Educational level, voluntary private health insurance and opportunistic cancer screening among women in Catalonia (Spain)

Health care services in Catalonia (Spain) are organized in a national healt h service with universal population coverage and include preventive service s such as mammography and Pap tests. In addition to a national health servi ce (NHS) coverage, 22% of the population is enrolled in a voluntary private health insurance (VPHI), leading to a double coverage. This situation offe rs an opportunity to study the impact of this organizational aspect of heal th 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 f or preventive purposes. Logistic regression was used to study the relations hip 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 mam mography were carried out on 42% and 25% of women, respectively. Participat ion 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 tha n it does in mammography, Women who had a VPHI showed a higher percentage o f screening tests than the rest of the population. There is also an increas e in the mammography practice related to the educational level in older gro ups, but this fact is not observed in women younger than 40 years, Multivar iate logistic regression analysis showed an increase in the likelihood of e ver had a mammography and a Pap test according to age and to educational le vel, although this situation is less pronounced in older age groups. Both v ariables (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 c onclusion the opportunistic screening is associated with age, educational l evel and VPHI, Educational level is also associated with participation in b oth screening tests after adjusting by age. Furthermore, screening for cerv ical cancer shows a higher educational gradient than for breast cancer scre ening. The influence of VPHI after adjusting by age and by educational leve l poses the question about the role of private health insurances with regar d to preventive practices in the context of a national health service aimed at promoting equity of health care access. (C) 1999 Lippincott Williams & Wilkins.