Quality differences between rural and urban primary care: the case of a cervical cancer screening programme

To measure the difference between rural and urban primary care quality in terms of an early cervical cancer detection programme.

Seven hundred and fifty smear reports from rural primary care units and 750 from urban primary care units were selected at random from three institutions: the Ministry of Health, the largest Mexican social security institution, and one University Hospital, during August 1995-March 1996. Excluded were reports from women who were pregnant, menopausal or those who had undergone hysterectomy, as well as those tested positive for dysplasia and cancer.

Quality was measured through indicators and standards set by consensus of recognized field experts, based mainly on recommended national and international parameters.

There was no difference between the overall quality of the urban and rural units. Both registered fairly satisfactory levels (achievement: 76.2%; 95% CI: 72.7-77.0%, versus 75.2; 95% CI: 69.8-78.9%, respectively). The quality of the smear sampling was highly unsatisfactory in rural units and unsatisfactory in urban units (achievement: 64.2%; 95% CI: 58.2-70.0%, versus 47.3%, 95% CI: 42-52.7%; P < 0.00001). Quality of coverage was unsatisfactory for both regions. Quality of smear processing and timeliness were highly satisfactory for both rural and urban units.

Efforts should be directed toward smear quality improvement, especially in rural units. Health care workers who take smears need training programmes and better instruments. They should receive feedback on smear adequacy from the laboratory. Health education is necessary to improve utilization and programme coverage quality.