Screening: data

Data on screening programmes are available from Public Health Scotland for:

• Bowel cancer 
• Breast cancer 
• Cervical cancer.
• Abdominal aortic aneurysms (AAA) 

Data on diabetic retinopathy screening uptake are available from the Scottish Diabetic Retinopathy Screening Collaborative (see programme and performance reports).

Inequalities in uptake

A challenge for screening programmes is to ensure equality in uptake and linkage into care pathways among deprived and affluent populations. Data show that inequalities in screening uptake exist in Scotland and screening programmes in general have the potential to exacerbate existing inequalities in health outcomes.

Bowel cancer

Key performance indicator (KPI) data are available for each NHS board. The latest data for the period of screening invitation May 2020 to April 2022 show that:

• Consistently across all NHS boards and Scotland as a whole a greater percentage of eligible women than men take up this screening (Scotland: 64.3% men vs 69.1% women (KPI 1)).*
• Analysis by deprivation (Scottish Index of Multiple Deprivation (SIMD2020) quintile) reveals a clear deprivation gradient from greatest uptake of screening in the least deprived quintile to the lowest uptake in the most deprived quintile for both males and females across all NHS boards and for Scotland as a whole (Scotland: 72.8% least deprived vs 52.4% most deprived quintile for men and 77.7% least deprived vs 56.4% most deprived quintile for women (KPI 2)).

*The Healthcare Improvement Scotland (HIS) standard and bowel screening programme target for uptake is 60%. 

Breast cancer

Data are available for Scotland and by NHS board. Latest data the three-year period 2019/20 - 2021/22 shows

• A clear deprivation gradient with uptake for Scotland 81.5% in the least deprived quintile vs 62.7% in the most deprived quintile (SIMD2020).
• Variation in uptake by NHS Board, but all Boards met the acceptable uptake standard of 70%, the first time this has happened since 2008/11. 

Cervical cancer

Latest data are available for 1^st April 2021 to 31^st March 2022 and show*:

• The greatest uptake was in those aged 50-54 years (78.6%), with lowest uptake in younger women (lowest for those aged 25-29 years at 53.0%). Uptake increased from a low for those aged 25-29 years to a high for those aged 50-54 but reduced for ages thereafter, a pattern seen on the whole across all the NHS Boards except for Shetland where uptake was 0.1% greater for those aged 45-49 years.
• A gradient of uptake across SIMD quintiles with uptake higher in areas of lower deprivation; uptake was 73.1% for women aged 25-64 years in the least deprived areas compared with 62.4% in the most deprived areas. The difference in uptake by deprivation was most marked amongst women aged 50-64 years. 

The Audit Scotland report Health inequalities in Scotland: Extent of health inequalities: detailed analysis (December 2012) (578Kb) highlighted the above inequalities in Scottish uptake of bowel and breast screening services. The Midlands and East Screening Equity Project 2012/13 included a literature review looking at the defined equality groups and barriers to screening services (March 2013). This showed that groups defined by the protected characteristics of the Equality Act 2010 face additional barriers to uptake of screening services, which can lead to inequalities.

*Note that for the period reported, cervical screening was routinely offered to women aged 25-64 in Scotland: those aged 25-49 every three years and those aged 50-64 every five years.

Abdominal Aortic Aneurysms

Data for uptake rates for eligible men for screening to year ending 31^st March 2022 shows that there was a gradient of uptake rate by deprivation area with uptake lowest in the most deprived areas: 80.2% in the least deprived quintile compared to 63.7% in the most deprived quintile in Scotland (SIMD2020). This is a trend largely seen in all NHS Board areas.

Analysis of data from the Grampian AAA screening programme has also shown that overall uptake is high (89%) but that both urban-residence and social deprivation are independently associated with lower uptake (Crilly et al 2015).

Diabetic retinopathy

Analysis of data for the Diabetic retinopathy screening programme (DRS) has shown that uptake (latest data 2019):

• Is lowest in the most deprived SIMD quintile increasing steadily across the quintiles to a high in the least deprived quintile.
• Falls from those aged 12-14 years to a low amongst those aged 25-34 years, rises to a high for those aged 65-74 years and thereafter drops off slightly.
• Varies across ethnic groups being lowest in those of Black African ethnicity* (source: personal communication Mike Black, Scottish DRS Collaborative Coordinator). (* note that ethnic groups are those defined by the software used and so are not to current Scottish definitions).
• Varies across NHS Board.

Other research has also shown that inequalities in screening uptake differ by screening type, for example:

• Participation in the NHS cancer screening programmes seems to be lower for breast, cervical and colorectal cancer in ethnic minority groups (see Hoare, 1996; Webb et al, 2004; Moser et al, 2009; Weller et al, 2007; Robb et al, 2008 cited in Waller et al, 2009).

• An education gradient in screening for breast, cervical and colorectal cancer exists across Europe, with the strongest educational inequalities evident for cervical screening (Willems and Bracke, 2018).

• Colorectal cancer screening - Review of qualitative and quantitative studies published in English (the majority conducted in USA) by Javanparst et al (2010) found socio-economic status, ethnicity, age and gender to be predictors of test participation. Findings concurred by a systematic review of Wools et al, 2015 (many studies from USA). Analysis of participation in London showed a strong socio-economic gradient in uptake and ethnic diversity also contributed to lower uptake (von Wagner et al, 2009). Recent analysis of uptake using a market segmentation tool for the Derbyshire population showed that groups with low uptake were characterised by high levels of social-rented accommodation, multicultural urban communities and transient populations (Gavens et al, 2019)

• Breast and cervical screening - have been adopted more in more affluent areas (see references in von Wagner et al, 2011) and areas of lower socio-economic deprivation (Smith et al, 2019). Analysis of survey data for Great Britain has shown that indicators of wealth are more important for breast screening uptake and indicators of ethnicity for cervical screening, uptake being lower for non-white females (Moser et al, 2009). Women with higher levels of education are also more likely to take up both types of screening (Damiani et al, 2015).

• Cervical screening – uptake is lower among lesbian and bisexual women (see references in Johnson et al, 2016) and a systematic review by Connolly et al (2020) has also shown that cervical cancer screening uptake is lower among gender minorities assigned female at birth than cis women.

• Diabetic retinopathy screening programmes - analysis has highlighted that in areas with the greatest socioeconomic deprivation in Gloucestershire, diabetic prevalence is highest and attendance is poorest (Scanlon et al, 2008). As well as finding a similar deprivation effect, analysis in Oxfordshire has found that uptake is low among the youngest and oldest age groups and that practice-level factors can affect uptake (Moreton et al, 2017).

• Abdominal aortic aneurysms screening – analysis for the Highland aneurysm screening programme in Scotland has shown a gradient of uptake associated with deprivation, despite levels being at almost 80% in the most deprived area (Ross et al, 2013). Similarly, analysis in Sweden has shown that uptake varies between different geographical areas and specifically men from low socio-economic status generally showed lower uptake (Zarrouk et al, 2013). An English study has also shown that along with uptake, the rate of those who actively decline the offer of screening is associated with deprivation (Jacomelli et al, 2017).