title: Health care access dimensions and cervical cancer screening in South Africa: analysis of the world health survey.
abstract: BACKGROUND
  Cervical cancer is the most commonly diagnosed cancer and the leading cause of cancer mortality among women in sub-Saharan Africa. Recent recommendations for cervical cancer primary prevention highlight HPV vaccination, and secondary prevention through screening. However, few studies have examined the different dimensions of health care access, and how these may influence screening behavior, especially in the context of clinical preventive services.
  
  
  METHODS
  Using the 2003 South Africa World Health Survey, we determined the prevalence of cervical cancer screening with pelvic examinations and/or pap smears among women ages 18 years and older. We also examined the association between multiple dimensions of health care access and screening focusing on the affordability, availability, accessibility, accommodation and acceptability components.
  
  
  RESULTS
  About 1 in 4 (25.3%, n = 65) of the women who attended a health care facility in the past year got screened for cervical cancer. Screened women had a significantly higher number of health care providers available compared with unscreened women (mean 125 vs.12, p-value <0.001), and were more likely to have seen a medical doctor compared with nurses/midwives (73.1% vs. 45.9%, p-value = 0.003). In multivariable analysis, every unit increase in the number of health care providers available increased the likelihood of screening by 1% (OR = 1.01, 95% CI: 1.00, 1.01). In addition, seeing a nurse/midwife compared to a medical doctor reduced the likelihood of screening by 87% (OR = 0.13, 95% CI: 0.04, 0.42).
  
  
  CONCLUSIONS
  Our findings suggest that cost issues (affordability component) and other patient level factors (captured in the acceptability, accessibility and accommodation components) were less important predictors of screening compared with availability of physicians in this population. Meeting cervical cancer screening and HPV vaccination goals will require significant investments in the health care workforce, improving health care worker density in poor and rural areas, and improved training of the existing workforce.
authors.affiliation: Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA. tomiakin@uab.edu.
authors.forename: Tomi F
authors.initials: TF
authors.lastname: Akinyemiju
authors.affiliation: Department of Epidemiology, Columbia University Medical Center; Mailman School of Public Health, New York, NY, USA. jam2319@columbia.edu.
authors.forename: Jasmine A
authors.initials: JA
authors.lastname: McDonald
authors.affiliation: Department of Health Policy and Management, Milken Institute School of Public Health, the George Washington University, Washington, DC, USA. plantz@gwu.edu.
authors.forename: Paula M
authors.initials: PM
authors.lastname: Lantz
mesh_terms: D000293:Adolescent; D000328:Adult; D017954:Africa South of the Sahara; D055088:Early Detection of Cancer / Q000706:statistics & numerical data*; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006306:Health Surveys; D006280:Health Workforce / Q000458:organization & administration; D006801:Humans; D008875:Middle Aged; D011322:Primary Prevention / Q000706:statistics & numerical data; D013019:South Africa; D002583:Uterine Cervical Neoplasms / Q000175:diagnosis / Q000517:prevention & control*; D014626:Vaginal Smears; D016387:Women's Health