Cervical cancer is the most common malignancy in women, caused by unresolved long-term infection with distinct genotypes of human papillomavirus (HPV).¹ It is the fourth most common cancer neoplasia in women worldwide.² The two oncogenic genotypes, HPV 16 and 18, are responsible for over 70% of cervical cancers worldwide.¹ Cervical cancer remains a major public health problem worldwide.^3,4 It is the most common gynaecological cancer in developing countries.¹ It is a preventable cancer but is also widespread in many low- and middle-income countries (LMICs), including sub-Saharan Africa (SSA),⁵ South Africa⁶ and Ethiopia,⁷ among others.

Cervical cancer continues to represent a significant burden of morbidity and mortality in LMICs.⁸ It is the leading cause of cancer death among women in 37 countries, mainly in SSA,⁹ the second leading cause of cancer death and one of the 20 leading causes of death among women in Ethiopia.^7,10,11 It ranks among the top five cancers in terms of incidence and mortality in LMICs.¹² Every year, over 650 000 women worldwide are diagnosed with cervical cancer, and more than half of them succumb to the disease.^6,13,14 Lack of awareness and insufficient access to early detection and pre-cancer treatment contribute to high mortality.⁸ Less than one in six eligible girls is vaccinated against HPV worldwide.⁹ Cancer, as a whole, has a negative impact on the economic growth of countries¹⁵ and is a major public health problem, responsible for nearly one in six (16.8%) and one in four (22.8%) deaths from non-communicable diseases (NCDs) worldwide.¹⁶ The disease causes enormous pain and suffering for the individual and has significant negative effects on the well-being of their family and community.¹⁷

In 2022, around 1800 women were diagnosed with cervical cancer and nearly 1000 women died from the disease worldwide.⁹ A study on the integration of opportunistic screening into primary healthcare conducted in Dakar between 2018 and 2021 showed a visual inspection with acetic acid (VIA) positivity of 3.5% (Selmouni 2022).¹⁸

Cervical cancer is one of the easiest forms of cancer to prevent and treat if detected early. Primary cytology screening and molecular HPV testing are important for cervical cancer prevention.¹ Only 36% of women worldwide have been screened for cervical cancer, with major disparities from one country to another (4% in Ethiopia), with almost 100% of women in Sweden and the Netherlands.⁹ In developed countries, over 60% of women have been screened for cervical cancer. However, in SSA, only 12% of women have been screened for precancerous cervical lesions.¹⁹

More than 80% of cervical cancer cases in SSA are detected at late stages, mainly because of the absence or inaccessibility of preventive services.²⁰ Largely because of low uptake of cervical cancer screening (CCS) services,²¹ Senegal ranks 17th worldwide for cervical cancer incidence.²² For women aged 18–69 years in Senegal, the CCS rate is very low (6.9%).^21,23 For women aged from 40 years to 49 years in rural areas of the country, the screening rate is less than 2%.²³ As a result, women often present with advanced cancers. Lessons from higher-resource countries show that incidence and mortality rates are falling, and that premature deaths could be avoided through early detection, follow-up and appropriate treatment.²²

To improve screening rates, it is helpful to understand the factors that contribute to lower screening rates in various contexts.^3,4 Age, place of residence, education, occupation, level of knowledge about cervical cancer and screening and attitude towards CCS are important determinants of the uptake of CCS. Other factors include personal barriers such as fear, lack of knowledge, cultural beliefs and women’s role as caregivers. Systemic barriers include communication problems, shortage of primary care providers and negative health experiences. Motivating factors that prompt women to undergo screening may include a family history of cancer, encouragement from providers and reminders from clinics.⁴ Taking these factors into account when developing policies and programmes could improve uptake of CCS.^4,10

This research focuses on the barriers to screening that result in under-utilisation of screening services. While many studies focus on global factors in CCS, few studies focus specifically on healthcare facilities. This research focuses on the barriers to screening that result in under-utilisation of CCS services in order to further inform the shaping of health policies, the management of health facility-level barriers to screening and, ultimately, to improve screening rates. Hence, this study aims to investigate the barriers to CCS in healthcare facilities in various contexts in Senegal, the Dakar (urban and semi-urban) and Kédougou (rural) regions in 2023.

This study has several strengths, such as the use of a two-stage cluster sampling method and the inclusion of variables related to the use of screening services. Furthermore, the relatively large sample size and the use of multivariate analysis, which helped to account for confounding factors, strengthen the validity of the results. However, a number of limitations are noted, such as the cross-sectional study design and the distribution of the sample across six districts. Additionally, some data are self-reported, which may introduce social desirability and recall biases.

The study found that 18.6% of women had undergone CCS. Factors associated with screening were age, marital status, level of education and healthcare facility-related factors, including hearing about a CCS test or the HPV vaccine, regular attendance at a healthcare facility or traditional healer for care and the professionalism of healthcare facility workers.

In our study, 18.6% of women were screened for cervical cancer. These results are similar to those of Jemal et al., who found that, worldwide, a significant proportion of women make little use of CCS services (only 19.6% screened).²⁵ Yimer et al. found a lower rate of 12.87% in SSA²⁶ and in Ethiopia 4%.²⁶ Our results are below those of the American Cancer Society, where only 36% of women worldwide have been screened for cervical cancer, with significant disparities from one country to another. In Sweden and the Netherlands, nearly 100% of women eligible for screening have undergone it.⁹ Even in nursing cohorts, the CCS rate remains low at 27.7%. Despite being considered a disease of public health importance by 74.0% of nurses,⁶ Lawson et al. found 81% among those who received VIA as their first screening, 19% HPV deoxyribonucleic acid (DNA) testing and less than 1% receiving both at the same time.⁸ Yasin et al. also found low screening at 30.3% among HIV-positive women.¹¹ This difference in screening rates may be explained by the importance attached to this disease or by ignorance or misunderstanding of the disease. Cervical cancer continues to represent a significant burden of morbidity and mortality in LMICs. Strategies must therefore be undertaken to increase screening rates,⁸ such as structured population-based programmes to achieve the goal of eliminating cervical cancer.²⁷ Decentralisation of the screening programme and intensification of efforts at primary and secondary care levels are needed to increase screening performance.²⁸

Our study found a mean age of 36.9 (± 10.2) years among women, and that age is a predictive factor (adjusted odds ratio [ORa] = 1.07 [1.03–1.1]). The older you get, the more likely you are to be screened for cervical cancer. These results concur with those of these authors. For Ezzelarab et al., the average age of women at the time of screening was 38.5 years (± 10.5).²⁷ According to Yimer et al., age is a predictive factor.²⁶ In a study by Legasu et al., age was a significant determinant of CCS uptake.⁷ Gebremeskel et al. also demonstrated belonging to the 18–30 years age group (ORa = 0.46 [0.22–0.98]) as a determinant of CCS uptake among HIV-positive women.¹⁰ Assefa et al. concurred, stating that the 35+ age group is a determinant of CCS uptake.¹⁷

The present study found that higher levels of education from secondary onwards increased the likelihood of screening (ORa = 3.36 [1.57–7.21]). These results confirm those of Legasu, where secondary education is a significant determinant of the use of CCS services,⁷ and Yimer et al.²⁶ and Jemal et al. showed that having a degree (ORa = 0.48 [0.24–0.98] was statistically significantly associated with the use of CCS.²⁵ Gebremeskel et al. also demonstrated a lack of formal education (ORa = 0.25 [0.14–0.45]) and primary education (ORa = 0.28 [0.16–0.49]), as determinants of CCS uptake among HIV-infected women.¹⁰ Heinert et al. demonstrated the delay in CCS, which was significantly higher in patients who did not have a high school diploma (p = 0.01).²⁹

The present study found that 76.4% of those surveyed had heard of cervical cancer, 65.0% had heard of a CCS test, 30.0% had heard of the HPV and 40.7% had heard of the HPV vaccine. A survey of healthcare workers, in this case nurses, showed that the majority had insufficient knowledge about cervical cancer and screening. Among them, 16.0% thought that the cervical cancer vaccine should not be given to girls under 16 years.⁶

Our study found that hearing about a CCS test (ORa = 12.17 [2.6–56.92]) increased the likelihood of screening, as did hearing about the HPV vaccine (ORa = 2.05 [1.03–4.1]). Some authors have demonstrated a significant link between knowledge of the disease and use of screening services. This is the case of Yasin et al., who found that women who were knowledgeable about cervical cancer were 2.54 times more likely to benefit from CCS than those who were uninformed (ORa = 2.54 [1.42–4.56]).¹¹ Yimer et al., in a meta-analysis of seven studies, showed that knowledge of cervical cancer increased screening uptake by a factor of almost five (odds ratio [OR] = 4.81 [3.06–7.54]), and knowledge of screening sites was also a predictive factor.²⁶ Good knowledge of CCS is a significant determinant of the use of CCS services, according to Legasu et al.⁷ Gebremeskel et al. also demonstrated low knowledge of cervical cancer as a determinant of CCS uptake among HIV-infected women.¹⁰ Jemal et al. also demonstrated that knowledge of CCS was associated with CCS uptake.²⁵ Lack of awareness of screening recommendations is a barrier to CCS.^29,30 To improve uptake of screening, healthcare professionals should strive to raise awareness of cervical cancer, improve attitudes towards CCS and advance knowledge of the disease. The collaboration of healthcare providers with governmental and non-governmental stakeholders plays a crucial role in addressing issues of accessibility and uptake of screening services.¹¹ Chitha et al. have highlighted nurses’ lack of knowledge about cervical cancer and negative attitudes towards the HPV vaccine and screening, issues that the healthcare system needs to address urgently. A number of patient and healthcare system barriers affect participation in CCS. All these challenges require a systemic approach to nurse training, capacity building and health system strengthening.⁶ In addition, community uptake of HPV vaccines can only be improved if the attitudes of nurses and other healthcare workers improve, as they will advocate for the uptake of these vaccines by community members. There is a need to improve nurses’ attitudes towards the HPV vaccine and to remove barriers to CCS faced by patients and health systems.⁶

In our study, regular attendance at a healthcare facility for treatment (ORa = 4.34 [1.31–14.28]) increased screening uptake by more than four-fold. It would therefore be advisable to encourage the use of healthcare facilities. In some countries, however, most healthcare facilities do not offer CCS.³¹ According to Heinert et al., the delay in CCS was significantly higher among patients who had not had a routine examination in the previous 5 years (p = 0.01).²⁹ Obstacles to low uptake of screening are highlighted, including lack of health education materials, limitation of service to a specific area, interruption of service, provider incompetence, lack of trust and lack of attention from the trained provider. Contextualised discussions and health promotion through training focused on low levels of knowledge, low levels of education, and the availability of CCS services are essential.²⁵

In our study, regular attendance of a traditional healer for care (ORa = 0.46 [0.22–0.98]) decreased the use of screening. Chitha et al. found reasons, such as belief in traditional medicine, given by patients for not returning for their CCS results.⁶ The attitude of healthcare professionals influences women’s behaviour. Indeed, our study showed that the professionalism of healthcare workers in healthcare facilities is a factor contributing to screening (ORb = 11.11 [1.53–100]). Screening was less observed among women who said their healthcare provider was too far away for them to see him regularly. The healthcare provider’s remoteness for regular visits (ORb = 0.47 [0.27–0.84]) is a determinant of the use of care. One of the reasons given by patients for not returning for their CCS results was lack of transport.⁶

Women who regularly received adequate information and explanations about their health status and care, as well as those who agreed to follow the advice given in healthcare facilities to patients, carried out more screening (ORb = 2.22 [1.11–4.54] and ORb = 8.33 [1.15–50.0], respectively). One strategy for improving CCS is to integrate it into family planning centres, which offers great potential for reaching large numbers of women of childbearing age.⁵ Some strategies are considered effective. These include removing barriers, promoting motivating factors and widening access to screening services to reduce the number of cases and deaths because of breast and cervical cancer.⁴

The uptake of CCS by women was low at 18.6%. Factors associated with screening were age, marital status, level of education and factors related to health facilities, including hearing about a CCS test or the HPV vaccine, regular attendance at a health facility or traditional healer for care and the professionalism of health workers at health facilities. Participation in CCS is low in the districts studied and influenced by several factors. The same situation is observed in SSA. Taking these factors into account when developing policies and programmes could improve the uptake of CCS at district and national levels. It is necessary to strengthen the information and communication policy, educate girls and, above all, review the attitude of health workers to improve the reception and setting in order to increase the use of screening services. Awareness-raising and health promotion targeting the predictive factors identified are important to increase the use of screening services.