…Study reveals education, not age or motherhood, determines who accesses life-saving prevention
Public Health | 5 February 6, 2026
The women most vulnerable to cervical cancer in Nigeria are the same women least likely to access the screening and vaccination that could save their lives. This stark pattern emerged from new research examining why preventive services fail to reach those who need them most.
A study published in the International Journal of Modern Medicine tracked knowledge, attitudes, and behaviours among 402 women at primary health centres in Anambra State. The findings paint a troubling picture: educational attainment, more than any other factor, determines whether women know about cervical cancer prevention, understand available interventions, or take action to protect themselves.
Age doesn’t matter. Neither does having children, being sexually active, or marital status. What matters is schooling. Women with secondary or tertiary education consistently demonstrate better knowledge and engagement with prevention than women with limited education, regardless of their life circumstances.
The research challenges widespread assumptions about how to reduce cervical cancer deaths. Simply providing information to all women equally won’t work when some women lack the literacy, confidence, resources, or household autonomy to act on that information.
The Cancer That Shouldn’t Kill
Cervical cancer represents a particular tragedy because it’s largely preventable and, when caught early, highly treatable. Two effective interventions exist: Pap smear screening detects precancerous changes before they become malignant, and human papillomavirus vaccination prevents the viral infection that causes most cervical cancers.
Yet in Nigeria, uptake of both interventions remains dismally low. Most women have never had screening. Vaccination reaches only a small fraction of eligible girls. Women typically present to healthcare facilities only after developing symptoms of advanced disease, when treatment options are limited and survival rates poor.
Nigeria has one of the highest cervical cancer mortality rates globally. Thousands of women die annually from a disease that could have been prevented or detected early with routine screening.
“We have effective tools, but they’re not reaching the women who need them,” explains Dr Kenechi Gerald Ike, the study’s first author and Consultant Histopathologist at Nnamdi Azikiwe University Teaching Hospital in Nnewi. “The question we wanted to answer was why. What factors determine whether a woman accesses cervical cancer prevention?”
SURPRISING RESULTS
The researchers surveyed women aged 15 to 64 attending primary health centres in Nnewi-North Local Government Area. They assessed knowledge about cervical cancer, understanding of screening and vaccination, attitudes toward prevention, and actual preventive behaviours.
The results challenged common assumptions. Variables that health programmes often target, such as age, number of children, sexual activity status, and marital situation, showed weak or no association with prevention knowledge or behaviour.
Instead, one factor stood out with remarkable consistency: educational attainment. Women who had completed secondary or tertiary education knew more about cervical cancer, better understood what Pap smear screening involves, were more aware of HPV vaccination, and expressed greater willingness to access prevention services.
The differences weren’t subtle. Education emerged as the strongest statistical predictor across all measured outcomes, dwarfing the effects of other demographic variables.
“We expected education to matter, but the magnitude of the association surprised us,” notes Abba Sadiq Usman from the Nutrition and Health Department at Action Against Hunger in Maiduguri. “A young woman with secondary education knows substantially more and engages more with prevention than an older woman with only primary schooling, even if the older woman has multiple children and extensive reproductive history. That tells us we’re missing something fundamental about how prevention works.”
MULTIPLE PATHWAYS
The research team identifies several mechanisms through which education shapes cervical cancer prevention behaviour.
Health literacy provides the foundation. Women with more education find it easier to understand health information, grasp explanations of disease processes, interpret screening recommendations, and make informed decisions. They can read educational materials, comprehend consent forms, and formulate questions for healthcare providers.
Access to information differs dramatically by educational level. More educated women encounter health information through various channels: media, workplace discussions, educated social networks, and interactions with healthcare systems. Women with limited education may live and work in environments where such information rarely circulates.
“Information doesn’t flow equally to all women,” observes Dr Chisom Lucky Emeka from the Vaccine Preventable Diseases Unit at the World Health Organisation Country Office in Abuja. “We design campaigns assuming information will reach everyone, but women’s educational backgrounds strongly determine whether they encounter that information, whether they can process it, and whether they feel empowered to act on it.”
Agency and self-efficacy vary with education. Women with more schooling report greater confidence in navigating health systems, questioning providers, and advocating for their needs. They believe they can and should make decisions about their own health.
Economic resources correlate with education. More educated women are more likely to have formal employment, health insurance, disposable income for healthcare expenses, and schedule flexibility to attend appointments. These practical resources matter enormously for accessing services.
Household decision-making power may depend on education. In contexts where husbands or male relatives control women’s healthcare decisions, educated women sometimes have more autonomy to seek services independently, though cultural factors complicate this relationship.
THE SERVICE DESIGN PROBLEM
The findings have implications for how cervical cancer prevention services are designed and delivered. Current approaches typically assume that all women, once aware of screening availability, can access it equally. The research suggests this assumption is fundamentally flawed.
Consider a typical service model. Health facilities offer Pap smear screening. Posters and radio announcements inform women about availability. Women are expected to request screening during health visits or make special appointments.
This model works reasonably well for educated women. They see the posters, understand the announcements, feel confident requesting screening, can navigate registration processes, and overcome practical barriers like cost and transportation.
For women with limited education, the same model creates multiple obstacles. They may not understand poster text, may miss the significance of radio messages, may feel too intimidated to request unfamiliar services, may not know how to navigate registration systems, and may face greater practical barriers.
“We’ve designed services for educated, empowered women and then wondered why uptake is low,” argues Dr Bartholomew Ituma Aleke from the Faculty of Health, Wellbeing & Social Care at Global Banking School in Leeds. “The women who most need screening face the greatest barriers to accessing it. That’s not an accident of individual behaviour. It’s a design failure.”
RETHINKING PREVENTION STRATEGY
The research team proposes fundamental shifts in how cervical cancer prevention is approached.
Integration into routine care could reduce barriers. Rather than treating screening as a special service requiring active seeking, make it standard practice during women’s health visits. When Pap smears become routine like blood pressure checks, educational barriers to uptake may diminish.
Targeted approaches for women with limited education are essential. This means using visual materials instead of text-heavy pamphlets, providing one-on-one explanations rather than assuming women will ask questions in group settings, delivering information in local languages and culturally appropriate idioms, and building trust through community health workers from similar backgrounds.
“Generic information campaigns won’t reach women with limited education,” notes Dr Tochukwu Patrick Ugwueze from the Department of Family Medicine at University College Hospital in Ibadan. “We need approaches specifically designed for women with low literacy, limited prior exposure to biomedical concepts, and little experience navigating formal health systems. That requires different communication strategies, different service delivery models, and sustained community engagement.”
Addressing practical barriers is crucial. For women with limited education who also face economic constraints, even small costs, transportation requirements, or time away from income-generating work can prevent access. Services need to account for these realities through subsidies, mobile clinics, convenient scheduling, and accompaniment services.
Engaging household decision-makers matters in contexts where women lack autonomy. When husbands control healthcare access, prevention programmes must include men rather than expecting women to overcome this barrier individually.
Long-term investment in girls’ education represents primary prevention. Keeping girls in school longer creates tomorrow’s women who can better engage with health systems. Educational investments made today will reduce cervical cancer mortality decades hence.
THE NIGERIAN REALITY
Nigeria’s context amplifies these challenges. Educational inequality remains pronounced, particularly by region and gender. Many women, especially in northern states, have no formal schooling. Even in southern states like Anambra where this study took place, substantial proportions of women have only primary education.
Healthcare infrastructure varies enormously. Major hospitals may have screening capacity, but many primary health centres lack equipment, trained personnel, or supply chains to offer Pap smears. Referral systems often fail, leaving women without clear pathways to access screening even when motivated.
Cultural factors interact with educational inequality. Reproductive health discussions remain taboo in some communities. Seeking gynaecological care before experiencing symptoms may be viewed as inappropriate. Male control over women’s healthcare decisions varies but can be significant.
Financial constraints affect both individuals and health systems. Women may not afford screening costs even when modest. Health systems may lack funding to provide free or subsidised services at scale.
“These factors compound,” explains Solomon Atuman from Family Health International. “A woman with limited education faces not just one barrier but multiple interconnected obstacles: she may not know screening exists, may not understand its importance, may lack confidence to seek it, may not be able to afford it, may not have household permission to access it, and may find services unavailable at accessible facilities. Effective interventions must address this complexity.”
BEYOND AWARENESS
Perhaps the most important implication concerns the limitations of awareness campaigns. Public health programmes have invested heavily in raising awareness about cervical cancer, assuming knowledge drives behaviour.
The research suggests this model is incomplete. Knowledge matters, but knowledge alone is insufficient when structural barriers prevent women from acting on what they know.
Many women in the study demonstrated some awareness of cervical cancer but lacked specific knowledge about prevention methods, didn’t understand how to access services, didn’t feel confident requesting screening, or faced practical obstacles that awareness couldn’t overcome.
The gap between awareness and action is not randomly distributed. It falls along educational lines. More educated women can translate general awareness into specific action. Women with limited education struggle to make that translation even when motivated.
“We need to move beyond awareness to enablement,” argues Dr. Festus Ituah, Senior Lecturer at School of Health and Sports Science, Regent College, London, United Kingdom. “The question isn’t just whether women know about screening. It’s whether they have the literacy, confidence, resources, autonomy, and access required to obtain screening. For many women, those prerequisites are absent.”
RESEARCH LIMITATIONS
The study has limitations that future research should address. The sample of 402 women from one local government area cannot represent all Nigerian women. Patterns may differ in other regions, particularly northern Nigeria where educational and cultural contexts differ substantially.
The research measured knowledge and attitudes but had limited data on actual screening uptake. Future studies should examine whether education-sensitive interventions actually increase screening rates, not just awareness.
Causation cannot be definitively proven. Other factors correlated with education might explain observed patterns. Larger longitudinal studies would strengthen causal inference.
Qualitative research exploring women’s lived experiences would provide valuable insights. Understanding how educational background shapes interactions with health systems from women’s perspectives would inform more effective interventions.
Intervention studies are particularly needed. Testing different approaches to reaching women with limited education would identify what actually works rather than what seems theoretically promising.
A STRUCTURAL CHALLENGE
Ultimately, the research frames cervical cancer prevention as a structural challenge requiring systemic solutions rather than an individual behaviour problem requiring personal change.
Educational inequality is not an individual characteristic but a structural condition shaped by historical and ongoing inequities in access to schooling. The health consequences of educational inequality reflect failures in both education and health systems.
“We’ve known for years that education influences health,” concludes Dr Kennedy Oberhiri Obohwemu, Senior Researcher and Project Coordinator of PENKUP Research Institute. “What this research shows is how that relationship operates specifically for cervical cancer prevention in Nigerian contexts. Education isn’t just a personal characteristic. It’s a structural factor that determines whether women have the information, resources, confidence, and power to protect themselves. Effective prevention requires addressing those structural inequalities, not just exhorting women to change their behaviour.”
Whether Nigeria will embrace such structural approaches remains uncertain. But the evidence is clear: without addressing educational inequality as a health determinant, cervical cancer will continue killing women whose deaths could have been prevented.
ABOUT THE STUDY
The research, “Educational Attainment as a Structural Determinant of Cervical Cancer Prevention Behaviour Among Women in Southeast Nigeria,” appears in the International Journal of Medicine and Medical Sciences, Volume 5, Issue 2. The study was conducted as part of the PENKUP Collaboration, a collaborative research project involving multiple researchers affiliated with PENKUP Research Institute in Birmingham, UK.
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