Public health aims to provide universal safety and progressive opportunities to populations to realise their highest level of health through prevention of disease, its progression or transmission . Screening as a public health strategy entails early detection of disease or its precursors in asymptomatic populations deemed to be at risk [2–5]. Its key objectives and rationale include detecting diseases early when treatment is more cost-effective; identifying disease predisposing factors and appropriate management of identified risk factors [2, 3]. Depending on the epidemiological characteristics of the disease, defined by its occurrence and resource availability for care and management, screening may be mounted as voluntary or mandatory national program with a long-term aim of reducing morbidity and mortality [2, 6–8].
The process of screening to detect early different diseases inherently is fraught with diverse ethical challenges [6, 9]. However, analysis of these challenges may be taxing to decision-makers and service providers since ethics constructs for considering public health practice are varied [10, 11]. Ethical analysis is needed to clarify the contextual level of public health necessity as well as evaluate the rationale for, prioritize and justify activities designed to accomplish the stated public health objectives . Policies on screening for syphilis and cancer of the cervix in Kenya vary given their epidemiological as well as medical characteristics [13–16]. They were considered simultaneously in the current study to help clarify ethical issues in screening for them based on the perceptions of women undergoing the process.
Epidemiological and policy context for screening in Kenya
The prevalence of antenatal syphilis in Kenya is estimated at 3.8% and more than half of these develop unfavorable obstetric outcomes, such as maternal deaths, prolonged morbidity and congenital fetal syphilis. Untreated syphilis pose high threats to the general population because of its potential for an outbreak [17, 18]. Screening for maternal syphilis early in the first trimester is a mandatory exercise aimed at minimizing the adverse outcomes to the mother and the unborn child as well as to control disease spread or potential epidemics in the general population. This is plausible since syphilis is an infectious but preventable and easily treatable disease, although on the other hand, this may be perceived as a way of compulsion and control. While sufficient service coverage is necessary, apparently few antenatal mothers access these services as stipulated given that majority of women in Kenya initiate antenatal clinic visits late (at a mean gestation of 5.9 months). Even then, less than one third of receive relevant information and fewer ever obtain blood tests .
Cervical cancer on the other hand, is the leading cause of reproductive tract cancers in Kenya. It is associated with high morbidity and mortality burden among women at risk yet it is largely preventable and can be effectively treated if detected early . Consequently, its prevention through health promotion and education activities, early detection through screening and effective management of cases has been prioritized in the National Reproductive Health Strategy. The national operational guidelines are available to enhance procedure administration. It is stipulated that providers should take informed consent and document adequate reproductive health history during screening. Additionally, after the procedures results as well as plans for return visits should be discussed with the client. These steps help to improve both clients’ pre- and post-screening psycho-cognitive status . However, it is still unclear how patients experience screening procedures/services vis-à-vis their perceptions/experiences of cervical cancer.
As the Kenya national public health policy goals evolve, elimination of disease ; community participation ; promotion of effective, accessible, acceptable and affordable quality health services  and enhanced regulatory capacity of Ministry of Health (MoH) have been critical . The recent national health guidelines [7, 20, 22–26] have progressively adopted a life-cycle, rights-based essential health care, presuming the right to ‘the highest attainable standard of health’ for everyone. The core values of a rights-based approach include fairness, respect, equality, dignity and autonomy  as well as accountability and community participation .
Under the national reproductive health program  whose aim is to improve maternal health; reduce neonatal/child mortality and morbidity; reduce the spread of HIV/AIDS and promote empowerment of women, integrated screening, including for both syphilis and cancer of the cervix, has been incorporated as part of the essential health package . These services are largely integrated within the existing outpatient departments , maternity units and comprehensive care clinics at all health service tiers [7, 30]. Specifically for syphilis, the Public Health Act in Chapters 45 (a) – (c), 48 and 51 provides for mandatory surveillance to identify localities of high disease prevalence and undertaking of appropriate medical and public health interventions. However, the Act also provides that services must be provided in the context of informed consent, privacy, confidentiality, information, education and appropriate communication. Further, a client or her partner(s) must be notified once the disease is diagnosed and provided with written instructions about the condition, appropriate education and counseling while, ensuring strict privacy and confidentiality of their medical records [7, 31].
There are challenges in studying or implementing programs for Syphilis and cervical cancer given they are associated with sex and reproduction. Social or psychological status may be harmed by positive results due to loss of personal and social esteem, stigma, anxiety and fetal loss, among others. On the other hand, curveillance and disease notification within the context of screening are necessary in identifying proportionate distributions of disease burden in populations as well as the level of prevention and care resources required [10, 12]. The fundamental policy and operational challenge remains how to achieve a balance in effective population coverage while minimizing potential harms to individuals or communities . These potential harms have not been sufficiently explored in Kenya. This study sought to explore women’s perception of mandatory screening for syphilis and voluntary screening of cervical cancer in Nyanza, Kenya with an aim to identify evolving ethical issues. The results highlight local interpretative notions useful for progressive planning and implementation decisions [33, 34].