Perceived Susceptibility,and Cervical Cancer Screening Benefits and Barriers in Malaysian Women Visiting Outpatient Clinics

Aims: A main reason for increasing incidence of cervical cancer worldwide is the lack of regular cervicalcancer screening. Coverage and uptake remain major challenges and it is crucial to determine the perceivedsusceptibility to cervical cancer, as well as the benefits of, and barriers to, cervical cancer screening among women.Materials and Methods: A cross-sectional survey was conducted among 369 women attending an outpatient centrein Malaysia and data were collected by administering a self-report questionnaire. Results: The majority of theparticipants (265, 71.8%) showed good level of perception of their susceptibility to cervical cancer. Almost allresponded positively to four statements about the perceived benefits of cervical cancer screening (agree, 23.1% orstrongly agree, 52.5%), whereas negative responses were received from most of the participants (agree, 29.9%orstrongly agree, 14.6 %) about the eleven statements on perceived barriers. Significant associations were observedbetween age and perceived susceptibility(x2=9.030, p=0.029); between employment status (p<0.001) as well asethnicity and perceived benefits (p<0.05 [P=0.003]); and between education and perceived barriers to cervicalcancer screening (p<0.001). Conclusions: Perceived susceptibility, including knowledge levels and personal riskassessment, should be emphasized through education and awareness campaigns to improve uptake of cervicalcancer screening in Malaysia.     

Screening and Perceived Severity of Cervical Cancer among Women Attending Mahalapye District Hospital,Botswana

Objectives: The objectives of the study were to describe women’s perceived severity to cervical cancer andits associations with socio-demographic characteristics. Methods: A cross-sectional study was conducted by aquestionnaire survey with a total of 300 participants selected by convenience sampling techniques. Results: Theparticipants’ mean age was 37years (SD=11) and the cervical cancer screening rate was 39%. Most of the womenwere sure about the severity of cancer as they responded mostly agreeing or strongly agreeing with statementsabout severity of cervical cancer. The range of average responses was 2.58 to 3.56. When the ever screened andthe never screened for cervical cancer was compared, it was observed that both groups equally believed thatthere is effective treatment for cervical cancer, and that cervical cancer makes a woman’s life difficult. Overall,60% of the never screened had low perceived severity while 33% of the screened had high perceived severity tocervical cancer. There was no significant association between perceived severity and screening for cervical cancer(c2 = 1.0795; p = 0.2988). Monthly income (c2=13.077; p<0001) and residential area (c2=15.457; p=0.004) weresignificantly associated with perceived severity. Conclusion: The screening rate is still far too low compared tothe national target of greater than 75%. Therefore, despite awareness of the perceived severity of cervical cancer,the reasons why at risk women fail to participate in cervical cancer screening need to be adequately explored.     

Understanding Barriers and Facilitators of Breast and Cervical Cancer Screening among Singapore Women: A Qualitative Approach

Objective: The uptake of breast and cervical cancer screening services among women in Singapore remains inadequate. Little is known about how gender norms influence women’s decision to undergo these screening services in a multi-ethnic Asian context. This research aimed to explore how gender-based qualitative factors influence women’s decision to screen. Methods: Qualitative data were collected using semi-structured interviews from 40 racially diverse women aged 25 and above who had visited polyclinics for their chronic disease management. Women were recruited using a purposive maximum variation sampling strategy to ensure representation of their views from the three major ethnic groups and based on inclusion criteria. Interviews were conducted either face-to-face or via telephone call. Interviews were audiotaped and lasted 30 minutes on average. Interviews were conducted until data saturation was reached. The data was transcribed and analysed thematically. Results: Gender norms and gender non-concordance with the healthcare professionals did not inhibit women from undergoing breast and cervical cancer screening services to a large extent. Women were empowered and had a central role in decision-making for screening services. Healthcare initiatives such as subsidies and mobile health applications facilitated the uptake of breast and cervical cancer screening services but can be improved further. Some of the barriers reported by Malay Muslims were not dissimilar to previous qualitative studies with women in this ethnic and religious group. Conclusion: Gender socialisation, empowerment, and healthcare initiatives did not inhibit our study participants’ decision to undergo breast and cervical cancer screening services. However, new initiatives and strengthening of the existing healthcare initiatives are needed to overcome any remnants of gender-related nuances and convert non-doers into doers.     

Barriers to Cervical Cancer and Breast Cancer Screening Uptake in Low-Income and Middle-Income Countries: A Systematic Review

Background: Cervical cancer (CCa) and breast cancer (BCa) are the two leading cancers in women worldwide. Early detection and education to promote early diagnosis and screening of CCa and BCa greatly increases the chances for successful treatment and survival. Screening uptake for CCa and BCa in low and middle - income countries (LMICs) is low, and is consequently failing to prevent these diseases. We conducted a systematic review to identify the key barriers to CCa and BCa screening in women in LMICs. Methods: We performed a systematic literature search using Ovid MEDLINE, EMBASE, PsycINFO, SCOPUS, CINHAL Plus, and Google scholar to retrieve all English language studies from inception to 2015. This review was done in accordance with the PRISMA-P guidelines. Results: 53 eligible studies, 31 CCa screening studies and 22 BCa screening studies, provided information on 81,210 participants. We found fewer studies in low-income and lower - middle - income countries than in upper - middle - income countries. Lack of knowledge about CCa and BCa, and understanding of the role of screening were the key barriers to CCa and BCa screening in LMICs. Factors that are opportunities for knowledge acquisition, such as level of education, urban living, employment outside the home, facilitated CCa and BCa screening uptake in women in LMICs. Conclusions: Improvements to CCa and BCa screening uptake in LMICs must be accompanied by educational interventions which aim to improve knowledge and understanding of CCa and BCa and screening to asymptomatic women. It is imperative for governments and health policy makers in LMICs to implement screening programmes, including educational interventions, to ensure the prevention and early detection of women with CCa and BCa. These programmes and policies will be an integral part of a comprehensive population-based CCa and BCa control framework in LMICs.     

Perceived Benefits of Cervical Cancer Screening among Women Attending Mahalapye District Hospital,Botswana

Objectives: The objectives of the study were to describe women’s perceived benefits regarding cervical cancer and their association with socio-demographic characteristics. Methods: A cross-sectional hospital-based study was conducted by questionnaire survey. A total of 300 participants were selected by convenience sampling techniques. Results: Participants’ mean age was 37 years (SD=11) and their cervical cancer screening rate was 39%. The majority (87%) either agreed or strongly agreed that ‘screening is important to be done’, while 75% believed screening could find changes in the cervix before full cancer arises and 84% that when found early cervical cancer can be easily cured. Comparing between ever screened and never screened, both groups agreed or strongly agreed that screening is important (88.8% versus 87.3%), and can find changes before they become cancer (83% versus 69.8%) and that cervical cancer is easily curable when detected early (92.4% versus 79.5%). Some 42.4% ever screened and 36.1% never screened responded not sure to whether cervical cancer decreases chances of an abortion. We did not find any socio-demographic variables which were significantly associated with perceived benefits of cervical cancer screening. Perceived benefits was not a significant predictor for cervical cancer screening (OR=1.291, p=0.33). Conclusion: The screening rate is still far too low compared to the National target of greater than 75%. Therefore, despite awareness of the perceived benefits of cervical cancer, the reasons why at risk women fail to participate in cervical cancer screening needs to be adequately explored.     

Knowledge and Barriers Towards Cervical Cancer Screening Among Young Women in Malaysia

Objectives: This study examined the level of knowledge and barriers towards cervical cancer screening of female university students. Methodology: A cross-sectional design was used for 287 female students at a tertiary institution located in Selangor, Malaysia. A name list of all students in the all faculties were obtained from each faculty’s registrar and the ethics committee of the Faculty of Health and Life Sciences, approved the study. Respondents completed a consent form before they were given the questionnaire consisting of four sections: socio-demographic characteristics (six questions); risk factor of cervical cancer (six); knowledge about cervical cancer and the Pap smear test (ten); and finally barriers to Pap screening (eleven). Data were analyzed using SPSS version 13. Results: The prevalence of ever having had a Pap test was 6%. Majority of the participants had adequate knowledge about risk factors of cervical cancer. The highest knowledge about cervical cancer risk factor reported by the respondents was having more than one sex partner (77.5%), whereas the lowest was the relationship between HPV and cervical cancer (51.2%). Age, marital status, ethnicity, monthly family income and faculty were significantly associated with knowledge of cervical cancer screening (p=0.003; p=0.001; p=0.002; p=0.002; p=0.001 & p=0.002; respectively). The most common barriers of cervical cancer screening were the Pap smear test will make them worry (95.8%) whereas the least common barrier reported among participants was no encouragement from the partner (8.8%). Conclusion: Some misconceptions and barriers in uptaking Pap smear test are still serious problems among young women. Although knowledge about cervical cancer screening is adequate they have a very poor practice of Pap smear test. The introduction of reproductive health subjects is warranted for all university students.     

Effectiveness of Cervical Cancer Screening among Chinese Women in North America

Background. Chinese North American women have high invasive cervical cancer rates and low screeningrates. The cost-effectiveness of strategies to improve Pap testing rates for Chinese women living in Seattle,Washington and Vancouver, British Columbia was examined. Objectives. To calculate the costs and costeffectivenessof implementing two strategies to motivate women to obtain a Pap smear. Research Design. Athree-armed randomized, controlled trial was conducted. Women in each of two interventions (high-intensityoutreach and low-intensity mailing intervention) were compared to a group of women who received usual care.Measures. Costs were captured via a group discussion of costs, accounting records, sampling of staff time logs,and estimation of costs and task times. Effectiveness was measured as the proportion of women in eachintervention arm who reported receiving a Pap smear since the trial began. Cost-effectiveness was calculated asthe incremental cost of screening each additional woman between an intervention arm and the control arm.Results. A greater percentage of women who received the outreach intervention had a Pap test than women whoreceived mailed materials or women who were in the usual care arm. The intent-to-treat cost for each additionalwoman to be screened for a Pap test was $ 415 in the Outreach arm and $ 676 for the Direct Mailing arm. Theoutreach worker intervention, though more expensive overall, was more cost-effective than the mailingintervention. Conclusions. Outreach intervention is cost-effective for sponsors and should be considered as astrategy to motivate Chinese women living in North America to seek cervical cancer screening.     

Breast and Cervical Cancer Screening Prevalence and Associated Factors among Women in the South African General Population

Purpose: The aims of the study were to estimate the prevalence of breast and cervical cancer screening amongwomen in the South African general population and assess associated factors. Methods: Data from a national populationbasedcross-sectional household survey in South Africa in 2012 for 10,831 women aged 30+ years were analysed usingbivariate and multivariable logistic regression. The outcome variables were cervical cancer screening (Papanicolaousmear test) and breast cancer screening (mammography). Exposure variables were sociodemographic factors, lifestylevariables, and chronic conditions. Results: The prevalences of Papanicolaou (PAP) smear test and mammographyparticipation were 52.0% and 13.4%, respectively. On multivariable logistic regression analysis, women with highereducation, those who were non-black African, having medical aid and having chronic conditions were more likely toundergo a Pap smear test and mammography. Living in rural areas was related to a lower likelihood of receiving bothtypes of screening. In addition, undertaking moderate or vigorous physical activity was associated with breast cancerscreening. Conclusion: Screening for cervical cancer was relatively high but for breast cancer it was low, despite thelatter being a major public health problem in South Africa. This may be attributed to the limited availability, affordability,and accessibility of breast cancer screening services among socio-economically disadvantaged individuals There aresome socio-economic disparities in adopting both breast and cervical cancer screening guidelines that could be targetedby interventions.     

Cervical Cancer Screening among Women Receiving Antiretroviral Therapy in a Resource-Limited Environment

Background: Cervical cancer is among the most prevalent cancer among women worldwide and women living with HIV are at increased risk, especially in a resource-limited environment. Objective: This study aimed to determine levels of awareness, knowledge, uptake, and willingness to screen for cervical cancer among women receiving care in an HIV clinic at Dodoma Regional Referral Hospital (DRRH), Tanzania. Methods: Data were collected for a period of three weeks from July 21 to August 11, 2017 using a mobile phone data collection App. A total of 421 Women aged 18-50 years old were included in the study. Results: Majority of the women interviewed (n=306, 73%) were aware of cervical cancer. Among those who were aware, 84% (n=257) did not recall ever being screened for cervical cancer, and majority had a poor knowledge of cervical cancer. Educational level completed (p=0.01), income per month (p=0.02), age group (p<0.0001), and area of residence (p<0.0001) were all significantly associated to awareness of cervical cancer. Most of the women who have never screened (n=231, 91%) expressed willingness to be screened. Prior uptake of cervical cancer screening was associated with number of live births (p=0.001) and area of residence (p=0.04). And Willingness to screen was significantly associated with age groups (p=0.03) and the number of live births (p=0.03). Moreover, we found that younger age and urban residence was positively associated with awareness and uptake of cervical cancer screening. Willingness was found to decrease as age increased. Conclusion: The study found that despite older women’s higher risk of cervical cancer, those who indicated willingness to screen were younger. Additional education, health promotion, and integration of cervical cancer screening services is needed to improve cervical cancer awareness and screening uptake at the HIV clinic.     

Breast Cancer Characteristics and Survival Differences between Maori,Pacific and other New Zealand Women Included in the Quality Audit Program of Breast Surgeons of Australia and New Zealand

Background: The Quality Audit (BQA) program of the Breast Surgeons of Australia and New Zealand (NZ)collects data on early female breast cancer and its treatment. BQA data covered approximately half all early breastcancers diagnosed in NZ during roll-out of the BQA program in 1998-2010. Coverage increased progressivelyto about 80% by 2008. This is the biggest NZ breast cancer database outside the NZ Cancer Registry and itincludes cancer and clinical management data not collected by the Registry. We used these BQA data to comparesocio-demographic and cancer characteristics and survivals by ethnicity. Materials and Methods: BQA datafor 1998-2010 diagnoses were linked to NZ death records using the National Health Index (NHI) for linking.Live cases were followed up to December 31st 2010. Socio-demographic and invasive cancer characteristics anddisease-specific survivals were compared by ethnicity. Results: Five-year survivals were 87% for Maori, 84%for Pacific, 91% for other NZ cases and 90% overall. This compared with the 86% survival reported for allfemale breast cases covered by the NZ Cancer Registry which also included more advanced stages. Patterns ofsurvival by clinical risk factors accorded with patterns expected from the scientific literature. Compared withOther cases, Maori and Pacific women were younger, came from more deprived areas, and had larger cancerswith more ductal and fewer lobular histology types. Their cancers were also less likely to have a triple negativephenotype. More of the Pacific women had vascular invasion. Maori women were more likely to reside in areasmore remote from regional cancer centres, whereas Pacific women generally lived closer to these centres thanOther NZ cases. Conclusions: NZ BQA data indicate previously unreported differences in breast cancer biologyby ethnicity. Maori and Pacific women had reduced breast cancer survival compared with Other NZ women, afteradjusting for socio-demographic and cancer characteristics. The potential contributions to survival differencesof variations in service access, timeliness and quality of care, need to be examined, along with effects of comorbidityand biological factors.     

Cervical Cancer: Screening and Prevention

Cancer of the cervix is the second most common life-threatening cancer among women worldwide and bothincidence and mortality rates are likely to be underestimated in developing countries. HPV high risk strains play atleast the major if not an absolutely necessary role in the etiology. The concept of cervical intraepithelial neoplasia(CIN) was introduced in 1968 as an equivalent to the term dysplasia, which means abnormal maturation. Cervicalcancer progresses slowly from preinvasive CIN to invasive cancer and therefore screening for dysplasia is an importantpublic health effort worldwide, given the accessibility of the primary organ site, the acceptability of current screeningmethods, and the long preinvasive period in which to detect disease and successfully intervene. It is widely acceptedthat detection and treatment of HPV-related dysplastic epithelial change in the form of CIN-2 and CIN-3 canprevent the development of invasive cervical cancer in individual patients. The mainstay of screening programs hasbeen the Pap smear, introduced originally by George Papanicolaou in 1941. However, considerable numbers of falsenegativePap smears may occur with the traditional Pap technique, mostly due to sampling error. More recently, theuse of liquid-based technologies such as ThinPrep and AutoCyte Prep have gained popularity, in part because ofevidence suggesting reduction in the incidence of inadequate smears. It is also hoped that the ability to identifypatients with oncogenic HPV types will lead to improved detection in women more likely to have squamousintraepithelial lesions. Hybrid Capture 2 is the latest refinement of HPV tests and has been described as havingenhanced sensitivity. HPV DNA testing can be used as an adjunct to cytology in routine cervical disease screeningprograms. Establishment of the link between HPV and cervical cancer has further provided the impetus for researchinto prophylactic vaccination against the most common HPV types associated with the disease, HPV 16 and 18.Initial studies have provided evidence that L1 virus-like particle vaccines against HPV types (as monovalent, bivalent,or quadrivalent vaccines) prevent at least 90% of incident and persistent infections and their associated precursorsof cervical cancer. This vaccine has sustained long-term vaccine efficacy against incident and persistent infectionsand in the long term should provide an answer to the cervical cancer problem. For the vast majority of women whohave already been infected, however, continued screening and resection need to be emphasized.     

Challenges to Cervical Screening in a Developing Country: the Case of Malaysia

Objectives: Many developing countries, including Malaysia, will need to continue relying on cervical screeningbecause they will not be able to cover their entire female adolescent populations with HPV vaccination. The aimof this paper was to establish the extent of the health care, informational, financial and psychosocial barriers tocervical screening in Malaysia. Methods: A literature search was made for reports on implementation, perceptionsand reception of cervical screening in Malaysia published between January 2000 and September 2008. Results:Despite offering Pap smears for free since 1995, only 47.3% of Malaysian women have been screened. Severalfactors may have contributed to this. No national call-recall system has been established. Women are informedabout cervical screening primarily through mass media rather than being individually invited. Smears are freeof charge if taken in public hospitals and clinics, but the waiting times are often long. The health care system isunequally dense, with rural states being underserved compared to their urban counterparts. If the screeningcoverage was to increase, a shortage of smear-readers would become increasingly apparent. Conclusions:Improving screening coverage will remain an important strategy for combating cervical cancer in Malaysia.The focus should be on the policy-making context, improving awareness and the screening infrastructure, andmaking the service better accessible to women.     

A Qualitative Exploration of Barriers to Treatment Among HPV-Positive Women in a Cervical Cancer Screening Study in Western Kenya

BackgroundCervical cancer screening through self-collected high-risk human papillomavirus (HPV) testing has increased screening uptake, particularly in low-resource settings. Improvement ultimately depends, however, on women with positive results accessing follow-up treatment. Identifying the barriers to timely treatment is needed to tailor service delivery for maximum impact.Materials and MethodsThis qualitative study was conducted within a self-collected HPV screening trial in Migori County, Kenya. HPV-positive women were referred for no-cost cryotherapy treatment at the county hospital. Women not attending within 60 days of receiving HPV-positive results were randomly selected for in-depth interviews (IDIs). IDIs were coded and analyzed to develop an analytical framework and identify treatment barriers.ResultsEighty-one women were interviewed. IDIs showed a poor understanding of HPV and cervical cancer, impacting comprehension of screening results and treatment instructions. All 81 had not undergone treatment but reported intending to in the future. Eight reported seeking treatment unsuccessfully or not qualifying, primarily due to pregnancy. Transportation costs and long distances to the hospital were the most reported barriers to treatment. Other obstacles included work, household obligations, and fear of treatment. Impacts of social influences were mixed; some women reported their husbands prevented seeking treatment, others reported their husbands provided financial or emotional support. Few women experienced peer support.ConclusionsWomen faced many barriers to treatment following HPV screening in rural Kenya. Transportation barriers highlight a need for local treatment capacity or screen-and-treat approaches. Ensuring women understand their results and how to seek treatment is essential to improving cervical cancer screening in low-resource settings.     

Limited Understanding of Pap Smear Testing among Women,a Barrier to Cervical Cancer Screening in the United Arab Emirates

Global data indicate that cervical cancer is the fourth most common cancer among women worldwide. Important factors that affect interventions for early diagnosis of cervical cancer include social beliefs and values and poor knowledge. These may contribute to women’s participation in screening for cervical cancer and have a significant impact on decisions to take preventive action. The present study was conducted with 599 women in the UAE between September 2016 and March 2017. A cross-sectional survey was conducted to determine knowledge about cervical cancer and screening, demographic characteristics and perceived barriers. Knowledge about the Pap smear test was limited, and awareness that they should undergo the Pap smear test every three years even with an initial negative/normal Pap smear result was abysmal. In spite of the positive attitude of the women towards the Pap smear test, almost 80% of the women surveyed had no knowledge of precancerous lesions. Having higher income (21/29, 72%, p=0.027) and more miscarriages were associated with better practice of Pap smears (19/26, 73%, p=0.010). Knowledge levels were significantly higher (66.3±22.2,) that values for attitude (60.5±20.9, p= 0.03, 95% CI {0.22-11.3}, Chi-square 4.38) and practice (53.7 24.1, p= 0.001, 95% CI {6.9-18.1}, Chi-square 19.7). A well-designed health education programme on cervical cancer and benefits of screening should increase the awareness among women in UAE. One point to stress is that better communication with health professionals and improvement of access to health care services should increase the rate of cervical cancer screening.     

Cost Effectiveness of a Program to Promote Screening forCervical Cancer in the Vietnamese-American Population

Objectives: To conduct a randomized controlled trial to evaluate the cost effectiveness of a lay health workeradministeredcervical cancer screening intervention for Vietnamese-American women. Methods: The study groupincluded 234 Vietnamese women in the Seattle, Washington area who had not received a Pap test in the last threeyears. Experimental group participants received a lay health worker home visit. The travel distance and timespent at each visit were recorded. Our trial end-point was Pap smear receipt within six months of randomization.Pap testing completion was ascertained through medical record reviews. Results: For all Vietnamese women,regardless of their prior history of screening, the cost per intervention was $104.0 (95% CI: $89.6-$118.4). Thechange in quality-adjusted life days per intervention was 1.26 (95% CI: -5.43-7.96), resulting in an incrementalcost-effectiveness ratio (ICER) of $30,015 per quality-adjusted life year. The probability that the ICER exceeds$100,000 is 9.1%. Conclusions: The degree of cost effectiveness of such interventions is sensitive to the assumedduration of behavioral change and the participants’ prior history of screening.