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Lifetime Prevalence of Cervical Cancer Screening in 55 Low- and Middle-Income Countries

Educational Objective
To understand why the prevalence of cervical cancer screening varies among low- and middle-income countries.
1 Credit CME
Key Points

Question  What is the lifetime prevalence of cervical cancer screening in 55 low- and middle-income countries?

Findings  In this cross-sectional study based on self-reported data collected in 55 countries between 2005 and 2018, the country-level median lifetime prevalence of cervical cancer screening was 43.6% (range, 0.3%-97.4%).

Meaning  Although a wide range of variation in self-reported cervical cancer screening prevalence existed among these countries, the overall findings support the need to increase the rate of screening.

Abstract

Importance  The World Health Organization is developing a global strategy to eliminate cervical cancer, with goals for screening prevalence among women aged 30 through 49 years. However, evidence on prevalence levels of cervical cancer screening in low- and middle-income countries (LMICs) is sparse.

Objective  To determine lifetime cervical cancer screening prevalence in LMICs and its variation across and within world regions and countries.

Design, Setting, and Participants  Analysis of cross-sectional nationally representative household surveys carried out in 55 LMICs from 2005 through 2018. The median response rate across surveys was 93.8% (range, 64.0%-99.3%). The population-based sample consisted of 1 136 289 women aged 15 years or older, of whom 6885 (0.6%) had missing information for the survey question on cervical cancer screening.

Exposures  World region, country; countries’ economic, social, and health system characteristics; and individuals’ sociodemographic characteristics.

Main Outcomes and Measures  Self-report of having ever had a screening test for cervical cancer.

Results  Of the 1 129 404 women included in the analysis, 542 475 were aged 30 through 49 years. A country-level median of 43.6% (interquartile range [IQR], 13.9%-77.3%; range, 0.3%-97.4%) of women aged 30 through 49 years self-reported to have ever been screened, with countries in Latin America and the Caribbean having the highest prevalence (country-level median, 84.6%; IQR, 65.7%-91.1%; range, 11.7%-97.4%) and those in sub-Saharan Africa the lowest prevalence (country-level median, 16.9%; IQR, 3.7%-31.0%; range, 0.9%-50.8%). There was large variation in the self-reported lifetime prevalence of cervical cancer screening among countries within regions and among countries with similar levels of per capita gross domestic product and total health expenditure. Within countries, women who lived in rural areas, had low educational attainment, or had low household wealth were generally least likely to self-report ever having been screened.

Conclusions and Relevance  In this cross-sectional study of data collected in 55 low- and middle-income countries from 2005 through 2018, there was wide variation between countries in the self-reported lifetime prevalence of cervical cancer screening. However, the median prevalence was only 44%, supporting the need to increase the rate of screening.

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Article Information

Corresponding Author: Pascal Geldsetzer, MBChB, ScD, MPH, Division of Primary Care and Population Health, Department of Medicine, Stanford University, 1265 Welch Rd, Stanford, CA 94305 (pgeldsetzer@stanford.edu).

Accepted for Publication: August 10, 2020.

Author Contributions: Ms Lemp and Dr Geldsetzer had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Lemp, De Neve, Ebert, Tsabedze-Sibanyoni, Martins, Vollmer, Bärnighausen, Geldsetzer.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Lemp, Manne-Goehler, Tsabedze-Sibanyoni, Davies, Geldsetzer.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Lemp, De Neve, Chen, Ebert, Gathecha, Bärnighausen, Geldsetzer.

Obtained funding: Manne-Goehler, Geldsetzer.

Administrative, technical, or material support: Bussmann, Chen, Manne-Goehler, Theilmann, Marcus, Tsabedze-Sibanyoni, Kibachio, Moghaddam, Martins, Gurung, Farzadfar, Bärnighausen.

Supervision: Sturua, Farzadfar, Davies, Vollmer, Bärnighausen, Geldsetzer.

Other - Review of results and policy implications of the results: Atun.

Other - Data visualization: Probst.

Conflict of Interest Disclosures: Dr Dryden-Peterson reported receiving personal fees from UpToDate Inc outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Tsabedze-Sibanyoni reported receiving grants from the WHO and nonfinancial support from Eswatini Ministry of Health during the conduct of the study. Dr Bärnighausen was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the Federal Ministry of Education and Research; the German Research Foundation; the Wellcome Trust; and by grants R01-HD084233 from the National Institute of Child Health and Human Development, P01-AG041710 from the National Institute on Aging, R01-AI124389 and R01-AI112339 from the National Institute of Allergy and Infectious Diseases, and D43-TW009775 from the Fogarty International Center, all of the of National Institutes of Health. Dr Geldsetzer was supported by grant KL2TR003143 from the National Center for Advancing Translational Sciences of the National Institutes of Health. Dr De Neve was supported by the Alexander von Humboldt Foundation. Dr Manne-Goehler was supported by grant T32 AI007433 from the National Institute of Allergy and Infectious Diseases. This study uses data from multiple STEPS surveys (as specified in the Table), which were implemented by the respective Ministry of Health with the support of the WHO. This study uses data from WHO’s Study on Global Ageing and Adult Health (SAGE). SAGE is supported by the US National Institute on Aging through Interagency Agreements OGHA 04034785; YA1323-08-CN-0020; Y1-AG-1005-0, and through research grants R01-AG034479 and R21-AG034263. This study is also based on data from Eurostat, European Health Survey 2014.

Role of the Funder/Sponsor: Funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank each of the survey teams and study participants who made this analysis possible, the Sri Lankan Department of Census and Statistics for providing us with data from the Sri Lanka 2016 DHS survey, and Anju Ranjit, MD, MPH, Howard University Hospital, for providing us with data from the Nepal 2014 SOSAS survey for which she was not compensated.

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