MMed, Community Medicine, Faculty of Health Sciences, University of the Witwatersrand / INTRODUCTION: Cervical cancer continues to be a significant cause of morbidity and mortality, particularly in women in the developing world, due to the lack of effective population screening. It has proven difficult to implement and sustain cytological screening programmes as health systems in these settings are not functional. South Africa has adopted an organised cervical screening programme, and the goal is to screen 70% of women over 30 years nationally, within ten years of initiating the programme. However, it is also necessary to ensure that women with abnormal Pap smears are treated if we are to reduce cervical cancer incidence. Ensuring treatment of abnormal Pap smears is a challenge, and current data on this is needed to inform service delivery. AIM: The study aims to assess the current status of the cervical screening programme in the Johannesburg Metro District, specifically looking at screening coverage, and referral for treatment in women with abnormal Pap smears. METHODOLOGY: Secondary analysis of data in the District Health Information System was done; and registers at a sample of primary health care clinics and their referral colposcopy services were evaluated for the period April 2007 – March 2008. Descriptive statistics were employed to analyse the data. Multivariate analysis was also done to evaluate factors associated with colposcopy attendance. vi RESULTS: Screening coverage for the district was 6.3% for 2008 and the cumulative coverage from 2000 to 2008 was 35.8%, with significant variation between subdistricts. A high proportion (19%) of smears was done in women less than 30 years. Of 557 women with abnormal Pap smears requiring further treatment, 57% were informed of their results and referred, 38% had appointments for colposcopy, and only 28% attended these appointments. Women experienced long waiting times for appointments (up to 15 months), and there was inadequate record keeping and client tracing. HIV status and the sub-district and health authority where women were screened were associated with colposcopy attendance; the referral hospital was associated with length of waiting time between Pap smear and colposcopy. CONCLUSION: Cervical screening coverage is below target, and the referral for diagnosis and treatment remains a challenge. Unless referral and access to colposcopy services is improved, increasing screening coverage will not have an impact on decreasing cervical cancer incidence and mortality. It is hoped that this study will provide the data to target interventions to improve cervical screening coverage and effective referral and treatment in the district.

No description available.

This is the first systematic large-scale study of lesbian health that has been conducted in the U.K. Its purpose is to provide data about lesbians' breast and cervical screening behaviour and experiences of health care. Comparable studies in the U.S.A. suggest that lesbians do not attend for routine screening tests and are less likely, than heterosexual women, to practise breast self examination. A questionnaire (the Lesbians and Health Care Survey) was distributed to 1066 lesbians in the UK. Four follow-up focus groups (n = 30) were used to explore some of the issues arising from the survey. The major quantitative survey findings include: 12 per cent of lesbians have never attended for a cervical smear; 20 per cent have never practised BSE, and only 11 per cent attend for a mammogram every three years. The qualitative survey data were content analysed in order to identify the reasons given by lesbians for their healthcare behaviour. In the follow-up focus groups, breast health is taken as a case study. This thesis contributes to defining a lesbian feminist health agenda by its valuing of lesbians' own perspectives; by providing alternative conceptions of lesbians' health that do not rely on biomedical, disease models; and it locates lesbians' health experiences within a socio-political framework. By providing a range of data about-lesbians' health, the findings may help to inform the understanding of health providers about lesbians' health needs, improve the practice of health care delivery for lesbians and be of value to lesbians in making decisions about their health care behaviour.

No description available.

No description available.

The management of women with mild and moderate dyskaryosis remains controversial. Any strategy must aim to be safe, efficient and cost effective. Two alternative strategies consist of immediate colposcopy for all women or a policy of cytological surveillance with colposcopy reserved for women with persistent dyskaryosis. Instead of a blanket policy for all women, selective approaches might be useful if accurate predictors of underlying high grade cervical intraepithelial neoplasia (CIN) were identified. Finally the effective treatment of women is important to prevent the development of invasive cancer. Large Loop Excision of the Transformation Zone or LLETZ is a relatively new treatment modality which has rapidly been established as the preferred treatment for women with CIN but it's efficacy has not been studied beyond a period of six months. The core of the thesis is description of a large prospective randomised study carried out in the University of Aberdeen. This was a four year project sponsored by the charity Birthright (now Well-being). Nine hundred and two women with a single smear showing mild or moderate dyskaryosis were recruited and allocated in a random fashion to either an immediate treatment group and one of three surveillance groups with periods of up to 24 months before treatment. Outcome measurements included the cytological and histological results. The cost effectiveness of two alternate management strategies for women with mild dyskaryosis is also described. The use of social factors and virological tests as secondary screening techniques is examined to determine if they might select women with high grade disease. Finally, the outcome of treatment of women including 400 women from the Birthright study using large loop excision of the transformation zone (LLETZ) is assessed.

Aim: To explore potential methods of increasing cervical screening coverage. Methods: Cervical screening defaulters in Dumfries and Galloway were identified in 2012, split into a control (N=64) and 7 intervention groups who were offered multiple screening options including self-collecting a vaginal sample at home. Self-samples were tested for high-risk human papillomavirus (HPV). A total of 3323 were invited to request a kit and 492 were sent a kit directly. Women who declined screening were asked to complete a questionnaire. Colposcopy referrals from defaulters were audited to identify changes over time. Defaulters attending the hospital smear clinic were questioned to ascertain barriers to cervical screening. Results: Among seven intervention groups the proportion responding varied between 32% (25%-38%) and 14% (11%-17%) compared to 6% among controls. One hundred and thirty women were HPV positive on self-sample, 8 of whom had CIN2+ diagnosed. A significantly higher number of defaulters were referred to colposcopy in June-December 2012 (n=51) than in the same period in 2011 (n=17; OR=3.8, 2.1-6.9). Defaulting was more commonly attributed to practical (112/155=72%) than attitudinal barriers (23/115=15%) (RR=4.9, 3.3-8.0). Conclusions: Practical barriers are often the cause of women not attending for cervical screening and offering more options, particularly the option of self- sampling at home, increases screening coverage.

Three hundred and four women with mild dyskaryosis were recruited into this study. They were examined using cervical cytology, HPV 16 & HPV 18 detection and colposcopic assessment, and the histological outcome was diagnosed by Large Loop Excision of the Transformation Zone. The resulting statistical analysis of this data showed that a secondary screening programme that combines HPV 16 & HPV 18 level with repeat cytology would not be a very efficient screening programme for the management of women with a mildly dyskaryotic smear. The study women were also examined for the presence of a specific P4501A1 polymorphism. When considering the women who had high grade disease, it was discovered that the mean age of the women with the normal genotype was 29 years, whereas the mean age of the women with the 'high' risk genotype was 25 years. This difference was significant and could not be accounted for by years the women with the 'high' risk genotype have smoked, or how many cigarettes these women smoked a day. CIN is commonly treated by excisional surgical procedures. Chemotherapy, however, would represent a new, less invasive and potentially less expensive alternative for the prevention of cervical cancer. There are a number of anticancer drugs available, daunorubicin and doxorubicin being the 2 most commonly used antracyclines. However, the use of such drugs is strongly limited by their lack of selectivity for cancer cells. A method has thus been adapted to test whether DaunoXomes (daunorubicin encapsulated liposomes) could be used to kill cervical cancer cells. The long term aim of this is to achieve specific targeting of DaunoXomes to cancer cells using antibody-enzyme conjugates. Preliminary results appear promising as death of cancer cells was achieved by release of the DaunoXomes contents in the close proximity of the cancer cells.

This thesis provides a social history of the introduction the Pap smear and the expansion of population-based cervical screening programs in Australia throughout the latter decades of the twentieth century. By placing cervical screening in a broad social context, this history helps to reveal the complex interrelationship between developments in scientific medicine, social, political and economic concerns, changing beliefs and attitudes, and the growing influence of commercialisation and consumerism. It also highlights the tendency for public health strategies to serve as a means of social and moral control. Furthermore, the thesis examines the conflict between the population-based approach of public health and the concern of clinicians for the welfare of individual patients. This conflict has emerged in other areas of medicine. In casting light on such conflict, the thesis will provide historical insight into reasons for why medicine is often perceived to be in a state of crisis today.

Free cervical cancer screening services are provided in Malawi’s public healthcare institutionssince 1999. Few women aged 42 and older, utilise these services. Cervical cancer continues to be a major cause of morbidity and mortality among this group of women. Structured interviews were conducted with 381 women who attended three healthcare centers in Blantyre and semi-structured interviews with 14 nurse/midwives working at the same centers. The results for both phases arepresented within the Health Belief Model’s constructs. Phase 1 revealed that women had low levels of perceived susceptibility to cervical cancer. Although the interviewed women perceived cervical cancer to be a serious condition, they did not regard themselves to be at risk of suffering from cervical cancer. Knowledge that cervical cancer screening could detect this cancer at an early stage, embarrassment, stigma, social support, financial costs, traditional practices and available sources of information, influenced women’s intentions to be screened for cervical cancer. In phase 2, the nurse/midwives indicated that Malawian women lacked information about cervical cancer, available screening tests and the purpose of such screening.These women perceived cervical canceras being incurable and linked to witchcraft. Women’s utilisation of cervical screening services was hampered by barriers relating to healthcare institutions, women themselves and nurse/midwives. Local radio and television broadcasts, friends and nurse/midwives motivated individual women to use these screening services.Women preferred receiving information about cervical cancer screening during community activities. Health education should be intensified, nurse/midwives should be more empathetic, clinic days and hours should be extended. Misconceptions should be addressed and more service providers should be trained. This would enable more Malawian women to use cervical screening services, enhancing early detection and treatment of cervical cancer and reducing the morbidity and mortality statistics related to this condition in Malawi. / Health Studies / D. Litt. et Phil. (Health Studies)