title: Integrated Review of Barriers to Cervical Cancer Screening in Sub-Saharan Africa.
abstract: The aim of this study was to review published studies to identify and describe barriers to Papanicolaou (Pap) smear screening among women in sub-Saharan Africa.
  
  
  
  Guided by Cooper's integrative review methodology, studies published between 2006 and 2015 were identified by searching electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, MEDLINE, ProQuest, and PsycINFO using specified search terms. Using this strategy, 224 articles were identified and screened for duplication and by reading titles, abstracts, and full texts. Seventeen articles met the inclusion criteria and were appraised using relevant tools for qualitative and quantitative designs. No relevant articles published in 2006, 2007, and 2014 were found.
  
  
  
  All 17 articles had good methodological quality and were included in the review. The studies were from 10 sub-Saharan countries and from different settings. Content analysis of the data revealed three major themes coded as client, provider, and system barriers. The most common client barriers were lack of knowledge and awareness about Pap smear screening, fear of cancer, belief of not being at risk for cervical cancer, and that a Pap smear is not important unless one is ill and cultural or religious factors. Provider barriers were failure to inform or encourage women to screen. Major system barriers were unavailability and inaccessibility of the Pap test.
  
  
  
  The review provided evidence of barriers to Pap smear screening among sub-Saharan women. Although there were some variations from country to country, sub-Saharan countries share similar constraints to Pap smear screening. These findings have important implications for practice and policy.
  
  
  
  Understanding the client, provider, and system barriers to cervical cancer screening could guide development of effective interventions.
authors.affiliation: Alpha Omega, Associate Professor, College of Nursing and Public Health, Adelphi University, Garden City, NY, USA. dmcfarland@adelphi.edu.
authors.forename: Ditsapelo M
authors.initials: DM
authors.lastname: McFarland
authors.affiliation: Professor Emeritus, Case Western Reserve University, Nursing, Cleveland, OH, USA.
authors.forename: Sarah M
authors.initials: SM
authors.lastname: Gueldner
authors.affiliation: Tau Lambda-at-Large, Associate Professor, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana.
authors.forename: Keitshokile D
authors.initials: KD
authors.lastname: Mogobe
mesh_terms: D017954:Africa South of the Sahara; D055088:Early Detection of Cancer; D005260:Female; D006297:Health Services Accessibility; D006801:Humans; D065006:Papanicolaou Test / Q000706:statistics & numerical data*; D002583:Uterine Cervical Neoplasms / Q000517:prevention & control*
keywords: Barriers; Pap smear; cervical cancer; screening; sub-Saharan Africa