Disparities and Determinants of Testing for Early Detection of Cervical Cancer among Nepalese Women: Evidence from a Population-Based Survey

Cervical cancer ranks as the fourth most common cancer among women worldwide, posing significant health challenges (1). More than 95% of cervical cancer cases are attributed to the human papillomavirus (HPV; ref. 1). In 2022, approximately 662,301 women were diagnosed with cervical cancer globally and 348,874 women lost their lives due to this disease (2). South Asian countries bear a significant burden of cervical cancer, accounting for nearly 25% of new cases and deaths (15.8 and 10.0 per 100,000 women respectively; refs. 2–4).

Nepal, a lower middle-income country in South Asia, faces multiple challenges in its battle to combat noncommunicable diseases, with cancer being a particularly pressing concern (5). Cervical cancer holds the highest cancer mortality rate among women in Nepal (2), with an estimated 2,169 new cases and 1,313 deaths (14.2 and 8.7 per 100,000 women, respectively) reported in 2022 (2). Early detection and appropriate treatment may alleviate the burden associated with cervical cancer (6). There are two approaches to early detection: screening of asymptomatic individuals in a target population and early diagnosis of symptomatic individuals (7). Although the two approaches may use the same testing method (e.g., Pap smear), they are fundamentally different in terms of purpose and resource requirements. As for screening, the World Health Organization (WHO) recommends initiating cervical cancer screening at the age of 30 years, followed by regular testing at intervals of 3 to 5 years using visual inspection with acetic acid (VIA) or cervical cytology or 5 to 10 years using HPV testing (8). Nepal has established institutional efforts to prevent and screen for cervical cancer (9). The Cervical Cancer Screening and Prevention (CCSP) guidelines, endorsed in 2010, aimed to screen 50% of women aged 30 to 60 years by 2015, utilizing VIA as the primary screening method (9–12). This target was revised in 2017 to encompass the screening of 70% of women aged 30 to 60 years. Recently, Nepal has updated its CCSP guidelines in alignment with the new WHO cervical cancer screening recommendations. These revised guidelines incorporate both VIA every 3 years for women between the ages of 30 and 49 and HPV-DNA testing for all women above 30 years, prioritizing the latter when available (13). Despite the implementation of the national guideline for cervical cancer screening, the percentage of women who underwent cervical cancer testing in Nepal remains low. In 2015, only 5.4% of women aged 30 to 65 reported having ever undergone screening (14, 15). However, it is difficult for women themselves to distinguish between a test for screening and early diagnosis for cervical cancer.

Nepalese women’s low uptake of test for cervical cancer is also evidenced by previous small-scale studies conducted in small geographical areas (16–18). Even when women possess sufficient knowledge about Pap smear, they may hesitate to undergo a test due to various factors, including pain, embarrassment, and fear of abnormal results (19, 20). Furthermore, previous studies have identified several important factors that influence the decision to get a cervical cancer test among women in Nepal, including older age (14, 21), level of education (12, 20–22), duration of marriage (21), and family history of cancer (14, 21). However, those studies did not adequately consider essential individual-level factors such as membership in a health insurance scheme and household-level factors e.g., socioeconomic status (SES). Additionally, various contextual factors, such as urban residence, may influence the uptake of cervical cancer testing (23, 24). Although small-scale studies revealed lower uptake rate among uneducated women and those residing in rural areas (22, 25), the extent and depth of education-based and degree of socioeconomic inequality remain elusive. Measuring inequalities is crucial to identify vulnerable groups and address disparities and other barriers, ultimately ensuring the effectiveness of the screening program. Therefore, the objectives of this study are to quantify the magnitude of socioeconomic and education-based inequalities in the uptake of cervical cancer testing among Nepalese women using recently conducted nationally representative household survey. Additionally, we identified factors associated with the uptake of cervical cancer testing.

We analyzed data from the 2019 Nepal Noncommunicable Disease Risk Factors Survey [WHO-STEPwise approach to noncommunicable risk factor surveillance (STEPS)], conducted by the Nepal Health Research Council in collaboration with the Ministry of Health and Population and the WHO (26). This nationwide cross-sectional household survey, conducted between February and May 2019, employed a multistage cluster sampling design to select households and eligible adult men and women for interviews and physical examinations. The sampling strategy considered Nepal’s current federal structure to ensure that the results could be generalized to the provincial levels. At the first stage, a total of 259 primary sampling units (PSU) were selected, with 37 PSUs from each province, following the sampling process previously outlined (26). Subsequently, 25 households per PSU were sampled using systematic random sampling. One adult member aged 15 to 69 years was randomly chosen from each household to participate in the survey.

The survey included 5,593 (64.3% women) adult participants aged 15 to 69 years, resulting in an overall response rate of 86.4%. Of the 3,595 women invited to the interview, 3,439 participated. Considering that cervical cancer screening is recommended for women aged 30 years and above (8), we included 2,332 women aged 30 to 69 years who responded to the screening-related questions (Supplementary Fig. S1).

The study focuses on the uptake of cervical cancer testing. The Nepal STEPS survey gathered information on ever uptake of a test for cervical cancer and uptake within the past 5 years. The respondents were asked whether they ever had a test for cervical cancer using any of the following methods: VIA, Pap smear, and HPV test. Additionally, respondents were asked about the timing of their most recent cervical cancer test by selecting from the following response options: less than 1 year ago, 1 to 2 years ago, 3 to 5 years ago, more than 5 years ago, don’t know, or refused to answer. Although data on ever uptake of cervical cancer testing provides a broad overview of participation rates among eligible women, analyzing the uptake within the last 5 years yields valuable insights into the influence of recent policy shifts and the evaluation of cervical cancer testing trends over time.

The study focused on two main exposures: education level of the respondent and SES of their household. The STEPS survey collected information on respondents’ educational attainment, categorized as no education, basic education, secondary education, and higher education (0, 1–8, 9–12, and 13 years or more of schooling, respectively). Household wealth index was used as a proxy measure of household SES. The wealth index is a composite index derived from a range of household assets and housing characteristics using a principal component analysis (27). Household assets included whether the household owns the following items: electricity, radio, television, landline, mobile phone, computer, refrigerator, inverter, bed, sofa, table, fan, chair, watch/clock, bicycle, motor cycle/scooter, car/truck/jeep/tractor, dhiki/jato, animal-drawn cart, and domestic animal. In addition, main material of the roof of the house was included as the housing characteristics. Later, the wealth index is classified as wealth quintiles: poorest (lowest 20%), poorer, middle, richer, and richest (highest 20%).

We additionally considered individual- and household-level factors and contextual factors, as covariates in line with previous studies (28–30). Individual-level factors included age (30–39, 40–49, or 50–69 years), education level, marital status (currently married or other including divorced and separated), employment status (government or nongovernment, self-employed, homemaker, or other), body mass index defined as kilograms/meter² [kg/m²; underweight (<18), normal (18–25), or overweight (≥25)], tobacco product user (no or yes), alcohol consumption (life-time abstainer, former or occasional drinker, or current drinkers), diabetes status (no or yes), and membership in any health insurance scheme (no or yes). Household SES was considered as a household-level variable. We included respondent’s place of residence (urban or rural) and the province (Koshi, Madhesh, Bagmati, Gandaki, Lumbini, Karnali, or Sudhurpashchim) as community-level (contextual) variables. Details of the included covariates are presented in Supplementary Table S1.

Descriptive statistics were used to provide an overview of the background characteristics of the study population, and the uptake rate of cervical cancer testing was reported with a 95% confidence interval (CI). All statistical analyses took sampling weights into account to ensure accurate representation of the population. This study evaluated the degree of absolute and relative inequality in the uptake of cervical cancer test based on SES and education level. The regression-based slope index of inequality (SII) was utilized as an absolute measure of inequality, indicating the difference in estimated indicator values between the highest and lowest subgroups of an equity stratifier while considering all intermediary subgroups as well (31–33). To calculate the SII, initially, the entire population is organized by assigning weights and ranking them within the cumulative distribution across dimensions of inequality, such as SES or education levels, with the rank of 0 designated for the lowest or most disadvantaged subgroup, and the rank of 1 for the highest or most advantaged subgroup. Then, the midpoint within the cumulative distribution’s range is determined for each subgroup. Later, the outcome variable is regressed using a generalized linear model with logit link against the midpoint value. The SII is finally calculated as the difference in the predicted values between the most advantaged and most disadvantaged subgroups. A positive value of SII suggests that the indicator is more prevalent among the advantaged group and vice versa (33). The relative concentration index (RCI) served as the relative measure of inequality, capturing the concentration of indicator between disadvantaged and advantaged subgroups while taking into account other subgroups as well. The RCI value ranges from –1 to 1, with 0 indicating equality. A positive RCI value indicates concentration among the most advantaged subgroups, whereas a negative RCI value signifies a higher occurrence among the least advantaged groups. The magnitude of the RCI reflects the depth of the inequality in the outcome. Details of the RCI are presented elsewhere (33). In addition to the inequality assessment, a modified Poisson regression model with a random intercept term at community-level was used to identify the potential factors associated with the uptake of test for cervical cancer among Nepalese women. As the outcome was binary and rare, a modified Poisson regression analysis was chosen instead of a binary logistic regression model (34). The modified (robust) Poisson regression models are preferred as it provided unbiased estimates (35). The study reported both crude and adjusted prevalence ratio (PR) with 95% CI. Two models were utilized for adjustment: a partially adjusted model that considered individual and household factors and a fully adjusted model that incorporated those factors along with contextual factors. All statistical analyses were conducted using Stata MP version 17.

The protocol for the 2019 STEPS survey underwent a rigorous review process and received approval from the Ethical Review Board of the Nepal Health Research Council, Government of Nepal (Registration number 293/2018). Prior to their participation in the survey, all respondents provided written informed consent. In the cases of minors (individuals below 18 years old), both the assent of the participants and the consent of their parents or legal guardians were obtained by the survey authority, in strict accordance with the national ethical guidelines for health research in Nepal. For this study, we utilized a de-identified publicly available dataset provided by the WHO NCD Microdata Repository. As such, this study was therefore exempted from review by the institutions’ Institutional Review Board.

The data analyzed in this study (the 2019 Nepal STEPS survey dataset) are publicly available in the WHO NCD Microdata Repository at https://extranet.who.int/ncdsmicrodata/index.php/home.

Table 1 presents the background characteristics of the included 2,332 Nepalese women aged 30 to 69 years. About 39% of the included women were between 30 and 39 years of age, 28% between 40 and 49 years, and 33% were between 50 and 69 years. More than two thirds of the participants were uneducated (67.3%) and 4.7% of women had a higher education (13 years of schooling or more). Only 7.4% of included participants were covered by health insurance. About 63% of participants were from urban areas. Around 58% of the participants had normal weight, whereas 32.8% women were overweight. More than 12% of participants were current alcohol drinkers and 17.5% were tobacco users.

The percentage of women who ever had a cervical cancer test was 7.1% (95% CI: 5.1–9.9) compared with 5.1% (95% CI: 3.4–7.5) who had a test within the last 5 years (Table 1). Ever uptake was slightly higher among women aged 30 to 39 years (8.7%, 95% CI: 5.3–13.9), those with a higher education (23.2%, 95% CI: 9.9–45.4), and women who had health insurance (14.1%, 95% CI: 5.8–30.4). The uptake rate was also higher among overweight or obese women (10.2%, 95% CI: 6.2–16.2), those who reported not using tobacco products (7.5%, 95% CI: 5.2–10.7) and women from the richest households (11.1%, 95% CI: 6.0–19.9; Table 1), whereas the uptake was very low among lower or uneducated women from urban areas (Fig. 1; Supplementary Table S2). Reasons for cervical cancer testing indicate that only 18.8% of women had a test as a preventive measure, whereas nearly 56% women received a cervical cancer test due to symptoms such as pain, a follow-up checkup, prompted by prior abnormal or inconclusive results. Around 15% women who had a cervical cancer test followed the recommendation of a healthcare provider (Supplementary Table S3).

The magnitude of absolute SES inequality in testing for cervical cancer is presented in Fig. 2 and Supplementary Table S4. Ever uptake of cervical cancer testing among women from richest households was 5.1 percentage points higher compared with women from the poorest households (SII: 5.1, 95% CI: −0.1 to 10.2). The magnitude of such pro-rich inequality was also high among those from urban areas (SII: 10.0, 95% CI: 2.8–17.3). Results were similar for testing within the last 5 years. The uptake of a test for cervical cancer was more concentrated among women from the richest households [RCI: 14.0 (95% CI: 4.0–24.0) for ever uptake and RCI; 10.6 (95% CI: −0.4 to 21.6) for uptake within last 5 years] than women from the poorest households (Table 2).

At the national level, the proportion of women who had ever undergone a test for cervical cancer was 11.5 percentage points higher (SII: 11.5, 95% CI: 5.4–17.6) among higher educated women compared with women with no education (Fig. 2; Supplementary Table S4). The difference was even greater among urban dwellers, with a percentage point gap of 13.9 (SII: 13.9, 95% CI: 5.8–21.9) between higher educated and uneducated women, also pronounced for testing within the last 5 years (SII: 9.3, 95% CI: 3.9–14.6). The RCI indicated that both ever uptake of cervical cancer testing and uptake within the last 5 years are concentrated more among higher educated women [RCI: 18.7 (95% CI: 10.7–26.7) for ever uptake and RCI: 19.9 (95% CI: 9.9–29.9) for uptake within the last 5 years; Table 2]. The magnitude of education-based relative inequality was even higher among urban women [RCI: 18.8 (95% CI: 9.4–28.1) for ever uptake and RCI: 21.5 (95% CI: 8.7–34.2) for uptake within the last 5 years].

The results of multilevel Poisson regression models identifying associated factors for ever uptake of cervical cancer testing are presented in Table 3. After adjusting for individual-, household-, and community-level covariates, higher education, overweight, membership in a health insurance scheme, and residence in Karnali and Bagmati provinces were associated with ever receiving a test for cervical cancer. Women who were enrolled in a health insurance scheme had 1.55 times (PR: 1.55; 95% CI: 1.02–2.36) higher PR of ever testing than women who were not enrolled. Similarly, higher education (PR: 2.43; 95% CI: 1.34–4.39), being overweight (PR: 1.50; 95% CI: 1.08–2.07), and membership in any health insurance scheme (PR: 1.87; 95% CI: 1.08–3.21) were identified as factors associated with higher uptake of cervical cancer testing within the last 5 years (Supplementary Table S5). On the other hand, women aged 50 and above were less likely to get tested for cervical cancer in the past 5 years (PR: 0.63; 95% CI: 0.42–0.97).

This study utilized nationally representative data from the 2019 Nepal STEPS Survey to examine the uptake of cervical cancer testing among women aged 30 to 69 years. The findings reveal that only 7.1% of women in this age group ever had a test for cervical cancer, only 5.1% within the past 5 years. We observed a pronounced SES- and education-based inequality in cervical cancer testing. The magnitude of such inequalities was relatively high among city dwellers. Our analysis identified potential determinants for receiving a cervical cancer test, including younger age, higher level of education, being overweight, membership in a health insurance scheme, and residence in the Karnali and Sudhurpashchim provinces. To the best of our knowledge, this is the most comprehensive study in Nepal discussing the magnitude of SES- and education-based inequality in the national and residential contexts related to cervical cancer testing.

The present study revealed a low uptake of cervical cancer testing in Nepal. The rates are notably lower than those reported in a recent systematic review (16% for women aged 15–65 years) conducted in community settings (25). It is plausible that discrepancies arise from the inclusion of small-scale studies, conducted in confined geographical regions such as at district level or within a subset of districts (25). Nonetheless, the utilization of test for early detection of cervical cancer including screening remains significantly below the national target of 70% among women aged 30 to 60 years, as outlined in the country’s implementation plan (36). Current testing practices also remains inadequate to achieve the 2030 target of the global strategy aimed at the elimination of cervical cancer, which stipulates that by the age of 35 and again by 45, 70% of women should be screened using a test with high diagnostic performance (37). The WHO recommends that women aged 50 years and above may consider discontinuing cervical cancer screening after obtaining two consecutive negative HPV-DNA test results. However, the uptake of cervical cancer testing among Nepalese women aged more than 50 years is even lower than younger women, underscoring the imperative for targeted awareness campaigns among these women.

This shortfall may be partially attributed to limited availability of healthcare facilities providing screening services and a shortage of trained staff (38, 39). The provision of services for early detection of cervical cancer varies across different tiers of healthcare facilities, with tertiary-level hospitals standing out for providing superior facilities compared with local-level hospitals, private hospitals, primary healthcare centers, and other facilities such as health posts, community health units, and urban health centers (38, 39). Despite awareness among many Nepalese women about the availability of screening services provided by various healthcare facilities, their utilization is predominantly limited to instances when they experienced severe abdominal pain, bleeding, or vaginal discharge (11). This healthcare seeking pattern is indicative of the prevalent belief that cervical cancer testing unnecessary due to the absence of noticeable symptoms (12, 40).

Our study revealed significant disparities in the uptake of cervical cancer testing among different provinces, with Karnali province demonstrating higher uptake and Koshi and Madhesh provinces showing lower uptake. The 2021 Nepal Health Facility Survey reported that the availability of cervical cancer screening services varies across provinces (38, 39). Only 4.4% of health facilities in Madhesh province compared with 13.2% in Gandaki province and 20.2% of health facilities in Bagmati province provide such services. This discrepancy in service availability likely contributes to the lower uptake rates observed in Koshi and Madhesh provinces. Geographic obstacles hinder access to healthcare services (41), particularly for people residing in remote municipalities across all provinces, due to limited transportation options and irregular service availability (42). In addition, some ethnic groups in Nepal, for instance, the Madheshi ethnic community, which is prominent in the Madhesh province, face socioeconomic marginalization and limited healthcare access (43).

Consistent with previous studies conducted in India (44) and Malawi (45), our study observed wide socioeconomic inequality in the uptake of cervical cancer testing, with higher uptake among richer women. The degree of such inequality was even higher in urban areas. A recent study in 18 resource-constrained countries reported higher utilization of cervical cancer screening services among wealthy subgroups (46). Around 20% of Nepalese experience multidimensional poverty (47). Individuals residing below the poverty line face challenges in fulfilling their basic necessities, which can lead to deprioritizing healthcare seeking. For women in particular, the financial burden of potential subsequent follow-up procedures of cancer screening is difficult. The introduction of private health services has improved accessibility, primarily benefitting urban dwellers and individuals with higher incomes (48). However, this has resulted in greater disparities for poorer households, facing high out-of-pocket expenses. Despite the availability of free cervical cancer tests at government healthcare facilities, the indirect costs associated with the service may pose a barrier to its utilization (49, 50).

This study also exhibited significant education-based inequality, with higher uptake among women with higher education levels, particularly in urban areas. Insufficient knowledge poses a challenge to early detection, whereas well-educated women tend to possess greater awareness of cancer and practice to prevent cervical cancer (12, 51). A previous meta-analysis and studies in Ghana and Nigeria indicated a correlation between women’s level of knowledge and awareness about cervical cancer, and their utilization of screening services (25, 52, 53). Further, numerous studies have highlighted the significant role of women’s knowledge in shaping their perception of the importance of cervical cancer screening and subsequent procedures (19, 54–56). To effectively improve the uptake rate of cervical cancer screening, enhancing literacy rates among girls and women, integrating comprehensive reproductive health education into curricula, and implementation of educational campaigns in schools and communities might be beneficial (57, 58). These strategies will play a crucial role in increasing awareness and knowledge about early detection of cervical cancer, which may ultimately lead to improved screening rates.

Other factors, which may be associated with the uptake of cervical cancer testing in Nepal include younger age, being overweight, membership in a health insurance scheme, and residing in Karnali and Sudhurpashchim provinces. Our findings imply that enhancing the accessibility of health insurance may yield beneficial impact on cervical cancer screening rates in Nepal while concurrently addressing socioeconomic disparities in the uptake of cervical cancer testing (59). The healthcare landscape in Nepal is characterized by challenges related to transportation, inadequately equipped medical facilities and clinics, and limited access to health information. In this specific context, health insurance assumes a pivotal role in mitigating the financial barriers associated with cervical cancer screening. Health insurance policies that cover diagnostic tests and the associated treatment costs alleviate the financial concerns associated with a positive screening result, thereby playing a vital role in promoting women’s willingness to participate in screening procedures. Several additional factors also contribute to the underutilization of cervical cancer testing services, including inadequate awareness, limited access to healthcare services, the attitudes, practices, and competence of healthcare providers, and low awareness of the relationship between sexually transmitted HPV infection and the development of cervical cancer (60). Furthermore, the apprehension of societal stigma associated with a cervical cancer diagnosis has been recognized as a deterrent to accessing screening services (61, 62).

To achieve the ambitious global targets by 2030 on the path toward cervical cancer elimination, known as the 90-70-90 targets, prioritizing the expansion of services to community clinics and investing in capacity building of healthcare providers for cervical cancer screening in Nepal is of paramount importance. Moreover, it is essential for the government to recognize the existence of provincial disparities in terms of economic development, poverty levels, female literacy rates, cultural differences, and land topography. Notably, Karnali, Sudhurpashchim, and Madhesh Provinces exhibit lower levels of development and higher poverty rates compared with the national average (63–65). Taking these contextual factors into account is vital when implementing strategies to enhance early detection of cervical cancer and address the observed disparities across provinces in Nepal.

There are a few limitations to this study. First, we relied on self-reported data on test for cervical cancer, which introduces the possibility of recall bias. In particular, the questions used in the STEP survey “have you ever (or in the past 5 years) had a screening test for cervical cancer?” can pose comprehension challenges. Respondents may not be able to distinguish between cervical cancer screening, a routine pelvic examination, or an STI test unless their healthcare provider explicitly explains the difference. In addition, it was not possible to assess the validity of participant’s response on cervical cancer testing. Future research should take these factors into account when assessing cervical cancer screening rates. Second, the study design was cross-sectional, precluding the establishment of a causal relationship between the outcomes and exposures. Despite these limitations, it is worth noting that this study is the first of its kind to provide nationally representative findings on early detection of cervical cancer among Nepalese women. This unique aspect allows for a comprehensive understanding of the actual scenario of cervical cancer screening among Nepalese women.

In conclusion, less than one in ten women in Nepal gets tested for cervical cancer, with higher uptake among higher educated and affluent women. These significant pro-rich and education-based inequalities, coupled with the overall low uptake rates, underscore the urgent need for concerted efforts to improve access to and uptake of cervical cancer testing. The findings emphasize the need for targeted interventions to address these disparities and ensure equitable access to all women in Nepal.

No disclosures were reported.

Where authors are identified as personnel of the International Agency for Research on Cancer/World Health Organization, the authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policies, or views of the International Agency for Research on Cancer/World Health Organization. The funders had no role in the study design, analysis, and interpretation of data and writing of the manuscript.

M.S. Rahman: Conceptualization, software, formal analysis, supervision, validation, visualization, methodology, writing–original draft, project administration, writing–review and editing. M.M. Rahman: Conceptualization, formal analysis, writing–original draft, writing–review and editing. K. Acharya: Data curation, writing–original draft, writing–review and editing. R. Haruyama: Validation, writing–original draft, writing–review and editing. R. Shah: Validation, writing–review and editing. T. Matsuda: Validation, writing–review and editing. M. Inoue: Conceptualization, funding acquisition, project administration, writing–review and editing. S.K. Abe: Conceptualization, supervision, funding acquisition, writing–original draft, writing–review and editing.

This study was supported by the Japanese National Cancer Center Research and Development Fund (2022-A-21; S.K. Abe, M. Inoue, and T. Matsuda). In addition, we thank Bihungum Bista (Kathmandu University School of Medical Sciences and National Health Research Council, Nepal) for his valuable suggestions and insightful clarifications about the Nepal STEPS data.