Association Between Sexual Behavior

and Cervical Cancer Screening

Anthony M.A. Smith, Ph.D.,

1

Wendy Heywood, B.A. (Hons),

1

Richard Ryall, B.App.Sc. (Hons),

1

Julia M. Shelley, Ph.D.,

1,2

Marian K. Pitts, Ph.D.,

1

Juliet Richters, Ph.D.,

3

Judy M. Simpson, Ph.D.,

4

and Kent Patrick, Ph.D.

1

Abstract

Background: Not much is known about whether women who follow Pap testing recommendations report the
same pattern of sexual behavior as women who do not.
Methods: Data come from part of a larger population-based computer-assisted telephone survey of 8656 Aus-
tralians aged 16–64 years resident in Australian households with a fixed telephone line (Australian Longitudinal
Study of Health and Relationships [ALSHR]). The main outcome measure in the current study was having had a
Pap test in the past 2 years.
Results: Data on a weighted sample of 4052 women who reported sexual experience (ever had vaginal inter-
course) were analyzed. Overall, 73% of women in the sample reported having a Pap test in the past 2 years.
Variables individually associated with Pap testing behavior included age, education, occupation, cohabitation
status, residential location, tobacco and alcohol use, body mass index (BMI), lifetime and recent number of
opposite sex partners, sexually transmitted infection (STI) history, and condom reliance for contraception. In
adjusted analyses, women in their 30s, those who lived with their partner, and nonsmokers were more likely to
have had a recent Pap test. Those who drank alcohol at least weekly were more likely to have had a recent test
than irregular drinkers or nondrinkers. Women with no sexual partners in the last year were less likely to have
had a Pap test, and women who reported a previous STI diagnosis were more likely to have had a Pap test in the
past 2 years.
Conclusions: There are differences in Pap testing behavior among Australian women related to factors that may
affect their risk of developing cervical abnormalities. Younger women and regular smokers were less likely to
report a recent test. Screening programs should consider the need to focus recruitment strategies for these
women.

Introduction

P

articipation in Papanicolaou (Pap) Screening

has

been associated with a number of sociodemographic

characteristics, although not consistently.

1–12

Little research

has investigated interval between Pap tests and sexual be-
havior, however, which is surprising, given the primary cause
of cervical cancer is sexually acquired persistent human
papillomavirus (HPV).

13–16

In the United States, having had a

Pap test in the past year was more common among women
reporting one of the following: being £ 15 years at first sex,
having ‡ 10 lifetime sex partners, having a history of pelvic

inflammatory disease (PID), having a history of sexually
transmitted disease (STD), and with male sexual partners
having sex with other women in the past 12 months.

3

A Swedish study interviewed women on a cytology register,
finding that women with two or more sex partners during the
last 5 years were more likely to have had a recent Pap test,
whereas age at first sex and total number of sex partners were
not associated with screening. Not being screened was posi-
tively associated with the nonuse of oral contraceptives and
frequent condom use.

2

Having two or more sex partners was

associated with Pap testing in the last 3 years in a Spanish
study, although age at first sex was not.

17

Finally, a recent U.S.

1

Australian Research Centre in Sex, Health & Society, La Trobe University, Melbourne, Australia.

2

School of Health and Social Development, Deakin University, Melbourne, Australia.

3

School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia.

4

Sydney School of Public Health, University of Sydney, Australia.

JOURNAL OF WOMEN’S HEALTH
Volume 20, Number 7, 2011
ª Mary Ann Liebert, Inc.
DOI: 10.1089/jwh.2010.2585

1091

study found women in same-sex relationships were less likely
to have had a Pap test in the last 3 years than were women in
relationships with men.

18

Given the importance of regular cervical screening and the

paucity of research on and inconsistency of findings about the
relationship between having a recent Pap test and sexual and
behavioral factors, further examination of this topic is essen-
tial. Here, we examine if women who report their last Pap test
as being no more than 2 years ago (the Australian recom-
mendation for Pap testing is every 2 years once sexually ac-
tive

19

) report the same patterns of sociodemographic and

behavioral characteristics, including sexual behavior, as do
women reporting longer time since their most recent
test. In Australia, all or part of the costs associated with Pap
testing are subsidized by the universal healthcare system,
Medicare.

20

Materials and Methods

Recruitment

The present study was a component of the Australian

Longitudinal Study of Health and Relationships (ALSHR).

21

The aim of the ALSHR was to document the natural history of
sexual and reproductive health of the Australian adult pop-
ulation. To be able to identify a statistically significant relative
risk of approximately 2.0 when exposures have a prevalence
of at least 10%–20% and outcomes have an incidence over 3
years of at least 2%–4.5%, the ALSHR surveyed 4290 men and
4366 women in all states and territories of Australia. Only
women who reported sexual experience (ever had vaginal
intercourse), the target population for regular Pap testing,
were included in the current analysis.

Survey

Women were asked a range of sociodemographic ques-

tions, including age, education, occupation, cohabitation sta-
tus, residential location, language spoken at home, country of
origin, and frequency of use of tobacco and alcohol. Because
of previously reported associations between body mass index
(BMI) and Pap testing,

1,6,7

BMI, calculated as weight in kilo-

grams divided by height in meters squared, was investigated
using self-reported weight and height. Four categories cor-
responding to current World Health Organization (WHO)
recommendations were used: underweight, BMI < 18.5 kg/m

2

;

normal weight, BMI = 18.5–24.9 kg/m

2

; overweight, BMI =

25–29.9 kg/m

2

; obese, BMI ‡ 30 kg/m

2

.

22

Potential variables of interest were sexual identity (het-

erosexual, homosexual/lesbian, bisexual), age at first vaginal
intercourse, lifetime number of opposite sex sexual partners
(any form of sexual experience), and number of opposite sex
sexual partners in the year before the interview (any form of
sexual experience). Additional variables, including history of
sexually transmitted infections (STIs) (self-reported diagnosis
of chlamydia, genital herpes, genital warts, syphilis, gonor-
rhea, PID, bacterial vaginosis, trichomoniasis, or crablice) and
current reliance on condoms for contraception, were also in-
vestigated because of associations with Pap testing in past
research.

2,3

Finally, Pap testing behavior was assessed by two ques-

tions: if the woman had ever had a Pap test or Pap smear, and,
if so, at what age she had her most recent Pap test. Using these

two questions and the respondent’s current age, we derived
a binary variable indicating whether the women had had a
Pap test in the previous 2 years. A 2-year cutoff was se-
lected as being consistent with Australian cervical screening
guidelines.

19

Procedure

Approval for this study was granted by the human research

ethics committees of La Trobe University, the University of
New South Wales, and Deakin University and was conducted
during 2004 and 2005 using computer-assisted telephone in-
terviewing. Participants were first contacted through random
digit dialing and, after having the study explained to them,
either gave their verbal consent to be interviewed or refused.
Of those contacted, 56.0% agreed to participate. Age was
the only selection criterion used in this study, with partici-
pants interviewed only if aged between 16 and 64 years.
Where two or more eligible respondents lived in a household,
one was randomly chosen to be interviewed. All interviews
were conducted in English.

Data analysis

All frequencies were weighted by household size and

rounded to the nearest integer. Chi-square tests were used to
assess bivariate associations between Pap testing in the past 2
years and demographic characteristics, age at first vaginal
intercourse, number of lifetime opposite sex partners, number
of opposite sex partners in the last year, STI history, and
condom reliance. Variables were included in the initial mul-
tivariate logistic regression model only if bivariate analysis
gave p < 0.25.

23

The least significant variables were sequen-

tially removed from the model until all remaining variables
were statistically significant at p < 0.05. Removed variables
were then checked one at a time to ensure they were not
significant in the final model. All analyses were weighted by
household size. p values reported are for design-based F sta-
tistics from the weight-adjusted chi-square tests (unadjusted)
and Wald tests (adjusted) of the overall effect of each factor.

All associations between variables are reported as relative

risk (RR) with 95% confidence intervals (CI) estimated from
log-binomial regression. Log-binomial was used instead of
logistic regression as odds ratios (ORs) overstate the RR when
the outcome of interest is common ( > 10%), as is the case for
Pap testing.

24

Analyses were conducted using Stata, version

10.1 (StataCorp, College Station, TX).

Results

Of the 4366 women who completed the survey, 4236 indi-

cated they had ever had vaginal intercourse. A further 40
women were excluded because of invalid answers to the two
Pap test questions. After these exclusions, the following ana-
lyses are based on a weighted sample of 4052 women, 2969
(73%) of whom reported having a Pap test in the previous
2 years.

Sociodemographic and lifestyle factors

Table 1 displays the percentage and number of women

from each sociodemographic background who reported
having a Pap test in the last 2 years. In bivariate analyses, age
was strongly associated with recent Pap testing. In addition,

1092

SMITH ET AL.

Table

1. Association Between Having a Pap Test in Previous 2 Years and Demographic, Lifestyle,

and Sexual Behavior Correlates

Total n

Yes %

Unadjusted RR (95% CI)

a

Adjusted RR (95% CI)

b

Age

c

p < 0.001

p < 0.001

16–19

176

28

0.39 (0.30-0.51)

0.36 (0.26-0.48)

20–29

633

76

0.92 (0.87-0.96)

0.92 (0.87-0.97)

30–39

943

85

-

-

40–49

1059

82

0.96 (0.93-1.00)

0.96 (0.93-0.99)

50–59

950

65

0.77 (0.73-0.81)

0.78 (0.74-0.82)

60–64

291

54

0.64 (0.58-0.71)

0.66 (0.60-0.74)

Level of education

p < 0.001

p = 0.88

Less than secondary

1113

68

-

-

Secondary/college

1927

73

1.08 (1.04-1.14)

1.01 (0.97-1.05)

Postsecondary

1012

79

1.15 (1.09-1.21)

0.99 (0.95-1.04)

Occupation

p < 0.001

p = 0.09

Professional

1393

77

-

-

Associate professional

1566

76

1.00 (0.96-1.04)

0.99 (0.95-1.03)

Tradesperson

175

70

0.92 (0.84-1.02)

0.97 (0.89-1.06)

Unskilled

844

65

0.87 (0.83-0.92)

0.96 (0.91-1.01)

Cohabitation status

c

p < 0.001

p = 0.006

Live together

2845

78

-

-

Live separately

452

68

0.90 (0.84-0.96)

0.96 (0.90-1.03)

No regular partner

756

60

0.81 (0.76-0.86)

0.90 (0.84-0.98)

Residential location

p = 0.03

p = 0.13

Metropolitan

2023

75

-

-

Regional/remote

1983

72

0.96 (0.93-1.00)

0.98 (0.95-1.01)

Language spoken at home

p = 0.34

p = 0.05

English

3904

73

-

-

Other

148

69

0.93 (0.84-1.04)

0.91 (0.81-1.02)

Country of origin

p = 0.32

p = 0.15

Australia

3188

74

-

-

Overseas

865

72

0.97 (0.93-1.01)

0.96 (0.92-1.00)

Tobacco use

c

p < 0.001

p < 0.001

None

3101

75

-

-

Less often than weekly

61

79

1.05 (0.92-1.19)

1.00 (0.90-1.11)

Weekly to daily

891

68

0.92 (0.87-0.96)

0.90 (0.86-0.95)

Alcohol use

c

p < 0.001

p = 0.006

None

986

69

-

-

Less often than weekly

1396

73

1.05 (1.00-1.10)

1.05 (1.00-1.10)

Weekly to daily

1669

76

1.10 (1.05-1.15)

1.08 (1.03-1.13)

Body mass index

p = 0.008

p = 0.26

Underweight

170

68

0.90 (0.81-1.00)

1.01 (0.92-1.11)

Normal

1941

75

-

-

Overweight

1089

75

0.98 (0.94-1.02)

1.01 (0.97-1.05)

Obese

740

69

0.90 (0.86-0.95)

0.95 (0.91-1.00)

Sexual identity

p = 0.19

p = 0.31

Heterosexual

3961

73

-

-

Homosexual

36

65

0.92 (0.71-1.19)

0.97 (0.72-1.31)

Bisexual

55

62

0.84 (0.68-1.03)

0.90 (0.72-1.12)

Age at first vaginal sex

p = 0.61

p = 0.72

< 16 years

581

72

-

-

‡ 16 years

3471

73

1.00 (0.95-1.05)

1.00 (0.96-1.05)

Lifetime number of opposite sex partners

p < 0.001

p = 0.15

1

987

68

-

-

2–5

1610

72

1.06 (1.01-1.11)

1.03 (0.98-1.08)

6–10

773

78

1.13 (1.07-1.20)

1.04 (0.99-1.10)

11 +

533

79

1.14 (1.08-1.21)

1.04 (0.98-1.11)

Number of opposite sex partners in last year

c

p < 0.001

p = 0.04

0

623

60

0.78 (0.73-0.84)

0.91 (0.84-0.99)

1

3139

76

-

-

2 +

276

70

0.94 (0.87-1.02)

1.00 (0.93-1.08)

STI history

c

p < 0.001

p = 0.004

No

3342

72

-

-

Yes

710

80

1.09 (1.05-1.14)

1.06 (1.02-1.09)

(continued)

CERVICAL SCREENING AND SEXUAL BEHAVIOR

1093

education, occupation, cohabitation status, residential loca-
tion, frequency of tobacco and alcohol use, and BMI were all
individually associated with having had a Pap test in the last
2 years.

The final multivariate model contained age, cohabitation

status, tobacco use, alcohol use, number of opposite sex
partners in the last year, and STI history. Although number of
opposite sex partners was initially removed from the model
because of nonsignificance, it became significant when added
back into the final model and was, therefore, retained. In
multivariate analysis, younger and older women were less
likely to have had a Pap test than women in their 30s. Those
without a regular partner were also less likely to have had a
recent Pap test, as were women who smoked regularly.
Conversely, women who drank alcohol regularly were more
likely to have had a Pap test than women who did not drink.

Sexual behavior and Pap testing

In bivariate analysis, sexual identity, age at first sex, and

current reliance on condoms were not associated with having
a Pap test in the past 2 years, whereas lifetime number of sex
partners, number of sex partners in the past 12 months, and
STI history were associated with Pap testing (Table 1). After
taking into account significant sociodemographic and sexual
behavior variables, women reporting no sexual partners in the
previous year were less likely to have had a recent Pap test,
and those reporting at least one diagnosed STI were more
likely to have had a Pap test.

Finally, we expected there would be a strong relationship

between number of lifetime sexual partners and number of
sexual partners in the last year. We, therefore, calculated ad-
justed RRs for lifetime number of partners with ( p = 0.15) and
without adjusting for number of partners in the last year
( p = 0.11). Overall, this made little difference to the signifi-
cance of the factors, the adjusted RRs, and CIs (data not
shown). For consistency with other excluded variables, life-
time number of partners was adjusted for all variables sig-
nificant in the final model, including number of sexual
partners in the last year.

Discussion

Age, cohabitation status, tobacco and alcohol use, number

of opposite sex partners in the last year, and a history of STIs
were all associated with whether a women had a Pap test in
the previous 2 years. Compared with women aged 30–39
years, all other age groups were less likely to have had a Pap
test. Lower screening rates among younger women are not

unique to Australia; in England in 2005, < 50% of women
aged 20–24 who were eligible for screening had had a Pap test
in the last 5 years.

25

Furthermore, research has demonstrated

a fall in screening among younger women in developed
countries in recent years.

26,27

Women > age 50 also received

less frequent tests or had stopped screening early. This was
found despite current guidelines in Australia recommending
women should not cease screening until the age of 70 and only
if they have had two normal tests within the last 5 years.

19

Women with no regular heterosexual partner were less

likely to have been screened in the last 2 years than those who
lived with their partner. Interestingly, women who drank
regularly were more likely to have had a Pap test, whereas
those who smoked regularly were less likely to have had a
Pap test in the last 2 years. Lower levels of Pap testing among
smokers is of some concern, given that smoking increases the
risk of progression of cervical abnormalities by causing ad-
ditional damage to cells already damaged by HPV.

15

Al-

though there has been concern expressed about access to Pap
testing services in rural and regional areas of Australia,

12

we

did not find any differences in likelihood of women having
had a recent test based on their residential location after ad-
justing for confounding factors, nor did we find differences
related to socioeconomic status (education and occupation)
or sexual identity. This likely reflects universal access to
healthcare in Australia.

20

Number of recent sexual partners was associated with Pap

testing over and above the influence of sociodemographic
factors. Women who had not been sexually active in the last
year with a male partner reported lower levels of Pap testing
than women with only one partner, suggesting women who
were not currently sexually active may not be being tested
regularly. Furthermore, there was not a strong association be-
tween number of sexual partners in the last year and lifetime
number of sexual partners. More research is needed to clarify
the relationship between Pap testing and number of sexual
partners, given that risk of acquiring HPV and cervical ab-
normalities increases through having more sexual partners.

15

Consistent with previous research,

3

women with a history

of STIs were more likely to have had a Pap test in the previous
2 years. It was important to investigate STI history, as it has
been suggested that STIs, such as Chlamydia infection, lead to
cervical inflammation, which could potentially facilitate a
concurrent HPV infection to become persistent, increasing the
chance of cervical cancer.

15

It is possible, however, that being

diagnosed with an STI was a result of coming for a Pap test
rather than being a characteristic of women more likely to
present for Pap testing.

Table

1. (Continued)

Total n

Yes %

Unadjusted RR (95% CI)

a

Adjusted RR (95% CI)

b

Condom reliance for contraception

p = 0.11

d

p = 0.63

No

3533

73

-

-

Yes

520

77

1.08 (1.04-1.14)

0.99 (0.95-1.04)

a

Unadjusted relative risk (RR) and 95% confidence intervals (CI) for having a Pap test in the previous 2 years vs. not having a Pap test.

b

Adjusted RR and 95% CI for having a Pap test in the previous 2 years vs. not having a Pap test. Adjusted for age group, cohabitation

status, frequency of tobacco and alcohol use, number of opposite sex partners in the last year, and history of sexually transmitted infections.

c

Variable significant in final model.

d

Discrepancies between p values and CIs arise because p values are from chi-square tests and RR and their 95% CIs are from log-binomial

regression.

STI, sexually transmitted infection.

1094

SMITH ET AL.

Finally, age at first sex was investigated, as it has been

linked to increased risk of acquiring HPV, either through being
an indicator for future high-risk sexual behavior or because of
greater vulnerability during adolescence.

15,28

Our findings are

consistent with past studies that have found no association
between age at first sex and Pap testing behavior.

2,17

The present study has a number of strengths and weak-

nesses. Strengths of the study were its large sample size and
wide age range. Our sample included women from nearly all
age groups that are recommended to receive Pap testing in
Australia. Limitations include the reliance on self-report and
possible social desirability bias. Recent systematic reviews
and meta-analyses of studies investigating the accuracy of
self-reports of Pap testing compared to medical records have
found women overreport their participation in screening over
a given time frame.

29,30

Furthermore, our study says nothing

about intervals between Pap tests, only time since last Pap
test, nor does the study comment on Pap testing and same sex
partners. Finally, although the response rate may be relatively
low (56%), this should not influence findings about Pap test-
ing behavior. Similar sampling procedures have been shown
to produce representative samples in previous studies.

31

It is

possibly, however, that compliant individuals are more likely
to both complete surveys and receive healthcare screening,
such as Pap testing.

This study demonstrates that certain groups of Australian

women are vulnerable to not receiving Pap tests within the
recommended time frame, every 2 years once sexually active.
Furthermore, it demonstrates that sexual behaviors have an
impact on whether a Pap test had been conducted in the past 2
years beyond previously reported sociodemographic factors.
Screening programs should consider the need to focus re-
cruitment strategies for these women, particularly younger
women, older women, and regular smokers.

Acknowledgments

The study was funded by the National Health and Medical

Research Council through grants 234409 and 487304. We
thank Jason Ferris for assistance with data management and
the Hunter Valley Research Foundation for data collection.

Disclosure Statement

No completing financial interests exist.

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Address correspondence to:

Anthony M.A. Smith, Ph.D.

Australian Research Centre in Sex, Health & Society

La Trobe University

215 Franklin Street

Melbourne, Victoria 3000

Australia

E-mail: [e-mail]

1096

SMITH ET AL.

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