Abstract

Background

Cervical cancer ranks third in terms of cancer incidence and mortality in Cape Verde. Understanding the factors associated with the age of cervical cancer screening (CCS) is essential because it helps identify populations at risk of delayed screening, enabling targeted interventions to ensure timely detection and treatment, ultimately reducing the burden of cervical cancer. We examined the factors associated with age at first screening for cervical cancer among adult Cape Verdean women.

Methods

Data from the 2020听WHO STEPs survey were used. We analyzed data from 1,082 women aged 30鈥�69 years who had ever screened for cervical cancer. Bivariable and multivariable logistic regression models were computed in STATA version 18.

Results

Overall, 30.6% of women in the study had their first CCS before or at age 30. Except for visits to the health facility within the last 12 months, all variables significantly predicted women鈥檚 first age for CCS in the crude model. In the adjusted model, women with tertiary education showed greater odds [AORs鈥�=鈥�9.85; 95% CI: 4.12鈥�23.54] compared to those with no formal education. Compared to those who were never married, previously married women had significantly lower odds of screening at an early age [AOR鈥�=鈥�0.63; 95% CI: 0.39鈥�0.99]. Women without hypertension had higher odds [AOR鈥�=鈥�1.66; 95% CI: 1.18鈥�2.34] of early screening compared to those with hypertension. Also, women who were currently working had significantly higher odds of early screening than those unemployed [AOR鈥�=鈥�1.49; 95% CI: 1.09鈥�2.04].

Conclusion

In conclusion, implementing targeted educational campaigns, addressing socio-economic barriers, and integrating cervical cancer screening into routine healthcare services can increase the early screening uptake among Cape Verdean women. There is a need to integrate CCS in the routine healthcare services of women living with hypertension. Also, the positive association between formal education and age at first screening, it is imperative for the Cape Verdean public health departments to implement comprehensive education programs within schools to promote awareness about CCS.

Background

Worldwide, there is acknowledgement of the significance of early identification and detection of cervical cancer [1]. This recognition is exemplified in the World Health Organization鈥檚 new recommendation for cervical cancer screening [2], the WHO Director鈥檚 call for the elimination of cervical cancer [3], and also articulated in the 90-70-90 strategy [1]. Cervical cancer screening (CCS) offers an opportunity for healthcare providers to identify the disease at its early stages, thereby improving treatment outcomes, survivorship, and quality of life of the woman. Despite the recognized importance of CCS, its uptake remains low coupled with high incidence and mortality rates, particularly in low-and-middle-income countries (LMICs) and sub-Saharan Africa (SSA).

Report from the Global Cancer Observatory [4] indicates that globally, there were 662,301 new cases and 348,874 cervical cancer related deaths; thus, making the disease the 8th most reported cancer in the world, and the 9th leading cancer-related mortality. The report further shows that cervical cancer was the fourth leading cancer among women in 2022, with Asia and Africa contributing to 60% and 19% of all new cases of the disease, respectively [4]. In the context of Cape Verde, cervical cancer ranks third in terms of cancer incidence and mortality in the country [4]. Thus, making cervical cancer an important public health concern for Cape Verde.

In respect to CCS, one study involving 55 LMICs [5] revealed that 43.6% of women had ever screened for cervical cancer in their lifetime, with those in SSA having the lowest screening uptake (16.9%). However, in 2019, the WHO reported that the lifetime prevalence of CCS uptake in Cape Verde was 53% while screening uptake within the last five years was 42% [6]. While CCS uptake in Cape Verdean women is higher than in other SSA countries [5, 6], the prevalence falls short of the WHO鈥檚 recommendation of ensuring that by 2030, 70% of women would be screened by age 35 [1]. It must be noted that CCS in Cape Verde is not free but paid out-of-pocket. Also, like many African countries, Cape Verde relies on low sensitivity modalities of screening (e.g., visual inspection with acetic acid) due to the unavailability and high cost of operating high sensitivity screening tests (e.g., human papillomavirus [HPV] tests and cytology-based screening) [7]. Vilares et al. [7] further assert that most CCS in Cape Verde are based on opportunistic screenings as there is no national screening program.

The WHO recommends CCS initiation at age 30 for the general population and age 25 for those living with HIV [2]. However, in the context of Cape Verde, it is unclear what the situation is. There is currently no published empirical research that has investigated age at first screening for cervical cancer. Meanwhile, understanding the factors associated with the age of cervical cancer screening is essential because it helps identify populations at risk of delayed screening, enabling targeted interventions to ensure timely detection and treatment, ultimately reducing the burden of cervical cancer. This paucity of evidence on age at first screening for cervical cancer presents a significant knowledge gap that has implications for policy targeting and cost-effectiveness of CCS interventions. As such, we asked the following questions: (a) At what age do Cape Verdean women undergo their first screening for cervical cancer? and (b) What factors predict the age at first screening for cervical cancer? To find answers to these questions, we examined the factors associated with age at first screening for cervical cancer among adult Cape Verdean women.

Methods

Data source and design

Data was sourced from the 2020 WHO STEPS survey of non-communicable disease (NCD) risk factors conducted in Cape Verde. This survey was conducted between February and March 2020 [8]. It encompassed three steps. Step 1 involved gathering socio-demographic and behavioral information. In Step 2, physical measurements such as height, weight, and blood pressure were collected. Step 3 involved collecting blood and urine samples for biochemical measurements, including assessing blood glucose levels, cholesterol levels, and salt intake. This survey was conducted on a population-based sample of adults aged 18鈥�69 [8]. A multiple-stage probability sampling design was employed to ensure the representativeness of the data for that age group in Cape Verde. A total of 4,563 adults participated in Steps 1 and 2, while a subsample of 2,436 adults participated in Step 3 [8]. The overall response rate was 64%.

Measures

Outcome variable

The outcome variable was age at first screening for cervical cancer. This was derived from the question, 鈥淎t what age did your first test for cervical cancer鈥�. We recoded the raw ages as 鈥�1鈥�=鈥塀efore or at age 30鈥� and 鈥�0鈥�=鈥堿fter age 30鈥�. This categorization was informed by the WHO鈥檚 recommendation for CCS to be initiated at age 30 for the general population [2].

Explanatory variables

While our literature review did not show evidence of any existent studies that have examined the age at first screening for cervical cancer, we relied on a plethora of studies [9,10,11,12,13] that have investigated the determinants of CCS uptake to select the explanatory variables. These variables included educational level, place of residence, marital status, alcohol consumption, hypertension status, visit to health facility in the last 12 months, and employment status.

Statistical analysis

The dataset had a total of 4,563 observations. However, for the purposes of this study, there was a need to exclude all those who had never undergone CCS. This brought the data to 1,950 observations. The 1,950 included observations of women who had or had not undergone CCS. However, our inferential analysis was based on only those who had undergone CCS (n鈥�=鈥�1,082). We then applied the sample weight to address any issues of over or under-estimation of the age at first screening and the explanatory variables. Descriptive analysis was conducted to know the distribution of age at first screening for cervical cancer. The results were presented in frequencies and percentages. Also, Pearson鈥檚 chi-square test was computed to check for statistical differences in the distribution of age at first screening for cervical cancer. A bivariable logistic regression was then conducted to examine the association between each variable and age at first screening. We also conducted a multivariable logistic regression to adjust for the effects of all the variables. The results from the multivariable logistic regression model were presented in adjusted odds ratio (AOR) with their corresponding 95% confidence interval (CI). All analyses were conducted in STATA version 18 (StataCorp, College Station, TX, USA)听and R.v.4.3.2.

Ethical approval

We did not seek ethical approval as this has already been done for all the STEPS survey of NCD risk factors. Rather, we formally requested the data from the WHO NCD Microdata Repository: .

Results

Distribution of overall CCS uptake, location, timing and main reason for last test

More than half of respondents (53%) reported having undergone CCS. Among those who had undergone screening, 32.1% had their screening within the past year, while 25% had it over five years ago. The primary reason for the last CCS was that it was part of a routine exam (53%), followed by recommendations from healthcare providers (33.7%). Regarding the location of the last CCS, most screenings took place in a doctor鈥檚 office (44.3%), with hospitals and community clinics also being common venues (Fig.听1).

Distribution of the age at first screening for cervical cancer

Overall, only 30.6% of women in the study had their first CCS before or at age 30 (Table听1). Early age at screening was higher among individuals with tertiary education (48.1%), urban residents (33.3%), never married women (35.7%), those who consumed alcohol (34.5%), and those living without hypertension (34.9%). Additionally, women who visited the health facility in the last 12 months (32.0) and those employed (36.6) reported higher early age at screening. These differences in distribution were statistically significant with p-values less than 0.05 (see Table听1).

Table 1 Distribution of the age at first screening for cervical cancer

Factors associated with age at first screening for cervical cancer

Table听2 presents the factors associated with women鈥檚 age at first CCS uptake. Except for visits to the health facility within the last 12 months, all variables significantly predicted women鈥檚 first age for CCS in the crude model. In the adjusted model, women with tertiary education showed greater odds [AORs鈥�=鈥�9.85; 95% CI: 4.12鈥�23.54] of getting screened early compared to those without formal education. Compared to those who were never married, previously married women had significantly lower odds of screening at an early age [AOR鈥�=鈥�0.63; 95% CI: 0.39鈥�0.99]. Women without hypertension had higher odds [AOR鈥�=鈥�1.66; 95% CI: 1.18鈥�2.34] of early screening compared to those with hypertension. Also, women who were currently working had significantly higher odds of early screening than those unemployed [AOR鈥�=鈥�1.49; 95% CI: 1.09鈥�2.04].

Table 2 Factors associated with age at first screening for cervical cancer

Fig. 1

Distribution of overall CCS uptake, location, timing and main reason for last test

Discussion

The age at which women undergo their first screening for cervical cancer is a critical factor in early detection and prevention efforts. In this study, we examined the factors influencing age at first screening among adult Cape Verdean women, utilizing data from the 2020 WHO STEPS survey. We found that 53% of adult women in Cape Verde had ever undergone screening for cervical cancer. This aligns with the WHO鈥檚 report on Cape Verde that also found a screening uptake rate of 53% [6]. Consistent with previous literature [14, 15], we found that recommendations from healthcare providers and screening being part of routine health examinations were the main reasons why Cape Verdean women got screened for cervical cancer. This highlights the critical role of healthcare professionals as champions in encouraging to avail themselves for CCS. In line with Agbeko et al. [16], our study showed that women sought for CCS after they have experience pain or other cervical cancer symptoms. The implication of women seeking cervical cancer screening only after experiencing symptoms is that many cases may be detected at more advanced stages when treatment options are limited and less effective. This delay in screening can lead to higher morbidity and mortality rates, as early-stage cervical cancer is often asymptomatic and more treatable.

Our findings also revealed that only 30.6% of Cape Verdean women who had undergone CCS initiated screening before or at age 30. This implies that 69.4% of Cape Verdean women initiate screening after age 30 鈥� a result that suggests non-compliance to the WHO鈥檚 recommended age for initiating CCS [2]. Such delayed initiation of screening increases the risk of detecting cervical abnormalities at more advanced stages [17, 18], potentially compromising treatment outcomes and exacerbating the burden of cervical cancer morbidity and mortality in Cape Verde.

Regarding the associated factors, the study shows that higher educational attainment is positively associated with age at first screening for cervical cancer. This means that women with higher education are more likely to initiate screening earlier than those with no formal education. This finding aligns with previous research conducted by Zeleke et al. [18], and is also corroborated by studies from SSA [9], Cameroon [19], and Pacific Island territories [20]. Plausible explanations for this association may include increased health literacy among educated women, enabling them to recognize the importance of early screening and take proactive steps towards initiating screening at the recommended age. Furthermore, higher education levels may be associated with greater access to healthcare information and resources, as well as increased autonomy in healthcare decision-making [9], all of which contribute to earlier engagement with CCS services.

Women who were employed were 1.49 times more likely to initiate CCS before or at age 30 compared to their counterparts who were unemployed. Thus, underscoring the significance of economic status as a significant predictor of age at first screening for cervical cancer. The observed association is inconsistent with a study conducted in Harare, Zimbabwe [21] which found no significant association between employment status and CCS. Nonetheless, our result is synonymous with Ba et al.鈥檚 study [22] which reported that women who are employed have a 13% higher likelihood of undergoing CCS. We argue from the perspective that being employed may confer greater financial stability, reducing economic barriers to accessing screening services and enabling women to initiate CCS earlier than their counterparts who are unemployed. In some instances, being employed increases women鈥檚 access to healthcare resources and benefits among employed women, including employer-sponsored health insurance or workplace wellness programs that facilitate access to preventive healthcare services such as CCS.

Our study also revealed that women who did not have hypertension were more likely to initiate CCS earlier compared to those who were hypertensive. This aligns with a study [22] that identified hypertension as a barrier to CCS uptake. Ordinarily, it would be expected that the reverse association would be the case as women living with hypertension would have frequent visits to the healthcare facility and may be more exposed to health messages including that of CCS. However, this was not the case in our study. According to Constantinou et al. [23], women living with chronic diseases tend to have poorer CCS practice due to the presence of competing health priorities and concerns. This may explain the observed association between hypertension status and timing of first CCS.

Implications for policy

The alarmingly high rate of Cape Verdean women initiating screening after age 30 (69.4%) highlights the urgent need for policy measures to promote adherence to the World Health Organization鈥檚 recommended age for initiating CCS. Efforts should focus on increasing awareness and education about the importance of early screening. Additionally, addressing socio-economic factors such as educational attainment and employment status is crucial. Policies aimed at improving access to education and employment opportunities may indirectly facilitate early engagement with CCS services by empowering women with the resources and knowledge needed to prioritize their health.

Strengths and limitations

This study was based on a population-based sample 鈥� thus, allowing us to extrapolate the findings to the larger population of women who screen for cervical cancer in Cape Verde. Also, appropriate statistical analyses were conducted which adds to the validity of the results. However, we cannot infer causality since the data is based on a cross-sectional design. There is the possibility of recall bias with respect to the age at first screening for cervical cancer since it was self-reported rather than from a health facility register. As such, there is the possibility of over or under-estimation. We are also unable to tell whether the individual screened before knowing their hypertension status. The relatively low overall response rate in the data is another limitation of the study.

Conclusion

Based on the findings, we conclude that the majority of Cape Verdean women initiate CCS after age 30. Implementing targeted educational campaigns, addressing socio-economic barriers, and integrating cervical cancer screening into routine healthcare services can increase the early screening uptake among Cape Verdean women. There is a need to integrate CCS into the routine healthcare services of women living with hypertension. Also, the positive association between formal education and age at first screening, it is imperative for the Cape Verdean public health departments to implement comprehensive education programs within schools to promote awareness about CCS.