Rural-urban differences and association of sexual autonomy with uptake of breast and cervical cancer screening services among women of reproductive age in Ghana

Introduction

Breast cancer (BC) and cervical cancer (CC) remain global public health concerns (1). BC is the second most common cancer and CC is the eighth most common cancer worldwide. In 2022, 2,296,840 BC cases and 662,301 CC cases were reported globally, with an estimated 666,103 BC-related and 348,874 CC-related deaths (1). The incidence and mortality of both cancers are disproportionately high in low- and middle-income countries, including those in Africa (2).

In Africa, BC and CC remain the two most common cancers among women (1). In 2022, 198,553 BC cases with 91,252 deaths, and 80,614 CC cases with 125,699 deaths were reported (1). Although CC case numbers are lower than BC cases, CC mortality rates are notably high, reflecting late-stage diagnoses and limited access to treatment. The burden of BC is particularly pronounced in West Africa, which recorded the second-highest incidence (37.3 per 100,000 women) and the highest BC mortality rate (17.8 per 100,000) compared to other African sub-regions (3).

In Ghana, the incidence of BC increased from 23.8 per 100,000 women in 2008 to 37.8 per 100,000 women in 2018 (4). In 2020, 4,645 new BC cases were recorded, with approximately 50% case fatality rate; BC accounts for 12.4% of all cancer deaths among women in Ghana (5). CC is the second most common cancer among Ghanaian women, with incidence of 35.4 per 100,000 women, far exceeding the SDG 3.4 target of below 4 per 100,000. An estimated 2,797 women are diagnosed with CC annually, and approximately 60% die from the disease (6).

Known risk factors for BC and CC include age, obesity, high parity, and human papillomavirus (HPV) infection, compounded in Ghana by rapid demographic and epidemiological transitions (7). Critically, Ghana has no national BC or CC screening programme, making screening opportunistic and uptake low: a further analysis of the 2022 GDHS found that only 18.4% and 5% of women of reproductive age had ever screened for BC and CC, respectively (8).

Marked disparities exist between rural and urban populations, with urban women consistently more likely to utilise cancer screening services (8). These disparities are attributed to differences in awareness, distance to screening centres, and cost of services (9).

Sexual autonomy, defined as a woman's ability to make independent decisions regarding her sexual and reproductive health, has been identified as a critical determinant of health service utilisation. Agency theory suggests that women with greater decision-making power are better able to initiate preventive health behaviours, including screening, through increased self-efficacy, reduced dependence on partner permission, and improved communication with health providers (10). Studies confirm that sexually autonomous women are more likely to use contraceptives (10) and a case-control study in Ethiopia found a positive association between sexual autonomy and CC screening uptake (11). It is hypothesised that where sexual autonomy is lower, particularly in rural areas, its effect on preventive health behaviour may be attenuated by structural and social barriers, which could explain why sexual autonomy was not a significant predictor of CC screening in rural settings.

The extent to which sexual autonomy is associated with BC and CC screening uptake across rural-urban contexts in Ghana remains underexplored. This study therefore examined rural-urban differences in the association between sexual autonomy and uptake of BC and CC screening among women of reproductive age in Ghana.

Methods

Data source

This study analysed secondary data from the 2022 Ghana Demographic and Health Survey (GDHS), which is publicly available at https://dhsprogram.com/data/. Data were collected from 17 October 2022 to 14 January 2023 by the Ghana Statistical Service, with funding from the United States Agency for International Development (USAID) and the United States President's Malaria Initiative, with ICF providing technical assistance. The 2022 GDHS collected data on demographic and health indicators including age, educational status, wealth status, sexual autonomy, and screening for BC and CC.

Population and sampling

The target population was women of reproductive age (15–49 years) across the 16 administrative regions in Ghana. The updated sampling frame from the 2021 Population and Housing Census was used. A stratified two-stage cluster sampling design was employed: in stage one, 618 clusters (comprising 612–618 primary sampling units) were selected from the frame using probability proportional to size (12). In stage two, households were listed and mapped in each cluster; 18,450 households were selected and all women who had spent the night before the survey in selected households were eligible. A total of 15,014 women aged 15–49 years were interviewed.

Study population and exclusion criteria

Of the 15,014 women interviewed in the 2022 GDHS, this study focused on women for whom data on the key sexual autonomy variables were available. Women who reported they had never had a husband or sexual partner (and to whom sexual autonomy questions were not applicable), as well as participants with missing or ‘don't know’ responses on any of the key study variables, were excluded. This resulted in a weighted analytic sample of 8,044 women. A total of 6,970 women were excluded. Figure 1 presents a STROBE-compliant participant flow diagram.

Study variables

Outcome variables

Women were asked whether a doctor or other healthcare provider had ever examined their breasts to check for cancer (BC screening) or had ever tested them for cervical cancer (CC screening). Responses were originally coded ‘1 = Yes, 2 = No’ and were re-coded as dummy variables (‘1 = Yes, 0 = No’). These are self-reported measures, which may be subject to recall bias, as there was no time limit on the question.

Primary independent variable—sexual autonomy

Sexual autonomy was operationalised as a composite index derived from three items: (1) whether the respondent can refuse sex; (2) whether the respondent can ask her partner to use a condom; and (3) whether the wife is justified in asking her husband to use a condom if he has a sexually transmitted infection. Responses were coded ‘1 = Yes’ and ‘0 = No’, generating a total score of 0–3. Scores of 0–1 were classified as ‘No sexual autonomy’ and scores of 2–3 as ‘Yes/Has sexual autonomy’, consistent with prior studies using similar DHS-derived indices (13). It is acknowledged that the third item measures norms (justification) rather than individual behaviour or ability, which introduces some heterogeneity in the construct. This is discussed in the Limitations section.

Other independent variables

Contraceptive use (no method; hormonal methods, including pill, injectable, and implant; non-hormonal methods, including intrauterine device, condom, and withdrawal); age (15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49 years); educational level (none, primary, secondary, higher); religion (Christianity, Islam, Traditional/African, No religion); wealth quintile (poorest, poorer, middle, richer, richest) as derived from the standard DHS asset-based wealth index (12); frequency of reading newspaper, listening to radio, and watching television (not at all, less than once a week, at least once a week); and current employment (no, yes).

Data analysis

Stata/SE version 17 was used for all analyses. Sampling weights, clustering, and stratification were accounted for using the ’svyset’ command (complex survey design). Descriptive statistics were computed for participant characteristics and for the prevalence of BC and CC screening and sexual autonomy. Chi-square tests assessed associations between categorical variables and screening outcomes at the bivariate level. Multivariable logistic regression analyses were performed to assess the association between sexual autonomy and each screening outcome. All covariates that were statistically significant in the bivariate analysis were included in the multivariable model. Six logistic regression models were fitted: factors associated with BC screening among urban women (Model 1), rural women (Model 2), and all women combined (Model 3); and factors associated with CC screening among urban women (Model 4), rural women (Model 5), and all women combined (Model 6). A p-value of < 0.05 was considered statistically significant and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) are reported. An interaction term between sexual autonomy and place of residence was tested to formally assess whether the rural-urban stratification was warranted; the interaction was statistically significant (p < 0.05), supporting the stratified analysis. Cross-sectional data preclude causal inference; therefore, terms such as ‘influence’ and ‘predictor’ are used in the descriptive sense to indicate statistical association.

Ethical consideration

The 2022 GDHS obtained ethical approval from the Ghana Health Service Ethics Review Committee, and informed consent was obtained from all participants prior to the survey. Written informed consent was obtained from participants aged ≥18 years; written parental/guardian consent plus participant assent was obtained for those aged 15–17 years. This secondary analysis did not require additional ethical approval, as it used de-identified, publicly available data downloaded from the DHS Programme website after obtaining permission. All procedures complied with the Declaration of Helsinki (2013 amendment). The STROBE guidelines for cross-sectional studies were followed.

Results

Descriptive statistics of participant characteristics

Of the 8,044 women included in the analysis, approximately 14.7% were young women (15–24 years) and more than half had secondary school education (51.1%). One in five (20.3%) participants were in the poorest wealth quintile, 84.7% were employed, and 14.2% resided in the Greater Accra region. Most participants (91.9%) did not read newspapers; 43.9% listened to the radio and 60.5% watched television at least once a week. More than half (71.7%) professed Christianity and 36.4% were using contraceptives, of whom 21.7% used hormonal methods and 14.7% used non-hormonal methods (including condom, IUD, and withdrawal).

Regarding sexual autonomy, 79.0% of the participants had sexual autonomy. A higher proportion of women in urban areas (93.5%) than rural areas (86.5%) had sexual autonomy (p < 0.05). These proportions refer to the distribution within the BC-screening sub-sample (Table 1); the overall prevalence of sexual autonomy across the full analytic sample was 79.0%.

Table 1. Descriptive statistics and factors associated with BC and CC screening among women of reproductive age in Ghana.

p-value < 0.05.

A total of 20.9% of participants had ever screened for BC, with higher prevalence in urban areas (27.8%) compared to rural areas (13.6%) (p < 0.05). For CC screening, 6.4% of participants had ever screened, with urban women (9.1%) more likely to have screened than rural women (3.5%) (p < 0.05).

Among women who had screened for BC, 91.3% had sexual autonomy; this was higher in urban (93.5%) than rural (86.5%) areas. Among those who had screened for CC, 91.7% had sexual autonomy; urban (93.8%) compared to rural (85.7%). BC and CC screening uptake were significantly associated with age, education, wealth index, religion, employment status, region, contraceptive use, and frequency of media exposure (p < 0.05) (Table 1).

Factors associated with breast and cervical cancer screening among urban and rural women

Overall, women with sexual autonomy (AOR = 2.10, 95% CI: 1.68–2.63) were approximately twice as likely to have screened for BC compared to those without sexual autonomy. Stratified by place of residence, both urban women (AOR = 2.16, 95% CI: 1.57–2.98) and rural women (AOR = 1.92, 95% CI: 1.40–2.63) with sexual autonomy had higher odds of BC screening, with the odds being higher among urban women. The odds of BC screening also increased with age, higher education, greater wealth, and more frequent media exposure. Women using non-hormonal contraception (AOR = 1.37, 95% CI: 1.11–1.71) had higher odds of BC screening than non-users. Women in the North East region (AOR = 3.59, 95% CI: 2.02–6.38) had significantly higher odds of BC screening compared to those in Greater Accra. Frequency of newspaper reading and television watching were significant predictors in urban areas, while radio listenership was significant in rural areas.

For CC screening, women with sexual autonomy had higher odds of having screened overall (AOR = 1.95, 95% CI: 1.32–2.88). Stratified analyses showed that sexual autonomy was a significant predictor of CC screening among urban women (AOR = 2.06, 95% CI: 1.22–3.48) but was not statistically significant among rural women (AOR = 1.66, 95% CI: 0.96–2.87). Higher education, greater wealth, and certain regional characteristics were also associated with CC screening. Radio listenership was significant among rural women for CC screening but not among urban women (Table 2).

Table 2. Factors influencing BC and CC screening among rural and urban women of reproductive age in Ghana.

p-value < 0.05.

Discussion

This study examined rural-urban differences in the association between sexual autonomy and uptake of BC and CC screening services among women of reproductive age in Ghana. The findings are discussed in the context of the existing literature, with attention to methodological considerations and implications for policy and practice.

The prevalence of sexual autonomy in this study was 79.0%, which is higher than the 75% reported among women in 29 sub-Saharan African (SSA) countries (13) and slightly lower than the 83% reported by Adu et al. (14) among women in sexual unions across 31 SSA countries. Direct comparisons should be interpreted cautiously, however, as those studies differed in their definitions and components of sexual autonomy and focused exclusively on women in sexual unions across multiple countries, whereas the present study included only married Ghanaian women (13, 14). A complementary study by Salifu et al. (15) also using the 2022 GDHS but restricting the sample to currently partnered women aged 15–24, reported a sexual autonomy prevalence of 77.2%, and found that sexual autonomy significantly increased the likelihood of BC (AOR = 2.75) and CC screening (AOR = 5.45) (15). The convergent direction of findings, despite sample and methodological differences, reinforces the public health relevance of sexual autonomy for cancer screening in Ghana. The finding that a substantial minority of women in Ghana lack sexual autonomy has serious public health implications: women who cannot refuse sex or insist on condom use face heightened risks of unwanted pregnancy, sexually transmitted infections, and unmet contraceptive need (10).

Consistent with the literature in SSA (16–18), sexual autonomy was higher among women in urban areas. Women in urban areas are more likely to have higher socioeconomic status, including higher education and employment rates, greater access to information, and exposure to gender-equitable norms that support decision-making autonomy over sexual and reproductive matters. This finding underscores the structural inequalities that constrain the sexual and reproductive health of rural women, including risks of sexual violence, sexually transmitted infections, and restricted access to health services. The association between higher socioeconomic status and sexual autonomy may operate through multiple pathways, including access to family planning services, reduced economic dependence on partners, and exposure to gender-equitable messaging in education and media.

Uptake of BC and CC screening was low, particularly in rural areas, corroborating prior studies in Ghana (8, 19, 20). The rural-urban gap likely reflects differences in awareness of screening benefits, physical distance to screening facilities, financial barriers including transportation and service costs, and psychosocial barriers such as fear of cancer diagnosis and associated stigma (21). Late-stage cancer detection in rural areas can result in poor treatment outcomes, increased healthcare expenditure, and higher rates of invasive procedures including mastectomy and cervicectomy. Addressing these gaps will require multi-pronged strategies: community-based health education, subsidisation of screening costs, deployment of mobile and outreach services, and integration of cancer screening into primary and antenatal care.

Sexual autonomy was positively associated with BC screening uptake in both urban and rural areas, with higher odds among urban women. For CC screening, sexual autonomy was a significant predictor only in urban areas. These findings are consistent with Midaksa et al. (11) who, in a case-control study in Addis Ababa, Ethiopia, found that women with sexual autonomy were approximately three times more likely to screen for cervical cancer. The contextual differences between Ethiopia and Ghana are noteworthy: the Midaksa et al. (11) study was conducted in an urban capital setting with relatively good access to screening services, which may partially explain the larger effect sizes compared to the present study. In rural Ghana, the non-significant association for CC screening may reflect the combined influence of limited access to screening infrastructure, social norms that restrict women's independent health-seeking, and lower baseline awareness of CC screening services, which may attenuate the effect of sexual autonomy even where it is present. The proposed pathway is that sexual autonomy increases self-efficacy, reduces dependence on partner permission for health-seeking, and improves communication with healthcare providers, thereby facilitating screening access (10, 22). Holistic interventions addressing both individual empowerment and structural access barriers are therefore needed.

Beyond sexual autonomy, the likelihood of BC and CC screening increased with age, education, and wealth quintile, consistent with previous research (8, 23). Older women may have greater perceived susceptibility to cancer, as age is a recognised risk factor. Women with higher education may have greater health literacy and capacity for informed decision-making. Women in higher wealth quintiles are better positioned to afford transportation and screening services (24). These findings collectively indicate that women of lower socioeconomic status face compounded barriers to cancer screening.

Frequency of media exposure, particularly television viewing and radio listenership, was associated with BC screening. The rural-urban differences in media predictors are informative: newspaper reading and television viewing predicted screening in urban areas, while radio was the significant predictor in rural areas, likely reflecting higher rural radio penetration. These findings support the use of culturally appropriate mass media campaigns including radio-based community outreach, to raise awareness of cancer screening, consistent with evidence from SSA (8, 25, 26).

Limitations

Several limitations of this study should be acknowledged. First, the cross-sectional design precludes causal inference; the associations reported should be interpreted as statistical associations only. Second, both cancer screening and sexual autonomy were self-reported, which may be subject to recall bias and social desirability bias, respectively. Women may over-report screening due to inaccurate recall and may over-report sexual autonomy due to perceived social expectations. Third, the sexual autonomy composite index combines items that measure individual behaviour (ability to refuse sex, request condom use) with a normative item (whether a wife is justified in requesting condom use), introducing potential heterogeneity in construct measurement. This may reduce construct validity, and future studies should consider testing separate dimensions of sexual autonomy. Further, the DHS cancer screening question asks about ‘ever screened’ with no time limit, which may capture outdated behaviours. Also, the sample was restricted to women with applicable and complete data on sexual autonomy variables, which may introduce selection bias. Sixth, interaction between sexual autonomy and place of residence was tested and found to be statistically significant, supporting the stratified analysis; however, the modest difference in AORs between urban (2.16) and rural (1.92) BC screening may not be clinically meaningful in the absence of formal interaction testing in prior studies for comparison. Finally, comparisons with other studies should be made cautiously due to variation in how sexual autonomy is defined and measured across contexts.

Conclusions

This study found that sexual autonomy was positively associated with BC and CC screening uptake among Ghanaian women of reproductive age, with notable rural-urban differences. Sexual autonomy was associated with higher odds of BC screening in both urban and rural settings but was a statistically significant predictor of CC screening only in urban areas. Uptake of both screening types was substantially lower in rural than urban areas, reflecting structural inequalities in empowerment and access. Stakeholders should prioritise rural women when designing cancer screening interventions, integrating sexual autonomy-promoting programmes with expanded access to affordable, geographically accessible screening services. The use of radio-based communication for rural outreach and mass media for urban populations is supported by the findings. This study contributes nationally representative, rurally disaggregated evidence on the role of sexual autonomy in preventive cancer health behaviour in Ghana, filling a gap in the literature on this understudied intersection.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited by: Tullio Golia D'Augè, Sapienza University of Rome, Italy

Reviewed by: Tonnies Abeku Buckman, Kwame Nkrumah University of Science and Technology, Ghana

Asep Kusnali, National Research and Innovation Agency (BRIN), Indonesia