Cervical Cancer Screening in resource-poor settings of South Sudan: Access Coverage, Associated Factors and Health System Interventions

Abstract Background: The burden of cervical cancer remains a major challenge, particularly in resource-poor regions like South Sudan, where access to preventive measures is limited. Despite the availability of modern therapy options, the associated side effects are life-threatening and do not significantly prolong disease-free survival. Therefore, prevention through screening is crucial, especially for adult women. A lack of screening puts women at risk of advanced cervical cancer, which is alarming in South Sudan and accounts for up to 12% of the disease burden in women. This underscores the need to assess the extent of access, coverage, correlated factors, and health system interventions for cervical cancer screening in South Sudan. Therefore, this study aimed to examine the above factors to understand cervical cancer screening better and to identify effective interventions to increase coverage in under-resourced settings. Method: The study design was a community-based cross-sectional survey that aimed to assess cervical cancer screening behavior among women of reproductive age in five counties of South Sudan. The study population included women aged between 26 and 65 years, with a sample size of 575. The sampling process took place in four stages, with a simple random sample conducted in each stratum, targeting half of the Payams in each county. Structured interviews were used to collect primary data, and in-depth and key informant interviews were conducted to collect qualitative data. Data were analyzed using descriptive statistics and log-binomial regression models. The study area comprised Torit, Magwi, Terekeka, Raja, and Aweil North counties, with Torit located in the Eastern Equatoria state. The study targeted women of reproductive age as they are at risk of HPV infection. The study was community-based to prevent bias that might result from sampling women from healthcare settings. The study findings are expected to inform policy and practice to improve cervical cancer screening behavior in South Sudan. Results: The study found that only 11.5% of women in South Sudan had been screened for cervical cancer. Factors associated with cervical cancer screening rates included women who reported shorter waiting times for medical services (aPR=3.47 [CI=1.69-7.14]), received HPV vaccination (aPR=4.71 [CI=3.04-7.31]), kind and caring health workers (aPR=3.35 [CI=1.47-7.63]), and integrated cervical screening facilities (aPR=2.28 [CI=1.45-3.60]) had higher screening rates. However, the study found little evidence of community or institutional interventions aimed at increasing cervical cancer screening rates. Conclusion: Based on the findings, cervical cancer screening coverage for women in South Sudan is very low, at only 11.5%. However, certain factors were found to be associated with higher screening prevalence, including shorter wait times, caring and kind health workers, and integrated screening facilities were also associated with higher screening prevalence. It is concerning that there were virtually no interventions at institutional level to increase screening rates. These findings suggest the need for targeted interventions aimed at improving access to screening services, and strengthening health systems to increase cervical cancer screening coverage in South Sudan.