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Abstract

Using the structural intersectionality framework, world-system and the fundamental causes of diseases theories, and cross-sectional data of 61,543 women from the Population-Based HIV Impact Assessment Project conducted in Tanzania, Rwanda, Malawi, and Zimbabwe, this study examines the intersection of structural factors associated with inequalities in cervical cancer screening among women within the underdeveloped African countries. The findings suggest deeper-rooted intersecting structural factors that inhibit (or affect) the likelihood of being screened for cervical cancer in a lifetime among the marginalized (lower educated and poor) populations across the studied countries. There is also a significant rural-urban divide in the effect of socioeconomic status (SES) on cervical cancer screening, with rural women with lower education having a lower likelihood of being tested in Rwanda and Zimbabwe. Unexpectedly, rural-educated women in Tanzania and Malawi had a lower likelihood of being tested for cervical cancer in their lifetime compared to urban women. This research highlights the importance of implementing inclusive policy interventions that integrate new technologies in cervical cancer screening among marginalized women with multiple identities, as well as strengthening the roles of healthcare providers in reminding patients about the significance of regular screening in Africa. This is essential for Africa to keep pace with the advancements in cervical cancer screening strategies seen in the developed world.

Plain Language Summary

Although cervical cancer is preventable when diagnosed early, many women in underdeveloped or third-world countries still do not receive regular screenings for this disease. We analyzed data from 61,000 women across four African countries—Tanzania, Malawi, Rwanda, and Zimbabwe—to investigate the factors that inhibit women’s likelihood of being screened for cervical cancer in their lifetime. Our study revealed an overlapping social structure that affects individuals’ behaviors regarding cervical cancer screening, influenced by factors such as education, household wealth, and geographic location.

We found that rural women with lower levels of education in Rwanda and Zimbabwe were less likely to be screened for cervical cancer. Conversely, in Tanzania and Malawi, educated rural women also exhibited a lower likelihood of being screened for the disease. Based on these findings, we advocate for inclusive policies as well as technologies aimed at addressing the cervical cancer screening barriers faced by different groups with diverse backgrounds.

Keywords

political economy of healthcare healthcare disparities socioeconomic inequalities rural-urban divide periphery nations

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References

Adams

(2023). Over 90% of Rwandans have health insurance – the health minister tells an expert what went right. The Conversation. https://theconversation.com/over-90-of-rwandans-have-health-insurance-the-health-minister-tells-an-expert-what-went-right-195257

Altbach

P. G.

(1977). Servitude of the mind? Education, dependency, and neocolonialism. Teachers College Record: The Voice of Scholarship in Education, 79(2), 1–11.

Antabe

Luginaah

N. A.

Kangmennaang

Mkandawire

(2023). Determinants of cervical cancer screening among women living with HIV in Zimbabwe. Health Promotion International, 38(4), daad073. https://doi.org/10.1093/HEAPRO/DAAD073

Ashaver

B. T.

(2013). Poverty, inequality and underdevelopment in Third World countries: Bad state policies or bad global rules? IOSR Journal of Humanities and Social Science, 15(6), 33–38.

D. M.

Ssentongo

Musa

Agbese

Diakite

Traore

C. B.

Wang

Maiga

(2021). Prevalence and determinants of cervical cancer screening in five sub-Saharan African countries: A population-based study. Cancer Epidemiology, 72, 101930. https://doi.org/10.1016/J.CANEP.2021.101930

Beer

Boswell

(2002). The resilience of dependency effects in explaining income inequality in the global economy: A cross-national analysis, 1975–1995. Journal of World-Systems Research, 8(1), 30–59. https://doi.org/10.5195/JWSR.2002.273

Binyaruka

Mtenga

(2023). Catastrophic health care spending in managing type 2 diabetes before and during the COVID-19 pandemic in Tanzania. PLoS Global Public Health, 3(8), e0002180. https://doi.org/10.1371/JOURNAL.PGPH.0002180

Braveman

Egerter

Williams

D. R.

(2011). The social determinants of health: Coming of age. Annual Review of Public Health, 32(1), 381–398. https://doi.org/10.1146/annurev-publhealth-031210-101218

Brough

(2024). Tanzania: All residents must be covered by health insurance. Wtwco. https://www.wtwco.com/en-us/insights/2024/02/tanzania-all-residents-must-be-covered-by-health-insurance

10.

Brzoska

Wahidie

Yilmaz-Aslan

(2021). An intersectional perspective on the utilization of cervical cancer screening among migrants. A cross-sectional analysis of survey data from Austria. Cancers, 13(23), 6082. https://doi.org/10.3390/CANCERS13236082

11.

Burroway

(2017). Political economy, capability development, and fundamental cause: Integrating perspectives on child health in developing countries. Journal of World-Systems Research, 23(1), 62–92. https://doi.org/10.5195/JWSR.2017.639

12.

Burt

L. M.

Mccormak

Lecuru

Kanyike

D. M.

Bvochora-Nsingo

Ndlovu

Scott

A. A.

Rose

I. A.

Sharma

Plante

Nyongesa

Tigeneh

Fakie

Suneja

Gaffney

D. K.

(2021). Cervix cancer in Sub-Saharan Africa: An assessment of cervical cancer management. JCO Global Oncology, 7, 173–182. https://doi.org/10.1200/GO.20

13.

Castle

P. E.

Einstein

M. H.

Sahasrabuddhe

V. V.

(2021). Cervical cancer prevention and control in women living with human immunodeficiency virus. CA: A Cancer Journal for Clinicians, 71(6), 505–526. https://doi.org/10.3322/CAAC.21696

14.

Chipunza

Nhamo

(2023). Potential demand for National Health Insurance in Zimbabwe: Evidence from selected urban informal sector clusters in Harare. PLOS ONE, 18(5), e0286374. https://doi.org/10.1371/JOURNAL.PONE.0286374

15.

Crenshaw

(1989). Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory, and antiracist politics. University of Chicago Legal Forum, 1989. https://heinonline.org/HOL/Page?handle=hein.journals/uchclf1989&id=143&div=&collection=

16.

Crenshaw

(1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. In M. A.

Fineman

(Ed.), The public nature of private violence: Women and the discovery of abuse (pp. 93–118). Routledge. https://doi.org/10.2307/1229039

17.

Dickson

K. S.

Boateng

E. N. K.

Acquah

Ayebeng

Addo

I. Y.

(2023). Screening for cervical cancer among women in five countries in sub-Saharan Africa: Analysis of the role played by distance to health facility and socio-demographic factors. BMC Health Services Research, 23, 61. https://doi.org/10.1186/s12913-023-09055-w

18.

Donfouet

H. P. P.

Dmytraczenko

Sorgho

(2023, July 19). Three strategies to unlock the potential of primary health care in Sub-Saharan Africa. World Bank Blogs.

19.

Dzobo

Dzinamarira

Maluleke

Jaya

Z. N.

Kgarosi

Mashamba-Thompson

T. P.

(2023). Mapping evidence on the acceptability of human papillomavirus self-sampling for cervical cancer screening among women in sub-Saharan Africa: a scoping review. BMJ Open, 13(4), e062090. https://doi.org/10.1136/BMJOPEN-2022-062090

20.

Ezenwe

(1993). The African debt crisis and the challenge of development. Intereconomics, 28(1), 35–43. https://doi.org/10.1007/BF02928100/METRICS

21.

Falola

(1992). The crisis of African health care services. In Falola

Ityavyar

(Eds.), The political economy of health in Africa (pp. 3–32). Ohio University Press/Swallow Press.

22.

Fokom Defo

Fokom Domgue

(2020). Why consider self-sampling for cervical cancer screening in low- and middle-income countries? AMA Journal of Ethics, 22(2), E116–E125. https://doi.org/10.1001/AMAJETHICS.2020.116

23.

Forster

Kentikelenis

A. E.

Stubbs

T. H.

King

L. P.

(2020). Globalization and health equity: The impact of structural adjustment programs on developing countries. Social Science & Medicine, 267, 112496. https://doi.org/10.1016/J.SOCSCIMED.2019.112496

24.

Gatwiri

Amboko

Okolla

(2020). The implications of neoliberalism on African economies, health outcomes and wellbeing: A conceptual argument. Social Theory & Health, 18(1), 86. https://doi.org/10.1057/S41285-019-00111-2

25.

Gower

Salm

Falola

(1996). Swahili women since the nineteenth century: Theoretical and empirical considerations on gender and identity construction. Africa Today, 43(3). https://www.jstor.org/stable/4187108#metadata_info_tab_contents

26.

Hitzeman

Xavier

E. M.

(2012). Interventions to increase cervical cancer screening rates. American Family Physician, 85(5), 443–445. https://www.aafp.org/pubs/afp/issues/2012/0301/p443.htm

27.

Homan

Brown

T. H.

King

(2021). Structural intersectionality as a new direction for health disparities research. Journal of Health and Social Behaviours, 62(3), 350–370. https://doi.org/10.1177/00221465211032947

28.

ICAP. (2023). Population-based HIV impact assessment: Guiding the global HIV response. https://phia.icap.columbia.edu/about/

29.

Jayachandran

(2015). The roots of gender inequality in developing countries. Annual Review of Economics, 7(1), 63–88. https://doi.org/10.1146/ANNUREV-ECONOMICS-080614-115404

30.

Jedy-Agba

Joko

W. Y.

Liu

Buziba

N. G.

Borok

Korir

Masamba

Manraj

S. S.

Finesse

Wabinga

Somdyala

Parkin

D. M.

(2020). Trends in cervical cancer incidence in sub-Saharan Africa. British Journal of Cancer, 123(1), 148. https://doi.org/10.1038/S41416-020-0831-9

31.

Kentikelenis

A. E.

(2017). Structural adjustment and health: A conceptual framework and evidence on pathways. Social Science & Medicine, 187, 296–305. https://doi.org/10.1016/J.SOCSCIMED.2017.02.021

32.

Langa

(2023a). Dependency theory: An evaluation of the period-based changes in the utilization of maternal health care and neonatal mortality in Tanzania between 1991 and 2016. International Journal of Social Determinants of Health and Health Services, 53(2), 183–194. https://doi.org/10.1177/27551938231156033

33.

Langa

(2023b). Intersectionality and dependency lenses in neonatal mortality: Evidence of regional, residential, and socioeconomic inequalities from post-colonial Tanzania, 1991–2016. Sociological Perspectives, 66(4), 640–664. https://doi.org/https://doi.org/10.1177/07311214231167172

34.

Langa

(2024). Examining the period-based changes in the effect of socioeconomic status in maternal healthcare utilization across regional and residential contexts in postcolonial Tanzania (1991–2016). Sociological Focus, 57(3), 394–413. https://doi.org/10.1080/00380237.2024.2354450

35.

Langa

Bhatta

(2020). The rural-urban divide in Tanzania: Residential context and socioeconomic inequalities in maternal health care utilization. PLoS One, 15(11), e0241746. https://doi.org/10.1371/journal.pone.0241746

36.

Langa

Bhatta

Amuta

(2023). Intersecting upstream factors: Inequities in cervical cancer screening in Malawi. Women’s Reproductive Health, 11(2), 255–272. https://doi.org/10.1080/23293691.2023.2229308

37.

Mantula

Toefy

Sewram

(2024). Barriers to cervical cancer screening in Africa: a systematic review. BMC Public Health, 24(1), 1–22. https://doi.org/10.1186/S12889-024-17842-1/TABLES/3

38.

Mchenga

Gerald

Atamandike

Emily

(2022). Developing Malawi’s Universal health coverage index. Frontiers in Health Services 1:786186. doi: 10.3389/FRHS.2021.786186.

39.

Moore

Teixeira

A. C.

Shiell

(2006). The health of nations in a global context: trade, global stratification, and infant mortality rates. Social Science & Medicine (1982), 63(1), 165–178. https://doi.org/10.1016/J.SOCSCIMED.2005.12.009

40.

National Cancer Institute. (2023, June 15). What is cervical cancer? https://www.cancer.gov/types/cervical

41.

Navarro

(2009). What we mean by social determinants of health. International Journal of Health Services, 39(3), 423–441. https://doi.org/10.2190/HS.39.3.a

42.

Navarro

Shi

(2001). The political context of social inequalities and health. Social Science & Medicine (1982), 52(3), 481–491. http://www.ncbi.nlm.nih.gov/pubmed/11330781

43.

Ndejjo

Mukama

Kiguli

Musoke

(2017). Knowledge, facilitators, and barriers to cervical cancer screening among women in Uganda: a qualitative study. BMJ Open, 7(6), e016282. https://doi.org/10.1136/BMJOPEN-2017-016282

44.

Negi

Nambiar

(2021). Intersectional social-economic inequalities in breast cancer screening in India: Analysis of the National Family Health Survey. BMC Women’s Health, 21(1), 1–9. https://doi.org/10.1186/S12905-021-01464-5/FIGURES/1

45.

Ngugi

C. W.

Boga

Muigai

A. W. T.

Wanzala

Mbithi

J. N.

(2012). Factors affecting uptake of cervical cancer early detection measures among women in Thika, Kenya. Health Care for Women International, 33(7), 595–613. https://doi.org/10.1080/07399332.2011.646367

46.

Ochieng

H. K.

Yeonsung

(2021). Political economy of education: Assessing institutional and structural constraints to quality and access to education opportunities in Tanzania. SAGE Open, 11(3), 1–15.

47.

Organisation of African Unity (OAU). (2001). Abuja declaration on HIV/AIDS, tuberculosis and other related infectious diseases. https://au.int/sites/default/files/pages/32894-file-2001-abuja-declaration.pdf

48.

Peltzer

Phaswana-Mafuya

(2014). Breast and cervical cancer screening and associated factors among older adult women in South Africa. Asian Pacific Journal of Cancer Prevention: APJCP, 15(6), 2473–2476. https://doi.org/10.7314/APJCP.2014.15.6.2473

49.

Phelan

J. C.

Link

B. G.

(2013). Fundamental cause theory. In Cockerham

William C.

(Ed.), Medical sociology on the move. Springer, 127–154.

50.

Phelan

J. C.

Link

B. G.

(2015). Is racism a fundamental cause of inequalities in health? Annual Review of Sociology 41, 311–330. https://doi.org/10.1146/ANNUREV-SOC-073014-112305

51.

Phelan

J. C.

Link

B. G.

Tehranifar

(2010). Social conditions as fundamental causes of health inequalities: Theory, evidence, and policy implications. Journal of Health and Social Behavior, 51(1_suppl), S28–S40. https://doi.org/10.1177/0022146510383498

52.

Pretsch

P. K.

Spees

L. P.

Brewer

N. T.

Hudgens

M. G.

Sanusi

Rohner

Miller

Jackson

S. L.

Barclay

Carter

Wheeler

S. B.

Smith

J. S.

(2023). Effect of HPV self-collection kits on cervical cancer screening uptake among under-screened women from low-income US backgrounds (MBMT-3): A phase 3, open-label, randomised controlled trial. The Lancet Public Health, 8(6), e411–e421. https://doi.org/10.1016/S2468-2667(23)00076-2

53.

Ricketts

E. A.

(2013). Women’s access to secondary education in colonial and postcolonial Tanzania and Rwanda [Master thesis]. Loyola University Chicago. https://ecommons.luc.edu/luc_theses

54.

Rodney

(1972). How Europe underdeveloped Africa. Tanzania Publishing House.

55.

Sangmor

V. M.

(2013). The impact of colonialism on cultural identity: A comparative study of Ghana & South Africa. The University of Ghana.

56.

WHO Africa Region. (2024). Status of the Cervical Cancer Elimination Initiative in WHO African Region. https://www.afro.who.int/publications/status-cervical-cancer-elimination-initiative-who-african-region#:~:text=Publications-,Status%20of%20the%20Cervical%20Cancer%20Elimination%20Initiative%20in%20WHO%20African,increase%20from%20the%20current%20level

57.

Wimberley

D. W.

(1990). Investment dependence and alternative explanations of Third World mortality: A cross-national study. American Sociological Review, 55(1), 75–91. https://doi.org/10.2307/2095704

58.

World Cancer Research Fund. (2020). Cervical cancer statistics. https://www.wcrf.org/dietandcancer/cancer-trends/cervical-cancer-statistics

Unequal Access: Healthcare Disparities in Cervical Cancer Screening Among African Women

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