Health outcomes have been transformed over the past few decades.

Smoking rates have halved in Scotland (encouragingly less young people are taking it up) which has been credited for contributing to a 74% decrease in heart attacks.

Cancer outcomes have also significantly improved. The advent of immunotherapy drugs, improved awareness over symptoms and prevention and surgical and screening innovations have all contributed to increased survival rates.

However, the one puzzle that governments are struggling to solve is how to reduce the deprivation gap in screening uptake rates.

After decades of improvement, life expectancy in Scotland has stalled and mortality rates, particularly in deprived areas have started to increase.

Researchers are not exactly clear why this is the case and the pandemic may provide some answers but improving cancer detection rates across the demographic might go some way to improving the outlook.

Earlier this week the Scottish Government published the outcome of a major review which aims to drive improvements in the national screening programme for breast cancer. 

READ MORE: Cancer screening changes recommended after 'major adverse effects'

The document was release late in the day which always arouses some suspicion amongst journalists that its contents are not entirely positive.

Indeed, it recommends an overhaul of services after two ‘major adverse events’ which led to thousands of patients being missed off the list for mammograms due to IT glitches, in some cases because they had moved to a different GP.

Analysis: The health prevention puzzle that government can't solve

An investigation, published in 2016, found almost 200 women had gone on to develop the disease.

Last year it emerged that hundreds of women at high risk of breast cancer had missed the routine check due to an administrative error at NHS Lothian.

The review recommends a change in the way women are contacted for mammograms with patients called individually based on the date of their last check to help avoid anyone aged 50-70 being missed.

Average uptake for the health check over the last 10-years is 72%, just above the minimum acceptable standard of 70%. but there is a significant gulf in rates in deprived and affluent areas of Scotland.

Under six in ten women (59.5%) from the poorest communities attend mammogram appointments compared with almost eight in ten women (79.7%) living in the most affluent areas - a 20 percentage point difference.

READ MORE: 'Shocking' levels of asthma attacks amongst Scotland's poorest 

Data also shows that the uptake rate is also lower amongst younger women, aged 50- 53 years.

Women living in deprived communities were interviewed as part of the review to try to understand why they are less likely to book or attend appointments.

Some, mistakenly believed that mammograms were unnecessary, “if self examination revealed no lumps.”  Around half of breast tumours detected by screening would not be picked up with a physical examination. 

Analysis: The health prevention puzzle that government can't solve

There was also a strong association of the risk of breast cancer being tied with a family history of the disease or as something that mainly affects older women over the age of 70.

Many women said they were reluctant to ask for time off work to attend screening appointments as they felt these were not viewed as a priority by their employers.

Embarrassment and fear of discomfort was also mentioned by women from poorer areas as a barrier to attendance.

Breast cancer is not unique in this regard. The disparity in uptake rates exists in other cancers which have national screening programmes in place, including bowel cancer.

In this case it is all the more frustrating and tragic because outcomes for the most common female cancer have dramatically improved in recent years.

Around 86% of women in Scotland are now surviving at for least five years after their breast cancer diagnosis.

READ MORE: Why our current GP system is widening health inequalities 

There are many cancers for which screening is not an option. The majority of cases of ovarian cancer are still being diagnosed at a later stage because of this and the fact that symptoms such as bloating can mimic other, less serious health conditions.

Urban regeneration firm Clyde Gateway has been working with partners to try to narrow the cancer screening gap between Scotland’s most deprived communities and other marginalised groups such as people with learning disabilities.

Research carried out by Glasgow Centre for Population Health (GCPH) as part of this work found another barrier was the fear of bad news. 

“This was conflated with other everyday worries and the impact of poverty on people’s resilience to cope with multiple challenges.”

Some said that attending a medical appointment was simply not a priority when they were trying to pay for food shopping or electricity bills.

Analysis: The health prevention puzzle that government can't solve

Logistical barriers such as  transport and childcare were also mentioned. 

Many cancer patients face challenges remaining at work during treatment or returning to work after it has finished while limited research has shown that low‐wage earning cancer survivors are less likely to have access to workplace supports

The deprivation gap is not confined to cancer screening. Research by University College London found that one of the barriers to uptake of the Covid vaccine amongst deprived communities may have been because of the large numbers of people on zero-hour contracts or shift-working who would be reluctant to miss out on paid work.

Those who took part in the research by GCPH said that involving local communities in health campaigns could boost uptake for cancer tests and efforts have made in recent years to use  real-life cancer survivors in government awareness drives.

General practice is crucial for the early diagnosis of cancer but patients from deprived areas are also more likely to experience problems getting an appointment than those from more affluent areas.

Solving health inequalities is multi-factorial and complex but at the very minimum, every effort must be made to ensure there is equal access to preventative  healthcare.