Journal of Preventive Medicine

Introduction
Cervical cancer is the fourth most common cancer and the fourth leading cause of cancer-related death in women, causing 604,000 new cancer cases and 342,000 deaths worldwide in 2020. The incidence of cervical cancer in Iran is on the rise. Cervical cancer elimination takes significantly longer in low- and middle-income countries than in high-income countries. It is predicted that this disease will be eliminated in low- and middle-income countries by the end of the 21st century in case of high coverage of HPV vaccination. Screening women with no HPV vaccination can accelerate the elimination of cervical cancer. In this regard, it is important to know the factors affecting the use of cervical cancer screening services. Considering the social and geographical inequalities of cervical cancer, as well as the low level of public awareness and differences in screening methods in different parts of Iran, it seems necessary to conduct a study emphasizing awareness and access to cervical cancer screening facilities in the country. Therefore, this study aims to investigate demographic factors, knowledge, and accessibility of cervical cancer screening services among women from the outskirts of Bandar Abbas City, the capital of Hormozgan province, southern Iran.

Methods
This case-control study was conducted on women aged 18-49 years from the outskirts of Bandar Abbas City. The women in the case group had performed cervical cancer screening regularly in the past 3 years, while the control group had not performed screening in the past 3 years. To ensure that there was no cervical cancer screening in the control group, in addition to checking their information recorded in the SIB system of the health centers, the women were also interviewed. The inclusion criteria for the case group were age 18-49 years, living in the areas covered by the health service centers, performing regular cervical cancer screening in the past 3 years. The inclusion criterion for the control group were the lack of regular cervical cancer screening in the past 3 years. The common inclusion criteria were no pregnancy, being sexually active, no history of cervical cancer, consent to participate in the study, and the ability to read and write. The exclusion criteria were a family history of cervical cancer and the return of an incomplete questionnaire.
For each group, the minimum required sample size was 200; however, to increase the statistical efficiency, the sample size of the control group doubled (n=400). The samples were selected from those with medical records in 6 comprehensive health service centers in marginal areas. By simple random sampling, 33 women were selected from each center as the case group, and 66 women were selected as the control group. The data collection tool was a three-part questionnaire measuring demographic and health information, knowledge, and accessibility to cervical cancer screening services. Univariate and multivariate regression analysis was used for data analysis. The data was statistically analyzed in STATA software, version 14.2. P<0.05 was considered statistically significant.

Results
The mean age of participants was 30.33±4.892 in the case group and 31.35±6.149 in the control group. Most of participants (98.5% in the case group and 93.3% in the control group) were married with a high school diploma (49.5% in the case group and 64.5% in the control group), moderate economic status (83.5% in the case group and 69.8% in the control group), 1-2 deliveries (90.5% in the case group had 68% in the control group), and a history of sexually transmitted diseases (86% in the case group and 73.3% in the control group). Also, 96% in the control group and 67.5% in the case group had not observed personal sexual hygiene. The knowledge score of 28.2% of women in the control group and 50.5% in the case group was at a moderate level. The accessibility of cervical cancer screening services was reported to be “high” by 55.5% of women in the case group and 20.5% in the control group. 
Married women were 3 times more likely to perform cervical cancer screening than single women. Women with a diploma were 2 times and those with a university degree were 1.4 times more likely to perform cervical cancer screening than women with primary education. Both moderate and high economic status increased the odds of screening by 6 times. Non-smoking women were 1.1 times more likely to perform screening than smokers. Compared to women with low knowledge, women with moderate and high knowledge were 18 times and 13 times more likely to perform cervical cancer screening, respectively. In the group with moderate and high access to screening services, women were 4 and 8 times more likely to perform screening, respectively.

Conclusion
The present study has a significant potential to help policymakers in Iran for developing effective programs for cervical cancer screening on the outskirts of Bandar Abbas City. It is recommended to carry out qualitative studies on identifying barriers to cervical cancer screening by women living in the marginal lands, so that targeted interventions can be designed. It is also recommended to conduct studies on the factors affecting cervical cancer screening behavior of women in high-risk groups, such as sex workers and smokers.

Ethical Considerations

Compliance with ethical guidelines
This study was approved by the Hormozgan University of Medical Sciences (Code: IR.HUMS.REC.1398.267). 

Funding
This article was done with the financial support of Hormozgan University of Medical Sciences.

Authors' contributions
Study design and writing: Maryam Azizi Kutenaee;  study protocol, data collection and data curation: Seyed Hesamaddin Banihashemi; Final approval: All authors.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors would like to thank Hormozgan University of Medical Sciences as their financial support. The authors would also like to express their gratitude to the participants for their sincere cooperation in this study

References