The study is based on data from the European Health Interview Survey (EHIS) of 2009, 2014 and 2019, the basis of which was developed by Eurostat in compliance with a legal obligation. The EHIS uses a standardized questionnaire that contains the following main groups of questions: health status, use of the health care system, drug use, reasons for refusing health care, opinion about the health care system, use of preventive care, general well-being, factors affecting health, care, demographic data. The questionnaire also contains separate groups of questions for children. Its main purpose is to collect data for European health indicators (25, 26). The EHIS provides age data in three categories: 15-34, 35-64, and 65+, making it impossible to define a precise eligibility cutoff (e.g., 25–65 years) in alignment with national screening guidelines. Given this limitation, we used a binary classification: below 65 years and 65+ years, ensuring that the analysis captures the vast majority of screening-eligible women (i.e., those below 65) while distinguishing those who may have aged out of routine screening recommendations. Although some younger women (15-24) were included in the <65 category, they represent a minority, and their inclusion does not substantially affect overall trends, as participation in screening is expected to be low in this subgroup. This categorization balances data constraints with epidemiological relevance, allowing for meaningful comparisons while adhering to the best available classification method given the dataset structure.

In Hungary, the respondents were selected based on two-stage stratified sampling according to county and settlement size, the sampling method was developed by Hungarian Central Statistical Office (27). The total sample included 16,480 persons aged 15 and over living in private households, of which 8,910 were women, of whom 700 were women with diabetes. The outcome variable of the study was participation in cervical cancer screening among women with diabetes. In the questionnaire “When was the last time you had a gynecological cervical cancer screening?” question related to this: the five answer options were divided into two categories: the category of having participated in screening for less than 2 years and the category of having participated in screening for more than 2 years. Data on diabetes were obtained from answers to the question on diabetes, in the chronic diseases block.

As influencing factors age (≥65, <65) marital status (single/in a relationship), level of education (primary/secondary/tertiary), type of occupation (employed/unemployed), area of residence (urban/rural), regions (Central Hungary/Southern Great Plain/Southern Transdanubia/Central Transdanubia/Western Transdanubia/Northern Great Plain/Northern Hungary) financial situation (average/good/bad), income quintiles (first/second/third/fourth/fifth), BMI overweight + obese/normal), smoking status (smoker/non-smoker), alcohol consumption (drinker/non-drinker), self-perceived health (average/good/bad), hypertension (yes/no), hypercholesterolemia (yes/no), cardiovascular disease (yes/no), depression (yes/no), mental illnesses (yes/no), last visit to the dental office (more than a year ago/less than a year ago), taking prescription drugs (yes/no), taking supplements (yes/no) and breast cancer screening attendance (more than 2 years/within the past 2 years) were included. Variables with excessive missing values were excluded from the analysis, and missing data in retained variables were handled using listwise deletion.

The sample contains 700 women with diabetes, in the annual distribution below: 164 in 2009, 250 in 2014, and 285 in 2019. The age distribution of women with diabetes was as follows: 4.57% of the respondents belonged to the age group of 15-34, 40.57% to the age group of 35–64 and 54.86% to the age group of 65+.

Our aim was to identify the influencing factors that are contribute to the attendance of cervical cancer screening among diabetic women.

The participation rate of women with diabetes is declining compared to the 2009 baseline.

Higher education, good economic situation, participation in breast cancer screening and social support have a positive effect on participation in screening. Taking prescription drugs, lower economic status, and poorer perceived health negatively affected participation in screening.

Compared to the reference year (2009), the attendance rate was lower in the other two examined years, the result was significant in 2014. Some studies also show this declining trend on attendance (28), others report increasing participation rates (29). The decline in participation rate can be explained by the introduction of HPV vaccination in Hungary, which happened in 2014.

Similar to other studies (30, 31), positive correlations were detected to screening attendance with the following factors: higher educational level, social support, better financial state. International recommendations no longer recommend cervical cancer screening for people older than 65, except in some special cases (32, 33). This can explain why the younger age group took part in the screening examination in greater proportion. Participation in breast cancer screening also shows a correlation with participation in cervical cancer screening in other countries (34).

Some factors decreased the odds of the attendance of cervical cancer screening, these were bad financial state and worse perceived health status and taking prescription drugs. These factors have also been identified as influencing factors in other studies (35, 36). The decreasing participation rate does not only affect women with diabetes, but is also characteristic of the entire female sample based on the data examined. According to another study analyzing participation data in Hungary, attendance in cervical cancer screening during the period 2008–2021 initially showed an increase, but from 2016 onwards a continuously decreasing trend can be observed (37). Based on OECD statistics, from 2011–2021 among the examined 31 countries, Hungary had the third lowest attendance rate in cervical cancer screening, only Poland and Costa Rica had lower numbers. The OECD average rate was 53%, in Hungary this number was only 26%, and the OECD found that the attendance rate decreased with 12% compared to the data from 2011 (38).

Reviewing Hungarian cervical cancer mortality data, HPV vaccination and cervical cancer treatment, there are still areas that must be improved in order to reach the 90-70–90 goal formulated by the World Health Organization, which includes the following:90% HPV vaccination coverage rate among girls by the age of 15; a 70% coverage of cervical cancer screening at ages 35 and 45 and treating 90% of women with precancer and managing 90% of women with invasive cancer. The WHO goal for the incidence of cervical cancer is lower than 4 new cases per 100–000 women, each year (39). In Hungary the HPV vaccination rate was 82% in 2021, the number of new cases was 24,7/100–000 women, and the 75% of 25-65-year-old women were screened in the last three years (40). The situation in Hungary is not favorable in terms of screening participation, the participation rate in cervical cancer screening tests was under 50% in 2006 and it has been decreasing over the years (in 2019 only 30.2% of 20–69 year olds appeared for screening) (41). According to the results of a meta-analysis, increasing participation in cervical cancer screening would be facilitated by the possibility of self-sampling and sending invitation letters and reminders to affected women (42).

Many factors have influence on attendance of screening programs. Socioeconomic status (SES) influences people’s health behavior, studies found that higher SES has positive effect on the participation of screening programs (43, 44). However, analyzing the individual components of socioeconomic status (educational level, marital status, financial status), the relationship is not so clear. There are components that clearly have a positive effect on screening participation, e.g. married individuals have higher odds to attend screening programs (45, 46). On the other hand, about the association between educational level and screening attendance, some studies found no significant association (47, 48), while others described a positive correlation between higher educational level and the attendance (49, 50). Higher household income is associated with higher attendance rate on screening (31, 50).

In addition to these, some studies have also identified other factors that have a positive or negative effect on participation in cervical cancer screening: the most common barriers were pain/discomfort; embarrassment; and time, the most commonly reported facilitators were: ease of making appointments; peace of mind; and fear of cancer/preventing serious illness (51).

This study utilized data from the European Health Interview Survey (EHIS), which offers a representative sample of the adult population in Hungary. Although the same methodology was applied consistently across all three survey years, an aggregated dataset was employed for comparative analysis. Multiple logistic regression models were utilized to identify significant determinants of screening uptake, providing valuable insights for the design of targeted intervention strategies. Owing to the methodological design of the data collection process, the database includes only data from participants, with no information available for those who opted not to participate. The European Health Interview Survey (EHIS), as administered by Eurostat and the Hungarian Central Statistical Office (HCSO), did not differentiate between Type 1 and Type 2 diabetes mellitus. However Type 2 diabetes has higher prevalence, we assumed that the majority of respondents had type 2 diabetes. This limitation has been acknowledged, and results should be interpreted with this consideration in mind.

This study focused on the importance of cervical cancer screening participation in women with diabetes and highlights the benefits of screening within this population. In particular, it should be taken into account that the participation rate in screening is not homogeneous in terms of the population. In the case of participation in cervical cancer screening, it is lowest in those groups whose health-influencing factors are not very favorable (those with poor financial status, those with perceived poor health, those taking prescription medications). Therefore, the identification of groups with lower screening participation may be crucial in the context of the introduction of public health interventions aimed at improving the participation rate.