Individual- and county-level predictors of cervical cancer screening: a multi-level analysis

Objectives: Despite the gains in cervical cancer screening, there remain persistent socio-economic, geographical, racial, and ethnic disparities. This study examines the combined effect of individual- and county-level characteristics on the use of cervical cancer screening tests such as Papanicolaou (Pap) tests in Texas. Study design: Cross-sectional study. Methods: Individual-level information was obtained from 2014–2015 Texas Behavioral Risk Factor Surveillance System (BRFSS). Using the county of residence of the study population, the BRFSS data were linked to the American Community Survey (2010–2014) and the Area Health Resources File (2015). Women aged between 21 and 65 years, with no history of hysterectomy, and residing in 47 counties in Texas were included in the study (n = 4276). Multi-level logistic regression was used to assess the independent influences of individual- and county-level covariates on receipt of a Pap test in the past 3 years. Results: The odds of timely Pap testing were lower among women aged greater than 50 years, single women, and those with low education and income (<$25,000). Black women who reside in counties with higher percentages of Hispanics (quartile 4) were less likely to be screened compared with black women living in counties with a low Hispanic population (adjusted odds ratio [OR] = 0.08 [95% confidence interval [CI]: 0.02–0.37]). County-level socio-economic status, although associated with timely screening in bivariate analysis, was not a significant predictor of screening after controlling for individual characteristics. Conclusions: There are significant disparities in the uptake of cervical cancer screening across Texas counties. Individual-level socio-economic disparities as well as the number of obstetric-gynecologic physicians in a county are predictors of these disparities.