The global inequality in cervical cancer screening: An evidence synthesis

Background: The rising global burden of cervical cancer and persistent inequalities in screening access underscore the need to strengthen implementation. Therefore, we compiled the cervical cancer screening guidelines from different countries/regions and evaluated their implementation status and coverage situation. Methods: In this study, we conducted comprehensive search of the PubMed, Embase and Web of Science databases (from their establishment to February 1, 2025), websites and the World Health Organization (WHO) database. Studies included in our analysis provide detailed information on the official cervical cancer screening recommendations for each country. All indicators were stratified based on factors such as human development index (HDI), income level, geographical location, WHO regions, disease risk, and age. The systematic review was prospectively registered at Prospero (registration number: CRD420251087263). Results: Our study incorporated data from 77 countries/regions, only 62.3% (48/77) of them provided the year of published/updated protocol. Cytology was the primary screening test in 62 (80.5%) of 77 countries. Visual inspection with acetic acid (VIA) was the most recommended test in low HDI countries. The number of countries using Human papillomavirus (HPV) is relatively small. Screening coverage was associated with HDI/income (low HDI: 12.43% vs very high HDI: 49.74%; high-income: 51.68% vs low income and middle-income countries [LMICs]:34.45%), with high-risk regions (29.88%) significantly lower than other areas (46.76%). Age-stratified analysis showed minimal coverage in the 20-29 and 70-79 groups, while coverage peaked in the 30-39 group. Our results also showed substantial heterogeneity in screening quality indicators (positive rate, further assessment rate, detection rate, and positive predictive value [PPV]). Conclusions: This study highlights global inequities in cervical cancer screening guidelines, particularly in the transition of screening methods among different countries/regions. Global cervical cancer coverage remains significantly below the target of 70%. Accelerate screening strategies, improve screening-diagnosis-treatment accessibility, establish monitoring systems, and strengthen global cooperation. Key words: Cervical cancer; Global health; Health policy;Screening, Coverage, Systematic review