Introduction

In the report on Global Cancer Incidence, Mortality, and Prevalence (GLOBOCAN) estimates for 2022 by the International Association of Research on Cancer (IARC), new cancer cases were estimated to be 20 million, and deaths from cancer were estimated to be almost 10 million. The current second most commonly diagnosed cancer is female breast cancer, which contributes to about 11.6% of all cancers worldwide. The burden of cancer is estimated to increase by the year 2050 to about 35 million new cases worldwide [1]. Previously, the burden of cancer was reported to be at 28.4 million new cases by 2040 in 2020 [2]. Female breast cancer accounted for 670,000 deaths globally in 2022 [3] and affects all women of reproductive age.

Women’s empowerment is a crucial and multidimensional process that has various effects on women’s health. A woman’s level of empowerment predicts several decisions in the household, community, and country. Women’s empowerment affects decision-making concerning a woman’s health and the health of family members, especially children. Women’s empowerment is a process by which those who cannot make strategic choices get the chance and ability to do so [4]. It is a process that happens and changes over time and is described as a state of agency, as stated by Kabeer [5], where women themselves must take an active instead of passive role in ensuring that they are empowered. This is expected to promote women’s sense of worthiness, increase their ability to make their own choices, and thus be influential in social change. Some prerequisites for women’s empowerment are resources, perceptions, attitudes, and power [6].

Globally, it is reported that women live to achieve only 60% of their maximum capabilities following an assessment done using the Women Empowerment Index (WEI). Women also accomplish 28% less than men in crucial human development dimensions as measured by the Global Gender Parity Index (GGPI) [7]. According to the United Nations Women 2023 report, there are about 3.1 billion girls and women in countries with low or average empowerment levels, which represent almost 90% of the female population and this indicates that even at the global level, women’s empowerment levels remain low [7, 8].

The Gender Inequality Index (GII) is vital in assessing women’s empowerment. This index explicitly targets gender-based inequalities using three measures: reproductive health, empowerment, and economic activity. It focuses on the entire well-being of women and their empowerment in all countries across the globe. Some factors considered by this index include labor force participation, maternal mortality, and educational attainment [9]. As of 2022, Tanzania had a GII of 0.513 and ranked 131 out of 193 countries [10]. Tanzania ranks 54th out of 146 economies in the Global Gender Gap Index with a score of 0.734 [11]. This implies that despite some progress in closing the gender gap, gender inequalities and disparities are still prevalent in Tanzania. These inequalities affect women’s attainment of empowerment which in turn influences health services utilization.

The Survey-based Women Empowerment Index (SWPER) is an index that is used to measure women’s empowerment in Africa [12]. The index was developed based on Demographic and Health Survey (DHS) data from 34 African countries and focused on 15 variables that were indicative of women’s empowerment. These variables were under three domains of attitude towards violence (if beating is justified under any of the five reasons which include if the wife goes out without telling the husband, burns food, argues with her husband or refuses to have sex with her husband, or neglects the children), social independence (frequency of reading newspaper, woman’s education, age of woman at first birth and first cohabitation, age difference with husband or partner and if respondent worked in the past 12 months. Finally, the domain of decision making which included decision-makers on respondents’ healthcare, large household purchases and visits to family or relatives [12, 13]. The SWPER index was compared to the Gender Development Index and found to be reliable since it measures crucial aspects of women’s empowerment. One strength of this index is that it can be applied at the population and individual levels, unlike other indices [12].

The concept of women’s empowerment varies worldwide, and its indicators and indices are not uniform in all countries [14], because some of the indicators are context-specific; hence there is a need for every country to have a country-level index to measure women’s empowerment that applies to their setting. Mganga et al. [15] set out to develop a specific women empowerment index for Tanzania based on data from the demographic and health surveys. The index has six domains with 23 items, these domains include access to skilled health care, decision-making, attitude towards violence, age at menarche, age at first childbirth, and property ownership. These domains are also similar to those identified by Asaolu et al. [16] hence confirming their relevance in most African settings.

As a community and country, achieving public health goals also depends on women’s empowerment. Health-seeking behaviors among women to a large extent will rely on their level of empowerment. Women who are empowered have more control over decisions regarding the utilization of healthcare services [17, 18] for example, breast cancer screening [19]. These women tend to have an increased economic and social capacity, enabling them to seek health care. On the other hand, women who are not economically and intellectually empowered may be less assertive, have low decision-making attributes, and are less likely to utilize healthcare services [17].

Women’s empowerment also influences the uptake of obstetrics and gynecology services as the odds of a woman accessing such healthcare services are proven to be higher in women who are autonomous and empowered, unlike those who are not empowered [18, 20]. Despite some improvements in the accessibility of healthcare services in low-income countries, such services are underutilized. A cross-sectional study done in Liberia discovered that utilization of health services is high in empowered women, unlike unempowered women [21]. Furthermore, Bello et al. [22] also agree that women’s empowerment affects their utilization of healthcare services, for example, antenatal care visits. Findings revealed that women’s empowerment does not affect when women report for their first antenatal care visit, but women who are empowered attend more antenatal care visits than those not empowered.

The incidence of breast cancer is higher in developing countries as compared to developed countries and is attributed to various demographic changes and globalization [2]. Health systems must be empowered and have sustainable screening, prevention, and cancer management measures, as this will result in the control of the increasing cancer burden. Despite Africa having the lowest age-standardized breast cancer incidence rate of 36.2 for every 100,000 women per year, it has the highest mortality rate of 17.3 per 100, 000 women compared to other regions of the world [23].

Many regions in sub–Saharan Africa are reporting an increasing incidence of breast cancer every year [1]. This may be caused by changes in lifestyles, for example, having diets rich in calories and low in fruits and vegetables and the use of hormonal contraceptives [1, 24]. The survival rate from breast cancer after diagnosis is low in Sub-Saharan Africa as compared to developed and high-income countries [2]. This is because most cases of breast cancer are identified at a late stage, leading to poor prognosis. In developed countries, the survival rate is high as there is routine screening, proper cancer treatment, and management for those diagnosed with breast cancer [3].

In Tanzania, a country in East Africa, many women lose their lives to breast cancer despite there being a low incidence [25]. It is reported that almost 50% o women diagnosed with breast cancer do not survive, as the mortality-to-incidence ratio for breast cancer is 0.5 [26]. This high mortality is attributed to late diagnosis and treatment of breast cancer. Approximately 90% of women seek medical care in the advanced cancer stages [25]. Breast cancer screening, having access to healthcare without any barriers, and commencing cancer treatment while in the early stages are effective in reducing mortality. In Sub-Saharan Africa, the majority of late detections of breast cancer are found in countries like South Africa, Cameroon, Central Africa Republic, Malawi, and Tanzania [27].

Breast cancer screening identifies cancer in its early stages and helps find treatment therapies that deter further spread. Breast cancer screening is an essential aspect in reducing mortality secondary to late identification and management of breast cancers [3]. The National Comprehensive Cancer Network (NCCN) states that breast cancer screening varies according to factors like age, family, and medical history. It may include physical examination, risk assessment, screening mammography, and Magnetic Resonance Imaging (MRI). There are two main ways of screening for breast cancer, and these include Breast Self-Examination (BSE) and Clinical Breast Examination [28].

The mortality due to breast cancer has been shown to reduce following early adoption of breast cancer screening and treatment. In a study done in Norway, it was discovered that screening was associated with the reduction of breast cancer mortality as it contributed about one-third of the total reduction of breast cancer deaths [29]another study done in Sweden found a 40 to 50% reduction rate. Similar studies done in India and other low-middle-income countries emphasize the role of screening in reducing mortality [30, 31].

Women’s empowerment, as it is a process and dynamic concept keeps evolving; it is multidimensional, and dramatically influences health decision-making in women. Many studies have discovered that women’s empowerment influences various health services utilization in women [21, 22, 32]. However, a knowledge gap exists regarding women’s empowerment and its influence on the uptake of breast cancer screening as there is little information known. Moreover, there are no studies done in Africa, specifically Tanzania, that examined the role of women’s empowerment in the uptake of breast cancer screening services using demographic and health survey data. The study findings will provide valuable insights that will help to promote women’s empowerment and improve access and utilization of breast cancer screening services.

Objectives of the study

Using the Tanzania 2022 DHS data, the study aimed to investigate the association between women’s empowerment and the uptake of breast cancer screening, estimate the prevalence of breast cancer screening in Tanzania, and assess levels of women empowerment among Tanzanian women.

Methods

Study design and data collection

This study is based on secondary data obtained from the DHS program, which carries out nationally representative population-based household surveys that are often conducted every five years. It was implemented by the Tanzania National Bureau of Statistics in collaboration with the Ministries of Tanzania Mainland and Zanzibar [33]. Data collection was carried out in two stages to provide representative estimates for the whole population, and a stratified two-stage sampling technique was followed. This first involved a selection of sampling points consisting of enumeration areas (EAs) using the 2012 Tanzania population and housing census [33]. The EAs were selected with a probability proportional to their size within each stratum. A total of 629 clusters were selected, among which 211 were from urban areas, and 418 were from rural areas. In the second stage, about 26 households were selected from each cluster, which led to an estimated 16,312 households being selected. Tanzania is divided into nine zones to estimate geographical differentials. The sampling frame excluded institutional populations, such as those in hotels, barracks, hospitals, camps, and prisons.

The Tanzania Demographic Health Survey (TDHS) 2022, included 15,254 women and used five questionnaires. The women’s questionnaire is of interest to this study, as it collected information from all eligible women aged 15 to 49 years. The questionnaire included sociodemographic characteristics and questions regarding women’s work, reproductive and maternal history. It specifically included questions regarding knowledge of breast cancer and if the woman has ever undergone breast cancer screening.

After selecting the 20 to 49 years age group (as risk increases with age and screening is recommended for women in older age groups), 12,112 women remained. After data cleaning and excluding those with missing responses in variables relevant to the study, 4227 women remained. Of these only 4216 women had a valid response to the outcome variable and hence were included in the analysis as shown in Fig. 1.

Fig. 1
figure 1

Sample selection, Tanzania Demographic Health Survey, 2022

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Variables and measurement

Outcome variable

The uptake of breast cancer screening services is the outcome variable. Information on breast cancer screening was gathered by asking this question, ‘has a doctor or other healthcare provider examined your breasts to check for breast cancer?’ Responses were recorded as ‘One’ indicating ‘Yes’ (they have ever undergone breast cancer screening) and ‘two’ indicating ‘No’.

Independent variables

Some studies found age, place of residence, education, and parity as determining factors in the uptake of breast cancer screening [19, 34]. Literacy [35] and employment status [36] are other factors affecting breast cancer screening uptake. Independent variables used include the following, with their responses listed in brackets. Age was grouped into six age groups (20–24,25–29,30–34,35–39,40–44,45–49 years), education (No education, Primary, Secondary, Higher), marital status (married, living with partner), place of residence (urban, rural), Region or Zone (Western, Northern, Central, Southern Highlands, Southern, South West Highlands, Lake, Eastern, Zanzibar), Occupation (non-employed, employed, self-employed, professional, clerical, agricultural), wealth index (poorest, poorer, middle, richer, richest), heard about breast cancer (yes or no). Covered by health insurance (yes, no), and finally, parity which was categorized as nullipara (no children), low parity (1–3 children), moderate parity (4–7 children, and high parity (equal to or more than eight children).

Women empowerment indicators

The women empowerment variables used in the analysis were derived from various indices used to measure women empowerment that apply to Sub-Saharan Africa and specifically Tanzania. These include the following with their responses in brackets; ownership of a mobile phone or bank account (yes or no). When getting medical help, one needs permission to go, distance to a health facility, getting the money needed for treatment, and not wanting to go alone when seeking medical help. Responses were recorded as; no problem, big problem, not a big problem. Decision maker on the respondent’s healthcare, large household purchases, and visits to family or relatives (respondent, respondent and partner, self and another person, partner alone, someone else). Ownership of land or house alone or jointly (does not own, alone only, jointly with husband, jointly with someone else only, both alone and jointly), the respondent can refuse sex (yes or no).

Media exposure: frequency of reading newspapers or magazines, listening to the radio, and watching television (not at all, less than once a week, at least once a week, almost every day). Attitude towards domestic violence is comprised of five scenarios to which the respondent answered ‘yes’, meaning it is justified, and ‘no’, meaning it is not justified. The scenarios include; beating justified if the wife goes out without telling the husband, neglects children, if food is burnt, argues with the husband, or refuses to have sex. The responses were coded as 0 for No and 1 for Yes, respectively. A score was calculated for each case, and a combined variable indicating overall attitude towards violence was included in the analysis. A score of zero represented those who stated that violence is not justified, and any score equal to or greater than one represented those who accepted domestic violence under any of the reasons stated.

Data analysis

Analysis was performed using SPSS version 26, and descriptive statistics were used to describe the characteristics or attributes of the women included in this study. A bivariate analysis was done using the Pearson chi-square test to check the relationship between the outcome variable and each independent variable. The strength of associations between the variables was assessed using multivariate logistic regression. Variables with a statistically significant P-value of less than 0.05 were entered in the multivariate logistic regression model, and an adjusted odds ratio (AOR) with 95% confidence intervals was estimated. Adjusting the population size for sampling weights and computing weights was done. The researcher weighted the cases and inserted variables using the women’s sample weight (V005) which is the unit of analysis in this study.

Results

Sociodemographic characteristics

Table 1 The majority of the study participants were aged between 20 and 39 years (74.6%), with a mean age of 33.07 years and a standard deviation of 8.23. Most of the women (68.3%) reside in rural areas, while 31.7% dwell in urban areas. About 20.3% were uneducated, 53.4% had attained primary-level education, 25.1% were educated up to secondary level, and only 1.2% had attained tertiary-level education. Married women constituted 75.7% of the study population, while 24.3% were not married but living with their partner. Regarding literacy level, 23.7% could not read, 7.1% could read parts of a sentence, or they were visually impaired. Those who could read a whole sentence constituted 69.2% of the whole study population. Only 5.5% of the study population was covered by health insurance.

Table 1 Demographic characteristics of study participants, TDHS 2022
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The wealth index measures the living standard by looking into areas of ownership of selected assets like housing materials used, television, access to safe water, and basic sanitation facilities [33]. According to the scale, which categorizes the classes from the poorest to the richest, the richer and richest cumulatively accounted for 45.6%, the poorest and poorer constituted 33.9%, and 20.5% were in the middle class. Concerning the respondents’ occupations, about 31% were not working. The most prevalent occupation was agricultural employees, which comprised about 22.7% of the study population, seconded by unskilled manual workers at 17.1%. Skilled manual employees, women in service, clerical, sales, technical or professional positions, and other occupations cumulatively accounted for 29.2%. About 48.6% of the women had low parity, 38.2% had moderate parity, 8.5% had high parity, and 4.8% had never given birth. The majority (92.1%) of the women had ever heard of breast cancer. On the other hand, 94.8% of the women had never undergone breast cancer screening, those who did were only 5.2%.

Women empowerment in Tanzania

In Table 2, about 51.3% of women in the study population do not own any house. Only 3% own a house individually, and the majority (64.3%) do not own any land. Only 2.6% own land individually, and about 33.1% own lands alone and other lands jointly owned by their husband or partner. For 72.6% of the women, the distance to the nearest health facility was not a major problem, 85.1% also stated that it is not a major problem for them to go and get medical help alone while 14.9% considered seeking medical help by themselves as a major problem. About 67.4% of the women had no problem getting the money needed for medical treatment, while 32.6% did. Decision-making is another aspect used to measure women’s empowerment [22]. Only 21.8% could decide on their health care, while 55.8% of the respondents made such decisions jointly with their husbands or partners. Concerning large household purchases, 50.9% decided jointly with their husband or partner, and 35% of the population stated that only the husband or partner makes such decisions. Women who make such decisions alone accounted for 14.1% of the study population.

Table 2 Demographic characteristics and breast cancer screening, bivariate analysis of breast cancer screening among Tanzanian women
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In terms of overall attitude toward violence, 53.9% reported that beating is not justified under any circumstance, while 46.1% stated that it is justified under one or more of the scenarios mentioned. The majority 64%, of the women had mobile phones while only 7.7% had bank accounts. Only 6.1% of the women read newspapers or magazines at least once a week, while 80% never read newspapers or magazines. Women who never listened to the radio accounted for 42% of the study population, while those who listened at least once per week were 33.3%. About 56.1% of the women never watched television, while 27.7%, watched television at least once a week.

Factors associated with breast cancer screening

The bivariate analysis results in Table 3 indicate that age, place of residence, educational level, literacy, wealth index, occupation, health insurance, and parity are significantly associated with breast cancer screening. Breast cancer screening is high in women aged 35 to 49 years (3.1%), those residing in urban areas (2.8%), and those who have undergone up to the secondary education level (4.5%). Screening was also high in women covered by health insurance (4.2%), literate (4.2%), the richest at 2.7%, those with low parity (2.6%), and women who had ever heard of breast cancer (4.7%).

Table 3 Prevalence of women’s empowerment among women in Tanzania, TDHS 2022
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In Table 4, the women empowerment variables that are statistically significant concerning breast cancer screening are ownership of assets, having a mobile phone and bank account, media exposure, attitude towards violence, access to health care, decision-making on large household purchases, and respondents’ healthcare.

Table 4 Women empowerment and breast cancer screening, bivariate analysis of breast cancer screening among Tanzanian women
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Table 5(in the supplementary file) shows the results of the logistic regression. Women aged 45 to 49 years were 6.28 times more likely to go for screening, while those dwelling in rural areas were 1.48 times more likely to go for breast cancer screening. Those who could read the whole sentence were 1.13 times more likely to undergo breast cancer screening, and those with secondary or higher education were 1.1 times more likely to go for screening. The odds were 1.22 for those working than those not working and those women who had low parity were 3.02 times more likely to go for screening.

Table 5 Multivariate analyses of independent variables associated with breast cancer screening among women in Tanzania, TDHS 2022
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Women who owned a house alone were 3.08 times more likely to go for breast cancer screening while the odds in those who jointly did with their husband or partner were 1.7 times. Women who jointly owned land with their husbands or partners were 3.09 times more likely to go for breast cancer screening, while the odds were 1.6 times in those who owned land alone. Women who jointly decided on their healthcare with their husbands or partners were 1.18 times more likely to go for breast cancer screening.

The odds were 1.21 times higher in women whose husbands or someone else made decisions about large household purchases than when such decisions were made by the woman alone. The odds of going for breast cancer screening were 1.12 times in women who accepted that beating is justified for any of the five reasons, as compared to those who said beating is not justified for any reason. Women who had a phone were 1.23 times more likely to go for breast cancer screening. When it comes to media exposure, women who read newspapers or magazines, listen to the radio, and watch television at least once a week are less likely to go for breast cancer screening as compared to those who do not utilize any media at all.

Discussion

The major findings of the study indicate that age, education, literacy, ownership of assets, decision-making, and attitude toward domestic violence are significantly associated with the likelihood of going for breast cancer screening. These factors have been shown to increase the odds of going for screening. Findings also show that only 5.2% of women in Tanzania had ever undergone breast cancer screening. In most African countries, the prevalence of breast cancer screening among women in the reproductive age group is low. A similar study conducted in Kenya also revealed a low prevalence of only 10.2% [37]. Another study done in four African countries (Burkina Faso, Ivory Coast, Kenya, and Namibia) also found an overall prevalence of 12.9% [38]. The low prevalence of breast cancer screening has led to low survival rates in most low and middle-income countries, including Tanzania as diagnosis and management occur in later stages [39] Lack of awareness of breast cancer screening, shortage of resources, and socio-economic and cultural constraints are some of the contributing factors [26, 40]. Addressing such issues through education campaigns, sufficient allocation of resources, and eliminating any sociocultural barriers through community engagement is vital in enhancing the uptake of screening services.

Education and literacy are associated with an increased likelihood of going for breast cancer screening. Findings indicate that most of the women (92.1%) had ever heard of breast cancer. Nevertheless, only 5.2% of the women had ever undergone breast cancer screening while 94.8% had never undergone breast cancer screening. The highest prevalence of screening is seen in literate and women educated to at least the secondary level of education. Similar findings can be seen in studies done in Taiwan and Turkey [34, 41]. A study in India also found that states with high literacy levels had a high uptake of breast cancer screening [35]. According to the health belief model, for someone to engage in health preventive behavior, there has to be a perceived risk, benefits, barriers, and confidence to engage in that action [42, 43]. Education and literacy play a major role in this regard as learned and literate women understand and comprehend health information received and make informed decisions that may prompt preventive action and increase the likelihood of going for screening. Education is one requisite to ensure empowerment, improve decision-making, gain financial independence, and improve one’s social status [44].

Education empowers women through knowledge and awareness and enables them to be assertive, address any inequalities that may prevent them from achieving a healthy life, and make informed decisions [5] unlike their counterparts [34]. Despite there being an improvement in enrollment rates of girls in schools over the years, gender disparities remain. In 2010, the enrollment rate for girls in secondary school in low- and middle-income countries was 34% while for boys, it was at 40%, whereas 20 years ago the enrolment rate for girls was 22%, and for boys, it was 30% [45]. Addressing such inequalities through policies and legislation that encourage equal allotment and provide a good learning environment will help ensure that girls get an education and empower them to lead successful and healthy lives.

Ownership of assets has also been found to be significantly associated with ever going for breast cancer screening. This may be indicative of a good socioeconomic status (SES), which leads to economic empowerment [34]. SES is a vital aspect of achieving women’s empowerment as it determines financial status and improves access to better healthcare. According to the fundamental cause theory, SES highly influences and addresses health inequalities over time as those with high socioeconomic status use resources at their disposal to utilize health services [46]. Strategies to improve the utilization of breast cancer screening must, therefore address all inequalities that hinder women from owning properties. Equal property ownership rights ought to be given to both men and women to help bridge the poverty gap [44].

Women who take part in decisions regarding healthcare and large household purchases are more likely to undergo breast cancer screening. This implies a shared decision-making practice, which may promote support but, in other instances, may limit the woman’s autonomy. Joint decision-making between couples is a strong determinant in healthcare utilization by women and is also influenced by other factors like education [47]. Findings from studies done in Bangladesh and Liberia [17, 21]show that women’s empowerment in these areas is important as women with high decision-making power can utilize various health services. Women’s participation in decision-making is a concept that is highly indicative of women’s empowerment. Improving women’s decision-making capabilities has been shown to affect women’s health decision-making and utilization of services [48]. As Kabeer mentions in her Empowerment framework, ‘agency’ is a vital factor in achieving empowerment that incorporates being able to make decisions amidst challenging power relations, followed by decisive actions given the available resources [5].

There are several variations concerning whether domestic violence is justified or not in Tanzania and how it influences the uptake of breast cancer screening. Women who say that violence is justified based on either of the five reasons stated, were more likely to undergo breast cancer screening. There are higher levels of intimate partner violence among women who accept domestic abuse in Tanzania; such women have a low social value and are at more risk than those who oppose violence [49]. Contrary to the study findings, negative attitudes toward domestic violence are associated with the likelihood of utilizing health services [50] as women who strongly oppose violence under any circumstance are more likely to go and access and utilize health services [51]. Women who oppose violence are more likely to defend their rights and live empowered lives, which maximizes their chances of independence and adopting healthy lifestyles. These varying findings may be a result of underlying traditional or cultural norms that are welcomed in various settings, which is worrisome and a barrier to women’s empowerment. Community engagement, awareness campaigns, and entrepreneurship are some of the measures to correct such attitudes and promote women’s empowerment.

Empowerment enables women to make informed decisions regarding health by equipping them with knowledge, skills, resources, and opportunities that enhance their overall quality of life. Country-specific interventions and breast cancer screening awareness campaigns should include empowerment initiatives to promote healthy behavior and the uptake of screening to reduce the breast cancer burden, as well as enable women to lead healthy lives. The government and stakeholders should also have policies that ensure equity in the allocation of infrastructure, equipment, and resources to promote accessibility and utilization of breast cancer screening services in Tanzania.

Conclusion

Achieving gender equality and empowering all women and girls is the fifth goal of the Sustainable Development Goals (SDGs). It is essential to note that this goal is an intrinsic rather than instrumental goal. Attaining global women empowerment requires successfully incorporating education, employment, and political participation [5]. Findings from the study imply the need to focus on empowering women and advancing their abilities through promoting projects regarding education, small or large-scale businesses, and community involvement.

Strengths and limitations of the study

The study used women empowerment variables applicable to Tanzania and the findings give insight on the state of women empowerment in the country. The dataset did not include questions regarding attitudes and beliefs surrounding breast cancer screening, which can be used to better understand the varying prevalence of breast cancer screening. Further studies need to take into account factors like culture, attitudes, and beliefs that influence the uptake of health services.