The empowerment of adolescent girls and young women is widely recognized as crucial to global health equity and to achieving the United Nations' Sustainable Development Goals on health (SDG 3) and gender equality (SDG 5) (1, 2). In sub-Saharan Africa, these young women continue to bear a disproportionate burden of preventable diseases. For example, cervical cancer incidence in the region is the highest in the world, largely due to limited screening coverage (3). Likewise, adolescent girls and young women in SSA are at high risk of HIV: in 2022, women and girls accounted for about 63% of new HIV infections in sub-Saharan Africa (4). This disproportionate burden is especially concerning for young women who are married or cohabiting, as they often have constrained sexual autonomy and face high exposure to risk (5, 6). These statistics highlight that simply providing services is not enough; uptake depends on broader social and economic factors. For instance, even in Ghana, factors such as a woman's gender, the cost of care, and the availability of health services have been shown to strongly influence whether and where people seek care (7).

In Ghana, the pattern is equally striking. HIV testing programs (for example, integrating testing into antenatal care) have expanded access, but uptake remains low: only about 31% of Ghanaian women aged 15–24 have ever been tested for HIV (8). Uptake of cancer screening is even lower. National survey data indicate that only about 4%–5% of women have ever had a cervical cancer test (9); the DHS 2022 found screening rates of just 6.3% among urban women and 3.0% among rural women (9). Such figures hide deep inequalities. For example, women in poorer northern or rural regions often face greater distance, cost, and facility barriers that limit their use of screening services, so that preventive services remain concentrated among wealthier urban women (10). These disparities illustrate how structural factors shape young women's preventive health behaviors.

Overlaying these structural barriers is the dimension of individual agency, specifically, women's sexual autonomy. Sexual autonomy is often defined as a woman's capacity to refuse sex or insist on condom use and is theorized to empower women to protect their health (5, 11). Research across sub-Saharan Africa shows that sexual autonomy is associated with sexual health outcomes. For example, women with higher sexual autonomy were more likely to report a recent sexually transmitted infection (6) (perhaps reflecting greater awareness or risk). The link between autonomy and intimate partner violence has also been studied, with mixed findings, highlighting complex interactions (5, 12). However, evidence from Ghana is sparse. It remains unclear how women's sexual autonomy influences their uptake of HIV testing or cancer screening once socioeconomic and geographic factors are accounted for.

However, young, partnered women aged 15–24 years are a priority population because they are sexually active and often experience unequal power dynamics in relationships, which may constrain access to HIV testing and cancer screening (5, 13, 14). Previous studies indicate that disparities in HIV testing and cervical cancer screening are particularly pronounced in this group, emphasizing the need for targeted research (15).

To address these gaps, we use data from the 2022 Ghana Demographic and Health Survey (DHS) to conduct a spatial and multilevel analysis focused on young, partnered women (age 15–24). Specifically, our study will (1) map the geographic distribution and identify clusters of sexual autonomy, HIV testing, and breast and cervical cancer screening; (2) examine how sexual autonomy relates to uptake of these services, controlling for socioeconomic, demographic, and locational factors; and (3) quantify socioeconomic inequalities in screening uptake and decompose the contributions of key determinants. In revealing where screening uptake and autonomy are lowest and by identifying the main social and economic barriers, the study will provide clear evidence for directing resources and designing interventions to improve young women's health.

The persistent disparities in preventive healthcare utilization among young women in low- and-middle-income countries represent a critical challenge to global health equity and the achievement of Sustainable Development Goals (SDGs) 3 and 5 (16). In Ghana, despite national efforts to improve reproductive health services, young women continue to face substantial barriers to essential screenings including HIV testing, breast cancer screening, and cervical cancer screening (17). This theoretical framework integrates multiple perspectives to develop a comprehensive understanding of the multilevel determinants of healthcare utilization and situates the current study within existing literature.

This study provides a comprehensive, nationally representative analysis of the complex interplay between sexual autonomy, socioeconomic factors, and geographic disparities in shaping young Ghanaian women's uptake of essential health screenings. Our findings reveal a landscape of significant inequality, where a woman's ability to control her sexual and reproductive life is linked to her health-seeking behaviour, but this potential is mediated by deep-seated regional and economic disparities.

We found that 77.2% of young, partnered women in Ghana reported moderate to high levels of sexual autonomy. However, this national figure masks profound sub-national variations, with a clear spatial clustering forming a high-autonomy belt in the southern and middle regions (e.g., Eastern, Volta, Bono: 83%–90%) and a low-autonomy cluster in the northern regions (e.g., Northern, North-East, Savannah: 10%–65%). Our national prevalence is higher than the 51.7%—52.8% recently reported in other Ghanaian studies (2, 39) but aligns more closely with pooled sub-Saharan African estimates of 73.0% (5). This discrepancy can be attributed to several factors. First, our study focused specifically on young women (15–24), a demographic that may be increasingly exposed to modern ideas of gender equality and reproductive rights through education and media, unlike studies covering all reproductive age groups. Second, the specific indicators used to construct the autonomy index can vary, influencing the final prevalence. The stark north-south gradient we observed is consistent with the well-documented developmental divide in Ghana, where southern regions benefit from greater infrastructure, educational attainment, and economic opportunities (43). This pattern echoes findings from Ethiopia, where regional disparities in women's decision-making autonomy were also pronounced (11). Furthermore, studies across Africa consistently identify education, media exposure, and wealth as key multi-level predictors of autonomy (2, 21), which aligns with our spatial findings of high autonomy clustering in more developed regions.

Thus, national policies promoting gender equality must be more localized. In high-autonomy southern regions, programs can focus on sustaining and building upon existing empowerment. In the northern belt, interventions must be more fundamental, addressing root causes like girls' education, economic opportunities for women, and community-level dialogues to challenge norms that restrict female sexual agency, like strategies suggested by Kassahun & Zewdie (11). Also, sexual and reproductive health education programs, particularly in low-autonomy regions, should explicitly incorporate modules on negotiation skills, consent, and rights within relationships, moving beyond biological knowledge alone.

A central finding of this study is the differential association between sexual autonomy and screening types. Sexual autonomy was strongly associated with and likely facilitates both breast cancer screening and cervical cancer screening, even after controlling for wealth, education, and residence. In contrast, it was not a significant predictor for HIV testing. The link between autonomy and cancer screening is logical and supported by the literature. Breast and cervical cancer screening are often proactive, voluntary health-seeking behaviours. A woman with greater autonomy is more likely to prioritize her health, have the confidence to seek services for a non-acute condition, and overcome barriers like embarrassment or spousal disapproval (12, 21). Our finding that autonomy increased the odds of cervical screening five-fold is particularly striking and suggests that empowerment may be a crucial lever to overcome the well-documented barriers of fear, shame, and cultural sensitivity surrounding gynaecological examinations (13, 27).

The non-significant association with HIV testing, however, reveals a differing pattern. This is likely because HIV testing for young, partnered women in Ghana is often not a voluntary, autonomy-driven decision but a routine, and sometimes obligatory component of antenatal care (ANC). This is corroborated by our data showing that parity was the strongest predictor of HIV testing. This aligns with studies highlighting the success of prevention of mother-to-child transmission programs in institutionalizing HIV testing within ANC (8, 28, 40). Essuman et al. (8) specifically noted that factors like ANC attendance were key drivers of HIV testing among young Ghanaian women. Our findings extend Andersen's model by demonstrating that enabling factors (wealth, insurance) may be necessary but insufficient without women's agency (autonomy) and supportive community contexts. Further, the differential predictive performance across models (AUC: breast 0.881 vs. cervical 0.845) suggests that breast cancer screening may be more strongly determined by measured factors, while cervical screening involves substantial unmeasured barriers (stigma, cultural factors).

Thus, while autonomy drives voluntary screening, system-integrated testing can achieve high coverage even without it. Hence, cancer prevention campaigns should actively frame screening as an act of self-care and empowerment. These campaigns can partner with women's groups and use empowering messaging to appeal to autonomous women and inspire others. Also, the successful integration of HIV testing into ANC provides a powerful model. Policymakers should urgently accelerate plans to integrate cervical cancer screening into routine ANC and post-natal care services, thereby capturing a captive audience of women who may not otherwise seek screening proactively, as recommended by Mantula et al. (27).

Our inequality analysis uncovered a tiered system of access. HIV testing and breast cancer screening exhibited significant pro-rich inequality (CI = 0.288 and 0.334, respectively), with the richest women having 1.8 and 5.7 times the uptake than the poorest. Cervical cancer screening, meanwhile, was uniformly low across wealth quintiles (CI = 0.111, p > 0.05). Spatially, the maps reinforced this, showing screening hotspots in the more developed South (e.g., Eastern, Volta, Central for HIV; Volta, Western for breast cancer) and vast cold spots in the North. The pro-rich inequality in HIV and breast cancer screening is a consistent theme in Ghana and across sub-Saharan Africa, reflecting the cost (direct and indirect) of accessing health services and the correlation between wealth and health literacy (7, 10).

The extreme inequality in breast cancer screening is particularly alarming and suggests it is still perceived as a luxury service. The equitable, albeit catastrophically low, distribution of cervical cancer screening is an equality of deprivation. This finding contrasts with studies in other settings that often find pro-rich disparities (41), but it highlights that in Ghana, barriers like a near-total lack of awareness, extreme scarcity of services, and cultural fears are so universal that they suppress demand across all socioeconomic strata (42). Our spatial findings of a north-south divide are consistent with assessments of maternal health services in northern Ghana, which documented critical gaps in infrastructure and human resources (23). The finding that inequality was sometimes more pronounced within rural areas highlights that poverty and marginalization have layered effects, as even among disadvantaged populations, the least wealthy are further left behind. For HIV and breast cancer screening, targeted subsidies, vouchers, and strengthened national health insurance coverage for preventive services are crucial to level the playing field for poorer women, addressing the financing burdens identified by Macha et al. (10).

Nonetheless, the sub-4% screening rate demands an emergency response. Policy must focus on massive public awareness campaigns to generate demand, combined with rapid scale-up of service availability through primary health centres and mobile clinics, especially in rural and northern regions, as suggested by strategies in Zimbabwe (27). Also, the spatial maps provide an explicit blueprint for the Ghana Health Service, in that; regions identified as cold spots must be prioritized for the deployment of screening equipment, trained personnel, and community-based outreach programs to bridge the geographic disparities highlighted by Langa et al. (42).

Education and media exposure were consistent positive predictors of screening. The role of education and media in increasing health knowledge and shaping positive attitudes is well-established (14, 15). Our finding that radio and TV exposure predicted cervical cancer screening shows their value as channels for health promotion in Ghana, a finding echoed by Enyan et al. (15) in their study of Muslim women. The substantial contextual effect captured by the MOR is a critical insight. It suggests that factors like community norms, the density of health facilities, and the attitudes of local health workers create an environment that either facilitates or hinders screening. This aligns with the concept of clustering of health behaviours and highlights the limitations of interventions that target individuals without changing the community context. This is particularly relevant for cervical cancer, where cultural and religious sensitivities, as noted by Abubakari et al. (13) and Enyan et al. (15), can create a community-wide barrier.

Thus, national health education campaigns should strategically use radio and television, with content tailored to different regional languages and cultural contexts. Entertainment education and talk shows can be effective formats for disseminating messages about screening and normalizing discussions around women's health. Beyond individual awareness, policies should foster enabling environments. This includes training community health workers to promote screening, engaging local leaders and male partners to build supportive social norms, and ensuring that local health facilities are youth-friendly and non-stigmatizing, thereby addressing the multi-level barriers identified in our analysis and supported by Solanke et al. (21).

This study's major strength lies in its use of nationally representative data, which ensures generalizability of findings to young women across all 16 regions of Ghana. Also, the integration of spatial mapping, multilevel modelling, and inequality decomposition techniques, provided a comprehensive understanding of how sexual autonomy and sociodemographic factors influence women's participation in HIV, breast, and cervical cancer screening. The use of spatial visualization and concentration indices helped identify regional clusters and quantify socioeconomic disparities, while the application of sampling weights and model validation enhanced reliability. Also, our findings challenge purely economic explanations of health-seeking behaviours, contributing additional insights into healthcare disparities, particularly among disadvantaged populations. However, several limitations must be acknowledged. The cross-sectional design limits causal inference, and reliance on self-reported data may introduce recall or social desirability bias. The measure of sexual autonomy, though widely used, may not capture its full cultural and contextual dimensions. Unmeasured community-level factors such as local health promotion activities or service accessibility may also contribute to residual confounding. Despite these limitations, the study provides robust and policy-relevant insights into regional and socioeconomic inequalities in young women's screening behaviours and sexual autonomy in Ghana.

This study revealed significant geographical and socioeconomic disparities in young women's healthcare screening behaviours and sexual autonomy across Ghana. While HIV testing coverage was relatively high, participation in breast cancer and, particularly, cervical cancer screening remained remarkably low, with marked inequalities favouring wealthier and urban women. Spatial analyses demonstrated distinct north–south clustering, where higher screening uptake and sexual autonomy were concentrated in southern regions, and lower levels were observed in the northern belt. These disparities reveal persistent structural and contextual barriers such as limited access to screening facilities, low health literacy, and socioeconomic disadvantage that hinder equitable participation in preventive health services. Further, sexual autonomy emerged as a strong predictor of women's screening behaviour, highlighting the critical role of empowerment and informed decision-making in promoting preventive health practices. Thus, addressing these inequities requires a comprehensive policy approach that integrates women's health services into community-based platforms, enhances health education, and strengthens gender equity initiatives. Also, expanding access through CHPS compounds, mobile screening units, and digital health promotion campaigns could help bridge existing gaps. Ultimately, ensuring equitable access to screening and strengthening sexual autonomy among young women are essential for achieving Ghana's commitments to Universal Health Coverage and Sustainable Development Goal 3 on good health and well-being.