Beneath the surface: Exploring stress and bias in cervical cancer screening compliance.
Authors: Keenahan Laura , An Anjile , Ahsan Muhammad Danyal , Morley Faith , Tamimi Rulla M. , Lin Jeff Feng-Hsu , Cantillo Evelyn , Frey Melissa Kristen , Holcomb Kevin , Kensler Kevin , Chapman-Davis Eloise 
Published: June 2024

5535

Background: Identifying barriers to cervical cancer screening compliance is essential to decrease rates of invasive cervical cancer. We aimed to evaluate the influence of perceived stress and discrimination on adherence to cervical cancer screening. Methods: The NIH All of Us Research Program was used to evaluate receipt of cervical cancer screening among participants assigned female at birth without a diagnosis of cervical cancer or history of hysterectomy. Compliance with United States Preventative Services Task Force (USPSTF) guidelines was determined using electronic health record data; 1) Participants aged 21–29 with a cervical cytology within 3 years; 2) Patients aged 30–65 with cervical cytology alone within 3 years; 3) Participants aged 30–65 with high-risk HPV testing alone within 5 years; 4) Participants aged 30–65 with cervical cytology and high-risk HPV co-testing within 5 years. Participants completed Cohen’s Perceived Stress Scale (CPS) and the Everyday Discrimination Scale (EDS) to measure perceived stress and discrimination. Responses to CPS were categorized into low, medium, or high stress based on established cut-off points. EDS scores were categorized into quartiles based on the distribution in the entire cohort. The associations between CPS, EDS and compliance to USPSTF guidelines were evaluated using multivariable logistic regression models adjusting for 1) age and race and 2) socioeconomic status (SES) with age, race, insurance, education, income, employment, home ownership, and census region. Results: 21,083 participants were eligible. 15,276 (72%) self-identified as Non-Hispanic White, 2555 (12%) as Hispanic, 1807 (9%) as Non-Hispanic Black, and 1091 (5%) as Other. 6166 (30%) were adherent with screening recommendations; 14,917 (70%) were non-adherent. In the non-adherent group, 4114 (20%) identified as racial minorities, 4695 (32%) had annual income ≤ $50K; 2337 (16%) had public insurance and 1934 (13%) had a high-school degree or less. In non-adherent patients, 69% reported medium or high CPS scores and 56% reported EDS scores in the highest quartiles. In the age and race adjusted model, high perceived stress was associated with lower compliance to screening recommendations (OR=0.71, 95% CI: 0.62, 0.81, vs low stress) and these findings persisted in the SES-adjusted model (OR=0.81, 95% CI: 0.70, 0.94). Adjusting for age and race, participants in the highest quartile of EDS were 13% less likely to be compliant compared to those in the lowest quartile (OR=0.87, 95% CI: 0.80, 0.96). The association was consistent after adjusting for SES-related factors (OR=0.91, 95% CI: 0.82, 0.99). Conclusions: Perceived stress and discrimination may be important drivers of disparities in cervical cancer screening adherence. Targeted interventions to address these factors at the community and provider level are warranted to mitigate barriers to screening associated with this preventable cancer.