A population-based cross-sectional study on the situation of cervical cancer screening in Liaoning, China

In China, an estimated 28,010 women died from this preventable cancer, accounting for 12% of all CC deaths worldwide, CC is responsible for a heavy economic and social burden[15, 16]. CC is preventable and curable at early stages, screening of precancerous lesions can reduce its incidence and mortality. From the related results of the NORDCAN database, we found that the incidence of cervical cancer has been reduced by organized screening[17]. Therefore, CC screening is very important, and improving the proportion of screening of CC is helpful to reduce the incidence rate and mortality of CC. The World Health Organization (WHO) recommends that all women between the ages of 30 and 49 years should be screened for CC at least once[18]. In America, where CC screening programs have become well established, the annual incidence has declined by 75% or more over the past half century[19]. In our study, the proportion of screening in 2018 was 22.37%, which meant that more than three-quarters of women in Liaoning had not been screened for CC in the past 3 years. Though it was more than two times higher than 11.1% in 2013, it was still below 26.7% of the Chinese average proportion of screening, which was also still far below the proportion of screening in developed countries[12]. For example, the proportion of screenings amounted to 70% in Spain, 86.6% in Norway, 78% in UK, and 70% in Austria[20‐22]. Women’s willingness to participate in CC screening had a direct impact on the screening work. Therefore, we further investigated the respondents’ willingness in the next three years, and found that the respondents’ willingness to participate in CC screening was only 38.41%. Even if all the people who had the willingness will participate CC screening in the next three years, the CC proportion of screening only increases by 16.04%. According to this increasing rate, it will take 12 years to achieve 100% of proportion of screening.

We divided the risk factors into socio-demographic factors, socio-economic factors, regional factors and CC screening factors, and gradually incorporate the risk factors into the regression model. In the factors of the proportion of screening, we found that age, marital status, education level, type of occupation, medical insurance, family income, place of residence and regional economic level had a significant impact on the proportion of screening. The proportion of screening significantly increased by education level, family income and regional economic level. In China, the free gynecological examination organized by the company is one of the main opportunities for women to participate in cervical cancer screening, women who had high education level might also have high family income and better occupations, and had more opportunities to participate in cervical cancer screening[23]. The proportion of screening was first increased and then decreased along with the increase of age. Although the proportion of screenings of CC in urban and rural areas were similar among the respondents, it seemed that the regional differences have no significant impact, but in multivariate logistic regression analysis, place of residence showed a significant impact on the proportion of screening, the proportion of screening in rural areas was 64% lower than that in urban areas. There were an estimated 570,000 new cases and 311,000 deaths from CC in 2018, and around 85% of these occurred in low-income countries [24]. In China, the incidence rate for CC was about 10% higher in rural areas (12.35 per 100,000) than in urban areas (11.24 per 100,000), and the mortality rate was about 12% higher in rural areas (3.50 per 100,000) than in urban areas (3.12 per 100,000)[25]. The disease burden was heavier in rural areas than in urban areas, therefore, it is imperative to improve the proportion of screening of CC in rural areas.

In the factors of the screening willingness, we found that in model 1–3, age, marital status, education level, medical insurance type, family income, health status, place of residence and regional economic level had a significant impact on the screening willingness. Compared to the analysis on the factors of the proportion of screening, the type of occupation had no significant impact on the screening willingness. After the experience of CC screening was added in model 4, age, family income, health status, place of residence, regional economic level and CC screening still had a significant impact, but marital status, education level and medical insurance type had no significant impact. There was no significant difference in marital status, education level and medical insurance type after the factors of CC screening were added in model 4. This shows that after participating in CC screening, the respondents may learn more about the relevant knowledge of CC screening and pay more attention to the changes of the body. Therefore, we think it is very important to participate in CC screening for the first time in the future.

Age had a significant impact on the proportion of screening and willingness of CC. Young women, especially those with higher education level and/or higher income level, were likely to pay more attention to their health and had more access to relevant information to increase their knowledge[26]. There were some differences in the factors between the CC proportion of screening and the willingness of CC screening. Type of occupation had a significant impact on CC proportion of screening, but had no significant impact on the willingness of CC screening, people at work were more likely to participate in CC screening, and retiree or people without work were less likely to participate in CC screening. Physical examination is the main way for women to get CC screening, while people without work have few chances to get screening through physical examination by the occupational way. However, our study found that the proportion of screening of working women was only 25.50%, which reminded us that CC screening had not been well included in physical examination, and had a very limited effect on the prevention and control of CC in the population. Especially in small and medium-sized and private enterprises, physical examination belonged to the spontaneous behavior and had a certain market attribute. The specific implementation of physical examination including content, frequency and quality was not optimistic[27, 28]. In addition, the opportunity for retired women to receive CC screening was reduced. In China, the retirement age of women is mainly 55 years old, and they are still in the important age for CC screening[29]. At the same time, they are in the age of high CC mortality rate[30, 31]. Therefore, this part of the population should be considered in future screening.

Health status has a significant impact on the willingness of CC screening, but has no significant impact on CC screening. The coverage of screening might be still insufficient, and the willing women may not be able to access the screening due to potential barriers.[32, 33] Family income was an important socio-economic factor to promote women’s CC screening, which should be considered in improving the coverage of CC screening in China. The effect of family income on the proportion of screening emphasized that providing free screening services would have a positive significance in improving the current CC proportion of screening in China. At the same time, we should provide affordable and low-cost screening services for more people to accept screening voluntarily.

Regional factors, which included place of residence and regional economic level, were also the important factors that affect the proportion of screening and willingness of CC. Urban areas and regions with higher economic level usually had more infrastructure, medical and health system, and higher level of medical and health personnel, so CC screening services in these regions have higher accessibility. In China, the county-level/district-level institutions were the main prescreening institutions for CC screening in NCCSP. A nationwide study found that in terms of facilities, medical staff and equipment, medical institutions in urban areas can provide better CC screening equipment in general than the institutions in rural areas, a relatively large gap still exists in the current health service capacity between urban and rural areas[34].

Health education programs which aim to increase the understanding of CC and learn the benefits of screening had been found to be an effective method to increase screening willingness, as well as increase the likelihood of screening behaviors[35]. Previous studies had found that due to the low education level, a portion of women did not understand and/or were not willing to read the CC information booklet provided by the government. They preferred to attend free face-to-face seminars on CC prevention and control provided by health care workers, or watch relevant health promotion videos[36]. A multimedia health education program has been found to effectively improve the knowledge and awareness of CC and its screening, and also increased the uptake of screening services among adult rural women in Nigeria[37].

There were also some shortcomings in our study. First, we only selected counties/districts in Liaoning Province, this might make our extrapolation of results have a certain regional limitation. Nevertheless, we randomly selected 9 counties/districts in Liaoning Province, and grouped them according to different regions and different levels of economic development, which could fully reflect the situation of different people participating in cervical cancer screening and their willingness in the local regions, and could provide a certain reference basis for research in other regions. Second, in European countries, according to the questionnaire, there were large variations in cervical cancer screening policies, and the key organizational elements of the plan were also insufficient[38]. Compared to the research contents in European countries, our research paid too much attention to the common factors of the screening women, and did not involve the minimum requirements, the fairness and accessibility of the cervical cancer screening. We will further explore the relevant contents in the future study.