The role of education in the uptake of preventative health care: The case of cervical screening in Britain

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Abstract

This paper reports findings on the relationship between education and the take-up of screening for cervical cancer, as an example of preventative health-care activity. Theoretically, education can enhance the demand for preventative health services by raising awareness of the importance of undertaking regular health check-ups and may also improve the ways in which individuals understand information regarding periodical tests, communicate with the health practitioner, and interpret results. Furthermore, education enhances the inclusion of individuals in society, improving self-efficacy and confidence. All these factors may increase service uptake.

The empirical analysis uses data from the British Household Panel Survey (BHPS) and applies techniques for discrete panel data to estimate the parameters of the model. Results show that adult learning leading to qualifications is statistically associated with an increase in the uptake of screening. The marginal effect indicates that participation in courses leading to qualifications increases the probability of having a smear test between 4.3 and 4.4 percentage points. This estimate is strongly robust to time-invariant selectivity bias in education and the inclusion of income, class, occupation, and parental socio-economic status. These findings enrich existing evidence on the socio-economic determinants of screening for cervical cancer and enable policy makers to better understand barriers to service uptake.

Introduction

The provision of high-quality health services remains one of the top priorities for governments around the world. To achieve this aim in Britain, for example, Wanless (2002), Wanless (2004) suggests that the government's strategy should be based on improvements in the supply of health services together with reductions in the demand for health care. Yet not just in Britain, there is a tendency for governments to concentrate in the expansion of the supply of health services, leaving aside reductions in the demand for health-care services.

Reductions in the demand can be induced by preventative measures and the promotion of health related practices. Preventative health care can reduce mortality rates and the incidence of invasive illnesses. Cervical screening exemplifies prevention in that biological risk factors for cervical cancer can be detected and treated before progression to invasive disease. Early detection through screening programmes is particularly important in slowing the progression of some types of cancer, for example, cervical, breast or colorectal. Preventative health care should lead to long-run social savings by decreasing the likelihood of subsequent treatment due to ill health conditions.

Beyond the public benefit, the utilisation of health-care services for preventative reasons also has important individual benefits. Preventative health care provides individuals with security and knowledge about their health and the health of those for whom they care. Early detection and early treatment should be beneficial in terms of quality-adjusted life years, QALYs, and other quality of life terms. The uptake of screening for cervical cancer could have additional individual benefits for women since it provides the opportunity for general practitioners (GPs) to examine their general sexual health, to detect any sexually transmitted diseases, and, in some cases, to examine anomalies in the breast.

There is a large amount of literature on the socio-economic determinants of demand for preventative care and screening. The literature falls broadly into three areas: quantitative enquiry using health service data and geo-linked data from the census to assign socio-economic status (SES) and race (Simoes et al., 1999); quantitative enquiry using survey data, typically in the UK the General Health Survey, but also other surveys (Margolis, Lurie, McGovern, Tyrrell, & Slater, 1998; Selvin & Brett, 2003; Taylor, Mamoon, Morrell, & Wain, 2001); and qualitative enquiry, usually published by medical sociologists (Doyle, 1991; Kang & Bloom, 1993; King et al., 1998; Pee & Hammond, 1997). In nearly all cases the research shows lower use of preventative care by those in lower socio-economic groups.

There are several shortcomings from the results obtained so far. First, most health service data contain detailed information on uptake of preventative care but define SES in a very broad way. Hence, there is a tendency in the field of public health to associate lower uptake of preventative care to low social class or poverty or low education. Whether it is class, education or income that dominates as cause seems to be of little importance. Yet, there are complex interactions between SES, education, income and other background variables. For the task of understanding the determinants of preventative uptake it is important to be able to distinguish between these different socio-economic factors. Whatever one may think of income re-distribution on ethical grounds one must be clear about what it would achieve. If education is a strong driving force of health inequality then redistribution of income by itself is unlikely to solve the problem of health inequality (Goddard & Smith, 2001). A more dynamic intervention would address both income and education to tackle health inequalities.

Second, results from survey data typically utilise cross-sectional information, limiting the scope for inference from the results. For instance, Selvin and Brett (2003) find that non-Hispanic white women in the US with a bachelor's degree have an uptake of cervical screening which is 2.5 times greater than that of women with less than high school education. However, this may just reflect unobservable differences between these groups of women. One cannot determine whether education leads to an increase in uptake or whether education is simply acting as a proxy for other individual characteristics. In order to distinguish between these two possible explanations for the role of education one might utilise women's histories of screening as well as changes in educational qualifications.

Lastly, qualitative enquiry provides detailed information on the mechanism and processes underlying access to health services for different groups, but due to their commonly small sample sizes such results do not provide information to assess issues of causality for more general populations. For example, a study by Pee and Hammond (1997) evaluates the extent to which education materials, such as videos, have positive impacts on the health behaviours of young people. This detailed study involved 22 girls in years 11 and 12 at a comprehensive school in Surrey. Their results highlight some of the negative aspects of using videos; however, the authors state that these results should not be generalised.

The primary objective of this study is to assess the influence of education, measured as prior learning and continuing adult learning, on the demand for preventative health care, using screening for cervical cancer as an example of preventative activity. Amongst the socio-economic determinants of screening, there are strong theoretical grounds for the view that general education may be an important influence on the uptake of preventative health care and so a strong mediator of health inequality. If there are indeed benefits of learning on the uptake of screening for cervical cancer, it is likely that learning will have an effect in other preventative health services. In that case, the preventative health externalities of education are likely to be even more substantial than indicated here.

Our main focus is on the effects of education, but the data and method enable us to also assess the importance of other personal and area effects on screening probabilities. In particular, health risk behaviours such as tobacco smoking are important predictors of screening. Here we focus not only on smoking but also on changes in smoking behaviour. At area level we investigate the effects of long waiting times in clinics. The empirical analysis employs the British Household Panel Survey (BHPS), a nationally representative dataset. Our review of the literature suggests that this estimation has not been performed before.

Section snippets

Theoretical framework: the relationship between education and preventative health care

Education can enhance the demand for preventative health services for several reasons (Fig. 1), first by raising awareness of the importance of undertaking regular health check-ups and hence the willingness to do so (Hammond, 2002; Harlan, Bernstein, & Kessler, 1991; Simoes et al., 1999). Education may also improve understanding of information regarding periodical tests, communication with the health practitioner, and the interpretation of results (Hammond, 2003; Sligo & Jameson, 2000).

The model, data, and estimation issues

Let us approximate the influences on screening utilisation by the function f, such thatSit=f(Ed,Sit-k,X,Y,αi,λt,ηit)+eit,where i denotes individuals and t stands for time. S denotes uptake of the screening service, which is a function of education (Ed). The variable education contains a time invariant component, measured by the highest qualifications achieved, and a time-varying component, measured by continuing adult education. Sit−k indicates uptake of screening in previous periods; X is a

Results

Being enrolled in courses or training leading to qualifications was associated with a positive change in the probability of taking smear tests (Table 2). The magnitude of this effect, measured by the marginal effect, was 4.4 percentage points (Table 3). The estimated effect using the fixed effects linear probability model was very similar at 4.3 percentage points (Table 3). Participation in general training also increased the uptake of screening, but its statistical association was only

Discussion

In this study we investigated the role of education in the uptake of preventative health-care services, using screening for cervical cancer in Britain as an example of preventative activity. We introduced the effects of prior learning and continuing adult learning separately in our empirical model. We found that adult learning has a direct impact on the uptake of preventative screening which is not channelled by income, occupation or social class. The fact that the positive effect of education

Conclusions

Accessing health services is not solely the responsibility of the government. Wanless (2004) observes that individuals are primarily responsible for decisions about their and their children's personal health. Therefore, achieving good health for the nation requires individuals to be fully engaged, taking care of their health, changing risk behaviours, and utilising preventative measures in order to reduce future demand for health care. This paper is concerned with education as a mechanism for

Acknowledgements

Funding for this project has been provided by the Department for Education and Skills, UK. The authors would like to thank Cathie Hammond and other research staff at the Centre for Research on the Wider Benefits of Learning for their useful comments on this paper. We would also like to thank colleagues from the Centre for Health Economics in York who gave helpful comments when the paper was presented there in February 2004. Other useful suggestions were received from Julietta Patnick. Finally,

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