“Cervical Cancer—A Silent Disease in the Community”—A Qualitative Study on Awareness of Cervical Cancer in Tanzania

Prevalence

Cervical cancer (CC) is a major global public health issue and the fourth most common cancer among women of reproductive age (Binka et al., 2017; Bray et al., 2018). Over 570,000 new cases and 311,000 deaths occur annually, projected to reach 700,000 cases by 2030 without stronger prevention (Arbyn et al., 2020; Barrow et al., 2020; Runge et al., 2019; WHO, 2022). Sub-Saharan Africa (SSA) bears the highest burden, with 20% of global cases and 24% of deaths (Griesel et al., 2021), and mortality could rise by 50% by 2040 without expanded vaccination and screening (Barrow et al., 2020). In Tanzania, CC is the leading cancer among women, with an incidence rate of 59.1 per 100,000, well above the global average of 13.1 (Bruni et al., 2019, 2022; Gesink et al., 2020). Late-stage diagnosis (Stage III or IV) contributes to poor outcomes, with nearly 7,000 deaths annually (Moshi et al., 2018; Runge et al., 2019).

Prevention

Human papillomavirus (HPV) is the primary cause of CC and can be effectively prevented through screening and vaccination, potentially lowering incidence and mortality by up to 80% (Bénard et al., 2023). However, global vaccine coverage remains low, with only 27% of the target population receiving the first dose well below the 90% target set for 2030 (Simelela, 2021; WHO, 2022). A multicountry study across 78 low- and middle-income countries (LMICs) estimated that full implementation of the WHO 90-70-90 elimination strategy could reduce CC mortality by almost 99%, potentially saving more than 62 million women's lives (Canfell et al., 2020)

In LMICs, CC accounts for over 90% of related deaths (Arbyn et al., 2020; WHO, 2020), yet only 3% of eligible girls receive the HPV vaccine and 44% of women undergo screening (Duncan, 2022). The HPV vaccine uptake in Africa varies from 34% to 93.3%, and safe vaccines combined with screening could reduce incidence by 90% (Gavi, 2021); Gultekin et al., 2020). In East Africa, coverage is only 35%, underscoring the urgent need for improved implementation (Agimas et al., 2024). In Tanzania, CC prevention efforts include the National Cervical Cancer Prevention and Control Strategic Plan (United Republic of Tanzania, Ministry of Health and Social Welfare, 2015) and the introduction of the HPV vaccine program in 2018 (Mphuru et al., 2022). Nevertheless, uptake remains low (Nhumba & Sunguya, 2022), with national screening coverage at just 7.28% (Asgedom et al., 2024) and only 6% of women screened in the Kilimanjaro region (Cunningham et al., 2015). Low screening rates, especially among asymptomatic women, pose a major challenge to achieving the WHO 90-70-90 elimination targets by 2030 (Gultekin et al., 2020; Stefan et al., 2022;WHO, 2022).

Review of Literature

Prevention, early treatment, and raising awareness of CC are crucial to reducing the disease burden. Low levels of CC screening and HPV vaccination are linked to poorer awareness of available prevention services in rural compared to urban areas. Contributing factors include the absence of screening and HPV vaccination services in rural settings, low health literacy on CC and HPV infection/vaccination (Zhetpisbayeva et al., 2023), low coverage of CC screening and vaccination, financial constraints from out-of-pocket expenses, and geographical barriers (Appiah et al., 2025), all limiting access to healthcare services in rural areas. Social and cultural barriers (Asgedom et al., 2024) are also more prominent, while a shortage of qualified practitioners further reduces participation in prevention strategies in rural settings (Appiah et al., 2025; Banks et al., 2022).

Patel et al. (2020) found that low awareness among women led to poor screening uptake. In SSA, awareness of CC is generally low, especially in rural areas where 60–80% of cases occur (Drokow et al., 2020; Moshi et al., 2018; Osei et al., 2021). A lack of knowledge about prevention increases CC risk (Binka et al., 2017). Many women are unaware of CC symptoms, causes, or screening options before diagnosis, with some patients reporting shock upon learning about HPV (Demissie et al., 2022; Jibat et al., 2024). Low public awareness exacerbates CC morbidity and mortality by hindering the uptake of preventive measures (Binka et al., 2017; Shrestha et al., 2020). Education campaigns have shown success in correcting misconceptions, increasing screening, and improving awareness about CC and HPV vaccination (Cooper et al., 2021; Osei et al., 2021). In Tanzania, myths about HPV affecting fertility, spread by community leaders, have further limited vaccine uptake (Cinya & Mubangizi, 2024). A study in Kilimanjaro found that although many women were aware of CC, only 6% had been screened, and knowledge of HPV vaccination was low (Cunningham et al., 2015). There are limited qualitative research on community-level factors influencing CC awareness, as most studies are facility-based in SSA. Therefore, this study aimed to explore awareness of CC screening, care, and vaccination in urban and rural areas among men and women in Tanzania.

Study Design

This is a qualitative descriptive design, employing inductive content analysis to investigate awareness of CC screening, care, and vaccination among men and women in urban and rural areas of Tanzania. Data were collected through Focus Group Discussions (FGD; Krueger & Casey, 2015), a method suitable for capturing in-depth public insights. This approach was considered appropriate as qualitative methods are particularly effective for understanding participants’ experiences and perspectives of CC (Creswell & Poth, 2016). The study adheres to the Consolidated Criteria for Reporting Qualitative Research checklist, focusing on aspects such as research team reflexivity, study design, data analysis, and findings (Tong et al., 2007), see Appendix 1.

Research Questions

Are women and men in urban and rural areas of Kilimanjaro aware of CC screening, care, and vaccination?

Sample

A simple random sampling approach was used to select the study setting and participants. The study participants were men and women aged 18 and above in the Kilimanjaro region, which consists of seven districts. Two districts, Moshi Urban and Moshi Rural, were purposively chosen due to their high CC prevalence. The sample was drawn from communities with a high prevalence of CC, specifically the Moshi Urban and Moshi Rural districts of the Kilimanjaro Region, selected to capture populations most affected by the disease. According to data from the Kilimanjaro Population-Based Cancer Registry, the overall prevalence of CC in the region is 11.6%, with Moshi Rural exhibiting the highest prevalence at 57% (Kilimanjaro Christian Medical Centre, Cancer Care Centre, 2022).

Ethical Considerations

The study adhered to the guidelines on research on human subjects. The Declaration of Helsinki (WMA, 2013) ethical clearance certificates were obtained from the KCMC University Research Ethics Review Committee and the National Institute for Medical Research, Tanzania. The directors of the respective study sites granted permission. Written informed consent was obtained from participants, and participation in the study was voluntary. All information collected was handled at a high level of confidentiality. The participants had the freedom to withdraw anytime during the study without any negative consequences.

Data Collection

A semistructured FGD guide, (Appendix 2), was developed by researchers based on the study's objectives (Krueger & Casey, 2015). It included sections on sociodemographic characteristics, general awareness of cancer and CC prevention, risk factors, signs, and symptoms. The interview guide was initially created in English and translated into Kiswahili by bilingual researchers, followed by back-translation to ensure linguistic suitability for the community (Behr, 2017). The tool was piloted among male and female community groups of seven participants to assess the understanding of the guide. Only minor adjustments, such as typographical corrections and resequencing of questions, were made.

Data collection took place between April and May 2024. The same interview guide was used for all participants in every session. All FGDs were conducted face-to-face in the respective ward office conference room, with participants seated in a semicircle arrangement. All participants signed informed consent forms before the discussions started, following Marshall and Rossman (2016).

To maintain confidentiality, each participant was assigned a number displayed on paper for identification purposes. With participant consent, the FGDs were recorded using two digital recorders to ensure audio backup. The FGDs were moderated by two facilitators: for female groups, the first author (PhD student with an MSc in public health) and a female moderator; for male groups, a male social scientist with a master's degree in public health and extensive experience in qualitative research.

In the female FGDs, the social scientist acted as the note-taker, while the first author took notes during the male FGDs. All facilitators were assistant lecturers at the time of data collection. Each discussion lasted between 60 and 90 min. Data were collected only once, and transcripts were not returned to participants for review, though member checks were employed to enhance data accuracy. After each FGD, transcription and translation were completed, and data analysis began immediately, including data familiarization. Data saturation was reached after the third FGD in rural areas; however, the researchers agreed to conduct an additional (fourth) FGD in urban areas to confirm whether any new information would emerge.

Data Analysis

Data was analyzed using content analysis with an inductive approach inspired by Graneheim and Lundman (2004). The inductive content analysis was chosen, as the field was unexplored. This approach was chosen to explore the phenomenon directly from the participants, rather than being predetermined (Polit & Beck, 2017). The FGD audios were transcribed verbatim in Kiswahili. The transcripts were validated, meaning checked for quality, rigor, and relevance as per the audios, and later translated from Kiswahili into English by a bilingual Tanzanian for easy joint analysis for the whole research team and those who do not understand Kiswahili. The researchers read the transcripts several times to understand and be conversant with the transcripts to ensure the data quality. Checking the Kiswahili and English have the same meaning was also done before going to the next step of coding and analysis. The next step started with marking meaningful units in the transcripts. These were then condensed and given codes. Data was coded by three independent researchers. The codes containing similar meanings were developed into eight subcategories. Through this inductive analysis, developed by Graneheim and Lundman (2004), the subcategories were merged into three main categories. The researchers reached a consensus in the last step, see Table 1.

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Table 1.

Composed Main Categories, Subcategories, and Codes.

	Main category	Subcategory	Codes
1	Low health literacy	The silent disease	No one is speaking in the community about CC and CCS
			A community not aware is at risk of CC
			Lack of information on CC and HPV vaccine
			Discuss other diseases such as HIV, UTI, and fungus, but not CC and CCS
		Myths and traditional beliefs about CC	believes HPV vaccination will cause infertility later
			Cervical cancer is not preventable; only possible through prayer
			CC inherited from the family, out of is no risk of the disease
			Healthcare provider touches the cervix during CC screening
			Touching the cervix during screening increases the risk for CC.
			The uterus is pulled out, and then will be pushed in after CC screening
			CC induces pain in the uterus, & it is embarrassing!
2	Challenges in accessing cervical cancer prevention	Healthcare facilities barriers	Long waiting time at the health facility,
			the distance to reach the facility
			Wasted time due to the long walk to the facility Time spent accessing urban services
			The screening procedure disappoints women from going for screening
		Family and community barriers	Women don't have time for CC screening
			Masculinity hinders women's decision-making for CCS
			Travel cost for fare, even though service will be free/cost implications
			Not feeling sick, no need to go for CC screening
			a habit of not attending the hospital for any service if not sick
			Women are busy earning money for a living/bread breadwinners/economic reason
			Women are worried about what they will eat if they go for screening
		Fear of abandonment	A man runs away if the CCS tests positive
			A woman can go for screening and still fear disclosing in the community
3	Community involvement	Male involvement	The cultural practice
			Influence on decision making
			Couple involvement for family CCS and vaccination
		Involvement of opinion leaders	Government leaders trust
			Religious leader trust
			Influential people

CC: cervical cancer.

Rigor

To establish trustworthiness and rigor of the findings and research free from researcher bias, study's adherence to the trustworthiness criteria: credibility, dependability, transferability, and confirmability (Stenfors et al., 2020). Credibility was achieved by letting the data guide the analysis, supported by diverse samples from rural and urban areas, enhancing representativeness. Dependability, or data stability over time and conditions (Elo et al., 2014), was ensured through rigorous methods, including independent analyses, transcript validation, and bilingual translations. Inductive content analysis, participant quotations, and consensus on themes ensured confirmability. Transferability was strengthened by involving participants from varied settings, making the findings applicable to similar groups and contexts (Lincoln & Guba, 1985).

Sociodemographic Results

A total of 31 participants (16 females and 15 males) took part in four FGDs. Of these, 20 participants were from urban settings and 11 from rural areas, ensuring a diverse representation of perspectives across gender and geographical contexts. Further details of the participants’ characteristics are provided in Table 2.

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Table 2.

Socio Demographic Characteristics of Participants n=31

Variable	Frequency	Percentage	Mean± SD
Age			45±13
Age groups
23-40	12	38.7
41-50	10	32.3
51-69	9	29.0
Total		100.0
Gender
Male	15	48.4
Female	16	51.6
Total		100.0
Marital Status
Married	23	74.2
Unmarried	8	25.8
Total		100.0
Tribe
Chagga	10	32.3
Pare	10	32.3
Sambaa	7	22.6
Other	4	12.9
Total		100.0
Residence
Rural	11	35.5
Urban	20	64.5
Total		100.0

Research Questions Results

Regarding the research questions, the content analysis generated 20 codes from the raw data, eight (8) subcategories, and three (3) main categories: Low health literacy, Challenges in accessing CC prevention, and Community involvement. The three (3) main categories with eight (8) subcategories, as well as the codes, are presented in Table 1.

Low Health Literacy

This category highlights the generally low level of awareness regarding CC among participants across all groups. Many individuals were unaware of the causes of the disease and had never heard of HPV, HPV vaccination, or associated risk factors. The subcategories within this category are: The silent disease and Myths and traditional beliefs about CC.

Challenges in Accessing CC Prevention

Several barriers were identified as hindering the utilization of CC prevention services and efforts within the community. Personal, family, healthcare-related, and community-level barriers were highlighted as important challenges in accessing CC prevention. For instance, many women reported a lack of time due to busy schedules spent earning a livelihood and fulfilling household responsibilities. Additionally, cultural barriers were noted, as some women required their husbands’ approval to access prevention services. However, many husbands were unaware of the importance of CC prevention, further complicating efforts to address the issue. These challenges are evident in the three subcategories: Inadequate healthcare facilities, Family and community barriers, and Women's health versus financial priorities.

The Role of Community Involvement

Community involvement plays a major role in any program intervention. Participants narrated there was a low level of involvement, and most of the stakeholders were not involved and informed about CC screening and vaccination. Within this category, this is further developed in the subcategories of male involvement and involvement of community leaders.

Low Health Literacy

The study found low health literacy on cervical CC, with limited knowledge and confidence to discuss the disease. Poor public awareness underscores the need for better information dissemination, such as brochures and social media, which have proven effective for CC prevention (Baharum et al., 2020; Petersen et al., 2022). Unlike prior studies, participants were largely unaware of risk factors, including HPV and its vaccine (Chelva et al., 2024; Demissie et al., 2022; Drokow et al., 2020; Jibat et al., 2024; Lin et al., 2020; Rick et al., 2019), though women in both urban and rural areas identified multiple childbirths as a risk factor, an understanding absent among men. In contrast, Swai et al. (2023) found high awareness of CC risk factors, HPV, testing eligibility, and screening benefits, likely due to their hospital-based setting. Okyere et al. highlight the need for community sensitization and behavioral change to improve vaccination and screening uptake. Extensive campaigns have enhanced public confidence in discussing health issues, and similar efforts could boost CC awareness, increase preventive service use, and reduce CC-related morbidity and mortality, contributing to economic growth.

Participants in the present study believed that HPV vaccination causes infertility among their daughters, discouraging its acceptance in both urban and rural communities. This misconception, prevalent among women's groups, reflects a lack of awareness regarding the vaccine's role in preventing CC, despite the WHO (2024) confirming its safety and efficacy. Similar myths associating the vaccine with infertility or family planning have been reported in other studies (Chona et al., 2023; Hasahya et al., 2016). Additional concerns about vaccine complications, as noted by Almehmadi et al. (2019) and Drokow et al. (2020), further contribute to rejection. Dispelling these myths and emphasizing the vaccine's benefits is essential for increasing uptake and reducing the CC burden.

Misinformation about CC screening was found in this study, which limits women's access to preventive services. False beliefs increase fear and reduce screening uptake in rural and urban areas (Chona et al., 2023; Cunningham et al., 2015; Petersen et al., 2022). Some participants incorrectly believed that the cervix pulled out during screening, which reflects a lack of accurate information, also confirmed in research (Hasahya et al., 2016). Furthermore, the perception of CC as solely hereditary lowers perceived risk, particularly among men in rural areas, who see no need for vaccination or screening. This aligns with findings by Adedimeji et al. (2021). Addressing these myths through community education could help meet WHO's (2020) goal of screening 70% of women aged 35–45, enabling early CC detection and treatment in LMICs.

Challenges in Accessing CC Prevention

This study identified key barriers to CC prevention, including inadequate healthcare infrastructure, limited parental involvement in HPV vaccination, financial constraints, cultural factors, and fear of abandonment. Rural women faced added challenges such as long travel distances, transport costs, and time spent accessing urban screening services, consistent with earlier studies (Asgedom et al., 2024; CDC, 2024; Gizaw et al., 2022; Hussein et al., 2024; Isaacson et al., 2023; Srinath et al., 2023). Long wait times and associated costs also deterred use, particularly in rural areas where facilities are less equipped (Adedimeji et al., 2021; Bensemmane et al., 2022; Chapola et al., 2021).

Parental involvement was a barrier, especially among rural women and urban men, with parents feeling excluded from HPV vaccination decisions for their daughters, leading to hesitancy (Ho et al., 2022; Mihretie et al., 2022; Osei et al., 2021; (Tobaiqy & MacLure, 2024) For rural women, cultural beliefs and low education may discourage provider engagement, while urban men's family health concerns drive their interest in inclusion. In contrast, higher parental acceptance has been reported when providers offer information (Anyaka et al., 2024; Davies et al., 2021). Strengthening parent–teacher partnerships and public awareness could improve uptake.

Financial difficulties significantly impacted healthcare prioritization, with urban men and women reporting that daily expenses took precedence over health, consistent with findings by the Osei et al. (2021), and Adler et al. (2023). Cultural norms favoring health-seeking only when symptomatic further lowered screening and vaccination rates (Adler et al., 2023; Tapera et al., 2019).

Fear of abandonment was another barrier, especially among urban women, who feared stigma and partner rejection if diagnosed with HPV or CC. This fear, often linked to low health literacy, reflects findings from other studies where women faced blame or abandonment after diagnosis (Chona et al., 2023; Dirar et al., 2022; Morse et al., 2023). Such concerns discourage screening and treatment, perpetuating low uptake (Bateman et al., 2019; Defo & Domgue, 2020; Ragan et al., 2018; Srinath et al., 2023).

Community Involvement

Engaging men in health promotion is crucial for effective CC prevention. This study found that rural and urban participants supported male involvement in HPV screening and vaccination to boost acceptance and uptake (Tobaiqy et al., 2023). Men were willing to support partners and vaccinate daughters if provided accurate information, consistent with findings from Uganda (de Fouw et al., 2023). Women's participation in CC screening is often shaped by male partners, who control resources and grant service permission, particularly in African contexts where men are key decision-makers (Adedimeji et al., 2021; Chapola et al., 2021; Chelva et al., 2024; de Fouw et al., 2023; Drokow et al., 2020; Jibat et al., 2024; Mantula & Toefy, 2023).

Opposition from male partners can hinder uptake, with married women sometimes less likely to be screened (Adewumi et al., 2019; Gizaw et al., 2022; Srinath et al., 2023), highlighting the need for effective male engagement. Involving trusted community leaders, such as religious and government figures, can also improve acceptance of CC prevention (Adewumi et al., 2019; Mantula & Toefy, 2023; Tapera et al., 2021). However, this study found these leaders were not actively promoting such services, likely due to low health literacy and misconceptions that can hinder HPV vaccine uptake (Cinya & Mubangizi, 2024). Training and sensitizing opinion leaders is therefore critical for improving outreach, acceptance, and early detection.

Study Strengths and Limitations

This study provides valuable insights into community experiences with CC prevention by incorporating perspectives from both men and women. Two skilled qualitative researchers (male and female) conducted focus groups, ensuring participant views were well represented (Creswell & Poth, 2016). Adherence to trustworthiness criteria, credibility, dependability, transferability, and confirmability (Stenfors et al., 2020) was achieved through diverse sampling, rigorous procedures such as transcript validation, bilingual translation, and independent coding (Elo et al., 2014), and consensus-based inductive analysis (Lincoln & Guba, 1985). While limited to specific geographic areas and subject to the inherent subjectivity of qualitative research (Polit & Beck, 2017), the study's methodological rigor and varied contexts strengthen the applicability of its findings.

Implications for Practice

The study found low awareness of CC in both urban and rural areas, underscoring the need for targeted interventions. These results provide baseline data to guide tailored health programs and inform policies that promote screening and vaccination among both adults and children. Such initiatives can increase preventive service use, helping Tanzania and other LMICs in SSA work toward the WHO elimination target and reduce CC-related morbidity and mortality (WHO, 2022).