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PubMed2005

Geographic disparities in cervical cancer mortality: what are the roles of risk factor prevalence, screening, and use of recommended treatment?

CONTEXT: Despite advances in early detection and prevention of cervical cancer, women living in rural areas, and particularly in Appalachia, the rural South, the Texas/Mexico border, and the central valley of California, have had consistently higher rates of cervical cancer mortality than their counterparts in other areas during the past several decades. METHODS: This paper reviews the published literature from 1966 to July 2002 to assess three potential pathways underlying this excess mortality--high human papilloma virus (HPV) prevalence, lack of or infrequent screening and advanced disease at diagnosis, and under-use of recommended treatment and shorter survival. FINDINGS: Living in rural areas may impose barriers to cervical cancer control, including lack of transportation and medical care infrastructures. Population characteristics that place women at greater risk for developing and dying from cervical cancer, such as low income, lack of health insurance, and physician availability, are concentrated in rural areas. Published data, however, are insufficient to identify the key reasons for the observed mortality patterns. CONCLUSIONS: At this time, given the lack of definitive evidence in the published literature, decisions about priorities in areas with high rates of cervical cancer mortality will depend on knowledge of current levels of screening, incidence, and stage distribution; and service delivery infrastructures, resources, and acceptability of interventions to the target population.

Female↗
PubMed1993

Increasing the uptake of cervical smears: strategies implemented among general practitioners in Auckland.

AIM: To evaluate three strategies designed to increase the uptake of cervical smears among specified groups of women through a collaborative partnership between the Auckland Area Health Board and selected Auckland general practitioners. METHOD: Using action-based research general practitioners and practice nurses were engaged to initiate ways of inviting women in their practices to have cervical smears. Both formative and process evaluations were made. Concurrently, outcomes were measured in terms of call/recall systems, uptake rates and cost barriers. RESULTS: Where financial incentives were given to establish call/recall systems for older women, overall uptake rates increased by 21%, and by 154% for women over 45 years. Over one third of a targeted group of women aged between 60 and 70 years responded to an invitation to have a free smear. Of these 109 women, fourteen, with a median age of 67 years, had their first smear. Almost two thirds indicated that cost had never been a barrier. CONCLUSIONS: The determining factor for women having a cervical smear in all three strategies was a personal invitation from their general practitioner or practice nurse. Invitations were dependent upon having accurate call/recall systems. This evaluation of the collaborative process between Auckland Area Health Board and local general practitioners demonstrated how manager and provider partnerships can benefit the consumer.

Adult↗
PubMedDate not supplied

Mammography and pap smear use by older rural women.

OBJECTIVE: To compare the characteristics of older women who did and did not have screening mammograms and Pap smears during the first two years both services were a Medicare Part B benefit. METHODS: A prospective study was conducted in five rural Pennsylvania counties of 2205 female community-dwelling Medicare Part B beneficiaries who volunteered to participate in a Medicare prevention demonstration project. The baseline health risk appraisal included information on demographics, insurance status, disease history, symptomatology, and functional and cognitive status. These variables were tested for their association with the use of mammography and Pap smear using Medicare utilization claims data from 1991 to 1992. RESULTS: Of 2175 women still alive after three years, 44.6% had had a mammogram and 14.6% had had a Pap smear in either 1991 or 1992. Multivariate logistic regression revealed that women were more likely to have a mammogram if they were younger, were more educated, had supplemental insurance, did not need assistance with activities of daily living, and did not have diabetes or arthritis. Younger, college educated, and non-widowed women were more likely to have Pap smears than women in other categories. CONCLUSIONS: With cost less of a barrier, more aggressive efforts to persuade older women to have mammograms and Pap smears must be developed.

Age Factors↗
PubMed2004

Pap testing adherence among Vietnamese American women.

OBJECTIVES: Vietnamese American women are five times more likely to be diagnosed with cervical cancer than their White counterparts. Previous research has demonstrated low levels of Papanicolaou (Pap) testing among Vietnamese. Our study objective was to examine factors associated with interval Pap testing adherence. METHODS: A population-based, in-person survey of Vietnamese women aged 18-64 years was conducted. Questionnaire content was guided by the Health Behavior Framework (HBF). The study sample was randomly selected from 1639 south Seattle households. Statistical methods included chi(2) tests and logistic regression. RESULTS: The response rate among eligible households was 82%, and the study included 352 women. Sixty-eight percent of the participants had been screened during the preceding 3 years. The following HBF factors were associated (P < 0.05) with interval Pap testing in bivariate comparisons: believing Pap tests decrease the risk of cervical cancer and believing cervical cancer is curable if detected early (perceived effectiveness); knowing testing is necessary for women who are asymptomatic, sexually inactive, or postmenopausal (knowledge); reporting concern about pain/discomfort as a barrier to screening (barriers); family member(s) and friend(s) had suggested testing (social support); doctor(s) had recommended testing; and had asked doctor(s) for testing (communication with provider). In a multivariate analysis, being married, knowing Pap testing is necessary for asymptomatic women, doctor(s) had recommended testing, and had asked doctor(s) for testing were independently associated (P < 0.05) with screening participation. CONCLUSION: Our results confirm low levels of Pap testing among Vietnamese women and demonstrate the importance of physician-patient communication in increasing screening adherence. Health education efforts should target unmarried women and reinforce the importance of Pap testing for all Vietnamese women.

Adolescent↗
PubMed1992

Condom performance during vaginal intercourse: comparison of Trojan-Enz and Tactylon condoms.

Forty-nine mutually monogamous couples used a total of 478 condoms during vaginal intercourse in a prospective trial whose purpose was to discover whether the performance of a new non-latex hypoallergenic condom was substantially equivalent to that of a leading condom brand already being marketed. Of these 478 condoms, seven (1.46%) either broke or fell off the penis during intercourse. Two (0.42%) of the 471 condoms that did not break or fall off during intercourse fell off the penis when it was being withdrawn from the vagina. Altogether, 469 (98.1%) of the 478 condoms used for intercourse survived intact throughout intercourse and withdrawal. Differences in breakage and slippage rates for the two condom brands were statistically insignificant. The overall 98.1% success rate is much higher than the rate of success found in a previous condom trial with nearly identical research protocol. The reason for the difference is attributed to much more precise questioning of subjects in the current trial.

Adult↗
PubMed1992

AIDS in sub-Saharan Africa: implications for health education.

This paper reviews the current epidemiologic status of AIDS in sub-Saharan Africa, focusing on what is currently understood about the distinctive features of heterosexual transmission in young men, women, and children. Epidemiologic data show that AIDS is transmitted primarily through heterosexual vaginal intercourse. Heterosexual transmission is highlighted both as the principal mode of spread of AIDS in east, central, and southern Africa and as the primary focus for AIDS education and control of the epidemic. The transmission of AIDS, like that of other sexually transmissible diseases, results from sexual behaviors that are rooted in social and cultural values that are not easily changed. The primary risk factors--including multiple sex partners, prostitution, and unprotected intercourse--are examined. The perceived obstacles to control of the epidemic include unfavorable government reactions to the epidemic, poor public knowledge, prevailing sexual attitudes, and reluctance to use condoms. These and other immediate and competing risk factors like unemployment and poverty combine to complicate the task of AIDS education.

Acquired Immunodeficiency Syndrome↗
PubMed2005

Pain predicts non-adherence to pap smear screening among middle-aged African American women.

BACKGROUND: Middle-aged African American women have the highest incidence and mortality of invasive cervical cancer in the United States and the lowest adherence to pap smear screening. METHODS: In 2001, we identified factors associated with non-adherence to screening recommendations using three focus group interviews and subsequently developed a questionnaire administered to 144 African American women aged 45 to 65 years. RESULTS: The perception that the Pap test was painful was associated with non-adherence to screening recommendations (OR = 4.78; 95%CI: 1.67-13.7). Difficulty to pay for the office visit coupled with perceived pain was associated with a nearly sixfold increase in risk of non-adherence (OR = 5.8; 95%CI: 2.8-15.5). Previously identified barriers to screening including lower education and socioeconomic status, poor access to care, knowledge of and exposure to known risk factors of invasive cervical cancer, cancer fatalism, and perceived racism were not independently associated with non-adherence. CONCLUSIONS: These data suggest that, among middle-aged African American women, future interventions addressing pain during a Pap test will likely increase acceptability of and adherence to cervical cancer screening. Pain could be addressed either by providing information during the pap test and/or using smaller lubricated speculums.

Black or African American↗
PubMedDate not supplied

Improving female preventive health care delivery through practice change: an Every Woman Matters study.

BACKGROUND: The levels of breast and cervical cancer screening in Nebraska primary care remain suboptimal despite awareness of their importance, and despite implementation of the Every Woman Matters program to assist low-income women. The GAPS model was used to develop a practice-based intervention to identify and reduce barriers to delivery of breast and cervical cancer screening services. METHODS: Seven primary care practices actively participated in this multimethod case study. A research nurse collected data and facilitated the intervention process at each site. Qualitative data from field notes, patient encounters, and in-depth interviews of physicians and key informants were collected to describe the process of Papanicolaou and mammogram service delivery, and to identify barriers/facilitators to screening, and potential change areas. Chart reviews provided information regarding the preintervention and postintervention identification/execution of Papanicolaou smears and mammograms. Qualitative and quantitative analyses led to individual practice case studies. Cross case comparisons identified common themes. RESULTS: The individual practice plans for change had many commonalities, ie, developing screening databases and reminder systems. The biggest differences involved practice contexts. Despite use of the GAPS model and a financial incentive to obtain "buy in" from providers and staff, change was difficult for all but 2 of the practices. CONCLUSION: The complexity of practice context and its effect on change cannot be underestimated. Individual practice providers and staff are often unaware of the potential challenges, and unable/unwilling to overcome them.

Breast Neoplasms↗
PubMed2000

Microbicides 2000: report of an international conference, 13-16 March, Washington DC.

'Microbicide' is the name for a number of new products currently under research which could become a new class of barrier method for use in the vagina and rectum for protection against HIV, prevention and/or treatment of other sexually transmitted diseases and/or act as a contraceptive. This is a summary report of this scientific conference, at which basic science, clinical trial efficacy and design, and ethical, behavioural and public health issues were on the agenda. There are many potential products but few have yet got beyond Phase I clinical trials. There is not likely to be an approved and available product for 5-10 years at best; finding a balance of low toxicity with high efficacy is the major challenge, given how rapidly HIV infection actually infects tissue. Phase III clinical trials of these products require new protocols and procedures. It was urged by many, and underscored by HIV positive women who were present that clinical trials must be treated as an opportunity to promote a total prevention package--STD treatment, voluntary HIV testing and counselling, condom use, practising safer sex--plus microbicides and contraception. Identifying effective products and making them available as soon as possible were obviously also a priority. How to do this--ethically and scientifically--were the main subject of the meeting.

Administration, Rectal↗
PubMed2005

Pressing the key pad: trial of a novel approach to health promotion advice.

BACKGROUND: A relatively simple procedure, the Pap test, is effective in detecting early changes in the cervix; however, many at-risk women, even in developed countries, do not have regular Pap tests. METHODS: A randomized controlled trial of an interactive voice response (IVR) cervical screening brief advice involving 17,008 households is described. The IVR system automatically made calls to households and explained the nature of the call; selected one eligible woman aged 18-69 years; determined her screening status; delivered a message appropriate to her screening status; offered additional messages to counter common barriers; offered additional information on cervical screening and cancer; offered additional contact numbers; and offered to arrange for someone to call back. Cervical screening rate data were obtained from the Australian Health Insurance Commission (HIC) for 6 months before and following the intervention. RESULTS: The cervical screening rate was found to have increased by 0.43% in intervention compared to the control postcodes, and the increase was greater for older women at 1.34%. CONCLUSIONS: The overall conclusion was that IVR technology was a feasible means to contact women to deliver brief interventions aimed at increasing cervical screening rates and could economically target at-risk groups. The potential for linking IVR to centralized Pap test Registers to issue Pap test reminders should be explored.

Adolescent↗
PubMed1999

Cervical cancer screening knowledge, behaviors, and beliefs of Vietnamese women.

PURPOSE/OBJECTIVES: To describe the knowledge, beliefs, and practices of cervical cancer screening of Vietnamese women who have migrated to the United States. DESIGN: Exploratory, descriptive. SETTING: Five Vietnamese churches in southeastern Louisiana. SAMPLE: Nonprobability sample of 96 adult Vietnamese migrant women. METHODS: Data were collected by a bilingual nurse during face-to-face interviews conducted in the language preferred by the subjects (English or Vietnamese). MAIN RESEARCH VARIABLES: Cervical cancer screening knowledge, behaviors, and beliefs. FINDINGS: Three fourths of the Vietnamese women interviewed could not correctly explain what a Pap test is used for, and few were aware that the most commonly occurring cancer in Vietnamese females in the United States is cervical cancer. Most believed that their risk of cervical cancer was low. Less than half reported ever having had a Pap test and cited not having a gynecologist, cost, and fear of the test as reasons for not ever having had the test done. CONCLUSIONS: The number of Vietnamese women who adhere to cervical cancer screening guidelines is low. Cultural beliefs and structural barriers influence the choices that Vietnamese women make regarding Pap test utilization. IMPLICATIONS FOR NURSING PRACTICE: When planning programs to promote cervical cancer screening, nurses must target those at greatest risk--Vietnamese women. Culturally sensitive educational interventions and cervical cancer screening programs for Vietnamese women are needed to increase Pap test utilization and the early detection of cervical cancer.

Adolescent↗
PubMed2005

A double blind, randomized trial on augmentation of labour with a combination of intravenous propranolol and oxytocin versus oxytocin only.

OBJECTIVE: To compare the combination of intravenous propranolol and oxytocin with oxytocin only in augmentation of labour. STUDY DESIGN: A prospective randomized double-blind study in an obstetric department of a large university hospital in Finland. A total of 107 parturients with arrested first stage of labour owing to inadequate uterine contractility were randomized to receive intravenously once or twice a 2 mg dose of propranolol or placebo combined with oxytocin infusion. The main outcome measure was the effect of intravenous propranolol on the frequency of Caesarean section among parturients with arrested labour. The secondary outcome measures were the duration of labour, the required dosage of oxytocin, CTG readings, neonatal outcome and maternal and cord plasma levels of beta-adrenoceptor-binding component of propranolol. Categorial variables between the groups were compared using Chi square and Fisher's exact tests. Continuous variables were compared using the Mann-Whitney U-test and Student's t-test. RESULTS: No reduction in Caesarean section rate was found in the propranolol group. Seventy-three percent of the parturients in the propranolol group and 85% in the placebo group had spontaneous vaginal delivery, RR=0.86 (95% CI 0.70-1.05). The percentage proportion of the augmented part of labour was significantly shorter in the propranolol group than in the placebo group. No differences in the required oxytocin dosage or CTG pathology were found between the groups. Propranolol was found to be safe for the neonates. The concentrations of its beta-adrenoceptor-binding component after a 2mg intravenous dose were quite similar in parturients and neonates at the time of delivery. The active drug component crossed placental barriers with an average neonate umbilical artery/parturient venous plasma ratio of 0.7. After a 4 mg dose the active drug concentrations in parturients were rather similar to those measured after 2 mg dose, whereas in neonates there were signs of drug accumulation. No picture could be obtained from the kinetics of the beta-adrenoceptor-binding component of propranolol from the data. CONCLUSIONS: Propranolol (2 or 4 mg i.v.) combined with oxytocin, as treatment for arrested labour did not affect the Caesarean section rate compared with placebo plus oxytocin. The percentage proportion of the augmented part of labour was significantly shorter after propranolol. Propranolol was safe for the neonates and can be used as an additional medication among parturients with arrested labour.

Adult↗
PubMed2004

Self-report and primary care medical record documentation of mammography and Pap smear utilization among low-income women.

PURPOSE: To determine whether self-report of mammography and Pap smear utilization was accurate and to determine whether racial/ethnic differences existed. METHODS: Face-to-face surveys were administered to 314 consecutively selected women over 40 attending two low-income inner-city family practice sites. Medical records were reviewed for documentation of mammography and Pap smear utilization. Level of agreement between self-report and chart review was reported. Sensitivity, specificity, positive predictive value and negative predictive value were calculated. MAIN FINDINGS: Puerto Rican women had lower income levels and were less educated than African-American and non-Latina white women. Self-report of mammograms and Pap smears were higher than medical record documentation. Level of agreement was higher for more recent tests. Negative predictive values for mammography were high (75-95.5%). Lower sensitivity, specificity, positive predictive value and negative predictive value for mammography were seen among Puerto Rican women compared to African-American and non-Latina white women. CONCLUSIONS: High negative predictive values suggest that asking women about mammography use may be an inexpensive, easy intervention in the primary care setting to increase screening among women currently not being screened by increasing conversations between patients and providers to address personal barriers to screening.

Adult↗
PubMed2001

Attitudes to screening for cervical cancer: a population-based study in Sweden.

OBJECTIVES: To investigate how attitudes and beliefs about Pap smear screening affect women's choice to participate in organized or opportunistic screening. METHODS: Telephone interviews were conducted with 430 (69.0%) non-attenders and 514 (80.7%) attenders to Pap smear screening, sampled from a population-based database. The interviews were conducted during 1998 in Uppsala County, Sweden. MAIN OUTCOME MEASURE: odds ratios (OR) and 95% confidence intervals (CI). RESULTS: Non-attendance was negatively associated with perceived severity of cervical cancer compared to other malignancies (OR = 1.9, 95% CI 1.1-3.4) as well as with satisfactory benefits (OR = 0.7, 95% CI 0.6-0.8), but positively associated with time-consuming and economical barriers (OR = 1.2, 95% CI 1.1-1.5 and OR = 1.7, 95% CI 1.2-2.5, respectively). Non-attendance was also negatively associated with anxiety, but was of borderline significance (OR = 0.9, 95% CI 0.8-1.0). The results were strengthened with increasing time since last smear or if self-reported attendance status was used instead of true attendance. Non-attenders kept holding harder to their preferences than did attenders, stating they would not participate if their preferences were not met. CONCLUSIONS: Important differences in attitudes and beliefs exist between non-attenders and attenders in Pap smear screening. Rather than being emotional, the main barriers are either practical or rooted in misunderstandings and lack of relevant information. These insights offer opportunities to increase attendance rates considerably.

Adult↗
PubMed2005

Cervical cancer prevention in remote rural Nicaragua: a program evaluation.

BACKGROUND: Nicaragua has some of the highest rates of cervical cancer in Latin America and the world. In 2003, the Nicaraguan Ministry of Health, the Central American Institute of Health and the Maria Luisa Ortiz Clinic combined efforts to create an effective remote rural service network, with centralized quality-controlled cytology, and coordinated treatment. METHODS AND MATERIALS: Data was taken from the clinic Pap log, tracking records, patient charts, and pathology reports. Patients were stratified by age (25 and older, and under 25). Standard indicators addressing key components in the entire continuum of an effective screening program were adapted from suggestions by a work group of the Pan American Health Organization. RESULTS: A total of 2132 women received Pap screening. 68% (N = 1448) were 25 and older and 32% (N = 684) were under 25. The proportion of high-grade abnormal screens was 3.7% for women over 25 and 0.4% for women under 25. The proportion of women with high-grade abnormal results who received diagnostic work-up and needed treatment was 94% for women over 25 and 100% for women under 25. The proportion of high-grade squamous cell Pap tests resulting in histologically confirmed disease was 68%. The ratio of pre-invasive disease to invasive disease was 1.9. The invasive cancer detection rate was 0.62%. CONCLUSION: This program evaluation demonstrates that outreach to high-risk women, quality cytology screening and high rates of diagnostic follow-up and treatment can be conducted in remote, low-resource settings when coordinated efforts are made to remove barriers and ensure quality.

Adult↗
PubMed1989

Sex worker, client sex behaviour and condom use in Harare, Zimbabwe.

One-hundred sex workers and 100 clients were interviewed at a bar/disco complex in Harare, Zimbabwe in 1989. Sociodemographic characteristics of sex workers and clients were examined. Almost a third of sex workers and nearly 90% of clients had engaged in commercial sex over 5 or more years. Sex workers reported that they worked an average of 4.6 nights a week, averaged 2.2 clients a night and charged a mean of Z$8.7 per session and Z$19.8 per night. Clients reported that they averaged 7.4 visits a month to a sex worker and paid a mean of Z$6.2 per session and Z$17.2 per night. Over half the sex workers said their last client was drunk and nearly two-thirds said he was a repeat client. Sex workers and clients were asked about the sex behaviours completed in their last paid sex act. Vaginal intercourse was reported by 98% of sex workers and clients alike. Manual stimulation of the sex worker's and client's genitalia was reported by roughly 80% of sex workers and clients. Oral and anal sex were rarely reported. Fifty-four percent of sex workers and 44% of clients reported using a condom in their last paid sex act. Client reports thus suggest that sex worker reports of sex acts and condom use with the last client possess considerable validity. Ethnographic approaches were used to study the social and work environment of sex workers. Ethnographic analysis demonstrated a lack of organisation among sex workers and a need to develop cohesive groups for successful health interventions. The study also highlighted the need to include clients in health interventions, the possible role of alcohol as an impediment to health interventions and the feasibility of using bar/disco security and the bar personnel as health educators.

Adolescent↗
PubMed1999

Trichomonad invasion of the mucous layer requires adhesins, mucinases, and motility.

BACKGROUND/OBJECTIVE: Trichomonas vaginalis, the causal agent of trichomonosis, is a flagellated parasitic protozoan that colonises the epithelial cells of the human urogenital tract. The ability of T vaginalis to colonise this site is in part a function of its ability to circumvent a series of non-specific host defences including the mucous layer covering epithelial cells at the site of infection. Mucin, the framework molecule of mucus, forms a lattice structure that serves as a formidable physical barrier to microbial invasion. The mechanism by which trichomonads traverse the mucous covering is unknown. Proteolytic degradation of mucin, however, may provide for a mechanism to penetrate this layer. The goal, therefore, was to determine how trichomonads cross through a mucous layer. METHODS: Secreted trichomonad proteinases were analysed for mucinase activity by mucin substrate-sodium dodecyl sulphate-polyacrylamide gel electrophoresis. The importance of trichomonad mucinases for traversing the mucous layer was examined on an artificial mucin layer in invasion chambers. Adherence to mucin and tissue culture cells was measured using a microtitre plate assay. RESULTS: Trichomonad isolate 24402 secreted five proteinases when incubated in PBS. All five proteinases were shown to possess mucinase activity. These mucinases were able to degrade bovine submaxillary mucin and to a lesser extent porcine stomach mucin. These enzymes were active over a pH range of 4.5-7.0 and were inhibited with cysteine proteinase inhibitors. Furthermore, T vaginalis was shown to bind to mucin possibly via a lectin-like adhesin. Adherence to mucin was increased threefold when parasites were grown in iron deficient medium. Adherence to soluble mucin prevented attachment to HeLa cells. Proteinase activity, adherence, and motility were required for trichomonads to traverse a mucin layer in vitro. CONCLUSIONS: These results show that trichomonads can traverse the mucous barrier first by binding mucin followed by its proteolytic degradation. The data further underscore the importance of trichomonad proteinases in the pathogenesis of trichomonosis. Finally, this study suggests that interference with trichomonad mucin receptors and proteinases may be a strategy to prevent colonisation by this parasite.

Animals↗
PubMed2000

Effects of social support, regular physician and health-related attitudes on cervical cancer screening in an Asian population.

OBJECTIVE: Out primary objective was to examine sociodemographic and attitudinal factors that affect uptake of the Pap smear in a multi-ethnic Asian population. METHODS: We conducted a prevalence survey among women aged 50-64 years living in Singapore and ascertained by means of an in-person questionnaire interview their Pap screening history, demographic characteristics, informal social support and attitudes towards early detection. RESULTS: We found that, after adjusting for demographic variables known to be predictors of Pap screening, women who reported ever having a Pap smear were more likely to have close friends with whom they could discuss health (adjusted odds ratio (OR) 2.1, 95% confidence intervals (CI) 1.2-3.6), and have a regular physician (adjusted OR 2.3 (1.3-4.1)). Based on responses to four indices measuring health attitudes, they were significantly less likely to express a fatalistic viewpoint towards health and illness (adjusted OR for highest vs. lowest tertile 0.3 (95% CI 0.1-0.7)), and more likely to believe that early detection could improve the outcome (adjusted OR 3.3 (95% CI 1.4-7.8)). The nature of the test itself was a significant barrier to having a Pap smear, but only among women with fewer years of education. CONCLUSIONS: Our results suggest that, within this Asian population, a multi-pronged approach is required to reach unscreened women. The role of physicians and close friends should be emphasized, and health messages should be formulated to address specific, relevant attitudinal barriers to Pap screening.

Aged↗