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Background  While organized and opportunistic cervical cancer screening (CCS) programs implemented across the European Union have increased participation rates, barriers to socioeconomically deprived women remain substantial, implying high levels of inequality in CCS uptake.    Aim  This study assesses how the  screening strategy  (as a score based on the availability of organized population-based CCS programs),  accessibility of the healthcare system  (as an index of out-of-pocket expenditure as a proportion of total healthcare costs, public health expenditure as a percentage of total GDP, and general practitioner (GP) density per 10′000 inhabitants) and  social protection  (as a decommodification index), impact education- and income-based inequalities in CCS uptake.    Methods  A two-level design with 25–64-year-old women ( N  = 96′883), eligible for Pap smear screening, nested in 28 European countries, was used to analyze data from the European Health Interview Survey’s second wave, using multilevel logistic regression modelling.    Results  Clear educational and income gradients in CCS uptake were found, which were smaller in countries with organized CCS programs, higher accessibility of the healthcare system and a higher level of decommodification. Furthermore, three-way interaction terms revealed that these gradients were smaller when organized CCS programs were implemented in countries with better accessibility of the healthcare system or a high level of decommodification.    Conclusion  This study indicates that the combination of organized screening and high accessibility of the healthcare system or social protection is essential for having lower levels of inequality in CCS uptake. In such countries, the structural threshold for poorer and lower educated women to engage in CCS is lower. This may be explained by them having a better interaction with their GP, who may convince them of the screening test, lower out-of-pocket payments, and financial support to buffer against a disadvantageous position on the labor market.    Supplementary Information  The online version contains supplementary material available at 10.1186/s12939-021-01548-6.

international journal for equity in health

Cervical cancer screening programs and their context-dependent effect on inequalities in screening uptake: a dynamic interplay between public health policy and welfare state redistribution