CERVICAL CANCER INEQUITIES IN COLOMBIA
Cervical cancer (CC) is the second most common cancer and third in cancer-related deaths among women. Developing countries account for most CC-related deaths and are highly impacted by CC mortality in young women. In South America, CC is the second most incident cause of cancer and first cause of cancer deaths among women 15-44 years. In Colombia, CC is the second most common cause of cancer mortality among women. Previous studies conducted in Colombia have shown inequities in CC prevention and mortality by different socio- demographic factors; however, there is a lack of nationwide studies evaluating these factors specifically in young Colombian women. The goal of this thesis was to identify socio-demographic characteristics associated with awareness of CC primary prevention, access to secondary prevention for CC, and CC mortality among young women in Colombia. The educational level, type of health insurance, having a rural or urban residence, and region of residence of women were common factors related to inequities in CC prevention and mortality in Colombia. Women with limited or no education had a reduced probability of having heard of HPV vaccination, with differing effects of education by age and region of residence. In the case of Pap testing, having a rural residence decreased the odds of Pap testing compared to having an urban residence, with wider differences in the odds among women with limited-to-no education compared to those with higher education. Additionally, a higher prevalence of no education in the neighbourhood where women lived resulted in lower odds of Pap testing in both rural and urban areas, especially when comparing women with limited-to-no education to women with a secondary or higher education. Measured at the administrative divisions or department level, a high prevalence of no education was associated with a low prevalence of Pap testing, specifically for departments being at or above the national prevalence of women living in rural areas. Similarly, mortality rates were higher among women with limited or no education compared to women with higher education, observing wider differences in younger age groups. Having subsidised insurance and not having insurance were associated with a decreased awareness of HPV vaccination. The effect of type of health insurance on Pap testing varied by whether women had a rural or urban residence. Departments with higher prevalences of women with subsidised insurance were associated with not having heard of HPV vaccination and not having had a Pap test. No significant differences in CC mortality were observed between women with subsidised insurance and those with no insurance. Also, mortality rates for different types of health insurance varied for some age groups. Women living in rural areas had a reduced awareness of HPV vaccination with variations by regions. Having a rural residence also decreased the probability of having Pap testing, particularly in some regions of Colombia and among women with no insurance or subsidised health insurance. Furthermore, increments in the department percentage of women living in rural areas increased the risk ratio of having women who had not had a Pap test in departments classified as at or above the national prevalence of no education. In contrast, living in rural areas was associated with lower CC mortality rates. Women from the Amazon-Orinoquía region had high rates of CC mortality and were less likely to have heard of HPV vaccination and have had a Pap test. Several departments located in the Amazon-Orinoquía region and a few departments from the Pacific, and Atlantic regions (e.g. Chocó, Sucre, and La Guajira) had a high risk of women not having access to primary and secondary CC prevention, after accounting for other risk factors.
Cervical cancer prevention, Inequities, Educational Status, Rural Population, Pap test, Papillomavirus vaccines, Mortality, Colombia
Doctor of Philosophy (Ph.D.)
School of Public Health