This study showed insufficient cervical cancer screening utilization in Iran. About half of the recommended target population in the national guideline (52.1 %) have reported having had at least one Pap test in their lifetime. Having 6-12 years of schooling, and being covered under primary or complementary health insurance plans were significantly associated with higher participation. Women living in urban settings had greater screening rates across almost all provinces. The highest screening uptake rate was obtained in Isfahan and the lowest in Sistan and Baluchestan. Moreover, this study has added to the small body of literature which has assessed socio-economic equity in cervical cancer screening in Iran. A pro-poor bias was observed across the country in cervical cancer screening participation.
In general, the cervical cancer screening participation rate in Iran was low 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.[23-25] 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). [26-29] 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 many at-risk women in the population.
Age was significantly associated with cervical cancer screening participation. The proportion screened increased with age until 40-49-year age group, but then declined in each subsequent age group afterward. This was aligned with other studies in Iran and United States of America.[30, 31] Probably women in their thirties and forties 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.[24, 27] 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.[14, 24] 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 contradicts similar studies in other countries, yet validates the results of studies conducted in Iran. [14, 32, 33] 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. [24, 34, 35] Health insurance plans can increase health service utilization by reducing out-of-pocket expenditures and alleviating potential financial barrier to the service uptake. In Iran, the basic health insurance plans cover most cervical cytology screening costs, and complementary plans provide a full coverage of the service fees.
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 participation in cervical cancer screening program. This may be partly due to the barriers such as negative cultural beliefs around cervical cancer, embarrassment about attending cervical screening, and lack of privacy. Since the screening service is provided by a community health care worker who lives in the same neighborhood. Moreover, the participation rates in rural areas might be more affected by under-reporting due to embarrassment in admitting to have been screened for cervical cancer than in urban settings, where negative beliefs associated with the disease is less common.
This study also revealed evidence of disparities in cervical cancer screening participation across socio-economic groups in Iran. Contradicting with findings in most countries, women with higher socio-economic status had shown lower participation in cervical cancer screening program. [23, 26] However, pro-poor inequality was shown in outpatient healthcare utilization in multiple studies in Iran.[38, 39] Perhaps this finding could be explained by the nature of the health care system In Iran, the primary health care facilities are all publicly owned. Women in lower socio-economic levels routinely visit these facilities for healthcare services such as maternal and child care, which provides opportunities for communication about cervical cancer screening. Whereas, women in higher socio-economic levels often see specialists directly and based on their health complaints. Therefore, preventive services are substantially underutilized by this group.
Regional variations in equity in cervical cancer screening participation could be understood by portioning the concentration index analysis across provinces. Provinces with higher participation rates in cervical cancer screening such as Isfahan (61.2%), and Tehran (51.4%) represented greater equity in cervical cancer participation, - 0.11 and - 0.08 respectively.
The major strength of the study is the use of a large nationally representative sample of rural and urban Iranian women, containing different socio-economic 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.