Racial inequalities in access to women's health care in southern Brazil

Clinical, epidemiological characteristics and mortality of pregnant and postpartum women associated with COVID-19 in Brazil: cohort study

Objective

To analyze the death of Brazilian pregnant and postpartum women due to COVID-19 or unspecific cause.

Methods

This is retrospective, descriptive-exploratory, population-based study carried out with the Sistema de Informação de Vigilância Epidemiológica da Gripe (SIVEP-Gripe) database, with pregnant and postpartum women of reproductive age who died from confirmed COVID-19 between 2020 and 2021. The chosen variables were: age, gestational period, type and number of comorbidities, skin color, using the statistical software R Foundation for Statistical Computing Platform, version 4.0.3 and Statistical Package for Social Science, version 29.0 for analysis.

Results

A total of 19,333 cases of pregnant and postpartum women aged between 10 and 55 years diagnosed with SARS were identified, whether due to confirmed COVID-19 or unspecific causes. Of these, 1,279 died, these cases were classified into two groups according to the cause of death: deaths from COVID-19 (n= 1,026) and deaths from SARS of unspecific cause (n= 253).

Conclusion

The risk of death increased among black and brown women, in the postpartum period and with the presence of comorbidities, mainly diabetes, cardiovascular diseases and obesity. The data presented here draw attention to the number of deaths from SARS, especially among sociodemographic profiles, precarious access to health, such as the black population. In addition, limitations in adequate access to health care are reinforced by even lower rates of ICU admissions among women who died from SARS of an unspecified cause.

Racial Inequities in the Control of Hypertension and the Explanatory Role of Residential Segregation: a Decomposition Analysis in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

The mechanisms underlying racial inequities in uncontrolled hypertension have been limited to individual factors. We investigated racial inequities in uncontrolled hypertension and the explanatory role of economic segregation in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). All 3897 baseline participants with hypertension (2008-2010) were included. Uncontrolled hypertension (SBP ≥ 140 mmHg or DBP ≥ 90 mmHg), self-reported race (White/Brown/Black people), and neighborhood economic segregation (low/medium/high) were analyzed cross-sectionally. We used decomposition analysis, which describes how much a disparity would change (disparity reduction; explained portion) and remain (disparity residual; unexplained portion) upon removing racial differences in economic segregation (i.e., if Black people had the distribution of segregation of White people, how much we would expect uncontrolled hypertension to decrease among Black people). Age- and gender-adjusted prevalence of uncontrolled hypertension (39.0%, 52.6%, and 54.2% for White, Brown, and Black participants, respectively) remained higher for Black and Brown vs White participants, regardless of economic segregation. Uncontrolled hypertension showed a dose-response pattern with increasing segregation levels for White but not for Black and Brown participants. After adjusting for age, gender, education, and study center, unexplained portion (disparity residual) of race on uncontrolled hypertension was 18.2% (95% CI 13.4%; 22.9%) for Black vs White participants and 12.6% (8.2%; 17.1%) for Brown vs White participants. However, explained portion (disparity reduction) through economic segregation was - 2.1% (- 5.1%; 1.3%) for Black vs White and 0.5% (- 1.7%; 2.8%) for Brown vs White participants. Although uncontrolled hypertension was greater for Black and Brown vs White people, racial inequities in uncontrolled hypertension were not explained by economic segregation.

Inequality by Skin Color in Breast Cancer Screening in Brazil: a Differences-in-Differences Analysis of the COVID-19 Pandemic

Breast cancer is the second most common cancer type and the first in mortality among Brazilian women. Mammograms are one of the main early diagnosis strategies. National breast cancer screening coverage is still low. Brazil's low screening coverage is due to high mammography access inequality. Skin color defines healthcare access differences. Our article explores the natural event of the COVID-19 pandemic to analyze differences in screening rates between two racial groups of women through the application of the differences in differences (DiD) estimator. The results indicate that BBI women (Black, Brown, and Indigenous Brazilian) have lower screening rates than WY women (White and Yellow) and that the pandemic reduced the difference between these two groups due to the lower number of mammograms performed by WY women. It is believed that the information channel can explain much of this result. The BA population, wealthier and more educated, may have had additional information about COVID-19 and its consequences, as well as an increased likelihood of working remotely and practicing social distance. Structural racism causes many social indicators to be correlated with inequality of access to mammography and negatively impacts health conditions for BBI women. Public policies are necessary for equal access to breast cancer screening for the most vulnerable women.

Racial Inequalities in the Health Establishment Access to the Treatment of COVID-19 in Brazil in 2020

The Brazilian health system simultaneously allows for the existence of the public and private sectors, which often imposes financial barriers to access to services and affects the health of exposed groups. Studies have shown evidence of higher lethality risks among Black/Biracial and Indigenous People admitted to hospitals due to COVID-19 during the pandemic when compared to White People. This paper evaluated the association between access to treatment for COVID-19, race, and COVID-19-related deaths among the five macro-regions of Brazil in 2020. We conducted a retrospective, cross-sectional observational, and population-wide study. Logistical models were used including first-order interactions between race and the health establishment administration sector using deaths as outcome, adjusted for covariates. The lethality risk, defined as the percentage of deaths among hospitalized patients, of Black/Biracial and Indigenous People was up to 78% (in the Midwest) and 29% (in the South) higher when compared to White People, respectively. The association of the race/access interaction with COVID-19-related deaths suggested the possibility of institutional racism in health establishments. The results highlight the need to guarantee adequate funding to the public health sector to improve equity in access to healthcare and the constant development of educational activities and increased participation of racialized minorities in the healthcare workforce at influential positions for health workers on topics such as racism.

Demographic and epidemiological characteristics of pregnant and postpartum women who died from severe acute respiratory syndrome in Brazil: A retrospective cohort study comparing COVID-19 and nonspecific etiologic causes

The objective of this study is to compare the demographic characteristics and symptoms in pregnant and postpartum women who died from Severe Acute Respiratory Syndrome (SARS) caused by COVID-19 or by nonspecific cause in different states of Brazil. This is a retrospective cohort study and the analysis was conducted on SARS death records between 02/16/2020 and 04/17/2021, obtained from the Information System for the Epidemiological Surveillance of Influenza (Sistema de Informação da Vigilância Epidemiológica da Gripe, SIVEP-Gripe). Pregnant and postpartum women, aged between 10 and 55 years, who died from SARS, were included and classified into two groups: SARS due to confirmed COVID-19 or SARS due to nonspecific cause. The cases were analyzed according to the women's demographic and epidemiological characteristics, clinical symptoms, risk factors and disease evolution. As results, 19,333 pregnant and postpartum women were identified. From these, 1,279 died (1,026 deaths from COVID-19 and 253 deaths from SARS with nonspecific cause). The groups showed significant differences in age, education, race, and occurrence of obesity and chronic lung disease. The group of women who died from confirmed COVID-19 presented a significantly higher frequency of symptoms of fever, cough, fatigue, loss of taste, and loss of smell, as well as a higher rate of admission to the intensive care unit (ICU). Data analysis draws attention to the high number of cases of SARS without a causal diagnosis, the low access to ICU and orotracheal intubation (OTI), which might be explained by the demographic and regional inequalities in the access to healthcare.

Health outcomes in women attending with clinical guideline PROGYNE to a primary care center for cervical cancer prevention

AIM

The objective of the current study was to analyze the health outcomes of women attending with a clinical guideline to consultations for cervical cancer (CC) prevention in a primary care center.

METHODS

A cross-sectional design was used, and data were collected from March to July 2016 with a sample of 87 women in Fortaleza, Brazil.

RESULTS

The following correlations were found: previous history of sexually transmitted infection (p = 0.025), women who used oral contraceptives (p = 0.035), and undergo the Papanicolaou test annually; having black skin color (p = 0.031) and attending to the first gynecological consultation; being single (p = 0.031), family history of cancer (p < 0.001), and undergoing the first Papanicolaou test within the first 3 years of sexual activity; age up to 30 years and positive colposcopy (p = 0.027); and being single and positive colposcopy (p = 0.021). CC was characterized by the presence of intraepithelial lesion detected on colposcopy (gold standard). Receiver operating characteristic curves were used to evaluate the diagnostic accuracy of visual inspection with Lugol's iodine, digital cervicography, and Papanicolaou test. The area under the curve values were as follows: digital cervicography: 0.558, p = 0.509; Lugol's iodine: 0.491, p = 0.919; and Papanicolaou test: 0.697, p = 0.024.

CONCLUSION

Colposcopy in primary care provided a faster diagnosis of pre-cancerous lesions. Understanding the health outcomes of women who underwent consultations for CC prevention, as well as the screening and diagnosis methods used, is essential to the service and national health system of the less developed countries.

Women's Participation in Pap Smear Screening in a Developing Country: Evidence for Improving Health Systems

Introduction

Every year about 83,000 women are diagnosed with cervical cancer in the Americas. Latin America and the Caribbean (LAC) has one of the highest incidence and mortality rates from cervical cancer in the world. Although incidence has decreased by half in the last 30 years, cervical cancer remains a public health concern. The detection of precursor lesions through Papanicolaou (Pap) smear remains a critical tool in the context of prevention in Costa Rica and many other LAC countries.

Objective

To determine predictors of participation in Pap smear screening among Costa Rican women, with a special focus on women who have never had a Pap smear or have had a smear 5 or more years ago.

Methods

The data source for this study is the Costa Rican Households National Survey conducted in 2014. This survey is representative at the national, urban/rural zone, and administrative region level. A subsample of women aged 20 to 69 years who responded to the survey's Papanicolaou Module were included in this study (n = 11,709). Statistical analyses were conducted in R-Studio. Statistical significance level was set at 5%. Two multinomial regression models were estimated. The first model aimed to explain the five different categories of cytology use, which were defined according to the last time women had a Pap smear. The second model aimed to explain the five different categories of reasons why women had never had a Pap smear. Both models controlled for age, educational attainment, and marital status.

Results

Young women with high educational attainment were more likely to have never had a cytology. Women with a lower educational attainment, married, or in domestic relationship and of older age had greater odds of having had a cytology 5 or more years ago. Each year increment in age was significantly associated with an increase in the odds of never having a Pap smear because of health care access issues or because of cultural reasons as compared to not having an active sexual life.

Conclusions

Findings can inform public policy targeted to higher risk female populations where access to health services can be improved.

Challenge of Incorporating New Drugs for Breast Cancer in Brazil: A Proposed Framework for Improving Access to Innovative Therapies

PURPOSE

The objective of this review is to address the barriers limiting access to treatment of advanced metastatic breast cancer (mBC) in Brazil, specifically for patients in the public health care system, arguably those with the least access to innovation.

MATERIALS AND METHODS

A selected panel of Brazilian experts in BC were provided with a series of relevant questions to address in a multiday conference. During the conference, responses were discussed and edited by the entire group through numerous drafts and rounds of discussion until a consensus was achieved.

RESULTS

The authors propose specific and realistic recommendations for implementing access to new drugs in cancer care in Brazil. Moreover, in creating these recommendations and framework, the authors strive to address the most important barriers and impediments for technology incorporation. A feasible and specific multidisciplinary process is proposed, which is based on the collective participation of all involved stakeholders.

CONCLUSION

Given the current benefits and likely future developments, there is a great need to expand treatments for mBC not only in Brazil but also in most other countries in the world where access issues remain an unresolved demand. Adapting the current framework is essential for accomplishing this goal. The recommendations in this review can serve as a framework for adoption of new technologies in countries with limited resources.

Mapping the Margins in Health Services Research: How Does Race Intersect With Gender and Socioeconomic Status to Shape Difficulty Accessing HealthCare Among Unequal Brazilian States?

Research on healthcare inequities has centralized whether marginalized racial, gender, or socioeconomic (SES) groups are afforded equitable access to care, yet scant investigations have focused on how race intersects with other social statuses to shape difficulty accessing health services. Contextual specificity has also been under-researched in this field of knowledge. Data from 59,249 respondents 18 years of age and over from the 2013 Brazilian National Health Survey were analyzed using multilevel regressions models. We test 3 hypotheses: racial, gender, and socioeconomically oppressed groups are each more likely to report difficulty accessing health services (H1); compared to high-SES white men, low-SES Black women report expressively higher frequencies of the outcome (H2); and intersectional healthcare inequities are larger among low-SES Brazilian states (H3). Partially supporting H1 and H2, results suggest that race and SES, but not gender, are each strong predictors of difficulty accessing healthcare, with low-SES Black respondents facing the highest odds of reporting this outcome. Although H3 was not supported, intersectional groups residing in low-SES Brazilian states were more likely to report difficulty accessing healthcare. This study demonstrated that, together with contextual specificity, the intersections of race with other axes of marginalization should be at the forefront of research and policy addressing healthcare inequities.

Perceptions and experiences regarding the impact of race on the quality of healthcare in Southeast Brazil: a qualitative study

Objective: To explore the impact of race on the quality of healthcare received by patients attending a primary care centre in Brazil.Design: This was a qualitative study consisting of 19 semi-structured interviews conducted on patients from six racial groups (as defined in Brazil as white, yellow, brown, black and indigenous and one self-identified 'other' group). The interviews were analysed using thematic analysis.Results: Four main themes were identified during analysis; factors affecting the access to healthcare, experiences regarding quality of healthcare, discrimination in healthcare and deep-rooted societal discrimination, which were categorised into a number of sub-themes. Within these themes, interviewees reported (1) experiences of racism in society towards the black racial group, (2) one personal perception and two observations of racial discrimination in healthcare, (3) perceived racial discrimination due to healthcare professional behaviour and (4) other factors, such as delays in appointments and long waiting times in health facilities were felt to impact access to care.Conclusion: The findings suggest that racial discrimination exists in Brazilian society but its direct impact on healthcare access was felt to be less obvious. Instead, organisational level factors were felt to contribute to difficulty accessing care. Interviewees perceived that racial discrimination may affect the quality of care, particularly for those designated as 'black'. Socio-economic factors were felt to influence discrimination in healthcare. The findings can help inform further studies and educational initiatives to help address discrimination and access to healthcare in Brazil.

Fatores limitadores e facilitadores para o controle do câncer de colo de útero: uma revisão de literatura

Resumo Este artigo revisa os fatores limitadores e facilitadores do acesso aos serviços públicos de saúde no Brasil na área da atenção ao câncer de colo de útero (CCU). Nesta revisão, foram utilizadas a base de dados bibliográficos Medline (interface com Biblioteca Virtual de Saúde/BVS e PubMed) e os portais Lilacs e SciELO. Buscou-se publicações referentes ao período 2011-2016, a partir do uso de termos específicos das fontes consultadas, relativos a ‘neoplasias do colo do útero’ e ‘acesso aos serviços de saúde’. Foram inicialmente encontrados 704 artigos, mas, considerando os critérios adotados, foram selecionados 31 artigos, dos quais foram incluídos 19. Foram mencionados aspectos facilitadores do acesso como ampla cobertura do exame Papanicolaou e de biopsias equivalente ao número de preventivos alterados. Entretanto, aspectos limitadores de acesso como periodicidade inadequada do Papanicolau, dificuldades para agendamento de consultas e exames, alto índice de estadiamento avançado e atrasos no diagnóstico e no início de tratamento, também foram apresentados.

Clinical manifestations and quality of life in hidradenitis suppurativa patients: survey of participants from an internet support group

BACKGROUND

Hidradenitis suppurativa is a complex and infrequent autoinflammatory disease that impacts on quality of life. Its pathogenesis is not fully understood, which limits the development of curative treatments.

OBJECTIVES

To evaluate clinical and quality of life aspects of hidradenitis suppurativa patients from a social group on the Internet.

METHODS

A cross-sectional, Internet-based survey study among participants in a discussion group (Facebook) of individuals with hidradenitis suppurativa. Patients were asked to answer a questionnaire about clinical-demographic aspects and quality of life (DLQI-BRA).

RESULTS

A total of 390 individuals agreed to participate in the study, 82% of them female, median age (p25-p75), of 31 (25-37) years old, disease onset at 15 (13-23) years, family member affected in 20% of cases, overweight (BMI 29 [25-33]) kg/m2 and severe impact on quality of life (DLQI 20 [13-25]). Regarding Hurley's classification, the participants provided information that enabled classification into: I (19%), II (52%) and III (29%). More severe cases were associated with males (OR = 1.69), higher weight (BMI: OR = 1.03) non-white color (OR = 1.43) and higher frequency of other autoinflammatory diseases (OR = 1.37).

STUDY LIMITATIONS

Voluntary adherence survey with self-completion of the questionnaire by 390 from about 1600 group members.

CONCLUSIONS

Hidradenitis suppurativa patients who participated in a social network group had onset of the disease after puberty, with a predominance in females and overweight people, with great impact on the quality of life.

The sociology of cancer: a decade of research

Biomedicine is often presented as the driving force behind improvements in cancer care, with genomics the latest innovation poised to change the meaning, diagnosis, treatment, prevention and lived experience of cancer. Reviewing sociological analyses of a diversity of patient and practitioner experiences and accounts of cancer during the last decade (2007-17), we explore the experiences of, approaches to and understandings of cancer in this period. We identify three key areas of focus: (i) cancer patient experiences and identities; (ii) cancer risk and responsibilities and (iii) bioclinical collectives. We explore these sociological studies of societal and biomedical developments and how sociologists have sought to influence developments in cancer identities, care and research. We end by suggesting that we extend our understanding of innovations in the fields of cancer research to take better account of these wider social and cultural innovations, together with patients, activists' and sociologists' contributions therein.

"We black women have to kill a lion everyday": An intersectional analysis of racism and social determinants of health in Brazil

The concept of intersectionality has been used to analyze and understand how multiple forms of identity and oppression interact to shape life experiences of marginalized groups. We conducted a qualitative study to explore how Black Brazilian women experience the intersections of race, class, and gender and the ways in which these intersecting experiences act as social determinants of health. Nine focus groups were conducted with Black, White, and mixed-race women of childbearing age (n = 37), social and health activists (n = 11), and health professionals (n = 20). The focus groups took place in two cities in the Brazilian state of Bahia during October and November 2012. Using a comparative approach, we describe participants' responses regarding the life experiences of women of differing racial and class backgrounds. Our findings highlight how the intersectional relationship between race, class, and gender alters women's social context and life course opportunities, as well as their stressors and protective buffers. We argue that the differing intersectional experiences of women due to race and class create unique social contexts that define the parameters of health and wellness. In addition, we argue that the experiences at each intersection (i.e., raceXclass, raceXgender, classXgender, raceXclassXgender) have a unique character that can be qualitatively described. Improved specification of exposures experienced by marginalized populations who experience intersecting forms of oppression can help explain intra- and inter-group differences in health outcomes, and may also lead to improved intervention models.

Social and Cultural Barriers to Women's Participation in Pap Smear Screening Programs in Low- and Middle-Income Latin American and Caribbean Countries: An Integrative Review

PURPOSE

Pap smear screening programs have been ineffective in reducing cervical cancer mortality in most Latin American and Caribbean countries, in part due to low screening rates. The purpose of this review was to analyze recent studies to identify demographic, social, and cultural factors influencing women's participation in Pap screening programs in Latin America and the Caribbean.

DESIGN/METHOD

For this integrative review, cervical cancer screening in Latin America and the Caribbean was searched using PubMed, CINAHL, EMBASE, and PsycINFO databases. Findings/Results: Demographic barriers to screening were socioeconomic status, education, race/ethnicity, and geography. Social barriers included lack of uniformity in screening guidelines, lack of knowledge regarding cervical cancer, and lack of preventive culture. Cultural barriers were fear/embarrassment and gender roles.

CONCLUSIONS

There are multilevel barriers to Pap smear utilization among women in Latin America and the Caribbean.

IMPLICATIONS FOR PRACTICE

Findings highlight a need for health system engagement, promotion of preventive care, and community-generated educational programs and solutions.

Low Impact of Traditional Risk Factors on Carotid Intima-Media Thickness: The ELSA-Brasil Cohort

OBJECTIVE

There is little information about how much traditional cardiovascular risk factors explain common carotid artery intima-media thickness (CCA-IMT) variance. We aimed to study to which extent CCA-IMT values are determined by traditional risk factors and which commonly used measurements of blood pressure, glucose metabolism, lipid profile, and adiposity contribute the most to this determination in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) cohort baseline.

APPROACH AND RESULTS

We analyzed 9792 individuals with complete data and CCA-IMT measurements. We built multiple linear regression models using mean left and right CCA-IMT as the dependent variable. All models were stratified by sex. We also analyzed individuals stratified by 10-year coronary heart disease risk and, in separate, those with no traditional risk factors. Main models' R(2) varied between 0.141 and 0.373. The major part of the explained variance in CCA-IMT was because of age and race. Indicators of blood pressure, lipid profile, and adiposity that most frequently composed the best models were pulse pressure, low-density lipoprotein/high-density lipoprotein ratio, and neck circumference. The association between neck circumference and CCA-IMT persisted significant even after further adjustment for vessel sizes and body mass index. Indicators of glucose metabolism had smaller contribution.

CONCLUSIONS

We found that >60% of CCA-IMT were not explained by demographic and traditional cardiovascular risk factors, which highlights the need to study novel risk factors. Pulse pressure, low-density lipoprotein/high-density lipoprotein ratio, and neck circumference were the most consistent contributors.

Carotid intima-media thickness value distributions in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

OBJECTIVE

Carotid intima-media thickness (IMT) is a noninvasive measurement of early atherosclerosis. Most IMT studies have involved populations with low rates of racial blending. The aim of the present article is to describe IMT value distributions and analyze the influence of sex and race on IMT values in a large Brazilian sample, a setting with a high rate of racial admixture.

METHODS

The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a multicenter cohort of 15,105 adult (aged 35-74 years) civil servants in six Brazilian cities. Baseline assessment included IMT measurements in both common carotid arteries. Race was self-reported. We studied the association between sex and race with IMT values using multiple linear regression models. We conducted analyses in all and low-risk individuals, defined as those without classical cardiovascular risk factors.

RESULTS

We analyzed complete IMT data from 10,405 ELSA-Brasil participants. We present nomograms by age for all and low-risk individuals, stratified by sex and race. We found that men had significantly higher maximal IMT values compared with women (β = 0.058; P < 0.001). This association remained for low-risk individuals (β = 0.027; P = 0.001). In addition, Brown and White individuals had lower maximal IMT values compared with Black individuals for all (β = -0.034 and β = -0.054, respectively; P < 0.001) and low-risk individuals (β = -0.027; P = 0.013 and β = -0.035; P < 0.001, respectively).

CONCLUSION

We found significantly higher IMT values in men. We found significantly higher IMT values in Black individuals than White and Brown individuals. These results persisted when analyses were restricted to low-risk individuals.

Association between cervical lesion grade and micronucleus frequency in the Papanicolaou test

The aim of this study was to evaluate the association between the frequency of micronuclei (MN) and the cellular changes detected in the conventional Papanicolaou test. One hundred and seventy-four Papanicolaou test smears with cellular changes were examined. MN screening was done in cytopathological smears by counting 1,000 cervical cells in a light microscope. MN frequencies were significantly higher in the group with cellular changes compared to the control group (p < 0.001). The mean MN frequencies were 0.95 ± 1.12 (mean ± SD) in the control group (n = 223), 2.98 ± 1.20 in individuals with atypical squamous cells of undetermined significance (ASC-US) (n = 50), 4.04 ± 1.45 in cervical intraepithelial neoplasia (CIN) I (n = 52), 5.97 ± 1.83 in CIN II (n = 30), 7.29 ± 1.55 in CIN III (n = 17) and 8.64 ± 1.55 in invasive cancer (n = 25). These findings suggest that MN monitoring should be included as an additional criterion for the early detection of cytogenetic damage in routine examinations. This monitoring should be done in the same smear as used for cytopathological examination. More specific and systematic studies are necessary to confirm this proposal.

Inequalities in Pap smear screening for cervical cancer in Brazil

OBJECTIVE

To examine the risk factors associated with never being screened for cervical cancer (CC) in Brazil.

METHODS

Using the National Household Sample Survey 2008 (PNAD), we analyzed data from 102,108 Brazilian women ages 25-64years. The patients were analyzed as having been or never having been screened with a Pap smear (Yes/No). Age-adjusted prevalence of never-screening was analyzed using a Chi-squared test. Crude and adjusted models using Poisson regression were performed.

RESULTS

The prevalence of never-screened women for CC was 12.9%, 11.5% and 22.2% in Brazil in general, urban and rural areas, respectively. The Brazilian region with the highest prevalence of never-screening was the North (17.4%, 14.7% and 27.3% in general, urban and rural areas, respectively). The factors associated with a higher risk for never being screened were the following: poverty, younger age, lower educational level, non-white skin color, a greater number of children, no supplemental health insurance and not having visited a doctor in the past 12months.

CONCLUSION

Socioeconomic and demographic conditions lead to inequalities in access to Pap smear screening in Brazil. Public health policy addressing these risk groups is necessary.