Cervical cancer ranks as the fourth most common cancer among women, with an estimated 660,000 new cases and 350,000 deaths recorded in 2022 alone 12. Although it is a global public health concern, low- and middle-income countries (LMICs) bear approximately 85% of the burden, with the highest incidence and mortality rates concentrated in Eastern and Southern Africa 34 Evidence demonstrates that comprehensive HPV vaccination coupled with precancer screening can significantly reduce cervical cancer incidence and mortality 56, potentially preventing 5.2 million cases and 3.7 million deaths over a decade 7. However, despite such interventions, cervical cancer remains a leading cause of death in sub-Saharan Africa and other LMICs 8.

In 2020, the World Health Organization (WHO) introduced the 90-70-90 targets, aiming to vaccinate 90% of girls by age 15, screen 70% of eligible women, and ensure 90% of women diagnosed with cervical cancer receive appropriate treatment by 2030 9.While high-income countries (HICs) have achieved an average screening coverage of 63%, LMICs lag behind with only 19% 10. Yet, uptake remains alarmingly low, with vaccination rates between 9–10% 1112, with only 7.5% having been screened in the last five years 12, screening coverage at 7.5% in the last five years, and only 4.8% in rural areas 13. While studies have explored barriers to cervical cancer screening in various populations, little attention has been given to refugees, despite Uganda hosting approximately 1.7 million refugees as of 2024, making it the fifth-largest refugee-hosting country globally 14. Although international organizations such as the United Nations High Commissioner for Refugees (UNHCR) provide basic health services, utilization rates remain lower among refugees, and the burden of cervical cancer, as well as awareness of risk factors, is poorly documented in this group 15. This study seeks to address this gap by examining cervical cancer screening uptake and associated factors among refugee women residing in Uganda, shedding light on their unique healthcare needs and informing strategies to improve preventive care in this underserved population.

Of the 731 participants, 72 (9.8%) reported having undergone cervical cancer screening. The mean age of screened women was 37 (±7) years, compared to 32 (±8) years for unscreened women. The majority of screened respondents, 67 (93.0%) were residents in the area for at least 6 years.

Majority of respondents, 351 (48%) were in age group 21 – 30. A significant proportion, 434 (59.4%) were based in the Southwestern region. Majority, 619 (84.7%) had lived in that area at least six years. The biggest number, 456 (62.4%) of respondents had attended primary education. Majority, 451 (61.7%) were married and about 416 (57.0%) were in a non-polygamous relation type. A significant proportion, 295 (40.4%) were of low socio-economic status. Majority of those screened, 42 (58.3%) were married women (Table 1).

At the univariable analysis level, factors significantly associated with cervical cancer screening included marital status (p = 0.027), relationship type (p < 0.001), age group (p = 0.002), and having ever been tested for HIV (p = 0.031). In the multivariable analysis, the independent factors significantly associated with cervical cancer screening were marital status (p = 0.03), relationship type (p < 0.001), age group (p = 0.003), and having ever been tested for HIV (p = 0.031) (Table 2).

Several studies have examined cervical precancer screening inequalities related to age, residence, education level, marital status and socio-economic status 21222324. In our study, women aged 31-39 were more likely to have undergone screening, with their odds of being screened being 2.5 times higher than those in the 21-30 age group. The finding is consistent with majority of studies done in Uganda and beyond. A study conducted in central Uganda examining predictors of cervical cancer screening uptake among women aged 25–49, the findings revealed that women in the 30–39 age bracket had higher screening rates than their younger and older counterparts 25. A systematic review of barriers and facilitators of uptake of cervical cancer screening among women in Uganda highlighted that, despite the availability of screening services, overall uptake in Uganda remains low, with lifetime screening rates between 4.8% and 30%, with women in their 30s more proactive in seeking screening services, influenced by factors like health consciousness and family planning considerations 25. This is could be, women in this age group are be more likely to seek healthcare due to increased awareness or health concerns as they grow older. Normally, women in their 30s often become more health-conscious and proactive about preventive care as they recognize the importance of regular check-ups and maintaining their health for themselves and their families. As they visit healthcare providers more frequently for family planning, pregnancy, or postpartum care, this creates opportunities for providers to recommend screening.

Socio-cultural factors, such as the influence of marital status, and relationship type in majority of Sub-Saharan countries play a role in health decisions. Married women and those in polygamous union possibly having greater access to healthcare through their spouses or family networks. Women in polygamous relationships may also recognize a higher potential risk of exposure to sexually transmitted infections (STIs), including HPV, because their partners may have multiple sexual partners. This increased perceived risk can drive them to seek preventive measures like cervical cancer screening. A study conducted in Nigeria assessed married men's knowledge and attitudes towards cervical cancer screening. Findings indicated that men were generally supportive of their wives undergoing screening 26

The absence of an association between socio-economic status and screening uptake is particularly noteworthy. In many LMICs, wealth is a known determinant of healthcare access, with poorer women being less likely to access screening services 2127. A study of 18 resource-constrained countries, of which eight were from sub-Saharan Africa further found that wealth status increased socioeconomic inequalities in cervical precancer screening 28. In addition, studies that have found low screening rates among women without formal education. In contrast, our study did not find education or socio-economic status to be a significant predictor of screening uptake 29 However, in the refugee context, where there is a degree of uniformity in socio-economic conditions, the typical barriers associated with wealth disparities may not be as pronounced. Additionally, the homogeneity of the refugee community in terms of access to resources and healthcare services might have minimized the impact of socio-economic status on screening behavior.

Our study reveals that a significant proportion of refugee women in Uganda remain at risk for cervical cancer due to low screening uptake. Public health strategies should be tailored to the unique socio-cultural context of refugee communities that include integrating cervical cancer screening programs into refugee health services and ensuring these services are accessible to all women, regardless of their socio-economic status or marital situation.

Firstly, the study relied on self-reported data, which is subject to recall bias. Secondly, the use of secondary data made key variables of interest, such as knowledge of cervical cancer, awareness of screening programs, or reasons for not screening not available limiting the scope of the analysis.