Cervical cancer is a serious global health challenge, the fourth leading cause of cancer-related mortality in women worldwide and the major cause of the deaths from cervical cancer is in low- and middle-income countries (LMICs) [1]. Cervical cancer is the second most common cancer in Bangladesh among women with an estimated 11,956 new cases annually and 6,585 deaths annually [2, 3]. Even though the cost-effective preventive screening method like Visual Inspection with Acetic Acid (VIA) and Papanicolaou (Pap) test are available in Bangladesh, still around 6.1 mortality per 10,000 women occurs compared to 2.2 per 10,000 women in high income settings [4]. Screening helps identify and treat cervical intraepithelial lesions (cervical pre-cancerous growth) before they become cancerous [5]. In rural Bangladesh, however, where almost 70% of women live, uptake of screening is disproportionately low [2]. Previous clinical studies highlight that failure to receive formal education, early marriage and limited understanding of early signs, such as post-coital or irregular vaginal bleeding, continues to result in late presentation [6, 7]. Additionally, the crisis is worsened by structural and health-system constraints. The tertiary care oncology services are clustered in urban centers, such as Dhaka and primary care in rural areas are under-resourced and are not equipped with trained clinical staff [8, 9]. Apart from health-system shortages, there are additional socio-cultural barriers for the rural Bangladeshi women. Limited autonomy in seeking healthcare is driven by patriarchal family structures, entrenched social taboos on gynecological healthcare and economic pressures [10, 11]. A knowledge of the perceived cervical screening practices and their reasons among rural women is important in planning targeted public health interventions. This study aims to explore the qualitative and quantitative evidence to assess women's perceptions, bottlenecks and support systems for cervical cancer screening in rural Bangladesh.

This study employed a secondary qualitative research design approach that was based on a positivist philosophy of science and deductive reasoning. Search Strategy and Eligibility Criteria A systematic literature search was conducted in electronic databases such as PubMed, MEDLINE, Google Scholar and ScienceDirect as well as institutionally generated document reports from WHO and Public Health Foundation Bangladesh. Searching with keywords and boolean operators used were: ("Cervical Cancer Screening" OR "VIA") AND ("Rural Women" OR "Barriers") AND "Bangladesh". Inclusion criteria: 1. Studies from 2009-2019 published in English, peer-reviewed journal articles that focus on Bangladeshi women's screening knowledge, cultural/economic barriers, health system infrastructure, and prevention programs. Exclusion criteria: 1. Studies published before 2009,non-English publications and studies with no qualitative/quantitative data relevant to cervical health in South Asia. Data Extraction and Analysis Data were analyzed using principles of grounded theory and thematic coding. Extracted qualitative descriptions, empirical observations, and epidemiological statistics were classified into key thematic areas.

Table 1 shows there is very little knowledge among rural women of Bangladesh regarding Human Papillomavirus (HPV) infection and the relationship between HPV and cervical cancer. Women don’t seek medical attention for screening until they experience severe pain, and the presence of a high level of illiteracy means that women are often not aware of the need for screening until they are in significant distress. Table 1: Knowledge and Perceptions Regarding Cervical Cancer Screening Aspect Key Observations & Empirical Evidence Impact on Screening Uptake Disease Etiology • Minimal understanding of Human Papillomavirus (HPV) infection. • Early marriage identified as a major contributing factor in rural areas. Prevents women from understanding their personal risk factors. Symptom Perception • Pre-cancerous stages are largely asymptomatic. • Women associate doctor visits only with severe pain or bleeding. Late-stage diagnosis and delayed clinical presentation. Awareness Levels • High illiteracy in rural areas limits health literacy. • Misconception that screening is unnecessary without physical symptoms. Low voluntary participation in routine screening programs. Table 2 shows experiences of pain with screening procedures and psychological anxiety are negative factors for screening participation. Avoidance of screening is due to fear of a deadly cancer diagnosis. In addition, discomfort experienced when the speculum is inserted into the vagina during exams, especially with inexperienced health workers, leads to reduced follow-up visits. Table 2: Psychological and Personal Screening Experiences Barrier / Experience Nature of Patient Experience Resulting Outcome Fear of Diagnosis Extreme fear of the word “cancer” and fatalistic beliefs regarding disease outcomes. Avoidance of testing to prevent emotional stress and anxiety. Procedural Pain Discomfort, intimidation, and pain experienced during speculum insertion during Pap tests. Reluctance to undergo repeat screening or follow-up procedures. Untrained Personnel Screenings performed by inexperienced staff leading to heightened physical discomfort. Negative word-of-mouth experiences shared within rural communities. Table 3 shows demonstrates cultural modesty, taboos cause women to avoid pelvic examination, especially by men Furthermore, male dominated household structures have placed the decision making on travel and medical expenses under the control of the male member of the household, and often considered gynecological screening as unnecessary or culturally inappropriate. Table 3: Socio-Cultural and Patriarchal Barriers Social Parameter Cultural Context & Dynamics Consequence on Women’s Autonomy Modesty and Religion • Cultural taboos surrounding genital exposure. • Reluctance to undress in front of medical professionals. Severe hesitation, especially when only male clinicians are available. Patriarchal Decision-Making • Male-dominated family decision-making (husbands, fathers, brothers). • Screenings perceived as “unethical” or unnecessary by male relatives. Women are restricted from traveling to clinics or spending funds on screening. Community Stigma Fear of social isolation or stigma attached to reproductive health diseases. Concealment of symptoms and avoidance of preventive healthcare. Table shows 4 lack of infrastructure is a major barrier to screening uptake. Oncology centers are concentrated in major cities and this makes it very costly for patients in the rural areas to travel to the major cities. Limited access to basic diagnostic services at the primary health care level is driven by the lack of trained female clinicians and inadequate public health funding. Table 4: Health System, Infrastructure, and Financial Bottlenecks Systemic Bottleneck Current Status in Bangladesh Direct Effect on Rural Healthcare Facility Centralization Tertiary oncology centers concentrated in metropolitan hubs (e.g., DMCH, NICRH). Long travel distances and excessive travel costs for rural residents. Workforce Shortages Severe shortage of trained female healthcare providers and paramedics in rural primary centers. Inability of rural health complexes to offer consistent screening services. Government Funding Low health budget allocations (e.g., Tk 150 million allocated in 2018 for cancer care). Sub-optimal supply of diagnostic equipment and screening reagents. Economic Affordability High rural poverty levels and out-of-pocket costs for advanced diagnosis. Low priority given to preventive health compared to basic daily needs. Table 5 shows there is a need to expand screening using Visual Inspection with Acetic Acid (VIA) at the primary care level as it is cost-effective and can provide immediate results to improve screening coverage. Male family decision makers should be engaged in awareness campaigns, and female health workers should be trained and empowered for culturally acceptable care in capacity building initiatives. Table 5: Recommended Support Services and Intervention Strategies Area of Improvement Proposed Action Strategy Expected Health Outcome Primary Screening Method Expansion of Visual Inspection with Acetic Acid (VIA) at community clinics. Low-cost, immediate result delivery suitable for low-resource settings. Public Awareness Launching target campaigns (e.g., “Say No to Cancer”) involving local leaders and media. Reduction of social stigma and improved health seeking behaviors. Community Engagement Educating male family members alongside female-focused health sessions. Reduced domestic opposition and increased male support for screening. Capacity Building Dedicated training programs for female paramedics and Community Health Care Providers (CHCPs). Enhanced patient comfort and improved diagnostic accuracy.

The results of this study indicate that individual, socio-cultural and structural barriers are all interacting in rural Bangladesh to reduce the uptake of cervical cancer screening. Similar to other cases of South Asian countries (such as rural India and Nepal), in rural areas, women are often reported as being afraid and anxious of being diagnosed with cancer [17]. Many women choose not to be screened in order to maintain their mental state in the short term when they have been diagnosed with cancer, believing that it will inevitably lead to death [13, 14]. There are also significant challenges to socio-cultural modesty taboos. Research with South Asian women has highlighted that it is often taboo to show the genitals to strangers or male health practitioners [10, 15]. Additionally, patriarchy, described by Lee [11] and Marlow et al. [18] as the ruling of men over women, impacts their financial decisions and their access to health care, limiting the ability of women to travel for routine preventative care and appointments, often under the control of their husbands or fathers-in-law. The structural analysis corroborates earlier findings by Basu et al. [8] and Hussain & Sullivan [9] that cancer services in LMICs are overburdened and imbalanced across regions. These public tertiary hospitals are overcrowded like Dhaka Medical College Hospital (DMCH) and primary health complexes of rural unions are lacking in trained female paramedics to perform VIA in a consistent manner [8, 19]. National interventions should focus on education campaigns at the community level, involving both women and male family leaders (e.g. "Say No to Cancer") to overcome these problems [7, 20]. Scalable solutions to geographical and cultural barriers in rural Bangladesh are seen in strengthening VIA training of women Community Health Care Providers (CHCPs) and/or increasing the number of mobile screening units [1, 16].

The low uptake of screening services among rural women on gender basis in Bangladesh is rooted in various socio-cultural taboos, lack of awareness regarding cervical cancer screening, patriarchal decision making process and system failure in health care. The solutions are wide-ranging: mobile Visual Inspection with Acetic Acid (VIA) screening clinics must be scaled up, in addition to targeted education campaigns at the community level, to be carried out in the presence of male household heads, and investment in rural health facilities is required. If these structural and educational changes are realised they will help to improve the chances of detecting cervical cancer early enough and of dying from it preventably among rural Bangladeshi women.

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