Uptake patterns and predictors of colorectal cancer screening among adults resident in Spain: A population-based study from 2017 to 2020

TYPE Original Research PUBLISHED 13 March 2023 DOI 10.3389/fpubh.2023.1151225 OPEN ACCESS EDITED BY Ozgur Karcioglu, Taksim Training and Research Hospital, Türkiye REVIEWED BY Carlo Senore, Piedmont Reference Center for Epidemiology and Cancer Prevention, Italy Maria José Bento, Portuguese Oncology Institute, Portugal *CORRESPONDENCE Jesús Cebrino [email protected] †PRESENT ADDRESS Silvia Portero de la Cruz, Department of Nursing, Pharmacology and Physiotherapy, University of Córdoba, Córdoba, Spain SPECIALTY SECTION This article was submitted to Life-Course Epidemiology and Social Inequalities in Health, a section of the journal Frontiers in Public Health RECEIVED 25 January 2023 ACCEPTED 22 February 2023 PUBLISHED 13 March 2023 CITATION Portero de la Cruz S and Cebrino J (2023) Uptake patterns and predictors of colorectal cancer screening among adults resident in Spain: A population-based study from 2017 to 2020. Front. Public Health 11:1151225. doi: 10.3389/fpubh.2023.1151225 COPYRIGHT ©2023 Portero de la Cruz and Cebrino. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms. Uptake patterns and predictors of colorectal cancer screening among adults resident in Spain: A population-based study from 2017 to 2020 Silvia Portero de la Cruz1† and Jesús Cebrino2* 1Research Group GC12 Clinical and Epidemiological Research in Primary Care, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, Córdoba, Spain, 2Department of Preventive Medicine and Public Health, University of Seville, Seville, Spain Background: Although population screening has improved the early diagnosis of colorectal cancer (CRC), most cases are diagnosed in symptomatic patients. This study aimed to estimate the prevalence and evolution over time of uptake patterns to fecal immunochemical test (FIT) as a screening test for CRC among individuals aged 50–69 in Spain, and to determine the predictive factors for uptake patterns to this type of screening based on sociodemographic, health, and lifestyle characteristics. Methods: A cross-sectional study with 14,163 individuals from the 2017 Spanish National Health Survey and the 2020 European Health Survey was performed, including as the main variable uptake pattern to FIT screening within the last 2 years, with which we analyzed sociodemographic factors, health status and lifestyle habits. Results: 38.01% of participants had undergone FIT in the previous 2 years, and from 2017 to 2020, a significant increase in the uptake rate for CRC was observed (2017: 32.35%, 2020: 43.92%, p<0.001). The positive predictors to FIT uptake pattern included factors such as being between 57 and 69 years, having a higher educational level or a higher social class, having at least one chronic illness, frequent contact with the primary care physician, alcohol consumption and physical activity, while immigration and smoking habit were negative predictors. Conclusion: In Spain, although the evolution of FIT uptake pattern over time is positive, the prevalence of FIT uptake is still low (38.01%), not reaching the level considered as acceptable in the European guidelines. Moreover, there are disparities in CRC screening uptake among individuals. KEYWORDS colorectal neoplasms, guideline adherence, health services, healthcare disparities, mass screening 1. Introduction Colorectal cancer (CRC) is the third biggest cause of cancer-related mortality in both men and women globally (1). In 2020, 40,441 new cases of CRC were recorded in Spain, accounting for up to 14.3% of all new cancer diagnoses (2). By 2040, the incidence of CRC is expected to rise by 27.81%, probably due to demographic changes (3). Moreover, CRC was the second-leading cause of mortality after lung cancer in 2020, with 16,470 deaths (4). Frontiers in Public Health 01 frontiersin.org Portero de la Cruz and Cebrino 10.3389/fpubh.2023.1151225 In Spain, the 5-year survival rate for CRC is 63.3% (5), and although changes in CRC risk factors typically result in a decrease in incidence and death rates, this occurs over a long rather than a short time frame, which means that a considerable period of time is needed to observe and analyze how changes in CRC risk factors prevalence impact incidence and mortality rates (6). As a result, different early detection strategies have been developed, with the assumption that early treatment of the diagnosed lesions may improve the prognosis of this tumor, thus reducing its gravity or lowering mortality (7). In fact, early detection with regular screening beginning at the age of 50 is successful in enhancing survival from CRC (the 5-year survival rate in screen-detected CRC is about 93%) (8), although high screening participation rates are required to achieve this. Following the recommendations of the European Screening Guidelines for CRC (9) and the National Health System’s cancer plan (10), a CRC screening program was gradually introduced in Spain beginning in 2000. This screening program is aimed at people aged 50–69 years and is conducted using a personal invitation letter every 2 years, which they are asked to perform a fecal immunochemical test (FIT), followed by endoscopic procedures to confirm the positive test (11). In recent years, the immunohistochemical fecal test has emerged as the primary choice for screening, since it is more sensitive and has a higher diagnostic accuracy for CRC than the traditional guaiac-based fecal occult blood test (12). CRC screening in Spain is well-organized (11) and does a better job than opportunistic screenings in terms of usage, reducing not just cancer mortality but also inequalities in access to and uptake of CRC screening, as well as being more cost-effective and enabling a larger number of individuals to be reached (13). Nevertheless, previous research performed in Spain has shown that uptake pattern for CRC screening is below 32% (14), which is lower than in other developed nations with comparable programs, such as England, Finland, Ireland, or Denmark (15). Moreover, the FIT uptake pattern rate recorded in Spain is much lower than the acceptable rate of uptake in European standards of over 45%, and ideally 65% to produce a significant benefit (9). Given these considerations, added to the fact that the vast majority of CRC cases are still discovered in symptomatic subjects (16), it is critical to achieve the greatest possible FIT uptake patterns rate and increase the effectiveness of CRC detection programs, with a specific emphasis on the factors that impact uptake. For this reason, the aims of this study were to estimate the prevalence and evolution over time of uptake patterns to FIT as a screening test for CRC among individuals aged 50–69 in Spain, and to determine the predictive factors for uptake patterns to this screening test based on sociodemographic, health, and lifestyle characteristics. 2. Material and methods A cross-sectional study was conducted, utilizing data from the Spanish National Health Survey 2017 (SNHS) (17) and European Health Survey in Spain 2020 (EHSS) (18). The National Statistics Institute performed both surveys under the auspices of the Spanish Ministry of Health and Social Affairs, using the same methods. The SNHS 2017 data collection period was from October 2016 to October 2017, while the EHSS 2020 was collected between July 2019 and July 2020. Individuals ≥15 years old were chosen using probabilistic multistage sampling, with the first-final units (individuals) chosen using random routes and sex-based and age-based quotas. Trained interviewers visited randomly-chosen homes and asked the residents to participate in the survey. Computer-assisted personal interviews were also used to obtain data. Additional details about the survey methodology may be found elsewhere (17,18). For study reasons, in accordance with the age guideline for FIT screening, we selected individuals aged 50–69 years (11). The total sample included 15,240 records: 7,687 from SNHS 2017 and 7,553 from EHSS 2020. Despite having identical characteristics to the others, 1,077 subjects (7.07%) were subsequently removed from the total sample due to their refusal to complete the surveys (SNHS 2017: n=453; EHIS 2020: n=624). Finally, the study sample consisted of 14,163 participants (7,234 from SNHS 2017 and 6,929 from EHSS 2020). The current study incorporates the self-reported responses from these questionnaires. To generate all the variables in our study accurately, we used identical questions in both surveys. Uptake pattern to FIT-based CRC screening was established as the dependent variable. The participants responded two questions: (i) “Have you ever had a fecal occult blood test?” (“Yes,” “No”) and (ii) “How long has it been since you last underwent a fecal occult blood test?” (In the last 12 months, “More than 1, but <2 years ago,” “More than 2, but <3 years ago,” and “More than 3, but <5 years ago,” and “More than 5 years ago”). According to their answers, participants were classified as: - Never-users: those who answered “No” the first question, therefore they had never undergone a FIT. - Uptakers: participants who answered affirmatively to the first question and answered in the second question: “In the last 12 months” and “More than 1, but <2 years ago,” in other words, individuals who had taken a FIT during the previous 2 years. - Under-users: subjects who answered affirmatively to the first question and responded in the second question: “More than 2, but <3 years ago” or “More than 3, but <5 years ago” or “More than 5 years ago,” meaning subjects who reported that they had undergone FIT more than 2 years. - Non-uptakers: individuals defined as “never-user” or “underuser.” The independent variables listed below were included: - Sociodemographic factors such as gender (men/women), age group (50–56/57–63/64–69), level of education (without studies/primary/secondary/university), marital status (single/married/widowed/separated-divorced), social class (upper/middle/lower) (19), residential location (rural/urban), and nationality (Spanish/foreign). - Variables related to health status, such as number of chronic diseases (0/1/ ≥2), presence of physician-diagnosed mental illness (yes/no), self-perception of health status in the last 12 months (very good/good/average/bad/very bad), insurance Frontiers in Public Health 02 frontiersin.org Portero de la Cruz and Cebrino 10.3389/fpubh.2023.1151225 TABLE 1 Uptake of fecal immunochemical test according to sociodemographic, health and lifestyle characteristics (n=14,163). Variables Uptake of FIT Total Yes No p-value n=14,163 (%) n=5,383 (%) n=8,780 (%) Gender Man 6,972 (49.23) 2,628 (37.69) 4,344 (62.31) 0.45 Woman 7,191 (50.77) 2,755 (38.31) 4,436 (61.69) Age group 50–56 years old 5,311 (37.50) 1,586 (29.86) 3,725 (70.14) <0.001 57–63 years old 5,025 (35.48) 2,052 (40.84) 2,973 (59.16) 64–69 years old 3,827 (27.02) 1,745 (45.60) 2,082 (54.40) Level of education Without studies 87 (0.61) 16 (18.39) 71 (81.61) <0.001 Primary 3,789 (26.75) 1,299 (34.28) 2,490 (65.72) Secondary 7,662 (54.10) 3,020 (39.42) 4,642 (60.58) University 2,625 (18.54) 1,048 (39.92) 1,577 (60.08) Marital status Single 2,112 (14.91) 702 (33.24) 1,410 (66.76) <0.001 Married 9,130 (64.46) 3,561 (39.00) 5,569 (61.00) Widowed 1,066 (7.53) 434 (40.71) 632 (59.29) Separated or divorced 1,855 (13.10) 686 (36.98) 1,169 (63.02) Social class Lower 6,592 (46.54) 2,284 (34.65) 4,308 (65.35) <0.001 Middle 4,914 (34.70) 1,985 (40.39) 2,929 (59.61) Upper 2,657 (18.76) 1,114 (41.93) 1,543 (58.07) Residential location Urban 6,428 (45.39) 2,333 (36.29) 4,095 (63.71) <0.001 Rural 7,735 (54.61) 3,050 (39.43) 4,685 (60.57) Nationality Spanish 13,383 (94.49) 5,178 (38.69) 8,205 (61.31) <0.001 Foreigner 780 (5.51) 205 (26.28) 575 (73.72) Number of chronic conditions 0 2,954 (20.86) 787 (26.64) 2,167 (73.36) <0.001 1 2,629 (18.56) 920 (34.99) 1,709 (65.01) ≥2 8,580 (60.58) 3,676 (42.84) 4,904 (57.16) Presence of physician-diagnosed mental illness No 11,881 (83.89) 4,422 (37.22) 7,459 (62.78) <0.001 Yes 2,282 (16.11) 961 (42.11) 1,321 (57.89) Self-perceived health status Very good 1,906 (13.46) 658 (34.52) 1,248 (65.48) <0.001 Good 7,566 (53.42) 2,787 (36.84) 4,779 (63.16) Fair 3,427 (24.20) 1,399 (40.82) 2,028 (59.18) Poor 990 (6.99) 421 (42.53) 569 (57.47) Very poor 274 (1.93) 118 (43.07) 156 (56.93) (Continued) Frontiers in Public Health 03 frontiersin.org Portero de la Cruz and Cebrino 10.3389/fpubh.2023.1151225 TABLE 1 (Continued) Variables Uptake of FIT Total Yes No p-value n=14,163 (%) n=5,383 (%) n=8,780 (%) Insurance status Public 13,424 (94.78) 5,145 (38.33) 8,279 (61.67) <0.01 Private 739 (5.22) 238 (32.21) 501 (67.79) Visits to the primary care physician in the previous 4 weeks No∗10,194 (71.98) 3,661 (35.91) 6,533 (64.09) <0.001 Yes 3,969 (28.02) 1,722 (43.39) 2,247 (56.61) Visits to the specialist physician in the previous 4 weeks No∗12,291 (86.78) 4,507 (36.67) 7,784 (63.33) <0.001 Yes 1,872 (13.22) 876 (46.79) 996 (53.21) Body Mass Index Normal weight 4,975 (35.13) 1,865 (37.49) 3,110 (62.51) 0.19 Underweight 156 (1.10) 71 (45.51) 85 (54.49) Overweight 6,139 (43.35) 2,357 (38.39) 3,782 (61.61) Obesity 2,893 (20.42) 1,090 (37.68) 1,803 (62.32) Current smoking habit No†10,491 (74.07) 4,216 (40.19) 6,275 (59.81) <0.001 Yes 3,672 (25.93) 1,167 (31.78) 2,505 (68.22) Alcohol intake in the last year No‡4,214 (29.75) 1,462 (34.69) 2,752 (65.31) <0.001 Yes 9,949 (70.25) 3,921 (39.41) 6,028 (60.59) Free time physical exercise No∗∗ 4,792 (33.83) 1,595 (33.28) 3,197 (66.72) <0.001 Yes 9,371 (66.17) 3,788 (40.42) 5,583 (59.58) FIT, Fecal immunochemical test. ∗No: between 4 weeks and 12/12 months or more ago/never. †No: I don’t currently smoke, but I have in the past/I don’t smoke and have never smoked on a regular basis. ‡No: I have not consumed alcohol in the last 12 months. ∗∗No: I do not practice any physical activity in my free time. status (public/private), visits to the primary care physician in the last month (yes/no), and visits to a medical specialist in the last month (yes/no). - Lifestyle habits, including body mass index (underweight/normal weight/overweight/obesity) (20) current smoking habit (yes/no), alcohol consumption in the last year (yes/no), and free time physical exercise (yes/no). Permission from an ethics committee is not required under Spanish law, because the database was obtained from the website of Spanish Ministry of Health, which is accessible to the public. The frequencies and percentages were used to provide the descriptive analysis of qualitative variables. For comparisons, we used chi-squared test. A binary logistic regression was also performed to determine the predictors of the FIT uptake pattern. We calculated crude and adjusted odds ratio (OR), as well as their 95% confidence intervals. We utilized the Wald statistic, in which the variables with p<0.15 were removed from the model one by one. The Hosmer–Lemeshow test was used to assess the quality of fit, and measure the goodness of fit, and we examined the adjusted coefficient of determination (R2), the F statistic and the normality of the residues. All the contrasts of hypotheses were bilateral, and statistical significance was set at p<0.05. The statistical analysis was carried out using the statistical program IBM SPSS Statistics version 25.0, which was licensed to the University of Córdoba (Spain). 3. Results The sample was composed of 14,163 records of individuals aged 50–69 years. Among the participants, 50.77% were women with a mean age of 59.08 ±5.69 years. The highest values of compliance with FIT were observed in people with a university education Frontiers in Public Health 04 frontiersin.org Portero de la Cruz and Cebrino 10.3389/fpubh.2023.1151225 FIGURE 1 Prevalence of fecal occult blood test use by age group (n=14,163). (39.92%), widowed (40.71%), belonging to the upper class (41.93%), living in rural residences (39.43%), Spanish nationality (38.69%), having, at least, two chronic illnesses (42.84%), suffering from a mental illness (42.11%), having a very poor self-perceived health status (43.07%), having public health insurance (38.33%), visiting a primary care physician (43.39%) or a specialist physician (46.79%) in the 4 weeks preceding survey completion, being a nonsmoker (40.19%), consuming alcohol in the last year (39.41%) and doing free time physical activity (40.42%; Table 1). The overall percentage of participants who had never undergone FIT was 46.12%, a figure which had decreased from 2017 (50.19%) to 2020 (41.87%; p<0.001). The overall prevalence of FIT under-users was 15.87%, which decreased over the years studied (2017: 17.46%, 2020: 14.21%, p<0.001). The overall percentage of FIT uptakers was 38.01%, which increased over time (2017: 32.35%, 2020: 43.92%, p<0.001). Moreover, the prevalence of FIT uptakers was highest at age 64–69 (45.60%, p<0.001; Figure 1). Table 2 shows the FIT uptake in the different autonomous communities during the study period (2017–2020). Navarra (59.86%), Cataluña (52.26%), and País Vasco (51.41%) were the autonomous communities with the highest percentage of FIT, while those with the lowest proportions were Andalucía (16.97%), Asturias (19.16%), and Extremadura (22.58%; p<0.001). In general, the FIT uptake rate increased from 2017 to 2020 in each group of variables analyzed, except for people without studies and those with a self-perceived very poor health status, in which FIT uptake rate did not vary over time (Table 3). Table 4 shows the factors associated with FIT uptake among subjects aged 50–69. Compared to individuals aged 50–56, participants aged 57–63 or 64–69 were more likely to show a higher FIT uptake. While more educated subjects were more likely to have taken a FIT within the 2 previous years, the opposite was found for foreign people. In addition, a trend toward a higher probability of FIT uptake with increasing social class was observed. A similar result was observed for individuals who had been diagnosed with a chronic disease. Furthermore, participants who had had an appointment with the primary care physician in the last 4 weeks increased their probability of compliance with FIT. Finally, the individuals who had consumed alcohol during the previous year TABLE 2 Uptake of fecal immunochemical test of Spanish people in the period 2017–2020 in the different regions of Spain. Autonomous community Year of CRC screening implementation Uptakers of FIT p-value n=5,383 (38.01%) Andalucía 2014 325 (16.97) Aragón 2013 94 (50.27) Asturias 2014 132 (19.16) Baleares 2015 200 (45.25) Canarias 2009 251 (34.76) Cantabria 2008 252 (41.11) Castilla y León 2010 351 (45.23) Castilla la Mancha 2015 425 (63.15) Cataluña 2000 763 (52.26) Comunidad Valenciana 2005 591 (48.28) <0.001 Extremadura 2017 168 (22.58) Galicia 2013 277 (33.54) Madrid 2017 419 (31.72) Murcia 2005 169 (27.35) Navarra 2013 343 (59.86) País Vasco 2009 401 (51.41) La Rioja 2010 142 (32.35) Ceuta 2017 61 (32.24) Melilla 2017 19 (30.16) FIT, Fecal immunochemical test. and had performed physical activity during their leisure time were more likely to have been screened, while the opposite was observed for smokers. 4. Discussion The present study used national representative surveys to analyze FIT uptake in Spain from 2017 to 2020 and to identify the variables associated with screening compliance among 14,163 individuals aged 50 to 69. According to our findings, almost half the Spanish population had never taken a FIT, despite being in the age range suitable for CRC screening. Furthermore, a part of the screened Spanish population does not adhere to the guidelines for test intervals. The Health Ministry of Spain set an objective in 2014 of a 100% adherence rate to FIT in the 50–69 year-old population residing in Spain by 2025 (21); nevertheless, given our findings, this seems implausible. The uptake pattern rate to FIT found in the current study was 38.01%, increasing from 32.35% in 2017 to 43.92% in 2020, demonstrating a substantial 11.57% rise. It is difficult to assess CRC screening uptake patterns across European countries since Frontiers in Public Health 05 frontiersin.org Portero de la Cruz and Cebrino 10.3389/fpubh.2023.1151225 TABLE 3 Distribution of uptakers of fecal occult blood testing, according to sociodemographic, health and lifestyle variables from 2017 to 2020 (n=5,383). Uptakers of FIT Variables 2017 2020 p-value n=2,340 (%) n=3,043 (%) Gender Man 1,151 (32.72) 1,477 (42.76) <0.001 Woman 1,189 (32.00) 1,566 (45.06) <0.001 Age group 50-56 years old 701 (25.24) 885 (34.93) <0.001 57-63 years old 876 (34.93) 1,176 (46.72) <0.001 64-69 years old 763 (39.15) 982 (52.29) <0.001 Level of education Without studies 11 (17.46) 5 (20.83) 0.72 Primary 644 (30.39) 655 (39.22) <0.001 Secondary 1,272 (33.27) 1,748 (45.53) <0.001 University 413 (33.60) 635 (45.49) <0.001 Marital status Single 296 (30.08) 406 (35.99) <0.01 Married 1,595 (32.93) 1,966 (45.86) <0.001 Widowed 199 (34.97) 235 (47.28) <0.001 Separated or divorced 250 (29.83) 436 (42.87) <0.001 Social class Lower 1,027 (30.05) 1,257 (39.60) <0.001 Middle 883 (34.72) 1,102 (46.48) <0.001 Upper 430 (33.78) 684 (49.42) <0.001 Residential location Urban 1,114 (31.27) 1,219 (42.53) <0.001 Rural 1,226 (33.39) 1,824 (44.89) <0.001 Nationality Spanish 2,293 (33.00) 2,885 (44.83) <0.001 Foreigner 47 (16.43) 158 (31.98) <0.001 Number of chronic conditions 0 295 (22.50) 492 (29.95) <0.001 1 358 (28.44) 562 (41.02) <0.001 ≥2 1,687 (36.17) 1,989 (50.79) <0.001 Presence of physician-diagnosed mental illness No 1,876 (31.66) 2,546 (42.75) <0.001 Yes 464 (35.47) 497 (51.03) <0.001 Self-perceived health status Very good 242 (27.75) 416 (40.23) <0.001 Good 1,152 (30.78) 1,635 (42.77) <0.001 Fair 660 (34.90) 739 (48.11) <0.001 Poor 222 (39.22) 199 (46.93) 0.02 Very poor 64 (39.51) 54 (48.21) 0.15 (Continued) Frontiers in Public Health 06 frontiersin.org Portero de la Cruz and Cebrino 10.3389/fpubh.2023.1151225 TABLE 3 (Continued) Uptakers of FIT Variables 2017 2020 p-value n=2,340 (%) n=3,043 (%) Insurance status Public 2,245 (32.66) 2,900 (44.27) <0.001 Private 95 (26.32) 143 (37.83) <0.001 Visits to the primary care physician in the previous 4 weeks No∗1,444 (29.68) 2,217 (41.61) <0.001 Yes 896 (37.84) 826 (51.59) <0.001 Visits to the specialist physician in the previous 4 weeks No∗∗ 1,856 (30.51) 2,651 (42.71) <0.001 Yes 484 (42.09) 392 (54.29) <0.001 Body Mass Index Normal weight 772 (31.05) 1,093 (43.91) <0.001 Underweight 38 (48.10) 33 (42.86) 0.02 Overweight 1,019 (32.58) 1,338 (44.44) <0.001 Obesity 511 (33.16) 579 (42.83) <0.001 Current smoking habit No†1,829 (34.29) 2,387 (46.29) <0.001 Yes 511 (26.89) 656 (37.02) <0.001 Alcohol intake in the last year No‡697 (32.27) 765 (37.24) <0.01 Yes 1,643 (32.38) 2,278 (46.73) <0.001 Free time physical exercise No∗∗ 715 (28.99) 880 (37.83) <0.001 Yes 1,625 (34.08) 2,163 (46.99) <0.001 FIT, Fecal immunochemical test. ∗No: between 4 weeks and 12/12 months or more ago/never. †No: I don’t currently smoke, but I have in the past/I don’t smoke and have never smoked on a regular basis. ‡No: I have not consumed alcohol in the last 12 months. ∗∗No: I do not practice any physical activity in my free time. preventative screening programs differ in terms of updating data, target age groups, screening intervals and the principal test utilized in each country (22). Nevertheless, the screening rates in other European countries with analogous programs are significantly >38.01% found in the current study, for example, France (51%) or Slovenia (56%) (13). The increase in uptake observed in the current study between 2017 and 2020 might be related to the adoption of the FIT over the guaiac-fecal occult blood test in most screening programmes in Spain, which is related to higher participation among people invited in organized screening settings (23). Despite the increase observed in Spain, and considering that the last 5 months of the 2020 data collection were conducted during the COVID-19 pandemic, restrictions in screening activities may have influenced the probability of undergoing screening during that period, limiting the percentage of uptakers and delaying CRC diagnosis. Moreover, the impact of the screening programmes cancellation could be longer than the period they were closed, because program’s restart was progressive and many people could have decided not to participate in the programmes to prevent unnecesary virus exposure (24). Some researchers have examined the effect of the cancellation of these CRC screening programmes on CRC. In that sense, a recent study showed that delaying CRC screening by 4–6 months would rise the number of advanced CRC cases and even mortality if delayed for more than 12 months (25). It is critical that health authorities officials ensure that the general population recognizes how essential these programmes are. On the other hand, it is important to highlight that the low level of FIT adoption in Spain could be influenced by the uneven implementation of the CRC screening program (10), owing to the fact that each region has a separate public health system overseen by its own regional government, despite the fact that Spain’s health system is public. This unequal implementation was due to each region having one public health system that is managed by a Frontiers in Public Health 07 frontiersin.org Portero de la Cruz and Cebrino 10.3389/fpubh.2023.1151225 TABLE 4 Determinants of fecal immunochemical test among subjects aged 50–69 residing in Spain (n=14,163). Variables OR (CI 95%) ORa∗(CI 95%) p-value Gender Man Reference Woman 0.97 (0.91–1.04) Age group 50–56 years old Reference Reference 57–63 years old 1.62 (1.49–1.76) 1.53 (1.41–1.67) <0.001 64–69 years old 1.97 (1.81–2.15) 1.83 (1.66–2.01) <0.001 Level of education Without studies Reference Reference Primary 2.32 (1.34–4.00) 1.96 (1.12–3.42) 0.02 Secondary 2.89 (1.68–4.98) 2.56 (1.45–4.51) <0.001 University 2.95 (1.71–5.10) 2.81 (1.61–4.91) <0.01 Marital status Single Reference Married 1.28 (1.16–1.42) Widowed 1.38 (1.19–1.61) Separated or divorced 1.18 (0.13–1.34) Social class Lower Reference Reference Middle 1.28 (1.18–1.38) 1.17 (1.08–1.26) <0.001 Upper 1.36 (1.24–1.49) 1.25 (1.11–1.41) <0.001 Residential location Urban Reference Rural 1.14 (1.07–1.22) Nationality Spanish Reference Reference Foreigner 0.57 (0.48–0.67) 0.68 (0.57–0.80) <0.001 Number of chronic conditions 0 Reference Reference 1 1.48 (1.32–1.66) 1.38 (1.22–1.55) <0.001 ≥2 2.06 (1.88–2.26) 1.86 (1.69–2.05) <0.001 Presence of physician-diagnosed mental illness No Reference Yes 1.23 (1.12–1.34) Self-perceived health status Very good Reference Good 1.11 (0.99–1.23) Fair 1.31 (1.17–1.47) Poor 1.40 (1.20–1.64) Very poor 1.44 (1.11–1.86) (Continued) Frontiers in Public Health 08 frontiersin.org Portero de la Cruz and Cebrino 10.3389/fpubh.2023.1151225 TABLE 4 (Continued) Variables OR (CI 95%) ORa∗(CI 95%) p-value Insurance status Public Reference Private 0.76 (0.65–0.90) Visits to the primary care physician in the previous 4 weeks No∗Reference Reference Yes 1.37 (1.27–1.47) 1.23 (1.13–1.33) <0.001 Visits to the specialist physician in the previous 4 weeks No∗Reference Yes 1.52 (1.38–1.68) Body Mass Index Normal weight Reference Underweight 1.39 (1.01–1.92) Overweight 1.04 (0.96–1.12) Obesity 1.01 (0.92–1.11) Current smoking habit No†Reference Yes 0.69 (0.64–0.75) 0.76 (0.70–0.83) <0.001 Alcohol intake in the last year No‡Reference Yes 1.22 (1.14–1.32) 1.24 (1.15–1.35) <0.001 Free time physical exercise No∗∗ Reference Yes 1.36 (1.26–1.46) 1.24 (1.15–1.34) <0.001 ∗No: between 4 weeks and 12/12 months or more ago/never. †No: I don’t currently smoke, but I have in the past/I don’t smoke and have never smoked on a regular basis. ‡No: I have not consumed alcohol in the last 12 months. ∗∗No: I do not practice any physical activity in my free time. OR, odds ratio.∗ORa, odds ratio adjusted for all socio-demographic characteristics, health-related status and lifestyle behaviors; CI 95%, 95% Confidence Interval. Hosmer-Lemeshow test χ2=11.77, p =0.16; Nagelkerke’s R2Square =0.41; p-value <0.001. different regional government, even though the health system in Spain is public. In Spain, Catalonia was the first autonomous community to carry out screening programs with a pilot study in 2000 (26) and, in our study, was the region with the highest percentage of FIT (52.26%) during 2017–2020. This percentage of FIT contrast with those obtained in Andalucía (16.97%), Asturias (19.16%), or Extremadura (22.58%), where CRC screening was more recently implemented, which is generating a growing demand for opportunistic CRC screening (27). The invitation to opportunistic screening is sporadic and is established by individual initiative or by general practitioners or specialized physicians. Its benefit in terms of morbidity and mortality has not been proven, there is no guarantee of quality control, and it is less equitable and likely less efficient (27). FIT screening compliance varies not only depending on the country, but also according to sociodemographic, health and lifestyle characteristics. Age was a significant predictor of FIT uptake, with uptake pattern to FIT rising with age. This result coincides with other studies conducted in Spain and other countries (14,28). Since CRC incidence increases with age, one possible explanation for this finding might be that people’s risk perception about getting CRC increases with age, leading to a higher screening rate as they become older (29). In terms of socioeconomic conditions, we discovered disparities based on educational level, social class and nationality. In our study, a higher educational level was a favorable predictor of uptake for FIT. Previously, a greater educational attainment has been linked to increased usage of preventive services, especially CRC screening (30). Compared to individuals with lower levels of education who may not perceive the value of screening, the higher educated group is related with improved risk perception, resulting in greater involvement in cancer screening (31). On the other hand, as in prior studies, the likelihood of complying with FIT improved with belonging to a higher social class (32). Belonging to a lower Frontiers in Public Health 09 frontiersin.org