Inequalities
Health inequalities principles for screening programmes.
Health inequalities are unfair and avoidable. They result from the wider social determinants of health, which include:
- general socioeconomic, cultural and environmental conditions
- living and working conditions
- social and community networks
- individual lifestyle factors
- age, sex and hereditary factors
Sub-groups that face barriers to screening will vary according to the eligible population for each programme, and may extend beyond those more usually identified (such as low socioeconomic status). For example, children who are home-schooled might find it difficult to access a screening programme delivered to children in school settings.
Systematic evidence-based screening should be offered to everyone in a target group, regardless of disability, ethnicity, socioeconomic status, education or other characteristics. It is an inherently fair concept that should reduce health disparities. However, barriers can result in some people being unable to access screening, or complete the screening pathway. This can result in people with the greatest need being less likely to benefit from screening, thus increasing health disparities. Inequalities can occur at any point along the screening pathway, including:
- cohort identification (invitation)
- provision of information about screening
- access to screening services
- access to treatment and onward referral
- outcomes
To mitigate against inequalities in screening, the prevention, identification and reduction of health inequalities should be embedded throughout all aspects of the underpinning research into, and design of, end-to-end population screening pathways. It should also be embedded throughout the commissioning, provision, quality assurance and evaluation of screening programmes.
Those responsible for any aspect of a screening programme, should be guided by evidence-based guidance and resources[footnote 1], such as the findings of the systematic evidence review, commissioned by Public Health England and published in 2021, of interventions to improve screening participation in underserved groups.
Policy makers should identify any gaps in the evidence base (programme-specific or cross-programme evidence) relating to screening inequalities and encourage and support the research community to fill those gaps.
Policy decisions should be informed by published research and screening inequalities data, for example data segmented by socioeconomic status (deprivation), ethnicity, disability or geographical area.
Equality impact assessments (EIAs) should be conducted to assess the effect of a policy, practice or programme of work on a population. They help identify inequality issues in systems, practices and processes, which should be considered during the development of a policy, practice or programme of work.
Such assessments can identify potential inequalities associated with proposed new screening programmes as well as modifications to existing programmes. They should inform the planning and implementation of end-to-end screening pathways in order to mitigate against health inequalities.
Policy makers should take an evidence-based approach to the identification, reduction and prevention of screening inequalities. Policy decisions should include interventions and structural changes that should help to reduce inequalities. A change to the method(s) of screening can be such an intervention.
Case study: introduction of the faecal immunochemical test in bowel cancer screening
In the UK, an example of a change to the method of screening that has helped reduce inequalities is the introduction of the faecal immunochemical test (FIT) as the primary bowel cancer screening test. FIT, introduced in England from April 2019, is an easier to complete and more acceptable test than the guaiac faecal occult blood test (gFOBt) kit that it replaced. In the years preceding FIT implementation (1 April 2017 to 31 March 2018 and 1 April 2018 to 31 March 2019), national uptake of bowel cancer screening was 59.2%.
When FIT was introduced, uptake increased to 67.0% (1 April 2019 to 31 March 2020). Uptake increased for both men and women, with men having the largest increase (from 56% to 61%). This is important because men are both less likely to take part in bowel cancer screening and more at risk of getting bowel cancer. Uptake also increased in all deprivation groups with the largest increase being in the lowest participating, most deprived group (up from 45% to 55%).
Case study: use of culturally adapted patient-targeted interventions to reduce racial or ethnic inequalities in access to cancer screening
A systematic review [footnote 2] found that culturally adapted patient-targeted healthcare interventions can help to reduce racial or ethnic inequalities in access to cancer screening programmes.
The review looked at 16 studies conducted in the United States and one in Israel. Fifteen of the 17 interventions selected were effective in increasing cancer screening rates.
Five of the 17 studies found an improvement in cancer knowledge, awareness, self-efficacy, attitudes, intention and perceptions, and 3 studies found a positive change in health beliefs and barriers. The results showed that culturally adapted interventions appear to increase the rate of participation in cancer screening. In addition, the effectiveness of the interventions seemed to be related to the use of small media, one-on-one interactions, small group education sessions, reminder strategies, and strategies for reducing structural barriers and out-of-pocket costs.
Consistent elements of all screening programmes should include the collection and recording of inequalities data. There should also be one or more standards or indicators that support screening commissioners and providers in the identification and reduction of inequalities.
Requirements to address inequalities should be included in screening guidance and other documents.
All screening programmes must be able to identify, invite, test and follow up as appropriate all eligible individuals.
It is important that people with a disability, impairment or sensory loss should be given information in a format they can access and understand and should receive any communication support they need.
Resources to support informed choice should be made available in a variety of formats to meet these needs. Recommended formats include written translations, easy guides and audio recordings.
Evidence-based guidance should be used to mitigate barriers to participation at all points along the screening pathway.
Those responsible for any screening programme should have a detailed understanding of the communities and needs within the screening location.
Action to address health inequalities can be targeted at a place or system level or to specific population groups, for example, the most deprived areas, ethnic minorities and population groups who are socially excluded.
A locally informed approach addresses health inequalities and the wider determinants of health through collaborative leadership and action between those who design, provide and are offered screening, in a way that is sensitive to local needs and priorities.
Those responsible for local health system delivery and other relevant parties should work together with communities to understand the needs of their local population and to identify and tackle inequalities.
They should:
- conduct assessments of access to screening to inform the planning of screening, covering equality characteristics, socioeconomic factors, local vulnerable populations and geographical variation
- tailor and target interventions when necessary
- access and interpret data to identify inequalities
- develop interventions and plans, following evidence-based guidance
- work with service users and communities to understand barriers to accessing screening and in the development of services to reduce those barriers
- use EIAs when considering making any local changes to the way screening is provided, for example any changes to screening clinic locations, accessibility or timings
- identify and support vulnerable and underserved populations, including those likely to be missing from the population registers that provide details of the eligible cohorts
- provide screening in a culturally sensitive way to meet the needs of diverse populations
- assure the identification and tackling of inequalities through local processes
- evaluate and monitor interventions to ensure they have the intended impact of reducing inequalities in practice
Screening policies, procedures and staff training may need to change to make sure services work equally well for people with physical or sensory disabilities, a learning disability, severe mental illness or long-term conditions such as dementia. Reasonable adjustments should be made to help make it as easy for disabled people to use screening services as it is for people who are not disabled.
Screening services should be able to provide evidence of how they have identified and addressed disparities to organisations involved in the commissioning or quality assurance of screening.
Tackling disparities should also be considered as part of the screening quality assurance process, to support commissioners and services to take action to address screening disparities.
Appropriate quality standards and performance metrics should be used to drive improvements in identifying and reducing inequalities.
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Duffy, S. W. et al, 2017. Rapid review of evaluation of interventions to improve participation in cancer screening services. J Med Screen. 2017 Sep; 24(3): 127–145.↩
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Vicenta Escribà-Agüir, Marina Rodríguez-Gómez, IsabelRuiz-Pérez. Effectiveness of patient-targeted interventions to promote cancer screening among ethnic minorities: A systematic review. Cancer Epidemiology 2016;44_22-39↩