Knowledge,Attitudes and Practices about the Pap Smear among Medical Workers in Naresuan University Hospital

Background: Cervical cancer, very common in females of the developing world, has a long premalignantperiod. Primary and secondary prevention can reduce the incidence. The Pap smear is the main screening modalityin Thailand but the coverage is rather poor. Objective: This study was performed to evaluate the knowledge,attitudes and practices of medical workers in Naresuan university hospital who met the WHO guidelines forscreening. Methods: A questionnaire covering general characteristics, knowledge, attitudes and practices aboutcervical cancer screening was administered and the data obtained were analyzed with SPSS version 16. Results:The majority of the 78 included participants were nurses with an education mostly more than diploma level.Knowledge about the importance of the Pap smear, early detection and the treatment of early stage cervicalcancer was adequate (90.9 % and 81.6%, respectively) but awarness of cervical cancer risk factors was quitelow. The most frequent reasons for avoiding Pap smear screening were fear of vaginal examination (27.6%),embarrassment (26.3%), lack of any symptoms (22.4%) and being busy (17%). Conclusion: The Pap smear isappropriate for detection of premalignant lesions of cervical cancer in Thailand but the coverage is still low.Although this study was performed with medical workers, their compliance with screening recommendationswas still low. If we can improve the knowledge and attitudes about Pap smear cervical cancer screening insuch experts, they should be able to readily provide appropriate and accurate information to the population tomotivate the general population to join screening programs.     

A Comparison of Cytology with Pap Smears Taken by a Gynecologist and with a Self-sampling Device

Cervical cancer is the most common cancer in Thai women and as yet screening programmes are minimally ‍effective. The Pap smear is the test accepted to be most appropriate for cervical cancer screening so far. One of the ‍main reasons why women do not come to have Pap smear done is “shyness”, which weakens compliance with ‍recommendations to undergo Pap smear with pelvic examination. The self-administered device by the Kato method ‍was established to overcome this problem and the present study was carried out to confirm the adequacy of the ‍specimens obtained with this technique in comparison with specimens collected by gynecologists. Two hundred ‍women were invited to participate in the study voluntarily. Each was allocated to have a Pap smear conducted by a ‍gynecologist and then instructed to produce a self-obtained smear using Kato’s device. The cytology results of Pap ‍smears from both methods were compared to test for agreement using Kappa statistics. ‍There was agreement between the adequacy of smears collected by gynecologists and those self-sampled with the ‍percentage agreement of 96.5% and a Kappa score of 0.43 (95% CI 0.33-0.54, P<0.001). There were 8 cases detected ‍as epithelial cell abnormalities from the cervical cells collected by gynecologists and also with the self-administered ‍technique. Good agreement for detection of cellular changes was found with a percentage of 78.0% and the Kappa’s ‍score was 0.61 (95% CI 0.46-0.76, P<0.001). The results from this study provide convincing evidence that the selfadministered ‍device can be an alternative choice for women who are too shy to undergo pelvic examination or even ‍for those who have limited time to visit health care centers or doctors to have a Pap smear test.     

Comparison of Pap Smear Screening Results between Akha Hill Tribe and Urban Women in Chiang Rai Province,Thailand

Cervical cancer is an important woman’s health problems worldwide, especially in low socio-economiccountries. The aim of this study was to compare the Pap smear screening results between Akha hill tribe andurban women who live in Chiang Rai province, Thailand. Screening was conducted for 1,100 Akha women and1,100 urban women who came to have the Pap smear at Chiangrai Prachanukroh Hospital and 1 private cytologylaboratory from January to June 2008. The demographic characteristics and factors related to abnormal Pap􀁖􀁐􀁈􀁄􀁕􀁖􀀃􀁒􀁉􀀃􀁗􀁋􀁈􀁖􀁈􀀃􀁚􀁒􀁐􀁈􀁑􀀃􀁚􀁈􀁕􀁈􀀃􀁊􀁄􀁗􀁋􀁈􀁕􀁈􀁇􀀃􀁘􀁖􀁌􀁑􀁊􀀃􀁆􀁏􀁒􀁖􀁈􀁇􀀃􀁐􀁒􀁇􀁈􀁏􀀃􀁔􀁘􀁈􀁖􀁗􀁌􀁒􀁑􀁑􀁄􀁌􀁕􀁈􀁖􀀑􀀃􀀤􀁅􀁑􀁒􀁕􀁐􀁄􀁏􀀃􀀳􀁄􀁓􀀃􀁖􀁐􀁈􀁄􀁕􀁖􀀃􀁚􀁈􀁕􀁈􀀃􀁇􀁈􀃀􀁑􀁈􀁇􀀃according to the Bethesda 2001 system. The results showed that the prevalence of abnormal Pap smears was12.2% in Akha women and 4.5% in urban women. The highest prevalence of Pap abnormalities was found inthe 41-50 years age group in both populations (4.5% in Akha and 1.7% in urban women). In both populations,abnormal Pap smears were found in <21 years age groups. From the questionnaires, the possible risk factors  related to the higher prevalence of abnormal pap amears in Akha woman wrew early age at marriage(17 years), high frequency pregnacies and high parity and no/low education level. In conclusion, cervical cancer control by education and early detection by Pap smear screening is necessary for hill tribe women. More Pap smear screening service units should be set to improve the coverage for the risk group women who got married in young age, especial in ethnic groups.     

Probability of early repeat Pap smear in an integrated cervical screening programme.

The integration of routine Pap smear practice based on self-referral into an organized programme based on personal invitation is the recommended approach to cervical cancer screening. In this study, the cytology archive of the integrated cervical screening programme implemented in the Faenza district (northern Italy) was used to compare the population of women responding to invitation with that of self-referred women for the cumulative probability of early (< 36 months) repeat Pap smear after a negative result. Between 1995 and 1998, women aged 25-64 living in five municipalities of the district were targeted by the first round of the programme. Eligible for the study were 2356 women responding to invitation for screening and 2221 women not invited because of self-referral for Pap smear at any other setting. The probability of early repeat Pap smear was estimated by the life table method. Differences were evaluated by the Gehan test. Multivariate determinants were assessed by the Cox regression analysis. At 36 months' follow-up, the cumulative probability of early repeat Pap smear was 44% among self-referred women and 6% among women responding to invitation (relative hazard = 4.8). For self-referred women, the probability was related to age (with a peak at 35-44 years), previous Pap smear history and municipality of residence. Among women responding to invitation, only an inverse association with age was demonstrated. In conclusion, the observed differences in overall probability and determinants of early repeat Pap smear between the two screening populations provided important information on Pap smear usage in the total target population.     

Monitoring and evaluation of a model demonstration project for the control of cervical cancer in Nakhon Phanom province, Thailand

Cancer of the uterine cervix is the second most common cancer in females in the world with about half a million new patients per year. Since the introduction by Papanicolaou of cervical smear screening, the incidence of cervical cancer has declined in many developed countries. The decrease in the incidence of and mortality from cervical cancer is mainly due to the organized mass screening using Pap smear programmes. Uterine cervical cancer is the leading cancer among women in Thailand with age-standardized incidence rates of 24.7 per 100,000 in 1999. Most cases present at advanced stages with poor prognoses of survival and cure. In the present study, cervical cancer screening programme with cervical cytology was organized for Nakhon Phanom province, Thailand. The specific objectives were: 1) to evaluate the reduction in incidence and mortality from cervical cancer in the province by means of an organised low-intensity cervical cytology programme. 2) to demonstrate the different aspects of programme implementation as a potential model for nationwide implementation. The screening activities were integrated in the existing health care system. Organized screening for women in the target population (aged 35-54 years) at 5-year intervals was free of charge. Sample taking was done by trained nurses (midwives) and primary health care personnel in the local health care centers. Sample quality was under continuous controlled by the cytology laboratories and pathologists. Confirmation and treatment were integrated into the normal health care routines. The screening results of the programme, including histologically confirmed diagnosis, were registered at the National Cancer Institute using PapReg and CanReg 4 programmes. A population-based cancer registry in Nakhon Phanom province was also set up in 1997. In the period 1999-2002, 32,632 women aged 35-54 years were screened. Women with low-grade lesions returned for routine follow-up smears. High-grade preinvasive disease was further evaluated by repeating Pap smear, conization or biopsy and subsequent treatment through surgical removal or ablation. This organized low-intensity cervical cytology programme showed a considerable increase in early carcinoma in situ and CIN II -III cases and should reduce incidence of and mortality from cervical cancer in Nakhon Phanom province in the future. Screening with the Papanicolaou smear plus adequate follow-up diagnosis and therapy can achieve major reductions in both incidence and mortality rates.     

Situation Analysis for Management of Abnormal Pap Smears in the Lower Southern Thailand

Objective: To identify the resources for management of abnormal Pap smears and the treatment facilities in preinvasive ‍cervical neoplasia in the lower southern Thailand. Methods: After reviewing the necessary data, an expert ‍meeting was scheduled for questionnaire development. The questionnaires were then sent to the general, regional, ‍and university hospitals in the lower southern Thailand for self-evaluation and on-site visits were made for intensive ‍interviews, exploring the services and treatment facilities for women with abnormal Pap smears. Results: All of the ‍12 target hospitals provided passive cervical cancer screening although the quality of cytological services was obscure ‍and the process of patient notification for the results of the abnormal Pap smears was not convincing. There was a ‍limitation in the pathological laboratory services. The incidence of the abnormal Pap smears in the one-year period ‍of the study, defined as atypical squamous cells of undetermined significance (ASCUS) or above and high grade ‍squamous intraepithelial lesions (HSIL) or above were 1.24%(95%CI 1.15-1.32) and 0.36%(95% CI 0.30-0.43) ‍respectively. All but one hospital reported having a colposcope, but only one could provide standard colposcopy ‍services. The efficiency of the referral system is questionable. Conclusion: The resources for the management of ‍abnormal Pap smears as well as the conventional referral system need to be reorganized. The data from this survey ‍support the concept of a centralized colposcopy service with the University hospital as suitable place for the referral ‍center. Two further 2 hospitals have potential for future development as referral centers.     

Epidemiologic report of gynecologic cancer in Thailand

Cancer has been the most common cause of death in Thailand from 2002 (65.4/100,000/year in 2002). With regard to leading cancers in Thailand for female population, the highest incidence falls into cervical cancer (25/100,000/year) followed by breast, liver and bile duct, bronchus and lung, colon and rectum, and ovarian cancer. In 2003, there were 6,243 new cases of cervical cancer with the death of 2,620 women. Therefore, in Thailand, seven women die from cervical cancer each day. However, the incidence of cervical cancer in Thailand is decreasing. The important factor contributed to this decreasing is the implement of Thailand dual-track strategy cervical screening program using both Pap smear and visual inspection with acetic acid (VIA)-cryotherapy. Learning about the epidemiologic data of gynecologic cancer could raise public awareness and play a part in establishing measures for prevention, control and treatment of the cancer which will contribute to the better health of women, and of course, decrease the expense used in various modalities of treatment.     

Prevalence and Risk Assessment of Cervical Cancer Screening by Papanicolaou Smear and Visual Inspection with Acetic acid of Pregnant Women at a Thai Provincial Hospital

Background Cervical cancer is the second most common in Thailand, but the mortality rate may be rising yearly. It is a cancer that can be prevented by early screening for precancerous lesions, several methods being available. Objective To identify the prevalence of abnormal Papanicolaou (Pap) smears and lesions with visual inspection with acetic acid (VIA) in pregnant women and assess risk factors for this group. Materials and Methods This prospective study was performed at Prapokklao Hospital, Thailand during April-July 2016. All pregnant women of gestational age between 12-36 weeks who attended antenatal clinic were recruited. All participants were screened for cervical cancer by Pap smear and VIA. If results of one or both were abnormal, colposcopic examination was evaluated by gynecologic oncologist. Results A total of 414 pregnant women were recruited. Prevalence of abnormal Pap smear and VIA were 6.0 and 6.7 percent, respectively. The most common abnormal Pap smear was low grade intraepithelial lesion (LSIL, 44%). Factor associated with abnormal Pap smear in pregnant women were low BMI, multiple partners and government officer. In pregnancy, Pap smear had higher sensitivity and specificity than VIA for detection of precancerous cervical lesion. Patients with young coitarche or more than 25 years of active sexual activity were high risk groups. Conclusions Prevalence of abnormal Pap smear and VIA in pregnant women was 6.0 and 6.7 percent, respectively. Factors associated with abnormal Pap smear were coitarche, years of sexual activity, low BMI, multiple partners and government officer.     

National Cervical Cancer Screening in Thailand

Background: Cervical cancer is an important public health problem in Thailand. It was the most common cancer in Thai women with the incidence rate of 23.4 per 100,000 women in 1990. Objective: The aim of this study was to share the experiences and summary the outcome of cervical cancer screening program in Thailand. Methods: The Ministry of Public Health in cooperation with the National Health Security Office, launched the National Cervical Cancer Screening Program, covering 76 provinces nationwide under Universal Coverage Scheme in 2005. The screening method are Pap smear and Visual Inspection with Acetic acid (VIA) for women aged 30-60 and 35-45 respectively with a 5-year screening interval. Detecting cervical pre-cancerous lesions will follow by day care treatment such as cryotherapy, Loop Electrosurgical Excision Procedure, etc. Results: The first phase (2005-2009), was carried out on 3,124,855 women, the coverage reached 77.5%. For the second phase (2010-2014), 7,637,226 women were screened, reaching 53.9% coverage of target women. However, we have few data of follow up examination after abnormal screening. Therefore, we conducted new system to get more follow up data in 2019. Under the coordination of many related partners, 10,762,081 women have been screened during 2005-2014. The incidence rate declined to 11.7 per 100,000 women which is ranked as the third most common in women in 2014. Conclusion: This article briefly reviews the challenge of implementing an efficient cervical cancer screening in Thailand. In 2020, HPV testing has been introduced as a primary screening test for all Thai women attending public health sector instead of conventional Pap test.     

Cervical cancer in Latin America

Cervical cancer is a common cause of morbidity and mortality in developing countries. In Latin America, the incidence rates in several cities are among the highest worldwide, probably due to a high frequency of risk factors and/or a low screening coverage for cervical cancer. Epidemiologic studies conducted in Latin America (and some in the Caribbean), that have investigated the main risk factors for the disease, as well as screening coverage by Papanicolaou (Pap) smear, were reviewed. The prevalence of human papillomavirus (HPV) infection among women with negative Pap smears does not seem to explain the risk observed in Latin American countries. Results of some studies have suggested that reproductive factors and male sexual behavior might be responsible, at least partially, for the high occurrence of cervical cancer in Latin America. Concerning cytology screening, many women have a smear taken regularly (some every year). However, a significant proportion of women, probably those with a high risk of cancer of the cervix, have never had a Pap test. To reduce cervical cancer in these countries, screening programs in Latin America should have a wider coverage, especially reaching those women at higher risk. Semin Oncol 28:188-197.     

Efficacy of a Training Course Given by Midwives Concerning Cervical Cancer Risk Factors and Prevention

Background: Cervical cancer is the second most common cancer type seen among women in most countriesand an important cause of mortality. Although it is a preventable disease, most women living in developingcountries cannot reach effective screening programs. It is essential that appropriate education about cervicalcancer is provided. Objective: This experimental field study was performed with the aim of evaluating theefficacy of training given to women about cervical cancer risk factors and primary and secondary preventionprecautions. Methods: The research focused on women between 25 and 29 years of age, literate, married andhaving social security. The study was conducted in the district of Evka 4 Health Care Center between the datesof April to August 2005. The women were given survey forms and questionnaires in order to determine theirsocio-demographic features and knowledge level about cervical cancer in the course of home visits. They weretrained and given a manual at the data collection stage. At a second visit, carried out three months later, thetrained women were again evaluated for their knowledge level about cervical cancer, risk factors and whetherthey had undergone a Pap smear test. Results: Together with the difference between pre-/post-training meaninformation scores related to women’s cervical cancer risk factors, the difference between the women’s havinga Pap smear test in the pre-/post-training period was found statistically significant. Only 16.3% of the womenstated that they had a Pap smear test in the post-training period. Conclusions: It was determined that thewomen were in need of knowledge about risk factors related to cervical cancer, prevention from and earlydiagnosis of cervical cancer, but there was no significant increase in the rate of having a Pap smear test despitethe increase in the knowledge level with the training given.     

Attitudes and Practice of Cervical Cancer Screening among Female University Students from 25 Low,Middle Income and Emerging Economy Countries

Cervical cancer, the third commonest cancer in women worldwide, can be prevented through early detection by cervical screening (Pap smear). The aim of this study was to investigate the attitudes and practice of cervical cancer screening among female undergraduate university students from 25 low, middle income and emerging economy countries. Using anonymous questionnaires, data were collected from 9,194 female undergraduate university students aged 18-26 years (mean age 20.9, SD=2.0) from 26 universities in 25 countries across Asia,Africa and the Americas. Overall, 11.6% of the female students indicated that they had conducted one or more times a cervical (Pap) smear test; 8.3% among 18-20 year-olds and 15.6% among 21-26 year-old students. There was considerable country variation on having had a cervical (Pap) smear test among 21-26 year-old female university students, ranging from 59.2% in Colombia and 50.9% in Barbados to 0% in India and 1.0% in Tunesia. Logistic regression showed that cervical cancer screening importance or positive attitude were highly associatedwith the cervical screening practice. Moreover, risky sexual behaviour and tobacco use, two cervical cancer risk factors, were associated with screening. Cervical cancer screening practices were found to be inadequate and efforts should be made to develop programmes that can increase the uptake of cervical cancer screening.     

Present standards for cervical cancer screening

Survival rates for cancer of the uterine cervix have improved over the last 40 years largely because of the impact of screening measures such as the Pap smear. The ability to screen and treat women for preinvasive disease, cervical dysplasia, is the key factor leading to the reduction in the incidence of invasive cervical cancer. More recently, the ability to test women for the causative agent, the human papilloma virus, has emerged as a potential screening tool. New research has focused on new technologies for Pap smear screening such as thin layer technology, the appropriate intervals for screening, and the appropriate methods of incorporation of human papilloma virus testing into the screening protocols. Reviews of published studies evaluating the efficacy of new technologies suggest that there is still insufficient information to confirm improved outcome; however, results to date suggest that thin layer Pap smear technology may improve sensitivity in the detection of cervical dysplasia. Automated rescreening technologies in use may decrease the number of false-negative Pap smears and are an option for laboratories. Various professional groups and countries have differing recommendations on the interval for screening, primarily on the basis of cost-effectiveness. Some of the most important new information this year regarding cervical cancer screening includes the new Bethesda System for the reporting of Pap smears and the new guidelines for the management of the abnormal Pap smear by the American Society of Colposcopy and Cervical Pathology. These guidelines incorporate human papilloma virus testing based on a multicenter trial documenting its efficacy in the triage of women with atypical squamous cells on Pap smear. These recommendations are reviewed along with the current literature on cervical cancer screening.     

Accuracy of Visual Inspection with Acetic Acid (VIA) for Early Detection of Cervical Dysplasia in Tehran,Iran

Objective: To evaluate the accuracy of visual inspection with 5% acetic acid (VIA) when used to detect cervical ‍cancer and its precursors. ‍Methods: The study population included women attended Family Planning and Gynecological Clinic in Bagher ‍Abad Health Center and Mirza Koochak Khan Hospital for regular cervical screening tests. After obtaining informed ‍consent from each woman, VIA was performed. One hundred with a positive VIA test and 100 women with a ‍negative VIA test were randomly selected for this study. Cytology and colposcopy examination were performed for ‍all 200 cases and cervical biopsies were conducted for those individuals showing abnormal colposcopic findings. ‍Results: Nine cases in VIA-positive group and two cases in VIA-negative group had an abnormal cytology. Ninety ‍five women in the VIA-positive group and 25 in the VIA-negative group had abnormal colposcopic findings. From ‍biopsy examination, 67 (71%) of cases in the VIA-positive group and 3 (12%) cases in the VIA-negative group had ‍a final diagnosis of dysplasia. Among biopsied samples, only 7 cases of VIA-positive group showed abnormal result ‍and the remaining were normal. Based on these results, VIA test sensitivity and specificity were 95.7% and 44.0% ‍respectively, while they were 10% and 92% for cytology tests. ‍Conclusions: The results of this study indicate that although VIA is a sensitive screening test for detection of ‍cervical dysplasia, it can not be used by itself. Applying VIA along with Pap smears helps to detect a higher number ‍of cases with cancer precursor lesions.     

Knowledge,Attitudes and Practices of Sudanese Women Regarding the Pap Smear Test and Cervical Cancer

Background: Despite the established role of the Pap smear test (PST) in prevention and early detection of cervical cancer, it is still rarely practiced in Sudan. Many challenges hinder the establishment of an effective cervical cancer screening program, including socio-cultural factors. Therefore, this study aimed to investigate the knowledge, attitudes and practices (KAP) of Sudanese women with regard to the Pap smear test and cervical cancer. Materials and Methods: A total of 500 married women aged 14 to 58 years were recruited from obstetric clinics, hospitals and universities in Khartoum in 2014. Data were collected using a standardized, pretested questionnaire that inquired socio-demographic characteristics and their KAP about cervical cancer and the PST. Results: More than 52% of participating women were above 30 years of age, and the majority (78.8%) were university degree holders. A total of 486 (97.2 %) of participants were resident in urban areas of Khartoum State. However about 48% of the respondents had never heard about PST, and only 15.8% of the participants had undergone a Pap smear test previously; 46.6% (233/500) knew that the human papilloma virus (HPV) was the causative agent, but only 39.2% (196/500) had heard about HPV vaccination, and only 11.4% (57/500) had received the vaccine. However 68% of the respondents agreed to do Pap smear if properly informed about the test and 75.4% of the respondents agreed to participate in a cervical cancer screening program. Conclusions: Despite a high educational level, less than half of our participants had accurate knowledge about cervical cancer, HPV, and cervical cancer screening. Health education about cervical cancer, HPV and sexually transmitted infections and the role of PST in cervical cancer prevention are crucial when designing interventions aimed at improving cervical cancer screening for Sudanese women.     

Is it Relevant to Screen Women Younger than 26 Years for Precancerous and Malignant Cervical Lesions ?

Cervical cancer is a serious health problem and most of the cases occur in less developed countries where effective ‍screening systems are lacking. The aim of our present study is to delineate the age for early detection of precancerous ‍cervical lesions. Cervical smears were screened (Pap test) over a period of four and half years from January 2000 to ‍June 2004. The pattern of lesions was found to be almost same among the age groups of 26 to 35 years and 36 to 45 ‍years. This result tempted us to think that detection of cervical lesions at an early age younger than 26 years may be ‍an important step forward towards complete cure.     

Effective cervical cytology screening programmes in middle-income countries: the Chilean experience

OBJECTIVE: To demonstrate that an effective cervical cancer screening programme based on the Papanicolaou (Pap) smear can be organized in a middle-income country, such as Chile. METHODS: The cervical cytology screening programme in Chile is evaluated by comparing process measures and cervical cancer mortality before and after its reorganization in 1987. FINDINGS: Two decades of opportunistic annual screening for cervical cancer from the mid-1960s to the mid-1980s did not reduce cervical cancer mortality in Chile. In 1987, a public health oriented program was launched, based on screening women aged 25-64 every 3 years, rather than the annual screening of low risk women attending family planning clinics that gathered mainly women less than 25 years of age. The reoriented program emphasized the optimization of existing resources, the timeliness of diagnosis and treatment, reliability of the Pap smear and low cost screening promotion strategies at the community level. More than 80% of women with abnormal Pap smears received prompt medical attention and 100% of the public laboratories were subject to external quality control. According to biannual national surveys, coverage by Pap smear screening in the target group rose from 40% in 1990 to 66% in 1996. The age adjusted cervical cancer mortality rate decreased from 12.8 in 1980 to 6.8 per 100,000 women in 2001. CONCLUSIONS: Improved organization of the national cervical cancer screening programme in Chile and more efficient use of existing resources resulted in a decrease of cervical cancer mortality.     

Cervical cancer epidemiology in Friuli Venezia Giulia

AIMS AND BACKGROUND: Until 1998 there was opportunistic screening in Friuli Venezia Giulia (FVG). Beginning in 1999, formal screening efforts were organized. The regional cancer registry was established in 1998, and data on incidence was collected for the period 1995-98. The scope of this study is to provide baseline data on the incidence of invasive cervical cancer in FVG for further examination of trends in incidence and of the effectiveness of screening efforts. METHODS: Data from the regional cancer registry database was examined and linked with data from the regional pap smear screening database. RESULTS: The incidence of cervical cancer in FVG was 8.6 per 100,000. Most women were diagnosed in stages I and II. Most cervical cancers (80%) were squamous cell. Opportunistic screening in FVG reached 39.8% of the total female population. Analysis by local health unit showed heterogeneous data. CONCLUSIONS: FVG has one of the highest incidence rates of cervical cancer in Italy. Approximately 1/3 of the diagnoses were in women over the age of 65. Pap smear screening prior to the formal program covered a low percentage of the female population. Screening efforts in the future should focus on screening coverage in the older female population.     

Effects of Group Counseling Based on Health Belief Model on Cervical Cancer Screening Beliefs and Performance of Rural Women in Kaboudrahang,Iran

Objective: Pap smear test is an appropriate screening method for early diagnosis of cervical cancer and reduction of mortality. This study targeted effects of group counseling based on the Health Belief Model on cervical cancer screening practices of Iranian rural women. Method: This quasi-experimental study was conducted on 80 rural women under coverage of the health care centers in rural areas in the city of Kabudrahang, Iran, in 2015. The data collection tool was a researcher-made questionnaire covering demographic information, Health Belief Model (HBM) constructs and screening performance. Data were collected using a multi-stage sampling method. Group counseling was conducted based on the Health Belief Model and the GATHER steps in three sessions for the intervention group. Counseling included an introduction to cervical cancer, disease symptoms, warning signs and prevention approaches. Pap smear testing in both intervention and control groups was evaluated two months after the group counseling. Results: Before the intervention, there was no significant difference between both groups in the HBM constructs and performance. After the intervention, a significant difference was seen in the perceived susceptibility (P<0.001), severity (P=006), benefits (P=012), barriers (P<0.001), and self-efficacy (P=002). Two months after the intervention, 17 patients (42.5%) in the intervention group, and 4 patients (10%) in the control group had undergone a Pap smear test (P<0.001). Conclusion: Design and implementation of counseling programs based on the HBM can modify the beliefs of rural women regarding cervical cancer screening and increase their performance.     

Cost-Effectiveness of HPV Vaccination in the Prevention of Cervical Cancer in Malaysia

Introduction: Cervical cancers (CC) demonstrate the second highest incidence of female cancers in Malaysia.The costs of chronic management have a high impact on nation’s health cost and patient’s quality of life that canbe avoided by better screening and HPV vaccination. Methodology: Respondents were interviewed from sixpublic Gynecology-Oncology hospitals. Methods include experts’ panel discussions to estimate treatment costsby severity and direct interviews with respondents using costing and SF-36 quality of life (QOL) questionnaires.Three options were compared i.e. screening via Pap smear; quadrivalent HPV Vaccination and combined strategy(screening plus vaccination). Scenario based sensitivity analysis using screening population coverage (40-80%)and costs of vaccine (RM 300-400/dose) were calculated. Results: 502 cervical pre invasive and invasive cervicalcancer (ICC) patients participated in the study. Mean age was 53.3 ± 11.21 years, educated till secondary level(39.39%), Malays (44.19%) and married for 27.73 ± 12.12 years. Life expectancy gained from vaccination is13.04 years and average Quality Adjusted Life Years saved (QALYs) is 24.4 in vaccinated vs 6.29 in unvaccinated.Cost/QALYs for Pap smear at base case is RM 1,214.96/QALYs and RM 1,100.01 at increased screening coverage;for HPV Vaccination base case is at RM 35,346.79 and RM 46,530.08 when vaccination price is higher. Incombined strategy, base case is RM 11,289.58; RM 7,712.74 at best case and RM 14,590.37 at worst case scenario.Incremental cost-effectiveness ratio (ICER) showed that screening at 70% coverage or higher is highly costeffective at RM 946.74 per QALYs saved and this is followed by combined strategy at RM 35,346.67 per QALYssaved. Conclusion: Vaccination increase life expectancy with better QOL of women when cancer can be avoided.Cost effective strategies will include increasing the Pap smear coverage to 70% or higher. Since feasibility andlong term screening adherence is doubtful among Malaysian women, vaccination of young women is a more costeffective strategy against cervical cancers.