The current study examines whether the extent of macrolevel gender inequality affects the association between women’s educational attainment and their participation in cervical and breast cancer screening and how this relationship is moderated by a country’s cancer screening strategy (organized vs. opportunistic). A multilevel design with women (Ncervical = 99,794; Nbreast = 55,021) nested in 30 European countries was used to analyze data from the European Health Interview Survey (2013–2015). Results of multilevel logistic regression models demonstrate that higher macrolevel gender inequality is associated with (a) a lower overall likelihood that women have had a mammography and Pap smear and (b) a larger gap in participation between women with low and high levels of education, regardless of a country’s screening strategy (i.e., no moderation by a country’s screening strategy was found). We conclude that macrolevel gender stratification should not be neglected when designing cancer screening policy.
BackhansMonaBurströmBoLeonAntonio Ponce deMarklundStaffan. 2012. “Is Gender Policy Related to the Gender Gap in External Cause and Circulatory Disease Mortality? A Mixed Effects Model of 22 OECD Countries 1973–2008.” BMC Public Health12(1):969. doi:10.1186/1471-2458-12-969
3.
BartleyMel. 2003. “Health Inequality and Societal Institutions.” Social Theory & Health1(2):108–29.
4.
BeckfieldJasonKriegerNancy. 2009. "Epi+ Demos+ Cracy: Linking Political Systems and Priorities to the Magnitude of Health Inequities—Evidence, Gaps, and a Research Agenda." Epidemiologic Reviews31(1):152–77.
5.
BeckfieldJasonOlafsdottirSigrun. 2009. "Empowering Health: A Comparative Political Sociology of Health Disparities." Perspectives on Europe39(2):9–12.
6.
BeckfieldJasonOlafsdottirSigrunBakhtiariElyas. 2013. "Health Inequalities in Global Context." American Behavioral Scientist57(8):1014–39.
7.
BeckfieldJasonBambraClareEikemoTerje A.HuijtsTimMcNamaraCourtneyWendtClaus. 2015. "An Institutional Theory of Welfare State Effects on the Distribution of Population Health." Social Theory & Health13(3):227–44.
8.
BirdChloe E.RiekerPatricia P.2008. Gender and Health: The Effects of Constrained Choices and Social Policies. Cambridge, UK: Cambridge University Press.
9.
BlomNielsHuijtsTimKraaykampGerbert. 2016. “Ethnic Health Inequalities in Europe. The Moderating and Amplifying Role of Healthcare System Characteristics.” Social Science & Medicine158:43–51.
10.
BorrellCarmePalènciaLaiaMuntanerCarlesUrquíaMarceloMalmusiDavideO’CampoPatricia. 2013. "Influence of Macrosocial Policies on Women’s Health and Gender Inequalities in Health." Epidemiologic Reviews36(1):31–48.
11.
BrackePietStraatVera Van DeMissinneSarah. 2014. "Education, Mental Health, and Education-Labor Market Misfit." Journal of Health and Social Behavior55(4):442–59.
12.
BuffelVeerleBeckfieldJasonBrackePiet. 2017. "The Institutional Foundations of Medicalization: A Cross-National Analysis of Mental Health and Unemployment." Journal of Health and Social Behavior58(3):272–90.
13.
Burton-JeangrosClaudineCullatiStéphaneManorOrlyCourvoisierDelphine S.BouchardyChristineGuessousIdris. 2016. "Cervical Cancer Screening in Switzerland: Cross-Sectional Trends (1992–2012) in Social Inequalities." European Journal of Public Health27(1):167–73.
14.
ChangVirginia W.LauderdaleDiane S.2009. “Fundamental Cause Theory, Technological Innovation, and Health Disparities: The Case of Cholesterol in the Era of Statins.” Journal of Health and Social Behavior50(3):245–60.
15.
CloustonSean A. P.RubinMarcie S.PhelanJo C.LinkBruce G.2016. “A Social History of Disease: Contextualizing the Rise and Fall of Social Inequalities in Cause-Specific Mortality.” Demography53(5):1631–56.
16.
CollinsRandallChafetzJanet SaltzmanBlumbergRae LesserColtraneScottTurnerJonathan H.1993. "Toward an Integrated Theory of Gender Stratification." Sociological Perspectives36(3):185–216.
17.
CutlerDavid M.Lleras-MuneyAdriana. 2008. “Education and Health: Evaluating Theories and Evidence.” Pp. 29–60 in Making Americans Healthier: Social and Economic Policy as Health Policy, edited by SchoeniR. F.HouseJ. S.KaplanG. A.PollackH.New York: Russell Sage Foundation.
18.
CutlerDavid M.Lleras-MuneyAdriana. 2010. “Understanding Differences in Health Behaviors by Education.” Journal of Health Economics29(1):1–28.
19.
DagherRada K.McGovernPatricia M.DowdBryan E.2014. “Maternity Leave Duration and Postpartum Mental and Physical Health: Implications for Leave Policies.” Journal of Health Politics, Policy and Law39(2):369–416.
20.
DahlEspenvan der WelKjetil A.2013. “Educational Inequalities in Health in European Welfare States: A Social Expenditure Approach.” Social Science & Medicine81:60–69.
21.
DahlinJohannaHärkönenJuho. 2013. “Cross-National Differences in the Gender Gap in Subjective Health in Europe: Does Country-Level Gender Equality Matter?” Social Science & Medicine98:24–28.
22.
DamianiGianfrancoBassoDanilaAcamporaAnnaBianchiCaterina B. N. A.SilvestriniGiuliaFrisicaleEmanuela M.SassiFrancoRicciardiWalter. 2015. “The Impact of Level of Education on Adherence to Breast and Cervical Cancer Screening: Evidence from a Systematic Review and Meta-analysis.” Preventive Medicine81:281–89.
23.
de KoningHarry J.2018. “Towards Improved Cancer Screening in Europe.” European Journal of Public Health28(suppl 4):cky213.784. doi:10.1093/eurpub/cky213.784.
24.
DelaruelleKatrijnHoutteMieke VanBrackePiet. 2018. “Educational Inequalities in General Health: Does the Curricular Tracking System Matter?”Acta Sociologica63(1):63–81.
25.
EikemoTerje A.HuismanMartijnBambraClareKunstAnton E.2008. “Health Inequalities According to Educational Level in Different Welfare Regimes: A Comparison of 23 European Countries.” Sociology of Health & Illness30(4):565–82.
26.
EspinasJosep A.AlisteLuisaFernandezEsteveArgimonJosep M.TresserrasRicardBorrasJosep M.2011. “Narrowing the Equity Gap: The Impact of Organized Versus Opportunistic Cancer Screening in Catalonia (Spain).” Journal of Medical Screening18(2):87–90.
27.
EU Commission. 2003. “Council Recommendation of 2 December 2003 on Cancer Screening (2003/878/EC).” Office Journal of the European Union L327:34–38.
28.
EydalGuðný B.RostgaardTine. 2011. “Gender Equality Revisited—Changes in Nordic Childcare Policies in the 2000s.” Social Policy & Administration45(2):161–79.
29.
FreeseJeremyLutfeyKaren. 2011. “Fundamental Causality: Challenges of an Animating Concept for Medical Sociology.” Pp. 67–81 in Handbook of the Sociology of Health, Illness, and Healing: A Blueprint for the 21st Century, Handbooks of Sociology and Social Research, edited by PescosolidoB. A.MartinJ. K.McLeodJ. D.RogersA.New York: Springer.
30.
GayeAmieKlugmanJeniKovacevicMiloradTwiggSarahZambranoEduardo. 2010. “Measuring Key Disparities in Human Development: The Gender Inequality Index.” United Nations Development Programme, Human Development Reports. Human Development Research Paper 2010/46.
31.
GkioulekaAnnaHuijtsTimBeckfieldJasonBambraClare. 2018. “Understanding the Micro and Macro Politics of Health: Inequalities, Intersectionality & Institutions - A Research Agenda.” Social Science & Medicine200:92–98.
32.
HausmannRicardoTysonLaura D.ZahidiSaadia. 2012. The Global Gender Gap Report 2012. Geneva: World Economic Forum.
33.
HernandezElaine M.VuoloMikeFrizzellLaura C.KellyBrian C.2019. “Moving Upstream: The Effect of Tobacco Clean Air Restrictions on Educational Inequalities in Smoking among Young Adults.” Demography56(5):1693–721.
34.
HomanPatricia. 2019. “Structural Sexism and Health in the United States: A New Perspective on Health Inequality and the Gender System.” American Sociological Review84(3):486–516.
35.
HoxJoop J.MoerbeekMirjamSchootRens van de. 2010. Multilevel Analysis: Techniques and Applications. New York: Routledge.
36.
HuismanMartijnKunstAnton E.BoppMatthiasBorganJens-KristianBorrellCarmeCostaGiuseppeDebooserePatrickGadeyneSylvieGlickmanMyerMarinacciChiaraMinderChristophRegidorEnriqueValkonenTapaniMackenbachJohan P.2005. “Educational Inequalities in Cause-Specific Mortality in Middle-Aged and Older Men and Women in Eight Western European Populations.” The Lancet365(9458):493–500.
37.
International Agency for Research on Cancer, ed. 2005. Cervix Cancer Screening. Vol. 10. Lyon: IARC Press.
38.
IyerAditiSenGitaÖstlinPiroska. 2008. “The Intersections of Gender and Class in Health Status and Health Care.” Global Public Health3(S1):13–24.
JusotFlorenceOrZeynepSirvenNicolas. 2012. “Variations in Preventive Care Utilisation in Europe.” European Journal of Ageing9(1):15–25.
41.
KawachiIchiroKennedyBruce P.GuptaVanitaProthrow-StithDeborah. 1999. “Women’s Status and the Health of Women and Men: A View from the States.” Social Science & Medicine48(1):21–32.
42.
KimSue E.Pérez-StableEliseo J.WongSabrinaGregorichSteveSawayaGeorge F.WalshJudith M. E.KaplanCelia P.2008. “Association between Cancer Risk Perception and Screening Behavior among Diverse Women.” Archives of Internal Medicine168(7):728–34.
43.
KunstAnton E.MackenbachJohan P.1994. “The Size of Mortality Differences Associated with Educational Level in Nine Industrialized Countries.” American Journal of Public Health84(6):932–37.
LorantVincentBolandBenoîtHumbletPerrine C.DeliègeDenise. 2002. “Equity in Prevention and Health Care.” Journal of Epidemiology & Community Health56(7):510–16.
46.
MackenbachJohan P.StirbuIrinaRoskamAlbert-Jan R.SchaapMaartje M.MenvielleGwennLeinsaluMallKunstAnton E.2008. “Socioeconomic Inequalities in Health in 22 European Countries.” New England Journal of Medicine358(23):2468–81.
47.
MarmotMichael2005. “Social Determinants of Health Inequalities.” The Lancet365(9464):1099–104.
48.
MastersRyan K.LinkBruce G.PhelanJo C.2015. “Trends in Education Gradients of ‘Preventable’ Mortality: A Test of Fundamental Cause Theory.” Social Science & Medicine127:19–28.
49.
MirowskyJohnRossCatherine E.1998. “Education, Personal Control, Lifestyle and Health: A Human Capital Hypothesis.” Research on Aging20(4):415–49.
50.
MirowskyJohnRossCatherine E.2003. Education, Social Status, and Health. New York: Transaction Publishers.
51.
MistryRiteshGalalOsmanLuMichael. 2009. “Women’s Autonomy and Pregnancy Care in Rural India: A Contextual Analysis.” Social Science & Medicine69(6):926–33.
52.
MontezJennifer K.HaywardMark D.ZajacovaAnna. 2019. “Educational Disparities in Adult Health: U.S. States as Institutional Actors on the Association.” Socius5:1–14. doi:10.1177/2378023119835345.
53.
O’BrienMargaret. 2009. “Fathers, Parental Leave Policies, and Infant Quality of Life: International Perspectives and Policy Impact.” Annals of the American Academy of Political and Social Science624(1):190–213.
OlafsdottirSigrunBeckfieldJason. 2011. “Health and the Social Rights of Citizenship: Integrating Welfare-State Theory and Medical Sociology.” Pp. 101–15 in Handbook of the Sociology of Health, Illness, and Healing: A Blueprint for the 21st Century, edited by PescosolidoB. A.MartinJ. K.McLeodJ. D.RogersA.New York: Springer.
56.
OsamorPauline E.GradyChristine. 2016. “Women’s Autonomy in Health Care Decision-Making in Developing Countries: A Synthesis of the Literature.” International Journal of Women’s Health8:191–202.
57.
PalènciaLaiaEspeltAlbertRodríguez-SanzMaicaPuigpinósRosaPons-ViguésMarionaPasarínMaría I.SpadeaTeresaKunstAnton E.BorrellCarme. 2010. “Socio-economic Inequalities in Breast and Cervical Cancer Screening Practices in Europe: Influence of the Type of Screening Program.” International Journal of Epidemiology39(3):757–65. doi:10.1093/ije/dyq003.
58.
PalènciaLaiaMalmusiDavideMoortelDeborah DeArtazcozLucíaBackhansMonaVanroelenChristopheBorrellCarme. 2014. “The Influence of Gender Equality Policies on Gender Inequalities in Health in Europe.” Social Science & Medicine117:25–33.
59.
PhelanJo C.LinkBruce G.Diez-RouxAnaKawachiIchiroLevinBruce. 2004. “‘Fundamental Causes’ of Social Inequalities in Mortality: A Test of the Theory.” Journal of Health and Social Behavior45(3):265–85.
60.
PhelanJo C.LinkBruce G.TehranifarParisa. 2010. “Social Conditions as Fundamental Causes of Health Inequalities Theory, Evidence, and Policy Implications.” Journal of Health and Social Behavior51(1):S28–40.
61.
PolonijoAndrea N.CarpianoRichard M.2013. “Social Inequalities in Adolescent Human Papillomavirus (HPV) Vaccination: A Test of Fundamental Cause Theory.” Social Science & Medicine82:115–25.
62.
Puigpinós-RieraRosaSerralGemmaPons-ViguésMarionaPalènciaLaiaRodríguez-SanzMaicaBorrellCarme. 2011. “Evolution of Inequalities in Breast and Cervical Cancer Screening in Barcelona: Population Surveys 1992, 2001, and 2006.” Journal of Women’s Health20(11):1721–27.
63.
RenardFrançoiseDemarestStefaanOyenHerman VanTafforeauJean. 2014. “Using Multiple Measures to Assess Changes in Social Inequalities for Breast Cancer Screening.” European Journal of Public Health24(2):275–80.
64.
RossCatherine E.WuChia-Ling. 1995. “The Links between Education and Health.” American Sociological Review60(5):719–45.
65.
RossCatherine E.SastryJaya. 1999. “The Sense of Personal Control.” Pp. 369–94 in Handbook of the Sociology of Mental Health, edited by AneshenselC. S.PhelanJ. C.Boston: Springer.
66.
RossCatherine E.MirowskyJohn. 2002. “Age and the Gender Gap in the Sense of Personal Control.” Social Psychology Quarterly65(2):125–45.
67.
RossCatherine E.MirowskyJohn. 2006. “Sex Differences in the Effect of Education on Depression: Resource Multiplication or Resource Substitution?” Social Science & Medicine63(5):1400–13.
68.
SabatesRicardoFeinsteinLeon. 2006. “The Role of Education in the Uptake of Preventative Health Care: The Case of Cervical Screening in Britain.” Social Science & Medicine62(12):2998–3010.
69.
SandovalJosé L.ThelerJean-MarcCullatiStéphaneBouchardyChristineManorOrlyGaspozJean-MichelGuessousIdris. 2017. “Introduction of an Organised Programme and Social Inequalities in Mammography Screening: A 22-Year Population-Based Study in Geneva, Switzerland.” Preventive Medicine103:49–55.
SeemanMelvinSeemanTeresa E.1983. “Health Behavior and Personal Autonomy: A Longitudinal Study of the Sense of Control in Illness.” Journal of Health and Social Behavior24(2):144–60.
72.
SeemanMelvinLewisSusan. 1995. “Powerlessness, Health and Mortality: A Longitudinal Study of Older Men and Mature Women.” Social Science & Medicine41(4):517–25.
73.
ShippeeTetyana P.WilkinsonLindsay R.FerraroKenneth F.2012. “Accumulated Financial Strain and Women’s Health over Three Decades.” The Journals of Gerontology Series B: Psychological Sciences and Social Sciences67(5):585–94.
74.
StirbuIrinaKunstAnton E.BoppMatthiasLeinsaluMallRegidorEnriqueEsnaolaSantiagoCostaGiuseppeMartikainenPekkaBorrellCarmeDebooserePatrikKaledieneRamuneRychtarikovaJitkaArtnikBarbaraMackenbachJohan P.2007. “Educational Inequalities in Avoidable Mortality in Europe”Journal of Epidemiology and Community Health64(10):913–920.
Van de VeldeSarahHuijtsTimBrackePietBambraClare. 2013. “Macro-Level Gender Equality and Depression in Men and Women in Europe.” Sociology of Health & Illness35(5):682–98.
77.
VarkeyPrathibhaKureshiSarahLesnickTimothy. 2010. “Empowerment of Women and Its Association with the Health of the Community.” Journal of Women’s Health19(1):71–76.
78.
WalshBrendanSillesMary A.O’NeillCiarán. 2011. “The Importance of Socio-economic Variables in Cancer Screening Participation: A Comparison between Population-Based and Opportunistic Screening in the EU-15.” Health Policy101(3):269–76.
79.
WardMichael M.2012. “Sense of Control and Sociodemographic Differences in Self-Reported Health in Older Adults.” Quality of Life Research21(9):1509–18.
80.
WellsMichael B.SarkadiAnna. 2012. “Do Father-Friendly Policies Promote Father-Friendly Child-Rearing Practices? A Review of Swedish Parental Leave and Child Health Centers.” Journal of Child and Family Studies21(1):25–31.
81.
WillemsBarbaraBrackePiet. 2018a. “The Education Gradient in Cancer Screening Participation: A Consistent Phenomenon Across Europe?”International Journal of Public Health63(1):93–103.
82.
WillemsBarbaraBrackePiet. 2018b. “The Impact of Regional Screening Policies on the Diffusion of Cancer Screening Participation in Belgium: Time Trends in Educational Inequalities in Flanders and Wallonia.” BMC Health Services Research18(1):943. doi:10.1186/s12913-018-3746-x.
83.
WübkerAnsgar2014. “Explaining Variations in Breast Cancer Screening across European Countries.” The European Journal of Health Economics15(5):497–514.
84.
Zapata-MoyaÁngel R.WillemsBarbaraBrackePiet. 2019. “The (Re) Production of Health Inequalities through the Process of Disseminating Preventive Innovations: The Dynamic Influence of Socioeconomic Status.” Health Sociology Review28(2):177–93.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
