Abstract
Introduction
Breast cancer is a major public health challenge and the most common malignancy among women globally. Screening remains one of the most effective strategies for reducing late-stage diagnoses. This study examined the prevalence and factors associated with breast cancer screening among young women in Tanzania.
Methods
We conducted a cross-sectional analysis using data from the 2022 Tanzania Demographic and Health Survey and Malaria Indicator Survey, including women aged 15-35 years. The outcome was self-reported breast cancer screening, defined as preventive practices among asymptomatic women, including breast self-examination (BSE), clinical breast examination (CBE), or mammography. Logistic regression models were applied to identify factors associated with screening.
Results
A total of 10 733 women (mean age 24 ± 5.9 years) were analyzed. The prevalence of breast cancer screening was 3.39% (95% CI: 3.07-3.75). Higher odds of screening were observed among women aged 25-35 years (aOR 2.30), those with primary or higher education (aORs ≈ 2.15), who were married/cohabiting (aOR 1.52), employed in professional or skilled manual occupations (aORs ≈ 1.70), aware of their HIV-positive status (aOR 2.59), covered by health insurance (aOR 2.59), and using modern contraceptives (aOR 1.40). In contrast, women residing in the Western zone had lower odds of screening (aOR 0.34).
Conclusion
Breast cancer screening among young Tanzanian women was uncommon. Screening was associated with sociodemographic, reproductive, and health system factors, with particularly low uptake in the Western zone. These findings suggest the need to consider integrating breast health education into family planning and HIV services, expanding health insurance coverage, and implementing targeted outreach in underserved regions to enhance early detection and reduce disparities.
Plain Language Summary
Breast cancer is the most prevalent cancer among women worldwide and is a growing concern in Tanzania. While screening programs often focus on women aged 40 years and older, younger women are also affected. Using data from a national survey of more than 10 000 women aged 15 to 35 years, this study looked at how many had ever been screened for breast cancer and the factors linked to screening. Screening included self-checking the breasts, being examined by a health worker, or having a mammogram. The results showed that very few young women had been screened; only about 3 out of every 100 had undergone screening. Screening was more prevalent among women who were older within this age group, married, educated, in skilled employment, living with HIV, using modern contraceptives, or covered by health insurance. Fewer women reported screening in some regions, such as Tabora and Kigoma. These findings suggest that younger women are not being adequately reached by current screening programs. Expanding breast health education, including it in family planning and HIV services, improving access to health insurance, and offering outreach initiatives could help increase screening and support earlier detection, leading to better outcomes for women in Tanzania.
Introduction
Breast cancer is a serious public health challenge and the most common malignancy among women. 1 In 2020, approximately 2.3 million new cases were diagnosed globally, accounting for about 12% of all cancers. 2 It was the fifth leading cause of cancer-related mortality, with an estimated 685 000 deaths annually, representing one in six cancer deaths worldwide. 2 The majority of breast cancer deaths occur in low- and middle-income countries (LMICs), where healthcare systems are weak and most patients present with late-stage disease.3,4 In Tanzania, breast cancer is the second most common female malignancy after cervical cancer. 5 The survival rates remain low due to limited awareness, inadequate screening services, late diagnosis, and insufficient treatment options.6-10
Breast cancer screening is a key strategy for reducing late-stage diagnoses and improving survival in high-, middle-, and low-income settings.11,12 Although the World Health Organization (WHO) recommends mammography as the gold standard for the early detection, its feasibility is limited in LMICs because of cost, infrastructure demands, and reduced sensitivity in younger women with dense breast tissues. 13 In such context, clinical breast examination (CBE) and breast self-examination (BSE) are considered practical and cost-effective alternatives.14-16 In Tanzania, breast cancer treatment guidelines introduced in 2020 emphasize the role of CBE in population-based screening. 17 However, despite these national and international efforts, screening coverage remains low, particularly in rural areas with limited healthcare facilities and personnel. 18
Although breast cancer is more common among older or postmenopausal women,19,20 younger women are also significantly affected. Among women aged 15-39 years, breast cancer accounts for nearly 30% of all cancers. 21 In the United States, 5.6% of invasive breast cancer cases between 2000 and 2014 occurred in this age group. 22 Breast cancer in younger women is often associated with larger tumors, adverse biological characteristics, advanced stage at diagnosis, and poorer outcomes.22-24 While global incidence is lower among women under 40 years, 2 evidence from SSA, including Tanzania, indicate that breast cancer frequently presents about a decade earlier than in high-income countries, 25 with 23%-56% of cases diagnosed before the age of 40 years.26,27 This earlier onset, combined with aggressive tumor biology, late presentation, and limited treatment options, contributes to worse outcomes in this setting.10,26
From a public health perspective, women aged 15-35 years constitute a critical group for several reasons. First, they are not routinely targeted by mammography-based screening programs, making CBE and BSE important approaches for awareness and early detection. 28 Second, this age group has frequent contact with reproductive, maternal, and child health services, creating opportunities to integrate breast cancer education and screening awareness into existing health platforms. In Tanzania, where organized population-based screening is limited, it is therefore important to assess screening practices among young women. Although mammography is not recommended for this age group, promoting BSE and CBE may foster awareness, encourage early health-seeking behavior, and reduce delays in diagnosis. 27 Generating evidence on screening uptake in this group is vital for guiding context-specific interventions and ensuring that early detection strategies do not overlook this young but vulnerable population.
Several individual, sociocultural, economic, and systemic factors have been shown to influence breast cancer screening.,15,16,29-33 These include levels of awareness and education, 29 access to healthcare services, 33 cultural beliefs and, 30 and the availability of screening programs and resources.15,16,33 However, limited research has examined the determinants of screening among young women. Understanding the factors that shape screening uptake in this group is crucial for developing age-appropriate interventions and policies to increase screening coverage and promote early detection. Therefore, the present study aimed to examine the prevalence and factors associated with breast cancer screening among young women in Tanzania using data from the 2022 Demographic and Health Survey.
Methods
Study Design and Data Sources
The present study was a cross-sectional analysis of data from the 2022 Tanzania Demographic and Health Survey and Malaria Indicator Survey (2022 TDHS-MIS). 34 The 2022 TDHS-MIS was a nationwide survey collecting information on several health-related issues, including maternal and child health, reproductive health, nutrition, and fertility. The 2022 TDHS-MIS also collected information on cervical and breast cancers. The survey was conducted from February to July 2022 by the Tanzania National Bureau of Statistics and the Office of Chief Government Statistician in partnership with the Ministries of Health of Tanzania Mainland and Zanzibar. The Inner City Fund (ICF) provided technical assistance for the survey. The reporting of this study conforms to STROBE guidelines. 35
Study Population and Sample Design
The sample design for the 2022 TDHS-MIS has been described elsewhere. 34 Briefly, a two-stage stratified sampling technique was used to sample participants in urban and rural areas in the Tanzania mainland and Zanzibar. The first stage involved selecting sampling points (clusters) comprising enumeration areas (EAs) established for the 2012 Tanzania Population and Housing Census. These EAs were chosen based on their size within each sampling stratum. A total of 629 clusters were selected. In the second stage, 26 households were systematically selected from each cluster, resulting in 16 354 households. A total of 15 254 women aged 15-49 years were interviewed for this survey. The analyses presented in this paper focus on a subsample of 10 733 young women aged 15-35 years.
Study Variables
Outcome Variable
The outcome variable for this study was breast cancer screening, assessed as a self-reported measure by asking women whether they had ever undergone a breast examination to check for cancer. In this context, breast cancer screening was defined broadly as preventive examinations conducted in asymptomatic individuals, including BSE, CBE by a health provider, or mammography.
Explanatory Variables
We included several explanatory variables in our analyses, which were selected based on a literature search15,16,33 and their availability within the 2022 TDHS-MIS dataset. The variables included age, educational level, marital status, occupation, exposure to reading newspapers/magazines, exposure to listening to radio, exposure to watching television, HIV status, sex of household head, geographical zone, place of residence, household wealth index, mobile telephone ownership, internet access in the last 12 months, heard of breast cancer, health insurance coverage, distance to the health facility, age at first sexual debut, and experience of contraceptive use.
Statistical Analyses
We utilized STATA version 18 for data management and analysis. Before the analysis, all the data were weighted and adjusted for clustering and stratification to account for the complex TDHS-MIS survey design. Initially, we conducted a descriptive analysis to summarize the characteristics of the study participants. Subsequently, we performed weighted bivariate and multivariable logistic regression analyses to identify factors associated with breast cancer screening. In the bivariate analysis, we examined the association of each explanatory variable with breast cancer screening. All variables with a P-value of <.2 in the bivariate analyses were included in the multivariable logistic regression to determine the independent factors associated with breast cancer screening. Both crude and adjusted odds ratios and their corresponding 95% confidence intervals are reported. All analyses were two-tailed, and a P-value less than 5% was considered statistically significant.
Ethical Consideration
Formal ethical approval was not required for this study because the dataset is publicly available. However, permission to use the data was obtained from the DHS Program. The 2022 TDHS-MIS itself was conducted with approval from national and international review boards, including the National Institute of Medical Research, the Zanzibar Medical Research Ethical Committee, the Institutional Review Board of ICF, and the Centers for Disease Control and Prevention in Atlanta. Verbal informed consent was obtained from all participants before the commencement of the survey. All data collected through the survey were de-identified, and no participant could be identified from the information provided.
Results
Characteristics of the Study Participants
Sociodemographic Characteristics of Tanzanian Young Women Aged 15-35 Years
aUnweighted results describe the study sample.
bWeighted results account for the complex survey design and provide estimates that are representative of the study population.
Factors Associated With Breast Cancer Screening
Weighted Bivariate and Multivariable Logistic Regression Modeling of Factors Associated With Breast Cancer Screening Among Young Women in Tanzania
aOR, adjusted odds ratio; CI, confidence interval; HIV, human immunodeficiency virus; OR, crude odds ratio; Ref, reference category.
In a multivariable analysis, older age, formal education attainment, being married/living with a partner, professional or skilled manual occupation, being aware of the HIV-positive condition, health insurance coverage, residing in the Western zone, and the use of modern contraceptives were independently associated with breast cancer screening. Women aged 25-35 years had more than two-fold greater odds of being screened for breast cancer than those aged 15-24 years (aOR 2.30, 95% CI 1.63-3.24). Similarly, the odds of being screened for breast cancer were two-fold greater among women with primary (aOR 2.16, 95% CI 1.17-3.98), secondary or higher (aOR 2.15, 95% CI 1.12-4.12) education than among those with no formal education. Compared with women who had never been in a marital union, married/cohabiting women had 52% greater odds of being screened for breast cancer (aOR 1.52, 95% CI 1.03-2.22). Women in professional (aOR 1.70, 95% CI 1.03-2.81) and skilled manual (aOR 1.71, 95% CI 1.10-2.64) occupations had 70% and 71% greater odds, respectively, of being screened for breast cancer than those in other occupations. The odds of being screened for breast cancer were more than two-fold greater for women who were aware of their HIV-positive status (aOR 2.59, 95% CI 1.33-5.06) than for those who were HIV-negative or unsure of their HIV status. Furthermore, women covered by health insurance had more than two-fold greater odds of being screened for breast cancer than those not covered (aOR 2.59, 95% CI 1.76-3.81). Women who used modern contraceptives had 40% greater odds of being screened for breast cancer than those who never used any of the contraceptive methods (aOR 1.40, 95% CI 1.04-1.87). Compared to women residing in other geographical zones, those in the Western zone had 66% lower odds of being screened for breast cancer (aOR 0.34, 95% CI 0.16-0.73).
Discussion
This study examined the prevalence and factors associated with breast cancer screening among young women aged 15-35 years in Tanzania using data from the 2022 TDHS-MIS. This age group was the focus because they are rarely included in formal screening initiatives, despite evidence that breast cancer in young women often presents with aggressive characteristics and poorer outcomes.23,24,36 The overall proportion of young women aged 15-35 years who reported ever undergoing any form of breast cancer screening was only 3.4%, highlighting the persistently low engagement in screening in Tanzania. This observation aligns with previous studies reporting similarly low uptake among undergraduate students 32 and women attending district hospitals. 37 Although mammography is regarded as the standard tool for early detection among older women, its utility is limited in those under 40 years due to relatively low incidence of breast incidence in this group, the presence of dense breast tissue that reduces diagnostic sensitivity, and the higher likelihood false-positive and false-negative results. 13 Furthermore, routine mammography is not cost-effective in younger populations, particularly in resource-limited settings such as Tanzania.14,38 In contrast, BSE and CBE represent practical, low-cost alternatives that may foster awareness, promote health-seeking behaviors, and facilitate earlier recognition of symptomatic disease in this population.15,16,27 In the Tanzanian context, where population-based mammography is less feasible, strengthening BSE and CBE through community- and facility-based education campaigns could serve as a sustainable approach to improving breast health engagement and minimizing diagnostic delays among young women.
In this study, women aged 25-35 years had higher odds of reporting breast cancer screening compared with those aged 15-24 years. This finding aligns with previous studies from some SSA countries,29,33,39 which reported an association between older age and breast cancer screening. The observed association may reflect differences in knowledge, experience, or awareness of health services between younger and older women. Additionally, since the risk of breast cancer increases with age, older women may have more exposure to health information and preventive services. Most breast cancer screening protocols prioritize women aged 40 years and above, which may result in fewer formal screening opportunities for younger women, despite evidence that breast cancer can occur in this age group and often presents with more aggressive features associated with poorer survival.22,24 These findings suggest that age-specific approaches could be considered when planning strategies to support breast cancer screening among young women.
Our study found that married or cohabiting women had higher odds of reporting breast cancer screening compared with women who had never been in a marital union. This association may reflect differences in social support or health-seeking behavior among women with partners, which could influence engagement with preventive healthcare services, including breast cancer screening. This finding differs from results reported in Namibia 16 but is consistent with studies from both developed 40 and developing33,41 countries. While the observed association suggests a potential role for sexual partnerships in relation to preventive healthcare utilization, further research is needed to better understand how partnerships may be linked to breast cancer screening.
Formal education attainment was another factor associated with breast cancer screening in this study. Women with primary, secondary, or higher educational levels had higher odds of reporting breast cancer screening compared with those without formal education. This finding is consistent with studies from Namibia 16 and Kenya, 33 which reported lower odds of breast cancer screening among women with no formal education. Education may provide greater opportunities to learn about preventive healthcare services, including breast cancer screening, and can be linked to improved ability to access and navigate healthcare systems. Educated women may also have increased exposure to health-related information through healthcare professionals, educational materials, mass media, and online platforms. Given the generally low awareness of breast cancer among Tanzanian women, 8 promoting health education broadly may be an important strategy for supporting screening uptake.
This study identified an association between occupation type and breast cancer screening. Specifically, women in professional and skilled manual occupations had higher odds of reporting breast cancer screening compared with those in other occupation categories. This association may reflect differences in awareness of preventive healthcare services, access to financial resources, and health insurance coverage among women in these occupations. Our results are consistent with a study from Iran, which found that employed women had higher odds of undergoing breast cancer screening compared with housekeepers, 42 and an Australian study that reported increased odds of breast cancer screening among women working in clerical occupations. 30
Our findings also indicated that women who were aware of their HIV-positive status had higher odds of reporting breast cancer screening compared with those who were not aware of their status. This association may reflect that women living with HIV often have regular contact with healthcare providers for routine HIV care, which could provide opportunities to access preventive healthcare services, including breast cancer screening. However, this finding differs from reports in other settings: a study from France found a non-significant difference in breast cancer screening between HIV-positive individuals and the general population, 43 and a population-based study from Canada reported that women living with HIV had lower odds of screening for breast cancer. 44
Furthermore, this study found that young women residing in the Western zone had decreased odds of reporting breast cancer screening compared with those in other geographical zones. The Western zone includes the Tabora and Kigoma regions, which are predominantly inhabited by farmers and livestock keepers with generally lower socioeconomic status. Geographical factors, 45 such as the distance from zonal referral hospitals where most cancer screening programs are coordinated, may partly contribute to the lower screening observed in these regions. These patterns are consistent with several studies in SSA countries,15,16,33 which reported geographical disparities in breast cancer screening.
Consistent with previous studies in SSA15,16,33,41,46 and Latin America, 31 this study found an association between health insurance coverage and reporting breast cancer screening, with higher screening observed among women with health insurance compared with those without. This association may reflect that women with health insurance have greater opportunities to access diagnostic and preventive healthcare services that involve costs, particularly mammography, which is not freely available in most public facilities. In contrast, BSE can be performed at home at no cost, 16 and CBE is generally available free of charge at public hospitals in Tanzania. Health insurance coverage could therefore be most relevant for facilitating access to screening services that require payment, potentially contributing to the observed association. These findings are in line with earlier research suggesting that insurance coverage is linked to increased utilization of healthcare services among women.
This study also found an association between ever using modern contraceptives and reporting breast cancer screening, with higher odds of screening observed among women who had used contraceptives compared to those who had not. This association may reflect that women accessing healthcare services for family planning also have a greater exposure to information about preventive healthcare services, including breast cancer screening. Awareness of potential breast cancer risks associated with certain hormonal contraceptives could also play a role in screening behavior. 47 Similar pattern have been reported in studies from five SSA countries, 41 indicating consistency with previous research.
Strengths and Limitations
The main strength of this study is the use of a large sample size from a nationally representative survey with high-quality data. A second strength is the application of weighting and adjustment for clustering, which makes the results generalizable to the Tanzanian population of young women. However, several limitations should be considered. First, the outcome variable was self-reported, which may suffer from desirability bias. Second, the survey instruments did not specify the outcome variable “breast cancer screening”; hence, the reported screening could refer to BSE, CBE, or mammography. Third, the study’s cross-sectional nature made it impossible to establish causality. Finally, the analysis was limited to variables included in the 2022 TDHS-MIS dataset, so other potentially relevant factors could not be assessed.
Conclusion
This study revealed a low prevalence of breast cancer screening among young women in Tanzania. Screening uptake was positively associated with older age, marital or cohabiting status, formal education, skilled employment, awareness of HIV-positive status, health insurance coverage, and modern contraceptive use. However, substantial geographical disparities were observed, with particularly low rates in the Western zone, including Tabora and Kigoma regions. These findings indicate the importance of considering multi-sectoral approaches to improve access to and utilization of breast cancer screening. Integration of breast health education into existing platforms such as family planning and HIV care services may offer practical opportunities for reaching young women. Efforts to expand health insurance coverage and increase the availability of affordable or free screening services at lower-level health facilities could help address financial barriers. Moreover, targeted initiatives such as mobile outreach programs and context-specific awareness campaigns may be useful in addressing regional disparities and improving coverage among underserved populations. Strengthening these approaches may support earlier detection and reduce inequities in breast cancer screening among Tanzanian women.
Footnotes
Acknowledgments
We acknowledge the DHS program for providing us access to the dataset.
Ethical Approval
Formal ethical approval was not required for this study because the dataset is publicly available. However, permission to use the data was obtained from the DHS Program. The 2022 TDHS-MIS itself was conducted with approval from national and international review boards, including the National Institute of Medical Research, the Zanzibar Medical Research Ethical Committee, the Institutional Review Board of ICF, and the Centers for Disease Control and Prevention (CDC) in Atlanta.
Consent to Participate
Verbal informed consent was obtained from all participants before the commencement of the survey. All data collected through the survey were de-identified, and no participant could be identified from the information provided.
Authors’ contributions
LPR and CHM conceived the study, performed the statistical analyses, interpreted the findings, and drafted and revised the manuscript. Both authors approved the final manuscript version.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.