Relationship between regular cervical cancer screening and social background in Japan during the COVID-19 pandemic

doi:10.21203/rs.3.rs-3012553/v1

Background: Among Organization for Economic Co-operation and Development countries, Japan has one of the lowest cervical cancer screening rates. The cancer screening rate has reportedly worsened with the coronavirus disease of 2019 (COVID-19) pandemic. This study investigated the COVID-19 history and socioeconomic background of people who did not undergo on-time cervical cancer screening (CCS) during the two years of COVID-19-related restrictions in Japan.

Methods: We used data from the Japan COVID-19 and Society Internet Survey, a nationwide, internet-based, self-report, cohort observational study conducted in 2022. The outcome variable was identified by asking whether the respondent had undergone on-time CCS within the last two years. This study used multivariate log-binomial regression models to evaluate inequalities during regular checkups for CCS. Adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) were estimated to incorporate socioeconomic background variables.

Results: Of 12,066 respondents, 6469 (53.6%) had yet to undergo CCS within two years. The prevalence ratio (PR) of on-time CCS was 0.70 (95% CI: 0.63–0.79) for those in their 20s and 0.78 (95%CI:0.70-0.87) for those in their 60s, compared to their 40s. Moreover, socioeconomic inequities were found in the following groups: unemployed/student, unmarried, high school graduate or lower, and household income below 4 million yen. PR of on-time CCS with a history of COVID-19, unvaccinated status, or fear of COVID-19 was not significantly different from that of respondents who underwent CCS. However, the PR of those who had not undergone on-time CCS was significantly lower than that of respondents who had undergone breast cancer screening (PR: 0.29, 95% CI: 0.28–0.31).

Conclusion: the relationship between socioeconomic inequalities and CCS hesitancy was prevalent among the younger respondents. Our findings will help policymakers identify problems and strategies to improve CCS screening rates in Japan.

Cervical cancer screening

social inequality

COVID-19 pandemic

internet survey

Cervical cancer screening (CCS) significantly reduces the mortality rate of cervical cancer [1]. Screening once every two years is recommended for those over 20 years old by Japan’s Ministry of Health, Labor, and Welfare. Among the Organization for Economic Co-operation and Development (OECD) countries, Japan has one of the lowest CCS screening rates, approximately half of the rate in the United States (U.S.) and 70–80% lower than that in European countries [2, 3]. The rate in 2019 was 43%, approximately 6% higher than that in 2010. However, only approximately 40% of women currently undergo regular on-time checkups [3]. Furthermore, it is estimated that there will be an increase in cervical cancer deaths by as many as 10,000 by 2069 due to the withholding of the Human Papilloma Virus (HPV) vaccine in Japan [4]. Although Japan's medical system provides access to medical facilities [5], there is still some CCS hesitancy. Public surveys of general companies have identified the time and financial problems as reasons for CCS hesitancy. Many existing reports are questionnaire-based descriptive reports [6, 7]. However, few have included the social backgrounds of those who did not take the test [8].

In Japan, the impact of coronavirus disease (COVID-19) is significant, with the first declaration of a state of emergency issued in March 2020, followed by “stay-at home restrictions” for approximately two and half years until the fourth declaration was lifted in September 2022 [9]. Regarding cancer screening and the withholding of medical examinations due to the COVID-19 disaster, the U.S. National Cancer Institute reported in 2020 that the COVID-19 pandemic affected the cancer screening uptake rate [10]. Reports from Japan have also indicated that people refrained from undergoing screening, particularly in urban areas [11]. Moreover, people with COVID-19 tend to refrain from going out even after their symptoms have improved [12], which may make it even more challenging to undergo cancer screening before and after infection. Although there are reports on the cancer screening uptake rate under behavioral restrictions [13, 14], such as those during a state of emergency, there are no reports on the uptake rate during the two years of the COVID-19 pandemic. Furthermore, there are no reports on socioeconomic inequality in Japan as a cause of low screening uptake rates at the time of societal changes in the composition of society itself in the wake of the COVID-19 pandemic. Therefore, this study aimed to analyze the COVID- 19 history and socioeconomic background of persons who did not receive on-time CCS during the 2-year period of COVID-19-related restrictions.

Study setting

The Japan COVID-19 and Society Internet Survey (JACSIS) is a nationwide, Internet- based, self-report, cohort observational study. The JACSIS study was established to assess the social and health inequities related to COVID-19. Similar studies have been ongoing since 2020 [11, 15–17]. These surveys were managed by a nationwide internet research company, Rakuten Insight, with 2.3 million registered candidates with demographic information. This data survey was conducted using JACSIS 2022, a general population survey, between September and October 2022. Panelists were randomly selected by sex, age, and place of residence. An invitation to participate was sent by e-mail. The participants provided consent, accessed the designated website, and responded to the survey question. They had the option of not responding to any part of the survey or discontinuing it. The survey was closed when the target number (32,000) of respondents for each sex, age, and prefecture was met. To maintain data quality, invalid responses were excluded. Inconsistent responses were defined as follows: (1) choosing an invalid response without following specified instructions; for example, “Please select the second item from the bottom”; (2) checking all items questions regarding drug use such as “Are you currently drinking or using alcohol or drugs, that is, marijuana, cocaine, or heroin?”, and (3) checking all items for “having 20 underlying chronic diseases.” Details of the algorithms, excluding invalid responses, are provided in a previous study. Of 32,000 respondents, 3370 with fraudulent responses were excluded. A total of 28,630 respondents were included. Of these, women, females at birth, and 20–69-year-olds were selected, resulting in a final sample of 12,066 respondents (Fig. 1).

Outcome variable:

In Japan, cervical cancer screening is recommended every two years from 20 to 69 years old. During cervical cancer screening, cervical cytology determines abnormalities by brushing the external cervical os. Cervical cancer screening using HPV typing is not widely used and was not included in this study. Outcome variables were identified by a specific question about whether a woman underwent on-time CCS: "Have you been screened for cervical cancer within the last two years?" The response was considered the outcome variable. Responses were selected from seven options; 1–3 corresponded to yes (1, no abnormality; 2, abnormality; 3, no results yet), while 4–7 corresponded to no (4, motivated to undergo screening, unaffected by COVID-19; 5, motivated to undergo screening, affected by COVID-19; 6, not motivated to undergo screening, not affected by COVID-19; 7, not motivated to undergo screening, affected by COVID-19). To investigate refusal to undergo CCS and social background, respondents who answered 1–3 and 4–7 comprised the "on-time screening" group and "under-screening" group, respectively.

Statistical analysis

First, chi-square tests were conducted to obtain socioeconomic information, health-related status, and personal characteristics to analyze the association between personal characteristics and screening behavior. This study used multivariate log-binomial regression models to evaluate inequalities during regular checkups for CCS. We chose log-binomial regression models, particularly those with cross-sectional data and an outcome percentage above 10% [18]. They are also easier to interpret and communicate with prevalence terms as measures of association [19]. The dependent variables were on-time CCS and under-screening. Adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) were estimated. The social background variables were age (20–29, 30–39, 40–49, 50–59, and 60–69), marital status (married, single/divorced/widow), employment status (unemployed/student, employed), education level ( high school or less, junior college/bachelor's degree, graduate degree/other), household income (< 4 million yen, 4–8 million yen, over 8 million yen, no answer/other), smoking status (none, ex-smoker, everyday), alcohol consumption (none, ex-smoker, everyday), use of preventive care for general checkups and breast cancer within the past two years, chronic diseases (hypertension, diabetes, asthma, chronic heart disease, stroke, chronic obstructive pulmonary disease, chronic kidney disease, hepatitis, cancer, depression), self-rated health status (excellent, good, fair, bad, very bad), COVID-19 vaccine doses (unvaccinated, 1–2, ≥ 3), and fear of COVID-19. We used the 7-item Japanese version of the fear of coronavirus-19 scale (FCV-19S) to assess fear of COVID- 19 [20, 21]. The variance inflation factor was estimated to check for multicollinearity; no evidence was found. All statistical tests were two-tailed, with p-values < 0.05 considered statistically significant. All analyses were performed using SAS OnDemand for Academics, a cloud- based software provided by SAS Institute Inc.

Ethical approval

All procedures were conducted in accordance with the ethical standards of the Declaration of Helsinki of 1975 (revised in 2013). The study protocol was reviewed and approved by the Research Ethics Committee of the Osaka International Cancer Institute (approved on June 19, 2020; Approval No. 20084). Before responding to the online questionnaire, all participants provided informed consent. The Internet survey agency adhered to the Act on the Protection of Personal Information in Japan. To encourage participation, credit points were offered to participants; these points could be redeemed for Internet shopping or as cash.

Patients’ characteristics

A total of 12,066 patients were included in the study: 5,597 (46.4%) underwent CCS once and 6,469 (53.6%) had not undergone CCS within two years. Table 1 presents the number of participants and weighted distribution of the underscreening group according to patient characteristics. Respondents with the following characteristics accounted for majority of those who did undergo CCS: 20–29 years old, unemployed/student, unmarried, high school graduate or lower, and household income below 4 million yen. There were no significant differences in screening uptake rates according to smoking status. Respondents who had undergone screening for general checkups and breast cancer were more likely to have undergone CCS (78.3%–86.6%). There were no significant differences in the coexistence of chronic diseases or CCS between the FCV-19S item. The CCS visit rate was higher among those who received the COVID-19 vaccine than among those who had never been vaccinated (34.2%).

Prevalence ratios of on-time CCS

Table 2 shows the prevalence of CCS implementation. The unadjusted PR of CCS obtained from a univariate analysis was included in Model 1. Respondents without a COVID-19 history had a PR of 0.92 (95% CI: 0.87–0.96) and no CCS visits. Regarding PR by age category, the PR was 0.70 (95% CI: 0.63–0.79) for those in their 20s and 0.78 (95%CI:0.70-0.87) for those in their 60s, especially when using their 40s as the reference age group. Looking at the relationship between other socioeconomic backgrounds and CCS visits, single/divorced/widow had a PR of 0.74 (95% CI: 0.71–0.77), and unemployed/student had a PR of 0.82 (95% CI: 0.79–0.86), especially significantly higher than married and the employed group. The CCS implementation rate for the education and income category increased with increasing years of education and annual income. No significant differences were found in the use of tobacco smoking or drinking alcohol. For each health-related status, PR decreased as self-rated health decreased. Those not receiving the COVID-19 vaccine had significantly lower PR for CCS. The PR for CCS was also significantly lower in the group that did not undergo general checkups or breast cancer screening (PR: 0.36, 0.43). Model 2 shows the PR adjusted for social background factors. In Model 2, there was no significant difference in APR according to COVID-19 history. However, the respondents aged 20–29 years, unemployed/student, never married, high school graduate or lower, and with a household income below 4 million yen had a significantly lower APR for CCS; this difference was significant when compared to the reference in each category. Model 3 shows the PR adjusted for health-related factors and COVID-19 vaccination status. In Model 3, those with no COVID-19 history were less likely to have undergone a CCS visit. The group without general checkups or breast cancer screening was also more likely to not undergo CCS after adjusting for other health-related conditions.

In this study, the younger generation (patients aged 20–29 years) accounted for majority of those who did not undergo CCS. Particularly, the CCS visit rates persons aged 20–29, students, unmarried persons, and those with annual household incomes below 4 million yen were lower than those of the other groups, indicating the need for immediate attention. The strength of this study is that it used a large dataset to analyze scheduled CCS visits, with adjustments for social background. Furthermore, considering the respondents’ COVID-19 history and trend analyses in hospital visits during the pandemic helped to identify issues to be addressed in the future Japan has one of the lowest CCS implementation rates among developed countries— 42.4% for the target age group—a rate that is significantly lower than the average of 60.7% among OECD member countries [2, 3, 22]. Existing studies on CCS hesitancy are mainly small regional and city-based descriptive surveys [6, 9]. These studies used a psychological approach. Two of the top three responses in this study were "Because I am confident in my health condition and do not feel the need" and "Because I can visit a medical facility whenever I am worried." Moreover, criticism of obstetrics and gynecology visits from the respondents’ entourage and resistance to consultations by male physicians were social challenges that need to be addressed.

In this study, it was possible to examine social practice policies using the data obtained after adjusting for various social backgrounds. This study made it clear that the 20–29 age group, students, unmarried persons, those whose educational level was lower than high school, and those whose annual household income was below 4 million yen were less likely to undergo CCS. Previous global studies have reported that low-income individuals often refrain from gynecological examinations [23, 24]. This is similar in Japan regarding CCS among low-income individuals. These conditions indicate that students, especially those in their 20s, and socially vulnerable groups such as unemployed and low-income individuals, should be targeted in the future. So far, the low CCS visit rate among students has been attributed to excessive self- consciousness about their health and lack of opportunities to visit hospitals [8]. The small increase in screening rates through the distribution of free coupons suggests that financial and knowledge-based interventions should be considered [25]. The following non-financial studies are also underway as ways to motivate people to take CCS. Okuhara etal. showed that a message that targeted the fundamental motive of kin care was as effective as one targeting the fundamental motive of disease avoidance [26]. A review by the U.S. Community Preventive Services Task Force on increasing cancer screening uptake recommends the use of small media such as pamphlets and newsletters, one-on-one education, and call recall through letters and phone calls [27]. Recent surveys on attitudes toward HPV vaccine implementation, particularly in urban areas, have found that recommendations from parents and the best friends are more effective ways to vaccinate [28]. Therefore, information on cervical cancer, its prevention, and CCS should be actively provided to women aged <40 years.

A systematic review reported that behavioral restrictions due to the COVID-19 pandemic have significantly impacted the decline in the cancer screening uptake rate [29]. With the movement restrictions, the use of online services and telemedicine replaced hospital visits, and thus served as infection control measures. The decrease in the cancer screening rate is considered significant because of the necessity of direct medical examinations. There is a concern that a reduction in the number of cancer screenings could lead to delays in diagnosis, leading to delays in cancer treatment, and increased mortality [30]. This study clarified the number of cancer examinations over two years rather than under short-term behavioral restrictions. The PR adjusted for social background factors and other factors showed no overall decline in visitation rates compared with pre-pandemic visitation rates. Interestingly, the PRs for CCS visits tended to be higher among those with a COVID- 19 history. It was difficult to conclude in this study whether COVID-19 increased the rate of CCS visits. However, we confirmed that for over two years, COVID-19 did not prevent CCS visits. We also found that the number of COVID-19 vaccine doses had no effect on the PR of CCS, and that CCS requires specific measures.

Looking at cervical cancer screening methods worldwide, cervical cancer screening kits performed at home have become popular in the U.S. and European countries [31]. The kits allow testing to be performed in the convenience of the home and are expected to reduce time and ensure privacy. However, this method has more disadvantages regarding the collection of samples than testing at medical institutions. These include including a decrease in testing accuracy owing to improper collection, the possibility of additional testing when abnormalities are detected, the time required to receive a diagnosis, and non-coverage of the cost of the testing kits by insurance services. However, the kits allow testing to be performed in the convenience of the home and are expected to reduce time and ensure privacy. Japan's home-based HPV sampling test is still only at the clinical research level [32]. Since this screening method is suited to the lifestyles of current women from the psychological point of view and access to medical facilities, it is necessary to promptly improve the environment in Japan as well.

This study has the following limitations: 1) Because this is an Internet-based, self-response, cohort observational study, there were questions asked to maintain data reliability by excluding respondents with inconsistent or invalid responses. However, the possibility of participant bias or incorrect responses cannot be completely ruled out. 2) Although this study considered the impact of the COVID-19 pandemic during the analyses, future trends in CCS visits should be assessed after the pandemic ends. 3) This study did not consider the differences among the regions of Japan and may not accurately reflect national trends. Finally, although we could identify low screening rates and a basis for future policies, further analysis is needed to determine the appropriate approach for these populations.

The CCS rate in Japan during the COVID-19 pandemic year (2020–2022) was not low in persons with a COVID-19 history. Socioeconomic inequalities of the group aged 20–29 years, students/unmarried persons, and those with annual household incomes below 4 million yen were lower than those of other groups, which contributed significantly to CCS hesitancy and the need for immediate attention. The findings of this study will help to identify problems and contribute to improving the CCS screening rate in Japan.

COVID-19

coronavirus disease of 2019

CCS

Cervical cancer screening

OECD

Organization for Economic Co-operation and Development

U.S.

United States

HPV

Human Papilloma Virus

JACSIS

Japan COVID-19 and Society Internet Survey

PR

prevalence ratio

APR

adjusted prevalence ratio

CI

confidence interval

FCV-19S

fear of coronavirus-19 scale

[Ethics approval and consent to participate]

All procedures were conducted in accordance with the ethical standards of the Declaration of Helsinki of 1975 (revised in 2013). The study protocol was reviewed and approved by the Research Ethics Committee of the Osaka International Cancer Institute (approved on June 19, 2020; Approval No. 20084). Before responding to the online questionnaire, all participants provided informed consent.

[Consent for publication]

Not applicable

[Availability of data and materials]

The data that support the findings of this study are available from the corresponding author upon reasonable request.

[Competing interests]

The authors declare no conflict of interest.

[Funding]

This research was supported by the Japan Society for the Promotion of Science (JSPS) KAKENHI Grants (grant numbers: 18H03062, 23EA1001)

[Author’s Contributions]

Conceptualization and methodology, T.M. and J.M; validation, O.H., C.O., and H.M.; formal analysis, C.O.; investigation, resources, and data curation, T.T.; writing—original draft preparation, T.M.; writing—review and editing, J.M.; supervision, C.O. and H.M.; project administration and funding acquisition, T.T. All authors have read and agreed to the published version of the manuscript.

[Acknowledgements]

We thank all the respondents for participating. We appreciate valuable feedback from the JACSIS study group researchers.

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Table 1

Characteristics of eligible women depend on CCS status within the last two years.
			CCS within 2 years
			On-time screening		Under screening		P-value
			n	(%)	n	(%)
Overall			5597	(46.4)	6469	(53.6)
Age		(years)					< 0.001
		20–29	908	(37.2)	1533	(62.8)
		30–39	1562	(50.8)	1511	(49.2)
		40–49	1246	(52.9)	1111	(47.1)
		50–59	997	(48.7)	1049	(51.3)
		60–69	884	(41.1)	1265	(58.9)
Social background
	Marital status						< 0.001
		Married	3936	(51.2)	3745	(48.8)
		Single, divorced, widow	1661	(37.9)	2724	(62.1)
	Employment status						< 0.001
		Unemployment, student	1832	(40.9)	2650	(59.1)
		Employed	3765	(49.6)	3819	(50.4)
	Education						< 0.001
		high school or less	1258	(40.2)	1869	(59.8)
		college	1751	(46.8)	1992	(53.2)
		university/graduate school	2588	(49.8)	2608	(50.2)
	Household annual income						< 0.001
		< 4 million	1168	(38.1)	1895	(61.9)
		4–8 million	1975	(50.1)	1967	(49.9)
		> 8million	1316	(58.9)	920	(41.1)
		other/ no answer	1138	(40.3)	1687	(59.7)
	Smoking						0.044
		Never	4074	(46.1)	4756	(53.9)
		Ex-smoker	1197	(48.2)	1287	(51.8)
		Current	326	(43.4)	426	(56.7)
	Alcohol						< 0.001
		None	2529	(44.0)	3217	(56.0)
		Sometimes	2439	(49.0)	2542	(51.0)
		Everyday	629	(47.0)	710	(53.0)
Health related status
	Use of preventive care
		General checkups					< 0.001
		Yes	4643	(60.4)	3050	(39.7)
		No	954	(21.8)	3419	(78.2)
		Breast cancer screening					< 0.001
		Yes	3538	(86.6)	549	(13.4)
		No	1151	(20.8)	4387	(79.2)
		Not applicable	908	(37.2)	1533	(62.8)
	Counts of chronic condition*						0.327
		0	4605	(46.7)	5250	(53.3)
		1,2	932	(45.1)	1134	(54.9)
		3,4	36	(40.0)	54	(60.0)
		> 4	24	(43.6)	31	(56.4)
	Self-rated health						< 0.001
		Very good	1215	(48.2)	1308	(51.8)
		Good	2159	(50.1)	2149	(49.9)
		Fair	1521	(42.7)	2043	(57.3)
		Bad	594	(43.4)	775	(56.6)
		Very bad	108	(35.8)	194	(64.2)
COVID-19 related status
	History of COVID-19 infection						< 0.001
		Yes	959	(49.9)	963	(50.1)
		No	4638	(45.7)	5506	(54.3)
	COVID-19 vaccination does						< 0.001
		Unvaccinated	512	(34.2)	987	(65.8)
		1 or 2	956	(46.9)	1081	(53.1)
		> 3	4129	(48.4)	4401	(51.6)
	FCV-19S						0.300
		7, 15	2042	(45.4)	2455	(54.6)
		16, 20	2049	(47.4)	2270	(52.6)
		21, 25	1253	(46.3)	1452	(53.7)
		26, 35	253	(46.4)	292	(53.6)
*Chronic condition includes hypertension, diabetes, asthma,chronic heart disease,stroke,chronic obstructive pulmonary disease, chronic kidney disease, hepatitis, cancer, depression CCS; cervical cancer screening, FCV-19S; fear of coronavirus-19 scales

Table 2

Adjusted models predicting undergone cervical cancer screening
Table 2. Adjusted models predicting undergone cervical cancer screening
			Model 1					Model 2					Model 3
			PR	(95% CI)			P-value	APR	(95% CI)			P-value	APR	(95% CI)			P-value
History of COVID-19 infection
		Yes	Ref.					Ref.					Ref.
		No	0.92	0.87	–	0.96	< 0.01	0.96	0.91	–	1.01	0.10	0.96	0.94	–	0.98	< 0.01
Age (years)
		20–29	0.70	0.63	–	0.79	< 0.01	0.77	0.72	–	0.83	< 0.01
		30–39	0.96	0.91	–	1.01	0.14	0.90	0.86	–	0.95	< 0.01
		40–49	Ref.					Ref.
		50–59	0.92	0.86	–	0.98	< 0.01	0.95	0.90	–	1.01	0.08
		60–69	0.78	0.70	–	0.87	< 0.01	0.86	0.80	–	0.91	< 0.01
Social background
	Marital status
		Married	Ref.					Ref.
		Single, divorced, widow	0.74	0.71	–	0.77	< 0.01	0.81	0.77	–	0.86	< 0.01
	Employment status
		Unemployment, student	0.82	0.79	–	0.86	< 0.01	0.85	0.81	–	0.89	< 0.01
		Employed	Ref.					Ref.
	Education
		high school or less	0.81	0.77	–	0.85	< 0.01	0.86	0.81	–	0.90	< 0.01
		college	0.94	0.90	–	0.98	< 0.01	0.94	0.90	–	0.98	< 0.01
		university/graduate school	Ref.					Ref.
	Household annual income
		< 4 million	0.65	0.60	–	0.70	< 0.01	0.77	0.72	–	0.81	< 0.01
		4–8 million	0.85	0.81	–	0.90	< 0.01	0.90	0.86	–	0.94	< 0.01
		> 8million	Ref.					Ref.
		other/ no answer	0.68	0.64	–	0.74	< 0.01	0.78	0.73	–	0.83	< 0.01
	Smoking
		None	1.06	0.98	–	1.16	0.15	1.34	0.91	–	1.17	0.43
		Sometimes	1.11	1.01	–	1.22	0.02	1.06	0.97	–	1.15	0.22
		Everyday	Ref.					Ref.
	Alcohol
		None	0.94	0.85	–	1.00	0.05	1.00	0.94	–	1.07	0.88
		Sometimes	1.04	0.98	–	1.11	0.20	1.07	1.01	–	1.14	0.03
		Everyday	Ref.					Ref.
Health related status
	Use of preventive care
		General checkups
		Yes	Ref.										Ref.
		No	0.36	0.34	–	0.38	< 0.01						0.64	0.60	–	0.62	< 0.01
		Breast cancer screening
		Yes	Ref.										Ref.
		No	0.24	0.23	–	0.26	< 0.01						0.29	0.28	–	0.31	< 0.01
		Not applicable	0.43	0.41	–	0.45	< 0.01						0.51	0.48	–	0.53	< 0.01
	Self-rated health
		Very good	Ref.										Ref.
		Good	1.04	0.99	–	1.09	0.12						0.99	0.96	–	1.01	0.33
		Fair	0.89	0.84	–	0.94	< 0.01						0.96	0.92	–	0.99	< 0.01
		Bad	0.90	0.85	–	0.96	< 0.01						0.94	0.90	–	0.98	< 0.01
		Very bad	0.74	0.64	–	0.87	< 0.01						0.88	0.79	–	0.98	0.02
	COVID-19 vaccination uptakes
		Unvaccinated	0.71	0.67	–	0.76	< 0.01						0.97	0.87	–	1.75	0.18
		1 or 2	0.97	0.92	–	1.02	0.24						1.05	1.02	–	1.08	< 0.01
		> 3	Ref.										Ref.
	Counts of chronic condition
		0	Ref.
		1,2	0.97	0.92	–	1.02	0.18
		3,4	0.86	0.66	–	1.11	0.23
		> 4	0.93	0.69	–	1.26	0.66
	FCV-19S
		7, 15	Ref.
		16, 20	1.04	1.00	–	1.09	0.06
		21, 25	1.02	0.97	–	1.07	0.45
		26, 35	1.02	0.93	–	1.12	0.65
	95% CI, 95% confidence interval; APR, adjusted prevalence ratio; FCV-19S, fear of coronavirus-19 scales; PR, prevalence ratio; Ref., reference Model 1 is unadjusted PR of ontime-CCS visits obtained from a univariate analysis. Model 2 is the PR adjusted for social background factors. Model 3 is the PR adjusted for health-related factors and COVID-19 vaccination status.

No competing interests reported.

Relationship between regular cervical cancer screening and social background in Japan during the COVID-19 pandemic

Status:

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Abstract

Figures

Background

Methods

Study setting

Outcome variable:

Statistical analysis

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Additional Declarations

Status:

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