The Delayed Diagnosis of Cervical Cancer in Low-Middle Income Countries (LMICs): A Scoping Review

The Delayed Diagnosis of Cervical Cancer in Low-Middle Income Countries (LMICs): A Scoping Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review The Delayed Diagnosis of Cervical Cancer in Low-Middle Income Countries (LMICs): A Scoping Review Sarah Parekh, Felix Chisoni, Hubert Amu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6092037/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Cervical Cancer (CC) is a significant public health concern worldwide. Low-and-middle-income countries (LMICs) bare 90% of the burden of CC morbidity and mortality due to delayed diagnosis of the disease which is preventable and curable if detected early. Vaccination campaigns and early screening have succeeded in reducing CC prevalence drastically in high-income countries (HICs), highlighting a gap of health inequities in LMICs. This review aimed at mapping factors associated with the delayed diagnosis (DD) of cervical cancer (CC) across LMICs. Methods A search across databases; Embase, Pubmed, Scopus, Web of Science and SCINHAL. ProQuest Dissertations and Ebsco between 2019 to 2024 was conducted. Two reviewers independently screened titles and abstracts followed by a full-text assessment to determine the final inclusion. Any disagreements were resolved through consensus. Data were extracted using a standardized form, and a narrative synthesis was performed. Results We retrieved 2116 studies, however only 40 studies (across 26 LMICs) met our inclusion criteria and were relevant to this review. Patient-related (individual) and health-system (institutional) delays are more prominent than community-related delays. Approximately 80% of studies suggested that low income and education are predominant individual factors that lead to delayed diagnosis of CC. 67.5% highlight the failure to recognise symptoms in these regions. In rural Africa and South Asia, transportation costs are a major factor. 58% of the studies suggested marital status as an associated factor but this was dependent on a community factor; husband’s awareness. Countries with better husband’s knowledge associate marriage with early detection. Institutionally, 47.5% of the studies evidenced the lack of national screening programs and the lack of skills, knowledge and training of healthcare workers as a factor to delayed diagnosis predominantly in Africa. Conclusions Low income and education, long distances, poor spousal awareness, absence of screening facilities and unskilled capacity impact CC’s delayed diagnosis. Context-specific solutions like; expanding awareness, building quality, culturally appropriate, decentralised screening infrastructures with health workforce capability and focus on socio-cultural barriers across regions is necessary to defeat CC in LMICs. Sexual & Reproductive Medicine Cervical Cancer delayed diagnosis Low and Middle Income Countries Figures Figure 1 Figure 2 Figure 3 BACKGROUND Globally, cervical cancer (CC) is one of the leading causes of mortality and morbidity in women. Incidence is substantially higher in Low-Middle-Income-Countries (LMICs) than in High-Income-Countries (HICs), representing global inequities 1 . If diagnosed early and treated accordingly, CC is a preventable and curable disease 2 . Accordingly, 90% of CC deaths occur in LMICs, attributing to more than 60% of cancer mortality in women. Despite an advancement in cancer diagnosis and treatment, incidence and prevalence continue to increase and many cases go unreported and undiagnosed in LMICs 2 . The majority diagnosed are presented with late-stage disease due to delayed medical help-seeking. Late treatment is less effective, leading to mortality/higher palliative care costs 3 . LMICs have a significantly higher prevalence of delayed diagnosis of CC than HICs e.g. prevalence of delayed diagnosis of CC in Malawi and UK were 38% and 77% respectively 2 . Timely diagnosis is imperative for optimistic results from awareness of symptoms to treatment. Early screening is the most successful strategy for reducing CC burden 4 . Being preventable, treatable and curable, if diagnosed early, and with the 90-70-90 goals of WHO to eliminate CC worldwide, understanding the factors leading to DD are imperative in LMICs to address these major themes of delayed consultation and avoiding advanced-stage diagnosis. Despite numerous studies on cervical cancer in LMICs, there is no evidence synthesis to specifically explore barriers to DD in LMICs across different regions globally. We, thus, undertook a broad scoping review to understand the current status of evidence for DD of CC across LMICs. METHODOLOGY Approach to the study We conducted a Scoping review in order to map factors that lead to the DD of CC in LMICs globally according to regions. Scoping reviews are appropriate for broad topics with diverse study designs 5 .The design of this review was guided by the JBI Manual for Evidence Synthesis 6 . The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Reviews (PRISMA-ScR) reporting guidelines. This review was conducted between April 2024 to September 2024 and a priori protocol was developed but was not registered. Eligibility criteria Participants Studies concerning DD/screening of CC among women were eligible. Other participants that contributed to technical data and deterrents to screening for the primary participants (women) such as healthcare workers (HCWs), medical practitioners and husbands/carers were included. Concept Only publications on CC diagnostic delays and associated factors, including barriers to early detection or screening were included. For papers including other cancers, only CC-related information was extracted. Papers focused on CC epidemiology, comorbidity, burden, risk-factors, prevalence, prevention, clinical treatments, country-specific management, elimination strategy implementation/effectiveness and policy considerations were excluded. Context Articles in English language, from LMICs only were selected. Only single-country studies were eligible. The World Bank (EPH, 2024) definition of LMICs using Gross National Income was used as an inclusion criteria. Types of Studies The review included both qualitative and quantitative studies as the concept of diagnosis has a technical background and associated factors for screening are ascertained better through descriptive and exploratory analysis of knowledge, attitudes and perceptions (KAP) to understand behaviours of individuals. Journal articles, grey literature and primary research studies were included in the study. Only studies from 2019–2024 were included for review. Information sources Electronic databases Between 2nd -7th March, 2024, we searched six electronic databases: Embase, Pubmed, Scopus, Web of Science and SCINHAL. ProQuest Dissertations and World Health Organisation website were also searched for grey literature. A hand search of included studies was carried out. The search strategy is presented in Appendix I. Selection of sources of evidence The review process had two screening levels; two reviewers conducted title and abstract screening to identify eligible publications, and full-text review (according to the inclusion and exclusion criteria). Any disagreement about final eligibility was resolved by consensus with a third review author acting as an arbiter. Data charting process and content analysis Data was abstracted and charted into a standardised data extraction form in Microsoft Excell, see Appendix II. Results were presented graphically, with a narrative analysis considering the review’s aims and objectives. Patient and public involvement Patients or public were not involved in any aspect of the study. RESULTS Study Selection A total of 2116 studies were identified through database hand searches. Removal of duplicates yielded 1059 papers. Titles and abstracts were screened; excluding 971 ineligible studies, leaving 88 retrievable. Reasons for exclusion are shown in Fig. 1 : PRISMA Flowchart. Ultimately, 40 studies were included in this review. Characteristics of included studies Characteristics of the 40 included studies are represented in a Table in Appendix II. The studies were published between 2019 to 2024 across 26 LMICs globally from Africa (46%), South Asia (SA)(27%), Latin America and Caribbean(LAC)(19%), Middle East(ME)(4%) and Oceania(4%). Studies(number) from Afghanistan(1), Argentina(1), Belize(1), Bolivia(1), Botswana(3), Brazil(1), Cameroon(1), China(1), Ethiopia(5), Fiji(1), Ghana(3), Iraq(1), India(2), Indonesia(1), Ivory Coast(2), Kenya(2), Korea(1), Nepal(1), Nigeria(2), Peru(2), Rwanda(2), South Africa(1), Tanzania(1), Thailand(1), Uganda(1), Zimbabwe(1) are represented in the review and depicted geographically in Fig. 2 . No European studies appeared after the time frame was adjusted. The study proposal included Europe; showing papers from Macedonia and Kazakhstan as well as Iran and Saudi Arabia from ME. After 2019, these countries were not in the search results. The majority of the studies were quantitative (27) comprising of cross-sectional(20), retrospective(3), prospective(1), time series(1), control(1) and a pilot study. Data was collated using questionnaires, surveys and national databases. There were 10 qualitative studies, 2 mixed method studies (cross-sectional and semi-structured interviews) and one descriptive paper. Study populations were 75% women, 10% HCWs, and 15% were FGDs with women and other stakeholders like partners, medical personnel and admin staff. All women ranged from 18–87 years old. Most studies (26) were conducted at hospitals, cancer care-centres and healthcare facilities (HCFs). Communities were explored for interviewing women and stakeholders in 10 studies. 4 studies used national cancer registry databases for their samples. Study settings were urban and rural (21), specifically urban (11), semi-urban (1) and rural (7). Half focused on either barriers, factors influencing screening uptake and KAP towards screening. 42% of the studies focused on factors affecting delays, their types (appraisal, help-seeking, diagnostic) and timeliness across intervals; making them succinct with the objective of the review. Delayed diagnosis, based on the Model Pathways of treatment, was central in 36% of studies. Although not labelled the same, the concept of delays was summarised as a combination of patient delays and HCP delays. Prevalence of Delayed Diagnosis of Cervical Cancer Prevalence of DD was extracted from each study and is summarised in Appendix III. 63% on average of all CC cases in Africa and South Asia are delayed, followed by Oceania (60%), Middle East (58%) and Latin America & Caribbean (56%). Factors affecting Delayed Diagnosis Countries were grouped into their respective regions and extracted data was analysed. Predominant factors that affect DD for each study were noted under the respective factor proxies; individual, community or individual. The frequency of each factor per region was presented; depicting a regional versus overall LMIC view (see Appendix IV). Overall, 90% of the studies show that DD of CC in LMICs is due to individual factors, 80% to institutional factors and 60% to community factors. Regionally, Africa shows a similar representation; 88% of DD of CC is due to individual factors, 79% to institutional and 58% to community factors. However, the picture overall does not match those of other regions. In the ME and Oceania, DD of CC is attributed equally to all three factors. In SA, individual factors account for 88% while community and institutional factors appear in 63% of studies. In LAC, community factors only contribute 50% and individual and institutional factors are more predominant. Regional comparisons are displayed in Fig. 3 . To understand what factors are common between regions and how these vary (according to review question); it is important to explore them. Appendix V depicts the results of this extraction according to the three themes. Individual Factors associated with DD of CC Sociodemographic, KAP, financial, personal responsibilities and risk factors were themes that were derived as individual factors that affect DD of CC across LMICs as seen in Appendix V. Sociodemographic Majority of the studies (n) i.e. 90% (32), predominantly from Africa (Botswana(3), Cameroon, Ethiopia(5), Ghana(3), Ivory Coast(2), Kenya, Nigeria(2), South Africa, Tanzania, Uganda, Zimbabwe) followed by SA (Afghanistan, China, India(2), Indonesia, and Thailand), LAC (Bolivia, Argentina, Peru (2) and Oceania (Fiji) showed a correlation between low income/socioeconomic status(SES) and DD. Low education also appeared as a key factor in 78%(31) of studies. Educated Ghanaian women were 122 times more interested in CC screening than uneducated women 7 . Individual’s occupation influenced screening uptake in 57.5% (23) of studies, with unemployed women less likely to screen. Poverty, encompassing lack of education and low income, was apparent in women from rural areas in; Africa (Ghana, South Africa, Tanzania, Ethiopia, Ivory Coast in Africa); Oceania (Fiji); SA (Thailand, India, Afghanistan, Nepal, China, Indonesia); LAC (Peru, Argentina and Bolivia) where women earned below the minimal wage, had extremely little education or no knowledge on CC and HPV and majority were unemployed 2 , 8 – 20 . 28 , 34 Botswana, Uganda, Nigeria and Korea portrayed better CC knowledge and income but other negative health-seeking/institutional factors remained 21 – 24 . Cross sectional studies proved low HPV awareness: 3% in Ghana, 5.7% in Ethiopia, 9% in Peru while in Uganda 92.8% knew of pap smears 2 , 7 , 24 , 25 . Married women had a lower chance of DD, and marital status was a factor in 57.5%(23) of studies. In Ghana, Thailand, India, Belize and Peru, husband’s education was a determining factor 13 , 16 , 25 – 27 . Older, unmarried or young women faced higher risk of DD(40% of studies). Where modesty and premarital virginity is valued e.g. Thailand, Indonesia and Tanzania, unmarried women hesitated to screen, increasing DD risks 13 , 17 , 28 . Living in rural areas versus urban areas was investigated as a factor for women with late-stage diagnosis in 42.5%(17) of studies 26 . Risk factors Risk factors that contribute to CC are discussed as they are associated with delays. Multiple pregnancies and multiple children are risk factors in 18(7) studies. Women living with HIV(WLWH) are prone to HPV and 15% (6) studies conclude that they are unlikely to have a DD in comparison to women without HIV. Early sexual-debutants are at risk of DD in 10% (4) of the studies. Long-term oral contraceptive usage and having multiple partners were not as prominent. Knowledge, Attitudes & Perceptions Many articles (67.5%, n = 27) suggested poor symptom recognition or mistaking symptoms for STDs delayed health-seeking behaviours the most. This finding was common across Africa (Botswana (3), Ethiopia (5), Ivory Coast (2), Kenya, Ghana (3), Nigeria, South Africa, Tanzania, Uganda, Zimbabwe), SA (Afghanistan, China, India, Indonesia), LAC; (Belize, Bolivia, Peru) and ME(Iraq). Of the 40 articles reviewed, 55% (22) found poor knowledge of CC influenced health-seeking. In Ghana, 82% of women denoted “inadequate knowledge of CC”, 95% of the women surveyed were unaware of sexual transmission and most couldn’t identify the signs and symptoms 7 . Similarly, 55% (22) highlighted HPV unawareness in women and not knowing it was preventable (42.5%, n = 17) resulting in negligent attitudes towards preventative screening. This ignorance was apparent in Nigeria, Uganda and Botswana. Despite having HPV knowledge, women in these countries did not seek screening for prevention but rather considered it after symptom presentation 24 , 29 , 30 . In Tanzania, the early asymptomatic nature of CC led to perceptions of low susceptibility, neglecting preventative screening 17 . This lack of seriousness towards screening was stipulated in 35%(14) of the articles and was further evidenced in 42.5%(17) of the studies indicating a lack of knowledge on screening 29 . Other factors of lower magnitude are listed in Appendix V. Financial Barriers & Responsibilities The cost of transport, identified in 53%(21) articles from: Africa (Cameroon, Ethiopia(2), Ghana(3), Kenya, Ivory Coast, Nigeria, South Africa), Oceania (Fiji), LAC (Argentina, Belize, Bolivia, Peru), ME (Iraq) and SA (Afghanistan, India, Indonesia, Nepal, Korea) and costs of screening, in 32% papers(13) are seen as a double-burden to women living in rural areas or those with low SES in seeking CC healthcare. This causes late-stage presentation at diagnosis. Bolivia and Fiji reported having no transportation facilities to screening centres, whilst in South Africa rural women walked long distances to seek care 10 , 11 , 19 . Contrary to this, in Rwanda, the cancer-care centre provides socioeconomic support including transport and accommodation 31 . Women with inequitable health insurance often view costs as a barrier to screening and presented themselves with diagnosis > Stage II in 20% (8) of studies. Low self-priority and delaying HCP consults were evident in 18% (7) of studies, indicating late presentation. Taking time off work/household responsibilities was a factor in 15% (6) of the studies. In Cameroon, a woman reported that no one would tend to her children if she left for a HCF 32 . In Fiji and South Africa, domestic roles restricted time to attend clinics and in Peru over 50% indicated that forfeiting housework and jobs was difficult; making responsibilities, chores and duties barriers to timeliness 10 , 11 , 25 . Community Factors associated with DD of CC From the factors extracted across the three themes (Appendix V), 37.5% (15) of the studies suggest husband’s knowledge or consent is a determining factor of DD in women. Husbands unaware of CC are less likely to permit, encourage, or pay for screening. The “machismo” effect mainly in SA(Afghanistan, Indonesia, Nepal, Iraq), LAC(Belize and Peru) and parts of Africa show that men often control their wives, cultural norms discouraged pelvic/cervical examinations and permission is required before screening 8 , 20 , 25 , 27 , 28 , 33 . In Ghana and Zimbabwe, women feared screening due to being labelled promiscuous 34 , 35 . In Ethiopia, husbands showed minimal support and discouraged visits to HCPs because of misconceptions about cancer being a satanic curse, leading to possible abandonments 36 , 37 . Muslim women in Thailand faced more resistance from husbands compared to Buddhists 13 . 37.5% (15) of the studies indicate that distance is a crucial barrier to early-stage diagnosis; the further the community of residence from a HCF, the less the inclination to travel for health-seeking purposes due to costs and geographical hindrances 38 . Women in South Africa, Bolivia, Nepal and China reported dangers of traversing long distances to reach cancer-care facility. Religious rituals and cultural practices contribute to late presentation in LMICs in 30%(12) of the papers. Stigma deters screening by women in 15/40 studies (27.5%). Many women that seek screening/diagnosis are labelled as promiscuous, practising witchcraft and in China; seen as breaching social taboo 12 , 37 . 22.5% (9) papers showed a disregard for women’s health concerns as seen in Afghanistan and Iraq. Low social-support, a poor attitude towards pelvic examinations in the community, whether cultural or religious and a lack of community knowledge and involvement are major deterrents to prompt identification of CC in women in LMICs 33 . Institutional Factors associated with DD of CC Four themes were identified with regards to institutional factors in this global study (Appendix V): health system inadequacies, HCP related delays, hispathological & diagnostic delays, and government delays. Government related The absence of national screening programs (NSPs) or guidelines was the most common factor in 47.5%(20) of the articles. In Africa; South Africa, Ghana, Tanzania, Ethiopia, Rwanda, Uganda and Nigeria lack NSPs leading to institutional delays. Multiple healthcare visits due to the fragmented systems, caused delays in 20%(8) of the papers. Poor funding of HCPs in rural areas and weak awareness campaigns were apparent in 15%(6) of the papers, contributing to knowledge gaps. The absence of guidelines and inadequate insurance coverage contributed to DD in 10%(4) of the articles. Only three studies from Korea, Brazil and Rwanda, identified the “distraction effect” (healthcare uptake was disrupted due to another disease) as a factor that led to DD after Covid-19 22,31,39 . HCP related 45% (18) of the studies emphasised the incompetency of HCWs with regards to lack of skills/knowledge/training in CC that contributes to DD. This was prevalent across African countries (South Africa, Ghana, Tanzania, Ethiopia, Rwanda, Cameroon, Ivory Coast and Uganda), SA(India, Iraq and Indonesia) and LAC (Belize and Bolivia). HCW shortages and gender of the provider were contributors to DD in 22.5% (9) of the studies. Women preferred to be screened by female nurses or doctors and some husbands denied male HCPs, especially in shared spaces and smaller communities 7 , 28 , 40 . Multiple pre-referral consultations allowed stage migration and this was evidenced in 20%(10) of the studies, with women in India having greater than three prereferral appointments 16 . This was reaffirmed by low confidence of HCPs in identifying early symptoms and failing to carry out a pelvic examination on first consultation in 17.5%(7) of the studies 41 , 48 . Long referral delays, poor provider-patient communication, discomfort, lack of counselling, negative attitudes of HCP and lack of confidentiality were other factors. Health systems delays Health system inadequacies were a significant theme, with the longest HCP delay from healthcare visit to diagnosis seen in Afghanistan of up to 213 days and the shortest seen in Botswana of 44 days 8 , 42 . Lack of resources being the most prominent factor in delays followed by a lack of equipment, poor infrastructure, long wait times and limited and inequitable accessibility to services were seen in 27.5%(17), 25%(10), 22.5%(9),17.5%(7), 17.5%(7), studies respectively. Hispathology & Diagnostic Delays due to lost results or hispathological delays were evidenced in 17.5%(7) of the studies. 12.5% of the studies mentioned stress on pathological services due to limited skilled HCWs and the absence of services on some days in 7.5%(3) of the papers and finally 5%(2) studies noted false negatives. This review shows the main factors contributing to DD of CC according to individual, community and institutional factors across LMICs in the table below. Table 1 : Predominant factors contributing to DD of CC across LMICs. DISCUSSION This scoping review identified 40 studies, highlighting the persistent global concern of delayed diagnosis (DD) of cervical cancer (CC) in low- and middle-income countries (LMICs). Findings show that DD exceeds 50% across LMICs, with Africa and South Asia displaying the highest rates, sometimes exceeding 80%. Factors differ according to regions and addressing region-specific factors is crucial for reducing this preventable condition. Individual Factors: Income, Education, Unemployment, Marital status, Transport Costs. From the results, sociodemographic factors play the biggest role in DD of CC at the individual level in LMICs. Low income and education levels are the most significant contributors to DD. Financial barriers, lack of knowledge, and poor health literacy limit women’s ability to recognize CC symptoms or seek care. Due to financial restrictions, women in Africa, South Asia (SA), Latin America and the Caribbean (LAC), and Oceania often prioritize daily expenses over healthcare. These findings coincided with another global systematic review on delayed CC diagnosis, indicating that low socioeconomic status (SES) increases the risk of delayed presentation 43 . Similarly, a sub-Saharan study also found that educated women are more likely to seek timely screening, as they better understand health information 44 . Ignorance about CC and its early symptoms perpetuates delays. Not knowing CC is preventable or can be asymptomatic, incited an arrogance towards screening as a preventative measure. Many women avoid screening due to stigma, fear, or attributing symptoms to aging or other conditions. For instance, in Ivory Coast, women fear gynaecological care may "wake up a sleeping illness" 45 . Similar misconceptions were reported in Ethiopia 53 and Tanzania where women who reported no knowledge nor awareness of symptoms and resorted to traditional healers for treatment 46 . Contrastingly, South African women sought care when symptoms affected their relationships 10 . Women with prior sexually transmitted diseases (STDs) often mistake CC symptoms for earlier infections, delaying screening in Ghana, Tanzania, Ethiopia, Ivory Coast and Nigeria in Africa, Belize in LAC and only India in SA. Similarly, a global systematic review concurred that prior infections lead to delayed screening 43 . Botswana’s integrated screening within HIV care, made it an anomaly and women with HIV were seen to have improved early detection 21 . This finding coincided with a SEA review (focusing on Thailand, Indonesia and Malaysia) as WLWH were seen to have early detection due to regular check-ups 47 . The evidence suggests that integrating CC screening with SRH may be beneficial to countries who cannot afford independent screening programs. In some instances, symptoms are attributed to long-term contraceptive use and ignored in older women, making them more prone to DD. The findings were succinct with those of a study done in Uganda, which verifies that attributing symptoms to bodily changes, perimenopause, long-term contraceptive use, STDs and low perceived risk of CC and self-management were common in late-presentation 48 . Compared to the Middle East where women have better accessibility, Iraq still has low knowledge levels compared to other HIC such as Kuwait. This is attributable to the fact that the Iraqi population has cultural barriers in cervical examinations and has been through wars and conflict with many demographical changes and a low priority on women’s health needs 33 . Iraq was the only country from the ME and studies from pre-2019 were omitted, showing that less research was done on CC after Covid-19, possibly due to a shift in focus and HC resources after the pandemic. Marital status is an important factor as most women who are unemployed or housewives rely on their husbands to pay for medical costs and transport. Married women who are child-bearing visit gynaecologists regularly, allowing early detection. A priori systematic review on CC diagnosis also found that women that have infrequent gynaecological examinations are prone to delays and those that have a number of biological children have a protective effect 43 . Being married contributes financially but also falls under a community factor as it is related to “husband’s knowledge”. Community Factors: Husband’s knowledge, Distance and Accessibility. In SA, LAC and rural Africa, women must often seek spousal consent for care 20 , 34 . Similarly, the “machismo” effect in LAC indicated husbands; refused male HCPs from examining their wives, had to consent to screening and usually thought it was unnecessary 25 , 27 . Misconceptions among husbands and stigma surrounding CC deter prompt action. However, in Botswana, spousal support encouraged timely diagnosis 21 . This finding was further evidenced in Uganda where lay consultations with husbands and community members were seen to prompt early diagnosis 48 . A meta-analysis done in Indonesia coincided with the findings; stating that women with spousal support were 3.39 times likely to be diagnosed early than women who did not have husband support 49 . In SA, religious beliefs, such as preserving virginity, further discourage cervical exams 28 in comparison to African women who engage in sexual behaviour much earlier than the recommended CDC age. Cultural barriers with pelvic examinations and low prioritisation in woman’s health in Afghanistan and the ME, verified why these regions contributed to higher community factors. A systematic review done on CC patients in SEA coincided with our findings that being married does not necessarily lead to early detection 47 . This presents an inconsistency due to the sociocultural context related to sexual behaviours in these conservative regions and more research needs to be done on making a generalisation that married women are likely to be diagnosed early in LMICs. Regionally, being married in SA, ME, LAC and some rural African countries is a deterrent to early detection whereas in countries with better spousal knowledge and HIC, being married deters DD. Rural areas face significant challenges, including long distances to healthcare facilities and transport costs. Consistent with the findings of previous studies, distance to healthcare facilities is regarded as a barrier to screening in this review mainly because of the cost of transport as seen in Africa and SA. South African and Nigerian women, travel hundreds of kilometres to the closest primary care facility which discourages screening 3 , 30 . This was seen in SA in countries like China, Afghanistan and Indonesia (being an archipelago). Poor road infrastructure and harsh weather conditions exacerbate the issue in countries like Bolivia. Additionally, women must often forgo work or household duties to seek care, further complicating access. Failures on the part of HCFs e.g. delayed results or multiple referrals also demotivates women to travel numerous times due to time and cost restraints. Findings from a study in Malawi, Cameroon and Namibia concur with these results; stating that although women were aware of screening, long distances from HCFs limited their health-seeking behaviours and follow ups due to costs 44 . Similarly, a study in Tanzania also confirmed the findings that high transport costs delay diagnosis by concluding 78.8% of the respondents stated that lack of funds to cover transport costs deterred HCF visits 46 . Furthermore, another study in South Africa and Uganda also confirms that transport costs were the greatest barrier to early detection 50 . A systematic global review was in sync with our findings and reported that being employed, living in urban areas, receiving correct advice, were associated with a short health seeking interval and low SES, low health literacy, use of traditional/complementary medicine, seeking advice from family members, non-disclosure of symptoms and living in rural areas were associated with delayed help-seeking 3 . Institutional factors: Lack of NSPs and lack of HCP skills and knowledge. Institutionally, the lack of National Screening Programs (NSPs) and the lack of skill, knowledge and training of healthcare workers (HCWs) are critical barriers to DD of CC. Only 14 of the 26 countries reviewed have NSPs, campaigns or outreach programs enabling awareness, cost effectiveness and accessibility of CC screening. Patients in countries without NSPs, therefore present themselves at primary healthcare facilities. HCWs in primary care settings (as seen in Africa) often; lack the skills and knowledge to perform cervical examinations (on first consultation) to infer diagnosis, have long wait times, lack pathology services and focus on infectious diseases, delaying referrals 7 , 9 , 24 , 38 , 40 , 41 These findings concurred with that of a study in Zambia 51 . Centralized cancer services in countries like Zambia and Ghana make accessibility particularly difficult for rural populations. Similarly, fragmented healthcare systems in Iraq (where HCW admit to a major gap in knowledge and expertise of gynacologists) and Brazil limit access to timely diagnosis 33 , 39 . A study in Uganda, verifies these findings, concluding that poor HCW knowledge results in false reassurances at first consultation and further upstaging and DD 48 .Another review also confirmed that omitting a cervical examination on first consultation deters early diagnosis 3 .The absence of campaigns and NSPs creates a huge knowledge gap in these countries, which is proven to be the main factor leading to DD, especially in African countries. In the Middle East, due to cultural sensitivities, the NSPs do not advocate and promote specialist training and skills for HCWs, resulting in poor capacity 33 . Similarly in SA; Afghanistan, Indonesia and Nepal encountered similar barriers to screening. Although India has screening programs at primary facilities, 43% of patients had; no cervical examination, over three pre-referral consultations, long wait times and poor service delivery. Across LAC; Peru decentralised cancer services but displayed a lack of experience in HCPs as 71.5% of patients mentioned mistreatment. Argentinians faced a fragmented HC system which limited accessibility to screening due to cost. Although NSPs exist in Brazil and Belize, disruptions in Brazil during the pandemic occurred. Insufficient training, staff shortages, strains on pathology, negative morales of HCWs in Belize still presented as huge institutional barriers in this region resulting in poor capacity being a predominant factor across all countries 39 . Institutionally, our findings were consistent with a study which showed that 86.3% of patients with CC that consulted a primary-care facility presented with DD 43 . Evidence showed that the odds of a person consulting at a primary-care facility having late stage presentation was 2.6 times higher than those that referred to a secondary or tertiary facility (explained by the lack of knowledge of HCW on CC at primary facilities). Furthermore, patients that did not have screening through NSPs during the last 3 years were most likely to have DD and those that had no cervical examination were associated with late presentation; emphasising the importance of NSPs providing strengthened capacity for cervical examinations and regular services. A previous South Asian study also provides evidence showing screening coverage increases with NSPs 52 , 53 . Limitations This single-researcher study had time constraints and potential biases. Variability in terminology and definitions of DD across and within same-country studies, along with differing thresholds for delays (e.g., > 60 vs. >90 days), posed challenges and suggests future definitions of delays in a standardised manner. The absence of quality assessment in scoping reviews highlights the need for more rigorous future research. Some regions have very little published on DD suggesting they have overcome the public health issue/not enough has been done yet. The absence of European countries in the study, after the time reduction, may be due to the distraction effect; suggesting research in CC needs to continue in these regions as Covid-19 did cause DD. The results from ME and Oceania, since represented by only a single-country study, overweighed the representation per factors in these regions. Since the study population relies on individuals to report on appraisal and health-seeking delays; recall and social desirability bias may have occur. Majority of the studies were African, which may explain why the overall LMIC result is skewed towards the African results. Lastly, from the research done, it can be concluded that very few qualitative studies have been done to ascertain the socio-cultural factors across all regions in depth. More research on the uptake of alternative treatment, traditional practitioners, lay beliefs and stigma that curb awareness on CC need to be assessed for culturally appropriate NSPs. Conclusion The delayed diagnosis of cervical cancer in LMICs is led by individual, institutional and lastly community factors. Low income, education and awareness, being married, husband’s knowledge, accessibility, the lack of national screening programs and a lack of capacity are the most prevalent factors in LMICs. Sociodemographic individual factors that deter screening in countries with populations of low income, low education, unemployment and low awareness of cervical cancer are apparent in Africa, South Asia (SA), Latin America & Caribbean (LAC) and Oceania. Marriage is a key factor that contributes to diagnostic delays in SA, LAC, Middle East (ME) and parts of Africa. Being married is associated with community factors; husband’s knowledge, religious beliefs and cultural practices. In regions with better husband’s knowledge and less emphasis on cultural modesty; being married was inversely associated to delayed diagnosis, showing a disparity that needs to be further researched. Cost of transport and distances that reduce accessibility are found to hinder early health-seeking and are common in rural areas of Africa and countries in SA the most. Finally, institutionally; the absence of national screening programs and lack of skills of HCP was seen most in LAC, Africa, ME and Oceania. In SA, robust screening programs and universal health coverage made institutional factors the least prominent out of all regions. The establishment of effective awareness, regionally specific, high quality, culturally appropriate screening programs together with quality infrastructures and health workforce capacity building are necessary to envision the WHO goals of cervical cancer elimination. Declarations Acknowledgements This paper was prompted by my desire to contribute to women’s health in Malawi especially because Malawi has the second highest prevalence and mortality rate of cervical cancer in the world. I would like to thank Dr Sam Meja, Felix Chisoni and Maureen Majamanda for their support. My supervisor, Mr. Hubert Amu, thank you for your guidance. Contributors Funding Competing interests Patient consent for publication Provenance and peer review Data availability statement ORCID iD Sarah Parekh: https://orcid.org/0009-0004-1014-7898 Felix Chisoni: https://orcid.org/0000-0003-1798-6446 Hubert Amu: https://orcid.org/0000-0003-0218-3843 References World Health Organization (2019) WHO guidelines for the use of thermal ablation for cervical pre-cancer lesions. https://apps.who.int/iris/bitstream/handle/10665/329299/9789241550598-eng.pdf accessed 5 February 2025) Zeleke S, Anley M, Kefale D et al (2021) Factors Associated with Delayed Diagnosis of Cervical Cancer in Tikur Anbesa Specialized Hospital, Ethiopia, 2019: Cross-Sectional Study. Cancer Manag Res 13:579–585 Nnaji CA, Moodley J Impact of the COVID-19 pandemic on cancer diagnosis, treatment and research in African health systems: a review of current evidence and contextual perspectives. ecancermedicalscience ; 15. 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Epub ahead of print 2021. 10.1186/s12905-021-01402-5 Park H, Seo SH, Park JH et al (2022) The Impact of COVID-19 on the Screening of colorectal, gastric, Breast and Cervical Cancer in Korea. Epidemiol Health ; e2022053 Akinnibosun O, Abakpa OG, Ujoh AJ et al (2024) Knowledge, Attitudes and Practices among Women of Reproductive Age on Human Papillomavirus Infection, Cervical Cancer and Vaccination in Otukpo, Nigeria. Ethiop J Health Sci 34:15–26 Lacika JL, Wabinga H, Kagaayi J et al Diagnostic and pre-treatment Intervals among Patients with Cervical Cancer Attending Care at the Uganda Cancer Institute: a cross-sectional Study. BMC Women Health ; 23. Epub ahead of print 2023. 10.1186/s12905-023-02785-3 Vasudevan L, Stinnett S, Mizelle C et al (2020) Barriers to the Uptake of Cervical Cancer Services and Attitudes Towards Adopting New Interventions in Peru. Prev Med Rep 20:101212 Appiah-Kubi A, Konney O, Amo-Antwi T (2022) Factors Associated with late-stage Presentation of Cervical Cancer in Ghana. Ghana Med J 56:86–94 Mittal A, Neibart SS, Kulkarni A et al (2023) Barriers and Facilitators to Effective Cervical Cancer Screening in Belize: a Qualitative Analysis. Cancer Causes Control 34:647–656 Tjokroprawiro BA, Novitasari K, Saraswati W et al (2024) The Challenging Journey of Cervical Cancer Diagnosis and Treatment at the Second Largest Hospital in Indonesia. Gynecol Oncol Rep 51:101325–101325 Rendle KA, Ramogola-Masire D, Monare B et al Patient Perspectives on Delays in Cervical Cancer Screening and follow-up Care in Botswana: a Mixed Methods Study. BMC Womens Health ; 22. Epub ahead of print 2022. 10.1186/s12905-022-01777-z Dozie UW, Ezeala OV, David CI et al (2023) Factors Associated with Health Seeking Delay in the Screening of Cervical Cancer among Women in Imo state, South Eastern Nigeria. Cancer Treat Res Commun 37:100765 Habinshuti P, Nshimyiryo A, Fejfar DL et al (2022) Impact of COVID-19 on Access to Cancer Care in Rwanda: a Retrospective time-series Study Using Electronic Medical Records Data. BMJ Open 12:e065398 Datchoua Moukam AM, Embolo Owono MS, Kenfack B et al (2021) Cervical Cancer screening: Awareness Is Not enough’. Understanding Barriers to Screening among Women in West Cameroon-a Qualitative Study Using Focus Groups. Reprod Health 18:147 Ali SM, Clark MT, Khedher Ghalib A et al We Don’t Have up to Date Knowledge about the Disease Practical Challenges Encountered in Delivery of Cervical Cancer Screening in Iraq. Eur J Cancer Care (Engl) ; 30. Epub ahead of print 2021. 10.1111/ecc.13457 Blackwell A (2020) Assessing the Percieved Barriers to Early Detection, Treatment, and Management of Cervical Cancer among Ghanaian Women. Electron Theses Diss, https://digitalcommons.georgiasouthern.edu/etd/2097/ Gutusa F, Roets L Early Cervical Cancer screening: the Influence of Culture and Religion. Afr J Prim Health Care Fam Med ; 15. Epub ahead of print 2023. 10.4102/phcfm.v15i1.3776 Demissie BW, Azeze GA, Asseffa NA et al (2022) Communities’ Perceptions Towards Cervical Cancer and Its Screening in Wolaita zone, Southern Ethiopia: a Qualitative Study. PLoS ONE 17:e0262142 Solomon K, Tamire M, Solomon N et al (2023) Misconceptions About Female Cancers Contributing to Late Presentation to Health Facilities in Ethiopia: A Qualitative Study. Int J Womens Health 15:299–309 Valerian Mwenda, Mwangi M, Gladwell Gathecha et al (2024) Factors Associated with Late Diagnosis of Cervical Cancer at Two National Referral hospitals, Kenya 2017: a Case Control Study. Gynecol Oncol Rep 52:101355–101355 Duarte MBO, Argenton JLP, Carvalheira JBC (2022) Impact of COVID-19 in Cervical and Breast Cancer Screening and Systemic Treatment in São Paulo, Brazil: An Interrupted Time Series Analysis. JCO Glob Oncol ; e2100371 Mwaliko E, Van Hal G, Bastiaens H et al (2021) Early Detection of Cervical Cancer in Western Kenya: Determinants of Healthcare Providers Performing a Gynaecological Examination for Abnormal Vaginal Discharge or Bleeding. BMC Fam Pract 22:52 Nkurunziza C, Ghebre R, Magriples U et al (2021) Healthcare Provider Challenges to Early Detection of Cervical Cancer at Primary Healthcare Level in Rwanda. Gynecol Oncol Rep 37:100810 Nassali M-N, Melese T, Modimowame J et al (2021) Timelines to Cervical Cancer Diagnosis and Treatment at a Tertiary Hospital in Botswana. Int J Womens Health 13:385–393 Allahqoli L, Dehdari T, Rahmani A et al (2022) Delayed cervical cancer diagnosis: a systematic review. Eur Rev Med Pharmacol Sci ; 26. https://www.europeanreview.org/wp/wp-content/uploads/8467-8480-1.pdf accessed 5 February 2025) Dickson KS, Boateng ENK, Acquah E et al (2023) Screening for cervical cancer among women in five countries in sub-saharan Africa: analysis of the role played by distance to health facility and socio-demographic factors. BMC Health Serv Res 23:61 Plaisy MK, Boni S, Coffie PA et al Barriers to Early Diagnosis of Cervical cancer: a mixed-method Study in Côte d’Ivoire, West Africa. BMC Womens Health ; 23. Epub ahead of print 2023. 10.1186/s12905-023-02264-9 Kabalimu TK, Mushi GK, Muindi R (2018) Social and Cultural Factors Affecting Treatment Seeking Behaviour of Patients with Cancer of the Cervix, at Ocean Road Cancer Institute in Dar es Salaam, Tanzania. Huria J Open Univ Tanzan 25:54–63 Vu TQC, Truong TG, Tran QD et al (2024) The Prevalence and Factors Related to Late-Stage Among Cervical Cancer Patients in Southeast Asian countries: A Systematic Review and Meta-Analysis. Indian J Gynecol Oncol 22:32 Mwaka AD, Okello ES, Wabinga H et al (2015) Symptomatic presentation with cervical cancer in Uganda: a qualitative study assessing the pathways to diagnosis in a low-income country. BMC Womens Health 15:15 Fitriah S, Kania N, Triawanti T et al The Relationship Between Husband’s Knowledge, Attitude and Support with The Behavior of Women for Early Detection of Cervical Cancer (Study Through Visual Inspection of Acetic Acid (VIA). J Berk Kesehat ; 9: 22–31 Moodley J, Constant D, Mwaka AD et al Anticipated help seeking behaviour and barriers to seeking care for possible breast and cervical cancer symptoms in Uganda and South Africa. ecancermedicalscience ; 15. Epub ahead of print 14 January 2021. 10.3332/ecancer.2021.1171 Mumba JM, Kasonka L, Owiti OB et al (2021) Cervical cancer diagnosis and treatment delays in the developing world: Evidence from a hospital-based study in Zambia. Gynecol Oncol Rep 37:100784 Aoki ES, Yin R, Li K et al (2020) National screening programs for cervical cancer in Asian countries. J Gynecol Oncol ; 31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7189071/ accessed 5 February 2025) Zewdie A et al (2023) Determinants of late-stage cervical cancer presentation in Ethiopia: a systematic review and meta-analysis, BMC Cancer , 23(1), p. 1228. [Online] Available at: https://doi.org/10.1186/s12885-023-11728-y Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6092037","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":419782076,"identity":"45caa1ae-55a7-433d-92d4-65ddd1a2afd6","order_by":0,"name":"Sarah Parekh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIiWNgGAWjYJACZgaGBB6GA8wHgGwJGVK0sCWAtPAQrYWB4QCPAYhDWIt8+9mHnwt3pMnw3cj5/OpGjQUPA/vhoxvwaTE4k24sPfNMDo/kjdxt1jnHgA7jSUu7gVcLQxqDNG9bBY8BUItxDhtQiwSPGV4t8v3PmH9DtOQ8M875R4QWhhtpbEBbckBamB/nthGhxeDGMzZr3jNpPJJnnpkx5/ZJ8LAR8ot8fxrzbd4dyfZ8x5Mff875VifHz374GH6HgQBjA5AQSGCTAHHYCCqHa+E/wPyBKNWjYBSMglEw4gAAqeVGnunJe9gAAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0004-1014-7898","institution":"Liverpool John Moores University","correspondingAuthor":true,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Parekh","suffix":""},{"id":419782077,"identity":"7adbf3c9-cde6-4de8-b221-acc3c7acb17f","order_by":1,"name":"Felix Chisoni","email":"","orcid":"https://orcid.org/0000-0003-1798-6446","institution":"Kamuzu University of Health Sciences","correspondingAuthor":false,"prefix":"","firstName":"Felix","middleName":"","lastName":"Chisoni","suffix":""},{"id":419782078,"identity":"eb2f0b04-dfac-4428-a4a1-eadc8272b7e0","order_by":2,"name":"Hubert Amu","email":"","orcid":"https://orcid.org/0000-0003-0218-3843","institution":"Liverpool John Moores University","correspondingAuthor":false,"prefix":"","firstName":"Hubert","middleName":"","lastName":"Amu","suffix":""}],"badges":[],"createdAt":"2025-02-23 21:31:20","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6092037/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6092037/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":77305261,"identity":"cbc4d095-0f17-4ac9-9e3b-012b899c8f07","added_by":"auto","created_at":"2025-02-27 08:58:45","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":58245,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePRISMA Flow Chart of study identification \u0026amp; selection\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6092037/v1/50bddf19cb6ee7b3ea354734.png"},{"id":77305265,"identity":"6a396547-cb1b-4421-bc83-06bf26977a2e","added_by":"auto","created_at":"2025-02-27 08:58:45","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":463813,"visible":true,"origin":"","legend":"\u003cp\u003eGeographical distribution of studies.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6092037/v1/98f1e3c62282a4dfaf606d53.png"},{"id":77305263,"identity":"5a824633-95ee-455d-8618-9898223e5306","added_by":"auto","created_at":"2025-02-27 08:58:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":52727,"visible":true,"origin":"","legend":"\u003cp\u003eRegional Comparison of Factors affecting DD of CC.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6092037/v1/a45f0391a0a800e8a600a2ca.png"},{"id":77308655,"identity":"3d8ce93a-a51a-45e3-b129-92cc87ba1232","added_by":"auto","created_at":"2025-02-27 09:30:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1700293,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6092037/v1/fb114c61-83db-428a-818c-483836282104.pdf"},{"id":77305310,"identity":"2bc9a49b-90ff-44a2-aee7-5e95a5861eac","added_by":"auto","created_at":"2025-02-27 08:58:55","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":3282166,"visible":true,"origin":"","legend":"","description":"","filename":"APPENDICES.docx","url":"https://assets-eu.researchsquare.com/files/rs-6092037/v1/472164df1f8ac276c4d16891.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eThe Delayed Diagnosis of Cervical Cancer in Low-Middle Income Countries (LMICs): A Scoping Review\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eGlobally, cervical cancer (CC) is one of the leading causes of mortality and morbidity in women. Incidence is substantially higher in Low-Middle-Income-Countries (LMICs) than in High-Income-Countries (HICs), representing global inequities\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. If diagnosed early and treated accordingly, CC is a preventable and curable disease\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Accordingly, 90% of CC deaths occur in LMICs, attributing to more than 60% of cancer mortality in women. Despite an advancement in cancer diagnosis and treatment, incidence and prevalence continue to increase and many cases go unreported and undiagnosed in LMICs\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The majority diagnosed are presented with late-stage disease due to delayed medical help-seeking. Late treatment is less effective, leading to mortality/higher palliative care costs\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. LMICs have a significantly higher prevalence of delayed diagnosis of CC than HICs e.g. prevalence of delayed diagnosis of CC in Malawi and UK were 38% and 77% respectively\u003csup\u003e2\u003c/sup\u003e. Timely diagnosis is imperative for optimistic results from awareness of symptoms to treatment. Early screening is the most successful strategy for reducing CC burden\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Being preventable, treatable and curable, if diagnosed early, and with the 90-70-90 goals of WHO to eliminate CC worldwide, understanding the factors leading to DD are imperative in LMICs to address these major themes of delayed consultation and avoiding advanced-stage diagnosis. Despite numerous studies on cervical cancer in LMICs, there is no evidence synthesis to specifically explore barriers to DD in LMICs across different regions globally. We, thus, undertook a broad scoping review to understand the current status of evidence for DD of CC across LMICs.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eApproach to the study\u003c/h2\u003e \u003cp\u003e We conducted a Scoping review in order to map factors that lead to the DD of CC in LMICs globally according to regions. Scoping reviews are appropriate for broad topics with diverse study designs\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.The design of this review was guided by the JBI Manual for Evidence Synthesis \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Reviews (PRISMA-ScR) reporting guidelines. This review was conducted between April 2024 to September 2024 and a priori protocol was developed but was not registered.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEligibility criteria\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eStudies concerning DD/screening of CC among women were eligible. Other participants that contributed to technical data and deterrents to screening for the primary participants (women) such as healthcare workers (HCWs), medical practitioners and husbands/carers were included.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eConcept\u003c/h3\u003e\n\u003cp\u003eOnly publications on CC diagnostic delays and associated factors, including barriers to early detection or screening were included. For papers including other cancers, only CC-related information was extracted. Papers focused on CC epidemiology, comorbidity, burden, risk-factors, prevalence, prevention, clinical treatments, country-specific management, elimination strategy implementation/effectiveness and policy considerations were excluded.\u003c/p\u003e\n\u003ch3\u003eContext\u003c/h3\u003e\n\u003cp\u003eArticles in English language, from LMICs only were selected. Only single-country studies were eligible. The World Bank (EPH, 2024) definition of LMICs using Gross National Income was used as an inclusion criteria.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eTypes of Studies\u003c/h2\u003e \u003cp\u003eThe review included both qualitative and quantitative studies as the concept of diagnosis has a technical background and associated factors for screening are ascertained better through descriptive and exploratory analysis of knowledge, attitudes and perceptions (KAP) to understand behaviours of individuals. Journal articles, grey literature and primary research studies were included in the study. Only studies from 2019\u0026ndash;2024 were included for review.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInformation sources\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eElectronic databases\u003c/h2\u003e \u003cp\u003eBetween 2nd -7th March, 2024, we searched six electronic databases: Embase, Pubmed, Scopus, Web of Science and SCINHAL. ProQuest Dissertations and World Health Organisation website were also searched for grey literature. A hand search of included studies was carried out. The search strategy is presented in Appendix I.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSelection of sources of evidence\u003c/h2\u003e \u003cp\u003eThe review process had two screening levels; two reviewers conducted title and abstract screening to identify eligible publications, and full-text review (according to the inclusion and exclusion criteria). Any disagreement about final eligibility was resolved by consensus with a third review author acting as an arbiter.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eData charting process and content analysis\u003c/h2\u003e \u003cp\u003eData was abstracted and charted into a standardised data extraction form in Microsoft Excell, see Appendix II. Results were presented graphically, with a narrative analysis considering the review\u0026rsquo;s aims and objectives.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePatient and public involvement\u003c/h2\u003e \u003cp\u003ePatients or public were not involved in any aspect of the study.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eStudy Selection\u003c/h2\u003e\n \u003cp\u003eA total of 2116 studies were identified through database hand searches. Removal of duplicates yielded 1059 papers. Titles and abstracts were screened; excluding 971 ineligible studies, leaving 88 retrievable. Reasons for exclusion are shown in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e: PRISMA Flowchart. Ultimately, 40 studies were included in this review.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003eCharacteristics of included studies\u003c/h2\u003e\n \u003cp\u003eCharacteristics of the 40 included studies are represented in a Table in Appendix II. The studies were published between 2019 to 2024 across 26 LMICs globally from Africa (46%), South Asia (SA)(27%), Latin America and Caribbean(LAC)(19%), Middle East(ME)(4%) and Oceania(4%). Studies(number) from Afghanistan(1), Argentina(1), Belize(1), Bolivia(1), Botswana(3), Brazil(1), Cameroon(1), China(1), Ethiopia(5), Fiji(1), Ghana(3), Iraq(1), India(2), Indonesia(1), Ivory Coast(2), Kenya(2), Korea(1), Nepal(1), Nigeria(2), Peru(2), Rwanda(2), South Africa(1), Tanzania(1), Thailand(1), Uganda(1), Zimbabwe(1) are represented in the review and depicted geographically in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. No European studies appeared after the time frame was adjusted. The study proposal included Europe; showing papers from Macedonia and Kazakhstan as well as Iran and Saudi Arabia from ME. After 2019, these countries were not in the search results.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eThe majority of the studies were quantitative (27) comprising of cross-sectional(20), retrospective(3), prospective(1), time series(1), control(1) and a pilot study. Data was collated using questionnaires, surveys and national databases. There were 10 qualitative studies, 2 mixed method studies (cross-sectional and semi-structured interviews) and one descriptive paper. Study populations were 75% women, 10% HCWs, and 15% were FGDs with women and other stakeholders like partners, medical personnel and admin staff. All women ranged from 18\u0026ndash;87 years old. Most studies (26) were conducted at hospitals, cancer care-centres and healthcare facilities (HCFs). Communities were explored for interviewing women and stakeholders in 10 studies. 4 studies used national cancer registry databases for their samples. Study settings were urban and rural (21), specifically urban (11), semi-urban (1) and rural (7). Half focused on either barriers, factors influencing screening uptake and KAP towards screening. 42% of the studies focused on factors affecting delays, their types (appraisal, help-seeking, diagnostic) and timeliness across intervals; making them succinct with the objective of the review. Delayed diagnosis, based on the Model Pathways of treatment, was central in 36% of studies. Although not labelled the same, the concept of delays was summarised as a combination of patient delays and HCP delays.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003ePrevalence of Delayed Diagnosis of Cervical Cancer\u003c/h2\u003e\n \u003cp\u003ePrevalence of DD was extracted from each study and is summarised in Appendix III. 63% on average of all CC cases in Africa and South Asia are delayed, followed by Oceania (60%), Middle East (58%) and Latin America \u0026amp; Caribbean (56%).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eFactors affecting Delayed Diagnosis\u003c/h2\u003e\n \u003cp\u003eCountries were grouped into their respective regions and extracted data was analysed. Predominant factors that affect DD for each study were noted under the respective factor proxies; individual, community or individual. The frequency of each factor per region was presented; depicting a regional versus overall LMIC view (see Appendix IV). Overall, 90% of the studies show that DD of CC in LMICs is due to individual factors, 80% to institutional factors and 60% to community factors.\u003c/p\u003e\n \u003cp\u003eRegionally, Africa shows a similar representation; 88% of DD of CC is due to individual factors, 79% to institutional and 58% to community factors. However, the picture overall does not match those of other regions. In the ME and Oceania, DD of CC is attributed equally to all three factors. In SA, individual factors account for 88% while community and institutional factors appear in 63% of studies. In LAC, community factors only contribute 50% and individual and institutional factors are more predominant. Regional comparisons are displayed in Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eTo understand what factors are common between regions and how these vary (according to review question); it is important to explore them. Appendix V depicts the results of this extraction according to the three themes.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eIndividual Factors associated with DD of CC\u003c/h2\u003e\n \u003cp\u003eSociodemographic, KAP, financial, personal responsibilities and risk factors were themes that were derived as individual factors that affect DD of CC across LMICs as seen in Appendix V.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eSociodemographic\u003c/h2\u003e\n \u003cp\u003eMajority of the studies (n) i.e. 90% (32), predominantly from Africa (Botswana(3), Cameroon, Ethiopia(5), Ghana(3), Ivory Coast(2), Kenya, Nigeria(2), South Africa, Tanzania, Uganda, Zimbabwe) followed by SA (Afghanistan, China, India(2), Indonesia, and Thailand), LAC (Bolivia, Argentina, Peru (2) and Oceania (Fiji) showed a correlation between low income/socioeconomic status(SES) and DD. Low education also appeared as a key factor in 78%(31) of studies. Educated Ghanaian women were 122 times more interested in CC screening than uneducated women \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eIndividual\u0026rsquo;s occupation influenced screening uptake in 57.5% (23) of studies, with unemployed women less likely to screen. Poverty, encompassing lack of education and low income, was apparent in women from rural areas in; Africa (Ghana, South Africa, Tanzania, Ethiopia, Ivory Coast in Africa); Oceania (Fiji); SA (Thailand, India, Afghanistan, Nepal, China, Indonesia); LAC (Peru, Argentina and Bolivia) where women earned below the minimal wage, had extremely little education or no knowledge on CC and HPV and majority were unemployed \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e. \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\n \u003cp\u003eBotswana, Uganda, Nigeria and Korea portrayed better CC knowledge and income but other negative health-seeking/institutional factors remained \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Cross sectional studies proved low HPV awareness: 3% in Ghana, 5.7% in Ethiopia, 9% in Peru while in Uganda 92.8% knew of pap smears \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e\n \u003cp\u003eMarried women had a lower chance of DD, and marital status was a factor in 57.5%(23) of studies. In Ghana, Thailand, India, Belize and Peru, husband\u0026rsquo;s education was a determining factor\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Older, unmarried or young women faced higher risk of DD(40% of studies). Where modesty and premarital virginity is valued e.g. Thailand, Indonesia and Tanzania, unmarried women hesitated to screen, increasing DD risks \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Living in rural areas versus urban areas was investigated as a factor for women with late-stage diagnosis in 42.5%(17) of studies \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n \u003ch2\u003eRisk factors\u003c/h2\u003e\n \u003cp\u003eRisk factors that contribute to CC are discussed as they are associated with delays. Multiple pregnancies and multiple children are risk factors in 18(7) studies. Women living with HIV(WLWH) are prone to HPV and 15% (6) studies conclude that they are unlikely to have a DD in comparison to women without HIV. Early sexual-debutants are at risk of DD in 10% (4) of the studies. Long-term oral contraceptive usage and having multiple partners were not as prominent.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\n \u003ch2\u003eKnowledge, Attitudes \u0026amp; Perceptions\u003c/h2\u003e\n \u003cp\u003eMany articles (67.5%, n\u0026thinsp;=\u0026thinsp;27) suggested poor symptom recognition or mistaking symptoms for STDs delayed health-seeking behaviours the most. This finding was common across Africa (Botswana (3), Ethiopia (5), Ivory Coast (2), Kenya, Ghana (3), Nigeria, South Africa, Tanzania, Uganda, Zimbabwe), SA (Afghanistan, China, India, Indonesia), LAC; (Belize, Bolivia, Peru) and ME(Iraq).\u003c/p\u003e\n \u003cp\u003eOf the 40 articles reviewed, 55% (22) found poor knowledge of CC influenced health-seeking. In Ghana, 82% of women denoted \u0026ldquo;inadequate knowledge of CC\u0026rdquo;, 95% of the women surveyed were unaware of sexual transmission and most couldn\u0026rsquo;t identify the signs and symptoms\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Similarly, 55% (22) highlighted HPV unawareness in women and not knowing it was preventable (42.5%, n\u0026thinsp;=\u0026thinsp;17) resulting in negligent attitudes towards preventative screening. This ignorance was apparent in Nigeria, Uganda and Botswana. Despite having HPV knowledge, women in these countries did not seek screening for prevention but rather considered it after symptom presentation \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. In Tanzania, the early asymptomatic nature of CC led to perceptions of low susceptibility, neglecting preventative screening \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. This lack of seriousness towards screening was stipulated in 35%(14) of the articles and was further evidenced in 42.5%(17) of the studies indicating a lack of knowledge on screening\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Other factors of lower magnitude are listed in Appendix V.\u003c/p\u003e\n \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n \u003ch2\u003eFinancial Barriers \u0026amp; Responsibilities\u003c/h2\u003e\n \u003cp\u003eThe cost of transport, identified in 53%(21) articles from: Africa (Cameroon, Ethiopia(2), Ghana(3), Kenya, Ivory Coast, Nigeria, South Africa), Oceania (Fiji), LAC (Argentina, Belize, Bolivia, Peru), ME (Iraq) and SA (Afghanistan, India, Indonesia, Nepal, Korea) and costs of screening, in 32% papers(13) are seen as a double-burden to women living in rural areas or those with low SES in seeking CC healthcare. This causes late-stage presentation at diagnosis. Bolivia and Fiji reported having no transportation facilities to screening centres, whilst in South Africa rural women walked long distances to seek care \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Contrary to this, in Rwanda, the cancer-care centre provides socioeconomic support including transport and accommodation \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e .\u003c/p\u003e\n \u003cp\u003eWomen with inequitable health insurance often view costs as a barrier to screening and presented themselves with diagnosis\u0026thinsp;\u0026gt;\u0026thinsp;Stage II in 20% (8) of studies. Low self-priority and delaying HCP consults were evident in 18% (7) of studies, indicating late presentation. Taking time off work/household responsibilities was a factor in 15% (6) of the studies. In Cameroon, a woman reported that no one would tend to her children if she left for a HCF\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e. In Fiji and South Africa, domestic roles restricted time to attend clinics and in Peru over 50% indicated that forfeiting housework and jobs was difficult; making responsibilities, chores and duties barriers to timeliness \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n \u003ch2\u003eCommunity Factors associated with DD of CC\u003c/h2\u003e\n \u003cp\u003eFrom the factors extracted across the three themes (Appendix V), 37.5% (15) of the studies suggest husband\u0026rsquo;s knowledge or consent is a determining factor of DD in women. Husbands unaware of CC are less likely to permit, encourage, or pay for screening. The \u0026ldquo;machismo\u0026rdquo; effect mainly in SA(Afghanistan, Indonesia, Nepal, Iraq), LAC(Belize and Peru) and parts of Africa show that men often control their wives, cultural norms discouraged pelvic/cervical examinations and permission is required before screening \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. In Ghana and Zimbabwe, women feared screening due to being labelled promiscuous \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. In Ethiopia, husbands showed minimal support and discouraged visits to HCPs because of misconceptions about cancer being a satanic curse, leading to possible abandonments\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. Muslim women in Thailand faced more resistance from husbands compared to Buddhists\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003e37.5% (15) of the studies indicate that distance is a crucial barrier to early-stage diagnosis; the further the community of residence from a HCF, the less the inclination to travel for health-seeking purposes due to costs and geographical hindrances\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. Women in South Africa, Bolivia, Nepal and China reported dangers of traversing long distances to reach cancer-care facility.\u003c/p\u003e\n \u003cp\u003eReligious rituals and cultural practices contribute to late presentation in LMICs in 30%(12) of the papers. Stigma deters screening by women in 15/40 studies (27.5%). Many women that seek screening/diagnosis are labelled as promiscuous, practising witchcraft and in China; seen as breaching social taboo \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. 22.5% (9) papers showed a disregard for women\u0026rsquo;s health concerns as seen in Afghanistan and Iraq. Low social-support, a poor attitude towards pelvic examinations in the community, whether cultural or religious and a lack of community knowledge and involvement are major deterrents to prompt identification of CC in women in LMICs\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n \u003ch2\u003eInstitutional Factors associated with DD of CC\u003c/h2\u003e\n \u003cp\u003eFour themes were identified with regards to institutional factors in this global study (Appendix V): health system inadequacies, HCP related delays, hispathological \u0026amp; diagnostic delays, and government delays.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\n \u003ch2\u003eGovernment related\u003c/h2\u003e\n \u003cp\u003eThe absence of national screening programs (NSPs) or guidelines was the most common factor in 47.5%(20) of the articles. In Africa; South Africa, Ghana, Tanzania, Ethiopia, Rwanda, Uganda and Nigeria lack NSPs leading to institutional delays. Multiple healthcare visits due to the fragmented systems, caused delays in 20%(8) of the papers. Poor funding of HCPs in rural areas and weak awareness campaigns were apparent in 15%(6) of the papers, contributing to knowledge gaps. The absence of guidelines and inadequate insurance coverage contributed to DD in 10%(4) of the articles. Only three studies from Korea, Brazil and Rwanda, identified the \u0026ldquo;distraction effect\u0026rdquo; (healthcare uptake was disrupted due to another disease) as a factor that led to DD after Covid-19 \u003csup\u003e22,31,39\u003c/sup\u003e.\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\n \u003ch2\u003eHCP related\u003c/h2\u003e\n \u003cp\u003e45% (18) of the studies emphasised the incompetency of HCWs with regards to lack of skills/knowledge/training in CC that contributes to DD. This was prevalent across African countries (South Africa, Ghana, Tanzania, Ethiopia, Rwanda, Cameroon, Ivory Coast and Uganda), SA(India, Iraq and Indonesia) and LAC (Belize and Bolivia). HCW shortages and gender of the provider were contributors to DD in 22.5% (9) of the studies. Women preferred to be screened by female nurses or doctors and some husbands denied male HCPs, especially in shared spaces and smaller communities \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. Multiple pre-referral consultations allowed stage migration and this was evidenced in 20%(10) of the studies, with women in India having greater than three prereferral appointments\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. This was reaffirmed by low confidence of HCPs in identifying early symptoms and failing to carry out a pelvic examination on first consultation in 17.5%(7) of the studies\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. Long referral delays, poor provider-patient communication, discomfort, lack of counselling, negative attitudes of HCP and lack of confidentiality were other factors.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\n \u003ch2\u003eHealth systems delays\u003c/h2\u003e\n \u003cp\u003eHealth system inadequacies were a significant theme, with the longest HCP delay from healthcare visit to diagnosis seen in Afghanistan of up to 213 days and the shortest seen in Botswana of 44 days\u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. Lack of resources being the most prominent factor in delays followed by a lack of equipment, poor infrastructure, long wait times and limited and inequitable accessibility to services were seen in 27.5%(17), 25%(10), 22.5%(9),17.5%(7), 17.5%(7), studies respectively.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\n \u003ch2\u003eHispathology \u0026amp; Diagnostic\u003c/h2\u003e\n \u003cp\u003eDelays due to lost results or hispathological delays were evidenced in 17.5%(7) of the studies. 12.5% of the studies mentioned stress on pathological services due to limited skilled HCWs and the absence of services on some days in 7.5%(3) of the papers and finally 5%(2) studies noted false negatives. This review shows the main factors contributing to DD of CC according to individual, community and institutional factors across LMICs in the table below.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e: Predominant factors contributing to DD of CC across LMICs.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cimg 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\"\u003e\u003cbr\u003e\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e This scoping review identified 40 studies, highlighting the persistent global concern of delayed diagnosis (DD) of cervical cancer (CC) in low- and middle-income countries (LMICs). Findings show that DD exceeds 50% across LMICs, with Africa and South Asia displaying the highest rates, sometimes exceeding 80%. Factors differ according to regions and addressing region-specific factors is crucial for reducing this preventable condition.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIndividual Factors: Income, Education, Unemployment, Marital status, Transport Costs.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eFrom the results, sociodemographic factors play the biggest role in DD of CC at the individual level in LMICs. Low income and education levels are the most significant contributors to DD. Financial barriers, lack of knowledge, and poor health literacy limit women\u0026rsquo;s ability to recognize CC symptoms or seek care. Due to financial restrictions, women in Africa, South Asia (SA), Latin America and the Caribbean (LAC), and Oceania often prioritize daily expenses over healthcare. These findings coincided with another global systematic review on delayed CC diagnosis, indicating that low socioeconomic status (SES) increases the risk of delayed presentation\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Similarly, a sub-Saharan study also found that educated women are more likely to seek timely screening, as they better understand health information\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIgnorance about CC and its early symptoms perpetuates delays. Not knowing CC is preventable or can be asymptomatic, incited an arrogance towards screening as a preventative measure. Many women avoid screening due to stigma, fear, or attributing symptoms to aging or other conditions. For instance, in Ivory Coast, women fear gynaecological care may \"wake up a sleeping illness\"\u003csup\u003e\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u003c/sup\u003e. Similar misconceptions were reported in Ethiopia\u003csup\u003e\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e and Tanzania where women who reported no knowledge nor awareness of symptoms and resorted to traditional healers for treatment\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e. Contrastingly, South African women sought care when symptoms affected their relationships\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Women with prior sexually transmitted diseases (STDs) often mistake CC symptoms for earlier infections, delaying screening in Ghana, Tanzania, Ethiopia, Ivory Coast and Nigeria in Africa, Belize in LAC and only India in SA. Similarly, a global systematic review concurred that prior infections lead to delayed screening\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Botswana\u0026rsquo;s integrated screening within HIV care, made it an anomaly and women with HIV were seen to have improved early detection\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. This finding coincided with a SEA review (focusing on Thailand, Indonesia and Malaysia) as WLWH were seen to have early detection due to regular check-ups\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e. The evidence suggests that integrating CC screening with SRH may be beneficial to countries who cannot afford independent screening programs.\u003c/p\u003e \u003cp\u003eIn some instances, symptoms are attributed to long-term contraceptive use and ignored in older women, making them more prone to DD. The findings were succinct with those of a study done in Uganda, which verifies that attributing symptoms to bodily changes, perimenopause, long-term contraceptive use, STDs and low perceived risk of CC and self-management were common in late-presentation\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCompared to the Middle East where women have better accessibility, Iraq still has low knowledge levels compared to other HIC such as Kuwait. This is attributable to the fact that the Iraqi population has cultural barriers in cervical examinations and has been through wars and conflict with many demographical changes and a low priority on women\u0026rsquo;s health needs\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Iraq was the only country from the ME and studies from pre-2019 were omitted, showing that less research was done on CC after Covid-19, possibly due to a shift in focus and HC resources after the pandemic.\u003c/p\u003e \u003cp\u003eMarital status is an important factor as most women who are unemployed or housewives rely on their husbands to pay for medical costs and transport. Married women who are child-bearing visit gynaecologists regularly, allowing early detection. A priori systematic review on CC diagnosis also found that women that have infrequent gynaecological examinations are prone to delays and those that have a number of biological children have a protective effect\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Being married contributes financially but also falls under a community factor as it is related to \u0026ldquo;husband\u0026rsquo;s knowledge\u0026rdquo;.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCommunity Factors: Husband\u0026rsquo;s knowledge, Distance and Accessibility.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn SA, LAC and rural Africa, women must often seek spousal consent for care\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Similarly, the \u0026ldquo;machismo\u0026rdquo; effect in LAC indicated husbands; refused male HCPs from examining their wives, had to consent to screening and usually thought it was unnecessary \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. Misconceptions among husbands and stigma surrounding CC deter prompt action. However, in Botswana, spousal support encouraged timely diagnosis \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. This finding was further evidenced in Uganda where lay consultations with husbands and community members were seen to prompt early diagnosis\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e. A meta-analysis done in Indonesia coincided with the findings; stating that women with spousal support were 3.39 times likely to be diagnosed early than women who did not have husband support\u003csup\u003e\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn SA, religious beliefs, such as preserving virginity, further discourage cervical exams\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e in comparison to African women who engage in sexual behaviour much earlier than the recommended CDC age. Cultural barriers with pelvic examinations and low prioritisation in woman\u0026rsquo;s health in Afghanistan and the ME, verified why these regions contributed to higher community factors. A systematic review done on CC patients in SEA coincided with our findings that being married does not necessarily lead to early detection\u003csup\u003e\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u003c/sup\u003e. This presents an inconsistency due to the sociocultural context related to sexual behaviours in these conservative regions and more research needs to be done on making a generalisation that married women are likely to be diagnosed early in LMICs. Regionally, being married in SA, ME, LAC and some rural African countries is a deterrent to early detection whereas in countries with better spousal knowledge and HIC, being married deters DD.\u003c/p\u003e \u003cp\u003eRural areas face significant challenges, including long distances to healthcare facilities and transport costs. Consistent with the findings of previous studies, distance to healthcare facilities is regarded as a barrier to screening in this review mainly because of the cost of transport as seen in Africa and SA. South African and Nigerian women, travel hundreds of kilometres to the closest primary care facility which discourages screening\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. This was seen in SA in countries like China, Afghanistan and Indonesia (being an archipelago). Poor road infrastructure and harsh weather conditions exacerbate the issue in countries like Bolivia. Additionally, women must often forgo work or household duties to seek care, further complicating access. Failures on the part of HCFs e.g. delayed results or multiple referrals also demotivates women to travel numerous times due to time and cost restraints. Findings from a study in Malawi, Cameroon and Namibia concur with these results; stating that although women were aware of screening, long distances from HCFs limited their health-seeking behaviours and follow ups due to costs\u003csup\u003e\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u003c/sup\u003e. Similarly, a study in Tanzania also confirmed the findings that high transport costs delay diagnosis by concluding 78.8% of the respondents stated that lack of funds to cover transport costs deterred HCF visits\u003csup\u003e\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u003c/sup\u003e. Furthermore, another study in South Africa and Uganda also confirms that transport costs were the greatest barrier to early detection\u003csup\u003e\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u003c/sup\u003e. A systematic global review was in sync with our findings and reported that being employed, living in urban areas, receiving correct advice, were associated with a short health seeking interval and low SES, low health literacy, use of traditional/complementary medicine, seeking advice from family members, non-disclosure of symptoms and living in rural areas were associated with delayed help-seeking\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInstitutional factors: Lack of NSPs and lack of HCP skills and knowledge.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eInstitutionally, the lack of National Screening Programs (NSPs) and the lack of skill, knowledge and training of healthcare workers (HCWs) are critical barriers to DD of CC. Only 14 of the 26 countries reviewed have NSPs, campaigns or outreach programs enabling awareness, cost effectiveness and accessibility of CC screening. Patients in countries without NSPs, therefore present themselves at primary healthcare facilities. HCWs in primary care settings (as seen in Africa) often; lack the skills and knowledge to perform cervical examinations (on first consultation) to infer diagnosis, have long wait times, lack pathology services and focus on infectious diseases, delaying referrals\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e,\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e,\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003eThese findings concurred with that of a study in Zambia\u003csup\u003e\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e\u003c/sup\u003e. Centralized cancer services in countries like Zambia and Ghana make accessibility particularly difficult for rural populations. Similarly, fragmented healthcare systems in Iraq (where HCW admit to a major gap in knowledge and expertise of gynacologists) and Brazil limit access to timely diagnosis\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. A study in Uganda, verifies these findings, concluding that poor HCW knowledge results in false reassurances at first consultation and further upstaging and DD\u003csup\u003e\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u003c/sup\u003e.Another review also confirmed that omitting a cervical examination on first consultation deters early diagnosis\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e.The absence of campaigns and NSPs creates a huge knowledge gap in these countries, which is proven to be the main factor leading to DD, especially in African countries.\u003c/p\u003e \u003cp\u003eIn the Middle East, due to cultural sensitivities, the NSPs do not advocate and promote specialist training and skills for HCWs, resulting in poor capacity\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e. Similarly in SA; Afghanistan, Indonesia and Nepal encountered similar barriers to screening. Although India has screening programs at primary facilities, 43% of patients had; no cervical examination, over three pre-referral consultations, long wait times and poor service delivery.\u003c/p\u003e \u003cp\u003eAcross LAC; Peru decentralised cancer services but displayed a lack of experience in HCPs as 71.5% of patients mentioned mistreatment. Argentinians faced a fragmented HC system which limited accessibility to screening due to cost. Although NSPs exist in Brazil and Belize, disruptions in Brazil during the pandemic occurred. Insufficient training, staff shortages, strains on pathology, negative morales of HCWs in Belize still presented as huge institutional barriers in this region resulting in poor capacity being a predominant factor across all countries\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eInstitutionally, our findings were consistent with a study which showed that 86.3% of patients with CC that consulted a primary-care facility presented with DD\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e. Evidence showed that the odds of a person consulting at a primary-care facility having late stage presentation was 2.6 times higher than those that referred to a secondary or tertiary facility (explained by the lack of knowledge of HCW on CC at primary facilities). Furthermore, patients that did not have screening through NSPs during the last 3 years were most likely to have DD and those that had no cervical examination were associated with late presentation; emphasising the importance of NSPs providing strengthened capacity for cervical examinations and regular services. A previous South Asian study also provides evidence showing screening coverage increases with NSPs\u003csup\u003e\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e,\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis single-researcher study had time constraints and potential biases. Variability in terminology and definitions of DD across and within same-country studies, along with differing thresholds for delays (e.g., \u0026gt;\u0026thinsp;60 vs. \u0026gt;90 days), posed challenges and suggests future definitions of delays in a standardised manner. The absence of quality assessment in scoping reviews highlights the need for more rigorous future research. Some regions have very little published on DD suggesting they have overcome the public health issue/not enough has been done yet.\u003c/p\u003e \u003cp\u003eThe absence of European countries in the study, after the time reduction, may be due to the distraction effect; suggesting research in CC needs to continue in these regions as Covid-19 did cause DD. The results from ME and Oceania, since represented by only a single-country study, overweighed the representation per factors in these regions. Since the study population relies on individuals to report on appraisal and health-seeking delays; recall and social desirability bias may have occur. Majority of the studies were African, which may explain why the overall LMIC result is skewed towards the African results. Lastly, from the research done, it can be concluded that very few qualitative studies have been done to ascertain the socio-cultural factors across all regions in depth. More research on the uptake of alternative treatment, traditional practitioners, lay beliefs and stigma that curb awareness on CC need to be assessed for culturally appropriate NSPs.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe delayed diagnosis of cervical cancer in LMICs is led by individual, institutional and lastly community factors. Low income, education and awareness, being married, husband\u0026rsquo;s knowledge, accessibility, the lack of national screening programs and a lack of capacity are the most prevalent factors in LMICs. Sociodemographic individual factors that deter screening in countries with populations of low income, low education, unemployment and low awareness of cervical cancer are apparent in Africa, South Asia (SA), Latin America \u0026amp; Caribbean (LAC) and Oceania. Marriage is a key factor that contributes to diagnostic delays in SA, LAC, Middle East (ME) and parts of Africa. Being married is associated with community factors; husband\u0026rsquo;s knowledge, religious beliefs and cultural practices. In regions with better husband\u0026rsquo;s knowledge and less emphasis on cultural modesty; being married was inversely associated to delayed diagnosis, showing a disparity that needs to be further researched. Cost of transport and distances that reduce accessibility are found to hinder early health-seeking and are common in rural areas of Africa and countries in SA the most. Finally, institutionally; the absence of national screening programs and lack of skills of HCP was seen most in LAC, Africa, ME and Oceania. In SA, robust screening programs and universal health coverage made institutional factors the least prominent out of all regions. The establishment of effective awareness, regionally specific, high quality, culturally appropriate screening programs together with quality infrastructures and health workforce capacity building are necessary to envision the WHO goals of cervical cancer elimination.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis paper was prompted by my desire to contribute to women\u0026rsquo;s health in Malawi especially because Malawi has the second highest prevalence and mortality rate of cervical cancer in the world. I would like to thank Dr Sam Meja, \u0026nbsp;Felix Chisoni and Maureen Majamanda for their support. My supervisor, Mr. Hubert Amu, thank you for your guidance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eContributors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProvenance and peer review\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eORCID iD\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSarah Parekh:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ehttps://orcid.org/0009-0004-1014-7898\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFelix Chisoni:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ehttps://orcid.org/0000-0003-1798-6446\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHubert Amu:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ehttps://orcid.org/0000-0003-0218-3843\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization (2019) WHO guidelines for the use of thermal ablation for cervical pre-cancer lesions. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://apps.who.int/iris/bitstream/handle/10665/329299/9789241550598-eng.pdf\u003c/span\u003e\u003cspan address=\"https://apps.who.int/iris/bitstream/handle/10665/329299/9789241550598-eng.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e accessed 5 February 2025)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeleke S, Anley M, Kefale D et al (2021) Factors Associated with Delayed Diagnosis of Cervical Cancer in Tikur Anbesa Specialized Hospital, Ethiopia, 2019: Cross-Sectional Study. 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[Online] Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12885-023-11728-y\u003c/span\u003e\u003cspan address=\"10.1186/s12885-023-11728-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Liverpool John Moores University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cervical Cancer, delayed diagnosis, Low and Middle Income Countries","lastPublishedDoi":"10.21203/rs.3.rs-6092037/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6092037/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCervical Cancer (CC) is a significant public health concern worldwide. Low-and-middle-income countries (LMICs) bare 90% of the burden of CC morbidity and mortality due to delayed diagnosis of the disease which is preventable and curable if detected early. Vaccination campaigns and early screening have succeeded in reducing CC prevalence drastically in high-income countries (HICs), highlighting a gap of health inequities in LMICs. This review aimed at mapping factors associated with the delayed diagnosis (DD) of cervical cancer (CC) across LMICs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA search across databases; Embase, Pubmed, Scopus, Web of Science and SCINHAL. ProQuest Dissertations and Ebsco between 2019 to 2024 was conducted. Two reviewers independently screened titles and abstracts followed by a full-text assessment to determine the final inclusion. Any disagreements were resolved through consensus. Data were extracted using a standardized form, and a narrative synthesis was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe retrieved 2116 studies, however only 40 studies (across 26 LMICs) met our inclusion criteria and were relevant to this review. Patient-related (individual) and health-system (institutional) delays are more prominent than community-related delays. Approximately 80% of studies suggested that low income and education are predominant individual factors that lead to delayed diagnosis of CC. 67.5% highlight the failure to recognise symptoms in these regions. In rural Africa and South Asia, transportation costs are a major factor. 58% of the studies suggested marital status as an associated factor but this was dependent on a community factor; husband’s awareness. Countries with better husband’s knowledge associate marriage with early detection. Institutionally, 47.5% of the studies evidenced the lack of national screening programs and the lack of skills, knowledge and training of healthcare workers as a factor to delayed diagnosis predominantly in Africa.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLow income and education, long distances, poor spousal awareness, absence of screening facilities and unskilled capacity impact CC’s delayed diagnosis. \u0026nbsp;Context-specific solutions like; expanding awareness, building quality, culturally appropriate, decentralised screening infrastructures with health workforce capability and focus on socio-cultural barriers across regions is necessary to defeat CC in LMICs.\u003c/p\u003e","manuscriptTitle":"The Delayed Diagnosis of Cervical Cancer in Low-Middle Income Countries (LMICs): A Scoping Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-27 08:58:40","doi":"10.21203/rs.3.rs-6092037/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b370dded-78d2-4f23-b5bf-b22847f89a4c","owner":[],"postedDate":"February 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":44750692,"name":"Sexual \u0026 Reproductive Medicine"}],"tags":[],"updatedAt":"2025-02-27T08:58:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-27 08:58:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6092037","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6092037","identity":"rs-6092037","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}