Socioeconomic inequalities in cervical pre-cancer screening among women in Ethiopia, Malawi, Rwanda, Tanzania, Zambia, and Zimbabwe – Analysis of Population-Based HIV Impact Assessment surveys

Abstract Background: Screening for cervical pre-cancerous lesions may be inequitable among women in sub-Saharan African countries. This study examined age, residence, education and wealth inequalities and their combinations on cervical pre-cancer screening in Ethiopia, Malawi, Rwanda, Tanzania, Zambia, and Zimbabwe. Methods: We used the Population-Based HIV Impact Assessment (PHIA) data, including cervical pre-cancer screening variables and measured the magnitude of inequality between subgroups in percentages points, considering differences of 20%+ as high inequality, 5% to 20% medium, 0 to 5% as low. We described the sample characteristics using descriptive statistics for each country and examined the associations between cervical pre-cancer screening and each inequality. We analysed the differences using multivariable logistic regressions, controlling for covariates. We estimated the inequalities in cervical pre-cancer screening probability for each inequality alone and in combinations using marginal effects models. Results: The sample size of females aged 25–49 years ranged from 5882 in Ethiopia to 9186 in Tanzania. Self-reported cervical pre-cancer screening was low in the surveyed countries ranging from 3.5% (95% Confidence Interval (CI) 3.1%–4.0%) in Rwanda to 17.1% (95% CI 15.8%–18.5%) and 17.4% (95% CI16.1%–18.8%) in Zambia and Zimbabwe. Inequalities in cervical pre-cancer screening were low based on age, residence, education, and wealth. Combining the inequalities led to significant inequalities in self-reported cervical pre-cancer screening between rural dwelling women aged 25–34 years, in the lowest wealth quintile, with a primary education level, and urban dwelling women aged 35–49 years, in the highest quintile, with the highest education level ranging from 4.4% in Rwanda to 44.6% in Zimbabwe. Conclusions: Cervical pre-cancer screening was inequitable and low. None of the countries achieved one-third of the World Health Organisation target of screening 70% of eligible women for cervical pre-cancer by 2030. Inequalities in cervical pre-cancer screening related to age, rural-urban residence, education, and wealth were low. Their combinations led to high inequalities, preventing younger, rural-dwelling, uneducated, women in the lowest wealth quintile from cervical pre-cancer screening. Governments should include and monitor equity in their cervical pre-cancer screening programmes. Research is needed to understand how to scale up equitable cervical pre-cancer screening.