Screening in primary care: health for all? A study in Dutch general practice

Background: In recent years there has been an increasing emphasis on the delivery of preventive care in general practice, At the same time, available evidence suggests people from lower social classes receive less preventive care compared with people from higher social class, The objective of this study was to assess the uptake of screening by blood pressure measurement, cervical cytology and manual breast examination in risk populations by patients attending their general practitioners and relate the findings to levels of educational attainment and type of health insurance. Methods: The study was based on data gathered in the Dutch National Survey of General Practice in which 161 GPs recorded sociodemographic data, reasons for encounter, diagnoses and interventions during a 3 month period. Persons receiving the above procedures as screening measures were counted and expressed as rates per 1,000 persons registered and per 1,000 persons consulting. These rates were examined at three levels of educational attainment and according to the health insurance of the patient using logistic regression methods. Results: When analysed by educational attainment, high levels of blood pressure measurement were found in persons of lower educational attainment in both males and females (30-59 years) while for cervical cytology (35-54 years) higher levels were found amongst the better educated and for breast examination (40-69 years) the rates were similar regardless of educational attainment. When analysed by insurance status parallel trends were observed, with higher rates for blood pressure measurement among the publicly insured and higher rates for cervical cytology among the privately insured. Conclusions: The results, whether based on persons registered or persons consulting, suggest no important social bias in the extent to which persons are screened by blood pressure measurement or breast examination. There were strong social gradients for cervical cytology favouring the better educated and privately insured. More effective targeting of women with low educational attainment and publicly insured is called for.