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European Journal of Cancer Prevention:


October 1999
RESPONSE FROM THE EDITORS: PDF Only

Educational level, voluntary private health insurance and opportunistic cancer screening among women
in Catalonia (Spain).
Borrs, J M; Guillen, M; Sanchez, V; Junc, S; Vicente, R

Abstract
Health care services in Catalonia (Spain) are organized in a national health service with
universal population coverage and include preventive services such as mammography and
Pap tests. In addition to a national health service (NHS) coverage, 22% of the population is
enrolled in a voluntary private health insurance (VPHI), leading to a double coverage. This
situation offers an opportunity to study the impact of this organizational aspect of health care
with regard to cancer screening access. The source of data was the Catalan Health Survey
(CHS), a cross-sectional survey conducted in a random sample of non-institutionalized
population carried out in 1994. Variables analysed were age, educational level and voluntary
private health insurance (VPHI). Women were asked if they had ever had a mammography
and Pap test for preventive purposes. Logistic regression was used to study the relationship
between these variables and the mammography or Pap test participation. The study sample
was 5865 women aged 20 years and older. A Pap test and mammography were carried out on
42% and 25% of women, respectively. Participation had a peak between the ages of 30 and 39
years in Pap test and between 40 and 49 years in mammography; it decreased in older
women. The percentage of Pap test practice increases according to a higher educational level
than it does in mammography. Women who had a VPHI showed a higher percentage of
screening tests than the rest of the population. There is also an increase in the mammography
practice related to the educational level in older groups, but this fact is not observed in
women younger than 40 years. Multivariate logistic regression analysis showed an increase in
the likelihood of ever had a mammography and a Pap test according to age and to educational
level, although this situation is less pronounced in older age groups. Both variables

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Educational level, voluntary private health insurance and op... : European Journal of Cancer Pr...

2 of 2

http://journals.lww.com/eurjcancerprev/Abstract/1999/10000/Educational_level,_voluntary_pri...

(educational level and age) remained significant after introducing the VPHI into the model
(women who reported having a VPHI were more likely to have had a Pap test and a
mammography than the rest of the women). In conclusion the opportunistic screening is
associated with age, educational level and VPHI. Educational level is also associated with
participation in both screening tests after adjusting by age. Furthermore, screening for
cervical cancer shows a higher educational gradient than for breast cancer screening. The
influence of VPHI after adjusting by age and by educational level poses the question about the
role of private health insurances with regard to preventive practices in the context of a
national health service aimed at promoting equity of health care access.
(C) 1999 Lippincott Williams & Wilkins, Inc.

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