Understanding barriers to cervical cancer screening in Botswana: Insights from a cross-sectional study

Cervical cancer is the leading cause of cancer deaths among women in Botswana, yet uptake of cervical screening remains suboptimal. Understanding knowledge and barriers to screening is essential to inform strategies to achieve cervical cancer elimination.

We conducted high-risk human papillomavirus (hrHPV) testing and an accompanying cross-sectional survey at health clinics and in the community in South East District, Botswana (February 2022-July 2023). Eligible participants were women aged ≥25 years with an intact cervix and no prior diagnosis of cervical cancer. Interviewer-administered structured questionnaires assessed demographics, prior screening attendance, knowledge of cervical cancer, and perceived barriers to screening. Open-ended responses were thematically categorized. Logistic regression was used to examine factors associated with knowledge and screening barriers.

Of 3000 women screened, 2994 (99.8%) had known HIV status and were included. Median age was 43 years (interquartile range [IQR] 36-51), and 1500 (50.1%) were women with HIV (WWH). Overall, 67.2% (2005/2994) reported prior cervical cancer screening, with substantially higher uptake among WWH than women without HIV (80.0% vs 54.5%, P < 0.001). Knowledge of cervical cancer etiology was limited, with only 27.1% (788/2905) correctly identifying hrHPV as the cause. Younger age, HIV-positive status, higher education, formal employment, and prior screening attendance were independently associated with better knowledge. Among women who had never been screened, the most commonly reported barriers were lack of prioritization (38.3%; 376/981), fear (17.0%; 167/981), lack of awareness (17.0%; 167/981) and service provision issues (12.0%).

Despite relatively high screening uptake, important gaps in knowledge and persistent individual- and system-level barriers remain. Strengthening cervical screening delivery through HPV self-collection alongside targeted education, would address current barriers to cervical screening in Botswana.