Guidance

Breast screening: identifying inequalities

Updated 20 February 2024

Applies to England

Identifying and addressing health inequalities is a legal duty for all screening services.

The NHS population screening inequalities strategy sets out aims to tackle screening inequalities.

Breast screening services, commissioners and other public health specialists should refer to the national strategy, this guidance and other national screening inequalities guidance in order to support work to identify inequalities and interventions that can improve access and reduce inequalities.

Screening inequalities can occur at any point along the screening pathway. Health inequalities can exist across a range of characteristics or dimensions, including social deprivation, geography and the 9 protected characteristics described in the 2010 Equality Act.

Evidence of inequalities in breast screening

Some individuals and groups within society are less likely to attend breast screening and this may increase health inequalities. Numerous studies ^{[footnote 1] [footnote 2] [footnote 3]} have demonstrated that breast screening uptake is lower in areas of social deprivation. Studies have also suggested that uptake is lower in ethnic minority communities, particularly South Asian women. In reality, both social deprivation and ethnicity have an impact on breast screening uptake.

Health equity audits

Breast screening services should use the health equity audit (HEA) guidance in conjunction with the generic Health Equity Audit Tool (HEAT) to:

• identify health inequalities for their eligible cohort
• assess health inequalities in relation to their screening service
• identify actions to take to help reduce those inequalities

Data reports

The first step towards identifying interventions to improve access to services and outcomes is to identify if there are any inequalities. In order to do this effectively you need to have data available and to be able to interpret it.

GP practice level uptake or coverage data will identify those practices with the lowest attendance rates which may benefit from focused input. Services may have commissioning for quality and innovation (CQUIN) indicators within their commissioning contract which can be used to incentivise increases in uptake. GP practice level uptake data is available from within the national breast screening IT system (NBSS). GP practice level coverage data is reported from the annual KC63 return and available on the breast screening information system (BSIS).

Experimental statistics detailing breast screening coverage for women with a learning disability, reported at clinical commissioning group (CCG) level, are available. These show a clear difference in coverage between women with a known learning disability compared to women without a known learning disability.

Planning and evaluating interventions

It is important for services to understand factors influencing attendance in order to reduce potential barriers where possible.

When planning changes to how a service operates it is important to decide what outcome you hope to achieve and how you will know if you have achieved it. You will need to consider if the change:

• has any positive or negative impacts that you weren’t expecting
• is cost-effective
• is sustainable

You will also need to consider what factors influenced the achievement or non-achievement of the outcome.

There are many different ways to evaluate changes depending on the type of change. You can use routine data to measure a change that affects a large number of women. However, the most disadvantaged groups often relate to a smaller number of people and it may not be possible to use data to see if there is an increase in access to the screening service. In these circumstances, you can evaluate whether a new process is working efficiently and effectively or you can qualitatively evaluate service user satisfaction.

Measures to promote breast screening, such as working with GP practices and undertaking effective evidence-based outreach activities for specific population groups, all require dedicated time from staff. Services should liaise with community health promotion professionals (such as learning disability teams) to make sure they are aware of what the local service offers. This can have beneficial impacts on uptake. It is also important that breast screening services identify an individual, or individuals, to lead on health promotion and there is enough time allocated for them to undertake this role. This could be a dedicated role or, more commonly, dedicated sessions allocated to existing staff such as a mammographer or clinical nurse specialist.

References

1. Bhola J, Jain A, Foden P. Impact of index of multiple deprivation and ethnicity on breast screening uptake in the North West of England. Breast Cancer Research 2015, 17(Suppl 1): P24 ↩

2. Maheswaran R, Pearson T, Jordan H, Black D. Socioeconomic deprivation, travel distance, location of service, and uptake of breast cancer screening in North Derbyshire, UK. J Epidemiol Community Health. 2006 Mar;60(3):208-12. doi: 10.1136/jech.200X.038398. ↩

3. Szczepura A, Price C, Gumber A. Breast and bowel cancer screening uptake patterns over 15 years for UK south Asian ethnic minority populations, corrected for differences in socio-demographic characteristics. BMC Public Health volume 8, Article number: 346 (2008) ↩