Rwanda’s cervical cancer screening gap defies near-universal awareness

In a finding that has stunned global health researchers, Rwanda has achieved something most countries can only dream of: near-universal awareness of cervical cancer. A sweeping new analysis of the 2025 Rwanda Demographic and Health Survey, published in BMC Cancer, reveals that 93.4% of women aged 15 to 49 have heard of the disease, and 80.4% know that a screening test exists. And yet, only 19.2% have ever been screened by a health worker. This is the knowledge–practice gap in its most dramatic form, and it is now the subject of intense scrutiny as scientists race to understand why awareness alone is failing to save lives.

The study, led by Gad Binayisa of the University of Rwanda’s College of Medicine and Health Sciences, analyzed data from 14,274 women with complete outcome records drawn from the nationally representative survey. The outcome was simple: whether a woman had ever been tested for cervical cancer by a health worker. Exposures spanned demographic characteristics, socioeconomic status, health-system contact, and screening-related knowledge. The team estimated weighted prevalence and bivariate associations, then fitted multivariable logistic regression in two nested blocks, before and after adding knowledge, to assess how much of the socioeconomic gradient in screening uptake was statistically associated with awareness. Standard errors were obtained from cluster-robust models and cross-checked against a full Taylor-linearized survey design incorporating weighting, clustering, and stratification. Data cleaning and analysis were performed using Python 3.14, with a sensitivity analysis conducted in R.

The results are as technically revealing as they are sobering. Screening was most strongly associated with parity, with an adjusted odds ratio of 2.74 (95% CI 2.08–3.61) for women with five or more living children compared to those with none. Age also mattered, as did HIV-positive status, which carried an adjusted odds ratio of 2.89 (95% CI 2.11–3.97). Health insurance was associated with increased uptake at an adjusted odds ratio of 1.32 (95% CI 1.12–1.57), and recent health-facility contact showed an adjusted odds ratio of 1.20 (95% CI 1.07–1.34). Remarkably, education showed no consistent gradient at all, challenging the assumption that schooling alone drives preventive health behavior.

But the single strongest predictor of screening uptake was knowledge itself. Women aware of both cervical cancer and the existence of a screening test had an adjusted odds ratio of 9.95 (95% CI 6.47–15.29) compared to those with no awareness, corresponding to an adjusted probability of screening approximately 18 percentage points higher. This is a massive effect, and it confirms what many in the field have long suspected: knowing that a test exists is the gateway to getting tested.

Yet here is where the story takes a turn that has researchers rethinking their models. Knowledge statistically accounted for 32 to 39% of the wealth gradient in screening uptake, but only about 9% of the geographic disparity between provinces, which was not distinguishably more than none. That geographic gap was stark: ever-screened prevalence ranged from 11.1% in Southern Province to 25.1% in Eastern Province. Provincial disparities were statistically independent of knowledge, a pattern consistent with, though not proof of, a supply-side health-system capacity gap.

The implications are profound. If knowledge explains only a third of the wealth gradient and essentially none of the geographic disparity, then awareness campaigns alone cannot close Rwanda’s screening gap. The study’s authors conclude that screening appears to be delivered largely opportunistically through existing health-facility contact, meaning women who visit clinics for other reasons are the ones most likely to get screened. Women outside these contact pathways, particularly in underperforming provinces, are being left behind.

This finding resonates far beyond Rwanda. Cervical cancer is a leading cause of cancer death among women across sub-Saharan Africa, despite being largely preventable through vaccination, screening, and early treatment. The World Health Organization has set ambitious 90-70-90 elimination targets: 90% of girls fully vaccinated with HPV vaccine by age 15, 70% of women screened by age 35 and again by age 45, and 90% of women with cervical disease receiving treatment. Meeting these targets will likely require expanding screening access outside opportunistic contact pathways and directing targeted attention to underperforming provinces.

The methodological rigor of the study adds weight to its conclusions. The team used a linear-probability-model decomposition to quantify the share of each socioeconomic gradient statistically associated with knowledge, describing patterns of statistical association with precision. The two-block nested logistic regression design allowed the researchers to isolate the attenuation of socioeconomic gradients after adding knowledge, effectively measuring how much of the observed inequality could be attributed to awareness rather than to structural barriers. The cross-validation of standard errors against a full survey design incorporating weighting, clustering, and stratification ensured that the findings were robust to the complex sampling structure of the DHS.

As the global health community grapples with the cervical cancer elimination agenda, Rwanda’s experience offers a crucial lesson: near-universal awareness is necessary but not sufficient. The knowledge–practice gap persists because screening is embedded within health-system structures that reach some women and miss others. Closing this gap will demand supply-side interventions that bring screening to women, rather than waiting for women to arrive at facilities where screening happens to be available. The study, published as an open-access research article, provides the evidence base for that pivot, and its findings are already being discussed as a template for other countries confronting the same paradox of high awareness and low uptake.

Subject of Research: Socioeconomic, demographic and health-system determinants of the cervical cancer screening knowledge–practice gap in Rwanda.

Article Title: Socioeconomic, demographic and health-system determinants of the cervical cancer screening knowledge–practice gap in Rwanda: a cross-sectional analysis of the 2025 Rwanda demographic and health survey

Article References: Binayisa, G., Absolomon, G., Ishimwe, J., Imanishimwe, J., Ndahimana, R., Mwiseneza, M. J., Iryumugabe, I. D., Bugingo, S., Mukaneza, H., Munyaneza, E., Habtu, M., & Condo, J. (2026). Socioeconomic, demographic and health-system determinants of the cervical cancer screening knowledge–practice gap in Rwanda: a cross-sectional analysis of the 2025 Rwanda demographic and health survey. BMC Cancer. https://doi.org/10.1186/s12885-026-17187-5

Image Credits: AI Generated

DOI: 10.1186/s12885-026-17187-5

Keywords: cervical cancer, cancer screening, Rwanda, health inequalities, knowledge-practice gap, Demographic and Health Survey, HPV, WHO 90-70-90 targets, health-system capacity, mediation analysis, sub-Saharan Africa, cancer prevention