both Pap smear and mammography uptake were smaller, while higher out-of-pocket payments had the opposite effect of increasing inequalities. CONCLUSIONS: Overall, our results show that social protection policies and healthcare system features affect cancer screening participation. We conclude that institutional and policy arrangements interact with individuals' (educational) resources and, through the (re)distribution of valued goods and resources at the macro level, these arrangements may contribute to enhancing preventive healthcare use and mitigating screening uptake inequalities.
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In the European Union, gatekeeping systems where a physician referral is required for screening were barriers to BC and CC screening.
“In the European Union, an international survey study revealed that gatekeeping systems where a physician referral is required for screening were barriers to BC and CC screening [37].”
From Improving cancer screening uptake: A behavioural and cultural insights perspective and rapid review (2026) · cites this paper as [37]
The Results report that GP referral combined with capitation was associated with lower Pap smear (CC) and mammography (BC) uptake. The claim omits capitation and describes an observed association as a barrier. The Methods (Data; Measures) also show that the 29-country sample included non-EU countries, so the study was not confined to the European Union. (LLM, conf=0.86)
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“Our results are in line with a population-level approach of prevention which attends to upstream socioeconomic determinants of health, as opposed to downstream approaches which focus on individual agency (McGill et al., 2015).”
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Improving cancer screening uptake: A behavioural and cultural insights perspective and rapid review
Palsola, M., Likki, T., Snijders, V., Corbex, M., Lasierra, L., & Curtis, B. (2026) · Glasnik javnog zdravlja · doi:10.5937/serbjph2601086p
- Authors
- Jolidon, V., Bracke, P., & Burton-Jeangros, C.
- Affiliations
- University of Geneva (CH)
- Ghent University (BE)
- Corresponding author
- Jolidon, Vladimir
- Venue
- SSM - Population Health
- Publisher
- Elsevier BV
- Published
- 2021-09
- Volume
- 15
- Pages
- 100830
- ISSN
- 2352-8273 (ISSN-L)
- PMC
- PMC8184663
- OpenAlex
- W3171875532
- Cited by
- 27
- References
- 2
- Citations by year
- 2026: 7 · 2025: 4 · 2024: 9 · 2023: 2 · 2022: 4 · 2021: 1
- FWCI
- 1.46
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- SSM - Population Health (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Ghent University Academic Bibliography (Ghent University) (publishedVersion, other-oa)
- Archive ouverte UNIGE (University of Geneva) (publishedVersion, other-oa)
- Ghent University Academic Bibliography (Ghent University) (submittedVersion, cc-by)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Archive ouverte UNIGE (University of Geneva) (submittedVersion, cc-by)
- Funders
- Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (176115)
- FWO (FWOOPR2018005701)
- Topics
- Health Sciences › Medicine › Oncology › Global Cancer Incidence and Screening
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Women's cancer prevention and management
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
- Keywords
- cancer screening uptake, health disparities, macro-level determinants, social protection expenditure, primary care, Pap smear, mammography, educational inequality, out-of-pocket costs, cross-national comparison, preventive medicine
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