Informed Choice in the German Mammography Screening Program by Education and Migrant Status: Survey among First-Time Invitees

<div><p>Breast cancer is the most prevalent cancer among women and mammography screening programs are seen as a key strategy to reduce breast cancer mortality. In Germany, women are invited to the population-based mammography screening program between ages 50 to 69. It is still discussed whether the benefits of mammography screening outweigh its harms. Therefore, the concept of informed choice comprising knowledge, attitude and intention has gained importance. The objective of this observational study was to assess the proportion of informed choices among women invited to the German mammography screening program for the first time. A representative sample of 17,349 women aged 50 years from a sub-region of North Rhine Westphalia was invited to participate in a postal survey. Turkish immigrant women were oversampled. The effects of education level and migration status on informed choice and its components were assessed. 5,847 (33.7%) women responded to the postal questionnaire of which 4,113 were used for analyses. 31.5% of the women had sufficient knowledge. The proportion of sufficient knowledge was lower among immigrants and among women with low education levels. The proportion of women making informed choices was low (27.1%), with similar associations with education level and migration status. Women of low (OR 2.75; 95% CI 2.18–3.46) and medium education level (OR 1.49; 95% CI 1.27–1.75) were more likely to make an uninformed choice than women of high education level. Turkish immigrant women had the greatest odds for making an uninformed choice (OR 5.30, 95% CI 1.92–14.66) compared to non-immigrant women. Other immigrant women only had slightly greater odds for making an uninformed choice than non-immigrant women. As immigrant populations and women with low education level have been shown to have poor knowledge, they need special attention in measures to increase knowledge and thus informed choices.</p></div

Proportion of sufficient knowledge, consistency, and informed choice, by education level and migration.^*

<p>Note: data are given as percent (number), p-values from chi-square tests</p><p>*Informed choice for women with intention to participate in mammography screening program or no intention to perform mammography</p><p>^a n = 3,560</p><p>^b n = 3,599</p><p>^c n = 3,601</p><p>Proportion of sufficient knowledge, consistency, and informed choice, by education level and migration.^{<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0142316#t003fn002" target="_blank">*</a>}</p

Linear regression effect estimates (β) for influence of migrant background and parental socioeconomic status on infant weight gain (weight z-score) during first six months of life, adjusted for covariates (n = 1,009).

<p>Linear regression effect estimates (β) for influence of migrant background and parental socioeconomic status on infant weight gain (weight z-score) during first six months of life, adjusted for covariates (n = 1,009).</p

Odds ratios (and 95% CI) for influence of migrant background on rapid weight gain between birth and six months of life, adjusted for covariates (n = 1,031).

<p>Odds ratios (and 95% CI) for influence of migrant background on rapid weight gain between birth and six months of life, adjusted for covariates (n = 1,031).</p

Characteristics of study participants included in the analysis (n = 1,287) by country of birth.

*<p>p-value from global F-Test (ANOVA) for continuous variables, chi-square test for categorical variables.</p>**<p>Scheffé test: Gestational weight gain differs between Turkey and Eastern Europe (p<0.05).</p><p>Birth height differs between Eastern Europe and Other (p<0.05).</p><p>Age of mother at birth different for all migrant groups compared to Germans (p<0.05).</p

Weight at birth, weight at six months, change in weight status during first six months (standard deviation and percent of infants with rapid growth by potentially influencing factors.

*<p>p-value from global F-test in ANOVA.</p

Linear regression effect estimates (β) for influence of migrant background on infant weight gain (weight z-score) during first six months of life, adjusted for covariates (n = 1,031).

<p>Linear regression effect estimates (β) for influence of migrant background on infant weight gain (weight z-score) during first six months of life, adjusted for covariates (n = 1,031).</p

Odds ratios (and 95% CI) for influence of migrant background and parental socioeconomic status on rapid weight gain between birth and six months of life, adjusted for covariates (n = 1,009).

<p>Odds ratios (and 95% CI) for influence of migrant background and parental socioeconomic status on rapid weight gain between birth and six months of life, adjusted for covariates (n = 1,009).</p

Flow chart describing the exclusion criteria and number of children excluded from analysis.

<p>Flow chart describing the exclusion criteria and number of children excluded from analysis.</p

Adjusted mean weight z-scores and 95% CIs according to migrant background and SES.

<p>(mean weight z-score adjusted for birth weight, gestational age, parental height, smoking during pregnancy, duration of exclusive breastfeeding).</p