Married women who engage in unsafe sex are less likely to test for cervical cancer

Most women know screening for the cancer is useful but few follow through


Married and cohabiting women who engage in risky sexual behaviour are less likely to seek cancer screening, reveals a new study.

A perceived lower risk of cervical cancer and other sexually transmitted infections (STIs), the study suggests, could explain the lack of interest in cancer screening. The study was published in the peer-reviewed Journal of Community Health.

Other past studies in Asia and Latin America found that married women shy away from medical examinations that involve physical touching of their bodies by others and that gynaecological examinations are an important predictor of use of a Pap smear, one of the methods for cancer screening.

Overall, women who are currently or formerly married or living with a partner were more likely (21 per cent) than those who are not married (14 per cent) to have a cervical cancer screening.

Sexually active women aged 15–49 who knew of cervical cancer were eligible for the study that is based on data from the 2014 Kenya Demographic and Health Survey.

Regardless of marital status, a significantly lower share of women who engage in risky sexual behaviour reported having cervical cancer examinations, with 15 per cent reporting that they had been screened compared to 21 per cent of women who were practising safe sex, according to the study.

The finding has significant public health implications, as these women are more likely to infect their spouses with HPV, says Dr Zelalem T. Haile, the lead researcher of the study and assistant professor of epidemiology at Ohio University.

“It is critical to develop contextually relevant strategies to increase cervical cancer examination among women engaged in high-risk sexual behaviour,” he says.

“For example, having community health workers, community leaders and men to provide social support can help facilitate use of screening services in a culturally acceptable manner,” says Dr Haile.

Risky sexual behaviour is when a woman reported having sex with at least one non-spousal partner without condoms.

There was no statistically significant association between risky sexual behaviour and having cervical cancer examination among women who were not currently married, shows the study.

Overall, women who are currently or formerly married or living with a partner were more likely (21 per cent) than those who are not married (14 per cent) to have a cervical cancer screening.

Data from the study indicates that one in five of the 6,104 women who have ever had sex and knew of the cancer had cervical cancer examination. Despite the low uptake of cervical cancer tests, figures from KDHS shows that three in four women in Kenya have heard about the cancer. Dr Haile says the fact that a low proportion of women had cervical cancer screening is an indication that barriers may exist in access to needed service. “This calls for a concerted multidimensional strategy to enhance cervical cancer screening in Kenya
among women of reproductive age,” reports the study.

A 2016 study in Kenya found that a large proportion of women knew that it is appropriate for all women to get cervical cancer screening, but only a small proportion of women actually got screening.

Prevents 80%

Early treatment prevents up to 80 percent of cervical cancers. Because precancerous lesions and cancer may take many years to develop, the World Health Organization (WHO) recommends screening for every woman age 30 to 49 at least once in her lifetime and ideally more frequently.


Cervical cancer is caused by human papillomavirus (HPV) infection, which is sexually transmitted. Most HPV infection is harmless and clears spontaneously. But persistent infection with certain types of high-risk HPV (especially type 16 and 18) can cause cancer of the cervix, vulva, vagina, anus, penis, and oropharynx.

According to the US Centers for Disease Control and Prevention, women can develop symptoms years after sex with an infected person, which makes it hard to know when they first became infected.

Figures from the International Agency for Research on Cancer (IARC) indicate that every year about 4,800 women in Kenya are diagnosed with cervical cancer and more than half of them (about 2,450) die from the disease. Cervical cancer is the most frequent cancer among women between 15 and 44 years and the leading cause of cancer-related deaths in Kenya.

Age and education

The likelihood of cancer screening also differed by age, education, wealth, residency, history of STI in the past 12 months, and the age of sex debut.

Findings from the study show that among married women or those living with a partner, age was strongly associated with cervical cancer screening and a Pap test. Particularly, women in the 25–39 and 40–49 age groups were more likely to undergo cervical cancer examination compared to those in the 15–24 age group.

Given that the average age for sexual debut of the study participants was 17, it is important to enhance awareness about cervical cancer screening, HPV and vaccination among youth in the 15–24 age group.

When education is factored in, women who had a secondary or higher level of education were more likely to undergo cervical cancer examination. This could be attributed to having adequate knowledge about cervical cancer and Pap smear tests. The proportion (23 per cent) of women with secondary education or higher who had an examination was almost triple the share of those with no education who had a screening (nine per cent). About 18 per cent of women with primary education had been screened for cervical cancer.

In the study, a quarter of the rich had been examined for the cancer, which was double the proportion of the poor who had been screened (13 per cent). A quarter of urbanites were screened for the cancer compared to 17 per cent of rural residents.

About a third of women who had an STI in the past 12 months had cervical cancer screening compared to a fifth of those who reported no STI over the same period.

Two common types of screening examinations are the Pap smear test and visual inspection with acetic acid (VIA) or with Lugol’s iodine (VILI).

Cervical cancer can be prevented by vaccination against HPV among teenage girls.
In the absence of a national HPV immunisation programme in Kenya cervical cancer testing seems to be an ideal approach to prevention but adequate screening is often plagued by limited availability of screening centres, lack of equipment and patient failure to follow up.


Screening aims to detect precancerous changes, which, if not treated, may lead to cancer. Women who are found to have abnormalities on screening need follow-up, diagnosis and treatment, in order to prevent the development of cancer or to treat cancer at an early stage. According to WHO, it takes 15 to 20 years for cervical cancer to develop in women with normal immune systems. It can take only five to 10 years in women with weakened immune systems, such as those with untreated HIV infection.

Risk factors for HPV persistence and development of cervical cancer include early first sexual intercourse, multiple sexual partners, tobacco use and immune suppression

The study shows that among women who have had an examination, more than half (57 per cent) had a Pap smear test while a third (38 per cent) underwent visual inspection with acetic acid (VIA) or with Lugol’s iodine (VILI).

The study was co-authored by Dr Caroline Kingori, an associate professor of community and public health at Ohio University; Asli Teweldeberhan Haile, a global-health instructor at Ohio University, Dr John Francescon a physician at Cleveland Clinic Akron General and Bhakti Chavan, a healthcare and research professional.

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