Cervical cancer screening in the United States: Pre- and post-pandemic disparities using National Health Interview Survey (NHIS) data

The COVID-19 pandemic disrupted routine preventive care. The long-term cervical cancer screening tendency, and who remains left behind, remains understudied.

We analyzed nationally representative data from the 2019, 2021, and 2023 NHIS, including women aged 21-65 with a cervix. The outcome was being "up-to-date" with cervical screening (last test <3 years). An intersectional variable combined insurance and Federal Poverty Level (FPL): uninsured and <100% FPL (reference), uninsured and ≥100% FPL, insured and <100% FPL, and insured and ≥100% FPL, was derived. Survey-weighted logistic regression models estimated adjusted odds ratios (aORs), controlling for sociodemographics.

Up-to-date rate declined (75.1% in 2019, 72.8% in 2021 and 69.9% in 2023). In multivariate models, being up-to-date were 16% (aOR = 0.84, 95%CI 0.77-0.91) and 30% (aOR = 0.70, 95%CI 0.64-0.77) lower in 2021 and 2023 respectively, compared with 2019. Age showed a midlife peak (aOR = 1.78 for ages 30-39; 1.48 for 40-52 vs. 21-29 y.o.). Women with a Bachelor's degree or higher were more likely to be up-to-date than those with less than high school (aOR = 2.32, 95%CI 1.99-2.70). While uninsured women ≥ FPL lacked significant advantage (aOR=0.88, 95%CI 0.71-1.09), insured women <FPL and ≥ FPL had higher odds of being up-to-date (aOR=1.61 and 2.16, respectively). Non-Hispanic Asians had significantly lower odds than Whites (aOR=0.47, 95%CI 0.41-0.53).

Cervical screening shows a sustained post-pandemic decline. Insurance status, rather than income alone, is the key gateway: insurance substantially increases the likelihood of being up-to-date, even among women living below the FPL. Policy efforts to restore cervical screening should prioritize expanding and stabilizing insurance coverage and addressing persistent gaps among specific groups, specifically Asian women.