Mailed faecal immunochemical test programmes and educational inequalities in colorectal cancer screening in Europe: a difference-in-differences analysis

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Abstract
Background: Colorectal cancer (CRC) screening has contributed to reducing CRC incidence and mortality in Europe. However, inequalities in screening persist, with lower participation among individuals with lower educational attainment. It remains unclear whether screening programmes can mitigate these inequalities. This study examined the impact of mailed faecal immunochemical test (FIT) programmes on screening participation and related educational inequalities. Methods: We analysed repeated cross-sectional data from 202 976 respondents aged 50–74 in 24 European countries from the European Health Interview Survey (2014 and 2019), a nationally administered population-based survey. Outcomes were self-reported stool-based screening uptake (lifetime and past 2 years). Educational attainment was categorized into three levels (lower, middle, higher) based on ISCED-2011. We used a difference-in-differences design to compare changes in screening uptake between 2014 and 2019 in countries that implemented nationwide FIT programmes and countries that did not. Results: In countries that implemented FIT programmes, lifetime and past-2-year screening uptake increased by 28.3 (95% CI: 12.3–44.3) and 30.2 (95% CI: 13.8–46.6) percentage points (ppts), respectively, compared with countries without programmes. The increase was larger among individuals with middle than higher education, with an additional 8.9 (95% CI: 3.3–14.5) ppts for lifetime and 6.4 (95% CI: 1.5–11.2) ppts for past-2-year uptake, indicating a reduction in inequality between these groups. No reduction in inequality was observed between individuals with lower and higher education. Conclusion: Mailed FIT programmes increased stool-based screening uptake and reduced inequalities between individuals with middle and higher education. To further promote equity in CRC screening, future initiatives should prioritize individuals with lower educational attainment.
Funding Information
  • Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung (219687)

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