College Attendance, Physical Disability, and Cervical Cancer Screening

Abstract

This cross-sectional study examines the association of physical disability and college attendance with undergoing guideline-recommended cervical cancer screening.

Introduction

Cervical cancer screening (CCS) in the US is far from the US Healthy People 2030 goal of 79.2% and has continued to decline over the past 2 decades.¹ Research has suggested that women with physical disability engage in less CCS than the general US population^2,3,4,5 and die of cervical cancer.⁶ This study used covariate intersectional analyses to examine the association of college attendance and physical disability with CCS.

Methods

This cross-sectional study used a subset of the Truveta database⁷ from January 1, 2017, through December 31, 2022. The study was considered exempt by the University of Michigan Institutional Review Board as data were deidentified and the study presented minimal risk to human participants. The study followed the STROBE reporting guideline for cross-sectional studies.

We selected women aged 20 to 60 years in 2016 with records through 2022 (representing women aged 21-65 years in 2017-2022 based on a 1-year look-back period) to capture the guideline-recommended screening event. Each patient must have had at least 2 unique annual health maintenance visits within the database to be eligible. We used medical codes indicating the laboratory test for CCS, not the visit type, to identify the outcome (eAppendix 1 in Supplement 1). We excluded patients who died during the time frame or had a hysterectomy before 2017, had any gynecological cancer at any time, or had evidence of CCS after hysterectomy, except if there was a supracervical hysterectomy or a history of cervical intraepithelial neoplasia grade 2 or 3 disease (eAppendixes 2 and 3 in Supplement 1). Age was defined at the time of CCS. Attendance at college (some or none) was noted. Race and ethnicity were self-identified (Asian, Black, Hispanic, White, other [American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiracial, not specified]). Race and ethnicity are associated covariates for CCS in the general population, mandating that they be included in all disability research. We defined the subpopulation of women with any physical disability by medical diagnostic codes (eAppendix 4 in Supplement 1), where each woman was counted only once regardless of the number of physical disabilities recorded.

Data were analyzed from April 24, 2023, through December 31, 2025. We excluded all patients with missing race, ethnicity, or college attendance data. We used multivariable logistic regression with Firth bias and Tukey correction applied to estimate CCS by disability status, adjusting for age, race, ethnicity, and college attendance. This multiplicative interaction test evaluated the interaction of disability status with all other covariates within the same model and cohort. All analyses were conducted using Truveta Prose Language⁸; PySpark, version 3.4 (Python Software Foundation); SparkR, Apache version 3.5 in R, Spark version 4.4.1 (Apache Software Foundation). A 2-tailed P < .05 was considered statistically significant.

Results

The analytic population included 2 265 395 women, including 15 727 (0.7%) with physical disability (median [IQR] age, 47 [37-55] years; 63.5% underwent CCS) and 2 249 668 (99.3%) without physical disability (median [IQR] age, 44 [33-53] years; 70.9% underwent CCS) (P < .001 for both age and CCS rates) (Figure). Missing data were 4.4% for race, 4.4% for ethnicity, and 3.2% for college attendance.

Figure. Bar Graph and Dot Plot of Population Distribution and Cervical Cancer Screening (CCS) Rates for Women With and Without Physical Disability.

Age group and some college are type III test results for overall categorical significance (P < .001). Differences in CCS rates calculated using χ² pairwise comparisons adjusted with Tukey test for multiple comparisons.

^aP < .001.

^bP < .05.

^cIncluded multiracial or not specified.

Women with physical disability had significantly lower odds of CCS than those without (odds ratio [OR], 0.79 [95% CI, 0.76-0.82]; P < .001) (Table). In particular, the odds of CCS for women with physical disability vs those without were progressively lower as women aged (21-29 years: OR, 0.43 [95% CI, 0.37-0.50]; 30-39 years: OR, 0.69 [95% CI, 0.61-0.78]; 40-49 years: OR, 0.82 [95% CI, 0.74-0.91]) (all P < .001). Significantly lower odds of CCS were found between women with and without physical disability identifying as Black (OR, 0.77 [95% CI, 0.68-0.88); P < .001), White (OR, 0.79 [95% CI, 0.74-0.84]; P < .001), or other (OR, 0.73 [95% CI, 0.54-0.98]; P = .02) race. Women with physical disability who attended some college had similar, nonsignificant odds of CCS as those without physical disability (OR, 1.02 [95% CI, 0.95-1.09]; P = .91).

Table. Odds of Cervical Cancer Screening by Covariates Between Women With and Without Physical Disability, 2017-2022.

Covariate	AOR (95% CI)a	Tukey P valueb
Disability	0.79 (0.76-0.82)	<.001
Age group, y
21-29	0.43 (0.37-0.50)	<.001
30-39	0.69 (0.61-0.78)	<.001
40-49	0.82 (0.74-0.91)	<.001
50-65	1.12 (1.01-1.23)	.01
Race
Asian	0.83 (0.59-1.17)	.73
Black	0.77 (0.68-0.88)	<.001
White	0.79 (0.74-0.84)	<.001
Otherc	0.73 (0.54-0.98)	.02
Ethnicity
Hispanic	0.87 (0.71-1.08)	.36
Non-Hispanic	0.78 (0.74-0.82)	<.001
Education
Some college	1.02 (0.95-1.09)	.91
No college	0.53 (0.50-0.57)	<.001

Abbreviation: AOR, adjusted odds ratio.

^a Conditional average treatment effects estimated using pairwise interaction terms for disability status with each of the secondary exposure covariates. The model was based on interacting disability status (exposure) with all other covariates of interest within the same model and cohort: cervical cancer screening ~ disability + age group + race + ethnicity + attended college + disability × age group + disability × race + disability × ethnicity + disability × attended college. Reference group, women without physical disability.

^b Least squares difference estimation with Firth correction applied to account for small sample sizes and sparse data. Tukey test applied for multiple pairwise comparison adjustment.

^c Included American Indian or Alaska Native, Native Hawaiian or Pacific Islander, multiracial, and not specified.

Discussion

Higher education is known to be associated with better health outcomes overall.^9,10 This cross-sectional study found that increased uptake of CCS was associated with higher education, but some college attendance completely mitigated the negative influence of advancing age, race, ethnicity, and physical disability on CCS. The intracategorical comparisons of disability, age, race, ethnicity, and college attendance with CCS provides clinical data that may generalize to women with physical disabilities.

A limitation is that we did not identify women with sensory or cognitive disabilities or lower-limb amputations; therefore, these types of disabilities may exist in both populations. The limitations of secondary data were minimized by the representativeness of the large database, the unlikelihood of miscoding a physical diagnosis, and the possibility of miscoding a surveillance CCS rather than a routine CCS.

Women with physical disability and some college education may be more likely to undergo CCS than those with no college education. Age, race, and ethnicity also differed intersectionally in their association with CCS. Future studies emphasizing the intersectionality of education with other negatively associated risk factors for lack of CCS may inform future CCS campaigns for women with physical disability.

Supplement 1.

eAppendix 1. Diagnostic Codes for Cervical Cancer Screening (and Unused Codes)

eAppendix 2. Exclusion Codes for Hysterectomy

eAppendix 3. Exclusion Codes for Gynecological Cancer

eAppendix 4. Physical Disability Codes

Supplement 2.

Data Sharing Statement