Temporal Evolution and Associated Factors of Adherence to Mammography Screening among Women in Spain: Results from Two National Health Surveys (2017–2020)

Citation: Portero de la Cruz, S.; Béjar, L.M.; Cebrino, J. Temporal Evolution and Associated Factors of Adherence to Mammography Screening among Women in Spain: Results from Two National Health Surveys (2017–2020). Healthcare 2023,11, 2934. https:// doi.org/10.3390/healthcare11222934 Academic Editor: Francesca Magnoni Received: 14 October 2023 Revised: 6 November 2023 Accepted: 7 November 2023 Published: 9 November 2023 Copyright: © 2023 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). healthcare Article Temporal Evolution and Associated Factors of Adherence to Mammography Screening among Women in Spain: Results from Two National Health Surveys (2017–2020) Silvia Portero de la Cruz 1,2,* , Luis M. Béjar 3and Jesús Cebrino 3 1Department of Nursing, Pharmacology and Physiotherapy, Faculty of Medicine and Nursing, University of Córdoba, Avda. Menéndez Pidal, S/N, 14071 Córdoba, Spain 2Research Group GE10 Clinical and Epidemiological Research in Primary Care, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, 14071 Córdoba, Spain 3Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Seville, Avda. Doctor Fedriani, S/N, 41009 Seville, Spain; [email protected] (L.M.B.); [email protected] (J.C.) *Correspondence: [email protected]; Tel.: +34-957-218-106 Abstract: Ensuring equity in cancer screening is recommended by the European Commission. Despite the fact that breast cancer screening is a free population-based program in Spain, there remains considerable variation in the adherence to screening rate among population groups. This study was designed to describe the adherence of breast cancer screening in women in Spain, to evaluate the evolution in the period from 2017 to 2020, and to determine the variables that influence choosing to undergo breast cancer screening. A nationwide cross-sectional study with 7220 females aged 50–69 years from the 2017 Spanish National Health Survey and the 2020 European Health Survey for Spain was performed. We investigated mammography uptake rates, with socio-demographic factors, lifestyle habits, and health-related characteristics as independent variables. Multivariable logistic regression was used to identify the associated factors of mammography adherence. Of the women, 78% had undergone mammography in the previous two years, and there was a significant decrease in the uptake rate for breast cancer screening from 2017 (81.23%) to 2020 (74.68%) ( p< 0.001 ). Educational level, marital status, residential location, nationality, smoking status, alcohol consumption, and leisure-time physical activity were all associated factors of mammography uptake. Keywords: breast neoplasms; guideline adherence; healthcare disparities; mammography; mass screening 1. Introduction Breast cancer is the most frequent disease and the leading cause of cancer mortality globally. By 2040, the number of newly diagnosed cases is projected to increase by over 40%, while deaths are expected to rise by more than 50% [ 1 ]. In Europe, an estimated 384,800 women were diagnosed with breast cancer, and 98,500 died from this cause in 2022 [ 2 ]. Surprisingly, the death rates for breast cancer in Spain are among the lowest among European Union member countries [3]. Nowadays, despite the decreased sensitivity of mammography shown in women with high breast density (which varies from 43 to 60%) [ 4 ], mammography is the only method used for screening [ 5 ], which has been shown to reduce breast cancer-related mortality [6–8] , enabling early breast cancer therapy and limiting the need for severe treatment such as mastectomy [ 9 ]. In Spain, a population screening program for breast cancer based on biennial mammography is available to females aged 50 to 69 who have had no family history of the disease [ 10 ]. At the age of 40, women with risk indicators are asked to join the program. Nevertheless, several private healthcare centers provide yearly mammograms from the age of 40 [ 11 ]. Currently, all women in the target group are individually invited every two years (by post and/or phone) to have a mammogram [12]. Healthcare 2023,11, 2934. https://doi.org/10.3390/healthcare11222934 https://www.mdpi.com/journal/healthcare Healthcare 2023,11, 2934 2 of 18 Previous studies have found that population-based cancer screening programs have led to a reduction in breast cancer mortality [ 13 , 14 ]. Nevertheless, the success of cancer screening programs is determined by the uptake rate among target groups [ 15 ]. As a result, it is important to research screening adherence and discover the factors that influence having breast cancer screening performed. Various Spanish research projects in this area have found varying adherence rates for mammography screening (from 72% to 80%) [ 11 , 16 ], with increased (82.6%) [ 16 ] and decreased (62%) [ 14 ] involvement in recent years. On the other hand, some determinants of mammography screening attendance are suggested by the scientific literature, including women’s socioeconomic level and certain lifestyle choices [ 17 ]. The lower involvement of less educated women is especially striking [ 18 ]. Similarly, ethnic minorities [ 19 ], rural living [ 20 ], and less healthy lifestyle behaviors [ 21 ] are linked to lower rates of screening attendance. Nonetheless, at this time, it is critical to understand the positive and negative characteristics related to breast cancer screening adherence as this will provide guidance for local health care providers and health departments in developing and implementing steps to reduce this imbalance. The Spanish population may be regarded as a suitable target group for examining the variables related to the screening program adoption rate [ 14 ]. The current study’s main goals were to describe the adherence of breast cancer screening in women in Spain, to evaluate the evolution in the period from 2017 to 2020, and to determine the variables that influence having breast cancer screening performed. 2. Materials and Methods Data from the Spanish National Health Survey (SNHS, 2017) [ 22 ] and the European Health Survey for Spain (EHSS, 2020) [ 23 ] were used to carry out a cross-sectional study. The data for the SNHS 2017 were gathered from October 2016 to October 2017, and the data for the EHSS 2020 were gathered from July 2019 to July 2020. Both surveys were conducted by the National Statistics Institute, under the auspices of the Spanish Ministry of Health and Social Affairs, and both were home-based computer-assisted personal interviews that obtained a representative sample of non-institutionalized persons (aged 15 and above) who lived in family homes (households) in Spain. The sampling design was multistage probabilistic, stratified by census areas (first stage), family homes (second stage), and individuals (third stage). An adult from each household was randomly chosen to complete the survey and was mailed the rationale behind the questionnaire, as well as the characteristics and anonymous nature of their participation. For the current research, we selected 7220 women aged 50–69 years for mammography update evaluation (SNHS 2017: n = 3709; EHSS 2020: n = 3511) based on screening guideline age groups (18). The sample initially included 7902 women aged 50–69 years, of whom 682 respondents (9.45%) were later excluded owing to their reluctance to answer the questions (SNHS 2017: n = 320; EHSS 2020: n = 362), despite having identical characteristics to the other women. The variables were determined by the questions included in the questionnaires, which were the same in all the surveys. The dependent variable was breast cancer screening uptake, which was measured by asking, “Have you ever had a mammogram?” Those who said yes were then asked, “When was the last time you had a mammogram?” According to the classification of women who complied with the recommended screening period [ 24 ], those who reported having their most recent mammography within the past two years were called “uptakers”. The remaining participants were labeled “non-uptakers”. The independent variables were as follows: – Socio-demographic: age group (50–56/57–63/64–69 years), educational level (without studies/primary/secondary/university), marital status (single/married/widowed/separated or divorced), residential location (rural/urban) [ 25 ], nationality (Spanish/foreigner), and social class. The social class was determined based on the neo-Weberian classification, the origins of which lie in the occupation of the primary breadwinner as developed Healthcare 2023,11, 2934 3 of 18 by the Working Group on Determinants of the Spanish Society of Epidemiology [ 26 ]: upper social class (directors and managers of companies with 10 or more employees and professionals normally qualified with university degrees, directors and managers of companies with fewer than 10 salaried employees, professionals normally qualified with university degrees, other technical support professionals, athletes, and artists), middle social class (intermediate professions and self-employed workers, supervisors and workers in skilled technical work), and lower social class (skilled workers in the primary sector and other semi-skilled workers and unskilled workers). – Health status: number of chronic conditions (0/1/ ≥ 2), self-perceived health status (very good/good, fair, poor, very poor), type of healthcare insurance (public/private), and visits to the primary care physician in the previous four weeks (yes/no). The existence of physician-diagnosed mental disorders, such as chronic anxiety, chronic depression, and other mental diseases, was assessed based on self-reported occurrence. Any woman diagnosed with one or more of these three disorders was labeled as “suffering a mental illness”. – Lifestyle behaviors: body mass index (underweight/normal weight/overweight/ obesity) [ 27 ], smoking status (never smoker/former smoker/current smoker), alcohol use (never/former/current), and leisure-time physical activity (non/lower [occasional–several times a month]/higher [several times a week]). The anonymized data are available to the general public on the website of the Ministry of Health, Consumer Affairs and Social Welfare [ 22 , 23 ]. The study was evaluated by the Research Ethics Committee of Córdoba (Spain), and it was determined that ethical approval was not necessary because secondary data were used, and the database was obtained from the website of Spanish Ministry of Health, which is accessible to the public. The categorical variables were expressed as frequencies and percentages. Chi-squared test was used to make comparisons in the variable distributions between 2017 and 2020 and to detect significant changes in mammography adherence from 2017 to 2020. Last, a binary logistic regression was performed. The dependent variable was adherence to mammography screening, with two possible values: uptakers (yes) and non-uptakers (no). The independent variables were socio-demographic factors, health status, and lifestyle behaviors. Those factors with >2 categories were incorporated into the model via dummy variables. The independent variables were introduced one by one into the crude model. Those with a potential relationship with dependent variable (p ≤ 0.15) were included in the multivariable model, and non-significant variables were excluded, using backward selection based on the likelihood of the Wald statistic. All possible interaction terms between variables in the logistic regression model were taken into consideration. The crude and adjusted odds ratios (ORs) with their 95% confidence intervals were used to measure the strength of association. The Nagelkerke R 2 , Hosmer–Lemeshow statistics, and − 2 log likelihood ( − 2 LL) change in deviance were calculated as measures of model fit. The level of statistical significance was fixed at α = 0.05. All analyses in this study were based on the unweighted data due to the nature of our research question and also following the recommendations of other authors [ 28 ]. SPSS 25.0 software, licensed to the University of Córdoba (Spain), was used to conduct the statistical analysis. 3. Results The records of 7220 women residing in Spain over 50 years of age were analyzed, resulting in a mean age of 59.15 (SD ± 5.69) years old. In 2017, and compared with 2020, women were more frequently married (2017: 63.39%, 2020: 58.93%, p< 0.001), belonged to the lower social class (2017: 48.58%, 2020: 45.54%, p< 0.01), had primary studies (2017: 22.54%, 2020: 19.11%, p< 0.001), lived in rural settings (2017: 42.68%, 2020: 45.00%, p= 0.04), perceived a better health status (2017: 8.41%, 2020: 6.58%, p< 0.01 ), had ≥ 2 chronic conditions (2017: 31.63%, 2020: 26.92%, p< 0.001), visited a general practitioner (2017: 34.92%, 2020: 26.55%, p< 0.001), and were overweight (2017: 36.07%, 2020: 35.63%, p= 0.02). Table 1shows the uptake rates for mammography based on socio- Healthcare 2023,11, 2934 4 of 18 demographic characteristics, health-related status, and lifestyle behaviors. Compliance with mammography practice was higher in women who were married, were born in Spain, had a university education, belonged to the upper class, and lived in rural settings. Moreover, a higher mammography adherence was found among women with private health insurance, those who visited a general practitioner in the four weeks preceding the survey completion, and those who had two or more chronic diseases. However, lower uptake was associated with former alcohol use, being underweight, being a current smoker, and not doing physical activity during leisure time. Table 1. Uptake of mammography according to socio-demographic characteristics, health-related status, and lifestyle behaviors (N = 7220). Variables Uptake of Mammography Total n (%) Yes n = 5635 (%) No n = 1585 (%) p-Value Age group 0.22 50–56 years old 2667 (36.94) 2083 (78.10) 584 (21.90) 57–63 years old 2570 (35.60) 2029 (78.95) 541 (21.05) 64–69 years old 1983 (27.47) 1523 (76.80) 460 (23.20) Educational level <0.001 *** Without studies 495 (6.86) 352 (71.11) 143 (28.89) Primary 1507 (20.87) 1145 (75.98) 362 (24.02) Secondary 3808 (52.74) 3000 (78.78) 808 (21.22) University 1410 (19.53) 1138 (80.71) 272 (19.29) Marital status <0.001 *** Single 922 (12.77) 658 (71.37) 264 (28.63) Married 4420 (61.22) 3554 (80.41) 866 (19.59) Widowed 875 (12.12) 685 (78.29) 190 (21.71) Separated or divorced 1003 (13.89) 738 (73.58) 265 (26.42) Social class <0.01 ** Lower 3401 (47.11) 2600 (76.45) 801 (23.55) Middle 2441 (33.81) 1927 (78.94) 514 (21.06) Upper 1378 (19.09) 1108 (80.41) 270 (19.59) Residential location <0.001 *** Urban 3163 (43.81) 2403 (75.97) 760 (24.03) Rural 4057 (56.19) 3232 (79.66) 825 (20.34) Nationality <0.001 *** Spanish 6929 (95.97) 5486 (78.91) 124 (42.61) Foreigner 291 (4.03) 167 (57.39) 1461 (21.09) Number of chronic conditions <0.01 ** 0 2815 (38.99) 2142 (76.09) 673 (23.91) 1 2287 (31.68) 1806 (78.97) 481 (21.03) ≥2 2118 (29.34) 1687 (79.65) 431 (20.35) Mental illness 0.14 No 5666 (78.48) 4401 (77.67) 1265 (22.33) Yes 1554 (21.52) 1234 (79.41) 320 (20.59) Self-perceived health status 0.53 Very good 925 (12.81) 719 (77.73) 206 (22.27) Good 3693 (51.15) 2896 (78.42) 797 (21.58) Fair 1892 (26.20) 1482 (78.33) 410 (21.67) Poor 543 (7.52) 415 (76.43) 128 (23.57) Very poor 167 (2.31) 123 (73.65) 44 (26.35) Healthcare 2023,11, 2934 5 of 18 Table 1. Cont. Variables Uptake of Mammography Total n (%) Yes n = 5635 (%) No n = 1585 (%) p-Value Type of healthcare insurance 0.03 * Public 6840 (5.26) 5321 (77.79) 1519 (22.21) Private 380 (5.26) 314 (82.63) 66 (17.37) Visits to the primary care physician in the previous 4 weeks 0.01 * No 4993 (69.16) 3856 (77.23) 1137 (22.77) Yes 2227 (30.84) 1779 (79.88) 448 (20.12) Body mass index 0.03 * Normal weight 3146 (43.57) 2476 (78.70) 670 (21.30) Underweight 131 (1.81) 89 (67.94) 42 (32.06) Overweight 2589 (35.86) 2021 (78.06) 568 (21.94) Obesity 1354 (18.75) 1049 (77.47) 305 (22.53) Smoking status <0.001 *** Never smoker 3695 (51.18) 2871 (77.70) 824 (22.30) Former smoker 1831 (25.36) 1497 (81.76) 334 (18.24) Current smoker 1694 (23.46) 1267 (74.79) 427 (25.21) Alcohol use <0.001 *** Never 1732 (23.99) 1307 (75.46) 425 (24.54) Former 1128 (15.62) 823 (72.96) 305 (27.04) Current 4360 (60.39) 3505 (80.39) 855 (19.61) Leisure-time physical activity <0.001 *** Non 2446 (33.88) 1802 (73.67) 644 (26.33) Lower 2937 (40.68) 2353 (80.12) 584 (19.88) Higher 1837 (25.44) 1480 (80.57) 357 (19.43) Statistical test used: Chi-squared test. Significance at the level: * p< 0.05; ** p< 0.01; *** p< 0.001. Of the total of women aged 50–69 years, 78% had received breast cancer screening in the previous two years. There was a significant decrease in mammography adherence during the previous two years in 2020 (79.22%) with respect to 2017 (85.59%) (p< 0.001). Moreover, the percentage of women who attended the screening between >2–3 years (2017: 8.04%, 2020: 13.29%, p< 0.001) and more than 3 years (2017: 6.36%, 2020: 7.49%, p< 0.001) was lower in 2017 than in 2020 (Figure 1). In general, the mammography uptake rate decreased from 2017 to 2020 in each group of analyzed variables, except for people with university studies and those who were single, were foreigners, had public insurance, belonged to the upper social class, and had a selfperceived very poor health status, in which the mammography uptake rate did not vary over time. On the contrary, the compliance increased from 2017 to 2020 among women who had private insurance (Table 2). A number of determinants were associated with mammography adherence in 2017 and 2020 (Table 3). In 2017, women with secondary and university studies had 37% and 45% higher odds of compliance (OR = 1.37, 95% CI 1.01–1.85 and OR = 1.45, 95% CI 1.02–2.07 , respectively). Being married was associated with 86% higher odds of adherence ( OR = 1.86 95% CI 1.46–2.38). Similarly, current alcohol consumption and higher levels of physical activity during leisure time were both associated with 30% and 46% higher odds of mammography uptake (OR = 1.30, 95% CI 1.19–1.75 and OR = 1.46, 95% CI 1.16–1.82, respectively). On the contrary, the odds of adherence decreased 63% among foreigner women (OR = 0.37, 95% CI 0.26–0.52), 27% in the case of current smokers (OR = 0.73, 95% CI Healthcare 2023,11, 2934 6 of 18 0.59–0.89), and 16% in women who lived in rural settings (OR = 0.84, 95% CI 0.71–0.93). The probability of adherence to mammography screening is given by the following equation: P (adherence) = 1/(1 + e−z) Z = logit (P) = 0.508 + 0.17X1+ 0.32X2+ 0.37X3+ 0.62X4+ 0.75X5+ 0.27X6− 0.17X7−0.99X8+ 0.02X9−0.32X10 −0.33X11 + 0.26X12 + 0.19X13 + 0.38X14 Healthcare 2023, 11, x FOR PEER REVIEW 5 of 18 Very good 925 (12.81) 719 (77.73) 206 (22.27) Good 3693 (51.15) 2896 (78.42) 797 (21.58) Fair 1892 (26.20) 1482 (78.33) 410 (21.67) Poor 543 (7.52) 415 (76.43) 128 (23.57) Very poor 167 (2.31) 123 (73.65) 44 (26.35) Type of healthcare insurance 0.03 * Public 6840 (5.26) 5321 (77.79) 1519 (22.21) Private 380 (5.26) 314 (82.63) 66 (17.37) Visits to the primary care physician in the previous 4 weeks 0.01 * No 4993 (69.16) 3856 (77.23) 1137 (22.77) Yes 2227 (30.84) 1779 (79.88) 448 (20.12) Body mass index 0.03 * Normal weight 3146 (43.57) 2476 (78.70) 670 (21.30) Underweight 131 (1.81) 89 (67.94) 42 (32.06) Overweight 2589 (35.86) 2021 (78.06) 568 (21.94) Obesity 1354 (18.75) 1049 (77.47) 305 (22.53) Smoking status <0.001 *** Never smoker 3695 (51.18) 2871 (77.70) 824 (22.30) Former smoker 1831 (25.36) 1497 (81.76) 334 (18.24) Current smoker 1694 (23.46) 1267 (74.79) 427 (25.21) Alcohol use <0.001 *** Never 1732 (23.99) 1307 (75.46) 425 (24.54) Former 1128 (15.62) 823 (72.96) 305 (27.04) Current 4360 (60.39) 3505 (80.39) 855 (19.61) Leisure-time physical activity <0.001 *** Non 2446 (33.88) 1802 (73.67) 644 (26.33) Lower 2937 (40.68) 2353 (80.12) 584 (19.88) Higher 1837 (25.44) 1480 (80.57) 357 (19.43) Statistical test used: Chi-squared test. Significance at the level: * p < 0.05; ** p < 0.01; *** p < 0.001. Of the total of women aged 50–69 years, 78% had received breast cancer screening in the previous two years. There was a significant decrease in mammography adherence during the previous two years in 2020 (79.22%) with respect to 2017 (85.59%) (p < 0.001). Moreover, the percentage of women who attended the screening between >2–3 years (2017: 8.04%, 2020: 13.29%, p < 0.001) and more than 3 years (2017: 6.36%, 2020: 7.49%, p < 0.001) was lower in 2017 than in 2020 (Figure 1). Figure 1. Frequency of mammography adherence in the period 2017–2020 in Spain. 0% 20% 40% 60% 80% 100% ≤ 2 years Between > 2 and 3 years More than 3 years 2020 2017 p < 0.001 p < 0.001 p < 0.001 Figure 1. Frequency of mammography adherence in the period 2017–2020 in Spain. Table 2. Distribution of uptakers of mammography, according to sociodemographic, health, and lifestyle variables from 2017 to 2020 (n = 5635). Variables Mammography Screening (n = 5635) 2017 n = 3013 n (%) 2020 n = 2622 n (%) p-Value Age group 50–56 years old 1140 (80.91) 943 (74.96) <0.001 *** 57–63 years old 1061 (81.99) 968 (75.86) <0.001 *** 64–69 years old 812 (80.72) 711 (72.77) <0.001 *** Educational level Without studies 246 (77.12) 106 (60.23) <0.001 *** Primary 671 (80.26) 474 (70.64) <0.001 *** Secondary 1554 (81.96) 1446 (75.63) <0.001 *** University 542 (82.37) 596 (79.26) 0.14 Marital status Single 313 (72.29) 345 (70.55) 0.61 Married 1959 (83.33) 1595 (77.09) <0.001 *** Widowed 392 (83.94) 293 (71.81) <0.001 *** Separated or divorced 349 (76.20) 389 (71.38) 0.09 Social class Lower 1453 (80.63) 1147 (71.73) <0.001 *** Middle 1022 (81.89) 905 (75.86) <0.001 *** Upper 538 (81.64) 570 (79.28) 0.27 Residential location Urban 1257 (79.41) 1146 (72.53) <0.001 *** Rural 1756 (82.60) 1476 (76.44) <0.001 *** Healthcare 2023,11, 2934 7 of 18 Table 2. Cont. Variables Mammography Screening (n = 5635) 2017 n = 3013 n (%) 2020 n = 2622 n (%) p-Value Nationality Spanish 2914 (82.11) 2554 (75.56) <0.001 *** Foreigner 99 (61.88) 68 (51.91) 0.10 Number of chronic conditions 0 1108 (80.23) 1034 (72.11) <0.001 *** 1 934 (80.87) 872 (77.03) 0.02 * ≥2 971 (82.78) 716 (75.77) <0.001 *** Mental illness No 2280 (81.02) 2121 (74.37) <0.001 *** Yes 733 (81.90) 501 (76.02) <0.01 ** Self-perceived health status Very good 339 (78.47) 380 (77.08) <0.001 *** Good 1505 (82.24) 1391 (74.66) <0.001 *** Fair 845 (81.72) 637 (74.24) <0.001 *** Poor 249 (79.81) 166 (71.86) 0.03 * Very poor 75 (74.26) 48 (72.73) 0.83 Type of healthcare insurance Public 2864 (81.23) 2457 (74.14) <0.001 *** Private 149 (81.42) 165 (83.76) <0.001 *** Visits to the primary care physician in the previous 4 weeks No 1945 (80.57) 1911 (74.10) <0.001 *** Yes 1068 (82.47) 711 (76.29) <0.001 *** Body mass index Normal weight 1277 (81.65) 1199 (75.79) <0.001 *** Underweight 46 (68.66) 43 (67.19) 0.86 Overweight 1101 (82.29) 920 (73.54) <0.001 *** Obesity 589 (79.59) 460 (74.92) 0.04 * Smoking status Never smoker 1556 (81.98) 1315 (73.18) <0.001 *** Former smoker 771 (83.53) 726 (79.96) 0.04 * Current smoker 686 (77.25) 581 (72.08) 0.01 * Alcohol use Never 851 (77.36) 456 (72.15) <0.001 *** Former 317 (81.28) 506 (68.56) <0.001 *** Current 1845 (83.15) 1660 (77.53) <0.001 *** Leisure-time physical activity Non 986 (77.33) 816 (69.68) <0.001 *** Lower 1209 (82.41) 1806 (77.82) <0.001 *** Higher 818 (84.59) 662 (76.09) <0.001 *** Statistical test used: Chi-squared test. Significance at the level: * p< 0.05; ** p< 0.01; *** p< 0.001. Healthcare 2023,11, 2934 8 of 18 Table 3. Variables associated with adherence to mammography screening among women residing in Spain stratified by year (2017 and 2020). Variables 2017 2020 OR (CI 95%) B ORa (95% CI) p-Value OR (CI 95%) B ORa (95% CI) p-Value Age group 50–56 years old Reference Reference 57–63 years old 1.08 (0.89–1.31) 1.05 (0.88–1.26) 64–69 years old 0.91 (0.80–1.21) 0.89 (0.74–1.08) Educational level Without studies Reference Reference Reference Reference Primary 1.21 (0.88–1.65) 0.17 1.18 (0.86–1.63) 0.30 1.59 (1.13–2.24) 0.38 1.46 (0.48–2.07) 0.31 Secondary 1.35 (1.01–1.80) 0.32 1.37 (1.01–1.85) 0.04 2.05 (1.49–2.82) 0.60 1.82 (1.29–2.54) <0.01 University 1.39 (0.99–1.93) 0.37 1.45 (1.02–2.07) 0.04 2.52 (1.78–3.58) 0.75 2.12 (1.44–3.09) <0.001 Marital status Single Reference Reference Reference Reference Married 1.92 (1.51–2.43) 0.62 1.86 (1.46–2.38) <0.001 1.41 (1.13–1.75) 0.34 1.41 (1.12–1.77) <0.01 Widowed 2.00 (1.45–2.77) 0.75 2.11 (0.89–2.96) 0.26 1.06 (0.80–1.42) 0.15 1.16 (0.85–1.57) 0.17 Separated or divorced 1.23 (0.91–1.66) 0.27 1.31 (0.96–1.77) 0.10 1.04 (0.80–1.36) 0.05 1.05 (0.80–1.39) 0.74 Social class Lower Reference Reference Middle 1.09 (0.90–1.31) 1.24 (1.04–1.47) Upper 1.07 (0.85–1.34) 1.51 (1.22–1.86) Residential location Urban Reference Reference Reference Reference Rural 0.81 (0.69–0.96) − 0.17 0.84 (0.71–0.93) <0.01 0.81 (0.70–0.95) − 0.22 0.80 (0.68–0.94) <0.01 Nationality Spanish Reference Reference Reference Reference Foreigner 0.35 (0.25–0.49) − 0.99 0.37 (0.26–0.52) <0.001 0.35 (0.25–0.50) − 0.91 0.40 (0.28–0.57) <0.001 Number of chronic conditions 0 Reference Reference Reference 1 1.04 (0.86–1.27) 1.30 (1.08–1.55) 0.30 1.35 (1.13–1.63) <0.01 ≥2 1.18 (0.97–1.45) 2.21 (1.01–1.46) 0.33 1.39 (1.14–1.70) <0.01 Mental illness No Reference Reference Yes 1.06 (0.87–1.29) 1.09 (0.90–1.33) Self-perceived health status Very good Reference Reference Good 1.27 (0.98–1.65) 1.26 (0.71–2.26) Fair 1.23 (0.93–1.62) 1.11 (0.64–1.92) Poor 1.08 (0.76–1.55) 1.08 (0.62–1.90) Very poor 0.79 (0.48–1.319 0.96 (0.52–1.77) Type of healthcare insurance Public Reference Reference Reference Private 1.01 (0.69–1.48) 1.80 (1.22–2.65) 0.45 1.56 (1.05–2.34) 0.03 Visits to the primary care physician in the previous 4 weeks No Reference Reference Yes 1.13 (0.95–1.35) 1.13 (0.94–1.34) Body mass index Normal weight Reference Reference Underweight 0.49 (0.29–0.84) 0.65 (0.38–1.12) Overweight 1.04 (0.86–1.26) 0.89 (0.75–1.05) Obesity 0.88 (0.70–1.10) 0.95 (0.77–1.18) Healthcare 2023,11, 2934 9 of 18 Table 3. Cont. Variables 2017 2020 OR (CI 95%) B ORa (95% CI) p-Value OR (CI 95%) B ORa (95% CI) p-Value Smoking status Never smoker Reference Reference Reference Reference Former smoker 1.12 (0.90–1.38) 0.02 1.02 (0.81–1.26) 0.81 1.46 (0.80–1.77) 0.22 1.25 (0.73–1.53) 0.12 Current smoker 0.75 (0.61–0.91) − 0.32 0.73 (0.59–0.89) <0.01 0.95 (0.79–1.14) − 0.11 0.90 (0.74–0.93) 0.03 Alcohol use Never Reference Reference Reference Reference Former 0.68 (0.41–1.11) − 0.33 0.72 (0.59–1.13) 0.11 0.84 (0.67–1.06) − 0.19 0.83 (0.65–1.07) 0.14 Current 1.27 (1.14–1.64) 0.26 1.30 (1.19–1.75) <0.01 1.29 (1.08–1.63) 0.16 1.18 (1.10–1.52) <0.01 Leisure-time physical activity Non Reference Reference Reference Reference Lower 1.37 (1.14–1.66) 0.19 1.20 (1.10–1.58) <0.01 1.39 (1.13–1.69) 0.18 1.20 (1.08–1.54) <0.01 Higher 1.61 (1.29–2.01) 0.38 1.46 (1.16–1.82) <0.01 1.53 (1.28–1.82) 0.32 1.38 (1.15–1.65) <0.01 OR, odds ratio; ORa, odds ratio adjusted for all socio-demographic characteristics, health-related status, and lifestyle behaviors; 95% CI, 95% confidence interval. B, regression coefficient. 2017: Constant = 0.508; Hosmer–Lemeshow test χ2 = 13.67, p= 0.09; − 2 log likelihood for the intercept = 3581.409, − 2 log likelihood for the final model = 3461.485, − 2 log likelihood χ2 = 119.925, p-value < 0.001; Nagelkerke’s R 2 square = 0.38; p-value < 0.001 . 2020: Constant = − 0.004; Hosmer–Lemeshow test χ2 = 7.68, p= 0.47; − 2 log likelihood for the intercept = 3973.244, − 2 log likelihood for the final model = 3831.468, − 2 log likelihood χ2 = 141.777, p-value < 0.001 ; Nagelkerke’s R2square = 0.43; p-value < 0.001. In 2020, while most of the factors associated to adherence remained consistent with those identified in 2017, certain determinants, such as the presence of 1 or ≥ 2 chronic conditions and having private insurance showed an increase in the odds of compliance with mammography screening of 35%, 39%, and 56% (OR = 1.35, 95% CI 1.13–1.63; OR = 1.39 , 95% CI 1.14–1.70; OR = 1.56, 95% CI 1.05–2.34, respectively). The following equation shows the probability of adherence to breast cancer screening: P (adherence) = 1/(1 + e−z) Z = logit (P) = −0.004 + 0.38X1+ 0.60X2+ 0.75X3+ 0.34X4+ 0.15X5+ 0.05X6− 0.22X7−0.91X8+ 0.30X9+ 0.33X10 + 0.33X11 + 0.45X12 + 0.22X13 −0.11X14 − 0.19X15 + 0.16X16 + 0.18X17 + 0.32X18 In none of the logistic regression models were the interaction terms statistically significant (p> 0.05). Table 4shows the logistic regression model for independent associated factors of mammography screening adherence in both years. Having completed secondary and university studies were associated with 57% and 84% higher odds of mammography uptake (OR = 1.57, 95% CI 1.26–1.89 and OR = 1.84, 95% CI 1.37–2.27, respectively). Also, married participants had 60% higher odds of compliance (OR = 1.60, 95% CI 1.36–1.90). Likewise, the year 2017 and having visited a general practitioner were associated with 48% and 13% higher odds of mammography adherence (OR = 1.48, 95% IC 1.32–1.67 and OR = 1.13 , 95% CI 1.05–1.35, respectively). Moreover, the odds of adherence increased 20% and 30% among women who had 1 or ≥ 2 chronic diseases (OR = 1.20, 95% CI 1.04–1.37 and OR = 1.30, 95% CI 1.13–1.50, respectively). Also, current alcohol consumption and higher levels of physical activity during leisure time were both associated with 34% higher odds of mammography uptake (OR = 1.34, 95% CI 1.19–1.51 and OR = 1.34, 95% CI 1.15–1.56, respectively). In contrast, the odds of adherence decreased 18% among women who lived in rural settings or were current smokers (OR = 0.82, 95% CI 0.73–0.92 and OR = 0.82, Healthcare 2023,11, 2934 16 of 18 16. 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