title: The impact of level of education on adherence to breast and cervical cancer screening: Evidence from a systematic review and meta-analysis.
abstract: OBJECTIVE
  To assess the inequalities in adherence to breast and cervical cancer screening according to educational level.
  
  
  METHODS
  A systematic review was carried out between 2000 and 2013 by querying an electronic database using specific keywords. Studies published in English reporting an estimation of the association between level of education and adherence to breast and/or cervical cancer screening were included in the study. Two different meta-analyses were carried out for adherence to breast and cervical cancer screening, respectively: women with the highest level of education and women with the lowest level of education were compared. The level of heterogeneity was investigated and subgroup analyses were carried out.
  
  
  RESULTS
  Of 1231 identified articles, 10 cross-sectional studies were included in the analysis. The meta-analyses showed that women with the highest level of education were more likely to have both screenings with an overall OR=1.61 (95% CI 1.36-1.91; I(2)=71%) for mammography and OR=1.96 (95% CI 1.79-2.16; I(2)=0%) for Pap test, respectively. Stratified meta-analysis for breast cancer screening included only studies that reported guidelines with target age of population ≥50 years and showed a reduction in the level of heterogeneity and an increase of 36% in the adherence (95% CI 1.19-1.55; I(2)=0%).
  
  
  CONCLUSIONS
  This study confirms and reinforces evidence of inequalities in breast and cervical cancer screening adherence according to educational level.
authors.affiliation: Department of Public Health, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy. Electronic address: gdamiani@rm.unicatt.it.
authors.forename: Gianfranco
authors.initials: G
authors.lastname: Damiani
authors.affiliation: Department of Public Health, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy.
authors.forename: Danila
authors.initials: D
authors.lastname: Basso
authors.affiliation: Department of Public Health, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy.
authors.forename: Anna
authors.initials: A
authors.lastname: Acampora
authors.affiliation: Health Care Walkers' Cooperative (OSA), Via Lucio Volumnio 1, 00178 Rome, Italy.
authors.forename: Caterina B N A
authors.initials: CB
authors.lastname: Bianchi
authors.affiliation: Department of Public Health, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy.
authors.forename: Giulia
authors.initials: G
authors.lastname: Silvestrini
authors.affiliation: Department of Public Health, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy.
authors.forename: Emanuela M
authors.initials: EM
authors.lastname: Frisicale
authors.affiliation: Health Division, Directorate for Employment, Labour and Social Affairs, OECD-Organization for economic Cooperation and Development, 2 rue André Pascal, 75775 Paris, Cedex 16, France.
authors.forename: Franco
authors.initials: F
authors.lastname: Sassi
authors.affiliation: Department of Public Health, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy.
authors.forename: Walter
authors.initials: W
authors.lastname: Ricciardi
mesh_terms: D000328:Adult; D001943:Breast Neoplasms / Q000175:diagnosis*; D055088:Early Detection of Cancer / Q000706:statistics & numerical data*; D004522:Educational Status; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008327:Mammography / Q000379:methods; D008403:Mass Screening / Q000706:statistics & numerical data; D008875:Middle Aged; D065006:Papanicolaou Test / Q000379:methods; D010342:Patient Acceptance of Health Care; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis*
keywords: Breast cancer; Cancer prevention; Cervical cancer; Education; Mammography; Pap test; Screening