This study showed insufficient participation of women aged 18 and above in cervical cancer screening program in Iran. The regression analysis confirmed the importance of socio-demographic characteristic in predicting participation in cervical cancer screening, contributing to the prioritization of initiatives to improve participation. Moreover, this study has added to the small body of literature which has assessed equity in cervical cancer screening in Iran. Interestingly a pro-poor bias was obtained across the country in the rates of cervical cancer screening participation.
In general, 41·6% of women in Iran reported having undergone cervical cytology, which was lower in comparison with most developed countries. In the United States of America 85·5% of women aged 21–64, in Spain 72% of women aged 25–65, and in Australia 61% of women aged 20–69 had undergone cervical cancer screening in the past three years.14–16 However, within developing countries, Iran holds an intermediate position. The prevalence of having ever been screened for cervical cancer was 19% in Jordan (in women aged 20–49), 46·3% in Thailand (in women 30 years and above), and 87·1% in Brazil (in women aged 25–64).17–19 Lack of an organized population-based screening program may underlie the lower participation rate in Iran. The opportunistic approach which has been in place for more than three decades, has failed to reach the majority of at-risk women in the population.
Age was significantly associated with cervical cancer screening participation. The proportion screened increased with age until 35-44-year age group, but then declined in each subsequent age group afterward. This was aligned with other studies in Iran and elsewhere.15, 20–22 Women in younger age probably tend to be more informed about cervical cancer and are more likely to visit healthcare providers for gynecological complaints.
As expected, married women were most likely to have undergone cervical screening, which was in line with previous studies.15,18 Married women tend to attend healthcare facilities more often for maternal and child health care.
With regards to education level, higher education was associated with higher participation until about 12 years of schooling. This finding is consistent with other study results conducted in Iran, but not with those of other countries.15,18,22,23 The finding suggests that university education in the country has no impact on raising women’s awareness or changing their attitude towards cervical cancer screening.
The present study determined that employment or being a university student were negative predictors for cervical cancer screening practice among women. This finding though contradicting similar studies in other countries, yet validates the results of studies conducted in Iran.22–25 Having less free time, might be the possible rationalization for this unexpected finding among working women. Furthermore, hours of operation in most healthcare facilities delivering cervical screening services coincide with usual working hours and may act as a barrier for employed women.
In parallel with other studies, women with health insurance coverage were more likely to have undergone cervical screening.15,25,26
Despite of the considerable success of the Iranian primary health care approach in delivering health services to remote and rural areas of the country in the past three decades, women who resided in rural areas had lower probability of being ever screened.27 This may be partly due to the barriers such as embarrassment and lack of privacy. Since the screening service is provided by a community health care worker who lives in the same neighborhood.
This study also revealed evidence of disparities in cervical cancer screening participation across socioeconomic groups in Iran. Contradicting with findings in most countries, women with higher socioeconomic status had shown lower participation in cervical cancer screening program.14,17 However, pro-poor inequality was shown in outpatient healthcare utilization in multiple studies in Iran.28,29 Perhaps this finding could be explained by the nature of the health care system in Iran. In the absence of family physician program and a referral system, women in higher socioeconomic levels often visit specialists directly and bypass primary health care facilities.30
Regional variations in equity in cervical cancer screening participation could be understood by portioning the concentration index analysis across provinces. Provinces with higher socioeconomic status, less cultural conservatism, and better social health represent greater equity in cervical cancer participation.
The major strength of the study is the use of a large nationally representative sample of rural and urban Iranian women, containing different socioeconomic levels, that allowed more confident inferences about the population. However, there are some potential limitations as well. First, the cross-sectional design of the study has limited the ability to draw conclusions about causal relationships. Second, the data on the history of having ever undergone cervical cytology were self-reported, and therefore may be susceptible to recall and social desirability biases. Lastly, by evaluating secondary data sources in this study, the assessment of all factors associated with cervical cancer screening participation was not possible.