Assessing the socioeconomic inequalities in cervical cancer screening in sub-Saharan Africa: a decomposition analysis

Cervical cancer remains one of the most diagnosed diseases among women in sub-Saharan Africa (SSA). Despite global efforts to eliminate this disease, the incidence rate in SSA continues to rise due to barriers to screening, vaccination, and treatment access. Numerous studies have examined the barriers women face in accessing cervical cancer screening, but little has been reported about inequality. The few available studies are limited to single countries. In this study, we examined the socioeconomic inequalities in cervical cancer screening in SSA. Data from the Demographic and Health Surveys of 10 sub-Saharan African countries was used for the analysis. A weighted sample of 46,471 women aged 30-49 was included in the study. We used wealth index and educational attainment as measures of socioeconomic status. Socioeconomic inequalities in cervical cancer screening were constructed using concentration curves. We then computed the concentration index (CIX) to quantify the magnitude of socioeconomic inequality. A decomposition analysis was conducted to examine the factors associated with socioeconomic inequality in cervical cancer screening. The concentration curve was below the line of equality for all countries, indicating a disproportionate concentration of cervical cancer screening uptake among the wealthy and educated, except for Mauritania, where educational attainment was insignificant. With wealth index, positive concentration indices, indicating being advantaged with higher screening uptake were found among women in the richest wealth index (CIX = 0.753), those with incomplete secondary (CIX = 0.195), complete secondary (CIX = 0.378) and higher education (CIX = 0.575), and women who were working at the time of the survey (CIX = 0.031). Similarly, positive concentration indices were observed among women with primiparity (CIX = 0.279) and multiparity (CIX = 0.128), those who read newspapers/magazines (CIX = 0.335), listened to radio (CIX = 0.108), and watched television (CIX = 0.301). With level of education, women with complete primary (CIX = 0.151), incomplete secondary (CIX = 0.478), complete secondary (CIX = 0.761) and higher education (CIX = 0.916), those in the richer (CIX = 0.077) and richest wealth index (CIX = 0.391), those currently working (CIX = 0.022), women with primiparity (CIX = 0.0.325) and multiparity (CIX = 0.147), those who were exposed to read newspapers/magazines (CIX = 0.511), listened to radio (CIX = 0.109), and watched television (CIX = 0.220) had positive concentration indices, indicating being advantaged with higher cervical cancer screening uptake. Cervical cancer screening in SSA is characterized by pro-rich and pro-higher educational inequalities. Existing interventions could be restructured to prioritise accessibility and inclusion, particularly for women from poorer households and those with a lower level of education. The findings are crucial for policymakers and public health practitioners aiming to address cervical cancer screening disparities in SSA.