Challenges of scaling up cervical cancer screening in Ethiopia: a qualitative socio-ecological study

Cervical cancer remains the leading cause of cancer-related death among Ethiopian women, second only to breast cancer. Previous qualitative studies have simply listed the barriers and facilitators without showing how the identified barriers interact across different levels to result in low screening coverage despite national efforts. Guided by the socio-ecological model (SEM), we aimed to explore barriers and facilitators influencing cervical cancer screening uptake in Ethiopia focusing on the dynamic interplay between women, their social networks, the health system, the community, and the policy at large.

A descriptive qualitative study design was employed among women, male partners, community and religious leaders, service providers, and health officials. The study was guided by the previously published SEM. Focused group discussions (FGDs), in-depth interviews (IDIs), and key informant interviews (KIIs) were conducted, and the audio recordings were transcribed, translated, and analyzed using Braun and Clarke's reflexive thematic analysis, supported by ATLAS.ti version nine software. The entire research team was involved in several rounds of discussion and consensus-building to refine themes and sub-themes. The study was conducted in four zones of the South Ethiopia Region in June 2025.

A total of 104 participants were included: 56 women in seven FGDs, 34 in KIIs, and 14 in IDIs. Barriers and facilitators did not act in isolation but interacted dynamically across SEM levels. At the individual level, fear of procedure and symptom-based screening were reinforced by interpersonal barriers, particularly fear of divorce following a positive diagnosis. Institutionally, service integration facilitates, but supply failures and transport costs erode trust. Community-level religious leaders endorse screening, yet prayer-based beliefs override this. Policy-level partnerships enable programs, but weak funding and broken equipment undermine delivery. Policy achievements do not translate into reliable frontline services.

According to the findings of this study, the complex interaction of barriers and facilitators across all levels of the SEM underscores the importance of multi-level implementation strategies to achieving treatment follow-up uptake.

Mrs Berta Kamprad Cancer research FBKS-2022-24-(432).