Uptake of Cervical Cancer Screening and Its Determinants among Refugee Women in Uganda: Insights from the Uganda Refugee Population-based HIV Impact Assessment
Abstract
Cervical cancer is the fourth most common cancer in women globally, with 660,000 new cases and 350,000 deaths in 2022. The burden is disproportionately high in low- and middle-income countries (LMICs), particularly sub-Saharan Africa. Despite proven interventions like HPV vaccination and screening, uptake remains low. While cervical cancer screening has been studied in the general population, little is known about uptake among refugee women in Uganda, which hosts approximately 1.7 million refugees. This study examines cervical cancer screening uptake and associated factors among refugee women in Uganda.
Methods
We conducted a cross-sectional secondary analysis of the 2021 Uganda Refugee Population-based HIV Impact Assessment (RUPHIA) survey, focusing on women aged 21–49 in refugee settlements in the West Nile and South-Western regions, which host 90% of Uganda’s refugee population. The primary outcome was self-reported cervical cancer screening status. We used descriptive statistics and logistic regression to identify factors associated with screening uptake.
Results
Among 731 women, only 72 (9.8%) reported undergoing cervical cancer screening. The mean age of screened women was 37 years (±7), compared to 32 years (±8) for unscreened women. Screening uptake was significantly higher among women aged 31–39 years (AOR = 2.67, 95% CI: 1.32–5.52, p = 0.007), married women (AOR = 12.0, 95% CI: 1.76–163, p = 0.03), and those in polygamous relationships (AOR = 4.76, 95% CI: 1.96–11.1, p < 0.001)
Conclusion
Cervical cancer screening uptake among refugee women in Uganda is critically low. Integrating culturally sensitive screening programs into refugee health services and addressing socio-economic barriers could improve access and utilization.
Author Contributions
Academic Editor: Anubha Bajaj, Consultant Histopathologist, A.B. Diagnostics, Delhi, India.
Checked for plagiarism: Yes
Review by: Single-blind
Copyright © 2025 Kikonyogo Steven, et al.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Competing interests
The authors have declared that no competing interests exist.
Citation:
Introduction
Cervical cancer ranks as the fourth most common cancer among women, with an estimated 660,000 new cases and 350,000 deaths recorded in 2022 alone 1,2. Although it is a global public health concern, low- and middle-income countries (LMICs) bear approximately 85% of the burden, with the highest incidence and mortality rates concentrated in Eastern and Southern Africa 3,4 Evidence demonstrates that comprehensive HPV vaccination coupled with precancer screening can significantly reduce cervical cancer incidence and mortality 5,6, potentially preventing 5.2 million cases and 3.7 million deaths over a decade 7. However, despite such interventions, cervical cancer remains a leading cause of death in sub-Saharan Africa and other LMICs 8.
In 2020, the World Health Organization (WHO) introduced the 90-70-90 targets, aiming to vaccinate 90% of girls by age 15, screen 70% of eligible women, and ensure 90% of women diagnosed with cervical cancer receive appropriate treatment by 2030 9.While high-income countries (HICs) have achieved an average screening coverage of 63%, LMICs lag behind with only 19% 10. Yet, uptake remains alarmingly low, with vaccination rates between 9–10% 11, 12, with only 7.5% having been screened in the last five years 12, screening coverage at 7.5% in the last five years, and only 4.8% in rural areas 13. While studies have explored barriers to cervical cancer screening in various populations, little attention has been given to refugees, despite Uganda hosting approximately 1.7 million refugees as of 2024, making it the fifth-largest refugee-hosting country globally 14. Although international organizations such as the United Nations High Commissioner for Refugees (UNHCR) provide basic health services, utilization rates remain lower among refugees, and the burden of cervical cancer, as well as awareness of risk factors, is poorly documented in this group 15. This study seeks to address this gap by examining cervical cancer screening uptake and associated factors among refugee women residing in Uganda, shedding light on their unique healthcare needs and informing strategies to improve preventive care in this underserved population.
Study Design and Setting
This study employed a cross-sectional design using secondary data from the 2021 Uganda Refugee Population-based HIV Impact Assessment (RUPHIA 2021), conducted between October and December 202116. The survey collected cervical cancer screening data through self-reported responses. Participants were asked whether they had ever undergone cervical cancer screening and the timing of their most recent screening. A structured questionnaire was administered to eligible women as part of the survey. The RUPHIA 2021 survey employed a two-stage cluster sampling design. In Stage 1, refugee settlements were selected as primary sampling units (PSUs), stratified by region. In Stage 2, households within selected settlements were systematically sampled, and eligible individuals (adults aged 15 years and older) were recruited for participation. The survey was led by the Government of Uganda through the Ministry of Health, with technical and financial support from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Centers for Disease Control and Prevention (CDC). Implementation was carried out by ICAP at Columbia University, in collaboration with other government agencies and partners.
Study population and sample size
The survey was conducted in the West Nile and South-Western regions of Uganda, which collectively host approximately 90% of all refugees in the country 17. The study population comprised adults aged 15 years and older residing in these refugee settlements. A total of 1,877 respondents participated in the survey, selected based on prior HIV prevalence data from similar surveys. For this analysis, the focus was narrowed to women aged 21–49 years, based on cervical cancer screening guidelines. The American College of Obstetricians and Gynecologists (ACOG) recommends screening for women aged 21–49 18, while the World Health Organization (WHO) recommends earlier screening for women at higher risk, such as those living with HIV 19. Of the total survey respondents, 731 women aged 21–49 years were included in this analysis.
Study Variables
The study population comprised adults aged 15 years and older residing in these refugee settlements. A total of 1,877 respondents participated in the survey, selected based on prior HIV prevalence data from similar surveys. For this analysis, the focus was narrowed to women aged 21–49 years, based on cervical cancer screening guidelines. The American College of Obstetricians and Gynecologists (ACOG) recommends screening for women aged 21–49 18, while the World Health Organization (WHO) recommends earlier screening for women at higher risk, such as those living with HIV 19. Of the total survey respondents, 731 women aged 21–49 years were included in this analysis. The primary outcome variable was cervical cancer screening status, categorized as either screened or not screened based on the respondents' self-reported responses. Independent variables included the following demographic, socio-economic, and health-related factors: Age categorized as (21–30, 31–40, and 41–49 years), Years lived in the settlement categorized as (0–2, 3–5, and 6+ years), Marital status classified as (never married, married, or widowed/separated), Education level grouped into (never attended school, primary, secondary, and tertiary education), Number of live births (parity) categorized as (0, 1–5, and 6+ children), Relationship type classified as (polygamous, non-polygamous, or not in a union), HIV status classified as (positive or negative), HIV testing history classified as Whether the respondent had ever been tested for HIV (yes or no), Socio-economic status (derived from wealth quintiles and categorized as low (quintiles 1–2), middle (quintile 3), or high (quintiles 4–5)). The wealth quintiles were calculated using the DHS Wealth Index 20.
Data Analysis
The data analysis was performed using R version 4.1.2 (2021-11-01). As the proportion of missing data was negligible, cases with missing values were excluded from the analysis. The uptake of cervical cancer screening was calculated as the percentage of women aged 21-49 years who participated in the survey and reported having undergone screening.
Descriptive statistics were used to summarize the demographic and socio-economic characteristics of the study population, while bivariate and multivariate analyses assessed associations between independent variables and cervical cancer screening status. Results were reported as odds ratios (ORs) with corresponding 95% confidence intervals (CIs).
A significance level of p < 0.05 was considered statistically significant for the final model, and all confounding variables were controlled for in the multivariate analysis to ensure accurate estimation of the associations. The potential for missing data was not addressed through imputation or other methods, and cases with missing values were excluded from the analysis
Results
Of the 731 participants, 72 (9.8%) reported having undergone cervical cancer screening. The mean age of screened women was 37 (±7) years, compared to 32 (±8) years for unscreened women. The majority of screened respondents, 67 (93.0%) were residents in the area for at least 6 years.
Majority of respondents, 351 (48%) were in age group 21 – 30. A significant proportion, 434 (59.4%) were based in the Southwestern region. Majority, 619 (84.7%) had lived in that area at least six years. The biggest number, 456 (62.4%) of respondents had attended primary education. Majority, 451 (61.7%) were married and about 416 (57.0%) were in a non-polygamous relation type. A significant proportion, 295 (40.4%) were of low socio-economic status. Majority of those screened, 42 (58.3%) were married women (Table 1).
Table 1. Socio-demographic Characteristics and health outcomes by Cervical Cancer Screening Status blastocyst grades| Characteristic | Category | Not screened f (%) | Screened f (%) |
|---|---|---|---|
| Age group | |||
| 21–30 | 329 (49.9) | 22 (30.6) | |
| 31–39 | 227 (34.5) | 36 (50.0) | |
| 40–49 | 103 (15.6) | 14 (19.4) | |
| Region | |||
| West-Nile | 263 (39.9) | 34 (47.2) | |
| South-Western | 396 (60.1) | 38 (52.8) | |
| Country of origin | |||
| Burundi | 30 (4.6) | 3 (4.2) | |
| Rwanda | 17 (2.6) | 2 (2.8) | |
| DRC | 265 (40.2) | 23 (31.9) | |
| South-Sudan | 297 (45.0) | 35 (48.6) | |
| Others | 50 (7.6) | 9 (12.5) | |
| Religion | |||
| Catholic | 163 (24.7) | 19 (26.4) | |
| Anglican/Protestant | 266 (40.4) | 26 (36.1) | |
| Pentecostal | 161 (24.4) | 11 (15.3) | |
| Muslim | 21 (3.2) | 7 (9.7) | |
| Others | 48 (7.3) | 9 (12.5) | |
| Years lived in the area | |||
| 0–2 | 29 (4.4) | 2 (2.8) | |
| 3–5 | 78 (11.8) | 3 (4.2) | |
| 6+ | 552 (83.8) | 67 (93.0) | |
| Marital status | |||
| Never married | 86 (13.0) | 4 (5.6) | |
| Married | 409 (62.1) | 42 (58.3) | |
| Widowed/Separated | 164 (24.9) | 26 (36.1) | |
| Relationship type | |||
| Polygamous | 38 (5.8) | 11 (15.3) | |
| Non-polygamous | 388 (58.9) | 28 (38.9) | |
| Not in union/Don’t know | 233 (35.3) | 33 (45.8) | |
| Education level | |||
| Never attended | 96 (14.6) | 8 (11.1) | |
| Primary | 411 (62.4) | 45 (62.5) | |
| Secondary | 143 (21.7) | 18 (25.0) | |
| Tertiary | 9 (1.3) | 1 (1.4) | |
| Socio-economic status | |||
| Low | 268 (40.7) | 27 (37.5) | |
| Middle | 240 (36.4) | 28 (38.9) | |
| High | 151 (22.9) | 17 (23.6) | |
| HIV status | |||
| Positive | 18 (2.7) | 5 (6.9) | |
| Negative | 641 (97.3) | 67 (93.1) | |
| Parity (Number of children) | |||
| 0 | 40 (6.1) | 2 (2.8) | |
| 1–5 | 412 (62.5) | 47 (65.3) | |
| 6+ | 207 (31.4) | 23 (31.9) | |
At the univariable analysis level, factors significantly associated with cervical cancer screening included marital status (p = 0.027), relationship type (p < 0.001), age group (p = 0.002), and having ever been tested for HIV (p = 0.031). In the multivariable analysis, the independent factors significantly associated with cervical cancer screening were marital status (p = 0.03), relationship type (p < 0.001), age group (p = 0.003), and having ever been tested for HIV (p = 0.031) (Table 2).
Table 2. Univariable and Multivariable Analysis of Cervical Cancer Screening Determinants| Univariable Analysis | Multivariable Analysis | ||||||
| Characteristic | Category | OR | 95% CI | p-value | OR | 95% CI | p-value |
| Age group | |||||||
| 21–30 | – | – | – | – | – | – | |
| 31–39 | 2.37 | 1.37, 4.19 | 0.002 | 2.67 | 1.32, 5.52 | 0.007 | |
| 40–49 | 2.03 | 0.98, 4.08 | 0.049 | 2.17 | 0.852, 5.43 | 0.1 | |
| Years lived in the area | |||||||
| 0–2 yrs | – | – | – | – | – | – | |
| 3–5 yrs | 0.56 | 0.09, 4.39 | 0.5 | 0.37 | 0.05, 3.12 | 0.3 | |
| 6+ yrs | 1.76 | 0.51, 11.0 | 0.4 | 1.33 | 0.35, 8.79 | 0.7 | |
| Marital status | |||||||
| Never married | – | – | – | – | – | – | |
| Married | 2.21 | 0.87, 7.50 | 0.14 | 12 | 1.76, 163 | 0.03 | |
| Widowed/Separated | 3.41 | 1.28, 11.8 | 0.027 | 1.16 | 0.38, 4.37 | 0.8 | |
| Relationship type | |||||||
| Non-Polygamous | – | – | – | – | – | – | |
| Polygamous | 4 | 1.79, 8.33 | <0.001 | 4.76 | 1.96, 11.11 | <0.001 | |
| Not in union | 1.96 | 0.88, 4.17 | 0.084 | 0.24 | 0.02, 1.82 | 0.2 | |
| Education level | |||||||
| Never attended | – | – | – | – | – | – | |
| Primary | 1.31 | 0.63, 3.09 | 0.5 | 1.68 | 0.71, 4.54 | 0.3 | |
| Secondary | 1.51 | 0.65, 3.81 | 0.4 | 2.37 | 0.89, 6.98 | 0.1 | |
| Tertiary | 1.33 | 0.07, 8.56 | 0.8 | 2.37 | 0.11, 19.4 | 0.5 | |
| Socio-economic status | |||||||
| Low | – | – | – | – | – | – | |
| Middle | 1.16 | 0.66, 2.03 | 0.6 | 1.15 | 0.61, 2.15 | 0.7 | |
| High | 1.12 | 0.58, 2.10 | 0.7 | 1 | 0.45, 2.17 | >0.9 | |
| Ever tested for HIV | |||||||
| Yes | – | – | – | – | – | – | |
| No | 0.11 | 0.01, 0.52 | 0.031 | 0.15 | 0.01, 0.75 | 0.067 | |
| HIV status | |||||||
| Positive | – | – | – | – | – | – | |
| Negative | 0.38 | 0.15, 1.17 | 0.062 | 0.46 | 0.16, 1.54 | 0.2 | |
| Parity (Number of children) | |||||||
| 0 | – | – | – | – | – | – | |
| 1–5 | 2.28 | 0.67, 14.3 | 0.3 | 1.01 | 0.25, 6.92 | >0.9 | |
| 6+ | 2.22 | 0.62, 14.2 | 0.3 | 0.73 | 0.15, 5.49 | 0.7 | |
Discussion
Several studies have examined cervical precancer screening inequalities related to age, residence, education level, marital status and socio-economic status 21, 22, 23, 24. In our study, women aged 31-39 were more likely to have undergone screening, with their odds of being screened being 2.5 times higher than those in the 21-30 age group. The finding is consistent with majority of studies done in Uganda and beyond. A study conducted in central Uganda examining predictors of cervical cancer screening uptake among women aged 25–49, the findings revealed that women in the 30–39 age bracket had higher screening rates than their younger and older counterparts 25. A systematic review of barriers and facilitators of uptake of cervical cancer screening among women in Uganda highlighted that, despite the availability of screening services, overall uptake in Uganda remains low, with lifetime screening rates between 4.8% and 30%, with women in their 30s more proactive in seeking screening services, influenced by factors like health consciousness and family planning considerations 25. This is could be, women in this age group are be more likely to seek healthcare due to increased awareness or health concerns as they grow older. Normally, women in their 30s often become more health-conscious and proactive about preventive care as they recognize the importance of regular check-ups and maintaining their health for themselves and their families. As they visit healthcare providers more frequently for family planning, pregnancy, or postpartum care, this creates opportunities for providers to recommend screening.
Socio-cultural factors, such as the influence of marital status, and relationship type in majority of Sub-Saharan countries play a role in health decisions. Married women and those in polygamous union possibly having greater access to healthcare through their spouses or family networks. Women in polygamous relationships may also recognize a higher potential risk of exposure to sexually transmitted infections (STIs), including HPV, because their partners may have multiple sexual partners. This increased perceived risk can drive them to seek preventive measures like cervical cancer screening. A study conducted in Nigeria assessed married men's knowledge and attitudes towards cervical cancer screening. Findings indicated that men were generally supportive of their wives undergoing screening 26
The absence of an association between socio-economic status and screening uptake is particularly noteworthy. In many LMICs, wealth is a known determinant of healthcare access, with poorer women being less likely to access screening services 21, 27. A study of 18 resource-constrained countries, of which eight were from sub-Saharan Africa further found that wealth status increased socioeconomic inequalities in cervical precancer screening 28. In addition, studies that have found low screening rates among women without formal education. In contrast, our study did not find education or socio-economic status to be a significant predictor of screening uptake 29 However, in the refugee context, where there is a degree of uniformity in socio-economic conditions, the typical barriers associated with wealth disparities may not be as pronounced. Additionally, the homogeneity of the refugee community in terms of access to resources and healthcare services might have minimized the impact of socio-economic status on screening behavior.
Conclusion
Our study reveals that a significant proportion of refugee women in Uganda remain at risk for cervical cancer due to low screening uptake. Public health strategies should be tailored to the unique socio-cultural context of refugee communities that include integrating cervical cancer screening programs into refugee health services and ensuring these services are accessible to all women, regardless of their socio-economic status or marital situation.
Limitations of the study
Firstly, the study relied on self-reported data, which is subject to recall bias. Secondly, the use of secondary data made key variables of interest, such as knowledge of cervical cancer, awareness of screening programs, or reasons for not screening not available limiting the scope of the analysis.
References
- 1.Stelzle D, Tanaka L F, Lee K K. (2021) Estimates of the global burden of cervical cancer associated with HIV. Lancet Glob Health. 9-2.
- 3.Sung H, Ferlay J, Siegel R L. (2021) Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. , CA Cancer 71(3), 209-249.
- 4.Abila D B, Wasukira S B, Ainembabazi P. (2024) . Coverage and Socioeconomic Inequalities in Cervical Cancer Screening in Low- and Middle-Income Countries Between 2010 and 2019. JCO Glob Oncol 10-1200.
- 5. (2021) WHO guideline for screening and treatment of cervical pre-cancer lesions for cervical cancer prevention use of mRNA tests for human papillomavirus (HPV). Published online 51
- 6. (2020) World Health Organization. Global strategy to accelerate the elimination of cervical cancer as a public health problem. World Health Organization. 1-56. Accessed. https://www.who.int/publications/i/item/9789240014107
- 7.Campos N G, Sharma M, Clark A. (2017) The health and economic impact of scaling cervical cancer prevention in 50 low- and lower-middle-income countries. , Int J Gynaecol Obstet 138, 47-56.
- 8.Hull1 R, Mbele M, Makhafola T. (2020) Cervical cancer in low and middle-income countries. Oncol Lett. 10-3892.
- 9.Davies-Oliveira J C, Smith M A, Grover S, Canfell K, Crosbie E J. (2021) Eliminating Cervical Cancer: Progress and Challenges for High-income Countries. Clin Oncol (R Coll Radiol). 33(9), 550-559.
- 10.Gakidou E, Nordhagen S, Obermeyer Z. (2008) Coverage of cervical cancer screening in 57 countries: low average levels and large inequalities. PLoS Med. 5(6), 0863-0868.
- 11.Isabirye A, Mbonye M, Asiimwe J B, Kwagala B. (2020) Factors associated with HPV vaccination uptake in Uganda: A multi-level analysis. BMC Womens Health. 20(1), 1-11.
- 12.Kabanda R, Kiconco A, Ronald A, KMM Beyer, John S A. (2024) Correlates of intention to screen for cervical cancer among adult women in Kyotera District, Central Uganda: a community based cross-sectional study. BMC Womens Health. 24(1), 1-8.
- 15.Adoch W, Garimoi C O, Scott S E. (2020) Knowledge of cervical cancer risk factors and symptoms among women in a refugee settlement: a cross-sectional study in northern Uganda. Confl Health. 14(1), 85-10.
- 16. (2021) Uganda Refugee Population-based HIV Impact Assessment. Summary Sheet - PHIA Project 2020-2021.
- 18.Updated Cervical Cancer Screening Guidelines | ACOG. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2021/04/updated-cervical-cancer-screening-guidelines
- 19.Sung H, Ferlay J, Siegel R L. (2021) Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. , CA Cancer 71(3), 209-249.
- 21.Chipanta D, Kapambwe S, Nyondo-Mipando A L. (2023) Socioeconomic inequalities in cervical precancer screening among women in. , Ethiopia, Malawi, Rwanda, Tanzania, Zambia, BMJ Open 13(6), 10-1136.
- 22.Ayenew A A, Zewdu B F, Nigussie A A. (2020) Uptake of cervical cancer screening service and associated factors among age-eligible women in Ethiopia: systematic review and meta-analysis. Infect Agent Cancer. 15-1.
- 23.Campos N G, Tsu V, Jeronimo J, Mvundura M, Kim J J. (2017) Evidence-based policy choices for efficient and equitable cervical cancer screening programs in low-resource settings. Cancer Med. 6(8), 2008-2014.
- 24.Adoch W, Garimoi C O, Scott S E. (2020) Knowledge of cervical cancer risk factors and symptoms among women in a refugee settlement: a cross-sectional study in northern Uganda. Confl Health. 14(1), 85-10.
- 25.Isabirye A, Mbonye M K, Kwagala B. (2020) Predictors of cervical cancer screening uptake in two districts of Central Uganda. PLoS One. 15-12.
- 26.Okedo-Alex I N, Uneke C J, Uro-Chukwu H C, Akamike I C, Chukwu O E. (2020) It is what I tell her that she will do”: a mixed methods study of married men’s knowledge and attitude towards supporting their wives’ cervical cancer screening in rural South-East Nigeria. Pan Afr Med. 36-156.
- 27.Abila D B, Wasukira S B, Ainembabazi P. (2024) . Coverage and Socioeconomic Inequalities in Cervical Cancer Screening in Low- and Middle-Income Countries Between 2010 and 2019. JCO Glob Oncol 10-1200.