Table 2.
Studies reporting barriers to Cervical cancer screening in low- and middle-income countries
| Author, Country, Year | Study design | Population | Sample size | Age (years) | Screening method | Barriers | Quality rating |
|---|---|---|---|---|---|---|---|
| Africa | |||||||
| Getahun T et al. Ethiopia, 2020 [13] |
Mixed methods Cross-sectional and IDIs |
Rural and urban women, Cervical cancer screening service providers | 821, 10 in-depth interviews | median age 39 years (range 30–49) | Not specified | Individual, Social, Health system | High |
| Megersa BS et al. Ethiopia, 2020 [14] |
Qualitative IDIs and FGDs |
Women who had participated in HPV self-sampling, sample collectors, community health care workers |
47 (25 -FGDs, 22-in IDIs). |
mean age 36 years | HPV self-sampling | Individual, Social, Cultural/ traditional/ religious | High |
| Ampofo AG et al. Ghana, 2020 [15] |
Quantitative Cross-sectional survey |
Women of reproductive age | 200 | 15–50 | VIA, pap smear | Individual, Social, Cultural/traditional/religious, Health system | High |
| Calys-Tagoe BNL et al. Ghana, 2020 [9] |
Quantitative Secondary data analysis |
Women | 2711 | Mainly ≥50 years | Pap smear | Individual, Cultural/traditional/religious, Structural | Medium |
| Stewart K et al. Nigeria, 2020 [10] |
Quantitative Secondary data analysis |
Women who had received cervical screening | 621 | Not specified | VIA/VILI, and pap smear | Structural | High |
| Harries J et al. South Africa, 2020 [16] |
Qualitative semi-structured interviews |
Women with potential breast or Cervical cancer symptoms in urban and rural areas | 18 | mean age 34.5 years (range 22–58) | Not specified | Individual, Social, Health system, Structural | High |
| Nyamambi E et al. Zimbabwe, 2020 [17] |
Quantitative Cross-sectional |
Sexually active women | 156 | 15–50 | VIA | Individual, Cultural/traditional/ religious, Health system, Structural | High |
| Getachew et al. Ethiopia, 2019 [18] |
Mixed methods Cross sectional and FGDs |
Women of reproductive age attending primary health centres | 520 | mean age 27.7 years (range 20–49) | Not specified | Individual, Health system, Structural | High |
| Nigussie T et al. Ethiopia, 2019 [19] |
Quantitative Cross sectional |
Women from a rural community | 737 | mean age 36.6 years (range 30–49) | VIA | Individual, Health system | High |
| Solomon K et al. Ethiopia, 2019 [20] |
Quantitative Cross sectional |
HIV positive women attending ARV clinics | 475 | 18 + years | VIA | Individual, Cultural/traditional/ religious | Medium |
| Williams MS et al. Ghana, 2019 [21] |
Quantitative Cross-sectional |
Women | 288 | mean age 32.4 years (range 19–64) | Pap smear | Individual, Cultural/traditional/ religious | High |
| Adewumi K et al. Kenya, 2019 [22] |
Quantitative Cross-sectional |
Women, community health volunteers | 604 | not specified | self-collected vaginal swabs for HPV | Social, Cultural/ traditional/religious, Structural | High |
| Oketch SY et al. Kenya, 2019 [23] |
Qualitative IDIs |
Women in Cervical cancer screening campaign | 120 | mean age 36.1 years | HPV self-sampling | Individual, Social, Structural | High |
| Lieber M et al. South Africa, 2019 [24] |
Mixed method IDIs, FGDs observations, chart reviews |
Women patients and healthcare providers | 12 patients, 3 healthcare providers | Not specified | VIA | Individual, Health system | Medium |
| Shiferaw S et al. Ethiopia, 2018 [25] | Mixed method, Cross-sectional and qualitative IDIs | HIV-positive women attending heath facilities | 581 | mean age 35 years (range 21–65) | Not specified | Individual, Cultural/traditional/ religious, Health system, Structural | High |
| Kangmennaang J et al. Kenya, 2018 [26] |
Quantitative Cross-sectional survey, secondary analysis of survey data |
Women of reproductive age | 14,741 | mean age 30 years (range 15–49) | Not specified | Individual, Social, Cultural/ traditional/religious, Structural | High |
| Ng’ang’a A et al. Kenya, 2018 [27] |
Quantitative Nested case-control study in a cross-sectional survey |
Women | 1180 | 30–49 | Not specified | Individual, Structural | High |
| Maree JE & Kampinda-Banda M. Malawi, 2020 [28] |
Quantitative Cross-sectional |
Women, convenient sample in rural district | 282 | mean age 36.1 years (range 30–45) | VIA | Individual, Health system | High |
| Keneema M et al. Uganda, 2018 [29] |
Quantitative Cross-sectional |
Women attending antenatal clinic | 100 | 25–49 | not specified | Individual, Cultural/traditional/ religious, Health system, Structural | Medium |
| Vhuromu EN et al. South Africa, 2018 [30] |
Quantitative Cross-sectional |
Women attending health clinics | 500 | 20–59 | pap-smear | Individual, Cultural/ traditional/religious, Health system | Medium |
|
Kokuro Ml. Ghana, 2017 Thesis [31] |
Quantitative Cross-sectional |
Women attending reproductive health services | 369 | 18 years+ | Not specified | Individual, Social, Cultural/traditional/religious, Structural | High |
| Bishwajit G & Kpoghomou M, Kenya, 2017 [32] |
Quantitative Cross-sectional secondary data analysis |
Women | 11,138 |
mean age 29.6 years range (15–49) |
Not specified | Structural | High |
| Lunsford NB et al. Kenya, 2017 [33] |
Qualitative FGDs |
Women, married men with partners 25–49 |
100 (10 focus groups) |
Women 25–49, men ≥18 | Pap versus VIA/VILI | Individual, Social, Cultural/Traditional/religious, Health systems, Structural | High |
| Tiruneh FN et al. Kenya, 2017 [34] |
Quantitative Cross-sectional |
Married women | 6498 | 15–49 | Pap- smear, urine sampling | Social, Structural | High |
| Filade TE et al. Nigeria, 2017 [35] |
Qualitative FGDs and IDIs |
Pregnant women in antenatal care, Healthcare workers |
82 pregnant women, 13 Healthcare workers | pregnant women, mean age 28.9 years | HPV DNA based tests | Individual, Cultural/traditional/religious, Health system, Structural | High |
| Momberg M. et al. South Africa, 2017 [36] |
Qualitative FGDs |
Women, first time colposcopy clinic attendees | 27 | mean age 34 years (range 18–49) | pap smear & colposcopy | Individual, Social | High |
| Malambo N. & Erikson S. Swaziland, 2018 [37] | Qualitative | Women, healthcare workers | 20 women, 7 healthcare workers | 19–49 | Not specified | Individual, Health system | Medium |
| Mitchell SM et al. Uganda, 2017 [38] |
Quantitative Cross-sectional |
HIV+ women attending a routine care | 87 | 30–69 | Not specified | Individual, Health system | High |
| Koneru A et al. Tanzania, 2017 [39] |
Quantitative Cross-sectional |
HIV+ women | 399 | 19 years+ | VIA and colposcopy | Individual, Health system | High |
| Modibbo IF et al. Nigeria, 2016 [40] |
Qualitative FGDs |
Muslim and Christian women purposively sampled | 49 |
18 years+ mean age 33 years |
Not specified | Individual, Social, Cultural/traditional/ religious, Health systems | High |
| Hweissa NAb et al. Libya, 2016 [41] |
Qualitative IDIs |
Healthcare workers from public and private sectors | 16 | Not specified | Pap smear | Individual, Cultural/traditional/religious, Health system, Structural | High |
| Adepoju EG et al. Nigeria, 2016 [42] |
Quantitative Cross-sectional |
Women | 287 | age 51.6 years (SD 14.3) | Pap smear, colposcopy | Individual | Low |
| Ndejjo R et al. Uganda, 2016 [43] |
Quantitative Cross sectional |
Women from predominantly rural districts | 900 | 25–49 | Not specified | Individual, Social, Health systems, Structural | High |
| Hasahya OT et al. Uganda, 2016 [44] |
Qualitative FGDs |
Women of whose daughters had received HPV vaccination. | 36 | 25–49 | Not specified | Individual, Social, Health system, Structural | High |
| Ghidei et al. Ethiopia and Tanzania, 2015 Research report [45] |
Descriptive Cross sectional |
Women | 23 | 19–45 | VIA | Individual, Cultural/traditional/ religious | Low |
| Compaore SC. et al. Burkina Faso, 2015 [46] |
Quantitative Cross-sectional |
Women | 351 | Not specified | VIA, VILI | Individual, Structural | Medium |
| Munthali CM. et al. Malawi, 2015 [47] | Qualitative interviews | Healthcare workers, cervical screening service providers, District coordinators | 53 | Not specified | VIA | Individual, Cultural/traditional/religious, Health system, Structural | High |
| Learmonth D. et al. South Africa, 2015 [48] |
Qualitative FGDs |
Women of low socioeconomic status | 15 | 25–51 | Not specified | Individual, Social, Cultural/traditional/ religious, Health system, Structural | High |
| Ebu NI et al. Ghana, 2014 [49] |
Quantitative Cross-sectional |
Women | 392 | 10–74 | Pap smear | Individual, Social, Cultural/traditional/ religious, Health system, Structural | High |
| Omondi Aduda DS & Mkhize N. Kenya, 2014 [50] |
Qualitative FGDs |
Women screened for syphilis and Cervical cancer | Not specified | not specified | Not specified | Individual, Health system, Structural | High |
|
Kibicho et al. Kenya, 2014 Thesis [51] |
Quantitative Cross -sectional |
Women of reproductive age in a gynaecology ward | 138 | mean age 31.6 years (Range 18–49) | Pap smear, coloscopy, VIA/VILI test | Individual, Cultural/traditional/religious, Health system, Structural | High |
| Abdulkadir IR. Ethiopia, 2013 Thesis [52] |
Quantitative cross-sectional |
Female university students | 392 | Mean age 23.3 years (range 18–52 | Pap smear | Individual, Cultural/traditional/religious, Health system, Structural | High |
|
Atuhaire L. Uganda, 2013 Thesis [53] |
Qualitative Exploratory and descriptive |
Women accessing maternal and child health services | 25 | 18–64 | all screening | Individual, Health system | High |
| Mwaka AD et al. Uganda, 2013 [54] | Qualitative | Healthcare workers | 15 | Not specified | Not specified | Individual, Cultural/traditional/religious, Health system, Structural | High |
| Paul et al. Peru, Uganda, Vietnam, 2013 [55] | Qualitative | Women, Healthcare workers, village health team | 109 | not specified | VIA | Individual, Social, Health system, Structural | High |
| Ngugi et al. Kenya, 2012 [56] |
Qualitative IDIs |
Women | 50 | Not specified | Not specified | Individual, Social, Cultural/traditional/religious, Health system, Structural | High |
| Hyacinth et al. Nigeria, 2012 [57] |
Quantitative Cross sectional |
Women in their workplace | 388 | 18–65 | Pap smear | Individual, Health system | High |
| Mupepi SC et al. Zimbabwe, 2011 [58] |
Quantitative cross-sectional |
Sexually active women | 12–84 | Pap smear | Individual, Social, Cultural/traditional/religious, Health system, Structural | High | |
| Asia | |||||||
| Andersen JG et al. Nepal, 2020 [59] |
Qualitative FGDs and IDIs |
Women, female community health volunteers | 48 | 30–60 | Not specified | Individual, Social, Cultural/traditional, Health system, Structural | High |
| Spagnoletti BRM et al. Indonesia, 2019 [60] |
Qualitative FGDs and semi-structured interviews |
Married women and men | 56 women, 30 men | women 22–57, men 35–45 | VIA and pap smear | Individual, Social, Health system, Structural | High |
| Gu et al. China, 2018 [61] |
Qualitative Semi-structured interviews |
Women at risk for cervical cancer in a prior study | 27 | 25–50 | pap smear test | Individual, Health system, Structural | High |
| Ashtarian H et al. Iran, 2017 [62] | Quantitative Cross-sectional | Women attending health centres | 355 | mean age 34.08 years | pap-smear | Individual, Health system | High |
| Osth J. Sri Lanka, 2015 Thesis [63] |
Quantitative Cross-sectional |
Male and female undergraduate students | 326 | 18–30 | Pap smear, cytological screening | Individual | High |
| Jia Y. et al. China, 2013 [64] | Quantitative Cross-sectional | Women | 5929 | 25–65 | Pap smear, VIA, colposcopy | Individual, Cultural/traditional/religious | High |
| Baskaran P. et al. Malaysia, 2013 [65] | Quantitative Cross-sectional | Women attending outpatient care | 369 | mean age 37.5 years (range 21–65) | Pap smear | Individual, Cultural/traditional/religious, Health system | High |
| Gan et al. Malaysia, 2013 [66] |
Quantitative Cross-sectional |
women from 1000 households | 959 | mean age 45.2 years (range 20–64) | Pap smear | Individual, Social | High |
| Demirtas B & Acikgoz I. Turkey, 2013 [67] |
Quantitative Cross-sectional |
women registering at a gynaecology outpatient clinic | 256 | 21–62 | Pap Smear | Individual | High |
| Guvenc et al. Turkey, 2013 [68] | Quasi-experimental | Women | 294 | 21+ | Pap smear | Individual | |
| Reis et al. Turkey, 2012 [69] | Qualitative | Women at gynaecology and obstetrics outpatient clinics | 387 | Not specified | Pap Smear | Individual | Medium |
| Gu et al. China, 2012 [70] | Quantitative Cross-sectional | Women | 167 | 25–50 | Not specified | Individual | High |
| Abdullah et al. Malaysia, 2011 [71] | Quantitative Cross-sectional | Female secondary school teachers | 403 | not specified | Pap smear | Individual, Health system | Medium |
| Gu et al. China, 2010 [72] | Quantitative Cross-sectional | Women | 184 | 25–50 | Not specified | Individual, Health system | Medium |
| Abdullah & Su, Malaysia, 2010 [73] | Qualitative Semi-structured interviews | Policy makers, healthcare workers | 11 | 37–57 | Pap smear | Individual, Health system | |
| Al-Naggar RA, Isa ZM. Malaysia, 2010 [74] | Quantitative Cross-sectional survey | female Malaysian university students | 287 | 18 years+ | Pap smear | Individual, Cultural/traditional/religious, Health system | Medium |
| Park SJ, & Park Wl. Korea, 2010 [11] |
Quantitative Secondary analysis |
Women aged 21+, no hysterectomy, eligible for Pap smears | 2590 | 21 years+ | Pap smear | Individual, Structural | High |
| North America | |||||||
| Gottschlich A et al. Guatemala, 2020 [12] | Quantitative Secondary data analysis | screened and unscreened women | 15,317 | 25–49 | Pap smear | Individual, Social, Structural | High |
| Bien-Aimé et al. Haiti, 2020 Thesis [75] |
Quantitative Cross sectional |
women in five urban areas | 200 | 25 years+ | Pap smear, Colposcopy, VIA, HPV test | Individual, Social | Medium |
| Lyons KD et al. Honduras, 2020 [76] |
Quantitative Cross sectional |
Rural women | 874 | Not specified | HPV PCR and pap smear | Individual, Structural | Medium |
| Chary AN & Rohloff PJ. Guatemala, 2014 [77] | Qualitative Semi-structured interviews | NGO service provider staff | 36 | Not specified | VIA | Health system | |
| South America | |||||||
| Barret BW et al. Peru, 2020 [78] |
Quantitative Cross sectional |
Rural women | 619 | 18–65 | HPV testing, VIA or pap smear | Structural | Medium |
| Collins JH et al. Peru 2019 [79] |
Quantitative Cross sectional |
Rural women | 121 women | mean age 42 years (range 21–76) | not specified | Individual, Structural | High |
| Nugus P et al. Ecuador, 2018 [80] |
Qualitative FGDs and semi structured interviews |
Women who had participated in a community-based Cervical cancer screening program | 28 | 24–69 | Pap smear | Individual, Social, Cultural/traditional/religious, Health system, Structural | High |
| Albuquerque et al. Brazil, 2014 [81] |
Quantitative Cross sectional |
Rural and urban women | 493 | Mean age 35.4 years (range15–69) | Pap smear | Individual, Health system, Structural | High |
| Stormo et al. Bolivia, 2012 [82] |
Qualitative Descriptive survey |
Healthcare workers | 42 | Not specified | VIA, cryotherapy | Individual, Social, Cultural/traditional/religious, Health system | Medium |
| Paz-Soldán VA, et al. Peru,2012 [83] | Qualitative semi-structured interviews | Policy makers and healthcare workers | 30 | Not specified | Not specified | Health system, Structural | High |
| Paolino M & Arrossi Sl. Argentina, 2011 [84] | Quantitative | Women attending hospital | 200 | 18+ | Pap smear | Individual, Health system, Structural | High |
| Oceania | |||||||
| Townsend JS et al. US Affiliated Pacific Island Jurisdictions (USAPIJ), 2014 [85] |
Quantitative cross-sectional |
Healthcare workers | 72 | not specified | HPV testing, Pap smear | Health system, Structural | High |
| Europe | |||||||
| Valerianova Z. et al. Bulgaria, 2010 [86] | Qualitative | Healthcare workers | 23–65 | Not specified | Individual, Health system | Medium | |
| Rada C. et al. Romania, 2010 [87] | Quantitative Cross sectional | Men, women | 1902 | 15–82 | Pap smear | Individual, Social | Low |
FGDs Focus group discussions, IDI In-depth interviews, VIA Visual inspection with acetic acid, VILI Visual inspection with Lugol’s iodine, HPV Human papillomavirus