Scoping Review of Barriers and Facilitators of Cervical Cancer Screening in Appalachia

BACKGROUND: Cervical cancer incidence and mortality in Appalachia exceed national averages, reflecting long-standing inequities in preventive care. Although cervical cancer screening (CCS) effectively reduces morbidity and mortality, participation among Appalachian women remains low. Understanding the multilevel factors that influence screening behavior is critical to inform culturally responsive and sustainable interventions. OBJECTIVES: To synthesize existing evidence on barriers to and facilitators of CCS among women residing in Appalachia using Levesque's Access to Care Framework. METHODS: A scoping review was conducted in accordance with the JBI Manual for Evidence Synthesis and reported following PRISMA-ScR guidelines. PubMed, CINAHL, and Scopus were searched for studies published between January 2002 and August 2025. Eligible studies reported original empirical data on CCS among women aged 21-64 living in Appalachian counties. Editorials, reviews, gray literature, and studies lacking disaggregated Appalachian data were excluded. Extracted data were categorized into Levesque's five patient-level domains: the abilities to perceive, seek, reach, pay, and engage in care. RESULTS: Of 3,457 records identified, 27 met inclusion criteria. Studies employed qualitative, quantitative, and mixed methods designs. Barriers included cost, lack of insurance, transportation challenges, medical mistrust, fatalism, low health literacy, and negative prior health care experiences. Facilitators included trusted and consistent patient-provider relationships, clear provider communication, social support, female clinician availability, and access to free or subsidized screening through Title X and the National Breast and Cervical Cancer Control Program services. DISCUSSION: Structural, interpersonal, and psychosocial factors intersect to shape screening behaviors in Appalachia. Findings highlight the importance of trust-building, trauma-informed, and culturally responsive communication, and system-level supports that address cost and access barriers. Expanding Medicaid, strengthening rural provider capacity, and increasing participation in Title X and national cervical cancer programs may reduce disparities and improve screening uptake. Future research should incorporate standardized measures of trust, health literacy, and psychosocial readiness to strengthen intervention design and cross-study comparability.