This study addresses a research gap concerning the socio-ecological drivers of cervical cancer screening rates in rural Southern United States by examining the relationships between Medicaid policy, rurality, and cervical cancer screening using a health equity lens.

Retrospective, cross-sectional data from the 2010–2020 Behavioral Risk Factor Surveillance System (BRFSS) were analyzed. The outcome of interest was cervical cancer screening behavior, defined as self-reported receipt of a Pap test within recommended intervals. Key predictors included Medicaid expansion status, rural residence, insurance coverage, race/ethnicity, and income. A survey-weighted logistic regression model was used, adjusting for age, marital status, and education.

The analytic sample included women aged 21–65 across 12 Southern states (n ≈ 85,000 across years). Women in Medicaid expansion states had higher odds of Pap test uptake compared to non-expansion states (adjusted odds ratio [aOR]: 1.42, 95% CI: 1.27–1.58). Rural residence was associated with lower screening odds (aOR: 0.76, 95% CI: 0.68–0.84), though this effect was moderated by Medicaid expansion (interaction p = 0.03). Insurance status (aOR: 1.83, 95% CI: 1.55–2.17) and income level (aOR: 1.34, 95% CI: 1.11–1.60) remained significant predictors. Racial differences were attenuated after adjusting for structural factors.

Cervical cancer screening disparities in the rural South are shaped by policy-driven and place-based social drivers of health. Medicaid expansion, insurance coverage, and geographic access were key factors in shaping preventive care behavior. These findings support targeted structural interventions, such as Medicaid expansion, rural health investment, and culturally tailored outreach, to improve screening equity in underserved populations.