Disparities in PAP Screening Utilization Among 18-30 Year Old Women in the United States

Background and Purpose:  Over the last fifty years, deaths from cervical cancer have decreased by 70% because of increased screening of pre-cancerous cells in the cervix using the Papanicolaou (PAP) test. Despite this progress, an estimated 12,710 women suffered from cervical cancer and 4,290 died from the disease in the United States in 2011. While the utilization rates of breast and colorectal screening have seen an upward trend in recent years, there has been a slight but significant decline in PAP screening utilization from 2000 to 2010. Studies indicate lower PAP screening rates among low-income and minority women, particularly Asians and Hispanics. Guided by the Behavioral Model of Health Care Utilization, this study identifies barriers and facilitators of PAP utilization among women aged 18-30 years in the U.S.

Methods: Research questions were answered using the 2010 National Health Interview Survey (NHIS) (N=3,129). To understand the relationship between PAP screening and barriers/facilitators, a multivariate logistic regression was conducted. The regression used “PAP in the previous three years” as the outcome and the predictors: race/ethnicity, age, marital status, education, family income, any live birth, annual flu shot, insurance status, usual source of care, and region of residence. Special statistical procedures were used to control for the complex survey design. Results are presented as odds ratios (OR). The pre-determined alpha level of significance was 0.05.

Results: The sample had 3,129 women aged 18-30 years old, representing about 27 million women in the U.S. Significant factors associated with lower PAP utilization were: 18-22 yrs. (vs. 23-30 yrs., OR=0.71), unmarried (vs. married/partnered, OR=0.62), no health insurance >1 year (vs. yes, OR=0.63), and no usual source of care (vs. yes, OR=0.72). Non-Hispanic Asian were less likely than non-Hispanic Whites to receive PAP screening but this result was borderline significant (OR=0.64, p=0.06). Significant factors associated with higher PAP utilization were: Non-Hispanic Black (vs. non-Hispanic White, OR=1.55), high school/GED completion (vs. no, OR=1.48), STI history (vs. no, OR=3.56), birth history (vs. no, OR=1.31), recent health care provider visit (vs. no, OR=4.56) and HPV vaccination (vs. no, OR=1.38).

Discussion/Implications: Being non-Hispanic Asian, unmarried, without insurance, and without a usual source of care were each barriers to PAP screening. Meanwhile, facilitators of PAP screening were: non-Hispanic Black, higher education, STI history, birth history or HPV vaccination. To address these barriers to PAP screening, targeted, culturally-appropriate education for both health care providers and women with lower PAP utilization needs to be assessed. The recent health care reform and its emphasis on prevention, the expansion of health insurance coverage, and quality offer additional opportunities for increasing PAP utilization.