OBJETIVO: Relacionar el nivel de conocimiento sobre cáncer cervical y la exposición a sus factores de riesgo en usuarias atendidas en los consultorios externos del Instituto Nacional Materno Perinatal, febrero – marzo del 2016. METODOLOGÍA: Estudio descriptivo, correlacional y transversal, que tuvo como muestra a 361 usuarias atendidas en el consultorio externo del Instituto Nacional Materno Perinatal durante los meses de febrero a marzo del 2016. En el análisis descriptivo, para los valores cuantitativos se estimaron medidas de tendencia central y de dispersión; para los valores cualitativos se estimaron frecuencias. Asimismo, se calculó la relación mediante la prueba de Chi cuadrado, la cual se consideró significativa cuando tuvo un valor de p<0.05. RESULTADOS: El nivel de conocimiento sobre cáncer cervical de las usuarias atendidas en los consultorios externos del Instituto Nacional Materno Perinatal fue de Medio (49%) a Alto (34%). Las usuarias tuvieron una mayor exposición a los factores de riesgo como presentar síntomas o signos de infección vaginal (64.5%), tener de dos a más parejas sexuales (58.7%), tener de dos a más hijos (44.3%), tener una alimentación deficiente de vegetales todos los días (38.8%), inicio de relaciones sexuales menor o igual a 17 años (36.6%) y haber tenido de dos a más partos (29.9%). Se observó que hubo relación significativa entre el número de parejas sexuales y el nivel de conocimiento sobre cáncer de cuello uterino (p=0.013). También hubo una relación significativa entre el nivel de conocimiento bajo sobre cáncer cervical y la alimentación deficiente de vegetales (p=0.006). CONCLUSIÓN: El nivel de conocimiento sobre cáncer cervical se relaciona de manera significativa con la exposición a dos o más parejas sexuales y a la alimentación deficiente de alimentos vegetales en usuarias atendidas en los consultorios externos del Instituto Nacional Materno Perinatal, febrero – marzo del 2016. PALABRAS CLAVES: Nivel de conocimiento, cáncer cervical, factores de riesgo, exposición. / --- OBJECTIVE: Relate the level of knowledge about cervical cancer and exposure to risk factors in users attended in outpatient clinics of the National Maternal Perinatal Institute, February-March 2016. METHODOLOGY: A descriptive, correlational and cross-sectional study, which was sample as 361 users assisted in the outpatient clinic of the National Maternal and Perinatal Institute during the months of February to March 2016. In descriptive analysis, quantitative values for measures of central tendency and dispersion were estimated for the qualitative values were estimated frequencies. The relationship also was calculated using the chi-square test, which is considered significant when it had a value of p <0.05. RESULTS: The level of knowledge about cervical cancer users assisted in the outpatient clinics of the Maternal Perinatal Institute National was Medium (49%) to high (34%). The users had greater exposure to risk factors such as symptoms or signs of vaginal infection (64.5%) have two or more sexual partners (58.7%), have two more children (44.3%), having a feed deficient vegetables every day (38.8%), onset of less than or equal to 17 years (36.6%) have had sexual intercourse and two more deliveries (29.9%). It is observed that there was significant relationship between the number of sexual partners and the level of knowledge about cervical (p = 0.013) cancer. There was also a significant relationship between low level of knowledge about cervical cancer and poor nutrition of vegetables (p = 0.006). CONCLUSIONS: The level of knowledge about cervical cancer is related significantly with exposure to two or more sexual partners and poor nutrition from plant foods in users attended in outpatient clinics of the National Maternal Perinatal Institute, February-March 2016. KEYWORDS: Level of knowledge, cervical cancer, risk factors, exposure.

MPH, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, 2009 / Introduction: Cervical cancer is caused by persistent infection with high-risk Human Papilloma Virus (HPV) and is a leading cause of cancer deaths in South African women aged 15-65years. We estimated prevalence of abnormal (Atypical squmous cells of unknown significance to invasive cervical cancer) cervical cytology and associated cofactors in 18-35-year old women who tested negative for Human Immuno deficiency Virus (HIV). Method: This cervical lesion study was secondary analysis of data collected during a Microbicide Feasibility Study (MFS). MFS recruited 1100 women from public health care facilities. Women were interviewed and socio-demographic, sexual behaviour and clinical information was collected. If HIV negative, cervical and vaginal swabs were collected for Pap smear and laboratory testing for sexually-transmitted infections (STI). For the cervical lesion study, 808 women were eligible and 752 were enrolled in the study. Associations with abnormal cervical cytology were analysed using multiple logistic regression, and were reported as adjusted odds ratio (AOR) with a 95% confidence interval (CI). Results: We analysed 570 cytology specimens. Prevalence of abnormal cervical cytology was 6.7% (95% CI 4.8-9.0). Women who had an abnormal cervical cytology result were more likely than those with normal cytology results to report abnormal vaginal discharge (OR 2.33; 95% CI 1.07-5.06; p=0.03). They were also more likely to have more than one child (OR 2.21; 95% CI 1.00-4.87; p=0.05). v Discussion and conclusion: Our study showed that LSIL is common in this younger age group. Because HPV infection and thus abnormal cervical cytology are high among the younger population, this result is not unexpected. Since most LSIL regress naturally, our data support the current South African screening protocol for cervical cancer.

Introduction: Although cervical cancer can be prevented through known interventions it still remains a major cause of mortality in developing countries. Currently in South Africa there is little literature on cervical cancer radiotherapy treatment and its prognostic factors. Knowledge of prognostic factors helps in understanding the determinants of a disease better and optimize treatment strategies. The aim of this study was to determine overall survival rate and to investigate potential prognostic factors for cervical cancer in patients who underwent radiotherapy during the period of 1 January 2004 to 31 December 2006 at the Division of Radiation Oncology, Charlotte Maxeke Johannesburg Academic Hospital. Methods: This was a retrospective cohort study of 900 patients who were treated with radiotherapy between 1 January 2004 and 31 December 2006. Patient and treatment related data was obtained from the hospital treatment records. Follow-up was then censored as of 31st of December 2008. Subjects of this study had either mono-therapy or a combination of therapies: external beam radiotherapy, brachytherapy and chemotherapy. A Cox regression model was fitted to determine the prognostic and predictive factors of cervical cancer. Kaplan Meier methods were used to establish the effect of different socio-demographic and clinic-pathological factors on overall survival. The overall two year survival was also determined. Results: At 2 years post-treatment for each individual patient, 26 out of 900 patients had died, 281 were still alive and 593 lost to follow up leaving 307 patients available for analysis. The overall 2 year mortality rate was 45 per 1000 person years and highest in the period of 0-6 months. In the final model, completion of brachytherapy remained a significant predictor of survival (HR=0.04, 95% CI: 0.01-0.11, p<0.001) after adjusting for all other factors. Furthermore, HIV status was the only significant prognostic factor (HR=3.23, 95% CI: 1.04- 10, p=0.042). Patients who had brachytherapy treatment prescribed and completed the prescription were 96% less likely to die compared to those who didn’t complete it at any point in time, after adjusting for age and HIV status. Patients who were HIV positive were approximately three times more likely to die as compared to HIV negative patients at any point in time after adjusting for age and completed brachytherapy. The overall 2-year survival rate was 92% for this group of patients. Conclusion: Completion of the brachytherapy prescription was a significant predictor of treatment outcome, while the patient’s HIV status was also a significant prognostic factor for treatment. Patients who were HIV positive were three-times more likely to die compared to HIV negative patients. The overall 2-year survival rate was 92%, however, these results need to be interpreted with caution due to the large loss to follow-up in this patient population. Prospective clinical trials are recommended in the future to confirm the validity of the findings of this work in a representative patient population. In addition this work puts forward some suggestions to optimize treatment of cervical cancer patients in typical university teaching public health centres in South Africa.

Faculty of Medicine School of Physiotherapy 82-29610 Tel: 011 452 3175 / Physiotherapists commonly assess head and shoulder posture and correct poor posture on the grounds that there is an association between the patients’ cervical symptoms and their posture. The aims of this study were firstly to compare the sagittal head and shoulder posture and demographic variables of patients with chronic cervical pain to those of “healthy” volunteers. Secondly, to investigate the relationship between the frequency and severity of pain and the sagittal head and shoulder posture of patients with chronic cervical pain. Lateral view photographs were taken of nineteen patients (experimental group) and eighteen “healthy” volunteers (control group) in a supported sitting position. The following five static postural positions were assessed: (1) neutral or natural head and shoulder posture (2) maximum head protraction (3) maximum head retraction (4) maximum shoulder protraction and (5) maximum shoulder retraction. The active range of anteroposterior glide (total excursion) of the participants’ head and shoulders was also assessed. The participants completed a questionnaire that included their demographic variables, medical history and leisure time activities. Differences in head and shoulder posture were observed between the two groups. Some of these differences supported postural relationships that have been described in the literature. The experimental group had a more forward head resting position than the control group. The range of motion (total excursion) of the head and shoulders of the experimental group was less than the control group. In contrast to clinical assumptions that have been described in the literature, a forward resting head posture was not related to a protracted shoulder position or to upper cervical spine extension when measured in the sagittal plane. A relationship was observed between the frequency and severity of pain in certain body regions and selected postural measurements in the experimental group. It is suspected that most of the findings might be the result of poor cervical and scapular muscle control caused by chronic pain. This emphasises the need to assess the influence of tissue and joint extensibility and muscle control on head and shoulder posture. Analysis of the questionnaires demonstrated that the experimental group’s ability to carry out activities of daily living was significantly affected by pain (p=0,001). There was no significant difference in the number of hours worked per week between the experimental and control groups (p=1,000). There was a tendency (p=0,118) for the control group to devote a greater number of hours to “active” leisure time activities. The control group might have been less symptomatic as a result thereof. This highlights the necessity to further investigate the effect of exercise on postural correction and prevention of cervical symptoms.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Science in the field of Epidemiology and Biostatistics. Johannesburg, June 2017 / Cervical cancer (CC) is the leading cause of female cancer morbidity and mortality in South Africa, despite the introduction of preventive programs. However, there is a paucity of information on current CC rates and trends in South Africa. This study aimed to evaluate the national trends and determinants of CC over a 19 year period (1994-2012). We conducted temporal analyses of age-standardised incidence rates (ASIR) from 1994 to 2009 and age-standardised mortality rates (ASMR) from 2004 to 2012 using data from the National Cancer Registry and Statistics South Africa, respectively. We also evaluated a novel surrogate measure (complement of MR: IR ratio) to calculate five-year relative survival rates of CC (2004-2009). Temporal analyses were stratified by the province of residence, histological type, population- and age-groups, while linear regression models were fitted to determine the average annual percent change (AAPC) of the time trends. Spatial distribution was conducted by utilising the GIS coordinates of SA to map the provincial ASMR. Unconditional logistic regression analyses were carried out for three casecontrol studies using data from the hospital-based Johannesburg Cancer Case-Control Study (JCCCS) (1995-2010), to evaluate the effect of HIV infection; tobacco smoking and alcohol abuse and sexual and reproductive behaviours on the risk CC in Black South Africans. The cases were participants with CC while controls were other female cancer participants that had no known association with CC and its risk factors. There were 75,099 incident cases and 25,101 mortalities from CC in the periods studied with women below 50 years accounting for 43.1% of the cases and 35.7% deaths. The ASIR was 22.1/100,000 in 1994 and 23.3/100,000 in 2009 and there was an average annual decrease in incidence of 0.9% (AAPC=-0.9%, P-value<0.001). The ASMR decreased slightly from 13.9/100,000 in 2004 to 13.1/100,000 in 2012 (AAPC = -0.6%, P-value < 0.001). Based on current trends, the ASIR and ASMR were predicted to increase to 26.3/100,000 and 14.6/100,000 in 2030, respectively. From 2004 to 2012, five provinces had increased mortality rates (AAPC: 1.2 – 8.3, P-value<0.001) while four provinces had decreased mortality rates (AAPC: -16.6 - -1.0, P-value<0.001). In 2012, the ASMR in Black population group was 5.7-fold higher than in the White population group. The highest mortality was recorded in Mpumalanga Province (19.8/100,000) and the least in the Eastern Cape Province (8.9/100,000). From 2000 to 2009, the ASIR of adenocarcinoma of the cervix was relatively low (2.00 to 2.6 per 100,000 women) and stable, while the incidence of squamous cell carcinoma was high (17.0 to19.0 per 100,000 women) and the rate increased by 1.4% annually. The relative survival rates were higher in White and Indians/Asian women (60-80%) than in Blacks and Coloureds (40- 50%). The results of the JCCCS studies showed that the association between CC and HIV infection increased from two-fold (adjusted odds ratio, (adjOR) =1.98; 95% CI: 1.34-2.92) during the pre-anti-retroviral therapy (ART) era (1995-2003) to three-fold (adjOR=2.94 95%CI: 2.26- 3.83) in the ART era (2004-2010). Current tobacco smoking (adjOR=2.1, 95%CI: 1.10-4.01) and snuff use (adjOR=1.3, CI: 1.08-1.61) increased the likelihood of CC among Black women in South Africa. The risk of CC increased with prolonged use of hormonal contraceptives (P-value for trend = 0.003) and high parity (>6) (adjOR=4.5, 95%CI: 2.85- 7.25). The incidence and mortality of CC are probably underestimated due to underreporting of cancer in the country. South Africa had minimal changes in overall CC rates between 1994 and 2012, despite the initiation of a population-based CC screening program in 2000 and the nationwide roll out of ART in 2004. There was a marked disparity in CC rates by population group, age and province. HIV-infected women and those who use tobacco are more likely to develop CC, therefore targeted programs should be introduced to inform women about risk factors for CC. Maternal and child health initiatives should also involve CC control activities since a considerable number of women of the reproductive age (15 – 49 years) were affected. / MT2017

Research report to be submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Masters of Medicine in the branch of Obstetrics and Gynaecology Johannesburg, 2017 / Introduction Cervical carcinoma is the second most common malignancy worldwide after carcinoma of the breast and most common in the developing world1,2. In Africa, the population of women who are 15 years and older is estimated to be 267.9 million with approximately 78 897 diagnosed with invasive cervical carcinoma annually and a 78% mortality1. Aim The aim of the study was to ascertain whether HIV sero-positive women in South Africa present with a more advanced disease of invasive cervical carcinoma than their HIV sero-negative counter parts as well as to assess the degree of immuno-suppression and its effect on the stage of the disease at initial presentation. Is there a difference between the studies done then and what is presented now? Methods This was a descriptive retrospective record review. A total of 1300 cases of cervical carcinoma were seen at Charlotte Maxeke Johannesburg Academic Hospital, Combined Oncology Clinic from 2009 to 2010. Variables analyzed were patient age, HIV status, ARV standing, CD4 count, parity, race, papsmear result, cell type FIGO staging. This was done using the SPSS (Statistical Package for Social Sciences) version 13. RESULTS The mean age of the patients analyzed was 50.74 +- 13.08. There were 436 (37.1%) HIV seropositive patients, with a mean CD4 count of 357.59 +- 361.15. The mean age of presentation for HIV sero-positive patients was 55.4 +- 11.8 and for sero-negative patients 42.1+- 9.5 (p=0.000). A majority of the patients presented with stage IIIB disease. The HIV status had no bearing on the stage of the disease at presentation (p=0.363), nor the degree of immunosuppression (p=0.999). Due to the HIV pandemic, sero-positive patients presented with invasive cervical carcinoma 10 years earlier than their sero-negative counterparts. Black patients were mostly affected when compared to other races with a (p= 0.004). Antiretroviral seemed to make no difference on clinical staging at presentation (p=0.152) Conclusion HIV sero-positive patients presented with invasive cervical carcinoma 10 years earlier than their sero-negative counterparts. The degree of immunosuppression and HIV sero-positivity has no bearing on severity of the disease. / MT2017

Cartas al editor

Objectives This dissertation had two overarching objectives: 1. To determine how stakeholders perceive women’s preferences for cervical screening modalities. 2. To understand methods to measure women’s cervical screening preferences, to inform the development and testing of a person-centered, evidence-informed approach to preference-elicitation. Methods The overarching conceptual framework was the Ottawa Decision Support Framework. The first objective was addressed by interview studies with (1) guideline developers and program managers and (2) health professionals and women considering screening. This was complemented by a systematic review of quantitative, qualitative and mixed-methods studies of women’s cervical screening preferences, using the Grading of Recommendations, Assessment, Development, and Evaluation approach to developing preference-based recommendations. This approach was also used in a systematic review of methods to elicit women’s preferences, addressing the second objective. These findings led to the development and field testing of a preference-elicitation tool using International Patient Decision Aid Standards criteria, and the development of a protocol for a population-based study of women’s preferences. iv Results Objective 1 Experts disagree about whether there is enough evidence to include alternative modalities in cervical screening programs. Women and health care professionals do not recognize that women face a choice to participate in cervical screening. A narrative synthesis of relevant literature presented challenges in aggregating preferences across diverse study objectives, designs, and contexts. Objective 2 Preference-elicitation approaches for cervical screening are heterogenous in design and rigour. I therefore developed and field tested a tool to elicit women’s preferences, which demonstrated that women found the tool helpful to identify their preferences. I then propose a study that uses multiple methods to apply the tool more broadly. Conclusions Synthesized preferences data might not be the optimal approach to incorporate preferences into cervical screening guidelines. A tool grounded in shared decision-making can help women identify their informed, values-based screening preferences.

Thesis (MPH)--University of Limpopo, 2009. / Cervical cancer is the second highest form of cancer among women in Botswana, with breast cancer being the commonest (Ferlay et al, 2002), and is currently the highest cause of cancer deaths in Botswana (Ferlay et al, 2002). Cervical cancer screening using Pap smear provides an appropriate way for early detection and prevention of cervical cancer if appropriately implemented. Cervical cancer screening was introduced in Botswana in 2003 free of charge to all women of age greater than 18 years attending government hospitals. Despite this step by the government to decrease the mortality and morbidity rates resulting from cervical cancer, the uptake of cervical cancer has remained low among women in Botswana (Botswana central statistic report, 2009). Aim of the study; The study was aimed at identifying and describing factors influencing cervical cancer screening uptake among women greater than 18 years attending Mahalapye District Hospital in Botswana using the Health Belief Model. Methodology; This study was a cross sectional survey in which a questionnaire was used to interview 300 participants in order to assess their perceived susceptibility to cervical cancer, their perceived severity of cervical cancer, their perceived benefits of doing cervical cancer screening and their perceived barriers of seeking cervical cancer screening. Descriptive statistics was used to identify and describe factors influencing cervical cancer screening uptake among women attending Mahalapye District Hospital, Botswana using the Health Belief Model construct. Each question in the questionnaire was scored using a 5-point Likert scale ranged from strongly agree (5) to disagree (1). Negatively worded questions had their scales reversed and scores for each construct of the Health Belief Model was added to get an average. Analysis compared women who had ever had „cervical cancer screening‟ with women who had never had „cervical cancer screening‟. Chi-square statistic was used to test for association of selected variables and binary logistic regression was used to measure the associations for the aggregate score of health belief model constructs. Results; Cervical cancer screening rates was 39%. Participants were aware of the perceived severity of cervical cancer (average response 2.58-3.60), perceived benefits of cervical cancer 6 screening (average response 3.10-4.33) and perceived barriers to seeking cervical cancer screening (average response 2.0-3.44) but these were not significantly associated with screening. The highest predictor of cervical cancer screening was perceived susceptibility and those with high perceived susceptibility were 3.2 times more likely to do cervical cancer screening than those with low perceived susceptibility. Main socio-demographic characteristics significantly associated with perceived susceptibility were employment, monthly income and residential area while perceived severity was significantly associated with monthly income and residential area. Conclusions; Perceived susceptibility to cervical cancer was significantly associated with cervical cancer screening. Educational programs geared towards increasing perceived susceptibility to cervical cancer can significantly improve the uptake of cervical cancer screening in Botswana as well as address issues of barriers and misconceptions associated with low uptake of cervical cancer screening.

Thesis (MPH)--University of Limpopo (Medunsa Campus), 2011. / BACKGROUND: In Botswana, cervical cancer is the most common cancer among women (18), and the Southern Africa regional prevalence rate of cervical cancer is 15.5% (25). In Nyangabgwe Referral Hospital, cervical cancer is the most common malignancy admitted in the gynecology ward, contributing 73% and 78% of all malignancy admissions in 2007 and 2008 respectively. It is estimated that 200,000 to 300,000 women die from cervical cancer every year, mostly in poor countries (1). The study intends to create more awareness on the importance cervical cancer screening in Nyangabgwe Referral Hospital and catchment areas. Purpose: The purpose of the study is to improve the uptake of cervical cancer screening by integrating a health promotion component to the standard program. Methods: The study was an interventional quantitative research. Two populations were selected for the study namely women attending Nyangabgwe Referral Hospital and the clinics in Francistown (the research group) and women attending Princess Marina Hospital (the control group). The population of women attending Nyangabgwe Referral Hospital was exposed to health promotion. The second population of women attending Princess Marina Hospital was unexposed to the health promotion intervention. A pre-test quantitative trend of cervical cancer screening patterns was collected from June to September 2009 in the health facilities before the intervention from October 2009 to January 2010. Intervention was conducted in the study sites and was followed by a post - test quantitative measure of cervical cancer screening trends in both the research group and the control groups. Instruments for the health promotion were; flyers with translations in English and Setswana given to participants, posters which were posted at various strategic positions in the hospital and as well as in female wards. The population of study was all women attending Nyangabgwe Referral Hospital and its catchment clinics (the study site). Interactive health education sessions were provided to the population. Questionnaires which had Setswana translation were administered to respondents who were screened for cervical cancer in the study and control sites. Results: The analysis of finding revealed that the total uptake of Pap smear test was higher during the period of intervention than in the pre-intervention period in all the sites and for all the age groups. Among the health promotion activities, the effect of health education talks in the hospital and clinics was greater (67%), than the effects of flyer or pamphlets (35%) and posters in hospitals and clinics (17%) in escalating uptakes of cervical cancer screening services. Conclusions: The standard cervical cancer screening program alone as designed and executed by health care workers is not enough to stimulate the desired response of increase access to cervical cancer screening services, because many women usually are left out. Recommendations: The study results call for the need of instituting a visible and accountable comprehensive health promotion component to the standard cervical cancer screening program in order to sustain a steady cervical cancer screening uptake that will result in the expected decline in morbidity and mortality due to cervical cancer disease.