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. Author manuscript; available in PMC: 2022 Jun 1.
Published in final edited form as: Cancer Epidemiol. 2021 Mar 20;72:101930. doi: 10.1016/j.canep.2021.101930

Prevalence and Determinants of Cervical Cancer Screening in Five Sub-Saharan African Countries: A Population-Based Study

Djibril M Ba 1, Paddy Ssentongo 1, Jonah Musa 2, Edeanya Agbese 1, Brehima Diakite 3, Cheick Bougadari Traore 3, Steve Wang 4, Mamoudou Maiga 5
PMCID: PMC8864323  NIHMSID: NIHMS1684409  PMID: 33756434

Abstract

Background:

Cervical cancer is the fourth most common cancer among women worldwide, with an estimate of 570,000 new cases and about 311,000 deaths annually. Low-resource countries, including those in sub-Saharan Africa, have the highest-burden with an estimate of 84% of all cervical cancers. This study examines the prevalence and socio-demographic-economic factors associated with cervical cancer screening in sub-Saharan Africa.

Methods:

A weighted population-based cross-sectional study using Demographic and Health Surveys data. We used available data on cervical cancer screening between 2011 and 2018 from the Demographic and Health Surveys for five sub-Saharan African countries (Benin, Ivory Coast, Kenya, Namibia, and Zimbabwe). The study population included women of childbearing age, 21–49 years (n=28,976). We fit a multivariable Poisson regression model to identify independent factors associated with cervical cancer screening.

Results:

The overall weighted prevalence of cervical cancer screening was 19.0% (95% CI: 18.5%−19.5%) ranging from 0.7% in Benin to 45.9% in Namibia. Independent determinants of cervical cancer screening were: older age (40–49 years) adjusted prevalence ratio (aPR)=1.77 (95% CI: 1.64, 1.90) compared with younger age (21–29 years), secondary/higher education (aPR= 1.51, 95 CI: 1.28–1.79) compared with no education, health insurance (aPR= 1.53, 95% CI: 1.44–1.61) compared with no insurance, and highest socioeconomic status (aPR= 1.39, 95% CI: 1.26–1.52) compared with lowest.

Conclusion:

The prevalence of cervical cancer screening is substantially low in sub-Saharan Africa countries and shows a high degree of between-country variation. Interventions aimed at increasing the uptake of cervical cancer screening in sub-Saharan Africa are critically needed.

Keywords: Cervical cancer screening, sub-Saharan Africa, Demographic and Health Surveys, women

1. Introduction

Globally, cancer is considered the second leading cause of death after cardiovascular diseases with an estimate of 9.6 million deaths in 2018 alone.1 The disability-adjusted life-years (DALYs) caused by cancer in 2015 for both men and women was 208.3 million worldwide.2 High-risk human papillomavirus (HPV) is a known causal agent of cervical cancer, a very common virus transmitted through sexual contact.3 Sexually active women are at high risk of getting infected with HPV during their lifetime, with an estimated lifetime highest prevalence reaching nearly 50% among those aged 20 to 24 years.4 To date, cervical cancer screening is the most effective cancer control method. Cervical cancer screening works by seeking abnormal changes in the cervical epithelial cells, which reduces the risk of cancer when discovered and treated early.5 Cervical cancer is a major cause of disease burden of public health significance affecting middle-aged women specifically, those living in low-resource countries such as sub-Saharan Africa (SSA).6 A recent study using data from 185 countries from the 2018 Global Cancer Observatory (GLOBOCAN ) database indicated that cervical cancer was the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death among women globally with an estimated 570,000 incident cases and about 311,000 deaths annually.1,6 However, in most SSA countries, it is considered to be the most commonly diagnosed cancer and the leading cause of cancer-related death among women.1,7 Consequently, low-resource countries, including those in SSA, have a disproportionately high burden of all cervical cancers with an estimate of 84% and 88% of all deaths caused by the disease.6 This is in contrast to high-income countries (HICs), where the cumulative incidence rates of cervical cancer and mortality are two to four times lower than those in lower-resource countries.6

The use of advanced screening methods at a population-based level such as the use of cervical cytology (also called the Papanicolaou (Pap) test or Pap smear) and the HPV DNA test are some of the major attributable factors of low incidence and mortality in HICs.8,9 Most countries in SSA mainly focus on fighting infectious diseases such as tuberculosis, malaria, and HIV/AIDS and as such, non-communicable diseases such as cancers have received low priority and has led to a lack of effective population-based level cervical cancer screening programs, very limited resources and expertise, and poor awareness about disease prevention.5,10,11 Cervical cancer screening plays a significant role in the early detection of cervical cancer, increases treatment options for affected women, and improves cancer survival rates.6 The major attributable factors to a low survival rate of cervical cancer in SSA include late-stage diagnosis and lack of or delayed access to quality health care. 21 The vast majority of women in SSA do take the initiative to seek help by visiting healthcare facilities once they start to experience gynecological symptoms such as abnormal vaginal bleeding, offensive vaginal discharge, lower abdominal pain, and hematuria.12–15 However, at the time more serious symptoms, appear, it is probably too late and the advanced stage of the disease makes survival dismal.

To accommodate strategies to increase the uptake of cervical cancer screening among women in SSA, it is crucial to fully understand regional and country-specific variations in the prevalence of cervical cancer screening and associated factors. Such knowledge will guide the prioritization of intervention strategies to the most at-risk countries in SSA and assist stakeholders to adequately identify potential reasons for the low prevalence of cervical cancer screening. However, these estimates are lacking because most previous studies that have examined cervical cancer screening in SSA have either focused mainly on an individual country such as Kenya16 or was limited to an abstract presentation17 using Demographic and Health Surveys data (DHS). Thus, we aim to fill this critical knowledge gap by conducting a multi-country population-based study of the prevalence of cervical cancer screening in five combined SSA countries and examining the associated socio-demographic-economic factors using all available most recent DHS data from 2011–2018.

2. Methods

2.1. Data Source and Participants

The current study included all SSA countries which we had access to that participated in the most recent DHS surveys conducted from 2011–2018 and collected data on cervical cancer screening among women of childbearing age. These countries were: Benin, Ivory Coast, Kenya, Namibia, and Zimbabwe. Each country contributed one-year of survey data. Data were collected by each host country in coordination with ICF international located in Rockville, Maryland.18 The DHS surveys are nationally representative household surveys and are funded by the U.S. Agency for International Development (USAID). The survey data from each country was conducted using face-to-face questionnaire interviews and used multistage cluster sampling, stratified sampling design to collect detailed information about demographics and population health status, health behaviors, neonatal mortality, nutritional status, and family planning in each country.19,20 The initial stage involves the division of each country into geographic regions. Then within these regions, populations are stratified by urban or rural areas. The primary sampling units (PSUs) were selected with a probability proportional to size within each stratum. In the second stage of sampling, all households within the cluster were listed, and ~25 households were randomly selected for an interview using equal probability systematic sampling. The year of the administration of the relevant DHS survey for each country can be seen in Table 1. In 2012, there was consensus among professional organizations that issue cervical cancer screening guidelines to adopt the consistent recommendation of getting a Pap smear every three years for women aged 21 or older and no Pap smear for women younger than 21 years.21 In addition, the DHS data for cervical cancer screening questions for most countries included in this study (4 out 5) were limited to only women of childbearing age (15–49 years old). Therefore, the present weighted analysis was limited to women of childbearing age from 21–49 years (N=28,976) with cervical cancer screening data.

Table 1.

Background characteristics of the weighted survey participants, the prevalence of cervical cancer screening, and the multivariable-adjusted prevalence ratio by country and survey year (N=28,976)

All Participants Cervical Cancer Screening Multivariable adjusted analysis
Countries Survey Year Na (%b) Nc (%) (aPR) (95% CI) P-Value
Overall 28,976 5,512 (19.0)
Benin 2017–18 5,708 (19.7) 38 (0.7) ref.
Ivory Coast 2011–12 2,968 (10.2) 94 (3.2) 3.14 (2.05, 4.82) <.001
Kenya 2014 9,129 (31.5) 1,943 (21.3) 18.07 (12.45, 26.22) <.001
Namibia 2013 4,872 (16.8) 2,237 (45.9) 37.13 (25.50, 54.05) <.001
Zimbabwe 2015 6,299 (21.7) 1,200 (19.1) 18.12 (12.41, 26.46) <.001
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Na = Weighted sample size of the combined dataset that is represented by that survey for each country

%b = The % of the combined dataset that is represented by that survey.

Nc= Prevalence of cervical cancer screening.

ref=reference

STI: Sexually transmissible infection

Model fully adjusted for country, health insurance coverage (yes/no), pregnancy status (yes/no), breastfeeding status (yes/no), age (categorical), education status (categorical), marital status (categorical), wealth index status (categorical), place of residence (urban/rural), employment status (yes/no), number of living children (categorical), STI (yes/no), contraceptive use (yes/no), sexually active in the last 4 weeks (categorical), household having a radio (yes/no), household having a television (yes/no), visited health care facility in the last 12 months (yes/no)

2.2. Ethical Considerations

We first sent a written request to the DHS program for permission, which was granted to download and use the data from http://www.dhsprogram.com. Each country’s procedures and questionnaires for standard DHS surveys were reviewed and approved by the ICF Institutional Review Board (IRB) and the IRBs of each host country. Written or oral informed consent was obtained from each participant before the survey. Survey respondents were not coerced into participation22 and all data are completely de-identified with no names or household addresses in the data files. All the ethical matters were handled by the ICF IRB and the IRBs of the five host countries (Benin, Ivory Coast, Kenya, Namibia, and Zimbabwe) who conducted the primary surveys and not by the authors of this article. Thus, no further IRB approval was needed by the institutions of the authors of the present manuscript. Details on the ethical matters are described elsewhere.23

2.3. Assessment of Cervical Cancer Screening (outcome)

The outcome of interest for the present study was defined as self-reporting to have ever undergone a screening test or exam for cervical cancer. This was the most reliable variable available in all countries with only 0.3% missing information. Eligible respondent women were asked whether they underwent any cervical cancer screening prior to the survey and was measured using questions such as: ‘Have you ever been screened for cervical cancer?’, and ‘Have you ever had a cervical examination?’ Screening options include Pap smears and visual inspection with acetic acid. Detailed information about cervical cancer screening questionnaires is described elsewhere.24 The binary response of cervical cancer screening (yes/no) was used as our dependent variable as done by previous researchers using the DHS data.16 Women with a missing value for cervical cancer screening or who did not know about their screening status were excluded from this study (n=75).

2.4. Assessment of Potential Socio-demographic-economic Factors

Based on previous literature on cervical cancer screening,16 the following socio-demographic-economic factors were examined to determine whether they were associated with a higher likelihood of cervical cancer screening: health insurance coverage, contraceptive use, age, wealth index status, educational status, marital status, place of residence, employment status, number of living children, household owning a radio, household owning a television, sexual activity status, and visited healthcare facility in the last twelve months. The aforementioned potential factors were collected by self-report. Previous studies reported that these socio-demographic-economic factors may affect women’s cervical cancer screening behaviors.16,17 Wealth index was recategorized from five quintiles into three categories by combining poorest and poorer into one category (called “lowest”); middle wealth level into the second category (called “middle”); and richer and richest into the third category (called “highest”), as done by previous researchers.25–27 We also recategorized the age of participants from a continuous scale into three groups for this study (21–29, 30–39, and 40–49 years old). Given the high prevalence of HPV among sexually active people28, we selected the ‘sexually active in the past 4 weeks’ variable as one of the determinants of cervical cancer screening because it could be a proxy for a causal factor. Also, sexually active women may experience some early symptoms that can trigger them to seek preventive care services including cervical cancer screening earlier than non-sexually active women.

2.5. Statistical Analysis

All statistical analyses were performed using SAS statistical software version 9.4 (SAS Institute, Cary, NC, USA) and R version 3.4.3 (R Foundation for Statistical Computing, Vienna, Austria) to generate figure 1. Statistical tests were reported as significant at p values less than 0.05. significance. Each country’s data for cervical cancer screening questionnaires were extracted and then combined to create a single analytical dataset. To ensure that the estimates were nationally representative, we followed the DHS’s recommendation to analyze the DHS survey data by using the appropriate weight for our analysis based on the selected variables.29 Univariate analyses were conducted using frequency distributions for categorical variables to describe the characteristics of the study participants. To better understand between-country differences, we also analyzed each demographic/social factor of cervical cancer screening stratified by country. The prevalence of cervical cancer screening was calculated as the number of women who had cervical cancer screening divided by the total number of women interviewed in that category and multiplied by 100. The multivariable analysis was conducted using generalized estimating equations (GEE; SAS Institute) with an independent correlation structure to explore the association between socio-demographic-economic factors and cervical cancer screening adjusting for the country of residence, health insurance coverage, pregnancy status, breastfeeding status, age, educational status, marital status, wealth index status, place of residence (urban/rural), employment status, number of living children, sexually transmissible infection (STI), contraceptive use, sexually active, household having a radio, household having a television, visited health care facility in the last twelve months. To specify the use of the robust variance estimator for Poisson regression, the REPEATED statement (in SAS) was used to account for possible clustering by countries.30 The REPEATED statement is usually used for repeated measures or longitudinal data. However, the method can also be used for cross-sectional data with no repeated measurements to generate a robust estimate of variance.30 Descriptive statistics are presented as the weighted prevalence of cervical cancer screening and the multivariable Poisson regression results are presented as adjusted prevalence ratios (aPR) with 95% confidence intervals (CIs). Benin was selected as the reference country because it was the country with the lowest rate of cervical cancer screening

Figure 1.

Figure 1.

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Weighted Prevalence of Cervical Cancer Screening in sub-Saharan Africa (%) in women of childbearing age 21–49 years shaded by Sub-Saharan countries in Africa. Countries shaded white were not included in the analysis.

3. Results

3.1. Sociodemographic Characteristics of the Participants

A total of 28,976 weighted participants were included in the current analysis (Table 1). The mean (SD) age was 32.6±7.8 years old which was close to the mean age of the women excluded from the study (31.8 ±8.3). More than two-thirds of the participants reported not having health insurance coverage (84.1%). The majority of the participants were from a wealthy household (53.5%) and over 50.0% of women had secondary/higher education. More than one-third of the participants were middle-aged women between the ages of 30–39 years old (36.1%). More than half of participants were married/living with a partner (69.4%), currently employed (68.9%), resided in urban areas (50.3%), sexually active in the last 4 weeks (59.6%), or visited a healthcare facility in the last 12 months (61.1%). The majority of women had access to a radio in the household (63.5%) but most did not have a television (52.9%). Women with one or more living children less than 5 years old at the time of the DHS interview constituted 70.0% of the survey respondents (Table 2).

Table 2.

Weighted Prevalence of cervical cancer screening by country stratify (N=28,976)

Benin (N=5,708) Ivory Coast (N=2,968) Kenya (N=9,129) Namibia (N=4,872) Zimbabwe (N=6,299)
Characteristic N (%) N (%) N (%) N (%) N (%)
Age group
21–29 10 (0.17) 25 (0.84) 691 (7.57) 637 (13.07) 295 (4.69)
30–39 19 (0.33) 39 (1.30) 754 (8.25) 884 (18.15) 546 (8.67)
40–49 9 (0.16) 30 (1.02) 498 (5.46) 716 (14.70) 359 (5.70)
Health insurance
No 34 (0.60) 71 (2.38) 1,172 (12.84) 1,447 (29.7) 833 (13.24)
Yes 4 (0.06) 23 (0.78) 771 (8.44) 790 (16.21) 367 (5.82)
Wealth index status
Lowest 3 (0.05) 7 (0.25) 311 (3.41) 473 (9.71) 168 (2.68)
Middle 4 (0.07) 5 (0.17) 298 (3.27) 418 (8.58) 113 (1.79)
Highest 31 (0.54) 82 (2.74) 1,334 (14.61) 1,346 (27.62) 919 (14.59)
Place of residence
Urban 27 (0.47) 78 (2.62) 1,059 (11.60) 1,516 (31.11) 789 (12.54)
Rural 11 (0.19) 16 (0.54) 884 (9.69) 721 (14.81) 411 (6.52)
Education
No education 9 (0.15) 20 (0.67) 29 (0.32) 63 (1.31) 11 (0.18)
Primary 5 (0.08) 35 (1.16) 868 (9.51) 310 (6.36) 182 (2.90)
Secondary/Higher 24 (0.43) 39 (1.33) 1,046 (11.46) 1,864 (38.25) 1,007 (15.98)
Marital status
Never married 6 (0.10) 17 (0.57) 198 (2.17) 992 (20.35) 47 (0.74)
Married/Living with partner 26 (0.46) 69 (2.33) 1,458 (15.97) 1,061 (21.79) 934 (14.83)
Widowed/Divorced/Separated 6 (0.10) 8 (0.26) 287 (3.15) 184 (3.78) 219 (3.49)
Employment status
No 6 (0.10) 18 (0.60) 262 (3.97) 722 (14.91) 429 (6.82)
Yes 32 (0.56) 76 (2.57) 1,581 (17.34) 1,504 (31.06) 771 (12.24)
Pregnancy status
No 34 (0.60) 89 (3.00) 1,851 (20.28) 2,087 (42.84) 1,138 (18.06)
Yes 4 (0.06) 5 (0.16) 92 (1.00) 150 (3.08) 62 (1.00)
Breastfeeding status
No 30 (0.53) 78 (2.62) 1,579 (17.30) 1,942 (39.87) 1,033 (16.41)
Yes 8 (0.13) 16 (0.54) 364 (3.98) 295 (6.05) 167 (2.65)
Number of living children
None 4 (0.06) 16 (0.55) 200 (2.19) 267 (5.48) 60 (0.96)
1 to 4 30 (0.53) 60 (2.01) 1,480 (16.21) 1,738 (35.69) 1,021 (16.21)
More than 4 4 (0.07) 18 (0.59) 263 (2.88) 232 (4.75) 119 (1.89)
Contraceptive use
No 27 (0.47) 67 (2.25) 756 (8.29) 838 (17.19) 387 (6.14)
Yes 11 (0.19) 27 (0.90) 1,187 (13.00) 1,399 (28.73) 813 (12.92)
STI
No 37 (0.64) 87 (2.95) 1,863 (20.52) 2,139 (44.14) 1,162 (18.50)
Yes 1 (0.02) 5 (0.16) 66 (0.73) 84 (1.74) 33 (0.53)
Sexually active in the last 4 weeks
Never had sex 1 (0.02) 0 (0.00) 9 (0.10) 19 (0.40) 1 (0.01)
Active last 4 weeks 21 (0.36) 58 (1.96) 1,348 (14.7 8) 1,153 (23.94) 848 (13.56)
Not active last 4 weeks 16 (0.28) 33 (1.12) 576 (6.32) 1,038 (21.56) 344 (5.50)
Household has radio
No 7 (0.13) 32 (1.09) 395 (4.43) 505 (10.68) 642 (10.65)
Yes 27 (0.49) 60 (2.08) 1,507 (16.90) 1,656 (35.00) 519 (8.61)
Household has television
No 10 (0.18) 16 (0.57) 798 (8.94) 839 (17.74) 415 (6.89)
Yes 25 (0.44) 76 (2.61) 1,105 (12.38) 1,322 (27.95) 745 (12.37)
Visited healthcare facility last 12mths
No 16 (0.29) 32 (1.09) 501 (5.49) 820 (16.84) 312 (4.95)
Yes 21 (0.37) 61 (2.07) 1,442 (15.81) 1,415 (29.05) 888 (14.11)
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In table 2, we only reported the number (%) of cervical cancer screening for each variable by country stratify. The numbers are not meant to sum up. We used the total number for each country as the denominator when calculating the prevalence of cervical cancer screening.

3.2. The Prevalence of Cervical Cancer Screening in SSA

The overall weighted prevalence of cervical cancer screening was 19.0%, 95% CI: (18.5–19.5%) during the study period, ranging from 0.7% in Benin to 45.9% in Namibia (Table 1 and Figure 1). The prevalence of cervical cancer screening was higher among women who were older 40–49 years old (25.6%), those who had access to health insurance coverage (42.4%), from higher socioeconomic status (23.9%), and those with a secondary/higher education (26.4%). Furthermore, cervical cancer screening was also higher among women using contraceptives (25.2%) and sexually active in the last 4 weeks (19.9%). The prevalence of cervical screening was lower among women with STI. Lastly, women living in urban areas had a higher prevalence of cervical cancer screening (23.8%) compared to those living in rural areas (14.2%) (Table 1). Country-stratified analysis (Table 2) indicated that the prevalence of cervical cancer screening also varied widely between countries in relation to different factors such as age, health insurance, wealth status, education level, employment status, and visited healthcare facility in the last 12 months. Namibia, Zimbabwe, and Kenya had the highest prevalence of cervical cancer screening among women aged 30–39 compared with the other countries. Additionally, Namibia and Kenya had the highest prevalence of cervical cancer screening among women in the highest socioeconomic status. Regarding the educational level, Namibia and Zimbabwe had the highest prevalence of cervical cancer screening among women with higher education.

3.3. Multivariable Analysis of Determinants of Cervical Cancer Screening

Results from the multivariable analysis indicated that the country of residence was the factor most strongly associated with cervical cancer screening in the present study (Table 1). The aPR of cervical cancer screening was highest in Namibia (aPR= 37.13, 95%CI: 25.50–54.05) followed by Zimbabwe (aPR= 18.12, 95%CI: 12.41–26.46), Kenya (aPR= 18.07, 95%CI: 12.45–26.22), and Ivory Coast (aPR= 3.14, 95%CI: 2.05–4.82). Sexually active status in the last 4 weeks was the strongest factor associated with cervical cancer screening (aPR=3.27, 95% CI: 2.29–4.97) (Table 3). We observed a dose-response relationship between age and cervical cancer screening, where increasing age was positively associated with a higher cervical cancer screening rate (Ptrend <.0001). Older women 40–49 years old were more likely to get screened for cervical cancer (aPR=1.77, 95% CI: 1.64–1.90) compared with younger women (21–29 years old). Women with secondary/higher education were more likely to undergo cervical cancer screening (aPR= 1.51, 95% CI: 1.28–1.79) compared with no education. Having health insurance coverage was also positively associated with cervical cancer screening (aPR= 1.53, 95% CI: 1.44–1.61) compared to those with no health insurance. Women in the highest socioeconomic status were more likely to undergo cervical cancer screening (aPR= 1.39, 95% CI: 1.26–1.52) compared to those in the lowest socioeconomic status. Participants living in rural areas were less likely to undergo cervical cancer screening (aPR=0.86, 95% CI: 0.81–0.92). Possession of a radio or television was not significantly associated with cervical cancer screening (Table 3).

Table 3.

Background characteristics of the weighted survey participants, the prevalence of cervical cancer screening, and the multivariable-adjusted prevalence patio (N=28,976)

All Participants Cervical Cancel Screening Multivariable-Adjusted analysis
Characteristic Na (%b) Nc (%) (aPR) (95% CI) P Value
Age group
21–29 12,200 (42.1) 1,658 (13.6) ref.
30–39 10,470 (36.1) 2,241 (21.4) 1.46 (1.37, 1.55) <.001
40–49 6,306 (21.8) 1,613 (25.6) 1.77 (1.64, 1.90) <.001
Health insurance
No 24,367 (84.1) 3,558 (14.6) ref.
Yes 4,605 (15.9) 1,953 (42.4) 1.53 (1.44, 1.61) <.001
Wealth index status
Lowest 8,283 (28.6) 963 (11.6) ref.
Middle 5,190 (17.9) 838 (16.2) 1.17 (1.07, 1.28) 0.001
Highest 15,503 (53.5) 3,711 (23.9) 1.39 (1.26, 1.52) <.001
Place of residence
Urban 14,569 (50.3) 3,469 (23.8) ref.
Rural 14,407 (49.7) 2,043 (14.2) 0.86 (0.81, 0.92) <.001
Education
No education 5,232 (18.1) 133 (2.5) ref.
Primary 8,663 (29.9) 1,399 (16.2) 1.38 (1.17, 1.63) 0.002
Secondary/Higher 15,081 (52.1) 3,980 (26.4) 1.51 (1.28, 1.79) <.001
Marital status
Never married 5,445 (18.8) 1,258 (23.1) ref.
Married/Living with partner 20,102 (69.4) 3,549 (17.7) 1.05 (0.98, 1.12) 0.21
Widowed/Divorced/Separated 3,429 (11.8) 705 (20.5) 0.99 (0.91, 1.08) 0.78
Employment status
No 8,983 (31.1) 1,537 (17.1) ref.
Yes 19,940 (68.9) 3,964 (19.9) 1.13 (1.07, 1.20) <.001
Pregnancy status
No 26,777 (92.4) 5,199 (19.4) ref.
Yes 2,199 (7.6) 313 (14.2) 1.14 (1.02, 1.27) 0.02
Breastfeeding status
No 22,617 (78.1) 4,663 (20.6) ref.
Yes 6,359 (22.0) 849 (13.4) 0.99 (0.93, 1.08) 0.99
Number of living children
None 3,661 (12.6) 547 (14.9) ref.
1 to 4 20,271 (70.0) 4,329 (21.4) 1.20 (1.09, 1.32) 0.003
More than 4 5,044 (17.4) 636 (12.6) 0.98 (0.86, 1.11) 0.76
Contraceptive use
No 15,358 (53.0) 2,075 (13.5) ref.
Yes 13,618 (47.0) 3,437 (25.2) 1.12 (1.06, 1.18) <.001
STI
No 27,655 (95.9) 5,288 (19.1) ref.
Yes 1,174 (4.1) 190 (16.2) 1.22 (1.09, 1.38) 0.001
Sexually active in the last 4 weeks
Never had sex 625 (2.2) 30 (4.8) ref.
Active last 4 weeks 17,212 (59.6) 3,428 (19.9) 3.37 (2.29, 4.97) <.001
Not active last 4 weeks 11,026 (38.2) 2,007 (18.2) 3.24 (2.21, 4.78) <.001
Household has radio
No 10,294 (36.5) 1,581 (15.4) ref.
Yes 17,888 (63.5) 3,771 (21.1) 1.01 (0.95, 1.06) 0.84
Household has television
No 14,895 (52.9) 2,079 (14.0) ref.
Yes 13,286 (47.2) 3,273 (24.6) 1.02 (0.95, 1.10) 0.57
Visited healthcare facility last 12mths
No 11,279 (38.9) 1,682 (14.9) ref.
Yes 17,687 (61.1) 3,828 (21.6) 1.26 (1.18, 1.32) <.001
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Na = Weighted sample size of the combined dataset that is represented by that survey for each country

%b = The % of the combined dataset that is represented by that survey.

Nc= Prevalence of cervical cancer screening.

ref=reference

Model fully adjusted for country, health insurance coverage (yes/no), pregnancy status (yes/no), breastfeeding status (yes/no), age (categorical), education status (categorical), marital status (categorical), wealth index status (categorical), place of residence (urban/rural), employment status (yes/no), number of living children (categorical), STI (yes/no), contraceptive use (yes/no), sexually active in the last 4 weeks (categorical), household having a radio (yes/no), household having a television (yes/no), visited health care facility in the last 12 months (yes/no)

4. Discussion

In this large population-based cross-sectional study of more than 28,000 women of childbearing age from five countries in SSA, we found for the first-time a high degree of heterogeneity and disparities in the prevalence of cervical cancer screening across SSA countries. The overall weighted prevalence of cervical cancer screening in SSA was only 19.0% compared to 81.1% in HICs (e.g. the United States)31 with Benin having the lowest prevalence at 0.7%. The low rate of cervical cancer screening among women of childbearing age in these low-resource countries is concerning and can increase the risk of cervical cancer in the future. West African countries had the lowest prevalence of cervical cancer screening than countries located in the East and South. The low prevalence of cervical cancer screening in our study is consistent with previous studies that also found low cervical screening rates in other SSA countries – 4.8% in Uganda32 and 6% both in Kenya33 and Tanzania.34

While cervical cytology (Pap test or Pap smear) and HPV DNA test are well-established screening methods for the early detection of cervical cancer in HICs, implementing such screening services can be cost-prohibitive and may not be feasible in many SSA countries.6,8,9,35,36 In contrast, most SSA countries lack national screening programs and have insufficient funds, inadequate infrastructure, and resources to screen all eligible women.36 In the absence of Pap smears or HPV DNA tests in most low and middle-income countries (LMICs), including those in SSA, a visual inspection of the cervix with acetic acid is the most effective and common screening technique implemented in these settings. However, this screening method has a lower sensitivity of 82.4% and a specificity of 87.4% when compared to Pap smears.37–40 Despite financial constraints, the Cancer Association of South Africa’s guidelines advocate for Pap smears at least every three years among women 25 years and older to detect abnormal cells as early as possible leading to better treatment and improved survivorship.41 Furthermore, the low prevalence of cervical cancer screening could also be explained by the fact that most countries in this region have competing health needs with a high burden of infectious diseases, maternal and child health problems, coupled with limited health resources thereby limiting prioritization on cancer prevention methods such as HPV vaccinations and national cervical cancer screening programs.5,42,43 In addition, lack of awareness about cervical cancer screening could also play a significant role because most women in SSA delay preventive care services and only seek medical assistance after noticing gynecological signs and symptoms such as abnormal vaginal bleeding, foul-smelling vaginal discharge, and hematuria.12–15 These clinical symptoms often herald advanced stage malignancy with consequent poor prognosis and increased risk of mortality.5,12,44

Findings from this study suggest that there are substantial variations in the prevalence of cervical cancer screening across these five countries. Such between-country variation is of public health and clinical significance because screening for early detection is a significant aspect in the control of cervical cancer and greatly improves survivorship.45,46 Our findings underscore the need to deploy more efforts in the field to encourage and promote early screening, which could have significant public health impacts in these low-resource countries.

The multivariable analysis of five combined countries indicated that factors independently associated with cervical cancer screening were country of residence, age, health insurance coverage, wealth index status, place of residence, education level, employment status, pregnancy status, contraceptive use, STI, being sexually active in the last 4 weeks, visiting a health care facility in the last twelve months, and the number of living children a woman has. The positive association between increased age and cervical cancer screening could be explained by older women being more informed about the potential health benefits of screening for preventing cervical cancer. This finding is consistent with previous studies that also found older women were more likely to be screened for cervical cancer than younger women.16,47,48 There was evidence of a “dose-response relationship” between age and cervical cancer screening. However, it should be noted that between country age differences regarding cervical cancer screening are mostly driven by three countries (Namibia, Zimbabwe, and Kenya). As anticipated, having health insurance coverage was positively associated with cervical cancer screening a finding that is consistent with other previous studies.16,49 Health insurance coverage provides an opportunity for women to undergo preventive care services at no additional out-of-pocket cost. Higher education was positively associated with higher cervical cancer screening in the present study because educated women are more likely to know about the adverse outcomes of cervical cancer.48 This also highlights the need for more educational-based programs about cervical cancer to promote and increase awareness about cervical cancer screening in low resource settings. Our finding agrees with previous studies that indicated that higher educated women were more likely to undergo cervical cancer screening than lower-level education.47,48 Furthermore, we found that family wealth status was positively associated with cervical cancer screening during our study period. A plausible explanation is that stronger financial power increases health insurance coverage, indirectly translating to an increased routine in preventive care services.50 Moreover, in most countries included in this study, access to cervical cancer screening is not freely available to all women. For example, one study noted that at Kenyatta National Referral Hospital, the cost of a pap smear test is approximately $7. However, the client is required to pay roughly $6.5 for a file or identification card.15 In Zimbabwe, visual inspection with acetic acid is the screening method offered in all public health care clinics for free.51 In addition, a previous study conducted in SSA indicated that only 18% of women screened for free would participate if there was a fee associated with the screening.52 This finding is also consistent with previous studies conducted in this region.16,48 Interestingly, women who were sexually active in the last 4 weeks and those who had STI, were more likely to undergo cervical cancer screening. A possible explanation could be that those who may have experienced some early signs or symptoms may trigger the need to seek medical care or that being sexually active leads to more hospital visits such as for contraceptives need or treatment of STIs. Consistent with previous studies, the negatively observed association between cervical cancer screening and living in rural areas was not surprising and could be due to disparities in access to health care services and lack of healthcare facilities.32,48 Lastly, in agreement with a previous study, we found that women who visited health care facilities within the last twelve months were likely to undergo cervical cancer screening.16

4.1. Study Strengths and Limitations

Our study has several strengths. To the best of our knowledge, this is one of the few comprehensive studies, and perhaps the largest to date, to examine the prevalence and determinants of cervical cancer screening across multiple SSA countries. The findings from this study are useful in enhancing the uptake of cervical cancer screening, counseling practices, and interventions in these countries and the entire SSA regions. Nevertheless, our study has a few limitations that should be addressed. First, the cross-sectional nature of the survey does not allow for the determination of temporal relationships and outcome measures. Secondly, this study was limited to only five of the 48 countries in SSA and thus, our finding may lack external validity especially in countries we did not include in the analysis. Thirdly, our study population was limited to only women of childbearing age (15–49 years), and yet cancer incidence increases as a function of age. Therefore, the true cancer screening uptake beyond 49 years of age could be slightly different from our findings, which could be subject to exclusion bias. However, because only 1 country out of the 5 collected data among women over age 49, it is unlikely that exclusion bias affects our findings. In addition, information on why women were screened such as signs or symptoms, part of prenatal care, or routine interaction with health care providers were not included in the survey. Lastly, the method of cervical cancer screening such as Pap smear was available only for 2 out of 5 countries. Nevertheless, this study provides important information regarding the prevalence of cervical cancer screening and associated factors among women of childbearing age for the first time in five SSA countries.

5. Conclusions

The overall prevalence of cervical cancer screening in SSA is low, which suggesting the need for targeted interventions to lower the burden of cervical cancer, improve the quality of life, and increase survivorship among women. Findings from this study indicated great heterogeneity in cervical cancer screening behaviors across SSA countries and are related to women’s demographic and personal characteristics. Being sexually active in the last 4 weeks, being older, having health insurance coverage, higher socioeconomic status, a higher level of education, and contraceptive use were some of the leading factors independently and positively associated with cervical cancer screening. The findings highlight an urgent need for interventions through health education to encourage screening behaviors for detecting cervical cancer in this region.

Novelty and Impact.

To the best of our knowledge, this is one of the few comprehensive studies, and perhaps the largest to date, to examine the prevalence and determinants of cervical cancer screening across multiple SSA countries. The prevalence of cervical cancer screening is substantially low in sub-Saharan Africa and shows for the first time a high degree of between-country variation.

Highlights.

  • Prevalence and determinants of cervical cancer screening in SSA was examined

  • The prevalence of cervical cancer screening is substantially low in SSA countries

  • There is a high degree of between-country variation in cervical cancer screening.

  • Older age, having health insurance coverage, and higher socioeconomic status are some of the independent leading factors associated with cervical cancer screening.

Acknowledgments

The authors thank the DHS program implemented by ICF for granting access to the original data. The authors also thank Kani Dembele for her assistance with the literature search.

Funding Source: JM received funding through an International Research Career Development Award from the NIH/FIC (grant #K43TW011416) that provided research-protected time for reviewing and writing of this manuscript. PS was aslo supported by the NIH Director’s Transformative Award 1R01AI145057. The funding agencies cited here did not play a role in the design, collection of data, analysis, interpretation, and writing of this manuscript or decision to publish the results. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of NIH/Fogarty International Center.

Abbreviations

aPR

adjusted prevalence ratios

DHS

Demographic and Health Surveys data

STI

sexually transmissible infection

IC

confidence intervals

IRB

Institutional Review Board

HICs

high-income countries

HPV

Human papillomavirus

Pap

Papanicolaou

PSU

Primary sampling units

LMICs

Low and middle-income countries (LMICs)

SSA

sub-Saharan Africa

STI

Sexually Transmissible Infection

Footnotes

Disclosure of conflicts of interest

All authors have no conflict of interest to disclose as it relates to this research.

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