Assessing the socioeconomic inequalities in cervical cancer screening in sub-Saharan Africa: a decomposition analysis – International Journal for Equity in Health

Report on Cervical Cancer Screening and its Alignment with Sustainable Development Goals

This report synthesizes current research on the global burden of cervical cancer, screening disparities, and strategic initiatives, with a significant emphasis on their intersection with the United Nations Sustainable Development Goals (SDGs). The analysis draws upon global cancer statistics, demographic and health surveys, and targeted studies, primarily focusing on low- and middle-income countries (LMICs), particularly in sub-Saharan Africa.

The Global Burden of Cervical Cancer: A Challenge to SDG 3

Cervical cancer remains a significant global health issue, posing a direct threat to the achievement of SDG 3 (Good Health and Well-being), specifically Target 3.4, which aims to reduce premature mortality from non-communicable diseases. Global cancer statistics from 2018 and 2020 confirm its substantial incidence and mortality rates, making it the fourth most common cancer among women worldwide. The burden is disproportionately borne by LMICs, where approximately 90% of deaths from cervical cancer occur, highlighting a critical gap in global health equity.

WHO’s Global Strategy for Elimination

In response to this challenge, the World Health Organization (WHO) has launched a “Global strategy to accelerate the elimination of cervical cancer as a public health problem.” This initiative is a cornerstone of efforts to achieve SDG 3 and is built upon three key pillars:

1. Vaccination: 90% of girls fully vaccinated with the HPV vaccine by age 15.
2. Screening: 70% of women screened with a high-performance test by age 35 and again by age 45.
3. Treatment: 90% of women identified with cervical disease receive treatment.

Achieving these “90-70-90” targets is projected to significantly reduce mortality, demonstrating a clear pathway to advancing global health and promoting well-being for all women, in line with SDG 5 (Gender Equality).

Inequalities in Screening: A Barrier to SDG 10

A primary obstacle to eliminating cervical cancer is the profound inequality in access to and utilization of screening services. This disparity directly contravenes SDG 10 (Reduced Inequalities). Research consistently demonstrates that screening uptake is critically low in sub-Saharan Africa, the region with the highest disease burden.

Socioeconomic and Geographic Determinants

Analysis of demographic and health survey data from numerous sub-Saharan African countries reveals a consistent pattern of socioeconomic disparity in screening uptake. These inequalities are linked to several SDGs:

• Wealth (SDG 1 – No Poverty): Women from wealthier households are significantly more likely to be screened than their poorer counterparts. Economic barriers prevent access to necessary health services.
• Education (SDG 4 – Quality Education): Higher levels of education are strongly correlated with increased screening uptake, as knowledge influences health-seeking behaviors and awareness of preventive care.
• Geography (SDG 11 – Sustainable Cities and Communities): Urban residents often have better access to screening facilities than rural populations. The distance to a health facility is a documented barrier for many women in rural areas.
• Healthcare Decision-Making (SDG 5 – Gender Equality): Women’s autonomy in healthcare decisions is a crucial factor influencing their ability to seek and receive preventive care like cervical cancer screening.

Barriers and Challenges in Sub-Saharan Africa

The challenges to implementing effective screening programs in sub-Saharan Africa are multifaceted, reflecting systemic issues that hinder progress towards universal health coverage (Target 3.8).

Identified Barriers

• Low Screening Coverage: Despite global recommendations, lifetime screening prevalence remains exceptionally low across the region.
• Systemic Challenges: Weak health systems, lack of infrastructure for HPV testing, and insufficient trained personnel pose significant hurdles.
• Socio-demographic Factors: Beyond wealth and education, factors such as age, marital status, and history of sexually transmitted infections also influence screening behavior.
• Lack of Awareness: Insufficient knowledge about cervical cancer, its causes, and the benefits of screening is a major reason for non-attendance in many communities.

Conclusion: An Integrated Approach for a Sustainable Future

Eliminating cervical cancer is an achievable public health goal, but it requires an integrated approach that addresses the root causes of inequality. Efforts must align with the broader 2030 Agenda for Sustainable Development. To create a cervical cancer-free future, policies must focus on strengthening health systems, ensuring equitable access to vaccination and screening, and empowering women through education and economic opportunity. By tackling these interconnected challenges, the global community can advance SDG 3, SDG 5, and SDG 10, ensuring a healthier and more equitable future for all women and girls.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

1. SDG 3: Good Health and Well-being
   • The core theme of the provided references is cervical cancer, a significant global health issue. The articles discuss its incidence, mortality, prevention through screening and vaccination, and treatment. This directly aligns with SDG 3’s mission to “ensure healthy lives and promote well-being for all at all ages.” References such as “Global cancer statistics” (4, 5), “Burden of cervical cancer in Sub-Saharan Africa” (6), and “Mortality impact of achieving WHO cervical cancer elimination targets” (9) explicitly address health outcomes and disease burden.
2. SDG 5: Gender Equality
   • Cervical cancer exclusively affects women, and addressing it is fundamental to ensuring women’s health and well-being, a key component of gender equality. The references focus on issues like “women’s healthcare decision making and cervical cancer screening uptake” (17) and screening among “rural women in the Akyemansa District of Ghana” (1), highlighting the gender-specific nature of this health challenge and the need to empower women with access to healthcare.
3. SDG 10: Reduced Inequalities
   • The references repeatedly highlight disparities in cervical cancer burden and access to care. They point to inequalities between “low-income and lower-middle-income countries” (9) and other nations, as well as socioeconomic inequalities within countries. Articles titled “Explaining socioeconomic inequality in cervical cancer screening uptake in Malawi” (20) and “Socioeconomic disparities in the uptake of…cervical cancer screening” (37) directly address the link between economic status and health access, which is a central focus of SDG 10.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. Target 3.4: Reduce premature mortality from non-communicable diseases (NCDs)
   • Cervical cancer is a non-communicable disease. The references extensively cover its mortality rates (“Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide,” 5) and strategies to reduce deaths through prevention and treatment (“Mortality impact of achieving WHO cervical cancer elimination targets,” 9). This directly relates to the goal of reducing premature mortality from NCDs.
2. Target 3.8: Achieve universal health coverage (UHC)
   • The discussion on “Barriers to utilisation of cervical cancer screening” (12), “cervical cancer screening coverage in sub-Saharan Africa” (14), and the “Global strategy to accelerate the elimination of cervical cancer” (35) all point towards the goal of ensuring everyone has access to essential health services. Screening and HPV vaccination are key preventative services, and improving their uptake is a step towards UHC.
3. Target 5.6: Ensure universal access to sexual and reproductive health and reproductive rights
   • Cervical cancer prevention, including HPV vaccination and screening, is an integral part of comprehensive sexual and reproductive healthcare for women. The focus on “women’s healthcare decision making” (17) and overcoming barriers to screening services in regions like sub-Saharan Africa (12, 13) aligns with ensuring women have access to and control over their reproductive health.
4. Target 10.2: Promote the social and economic inclusion of all
   • The references that analyze “socioeconomic inequality in cervical cancer screening uptake” (20, 21) demonstrate how economic status creates barriers to essential health services. By identifying these disparities, the research supports the aim of Target 10.2, which is to ensure that factors like economic status do not prevent individuals from accessing opportunities and services, including healthcare.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. Indicator 3.4.1: Mortality rate attributed to cancer
   • This indicator is directly addressed in references like “Global cancer statistics… GLOBOCAN estimates of incidence and mortality worldwide” (4, 5) and “Cervical cancer survival in sub-Saharan Africa” (16). These studies provide the data necessary to track mortality rates from cervical cancer, allowing for measurement of progress under Target 3.4.
2. Indicator 3.8.1: Coverage of essential health services
   • The article implies this indicator through numerous references measuring “cervical cancer screening coverage” (14), “screening uptake” (19, 41), and “progress with HPV vaccination” (6). These metrics are direct measures of the reach of essential preventative health services for cervical cancer, which is a component of UHC.
3. Implied Indicator: Cervical cancer screening uptake disaggregated by socioeconomic status
   • While not an official SDG indicator, this metric is crucial for monitoring progress on SDG 10. References such as “Explaining socioeconomic inequality in cervical cancer screening uptake” (20) and the use of the “DHS wealth index” (26, 27) in analysis show a clear focus on measuring how screening rates differ across wealth quintiles. This disaggregated data is essential for understanding and reducing health inequalities.

4. Table of SDGs, Targets, and Indicators

Source: equityhealthj.biomedcentral.com