Progress and inequality in cervical cancer screening in Lesotho (2009–2024): Decomposing within- and between-group inequality

Cervical cancer is a preventable and treatable disease, yet it remains a leading cause of cancer-related morbidity and mortality among women in low- and middle-income countries (LMICs), including Lesotho. Despite its high cervical cancer burden, Lesotho’s cervical cancer screenings (CCS) rates are still low. This study examines trends in CCS uptake over 15 years and evaluates socioeconomic and geographic disparities using data from Demographic and Health Surveys (DHS). Data from nationally representative Demographic and Health Surveys conducted in 2009, 2014, and 2023/24 were analysed to assess CCS trends among women aged 15–49 years. Lifetime and past-year CCS prevalence were the primary outcomes. Inequalities were quantified using the Erreygers Normalized Concentration Index (ENCI) and Theil index to measure and decompose disparities by socioeconomic status (SES) and place of residence. Lifetime CCS prevalence increased significantly from 6 % in 2009 to 21 % in 2023/24, while past-year screening prevalence rose from 2 % to 9 %. Socioeconomic and rural-urban disparities decreased substantially, with past-year screening among the poorest women achieving near-equity by 2023/24. However, lifetime CCS continued to show slight pro-wealthy and urban biases. The reducing overall inequalities were due to the near elimination of between-group inequalities. However, within-group disparities remained significant, highlighting heterogeneity in access barriers within SES and residence groups. Lesotho has made significant progress in CCS uptake, driven by targeted public health interventions and equity-focused strategies. However, persistent barriers and within-group disparities underscore the need for systemic reforms, including transitioning to organized screening programs, scaling up the integration of CCS with HIV care, and addressing structural and sociocultural barriers to achieve universal and equitable screening access.