title: Inequities in cervical cancer screening among Colombian women: a multilevel analysis of a nationwide survey.
abstract: OBJECTIVE
  To identify factors associated with whether women in Colombia have had a Pap test, evaluate differences in risk factors between rural and urban residence, and evaluate the contextual effect of the lack of education on having ever had a Pap test.
  
  
  METHODS
  Data used were from the 2010 Colombian National Demographic and Health Survey; 40,392 women reported whether they have had a Pap test. A multilevel mixed logistic regression model was developed with random intercepts to account for clustering by neighbourhood and municipality. The model evaluated whether having a rural/urban area of residence modified the effect of identified risk factors and if the prevalence of no education at the neighbourhood level acted as a contextual effect.
  
  
  RESULTS
  Most women (87.3%) reported having at least one Pap test. Women from lower socioeconomic quintiles (p=0.002), who were unemployed (p<0.001), and whose final health decisions depended on others (p<0.001) were less likely to have had a Pap test. Women with children were more likely to have had the test (p<0.001), and the effects of education (p=0.03), type of health insurance (p=0.01), age (p<0.001), and region (p<0.001) varied with having a rural/urban area of residence. Women living in rural areas (specifically younger ones, with no health insurance, living in the Atlantic and Amazon-Orinoquía regions, and with no education) were less likely to have had a Pap test when compared to those living in urban areas. Furthermore, women living in a neighbourhood with a higher prevalence of no education were less likely to have ever had a Pap test (p=0.005).
  
  
  CONCLUSIONS
  In Colombia, the probability of having had a Pap test is associated with personal attributes, area of residence, and prevalence of no education in the neighbourhood. Efforts to improve access to cervical cancer screening should focus on disadvantaged women with limited education, low socioeconomic status, and no health insurance or subsidised insurance, especially those in rural/isolated areas.
authors.affiliation: School of Public Health, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 5E5, Canada. Electronic address: silvia.bermedo@usask.ca.
authors.forename: Silvia
authors.initials: S
authors.lastname: Bermedo-Carrasco
authors.affiliation: School of Public Health, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 5E5, Canada.
authors.forename: Juan Nicolás
authors.initials: JN
authors.lastname: Peña-Sánchez
authors.affiliation: School of Public Health, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 5E5, Canada.
authors.forename: Rein
authors.initials: R
authors.lastname: Lepnurm
authors.affiliation: School of Public Health, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 5E5, Canada.
authors.forename: Michael
authors.initials: M
authors.lastname: Szafron
authors.affiliation: School of Public Health, University of Saskatchewan, 104 Clinic Place, Saskatoon, SK S7N 5E5, Canada; Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, SK S7N 5B4, Canada.
authors.forename: Cheryl
authors.initials: C
authors.lastname: Waldner
mesh_terms: D003105:Colombia; D055088:Early Detection of Cancer; D005260:Female; D006630:Hispanic or Latino; D006801:Humans; D055361:Multilevel Analysis; D065006:Papanicolaou Test / Q000379:methods*; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires; D002583:Uterine Cervical Neoplasms / Q000453:epidemiology
keywords: Colombia; Contextual effect; Educational status; Health survey; Multilevel analysis; Pap test; Rural population; Socioeconomic factors