{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,31]],"date-time":"2026-08-31T15:51:10Z","timestamp":1788191470389,"version":"build-2803163510"},"reference-count":39,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,7,26]],"date-time":"2026-07-26T00:00:00Z","timestamp":1785024000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Med. Sci.","Medical Sciences"],"abstract":"<jats:p>Background: Socioeconomic deprivation is a well-established determinant of participation in colorectal cancer (CRC) screening. However, less is known about the geographic clustering of screening adherence and whether spatial inequalities mirror regional patterns of socioeconomic disadvantage. This study investigated the association between socioeconomic deprivation and adherence to CRC screening across Italian regions and explored the presence of spatial autocorrelation using geographic analytical methods. Methods: We conducted a nationwide ecological cross-sectional study including 21 Italian regional units. Pearson correlation analysis was performed to explore associations between colorectal cancer (CRC) screening adherence, primary care physician (PCP) workload and socioeconomic deprivation. Multivariable linear regression was used after assessment of multicollinearity using variance inflation factors (VIFs). Sensitivity analyses included alternative deprivation indicators and leave-one-region-out analyses. Spatial dependence was evaluated using Global Moran\u2019s I and Local Indicators of Spatial Association (LISA). Results: CRC screening adherence showed substantial geographic variability across Italy, with higher participation in northern regions and lower participation in southern areas. Screening adherence was inversely associated with socioeconomic deprivation. Sensitivity analyses confirmed the robustness of the association across alternative deprivation measures and sequential exclusion of each regional unit. Spatial analysis demonstrated significant positive spatial autocorrelation (Moran\u2019s I = 0.275; p = 0.039), indicating that neighbouring regions tended to exhibit similar screening behaviours. LISA analysis identified significant High\u2013High clusters in northern Italy, Low\u2013Low clusters in southern and insular regions, and isolated spatial outliers, highlighting persistent territorial inequalities in preventive healthcare utilisation. Conclusions: Regional disparities in CRC screening participation were associated with socioeconomic deprivation and modest but significant spatial clustering. These findings provide a regional-level description of inequalities in screening participation and may help inform future public health strategies aimed at reducing disparities in organised colorectal cancer screening.<\/jats:p>","DOI":"10.3390\/medsci14040436","type":"journal-article","created":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T08:15:56Z","timestamp":1785140156000},"page":"436","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Socioeconomic Deprivation, Primary Care Physician Workload and Colorectal Cancer Screening Adherence Across Italian Regions: An Ecological Spatial Analysis"],"prefix":"10.3390","volume":"14","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-7503-008X","authenticated-orcid":false,"given":"Caterina Elisabetta","family":"Rizzo","sequence":"first","affiliation":[{"name":"Department of Prevention, Local Health Authority of Enna, 94100 Enna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5406-884X","authenticated-orcid":false,"given":"Vincenzo","family":"Restivo","sequence":"additional","affiliation":[{"name":"Department of Medicine and Surgery, University of Enna \u201cKore\u201d, 94100 Enna, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-3228-4414","authenticated-orcid":false,"given":"Maria Concetta","family":"Rizzo","sequence":"additional","affiliation":[{"name":"Department of Political and Social Sciences, University of Catania, 95100 Catania, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9282-1030","authenticated-orcid":false,"given":"Cristina","family":"Genovese","sequence":"additional","affiliation":[{"name":"Department of Biomedical Sciences, Dental Sciences and Morpho-functional Imaging, University of Messina, 98100 Messina, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1119","DOI":"10.4251\/wjgo.v16.i4.1119","article-title":"Colorectal cancer screening: A review of current knowledge and progress in research","volume":"16","author":"Lopes","year":"2024","journal-title":"World J. Gastrointest. Oncol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"101287","DOI":"10.1016\/j.lanepe.2025.101287","article-title":"Correction to \u201cUtilization of colorectal cancer screening tests across European countries: A cross-sectional analysis of the European health interview survey 2018\u20132020\u201d [The Lancet Regional Health\u2014Europe Volume 41, June 2024, 100920]","volume":"52","author":"Ola","year":"2025","journal-title":"Lancet Reg. Health Eur."},{"key":"ref_3","unstructured":"(2026, July 16). Italy. Presidency of the Council of Ministers. Decree of the President of the Council of Ministers: Definition and Updating of the Essential Levels of Care Pursuant to Article 1 (7) of Legislative Decree No. 502 of 30 December 1992 (DPCM 12 January 2017, No. 17A02015). Gazzetta Ufficiale della Repubblica Italiana. 2017; 65. Supplemento Ordinario No. 15. Available online: https:\/\/www.gazzettaufficiale.it\/eli\/id\/2017\/03\/18\/17A02015\/s."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Rousset, S., Strippoli, E., Senore, C., Spadea, T., Calcagno, M., Zengarini, N., and Ferrante, G. (2025). The impact of individual and contextual socioeconomic factors on colorectal cancer screening adherence in Turin, Italy: A multilevel analysis. BMC Public Health, 25.","DOI":"10.1186\/s12889-025-22396-x"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"103022","DOI":"10.1016\/j.pmedr.2025.103022","article-title":"The association between health literacy and cancer screening participation: A cross-sectional study across three organised screening programmes in Denmark","volume":"53","author":"Helgestad","year":"2025","journal-title":"Prev. Med. Rep."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"100243","DOI":"10.1016\/j.dialog.2025.100243","article-title":"Socio-economic and insurance factors in preventive care: A two-stage weighted structural analysis","volume":"7","author":"Nkouaga","year":"2025","journal-title":"Dialogues Health"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1016\/j.sopen.2023.12.001","article-title":"Engaging primary care physicians is critical in the screening and diagnosis of colorectal cancer at safety-net hospital systems","volume":"17","author":"Dimaano","year":"2023","journal-title":"Surg. Open Sci."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"100166","DOI":"10.1016\/j.lanprc.2026.100166","article-title":"The general practice workforce crisis in Europe: Scale of the challenge and available policy responses","volume":"2","author":"Russo","year":"2026","journal-title":"Lancet Prim. Care"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1186\/s12960-023-00842-4","article-title":"The layered crisis of the primary care medical workforce in the European region: What evidence do we need to identify causes and solutions?","volume":"21","author":"Russo","year":"2023","journal-title":"Hum. Resour. Health"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Wu, J., Tang, X., Zheng, Q., Gu, X., Ma, L., Xian, J., Mao, H., Gan, J., and Ji, G. (2025). Enhancing cancer risk awareness and screening management through artificial intelligence: A narrative review. Front. Oncol., 15.","DOI":"10.3389\/fonc.2025.1695749"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Zhu, T., Wu, R., Wu, J., Kwan, R.Y.C., Liu, M., Zhou, A., and Deng, R. (2025). Using nudges with electronic health records systems to improve advance care planning: A systematic review. BMC Palliat. Care, 24.","DOI":"10.1186\/s12904-025-01820-4"},{"key":"ref_12","first-page":"1711","article-title":"The impact of interventions addressing socioeconomic inequalities in cancer-related outcomes in high-income countries: A systematic review","volume":"9","author":"Bygrave","year":"2020","journal-title":"J. Public Health Res."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Vandenbroucke, J.P., von Elm, E., Altman, D.G., G\u00f8tzsche, P.C., Mulrow, C.D., Pocock, S.J., Poole, C., Schlesselman, J.J., Egger, M. (2007). Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): Explanation and elaboration. PLoS Med., 4.","DOI":"10.1371\/journal.pmed.0040297"},{"key":"ref_14","unstructured":"Osservatorio Nazionale Screening (2026, July 01). Colorectal Cancer Screening. Published 2025. Available online: https:\/\/www.osservatorionazionalescreening.it\/content\/lo-screening-colorettale."},{"key":"ref_15","unstructured":"Agenzia Nazionale per i Servizi Sanitari Regionali (AGENAS) (2026, July 01). Profili Sanitari delle Regioni e Province Autonome; AGENAS: Rome, Italy. Available online: https:\/\/stat.agenas.it\/web\/index.php?r=public%2Findex&report=30."},{"key":"ref_16","unstructured":"Istituto Nazionale di Statistica (ISTAT) (2026). Living Conditions and Household Income\u2014Year 2025, ISTAT. Available online: https:\/\/www.istat.it\/en\/press-release\/living-conditions-and-household-income-year-2025\/."},{"key":"ref_17","unstructured":"Eurostat (2025). Income and Living Conditions (EU-SILC): Reference Metadata, Statistical Office of the European Union. Available online: https:\/\/ec.europa.eu\/eurostat\/cache\/metadata\/en\/ilc_sieusilc.htm."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Wang, H., Li, L., Che, L., Kong, H., Wang, Q., Wang, Z., and Xu, J. (2021). Geospatial Least Squares Support Vector Regression Fused with Spatial Weight Matrix. ISPRS Int. J. Geo-Inf., 10.","DOI":"10.3390\/ijgi10110714"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"93","DOI":"10.1111\/j.1538-4632.1995.tb00338.x","article-title":"Local Indicators of Spatial Association\u2014LISA","volume":"27","author":"Anselin","year":"1995","journal-title":"Geogr. Anal."},{"key":"ref_20","unstructured":"R Core Team (2021). R: A Language and Environment for Statistical Computing, R Foundation for Statistical Computing. Available online: https:\/\/www.R-project.org\/."},{"key":"ref_21","unstructured":"QGIS.org (2026, June 30). QGIS Geographic Information System. Available online: http:\/\/www.qgis.org."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"D\u00edez-Mart\u00edn, A., Castro, M., Santiago, I., Almaz\u00e1n, R., G\u00f3mez-Amor\u00edn, \u00c1., Regueiro-Exp\u00f3sito, C., Davila-Pi\u00f1\u00f3n, P., and Cubiella, J. (2026). Organised Colorectal Cancer Screening and Changes in Mortality and Incidence Trends: A Population-Based Study. Cancers, 18.","DOI":"10.20944\/preprints202603.1685.v1"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"6689534","DOI":"10.1155\/adph\/6689534","article-title":"Italy\u2019s National Healthcare System and eHealth Landscape","volume":"2026","author":"Napoli","year":"2026","journal-title":"Adv. Public Health"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Greenley, R., Bell, S., Rigby, S., Legood, R., Kirkby, V., McKee, M., and CBIG-SCREEN Consortium (2023). Factors influencing the participation of groups identified as underserved in cervical cancer screening in Europe: A scoping review of the literature. Front Public Health, 11.","DOI":"10.3389\/fpubh.2023.1144674"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"101733","DOI":"10.1016\/j.pmedr.2022.101733","article-title":"Socio-economic inequality of utilization of cancer testing in Europe: A cross-sectional study","volume":"26","author":"Bozhar","year":"2022","journal-title":"Prev. Med. Rep."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"767","DOI":"10.1007\/s10654-025-01247-4","article-title":"Recent trends in self-reported utilization of colonoscopy and fecal occult blood test in Europe: Analysis of the European Health Interview Surveys 2013\u20132015 and 2018\u20132020","volume":"40","author":"Ola","year":"2025","journal-title":"Eur. J. Epidemiol."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e48150","DOI":"10.2196\/48150","article-title":"Association Between Socioeconomic Status and Adherence to Fecal Occult Blood Tests in Colorectal Cancer Screening Programs: Systematic Review and Meta-Analysis of Observational Studies","volume":"9","author":"Luo","year":"2023","journal-title":"JMIR Public Health Surveill."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e267024","DOI":"10.1001\/jamanetworkopen.2026.7024","article-title":"Barriers to Health Care and Cancer Screening","volume":"9","author":"Gurayah","year":"2026","journal-title":"JAMA Netw. Open"},{"key":"ref_29","first-page":"e234","article-title":"Social Determinants, Health Literacy, and Disparities: Intersections and Controversies","volume":"5","author":"Schillinger","year":"2021","journal-title":"Health Lit. Res. Pract."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"e17917","DOI":"10.2196\/17917","article-title":"Social Media Use for Health Purposes: Systematic Review","volume":"23","author":"Chen","year":"2021","journal-title":"J. Med. Internet Res."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Nicoara, D., Cristescu, C., Pop, I.C., Ilies, R.A., Nicoara, N., von Stauffenberg, A.O., Matei, S., Muntean, M.V., and Achimas-Cadariu, P. (2025). Family Physicians\u2019 Perspectives on Personalized Cancer Prevention: Barriers, Training Needs, Quality Improvements and Opportunities for Collaborative Networks. J. Clin. Med., 14.","DOI":"10.3390\/jcm14197073"},{"key":"ref_32","first-page":"4","article-title":"The colorectal cancer screening program in the local health unit n. 6 of Livorno: Evaluation of the screening activity in the period 2000\u20132011","volume":"55","author":"Zani","year":"2014","journal-title":"J. Prev. Med. Hyg."},{"key":"ref_33","first-page":"e2828","article-title":"Adhesion of a group of target women to breast cancer screening: An evaluation of the possible factors involved in the choice to be screened","volume":"11","author":"Rizzo","year":"2024","journal-title":"WCRJ"},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Restivo, V., Graci, D., Immordino, A., Mancuso, D.G., Morales, F., Pace, C., Pirrello, A., Casuccio, A., and Immordino, P. (2025). Cervical Cancer Screening in Refugee and Migrant Populations: Results of Systematic Review and Meta-Analysis in Cross-Sectional and Cohort Studies. Cancers, 17.","DOI":"10.3390\/cancers17182966"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"Chin, Z.S., Ghodrati, A., Foulger, M., Demirkhanyan, L., and Gondi, C.S. (2025). Beyond Barriers: Achieving True Equity in Cancer Care. Curr. Oncol., 32.","DOI":"10.3390\/curroncol32060349"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Graci, D., Piazza, N., Ardagna, S., Casuccio, A., Drobov, A., Geraci, F., Immordino, A., Pirrello, A., Restivo, V., and Rumbo, R. (2024). Barriers to and Facilitators for Accessing HPV Vaccination in Migrant and Refugee Populations: A Systematic Review. Vaccines, 12.","DOI":"10.3390\/vaccines12030256"},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Rizzo, C.E., Venuto, R., Caruso, M.G., Genovese, C., and Lagan\u00e0, P. (2026). Where Environment and Healthcare Meet: Air Pollution, Antibiotic Use, and Mortality in an Ageing Population in Southern Italy. Med. Sci., 14.","DOI":"10.3390\/medsci14020198"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"106410","DOI":"10.1016\/j.puhe.2026.106410","article-title":"Rethinking cancer screening in Italy: Equity, performance and innovation","volume":"258","author":"Rizzo","year":"2026","journal-title":"Public Health"},{"key":"ref_39","doi-asserted-by":"crossref","unstructured":"Genovese, G., Rizzo, C.E., Nirta, A., Bartucciotto, L., Venuto, R., Fedele, F., Squeri, R., and Genovese, C. (2025). Mapping Healthcare Needs: A Systematic Review of Population Stratification Tools. Med. Sci., 13.","DOI":"10.3390\/medsci13030145"}],"container-title":["Medical Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/4\/436\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T08:31:05Z","timestamp":1785141065000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3271\/14\/4\/436"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,26]]},"references-count":39,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["medsci14040436"],"URL":"https:\/\/doi.org\/10.3390\/medsci14040436","relation":{},"ISSN":["2076-3271"],"issn-type":[{"value":"2076-3271","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,26]]}}}