Trends and determinants in uptake of cervical cancer screening in Spain: an analysis of national surveys from 2017 and 2020

Citation: Portero de la Cruz, S.; Cebrino, J. Trends and Determinants in Uptake of Cervical Cancer Screening in Spain: An Analysis of National Surveys from 2017 and 2020. Cancers 2022,14, 2481. https:// doi.org/10.3390/cancers14102481 Academic Editor: Sadeep Shrestha Received: 18 April 2022 Accepted: 17 May 2022 Published: 18 May 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). cancers Article Trends and Determinants in Uptake of Cervical Cancer Screening in Spain: An Analysis of National Surveys from 2017 and 2020 Silvia Portero de la Cruz 1,2 and Jesús Cebrino 3,* 1Department of Nursing, Pharmacology and Physiotherapy, Faculty of Medicine and Nursing, University of Córdoba, Avda. Menéndez Pidal, S/N, 14071 Córdoba, Spain; [email protected] 2Research Group GC12 Clinical and Epidemiological Research in Primary Care, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Hospital Universitario Reina Sofía, 14071 Córdoba, Spain 3Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Seville, Avda. Doctor Fedriani, S/N, 41009 Seville, Spain *Correspondence: [email protected]; Tel.: +34-954-551-771 Simple Summary: Cervical cancer is the fourth leading cause of death and morbidity in women worldwide. Although screening is a successful technique for lowering these rates, there are still great differences in screening adherence in Spain. The aims of this study were to examine the evolution of cytology screening adherence from 2017 and 2020 and to identify the factors associated with uptake among women in Spain. We found that 73.18% of women had received a cytology test during the previous three years. From 2017 and 2020, there was an increase in cytology screening participation among women aged 45–65 years. Foreigners were less likely to have a cytology test. The characteristics associated with cervical cancer screening that we discovered have significant value for public health initiatives, as they will assist health professionals in identifying women who are less likely to undergo screening and encouraging these women to do so. Abstract: Cervical cancer rates have declined in industrialized nations as a result of cytology screening programs. However, there are still sizeable differences in screening adherence in Spain. This study aimed to identify the prevalence of cervical cancer screening among women in Spain, to analyze trends in that prevalence from 2017 and 2020 and to identify socio-demographic, health, and lifestyle factors related with adherence to this screening test. We conducted a cross-sectional study of 13,619 women aged 25–65 who participated in the 2017 Spanish National Health Survey and the 2020 European Health Survey for Spain. We used logistic regression to examine the relationship between sociodemographic, health and lifestyle factors and cervical cancer adherence. The prevalence of adherence was 73.18%. Additionally, there was a significant decrease in cervical cancer screening uptake from 2017 and 2020 among women aged 25–44 years (2017: 77.80%, 2020: 75.20%, p= 0.02), but an increase in the age group of 45–65 years (2017: 68.93%, 2020: 72.39%, p< 0.01) and in foreigners (2017: 64.29%, 2020: 72.29%, p< 0.01). Screening for cervical cancer is related with age, educational level, social class, insurance status, visits to the family doctor, alcohol consumption and free time physical exercise. Keywords: cytology; guideline adherence; healthcare disparities; mass screening; uterine cervical neoplasms 1. Introduction Cervical cancer is probably the most thoroughly studied and preventable human cancer [1] . However, it remains the fourth most common cancer and the fourth leading cause of cancer mortality in women, with an estimated 604,000 new cases and 342,000 deaths globally in 2020 [ 2 ]. In 2020, lowand middle-income countries accounted for over 90% of new cases and deaths worldwide [ 2 ]. Furthermore, while the incidence of cervical cancer has declined over time in Western Europe, particularly in Spain [ 3 ], which has one of the Cancers 2022,14, 2481. https://doi.org/10.3390/cancers14102481 https://www.mdpi.com/journal/cancers Cancers 2022,14, 2481 2 of 15 lowest age-standardized indices [ 4 ] partly due to the high coverage of cytological screening programs (72% of Spanish women over the age of 25) [ 5 ], the rate has increased in some regions such as Central and Eastern Europe [ 6 ] or Africa [ 7 ]. These differences in cervical cancer rates are largely due to variations in the prevalence of risk factors between countries, particularly exposure to human papillomavirus (HPV), as well as disparities in the capacity of health care systems to set up early detection programs for cancer lesions [8]. Cervical cancer is largely preventable through both vaccination and screening for precursor lesions, with appropriate follow-up and treatment [ 9 ]. At present, there are three vaccines to prevent HPV infection: 9-valent HPV vaccine (Gardasil 9, 9vHPV), 4-valent HPV vaccine (Gardasil, 4vHPV), and 2-valent HPV vaccine (Cervarix, 2vHPV). Each of these vaccines protects against HPV genotypes 16 and 18, which collectively cause about 70% of cervical cancers. Both Gardasil vaccines also protect against HPV genotypes 6 and 11, which cause 90% of genital warts. Gardasil 9 also protects against HPV genotypes 31, 33, 45, 52, and 58 [ 10 ]. Despite the three HPV vaccines now available have been shown to reduce the incidence of HPV infection, they do not protect against all HPV genotypes [ 10 ]. Moreover, HPV vaccinations have only recently been launched, and unvaccinated elderly women are not immunized against HPV infection [ 11 ]. Furthermore, vaccination coverage varies greatly by location and country [12]. Cervical cancer screening includes molecular screening method (HPV DNA testing), visual screening method (visual inspection with acetic acid) and cytology-based screening methods (PAP smear and liquid-based cytology) [ 13 ]. HPV DNA testing identifies a group of high-risk carcinogenic HPV genotypes, typically including up to 14 types (HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58 and 59, which are Group 1 carcinogens, and HPV66 and 68) [ 9 ]. Cytology tests (including the Papanicolaou smear test and liquid-based cytology) identify atypical cells on the cervix through the preparation and interpretation of slides using microscopy by a trained expert. Liquid-based cytology requires sophisticated processing to create slides from liquid specimens [ 14 ]. Papanicolaou smear test may provide a high number of unsatisfactory slides; however, liquid-based cytologic analysis solves some of these quality difficulties and allows for the performance of both molecular and cytologic tests with a single sample [ 14 ]. Visual inspection with acetic acid testing identifies acetowhite lesions that require treatment or additional evaluation by applying dilute acetic acid to the cervix without magnification. This method has been used in resource-constrained settings and nations with limited access to health care. However, the evidence that visual inspection with acetic acid reduces the incidence of cervical cancer is weak [ 14 ]. The addition of HPV testing to cervical cytology is one of the most recent improvements to cervical cancer screening standards. HPV-DNA testing can be performed on cervical specimens by signal amplification methods or by nucleic acid amplification with polymerase chain reaction. When high-risk HPV testing is combined with cytology, the sensitivity of a single Papanicolaou test for high-grade neoplasia can be increased from 50–85% to over 100% [ 9 ]. Previous research has shown that population-based cancer screening programs outperform opportunistic screenings in terms of reducing overuse and cancer mortality, as well as being more cost-effective and attempting to provide screening to all individuals in the target population, thereby reducing disparities in the access to and uptake of cervical cancer screening [8,15]. Since 2019, the Spanish guidelines for the early detection of cervical cancer recommend cytological screening in women aged 25–34 every three years and HPV testing in women aged 35–65 every five years as part of a population-based screening program [ 16 ]. The introduction of the HPV vaccine into the Spanish national immunization program in 2007–2008 , HPV detection methods, the first cohorts of women vaccinated against HPV reaching screening age, and advances in scientific knowledge have all prompted a review of the way the Spanish National Health System run the screening program [ 17 ]. Unfortunately, a substantial variety in screening strategy persists in Spanish regions, with most programs remaining opportunistic with varying degrees of adherence to national recommendations [ 18 ]. These factors, together with the fact that 60.7% of Spanish women diagnosed with cer- Cancers 2022,14, 2481 3 of 15 vical cancer have never had any cytology testing [ 19 ], are what prompted us to conduct the current study, which aimed to identify the prevalence of cervical cancer screening among women in Spain, to analyze trends in that prevalence from 2017 and 2020 and to identify socio-demographic, health, and lifestyle factors related with adherence to this screening test. 2. Materials and Methods To conduct this cross-sectional study, we used secondary data from the 2017 Spanish National Health Survey (SNHS) [ 20 ] and the 2020 European Health Interview Survey for Spain (EHIS) [ 21 ]. Both surveys were conducted from October 2016–October 2017 and July 2019–July 2020, respectively, by the National Statistics Institute under the supervision of the Spanish Ministry of Health and Social Affairs. These surveys were carried out by applying home-based personal interviews on a countrywide, representative sample of non-institutionalized subjects aged 15 years and older who had their main family residence in Spain. The team who administered the survey had previously been taught fundamental communication skills, associated processes, and in particular questionnaire training. Before taking the surveys, all the participants completed informed consent forms. More information on the methodology of SNHS 2017 and EHIS 2020 is available elsewhere [22,23]. The following samples of women aged 25–65 were chosen based on the screening guideline age groups [ 16 ]: 7695 women in SNHS 2017 and 6914 in EHIS 2020. Despite having similar characteristics to the other women, 990 participants (7.13%) were eventually discarded from the sample because they were unwilling to complete the questionnaires (SNHS 2017: n= 441; EHIS 2020: n= 549). Our study includes the self-reported responses from these surveys. The variables we used were based on many of the items contained in the questionnaires, which were the same in all the surveys. The dependent variable was cervical cancer screening uptake, which was measured by asking “Have you ever had a cytology test?” Those who answered yes were then asked, “When was the last time you had a cytology test?”. Following the classification of the women who followed the recommended screening period [ 16 ], those who admitted to having their most current cytology within the previous three years were referred to as “uptakers”. The other women were referred to as “non-uptakers” (Figure 1). As independent variables, we examined socio-demographic, health, and lifestyle factors. Age group (25–44, 45–65 years), educational level (without studies, primary, secondary, university), marital status (single, married, widowed, separated or divorced), social class (upper, middle, lower) [ 24 ], place of residence (rural/urban) [ 25 ] and nationality (Spanish/foreigner) were socio-demographic characteristics. In terms of health, their self-assessed state of health (very good, good, average, bad, very bad), insurance status (public/private) and visits to the family doctor in the preceding four weeks (yes/no) were all considered. The presence of physician-diagnosed mental illnesses, such as chronic anxiety or chronic depression, as well as other psychiatric disorders, was measured by self-reporting. Any woman who was diagnosed with one or more of these three illnesses was termed as “suffering from mental condition”. Finally, body mass index (underweight, normal weight, overweight, obesity) [ 26 ], tobacco habit (yes, no), alcohol consumption in the previous year (yes, no) and free time physical exercise (yes, no) were used to measure lifestyle behaviors. The qualitative variables were reported in terms of frequencies and percentages, while the quantitative variables were expressed in the form of mean and standard deviation (SD). To draw comparisons, the Chi-squared test was applied (from 2017 to 2020, Chi-squared trend analysis was employed widely to discover significant trends in cytology adherence). We also carried out a multivariable analysis to identify which characteristics were independent predictors of cervical cancer screening adherence, and we used the crude and adjusted odds ratio (OR), with their respective 95% confidence intervals, to assess the strength of association. The Hosmer–Lemeshow test was used to evaluate the quality of fit, and to Cancers 2022,14, 2481 4 of 15 measure the goodness of fit, we examined the adjusted coefficient of determination (R 2 ), the F statistic and the normality of the residues. The multivariate model contained only covariates which had a possible association (p ≤ 0.15) with the dependent variable, and non-significant variables were discarded using backward selection based on the likelihood of the Wald statistic. The level of statistical significance was set at α = 0.05. SPSS 25.0 software, licensed to the University of Córdoba (Spain), was used to carried out the statistical analysis. The research data are included in the Supplementary File S1. Cancers 2022, 14, x FOR PEER REVIEW 4 of 16 Figure 1. Study workflow. As independent variables, we examined socio-demographic, health, and lifestyle factors. Age group (25–44, 45–65 years), educational level (without studies, primary, secondary, university), marital status (single, married, widowed, separated or divorced), social class (upper, middle, lower) [24], place of residence (rural/urban) [25] and nationality (Spanish/foreigner) were socio-demographic characteristics. In terms of health, their selfassessed state of health (very good, good, average, bad, very bad), insurance status (public/private) and visits to the family doctor in the preceding four weeks (yes/no) were all considered. The presence of physician-diagnosed mental illnesses, such as chronic anxiety or chronic depression, as well as other psychiatric disorders, was measured by self-reporting. Any woman who was diagnosed with one or more of these three illnesses was termed as “suffering from mental condition”. Finally, body mass index (underweight, normal weight, overweight, obesity) [26], tobacco habit (yes, no), alcohol consumption in the previous year (yes, no) and free time physical exercise (yes, no) were used to measure lifestyle behaviors. The qualitative variables were reported in terms of frequencies and percentages, while the quantitative variables were expressed in the form of mean and standard deviation (SD). To draw comparisons, the Chi-squared test was applied (from 2017 to 2020, Chisquared trend analysis was employed widely to discover significant trends in cytology adherence). We also carried out a multivariable analysis to identify which characteristics were independent predictors of cervical cancer screening adherence, and we used the crude and adjusted odds ratio (OR), with their respective 95% confidence intervals, to assess the strength of association. The Hosmer–Lemeshow test was used to evaluate the quality of fit, and to measure the goodness of fit, we examined the adjusted coefficient of determination (R2), the F statistic and the normality of the residues. The multivariate Figure 1. Study workflow. 3. Results We evaluated the data from 13,619 women residing in Spain aged 25 to 65 years old. Most of these women were between the ages of 45 and 65 (57.19%), belonged to the lower socioeconomic class (45.37%) and did free time physical exercise (63.93%) (Figure 2). Cancers 2022,14, 2481 5 of 15 Cancers 2022, 14, x FOR PEER REVIEW 5 of 16 model contained only covariates which had a possible association (p ≤ 0.15) with the dependent variable, and non-significant variables were discarded using backward selection based on the likelihood of the Wald statistic. The level of statistical significance was set at α = 0.05. SPSS 25.0 software, licensed to the University of Córdoba (Spain), was used to carried out the statistical analysis. The research data are included in the Supplementary File S1. 3. Results We evaluated the data from 13,619 women residing in Spain aged 25 to 65 years old. Most of these women were between the ages of 45 and 65 (57.19%), belonged to the lower socioeconomic class (45.37%) and did free time physical exercise (63.93%) (Figure 2). Figure 2. Distribution of socio-demographic factors, health-related characteristics, and lifestyle habits. Table 1 shows the rates of cervical cytology uptake based on socio-demographic factors, health-related characteristics, and lifestyle habits. A higher uptake rate for cervical cytology was found in the youngest age group, those who were married, with university studies, belonging to the upper social class, of Spanish nationality, without mental illness, with private health insurance, those who visited a general practitioner in the four weeks preceding survey completion, were of normal weight, had consumed alcohol in the previous year and did physical activity during leisure time. Table 1. Uptake of cervical cytology according to socio-demographic, health, and lifestyle variables (N = 13,619). Variables Cervical Cytology Total n (%) Yes n = 9967 (%) No n = 3652 (%) p-value Age group <0.001 45–65 years old 7789 (57.19) 5499 (70.60) 2290 (29.40) 25–44 years old 5830 (42.81) 4468 (76.64) 1362 (23.36) Educational level <0.001 Without studies 57 (0.42) 21 (36.84) 36 (63.16) Primary 1877 (13.78) 1118 (59.56) 759 (40.44) Secondary 7762 (56.99) 5653 (72.83) 2109 (27.17) Figure 2. Distribution of socio-demographic factors, health-related characteristics, and lifestyle habits. Table 1shows the rates of cervical cytology uptake based on socio-demographic factors, health-related characteristics, and lifestyle habits. A higher uptake rate for cervical cytology was found in the youngest age group, those who were married, with university studies, belonging to the upper social class, of Spanish nationality, without mental illness, with private health insurance, those who visited a general practitioner in the four weeks preceding survey completion, were of normal weight, had consumed alcohol in the previous year and did physical activity during leisure time. Table 1. Uptake of cervical cytology according to socio-demographic, health, and lifestyle variables (n = 13,619). Variables Cervical Cytology Total n (%) Yes n = 9967 (%) No n = 3652 (%) p-Value Age group <0.001 45–65 years old 7789 (57.19) 5499 (70.60) 2290 (29.40) 25–44 years old 5830 (42.81) 4468 (76.64) 1362 (23.36) Educational level <0.001 Without studies 57 (0.42) 21 (36.84) 36 (63.16) Primary 1877 (13.78) 1118 (59.56) 759 (40.44) Secondary 7762 (56.99) 5653 (72.83) 2109 (27.17) University 3923 (28.81) 3175 (80.93) 748 (19.07) Marital status <0.001 Single 3235 (23.75) 2234 (69.06) 1001 (30.94) Married 8134 (59.73) 6158 (75.71) 1976 (24.29) Widowed 588 (4.32) 348 (59.18) 240 (40.82) Separated or divorced 1662 (12.20) 1227 (73.83) 435 (26.17) Social class <0.01 Lower 6179 (45.37) 4178 (67.62) 2001 (32.38) Middle 4473 (32.84) 3390 (75.79) 1083 (24.21) Upper 2967 (21.79) 2399 (80.86) 568 (19.14) Place of residence 0.79 Urban 4336 (31.84) 3167 (73.04) 1169 (26.96) Rural 9283 (68.16) 6800 (73.25) 2483 (26.75) Nationality <0.001 Spanish 12,158 (89.27) 8959 (73.69) 3199 (26.31) Foreigner 1461 (10.73) 1008 (68.99) 453 (31.01) Mental illness <0.01 No 11,486 (84.34) 8455 (73.61) 3031 (26.39) Yes 2133 (15.66) 1512 (70.89) 621 (29.11) Cancers 2022,14, 2481 6 of 15 Table 1. Cont. Variables Cervical Cytology Total n (%) Yes n = 9967 (%) No n = 3652 (%) p-Value Self-assessed state of health 0.14 Very good 2982 (21.90) 2194 (73.57) 788 (26.43) Good 7095 (52.10) 5235 (73.78) 1860 (26.22) Average 2648 (19.44) 1910 (72.13) 738 (27.87) Bad 685 (5.03) 481 (70.22) 204 (29.78) Very bad 209 (1.53) 147 (70.33) 62 (29.67) Insurance status Public 12,981 (95.32) 6422 (72.58) 3559 (27.42) <0.001 Private 638 (4.68) 545 (85.42) 93 (14.58) Visits to the family doctor in the preceding 4 weeks No 10,058 (73.85) 7310 (72.68) 2748 (27.32) 0.03 Yes 3561 (26.15) 2657 (74.61) 904 (25.39) Body Mass Index <0.001 Normal weight 73.27 (53.80) 5581 (76.17) 1746 (23.83) Underweight 417 (3.06) 317 (76.02) 100 (23.98) Overweight 3915 (28.75) 2760 (70.50) 1155 (29.50) Obesity 1960 (14.39) 1309 (66.79) 651 (33.21) Tobacco habit 0.28 No 9985 (73.32) 7332 (73.43) 2653 (26.57) Yes 3634 (26.68) 2635 (72.51) 999 (27.49) Alcohol use in the previous year <0.001 No 4825 (35.43) 3266 (67.69) 1559 (32.31) Yes 8794 (64.57) 6701 (76.20) 2093 (23.80) Free time physical exercise <0.001 No 4912 (36.07) 3411 (69.44) 1501 (30.56) Yes 8707 (63.93) 6556 (75.30) 2151 (24.70) In the previous three years, 73.18% of women between 25 and 65 years had undergone cervical cytology (Figure 3). Cancers 2022, 14, x FOR PEER REVIEW 7 of 16 Figure 3. Distribution of adherence to cervical cytology screening of women between 25 and 65 years. There were no variations in cytology testing from 2017 to 2020 (2017: 72.87%, 2020: 73.54%, p = 0.38). From 2017 and 2020, we observed an increase in the prevalence of cytology test adherence in foreigners (2017: 64.29%, 2020: 72.29%, p < 0.01) (Table 2). Table 2. Distribution of cervical cytology screening adherence according to the study variables from 2017 and 2020 (N = 9967). Variables Cervical Cytology (n = 9967) 2017 n = 5286 (%) 2020 n = 4681 (%) p-value Educational level Without studies 13 (38.24) 8 (34.78) 0.79 Primary 624 (57.88) 494 (61.83) 0.08 Secondary 3030 (73.05) 2623 (72.58) 0.64 University 1619 (81.19) 1556 (80.66) 0.67 Marital status Single 1152 (69.95) 1082 (68.14) 0.27 Married 3330 (75.10) 2828 (76.43) 0.16 Widowed 184 (57.50) 164 (61.19) 0.28 Separated or divorced 620 (72.68) 607 (75.03) 0.38 Social class Lower 2283 (67.11) 1895 (68.24) 0.38 Middle 1765 (75.82) 1625 (75.76) 0.97 Upper 1238 (81.23) 1161 (80.46) 0.34 Place of residence Urban 1643 (71.43) 1524 (74.85) 0.10 Rural 3643 (73.54) 3157 (72.93) 0.51 Nationality Spanish 4899 (73.62) 4060 (73.74) 0.91 Foreigner 387 (64.29) 621 (72.29) <0.01 Mental illness No 4432 (73.76) 4023 (73.45) 0.71 Yes 854 (68.59) 658 (74.10) 0.18 Self-assessed state of health Figure 3. Distribution of adherence to cervical cytology screening of women between 25 and 65 years. Cancers 2022,14, 2481 7 of 15 There were no variations in cytology testing from 2017 to 2020 (2017: 72.87%, 2020: 73.54%, p= 0.38). From 2017 and 2020, we observed an increase in the prevalence of cytology test adherence in foreigners (2017: 64.29%, 2020: 72.29%, p< 0.01) (Table 2). Table 2. Distribution of cervical cytology screening adherence according to the study variables from 2017 and 2020 (n = 9967). Variables Cervical Cytology (n = 9967) 2017 n = 5286 (%) 2020 n = 4681 (%) p-Value Educational level Without studies 13 (38.24) 8 (34.78) 0.79 Primary 624 (57.88) 494 (61.83) 0.08 Secondary 3030 (73.05) 2623 (72.58) 0.64 University 1619 (81.19) 1556 (80.66) 0.67 Marital status Single 1152 (69.95) 1082 (68.14) 0.27 Married 3330 (75.10) 2828 (76.43) 0.16 Widowed 184 (57.50) 164 (61.19) 0.28 Separated or divorced 620 (72.68) 607 (75.03) 0.38 Social class Lower 2283 (67.11) 1895 (68.24) 0.38 Middle 1765 (75.82) 1625 (75.76) 0.97 Upper 1238 (81.23) 1161 (80.46) 0.34 Place of residence Urban 1643 (71.43) 1524 (74.85) 0.10 Rural 3643 (73.54) 3157 (72.93) 0.51 Nationality Spanish 4899 (73.62) 4060 (73.74) 0.91 Foreigner 387 (64.29) 621 (72.29) <0.01 Mental illness No 4432 (73.76) 4023 (73.45) 0.71 Yes 854 (68.59) 658 (74.10) 0.18 Self-assessed state of health Very good 1090 (74.25) 1104 (72.92) 0.41 Good 2740 (73.72) 2495 (73.86) 0.89 Average 1094 (71.04) 896 (73.65) 0.14 Bad 271 (68.81) 210 (72.41) 0.28 Very bad 91 (67.91) 56 (74.67) 0.38 Insurance status Public 5002 (72.29) 4420 (72.91) 0.43 Private 284 (84.78) 261 (86.14) 0.63 Visits to the family doctor in the preceding 4 weeks No 3721 (72.72) 3589 (72.64) 0.93 Yes 1565 (73.23) 1092 (76.69) 0.25 Body Mass Index Normal weight 2974 (76.63) 2607 (75.65) 0.33 Underweight 160 (71.43) 157 (81.35) 0.12 Overweight 1433 (69.36) 1327 (71.77) 0.09 Obesity 719 (66.39) 590 (67.27) 0.68 Tobacco habit No 3826 (73.38) 3506 (73.49) 0.90 Yes 1460 (71.57) 1175 (73.71) 0.15 Alcohol use in the previous year No 1773 (67.75) 1493 (67.62) 0.92 Yes 3513 (7516) 3188 (76.69) 0.31 Free time physical exercise No 1856 (69.95) 1555 (70.05) 0.41 Yes 3430 (75.19) 3126 (75.42) 0.80 Figure 4illustrates the age-group distribution of cervical cytology screening adherence from 2017 and 2020. Women aged between 45 and 65 years old reported more frequently Cancers 2022,14, 2481 8 of 15 having undergone cytology screening in 2017 than in 2020 (2017: 68.93%, 2020: 72.39%, p< 0.01) . However, adherence to cervical cytology decreased across the study years in women aged 25 to 44 (2017: 77.80%, 2020: 75.20%, p= 0.02). Cancers 2022, 14, x FOR PEER REVIEW 8 of 16 Very good 1090 (74.25) 1104 (72.92) 0.41 Good 2740 (73.72) 2495 (73.86) 0.89 Average 1094 (71.04) 896 (73.65) 0.14 Bad 271 (68.81) 210 (72.41) 0.28 Very bad 91 (67.91) 56 (74.67) 0.38 Insurance status Public 5002 (72.29) 4420 (72.91) 0.43 Private 284 (84.78) 261 (86.14) 0.63 Visits to the family doctor in the preceding 4 weeks No 3721 (72.72) 3589 (72.64) 0.93 Yes 1565 (73.23) 1092 (76.69) 0.25 Body Mass Index Normal weight 2974 (76.63) 2607 (75.65) 0.33 Underweight 160 (71.43) 157 (81.35) 0.12 Overweight 1433 (69.36) 1327 (71.77) 0.09 Obesity 719 (66.39) 590 (67.27) 0.68 Tobacco habit No 3826 (73.38) 3506 (73.49) 0.90 Yes 1460 (71.57) 1175 (73.71) 0.15 Alcohol use in the previous year No 1773 (67.75) 1493 (67.62) 0.92 Yes 3513 (7516) 3188 (76.69) 0.31 Free time physical exercise No 1856 (69.95) 1555 (70.05) 0.41 Yes 3430 (75.19) 3126 (75.42) 0.80 Figure 4 illustrates the age-group distribution of cervical cytology screening adherence from 2017 and 2020. Women aged between 45 and 65 years old reported more frequently having undergone cytology screening in 2017 than in 2020 (2017: 68.93%, 2020: 72.39%, p < 0.01). However, adherence to cervical cytology decreased across the study years in women aged 25 to 44 (2017: 77.80%, 2020: 75.20%, p = 0.02). Figure 4. Distribution of adherence to cervical cytology screening according to age group from 2017 to 2020. Table 3shows the crude and adjusted ORs allowing for the identification of determinants of cervical cytology test adherence in the study population. Positive predictors were: age 25–44 (OR = 1.28), educational level (primary: OR = 2.20, secondary OR = 3.41, university OR = 4.28), social class (upper (OR = 1.39), middle (OR = 1.28), private health insurance (OR = 1.67), visits to the primary care physician in the previous four weeks ( OR = 1.25 ), consumption of alcohol in the last year (OR = 1.29) and doing leisure-time physical activity (OR = 1.17). However, foreign nationality was a negative predictor (OR = 0.88). Table 3. Variables associated with uptake of cervical cytology among women residing in Spain (2017–2020). Variables OR (CI 95%) OR a(CI 95%) p-Value Age group 45–65 years old Reference Reference 25–44 years old 1.37 (1.26–1.48) 1.28 (1.18–1.39) <0.001 Educational level Without studies Reference Reference Primary 2.53 (1.46–4.36) 2.20 (1.27–3.82) <0.001 Secondary 4.60 (2.68–7.89) 3.41 (1.98–5.89) <0.01 University 7.28 (4.22–12.54) 4.28 (2.46–7.45) <0.001 Marital status Single Reference Married 1.40 (1.28–1.53) Widowed 0.65 (0.54–0.78) Separated or divorced 1.26 (1.11–1.44) Social class Lower Reference Reference Middle 1.50 (1.38–1.64) 1.28 (1.17–1.40) <0.001 Upper 2.02 (1.82–2.25) 1.39 (1.22–1.58) <0.001 Cancers 2022,14, 2481 9 of 15 Table 3. Cont. Variables OR (CI 95%) OR a(CI 95%) p-Value Place of residence Urban Reference Rural 1.01 (0.93–1.10) Nationality Spanish Reference Reference Foreigner 0.76 (0.71–0.89) 0.88 (0.78–0.95) 0.04 Mental illness No Reference Yes 0.87 (0.79–0.97) Self-assessed state of health Very good Reference Good 1.01 (0.92–1.11) Average 0.93 (0.83–1.05) Bad 0.85 (0.71–1.01) Very bad 0.85 (0.63–1.16) Insurance status Public Reference Reference Private 2.21 (1.77–2.78) 1.67 (1.33–2.10) <0.001 Visits to the family doctor in the preceding 4 weeks No Reference Reference Yes 1.11 (1.01–1.21) 1.25 (1.14–1.37) <0.001 Body Mass Index Normal weight Reference Underweight 0.99 (0.79–1.25) Overweight 0.75 (0.69–0.82) Obesity 0.63 (0.57–0.70) Tobacco habit No Reference Yes 0.96 (0.88–1.04) Alcohol use in the previous year No Reference Reference Yes 1.53 (1.41–1.65) 1.29 (1.19–1.40) <0.001 Free time physical exercise No Reference Reference Yes 1.34 (1.24–1.45) 1.17 (1.08–1.27) <0.001 OR, odds ratio; OR a , odds ratio adjusted for all sociodemographic, health and lifestyle variables; CI 95%, 95% Confidence Interval. Hosmer–Lemeshow test χ2= 5.80, p= 0.15; Nagelkerke’s R2Square = 0.53; p-value < 0.01. 4. Discussion 4.1. Main Findings The current study analyzed cervical cytology screening adherence in Spain from 2017 and 2020 and shows predictors of cervical cytology testing in a nationally representative sample of women aged 25 to 65. The study also describes the characteristics of women who did not undergo cytology testing. In our study, 73.18% of the women surveyed reported undertaking a cervical cytology in the previous three years. This finding is very similar to the cytology uptake value previously reported in Spanish women [ 27 ] and may be due to the growing efforts by the Spanish Health System to raise awareness of the benefits of screening for cervical cancer [ 28 ]. Moreover, that adherence meets one of the World Health Organization’s stated objectives for 2030 for nations to target the elimination of cervical cancer: 70% of women screened by the age of 35, and again by the age of 45 [ 29 ]. Additionally, testing rates vary widely across Europe. The current study’s cervical cytology screening uptake rate lies midway between Northern European nations (ranging from 67% to 94%) and Eastern European countries, which have the lowest prevalence of cytology adherence (10.3%) [ 30 , 31 ]. Nevertheless, in response to the COVID-19 pandemic, screening activities in Spain were reasonably postponed, the priority of periodic cervical cancer screening decreased, and Pap smears