Racial and rural differences in cervical cancer prevention and control practices

Objective: Access to preventive services contributes to differences in cervical cancer screening, treatment, and survival. We examined access to advanced cervical cancer prevention technologies, including liquid-based Pap test cytology, HPV vaccination, and DNA testing among rural versus urban women.

Methods: We conducted a cross-sectional study of 2006 - 2008 visit-level data from National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS). Data were linked to the 2009 Area Resource File (ARF) based on provider and patient/visit location. Patient/visit and provider location were linked using FIPS codes.

To examine the likelihood of liquid-based Pap tests, the study population was limited to visits by female white and African American patients (9 – 70 years of age) with record of a Pap test. To examine the likelihood of HPV DNA testing, the study population was limited to visits for preventive screening or routine general exams.

To examine cervical cancer screening practices, patients were categorized by Pap test cytology (liquid-based, conventional, unspecified) and an HPV DNA test during their visit (yes/no). Race/ethnicity was classified as white or black. Location was examined based on patient county of residence and physician practice site.

SAS-callable SUDAAN was used to account for complex sampling required weighted analysis. Descriptive statistics and bivariate comparisons were computed using chi square tests.

Results: No significant differences were observed for Pap test cytology by patient residence (urban versus rural; p=0.21) or for receipt of liquid Pap testing between white and African-American women residing in urban or rural counties (p=0.35).

A significantly higher proportion of women living in rural counties (69.6%) received liquid based Pap testing in hospital outpatient settings than women in urban counties (39%; p=0.02). A significantly higher proportion of women residing in urban counties received HPV DNA testing versus women residing in rural counties (10% versus 3.3%, respectively). Report of HPV vaccination was too low during the study period to permit stable estimates for rural women, so no rural-urban comparisons can be offered. Differences in provider reimbursement were noted with higher proportions of publicly insured patients in rural practices than urban practices (p<0.01).

Conclusions: Women residing in rural counties did not differ from urban in conventional or liquid-based Pap test cytology; however, rural women were less likely to receive HPV DNA testing with no racial differences detected. More research is needed to determine if observed differences are the result of provider or patient barriers and acceptability.