Due to the fact that over 90% of cervical cancer fatalities occur in low- and middle-income countries (LMICs) where access to screening programs and treatment choices is restricted, cervical cancer is a persistently significant global public health problem (World Health Organisation, 2022). Cervical cancer screening techniques have significantly improved in recent years, with high-risk HPV testing presently acting as the main screening instrument (World Health Organisation, 2022). Despite these developments, many regions of the world continue to have substantial impediments to cervical cancer screening coverage and access.
There are still major challenges to implementing cervical cancer screening programs in LMICs, according to World Health Organization, (2021); Mwila, C. N et al., (2022); Anorlu, R. I. et al., (2022), a shortage of skilled workers, limited resources, and inadequate infrastructure.
Inadequate cervical cancer screening is also influenced by societal and cultural factors like ignorance and shame. As revealed through research conducted by Othman, E. E et al., (2022) low adoption rates among Egyptians can be attributed largely to apprehension about possible discomfort during the examination process--a concern amplified by limited resources.
To address these issues and increase cervical cancer screening coverage and accessibility in LMICs, several technical innovations and developments have been achieved. For instance, study carried undertaken in low-income areas of South Africa by Van der Burg, R et al., (2022) evaluated the success of neighborhood-based cervical cancer screening initiatives. According to the study, community-based programs were effective in increasing screening rates, especially among populations that are challenging to reach.
Cervical cancer is a severe public health problem even though it may be avoided and treated, especially in low- and middle-income countries (LMICs). LMICs, which have the highest cervical cancer incidence rates, also account for over 90% of cervical cancer fatalities. (World Health Organisation, 2022). The high death rate in LMICs is attributed to a variety of factors, including inadequate healthcare infrastructure, a lack of treatment options, and limited access to screening programs (Anorlu, R. I. et al., 2022).
Cervical cancer screening access and coverage are severely constrained in many parts of the world, despite the availability of effective screening methods including cervical cytology and high-risk human papillomavirus (HPV) testing (World Health Organisation, 2022). One of the key challenges is the lack of screening-related infrastructure and competent personnel. LMICs generally lack the resources necessary to establish and maintain screening programs, which causes low screening rates and delayed diagnosis (Anorlu, R. I et al., 2022). Additionally, poor screening rates among women in LMICs are a result of cultural and societal issues, such as stigma and a lack of knowledge (World Health Organisation, 2022).
Cervical cancer screening techniques have significantly improved in recent years, with the predominant screening tool now being high-risk HPV testing (World Health Organisation, 2022).
Several interventions, including community-based screening programs and task-shifting of screening services to non-physician healthcare professionals, have been proposed to alleviate the hurdles to cervical cancer screening in LMICs (Van der Burg, R et al., 2022). Community-based initiatives have been proven to be successful in raising screening rates, especially among populations who are difficult to reach, such as rural women (Van der Burg, R et al., 2022). It has also been demonstrated that task-shifting screening services to non-physician healthcare workers, such as nurses and midwives, improves access to screening services in LMICs (Anorlu, R. I. et al., 2022).
According to recent studies Rebecca L. Siegel et al., (2023); World Health Organisation, (2022), cancer remains a leading cause of preventable deaths globally, resulting in approximately 10 million deaths annually. These deaths account for about 23% of all deaths from non-communicable diseases (NCDs) and one in six deaths worldwide (World Health Organisation, 2022).
According to recent projections, the number of new cancer cases is expected to reach 27.5 million per year by 2040, which is a significant increase compared to current rates (Xia, Y et al., 2022). Unfortunately, cancer-related deaths are also projected to rise proportionately for all cancer types. The World Health Organization (WHO) reports that the most common types of cancer worldwide are rectal, colon, lung, prostate, and breast cancer (World Health Organisation, 2022); (Pineros, M et al., 2022). These alarming projections highlight the need for continued research and development of effective prevention, screening, and treatment strategies for cancer.
However, cervical cancer is a specific type of cancer that has received significant attention in recent years (International Agency for Research on Cancer, 2022). It has an annual incidence of about 604,000 cases globally, with a mortality rate of 57% (342,000) (Hull et al., 2020), (Torres-Roman et al., 2022). This mortality rate surpasses that of malaria, HIV, COVID-19, maternal mortality, and tuberculosis (Hamdi et al., (2021) indicating that cervical cancer is a significant public health concern that should not be overlooked.
Regular screening is crucial to reducing cervical cancer-related mortality and is currently recommended every three years for cytology and every five years for HPV DNA testing (World Health Organisation, 2021), (National Cancer Institute, 2022). Early detection enables the identification of HPV infections at an early stage, improving prognosis and treatment outcomes. Without screening, low-risk cervical dysplasia can progress to high-grade lesions and adenocarcinoma, leading to severe pain, nephrological, hematological, and systemic dysfunction (Fowler et al., 2023), (Boon et al., 2022), (Yoshida et al., 2021). Cervical cancer also has implications for reproductive and child health, with HPV infection being linked to infertility Qaderi et al., (2021), Tatjana Street, (2021) and pregnancy delivery via cesarean section, which is associated with morbidity and mortality (Yuill et al., 2021). Late-stage invasive cervical cancer treatment using concomitant adjuvant therapy is more aggressive and is associated with fatal and undesirable side effects (Nanda Horeweg et al., 2021).
Despite interventions such as behavior change communication Lozar et al., (2021), and the development of HPV self-sampling methods Nishimura et al., (2021) the rate of early detection of cervical cancer remains low Hull et al., (2020) particularly in Africa (Jedy-Agba et al., 2020), where cervical cancer is the second most common cancer and accounts for 11.3% of the national cancer burden in South Sudan (Union International Cancer Control, 2022); (World Health Organisation, 2020).
Cervical cancer is a significant public health problem in South Sudan, where the burden of the disease is high, and access to screening is limited (Ministry of Health, 2020a). The country has one of the highest cervical cancer mortality rates globally, and the disease is a leading cause of cancer-related deaths among women (World Health Organisation, 2023). Despite the availability of effective screening methods, coverage rates are low World Health Organisation, (2020), and associated factors hinder the implementation of effective screening programs. Limited health infrastructure, inadequate resources, low levels of health literacy, and cultural beliefs and practices are some of the factors that contribute to low screening rates and poor health outcomes. The lack of trained healthcare providers, insufficient laboratory facilities, and limited access to screening equipment also hinder effective screening programs (Ministry of Health, 2020).
To better understand these determinants and the healthcare system reforms that could improve the performance of screening programs, this study examined how cervical cancer screening is covered and available in South Sudan. Outcomes for women at risk of developing cervical cancer will be improved by using the results of this study to develop evidence-based treatments that remove the barriers to successful cervical cancer screening programs in South Sudan.
Study aim
The aim of this study was to assess cervical cancer screening coverage, its associated factors and health system interventions in resource-poor settings of South Sudan, so as to determine the number women eligible for cervical cancer screening in South Sudan, who have screened, what the antecedents of their screening behavior are, and to map any available health system interventions that have been put in place by the government of South Sudan, to augment cervical cancer screening.
Research Objectives and Research Questions:
- To establish the coverage of Cervical Cancer Screening among eligible women in the republic South Sudan
- To identify the factors associated with the utilization of cervical cancer screening services in resource-poor settings of South Sudan.
- To map and assess south Sudan’s health system interventions that target women for cervical cancer screening
The societal and scientific relevance of the study findings on cervical cancer screening in resource-poor settings of South Sudan are significant. From a societal perspective, the study sheds light on the barriers and facilitators to accessing and utilizing cervical cancer screening services in a setting with limited resources. The study findings can inform policy and programmatic interventions aimed at increasing the uptake of cervical cancer screening services and reducing the burden of cervical cancer in resource-poor settings.