The World Health Organisation, through the Alma-Ata declaration [1], has identified prevention as a public health priority. This has been incorporated as one of the main targets of the Greek health system, and has been addressed through the establishment of National Health System (NHS) primary care health centres. Prevention is considered as a basic component for the development of the primary health care sector and the main public schemes of primary health provision, such as NHS Health Centres and IKA (Social Insurance Fund) polyclinics—which cover about 85% of the Greek population—are responsible for providing and delivering preventive services free and equitably throughout the country.

Use of preventive services has been extensively studied in many European countries and in the U.S. The vast majority of these studies concern cancer screenings such as mammography, Pap-tests and cervical smears [2–5], whereas fewer studies concerned screenings for cardiovascular prevention such as blood pressure measurement, cholesterol screenings [4,6–10] or diabetes screening [11–14]. Socio-economic inequalities in the use of preventive services have been identified, with people better off financially reporting higher utilisation of preventive care services than those worse-off.

Prevention is not only associated with reduced morbidity and mortality, but may also result in reduced overall cost for health care systems. The appropriate use of preventive services results in early diagnosis of illness, improvement of future health, reduction of the future use of therapeutic services and of the related cost [6]. The relationship between cardiovascular prevention and the related cost—economic or other—has been studied during the last decade via a significant number of economic evaluations [15–17].

Cardiovascular disease (CVD) is a significant cause of morbidity and mortality and has a multifactorial aetiology. Studies have addressed factors that are related to the development or increase the risk of CVD such as hypertension, smoking, diabetes mellitus, dislipidaemia, obesity, alcohol consumption and physical inactivity [18–20], as well as their relation to socio-economic status [21,22].

According to the Greek National Statistical Service [23], CVD is the primary cause of mortality, and during the period 2000–2006 it accounted for 47%–52% of all recorded deaths (with a slight decline every year). Previous studies in Greece have extensively assessed the prevalence of risk factors related to the development of CVD and their relationship to socioeconomic status and lifestyle risk factors [24–27]. Contrarily, the use of preventive tests related to CVD has not yet been studied in Greece (as far as we know) and hence it is important to examine the use of preventive services for CVD in the Greek NHS, which provides access to primary and secondary health care free of charge at the point of use. The present study adds to existing research by attempting to determine the factors that affect the use of preventive screenings, in order to promote an international health policy on cardiovascular prevention.

The aim of this study was to investigate the extent to which preventive blood pressure, cholesterol and blood glucose tests are performed by the Greek population based on self-reported data. In a setting where screening rates are likely to be relatively high, we attempt to explore the factors that determine the pattern of cardiovascular preventive use, which according to the international literature are socio-demographic, access to health care, health behaviour and health need, to identify possible social disparities and to compare the results to those from other studies.

Socio-demographic characteristics of the sample, which roughly represent the gender distribution in Greece, according to the 2001 census, and rates of preventive tests use, are provided in Table 2.

According to Table 3 there were significant differences (p < 0.05) in use of preventive tests across each socio-demographic characteristic, except for private insurance and residence. Women, more elder and those with primary education had the highest rates of use. Utilization rates appeared to be almost uniform across most of the variables except for the younger age categories, marital status and regular source of care.

In this study we attempted to identify factors that determine the use of blood pressure, cholesterol and blood glucose tests. The preventive services which were chosen are provided in a primary setting and concern cardiovascular prevention. This research, based on general population data, determined which factors among socio-demographic data, access to health care, health risks and health status are the variables that best predict the use of the above preventive services in Greece.

This study showed that the rates of blood pressure, cholesterol and blood glucose screenings were very high, ranging from 72.8% for cholesterol to 85% for the blood pressure test. The extremely high use of preventive services may be attributed to the importance of looking after one’s health or to the ease of having these tests in the Greek health care system. The latter concerns the structure of the Greek health system and especially the public sector, which is based on insurance funds with free and easy access to primary and secondary health care. The fact that these tests concern general practice and are provided by semi-urban health services, outpatient hospital departments or insurance funds which are distributed around the country, implies that people can easily receive (free of cost) these preventive tests through their insurance funds after being referred by a primary physician, outpatient hospital departments or alternatively by purchasing from the private sector.

Gender is significant predictor only for the blood pressure test, with females having a higher likelihood of receiving it. The finding is comparable to those from previous studies concerning blood pressure testing [6,7,9]. Gender is not associated with the cholesterol test, and females seem to be more likely to be screened for diabetes, as has been stated previously as well [30]. However in our study the results were marginally not significant. Additionally, use of tests follows an expected trend with age with older people being more likely to receive these services. Obviously, this is associated with the higher prevalence of cardiovascular and other chronic diseases in elderly people.

Using education as an indicator of SES, our results highlight important educational and other social inequalities in the distribution of preventive screenings. Multivariate analysis controlling for the effects of the other variables showed that people with university level education were more likely to receive blood pressure, cholesterol or blood glucose screenings than people with only primary education and blood glucose screenings in the case of secondary education. Individuals with a lower SES had a higher risk of not receiving preventive tests, and this is in line with previous studies [3,4,6–8,31], keeping in mind the fact that the concentration of health needs (i.e., impaired health status) in less privileged socioeconomic groups is higher. A potential explanation may be that the higher the educational level the better the awareness or the compliance to medical advice or that the more educated were well informed [2] or had the ability to use better the available resources [4]. Our results confirmed those from a previous study, which showed that people with elementary education were less able to identify major CVD risk factors [32], which implies that interventions for dealing with inequality must be targeted at the improvement of knowledge by conducting educational programmes and campaigns for less privileged people of the society, in order to redress inequities in the distribution of the preventive screenings. The latter is related to the primary health care system in Greece which is considered to be fragmented and without continuity, generating inequality in the provision of health services and ineffectiveness. As it is stated [33], despite the several endeavours the establishment of integrated primary health care in Greece is still at its infancy.

Having a regular family doctor indicates a significant likelihood of receiving preventive tests for CVD risk, a finding that is evident in previous studies [21,34] where it was suggested that usual source of care increased the likelihood of receiving preventive services. Having a regular source of care means a well established physician-patient relationship where people have recommended services by experts and also a higher possibility for early diagnosis, good future health and quality of life. But the regular source of care is not absolutely effective. Educational differences still remain after controlling for the effect of regular source of care, implying that interventions to access to health care might only alleviate social inequalities moderately.

Two important issues must be pointed out. Firstly, the family doctor is not incorporated into the primary health care system. Usually the insured seek a family doctor in order to ensure continuity in the provision of health services by the same doctor. Secondly, due to the limited number of GPs, the family doctor is usually an internal medical doctor. Therefore the establishment of an integrated primary health care system, with the introduction of General Practitioners acting as family doctors as in the case of British NHS, may contribute to the better management of diseases and health risk factors in the community and to the development of health promotion

In terms of health need proxies, although they were consistent with the preposition that poor health is associated with increased likelihood of health care use and preventive services as well, the findings concerning the association between health risks and preventive services are not encouraging. Obesity, which is associated with increased CVD and diabetes mellitus, was not related to the use of cholesterol and diabetes tests, but it contributed significantly and positively to the use of the blood pressure test. Contrary to expectations, tobacco use did not affect the use of the preventive screenings, whereas alcohol consumption (>7 glasses/week) was associated negatively with the use of cholesterol and blood glucose screening. According to our results, those who are exposed to greater health risks were less likely to be screened, a fact that according to other studies [6,8] compromises the effectiveness of screenings for these risk factors, suggesting firstly that physicians must increase their efforts to provide preventive care to those who are inclined to harmful health behaviours, and secondly health policy interventions should support and enrich the role of prevention. The important issue is why these people did not use preventive tests. One possible explanation could be ignorance and the lack of health knowledge. A previous study in the Greek population [27] regarding the relationship between SES and cardiovascular risk factors showed that the majority (78%) of the lowest SES tertile and 23% and 21% of medium and highest tertiles respectively reported not believing that active or passive smoking may be harmful.

This study has some possible limitations. The data was based on self-reports and self-perceived health obviously involves a subjective evaluation. Self-reports for counting preventive tests may be subject to recall bias because they may overestimate the prevalence of tests, and thus may underestimate the differences in tests by social position and health risk factors. A complete health assessment requires information about the test results and whether these results were considered as normal or whether a portion of tests concerned follow-up tests due to previous abnormal results. Concerning the high rate of receiving these tests, a point that is not clear is whether these tests were periodic check-ups and were made due to systematic prevention or made on an opportunistic basis. A previous study has shown that one third of visits to family physicians involved opportunistic care [35].

Despite the high rates of preventive tests, social inequalities in the use of blood pressure, cholesterol and blood glucose tests still remain. Access to health care is an important factor for receiving recommended preventive tests by experts but could only merely moderate the social inequalities. Fragmentation, underdevelopment of the public primary health care and the medically-oriented Greek NHS impede the existence of an effective primary health care and produce inequalities. Problems persist with the inadequate provision of preventive tests to the most vulnerable. The establishment of an integrated primary health care system with continuity and coordination will contribute to the better management of diseases and health risk factors in the community and to the development of health promotion. Combined interventions in order to improve the knowledge of particularly the poorly educated, to empower the preventive role of the primary physicians mostly to more the vulnerable may consist an integrate approach to redress the inequalities and improve the effectiveness of the utilization of preventive services.