Determinants of cervical screening in Ghana: a systematic review

Abstract

Background

Cervical cancer remains a leading cause of morbidity and mortality among women in Ghana, yet screening coverage is extremely low and organised national programmes are limited. Although several studies have examined determinants of screening, no comprehensive synthesis has summarised the evidence to guide effective policy and intervention design.

Objective

To synthesise existing evidence on determinants of cervical screening in Ghana and identify opportunities to strengthen national screening strategies.

Design

This is a systematic review conducted following Aromataris and Pearson’s methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches across PubMed Central, CINAHL, Web of Science, Scopus and grey literature (January 2000–July 2025) identified studies reporting barriers and facilitators of cervical screening in Ghana. Risk of bias was assessed using standard appraisal tools.

Setting

This study was conducted in the context of Ghana.

Results

Of 7833 records screened, 32 studies met inclusion criteria. Barriers to cervical screening spanned individual, interpersonal, health system, socio-cultural and structural factors, including poor knowledge, fear, limited access, financial constraints and social norms. Facilitators included knowledge and awareness, provider recommendation, social support, positive health perceptions, healthcare access and cost-related enablers. Overall, 23 studies were rated low risk of bias, while nine were rated moderate risk of bias.

Conclusion

Cervical screening behaviour in Ghana is influenced by structural, cultural, psychological and informational factors. The reviewed evidence suggests that these determinants do not operate in isolation but interact in ways that may vary across contexts and populations.

OSF registration number

https://doi.org/10.17605/OSF.IO/M4XKT.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Followed Aromataris and Pearson’s systematic review methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines.

• Applied standardised Joanna Briggs Institute critical appraisal tools appropriate to each study design.

• Screening and data extraction were conducted by two independent groups, with the processes and outputs reviewed by two independent reviewers.

• Heterogeneity in study designs and quality may have affected comparability of findings.

• Focus on Ghana provides strong contextual relevance but may limit generalisability to other settings.

Introduction

Cervical cancer remains one of the leading causes of cancer-related deaths among women globally, despite being largely preventable through effective screening and early treatment.¹ According to the World Health Organization (WHO), about 660 000 new cases and 350 000 deaths from cervical cancer were recorded in 2022 alone,² with most cases occurring in low- and middle-income countries (LMICs). Persistent infection with high-risk strains of the human papillomavirus (HPV) is the primary cause of cervical cancer. While developed countries have significantly reduced incidence and mortality through HPV vaccination, organised screening programmes and treatment of precancer lesions,³ many LMICs continue to face a high disease burden due to limited access to these preventive measures.⁴

Sub-Saharan Africa (SSA), in particular, bears a disproportionate share of the cervical cancer burden, recording the highest incidence and mortality rates worldwide.⁵ Many women in SSA present with advanced-stage disease, often due to delayed diagnosis and lack of routine screening services.⁶ Despite global calls for cervical cancer elimination, most countries in SSA struggle with implementation of widespread, sustainable screening and HPV vaccination programmes.^{7 8}

In Ghana, cervical cancer is the second most common cancer among women,⁹ accounting for over 2700 new cases and approximately 1700 deaths yearly.¹⁰ Despite these alarming statistics, screening uptake remains critically low in Ghana,¹¹ with fewer than 10% of eligible women ever been screened.¹² Although screening methods like visual inspection with acetic acid (VIA), Pap smears and HPV testing are available in some facilities, uptake is low, especially among women living in rural areas.¹³ These screening approaches also differ in their effectiveness. Studies from Guatemala and India show that HPV DNA testing is the most effective screening method, significantly reducing advanced cervical cancer and mortality compared with VIA or cytology.^{14 15} These findings support WHO’s recommendation to adopt HPV DNA testing as the primary screening method.¹⁶ Ghana has begun transitioning toward HPV testing, but VIA and Pap smears remain dominant, reflecting slow implementation. National screening programmes also remain underdeveloped,¹⁷ with screening mainly occurring opportunistically. HPV vaccination, a key pillar of cervical cancer elimination,¹⁸ was successfully piloted in 2013 in Ghana, and a nationwide HPV vaccination rollout commenced in October 2025, targeting girls aged 9–14 years.¹⁹

While studies across SSA and other African countries have identified numerous determinants of cervical screening uptake, evidence suggests that these factors are highly context-specific. For example, a systematic review in SSA identified barriers such as fear of the procedure, limited knowledge, distance to facilities and negative experiences with healthcare providers.²⁰ A related review in the region also found that higher education, awareness and provider recommendation were key predictors of screening participation.²¹ Broader continental reviews report similar patterns. A review across Africa identified cultural beliefs, low awareness, human resource shortages and lack of equipment,²² while Akoto and Allsop²³ further emphasised the emotional and relational dimensions of screening behaviour in LMICs, such as fear, stigma and quality of provider-patient interactions. However, the relative influence of these factors varied by setting.

Country-level reviews support this variability. In Uganda, a systematic review by Black et al²⁴ showed that provider recommendation played a key role in encouraging screening, while rural residence, fear and embarrassment were major barriers. In Nigeria, another review identified lack of knowledge, financial constraints and misconceptions as dominant factors.²⁵ These findings show that while some barriers recur across the continent, their impact and interactions differ depending on the local context. Factors such as healthcare infrastructure, sociocultural norms and education systems in individual countries may be contributing factors to these differences.

Given these differences, a Ghana-focused systematic review is urgently needed to capture the unique combination of factors that influence screening behaviours in this setting. Although various primary studies have explored cervical screening in Ghana, no comprehensive synthesis has examined the full range of determinants. Without this, it is difficult to identify knowledge gaps, develop targeted interventions or inform evidence-based policy. A country-specific review is also essential to support Ghana’s progress towards WHO’s cervical cancer elimination goals and the Sustainable Development Goal 3.4 on reducing premature mortality from non-communicable diseases. The WHO strategy aims to reduce incidence below four cases per 100 000 women, with 90% of girls fully vaccinated against HPV by age 15, 70% of women screened with an HPV test by ages 35 and 45, and 90% of women with pre-cancer or cancer treated by 2030.¹⁸ Ghana remains far from these goals, with low HPV vaccination coverage and screening uptake.

This systematic review, therefore, aims to examine and synthesise existing evidence on the factors influencing cervical screening uptake among women in Ghana. By identifying and analysing key barriers and facilitators, the review seeks to inform evidence-based policy, guide targeted interventions and support improved screening practices tailored to the Ghanaian context.

Method

This systematic review was conducted following the guidelines by Aromataris and Pearson²⁶ as advocated by the Joanna Briggs Institute (JBI). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to guide the reporting of the review process and results.²⁷ The protocol for this systematic review was registered on the Open Science Framework with the ID https://doi.org/10.17605/OSF.IO/M4XKT.

Research question

The research question guiding this review was developed using the Population, Concept, Context (PCC) framework, which supports the inclusion of diverse study designs. In this review, the population refers to women eligible for cervical screening in Ghana. The concept pertains to the determinants of cervical screening (actual uptake or intention to screen), including barriers and facilitators. The context encompasses the Ghanaian health system and sociocultural environment, within which screening behaviours occur. The PCC framework provided a structured approach to defining the inclusion criteria and ensuring clarity in the scope of the review.

The main review question was:

1. What are the determinants of cervical screening in Ghana?

This question aimed to explore both the facilitators and barriers influencing cervical screening across different populations and settings in Ghana.

Inclusion and exclusion criteria

This review included studies that examined the determinants of cervical screening in Ghana. Both peer-reviewed journal articles and relevant grey literature (Masters and PhD theses) published from January 2000 onwards were considered for inclusion. Studies such as preprints, case reports, reviews, letters to the editor, conference papers, seminar papers and editorials were excluded.

Search strategy

To comprehensively address the review question, a systematic search of literature was undertaken using four primary databases including PubMed Central, CINAHL, Web of Science and Scopus. A chartered librarian from the Sam Jonah Library was consulted to construct a search strategy using Medical Subject Headings and pertinent keywords. This strategy aimed to maximise the breadth and depth of the search. The search strategies for all databases are presented in table 1 below. The initial search was done in PubMed Central and the search strategy was later modified to suit the three other databases. The literature search covered records published from January 2000 to July 2025. To capture additional relevant records, supplementary searches were conducted in platforms such as Google Scholar, Google, ProQuest and institutional repositories. Reference lists of selected full-text articles were also reviewed manually to identify any further eligible studies. The last search was done on 4 July 2025 (See online supplemental appendix 5).

Table 1. Search strategy.

Database	Search strategy
PubMed Central	Determinants[All Fields] OR factors[All Fields] AND ((“uterine cervical neoplasms”[MeSH Terms] OR (“uterine”[All Fields] AND “cervical”[All Fields] AND “neoplasms”[All Fields]) OR “uterine cervical neoplasms”[All Fields] OR (“cervical”[All Fields] AND “cancer”[All Fields]) OR “cervical cancer”[All Fields]) AND (“diagnosis”[Subheading] OR “diagnosis”[All Fields] OR “screening”[All Fields] OR “mass screening”[MeSH Terms] OR (“mass”[All Fields] AND “screening”[All Fields]) OR “mass screening”[All Fields] OR “early detection of cancer”[MeSH Terms] OR (“early”[All Fields] AND “detection”[All Fields] AND “cancer”[All Fields]) OR “early detection of cancer”[All Fields])) AND (“ghana”[MeSH Terms] OR “ghana”[All Fields]) AND (“2000/01/01”[PubDate] : “2025/07/04”[PubDate])
CINAHL	(factors OR determinants) AND ((MH “Uterine Cervical Neoplasms+”) OR (cervical AND cancer)) AND ((MH “Mass Screening+”) OR (screening) OR (early detection AND cancer)) AND (ghana) AND (PY 20000101–20250704)
Web of Science	TS=(factors OR determinants) AND TS=(“cervical cancer” OR “uterine cervical neoplasms”) AND TS=(screening OR diagnosis OR “early detection”) AND TS=(Ghana) AND PY=(2000–2025)
Scopus	TITLE-ABS-KEY(factors OR determinants) AND TITLE-ABS-KEY(“cervical cancer” OR “uterine cervical neoplasms”) AND TITLE-ABS-KEY(screening OR diagnosis OR “early detection”) AND TITLE-ABS-KEY(ghana) AND PUBYEAR>1999 AND PUBYEAR<=2025

Study selection

The selection of studies was conducted in three distinct phases. Initially, duplicate records were identified and removed using Mendeley reference management software. All retrieved records from the various databases were imported into Mendeley for this purpose. In the second phase, the remaining titles and abstracts were screened against predefined inclusion criteria. This screening was carried out by a team of 13 trained graduate students under the supervision of MA. In the final phase, the full texts of articles deemed potentially relevant were independently reviewed for eligibility by two separate groups of researchers (GSL, AOT, AG-S, PN) and (BN, MAA, VBH, GA). Any discrepancies or disagreements that arose during this process were resolved through discussions led by two independent reviewers (NIEE and MA). The entire screening and selection process was documented and presented using the PRISMA flow diagram to ensure transparency and traceability of the study inclusion pathway.

Quality appraisal

The methodological quality of all included studies was assessed using standardised critical appraisal tools, tailored to the specific design of each study. For cross-sectional studies, the JBI checklist for cross-sectional studies was applied. For qualitative studies, the JBI checklist for qualitative research was used and for mixed-methods studies, the Mixed Methods Appraisal Tool (MMAT) was employed.

Each study was scored according to the criteria outlined in its respective appraisal tool. For cross-sectional studies, scores of 1–4 indicated high risk of bias, scores of 5–6 indicated moderate risk of bias and scores of 7–8 indicated low risk of bias. Qualitative studies were rated using a similar scale, with scores of 1–5, 6–7 and 8–10, indicating high, moderate and low risk of bias respectively. For mixed-methods studies assessed using the MMAT, scores of 1–2 indicated high risk of bias, scores of 3–4 indicated moderate risk of bias and a score of 5 indicated low risk of bias.

The quality appraisal process was conducted independently by GSL, MAA, AG-S, GA and VBH, with disagreements resolved under the supervision of MA. Notably, no studies were excluded based solely on quality appraisal results. Instead, the quality ratings were used to inform and enhance the interpretation of the review findings. This ensured that methodological rigour was considered in the synthesis process.

Data extraction

A structured data extraction form was developed using Microsoft Word to systematically capture relevant information from the included studies. Key data fields included author(s) and year of publication, region(s) where the study was conducted, purpose of the study, study design, sample size, study population and reported determinants of cervical screening which were divided into barriers and facilitators. In line with the aims of this review, qualitative data were extracted at the level of reported findings rather than raw participant quotations. Direct quotations were not extracted because many included qualitative studies did not consistently report illustrative quotes, and the purpose of the review was to synthesise author-interpreted findings across studies rather than to reanalyse primary qualitative data. This approach aligns with a convergent integrated synthesis that integrates qualitative themes and qualitised quantitative findings at the level of reported results.

To ensure the accuracy and consistency of the extraction form, a pilot test was conducted using a sample of five randomly selected studies. This pilot phase helped identify potential gaps in the data extraction form and promoted a shared understanding of the variables among the research team. Following refinement of the form, data extraction was carried out independently by two groups of authors (GSL, AOT, AG-S, PN) and (BN, MAA, VBH, GA). The extracted data was independently reviewed by MA and NIEE. All discrepancies or inconsistencies identified during this process were addressed through discussion and consensus led by MA and NIEE.

Data analysis and synthesis

The search procedure used to identify articles relevant to this study and the procedure leading to the inclusion of some articles was summarised in a PRISMA flow chart according to the PRISMA outline. Descriptive data on the characteristics of included studies was analysed using Microsoft Excel and presented in the form of chart and map as appropriate. Regions where the included studies were conducted were presented in a map whereas the study designs used in the reviewed studies were presented in a bar chart. To address the review questions, thematic analysis was employed to synthesise qualitative and quantitative findings. This analysis was conducted in stages and guided by the Social Ecological Model (SEM).²⁸ Initially, similar findings from the included studies were grouped into preliminary categories called sub-themes. These were then mapped onto the different levels of the model and refined into broader themes that capture key patterns in the evidence base.

Following thematic analysis, a convergent integrated synthesis was adopted to enable integration of evidence from different study designs. Quantitative findings were qualitised, meaning that statistically significant quantitative results were translated into narrative statements to allow direct integration with qualitative themes. For cross-sectional studies, determinants of cervical screening were extracted from variables reported as statistically significant in the original analyses, typically using a p-value threshold of <0.05. Where available, associations derived from multivariable regression models were recorded, while studies reporting only bivariate or crude associations were also included. These findings were not analysed separately by statistical model but were integrated thematically to capture the breadth of empirically reported determinants across the literature.

Consistent with JBI guidance for convergent synthesis, quantitative evidence was incorporated in narrative and categorical form to complement qualitative findings, rather than being synthesised in parallel streams. Determinants were entered into the data extraction framework based on the reported direction of association with screening uptake, categorised as barriers or facilitators, and integrated within the corresponding thematic domains (see online supplemental appendix 2). This approach reflects the aim of the review, which was to develop an integrated understanding of contextual influences on cervical screening behaviour, rather than to compare effect sizes or infer statistical causality.

Although methodological quality was assessed and informed interpretation, no explicit priority or hierarchical weighting was assigned to studies based on appraisal scores. This decision was made because most included studies were rated as moderate or high quality, and because the review sought to synthesise patterns of determinants across heterogeneous designs rather than to privilege individual studies. Instead, consistency of findings across multiple studies and contexts was emphasised during interpretation, with recurrent determinants considered more robust, while less frequently reported findings were used to provide contextual depth. Given the use of a convergent integrated approach, findings were not reported separately by study design, as integration at the thematic level was central to achieving the objectives of the review.

Thematic categories were reviewed iteratively by the author team to ensure conceptual coherence, internal consistency and alignment with the review objective. The final synthesis was presented in a narrative format, structured around the main review question. Emphasis was placed on identifying recurring patterns, areas of divergence and gaps in the evidence base. To enhance transparency and usability, a summary table was included to map each synthesised theme to its contributing studies.

Results

Screening and selection of studies

An initial total of 7833 records were retrieved from four primary databases including PubMed Central, CINAHL, Web of Science and Scopus. An additional 19 records were identified through supplementary sources, including Google Scholar, ProQuest and institutional repositories. After importing all records into Mendeley reference management software, 655 duplicates were removed, resulting in 7197 unique records for screening. During the title and abstract screening phase, 7153 records were excluded based on the predefined inclusion criteria, leaving 44 articles for full-text review. Reference list screening of the selected articles yielded two additional studies, increasing the number of full-text articles assessed for eligibility to 46. Following the full-text review, 14 articles were excluded. Of these, seven were excluded because they were review papers and seven because they were conducted outside of Ghana. Ultimately, 32 studies met the inclusion criteria and were included in the final analysis. See figure 1 for details.

Figure 1. PRISMA flow chart illustrating search process and results. An initial total of 7833 records were retrieved from four primary databases including PubMed Central, CINAHL, Web of Science and Scopus. An additional 19 records were identified through supplementary sources, including Google Scholar, ProQuest and institutional repositories. After importing all records into Mendeley reference management software, 655 duplicates were removed, resulting in 7197 unique records for screening. During the title and abstract screening phase, 7153 records were excluded based on the predefined inclusion criteria, leaving 44 articles for full-text review. Reference list screening of the selected articles yielded two additional studies, increasing the number of full-text articles assessed for eligibility to 46. Following the full-text review, 14 articles were excluded. Seven because they were review papers and seven because they were conducted outside of Ghana. Ultimately, 32 studies met the inclusion criteria and were included in the final analysis. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Characteristics of included studies

Most (n=15, 46.8%) of the reviewed studies were conducted in the Ashanti region (see figure 2). Also, the majority (n=24, 75%) of the studies in this systematic review used the cross-sectional study design, followed by the qualitative study design (6). Only two studies used mixed-method study design (see figure 3).

Figure 2. Map showing where studies were conducted. Most (n=15, 46.8%) of the reviewed studies were conducted in the Ashanti region.

Figure 3. Study designs of reviewed studies. Majority (24) of the studies in this systematic review used the cross-sectional study design, followed by the qualitative study design (6). Only two studies used mixed-method study design.

Quality appraisal of included studies

Out of the 32 studies assessed, 231329,50 were rated as low risk of bias and nine as moderate risk. The low-risk group included 16 cross-sectional studies,1329,33 35 37 38 40 two mixed-methods studies^{43 49} and five qualitative studies.^{34 36 39 46 50} The moderate-risk group comprised eight cross-sectional51,58 and one qualitative study.⁵⁹

Among the cross-sectional studies, the most common methodological weakness was inadequate control of confounding variables. In these cases, studies failed to apply statistical controls, such as multivariable adjustment, to account for key confounders such as age, education, marital status and religion. This lack of control may have introduced bias into the observed associations between determinants and screening uptake or intention.

Among the qualitative studies, the main limitation concerned reflexivity. Reflexivity, as emphasised in the JBI Critical Appraisal Checklist for Qualitative Research, requires researchers to examine how their background and interaction with participants shape interpretation. Five studies^{34 36 39 46 59} did not clearly articulate the researcher’s positionality or reflect on how their perspectives might have influenced the data. Four^{34 39 46 59} of the six qualitative studies also omitted discussion of the reciprocal relationship between researcher and participant. See online supplemental appendix 1 for details.

Reporting approach

In line with the convergent integrated synthesis approach, results from qualitative, quantitative and mixed-methods studies are presented together within shared thematic categories. This structure allows areas of convergence, complementarity and divergence across methodological strands to be identified within each theme, rather than reporting findings separately by study design. The presentation therefore reflects how different forms of evidence collectively inform understanding of the determinants of cervical screening in Ghana.

Among the 32 included studies, most examined determinants of actual cervical screening uptake, typically measured as self-reported screening behaviour. However, a small subset focused on intention, readiness or motivational orientation rather than completed uptake.^{29 40 45 50 59} These findings were retained as proximal determinants and interpreted as indicators of psychological readiness or willingness to screen, rather than direct measures of screening behaviour.

Barriers to cervical screening

The thematic analysis identified multiple barriers to cervical screening across the different levels of the SEM, including individual, interpersonal, organisational (health system), community (socio-cultural), and policy and structural factors (see online supplemental appendix 3).

At the individual level, barriers related to knowledge and awareness were frequently cited. Poor knowledge of cervical cancer or screening was one of the most frequently reported barriers, appearing in 10 studies,2936 46 48,50 53 55 57 58 while low awareness of screening facilities was also documented in five studies.^{36 39 52 55 58} Under misconceptions and misinformation, misconceptions about causes of cervical cancer were reported.⁴⁹ Additionally, beliefs that screening is unnecessary due to perceived incurability of cancer,⁵² that Pap test leads to loss of virginity,⁵² that only women who have had babies need screening⁵² and that screening is only for diagnosing cancer⁵² were reported.

Barriers related to risk perception and perceived health status were also prominent. Low perceived susceptibility to cervical cancer was reported in six studies.^{32 39 46 52 53 55} Some studies reported participants having the perception that screening is only necessary for sexually promiscuous women,⁵⁴ that screening is unnecessary if one is not sexually active⁵⁵ and that screening is only for older or pregnant women.⁴⁶ Perceived good health due to absence of symptoms was also reported as a barrier in two studies.^{48 50}

Emotional and cognitive barriers were frequently reported across the included studies. Fear of pain during screening featured in six studies.^{36 45 48 52 54 55} Other commonly reported barriers included fear of vaginal examination,⁵³ fear of screening outcomes, identified in eight studies2936 43,45 50 52 55 and fear of misdiagnosis, identified in two studies.^{36 45} Negative prior experiences with vaginal examinations were also noted.⁵⁵ Embarrassment and shyness were reported across eight studies,^{36 43 45 46 50 52 55 57} alongside perception of screening as unpleasant,^{32 53} lack of interest in screening⁵³ and fatalistic beliefs regarding cancer.^{36 50 52}

Time constraints were also identified, with being too busy reported in four studies.^{45 46 48 57} Under attitudinal and behavioural factors, low perceived benefits of screening was reported in two studies.^{29 43} Conditional willingness to pay based on perceived severity of illness was also identified,⁵⁹ along with preference for alternative entry points such as pharmacies or public facilities based on perceived convenience.³⁵

Sociodemographic and socioeconomic characteristics were also documented. No formal education,³⁰ being unemployed,⁴² rural residence^{31 35} and belonging to minority ethnic group³⁵ were reported as barriers. Age 50 years and above was reported in two studies,^{35 38} while being widowed,^{35 38} being divorced or separated,⁴² never being married³⁸ and being married or cohabiting³⁸ were also noted. At the interpersonal level, lack of spousal support was cited as a major barrier in eight studies,^{13 34 36 43 49 52 55 57} while discouragement from friends was also reported.³⁴

Within organisational (health system) factors, several barriers were reported. Under provider-patient interaction, negative attitude of health workers was reported in three studies,^{34 36 57} alongside poor communication by healthcare providers³² and poor patient involvement in care.³⁸ In terms of accessibility and service availability, seven studies^{36 39 44 45 54 55 57} reported that screening services were unavailable or difficult to access. Difficulty scheduling test appointments,⁵⁵ long waiting time at health facilities^{32 43} and transport challenges such as walking to facility⁴³ were also reported. Health facility resource constraints featured inadequate staffing of clinics,⁴³ limited physical space for screening services⁴³ and lack of beds or logistics.⁴³ Financial barriers were also documented, with unaffordability of screening reported in 10 studies.^{32 36 39 43 45 46 52 54 55 57} In addition, lack of trust in healthcare system was identified as a barrier in one study.⁵⁹

At the community (socio-cultural) level, cultural and religious norms played a significant role. Cultural values were reported in two studies,^{45 55} religious beliefs discouraging screening uptake in four studies^{45 53 55 57} and Islamic modesty norms affecting willingness to undergo pelvic examination in three studies.^{13 41 47} Gender norms were also highlighted, with discomfort with male health professionals reported in five studies.^{32 45 49 50 59} Stigma and social judgement were reported through fear of being judged as sexually active,⁵² stigmatisation of women with cervical cancer⁴⁹ and threat to relationship if diagnosed with cervical cancer.⁴⁵ At the policy and structural level, lack of inclusion of cervical screening in National Health Insurance Scheme (NHIS) coverage was reported as a barrier,⁵⁵ along with lack of government subsidy for screening.³⁶

Facilitators of cervical screening

The thematic analysis identified several facilitators of cervical screening across the levels of the SEM, including individual, interpersonal, organisational (health system), community, and policy and structural factors (see online supplemental appendix 4).

At the individual level, knowledge and awareness were reported as important facilitators. Knowledge of cervical cancer and screening was reported in six studies,^{29 41 48 51 58 59} while awareness of available screening services and procedures was identified in three studies.^{44 45 50} Sociodemographic and socioeconomic characteristics also featured heavily across the literature. Higher level of education was reported in seven studies,^{13 31 33 38 42 47 58} while being formally employed⁴⁸ and being self-employed or having informal occupation^{37 44} were also identified. Higher income or wealth status was reported in six studies.^{13 31 33 35 41 47} Having ever schooled,³⁵ having only one child⁴² and age-related patterns associated with higher screening uptake (above 20 years)^{33 48 58} were also noted.

Facilitators related to risk perception and perceived benefits were also evident. Perceived susceptibility to cervical cancer was reported in two studies,^{52 58} while awareness that cervical cancer can affect younger women was identified in two studies.^{52 56} Belief that cervical cancer impacts life significantly⁵² and perceived seriousness of cervical cancer^{40 51} were also reported in one and two studies respectively. Belief that screening will facilitate early interventions³⁹ and perception of treatment effectiveness and curability^{45 52} were also reported.

Motivational and emotional drivers were also noted in the literature. Desire to detect abnormalities⁴⁶ and wanting to be sure if one has cervical cancer³⁹ were reported as facilitators. Positive attitude towards screening was reported,⁴¹ alongside high cues to screening⁴⁰ and fear of cervical cancer.^{39 55} Absence of fear or emotional barriers to screening was also reported in one study.²⁹ Other individual-level factors included early age at first sexual intercourse, reported in two studies.^{13 33} Symptom-driven and health experience cues such as history of obstetric or gynaecological illness⁴⁴ and experience of gynaecological symptoms like abnormal vaginal bleeding³⁰ were also identified.

At the interpersonal level, social networks and social influence were reported as facilitators. Knowing someone who has done the screening was reported in two studies,^{34 52} while family history of cancer⁴⁴ and having a friend who suffered cervical cancer³⁴ were noted in one study each. Under spousal support, encouragement from husbands³⁴ and husband’s willingness to pay for screening^{34 59} were reported in one and two studies respectively.

Within organisational (health system) factors, access to healthcare services was an important facilitator. Recent health facility visit was reported in two studies,^{31 47} while availability of female healthcare providers for screening was also identified in one study.⁴⁵ Under health financing and financial access, reduced screening cost was reported in one study,³⁴ while the perceived benefit of including cervical screening in NHIS to improve uptake was reported in three studies.^{13 34 47} Provider influence also played a role. Recommendation by health professionals was highlighted in three studies,^{45 52 55} while positive provider-patient relationship was identified in one study.³⁴ Dissatisfaction with previous healthcare was surprisingly reported as a facilitating factor in one study.³⁸

At the community level, cultural and contextual factors were identified. Being Christian was identified in one study,³⁵ while ethnic affiliations associated with screening uptake were identified in three studies.^{35 38 47} Geographic location and regional variation in screening uptake was also reported in four studies.^{13 31 33 47} Health communication channels also featured across the literature. Health education delivered by healthcare workers was reported as a facilitator in two studies.^{34 39} Additionally, media-based awareness campaigns were highlighted in seven studies,^{31 33 34 39 50 52 55} while the use of local languages in health education was identified in one study.³⁴ Community-based education interventions were also highlighted across the literature. Education in religious places or social gatherings was reported in two studies,^{50 52} while survivor- or specialist-led education,⁵⁰ educating men on cervical cancer,³⁴ and demonstrating how screening is done³⁴ were noted in one study each. At the policy and structural level, perceived government or programmatic efforts to reduce the cost of cervical screening was reported.³⁴

Discussion

This systematic review examined factors shaping cervical screening in Ghana. Screening behaviour is influenced by interconnected individual, interpersonal, organisational (health system), community, and policy and structural factors. Although barriers were more frequently reported, facilitators were also identified, with their influence varying across contexts and populations. Screening decisions therefore reflect the combined effects of personal experiences, structural conditions and cultural expectations rather than any single determinant. Importantly, this synthesis clarifies a Ghana-specific pattern that is often underemphasised in broader LMIC literature. This pattern is reflected in the persistent gap between awareness and screening uptake. Across studies, relatively high levels of knowledge and reported awareness frequently coexisted with low participation in screening. This suggests that information alone does not translate into behaviour change in this setting. Instead, uptake appears to be more strongly shaped by the interaction between structural access barriers, gendered health system experiences, and sociocultural expectations around reproductive health. Some methodological considerations should be taken into account when interpreting these findings. Most included studies were cross-sectional and relied on self-reported screening behaviour. Consequently, findings should be interpreted as associations rather than causal relationships. In addition, determinants from studies without multivariable adjustment were treated as exploratory and qualitatised to capture thematic patterns. While the included studies were rated as moderate or high quality, variations in analytical rigour were considered when assessing consistency across findings.

Individual factors like emotional and cognitive barriers featured significantly. Fear and embarrassment about screening procedure were the most reported deterrents, which may have been shaped by previous negative experiences or uncertainty about the procedure. These emotional responses are common in many LMICs, but may be more pronounced in Ghana, where sexual and reproductive health is often seen as private or taboo. A recent systematic review across SSA identified fear of the procedure, fear of a positive diagnosis, and stigma as widespread deterrents.²² Comparable patterns have been observed in Indonesia, Sri Lanka and Pakistan.60,62 These findings highlight the importance of supportive communication and patient-centred care to reduce anxiety and improve women’s screening experiences.

Individual attitudes and health-related behaviours such as unwillingness to pay for screening when asymptomatic also featured in this review. This may be because, in some households in low-resource settings, financial decisions are often made based on immediate need. In a multi-country systematic review, high out-of-pocket costs and indirect expenses like transportation were repeatedly linked to lower cervical screening uptake across LMICs.⁶³

Other individual factors like demographic characteristics also appeared to influence screening behaviour. For example, rural residents were generally less likely to screen, echoing trends in other regions.⁶⁴ Across other LMICs, rural women face similar disadvantages due to distance from screening centres, poor transportation, and fewer trained providers.^{63 65} However, associations across demographic groups were not always consistent. Being married, for instance, was linked with both higher and lower screening rates depending on the study. This is likely because marriage intersects with other variables like partner support, age and reproductive history. These findings suggest that demographic characteristics alone are insufficient to explain screening behaviour and must be understood in context, alongside personal history and social expectations.

Within this complexity, some factors identified as facilitators, particularly those related to age and geographic location, may reflect relative differences between population subgroups rather than independent enabling effects. For example, higher screening uptake observed in certain age or geographic groups may partly indicate lower uptake among comparison groups, rather than a direct facilitating influence. This highlights the need for cautious interpretation of such associations, particularly in cross-sectional studies where underlying disparities may shape observed patterns.

Additional individual-level barriers, particularly knowledge deficits and misconceptions, were widely reported across the literature. Beliefs that screening removes virginity, that it is only necessary when symptoms are present, or that it is intended solely for cancer diagnosis were associated with limited uptake. Similar misconceptions have been documented in Nigeria, where low health literacy and misconceptions correlate with poor screening rates.⁶⁶ Systematic reviews from Asia and the Pacific also support these findings.62,64 In Bangladesh and Pakistan, women also associated screening with sexual promiscuity or divine punishment, further discouraging participation.⁶¹ In Ghana, this gap is particularly concerning because it may reflect a deeper issue which is a lack of familiarity with preventive care in general. Few studies assessed how health education is delivered or whether it is culturally tailored, which makes it hard to judge how effectively information is reaching the women who need it most.

Interpersonal factors also played a major role in women’s decisions. Many of the reviewed studies highlighted the importance of spousal approval, peer opinion and fear of being judged. This reflects a model of decision-making that is relational rather than individual, consistent with patterns observed in other LMICs.^{61 62 64 67} In Ghana, the reviewed studies suggest social relationships acted as both barriers^{13 34 36 43 49 52 55 57} and facilitators,^{34 59} with some partners discouraging screening while others actively supported participation. This dual role suggests that interventions engaging partners and communities may be particularly effective but must be context-specific.

Organisational factors emerged as a central barrier to screening uptake, reflecting broader structural challenges. Poor provider-patient relationships, long waiting times and limited resources were commonly cited, echoing findings from other SSA settings where underinvestment in preventive services constrains access.⁶⁸ Similar patterns reported in Nigeria by Mafiana et al,²⁵ as well as studies from South and Southeast Asia, indicate that shortages of trained personnel and inadequate infrastructure limit screening coverage.^{63 64} In some rural parts of Bangladesh and Nepal, limited availability of equipment and under-resourced facilities were also noted as major deterrents.⁶¹

Another important organisational factor that appeared to influence screening behaviour was trust in the health system. Some women avoided screening not because they lacked access, but because they doubted the quality of care. Lack of trust in providers and previous negative experiences have also been highlighted in other LMICs as key deterrents to screening uptake.^{63 64} This suggests that interpersonal quality of care is as important as structural access. In addition, policy issues like the exclusion of cervical screening from the National Health Insurance Scheme appear to create an access gap, especially for lower-income women in Ghana. These findings suggest that screening may depend not only on service availability but also on affordability, perceived quality of care and trust in the health system.

Community (socio-cultural) factors also appeared to shape attitudes toward screening. Discomfort with male health providers was reported as a barrier. While it may initially present as emotional discomfort or embarrassment, the consistency of this finding across multiple studies suggests it likely functions as a substantive barrier to service utilisation rather than a minor affective concern. In settings where cervical screening involves intimate examination, the presence of male providers may discourage attendance, particularly where female provider options are limited or unavailable. This points to broader structural and gender-related constraints within service delivery, rather than individual preference alone. Consequently, provider gender appears to influence service utilisation, not just perceived comfort.

Additionally, socio-cultural influences such as religious modesty and gender norms were reported to shape screening attitudes. These issues are consistent with evidence from other conservative settings.⁶⁹ Reviews from South and Southeast Asia described comparable patterns, highlighting how gender and modesty norms transcend regional boundaries.^{60 64} However, socio-cultural factors were not uniformly restrictive. Christian affiliation was associated with higher screening in one Ghanaian study,³⁵ suggesting that religious institutions may also function as platforms for health promotion. This highlights how cultural beliefs are dynamic and can either hinder or support screening depending on how health messages are framed and delivered. Taken together, the findings suggest that barriers do not operate as direct opposites of facilitators but rather as uneven and interacting influences. In many cases, facilitators such as knowledge or provider support co-existed with persistent structural and sociocultural barriers.

While most studies focused on barriers, facilitators reported in the literature highlight opportunities to improve cervical screening. Individual factors like knowledge and awareness were consistently associated with positive screening behaviour, aligning with evidence that perceived susceptibility, perceived benefits and self-efficacy are associated with both willingness and actual uptake of cervical screening.⁷⁰ These further align with evidence from other reviews, where knowledge and awareness consistently emerged as correlates of screening participation.^{60 61 65} However, the existence of knowledge as a barrier elsewhere in the literature2936 46 48,50 53 55 57 58 suggests uneven distribution of information other than universal awareness.

Women’s attitudes and perceptions of risk were also important factors cited in the included articles. Those who saw cervical cancer as serious but treatable, or who wanted to know their health status, tended to report higher screening participation. Some were motivated by fear of the disease, while others were reassured by their belief in early treatment. These patterns were observed in other least developed countries, where women who perceived themselves at higher risk were significantly more likely to report screening.⁶⁴ This reflects a more proactive way of thinking about health, but again, fear played both roles. In some women, it appeared to encourage screening,^{39 55} while in others, it appeared to discourage it.2936 43,45 50 52 55

Sociodemographic and socioeconomic characteristics were also identified, although their effects appeared to depend on interactions with social support and healthcare access. Employment and income levels were important. Women who were formally employed or belonged to higher income groups were generally more likely to report screening. Similar associations between employment and screening have been found in similar settings, where working women tended to have higher screening rates due to financial independence and access to healthcare.^{61 64} However, a few studies reported higher screening rates among women in informal jobs,^{37 44} which challenges the idea that formal employment always makes access easier. This may reflect differences in time flexibility or access to community-based programmes.

Organisational (health system) factors like provider recommendation and supportive interactions^{45 52 55} were reported to be associated with positive screening behaviour, consistent with findings from other LMIC reviews.^{60 64 65} This further aligns with research evidence showing that provider endorsement is positively associated with screening behaviour.⁶ Interestingly, one study found that dissatisfaction with past care was positively associated with screening,³⁸ possibly because negative experiences raised a sense of vulnerability. This finding challenges the idea that only positive experiences drive health behaviour and suggests that emotional responses like fear or concern can sometimes motivate action.

Overall, these findings suggest that cervical screening behaviour in Ghana reflects the interaction of multiple reinforcing influences rather than isolated determinants. Structural, financial and sociocultural conditions shape whether knowledge and other enabling factors translate into actual screening uptake. This highlights the importance of considering how different levels of influence combine to affect cervical screening in low-resource settings.

Future research may provide additional insight into how these influences shape screening behaviour across different contexts and populations. Longitudinal and mixed-method studies could help clarify how knowledge, fear and social support interact to shape women’s screening decisions. Further studies focusing on underrepresented groups, such as older women, women in informal employment and rural residents, may also help to deepen understanding of how screening experiences and barriers differ across populations.

Limitations of the review

This review has some limitations that should be considered when interpreting the findings. Most of the included studies were cross-sectional, which limits the ability to draw conclusions about cause and effect. This study design also makes it difficult to rule out residual confounding by unmeasured or incompletely adjusted factors such as income or access to care. In addition, many relied on self-reported screening behaviour, which may be subject to recall or social desirability bias. Another limitation is the uneven geographical representation within the included literature. Many of the studies focused on urban or southern parts of Ghana, with fewer coming from northern or remote rural regions. This makes it difficult to fully understand how regional and cultural differences influence screening behaviour across the country. The findings may reflect the realities of better-served areas more than those of underserved populations, which deserve more targeted attention in future research.

Despite these limitations, this review has several strengths. It brings together a wide body of evidence on both barriers and facilitators of cervical screening, providing a balanced and comprehensive picture. The appraisal of methodological rigour of the included studies also adds to the credibility of the synthesis. Furthermore, the use of thematic analysis allowed us to capture both individual-level and system-level factors, highlighting how structural, cultural and personal dynamics interact. These insights could help inform practical and context-specific strategies to improve screening uptake in Ghana.

Conclusion

The included studies suggest that cervical screening behaviour in Ghana is shaped by a range of individual, interpersonal, organisational, socio-cultural and structural factors. Barriers such as cost, fear, limited access and misinformation remain widespread, while facilitators like provider encouragement, social support and accurate knowledge were associated with increased screening uptake. Overall, the findings suggest that screening behaviour is influenced by the coexistence of these factors across different contexts rather than any single determinant.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.