Orientador: Marilisa Berti de Azevedo Barros / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-17T02:24:18Z (GMT). No. of bitstreams: 1 Amorim_VivianMaeSchmidtLima_D.pdf: 1143037 bytes, checksum: 7b0304c669d1160e712a666b80ef0553 (MD5) Previous issue date: 2010 / Resumo: Justificativa: O câncer de mama, do colo de útero e de próstata são neoplasias importantes na incidência e na mortalidade no Brasil e são agravos que dispõem de métodos de rastreamento para detecção precoce oferecidos pelo Sistema Único de Saúde (SUS). Existe a necessidade de se identificar os grupos de mulheres e de homens que não realizam os exames de detecção precoce para esses agravos, como forma de implementar as estratégias para captação desses indivíduos visando minimizar as desigualdades sociais ainda existentes em relação ao acesso aos serviços de saúde. Objetivos: Analisar as práticas de detecção precoce para o câncer de mama, do colo uterino e de próstata, segundo características sociodemográficas, filiação a planos privados de saúde, morbidade e comportamentos relacionados à saúde. Material e Métodos: Estudo do tipo transversal, de base populacional, que teve como população de estudo todos os indivíduos do sexo feminino com idade de 20 a 69 anos residentes no município de Campinas, participantes do ISACAMP 2008/2009 e homens com idade superior a 50 anos residentes nos municípios de Campinas, Botucatu, Taboão da Serra, Embu e o distrito do Butantã em São Paulo, participantes do ISA-SP 2002/2003. Para a obtenção da amostra, os setores censitários dos municípios, foram agrupados em três estratos, segundo o percentual de chefes de família com nível universitário. Foram sorteados 10 setores censitários de cada estrato, e de cada setor censitário foram sorteados os domicílios e selecionados os indivíduos que seriam entrevistados, segundo os domínios de sexo e idade. As informações foram obtidas por meio de questionário estruturado em blocos temáticos, com a maioria das questões fechadas, aplicado diretamente à pessoa sorteada. O presente estudo incluiu 992 homens com 50 anos ou mais, 696 mulheres de 40 a 69 anos e 508 mulheres de 20 a 59 anos. Foram incluídos na análise dois grupos de variáveis: as independentes compostas por variáveis sociodemográficas, filiação a plano privado de saúde, comportamentos relacionados à saúde e estado da saúde e as dependentes, referentes à realização das práticas preventivas para a detecção do câncer de mama, do colo de útero e da próstata. Para as análises estatísticas foi utilizado os programas STATA 9 e STATA 11.0, que possibilitou levar em consideração as variáveis do plano de amostragem e o efeito de delineamento. As análises bivariadas incluíram estimativas de prevalência e intervalos confiança de 95% (IC) e modelos de regressão logística múltipla de Poisson. Resultados: O presente estudo verificou que 44,4% (IC 95%: 37,3-51,7) da população estudada dos homens de 50 anos ou mais, nunca haviam realizado exame preventivo para o câncer de próstata. Dos homens que referiram ter realizado exames de detecção do câncer de próstata (55,6%) o toque retal foi referido por 61,8%, o PSA por 73,2%, a ultra-sonografia por 28,2% e a biópsia por 7,3%. Dentre os homens que referiram ter realizado algum exame, 49,7% o haviam feito no ano que antecedeu a entrevista, 23% entre um a dois anos, 10% entre dois a três anos e 17% quatro anos ou mais antes da entrevista; Dos exames realizados, 41% foram financiados SUS. Os resultados da análise de regressão múltipla de Poisson apontam que a não realização dos exames preventivos para o câncer de próstata foi significativamente mais freqüente nos homens com menos de 70 anos, menor escolaridade, de menor renda familiar per capita, que não apresentam Diabetes Mellitus, que referiram algum tipo de deficiência visual e que não fizeram consulta odontológica no ano que antecedeu a entrevista. Em relação à realização da mamografia o presente estudo mostrou que das mulheres de 40 a 69 anos residentes no município de Campinas 47,7 % (IC95% 39,1-56,5) relataram filiação a planos privados de saúde e que 64,2% das mulheres realizaram a mamografia nos dois anos que antecederam a entrevista. O principal motivo apresentado para a realização da a mamografia foi realizá-la como procedimento de rotina sem a presença de queixas ou sintomas. Para as mulheres que nunca realizaram a mamografia o motivo mais alegado foi achar que a realização do exame não é um procedimento necessário s ser feito. Não ter o conhecimento do resultado do exame mostrou-se mais prevalente nas mulheres SUS dependente em relação as que têm plano privado de saúde. Das mamografias realizadas, 49,3 % foram financiadas pelo SUS e 50,7% pelos planos privados de saúde. A análise de regressão múltipla hierarquizada de Poisson revelou que persistiram significantes as variáveis: renda e plano privado de saúde, na 1ª etapa atividade física no lazer, diabetes mellitus e a consulta odontológica na 2ª etapa. Quanto a realização da citologia oncótica 46,4% (IC95% 34,1-59,2) das mulheres de 20 a 59 anos são filiadas a planos privados de saúde e que 86,2% (IC 95% 82,6-89,1) das mulheres entre 20 a 59 anos residentes no município de Campinas fizeram o exame nos últimos 3 anos, não sendo observada diferença na realização do Papanicolaou entre as mulheres que tem e as que não tem plano privado de saúde. Apenas 6,8% das mulheres entrevistadas referiram nunca ter realizado o Papanicolaou. O principal motivo alegado para a realização do exame foi fazê-lo como exame de rotina (92,8%). Já o principal motivo referido pelas mulheres que nunca fizeram o exame foi de acharem não ser um exame necessário. Quanto ao resultado do exame somente 4,5% não sabiam do resultado do último exame. Das citologias oncóticas realizadas, 55,7 % foram financiadas pelo SUS e 44,3% por planos privados de saúde. Não foi observada a associação entre as variáveis sócio-demográficas, de filiação a planos privados de saúde, de comportamento de saúde, morbidade e a realização da citologia oncótica nos três anos que antecederam a entrevista. Conclusão: Esse estudo mostrou importantes desigualdades socioeconômicas na realização do PSA, a presença da eqüidade na realização da citologia oncótica entre as mulheres de 20 a 59 anos residentes filiadas a planos privados de saúde e as SUS dependentes. Também apontou a existência de desigualdades, na realização da mamografia, entre das mulheres de 40 a 69 mostrando que as filiadas a planos privados de saúde realizam mais o exame do que as SUS dependentes. Quanto ao acesso na realização do Papanicolaou observou-se a existência da equidade apontando para a possibilidade de que o mesmo possa ocorrer em relação as outras praticas de saúde. Estratégias que garantam a equidade no acesso necessitam serem desenvolvidas com o objetivo de minimizar as desigualdades na realização da mamografia e do PSA e da integralidade das ações pertinentes às políticas nacionais da saúde do homem e da mulher / Abstract: Justification: Breast, uterine and prostate cancer are important malignancies in terms of incidence and mortality in Brazil. The Brazilian public healthcare system offers early detection methods for these conditions. There is need to identify groups of women and men who have not undergone early detection exams in order to implement strategies for reaching these individuals with the aim of minimizing existing social inequalities related to healthcare services. Objectives: The aim of the present study was to analyze early detection practices for breast, uterine and prostate cancer based on socio-demographic characteristics, affiliations with private health plans, morbidity and health-related behavior. Materials and Methods: A population-based cross-sectional study was carried out involving a study population of all females between 20 and 69 years of age in the city of Campinas (SP, Brazil) who participated in the ISACAMP 2008/2009 health survey and men aged 50 years or older residing in the cities of Campinas, Botucatu, Taboão da Serra and Embu and the district of Butantã in Sao Paulo (SP, Brazil) who participated in the ISA-SP 2002/2003 health survey. For the determination of the sample, the census sectors of the municipalities were grouped into three strata based on the percentage of heads of family with a university education. Ten census sectors of each stratum were selected by lots; residences were selected by lots from each census sector; and the individuals to be interviewed (based on gender and age) were then selected. The information was collected using a questionnaire structured in thematic blocks, with the majority of items closed questions, administered directly to the individual selected. The study involved 992 men aged 50 years or older, 696 women between 40 and 69 years of age and 508 women between 20 and 59 years of age. Two groups of variables were used in the analysis: independent variables, made up of socio-demographic variables, affiliations with private health plans, health-related behavior and health status; and dependent variables referring to preventive practices for the detection of breast, uterine and prostate cancer. The STATA 9 and STATA 11.0 programs were used for the statistical analysis, which allowed taking the sampling plan and design effect into consideration. The bivariate analyses included prevalence estimates and 95% confidence intervals (CI) as well as Poisson multiple logistic regression models. Results: A total of 44.4% (95% CI: 37.3-51.7) of population of males aged 50 years or older had never undergone a preventive prostate cancer exam. Among the men who reported having a prostate exam (55.6%), 61.8% reported undergoing the digital rectal exam, 73.2% reported undergoing the PSA exam, 28.2% reported undergoing ultrasonography and 7.3% reported undergoing biopsies. Among the men who reported undergoing an exam, 49.7% had done so in the year prior to the interview, 23% had done so one to two years earlier, 10% had done so two to three years earlier and 17% had done so four or more years prior to the interview. A total of 41% of the exams were financed by the Brazilian public healthcare system. The results of the Poisson multiple regression analysis revealed that the failure to undergo preventive prostate cancer exams was significantly more frequent among men under 70 years of age, those with less schooling, those with a lower household income, those without diabetes mellitus, those who reported some type of visual impairment and those Who had not visited the dentist in the previous year. With regard to mammography, among the female residents of the city of Campinas aged 40 to 69 years, 47.7% (95% CI: 39.1-56.5) reported affiliations with private health plans and 64.2% reported undergoing a mammogram in the two years prior to the interview. The main reason given for undergoing the exam was as a routine procedure, with no complaints or symptoms. Among the women who had never undergone a mammogram, the most reported reason was the belief that the exam is not a necessary procedure. A lack of knowledge regarding the results of the exam was more prevalent among those dependent on the public healthcare system in comparison to those with a private health plan. Among the mammograms performed, 49.3% were financed by the public healthcare system and 50.7% were financed by private plans. The following variables remained significant in the Poisson hierarchal multiple regression analysis: income and private health plan in the 1st step; and physical leisure activity, diabetes mellitus and dental appointment in the 2nd step. Regarding cancer cytology, 46.4% (95% CI: 34.1-59.2) of the women affiliated to private health plans between 20 and 59 years of age and 86.2% (95% CI: 82.6-89.1) of those between 20 and 59 years of age residing in the city of Campinas had taken the exam in the previous three years, with no significant difference in having undergone a Papanicolaou test between women with and without a private health plan. Only 6.8% of the women interviewed reported never having taken this exam. The main reason given for taking the test was as a routine exam (92.8%). The main reason given by the women who had never taken the test was the belief that it was unnecessary. Only 4.5% did not know the result of their last Papanicolaou test. A total of 55.7% of the cancer cytology exams were financed by the public healthcare system and 44.3% were financed by private plans. No associations were found between the socio-demographic variables, affiliation with private health plans, health-related behavior, morbidity and having undergone a cancer cytology exam in the three years prior to the interview. Conclusion: The present study demonstrated important socioeconomic inequalities with regard to having undergone a PSA exam as well as equity regarding having undergone cancer cytology exams among women between 20 and 59 years of age either affiliated to private health plans or dependent on the public healthcare system. Inequalities were detected in having undergone mammography among women aged 40 to 69 years, demonstrating that those affiliated to private health plans underwent the exam more than those dependent on the public healthcare system. Equity was found with regard to the Papanicolaou test, indicating the possibility that the same could also occur with other health practices. Strategies that ensure equity in relation to access to health services need to be drafted in order to minimize inequalities regarding mammography and the PSA test as well as the promotion of integral actions that are relevant to national health policies for men and women / Doutorado / Epidemiologia / Doutor em Saude Coletiva

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Objetivos: avaliar o desempenho da citologia oncÃtica convencional e da captura de hÃbridos II na detecÃÃo de lesÃes cervicais neoplÃsicas e prÃ-neoplÃsicas. Sujeitos e MÃtodos: foram recrutadas aleatoriamente 1685 mulheres, da demanda espontÃnea de postos de saÃde da rede pÃblica, em cinco municÃpios do estado do CearÃ. As pacientes, apÃs assinarem termo de consentimento, responderam a um questionÃrio prÃ-elaborado e, a seguir, foram submetidas à coleta de material para CO, CH II e à realizaÃÃo de colposcopia, que, sendo positiva, levou à imediata biÃpsia dirigida das Ãreas anormais. Os dados foram digitados no programa Microsoft Excel 2000 e analisados no SPSS-for Windows, versÃo 10.0. O desempenho da CO e CH II foram calculados atravÃs da sensibilidade, especificidade, dos valores preditivos positivo e negativo e dos respectivos intervalos de confianÃa de 95%. Considerou-se, para anÃlise, como padrÃo ouro negativo, o resultado da colposcopia negativo ou resultado negativo no exame histopatolÃgico e, como padrÃo ouro positivo, o resultado positivo do histopatolÃgico. Avaliaram-se dois pontos de corte distintos: qualquer achado prÃ-neoplÃsico e neoplÃsico do colo uterino e achados de lesÃes intra-epiteliais de alto grau ou cÃncer. Resultados: 56 mulheres (3,4%) apresentaram atipias celulares na CO, sendo a CH II positiva em 315 (19%). Embora 337(20,32%) mulheres tenham sido positivas em um dos testes, somente 19(1,1%) foram positivas nos dois. Entre as 150 que tiveram colposcopia positiva somente em 53 foram encontradas lesÃes no exame histopatolÃgico, sendo a prevalÃncia estimada de 3,2% para qualquer lesÃo e de 0,4% para lesÃes de alto grau/cÃncer. Considerando o ponto de corte o achado de qualquer lesÃo prÃ-neoplÃsica ou neoplÃsicas, a sensibilidade encontrada para a CO e a CH II foi de 30,2% e de 71,7%, respectivamente. A especificidade dos testes mencionados foi de 97,5% e de 82,7%. O VPP e VPN da CO foram de 28,6% e de 97,7%, respectivamente. Jà o VPP e VPN da CH foram 12,1% e 98,9%. Considerando o ponto de corte lesÃes de alto grau ou cÃncer, temos: sensibilidade e especificidade da CO de 28,6% e de 99,9%, enquanto os VPP e VPN foram de 54,8% e de 99,7%, respectivamente. A CH II alcanÃou 100% de sensibilidade e 81,3% de especificidade. Os VPP e VPN ficaram em 2,2% e 100%. ConclusÃo: o teste de detecÃÃo do DNA-HPV pela CH II foi mais sensÃvel, porÃm menos especÃfico que a CO. Quando associado à CO, melhora significativamente a detecÃÃo das lesÃes cervicais, principalmente as de alto grau e cÃncer. Para este grupo de lesÃes, a CH II isolada apresentou melhor especificidade sem perda da sensibilidade, mostrando-se um bom teste para o rastreamento primÃrio. / Objective: to compare the usual Pap smear (Papanicolaou) and the Hybrid Capture II tests in detecting cervical intraepithelial neoplasia in women of Ceara State. Subjects and Methods: 1685 women were enrolled from routine practice in five municipalities of the main Cearà State Health Regions. The whole study was explained to the volunteers, who accepted to participate by signing an informed consent form. The study procedures included filling a questionaire and a cervical sample collection, done by a physician, for cytology and HPV-DNA Hybrid Capture, followed by a complete colposcopic evaluation with directed biopsy if necessary. Data were analyzed in Statistical Package for Social Sciences - SPSS - for Windows 10.0. The accuracy of both tests â Pap smear and Hybrid Capture II - was evaluated by using the sensitivity, specificity, positive predictive value, negative predictive value and the respective 95% confidence intervals. The negative colposcopic examination or negative histological result were considered gold standard for negative results. Positive histological results were considered gold standard for positive results. Results: 56 women (3,4%) had abnormal pap smear. Hybrid Capture tests were positive in 315 women (19%). Despite 337 (20,32%) tests had positive results for one of the two tests, only 19 (1,1%) were positive in both tests. Lesions were detected in 53 women among those 150 considered positive in colposcopic examination. The prevalence for any lesion was estimated in 3,2% and for high grade lesions and cancer in 0,4%. Using the cut-off point as the finding of any cervical lesion, the sensitivity of pap smear and HC II was 30,2% and 71,7%, respectively. The specificity for pap smear and HC II was 97,5% and 82,7%, respectively. The positive and negative predictive value for pap smear was 28,6% and 97,7%, respectively. The positive and negative predictive value for HC II was 12,1% and 98,9%, respectively. By using the cut-off value as high grade cervical lesions and cancer, the sensitivity and specificity for pap smear were 28,6% and 99,9%, respectively, and the positive predictive value and negative predictive value for the same test were 54,8% and 99,7%. The sensitivity and specificity for HC II were 100% and 81,3%, respectively, as well as 2,2% and 100% for positive and negative predictive value. Conclusions: hybrid Capture II test was more sensitive than pap smear, however Hybrid Capture II test was less specific than pap smear. When both tests were used together for detecting cervical lesions the results improved significantly, mainly high grade lesion and cancer. For this group of lesions, HC II alone, presented better specificity, without loss of the sensitivity, apparently itâs a good test for primary sceening.

Denna studie undersökte kvinnors upplevelser när de fick ett HPV-positivt screeningresultat brevledes. Den svenska screeningen för förebyggande av livmoderhalscancer meddelar resultatet i ett kort, standardiserat brev. Efter att ha inkluderat humant papillomvirus (HPV) i analysen år 2014 verkade kvinnor bli mer oroliga för resultatet som kunde meddela en sexuellt överförd infektion (STI).En intervjustudie genomfördes med åtta kvinnor och empiriska data analyserades med receptionsteori. Resultaten visade vilka känslor kvinnor kämpade med, om de upplevde en negativ inverkan på deras sexualitet och om de var nöjda med ett brev som kommunikationssätt.Okunnighet om HPV och rädsla för cancer var centrala resultat. Kvinnor beskrev till och med en förändring i attityd till andra sexuella praktiker än vaginalt samlag. Resultatbrevet ansågs vara för kort och inte så informativt som nödvändigt. Detta fick samtliga kvinnor att söka efter mer information främst på internet för att hitta svar på deras frågor.Sammanfattningsvis finns det ett behov av grundlig och strukturerad information relaterad till HPV och påverkan på livmoderhalsen. Personal inom hälso- och sjukvårdssystemet bör vara lyhörda för kvinnors oro över deras screeningresultat. / This study explores women´s experiences when receiving their HPV-positive pap smear result as a letter. The Swedish screening programme for the prevention of cervical cancer notifies of the result in a short, standardised letter. After including human papilloma virus (HPV) in the analysis in 2014 women appeared to become more worried about the result showing a sexually transmitted infection (STI). An interview study was performed with eight women and the empirical data was analysed with reception theory. The study-results show which feelings women struggled with, whether they experienced a negative impact on their sexuality, and whether they were content with a letter as communication method for their results. Ignorance of HPV and fear of cancer were central findings. Women even described a change in attitude towards sexual practices other than vaginal intercourse. The result letter was considered to be too short and not as informative as needed. This caused all the women to look for more information foremost on the internet in order to find answers to their questions.In conclusion there is a need for thorough and structured information related to HPV and impact on the cervix. Healthcare system personnel should have a sensitive ear for women´s concerns about their pap smear results.

Att gå på en gynekologisk cellprovtagning är något flera kvinnor tycker är obekvämt. Det upplevs som ett oroligt och obehagligt möte. Studien undersöker därför följande frågeställning; Hur kan produktdesign stötta en stressad/oroad patient i ett väntrum inför en cellprovtagning? Syftet för studien är att förbättra kvinnors väntrums-upplevelser inom kvinnlig vård samt undersöka hur designmetoder och produktdesign kan bidra till framtagandet av en produkt som lindrar användarens stress och orosnivåer i väntrummet inför cellprovtagning. Studien förhåller sig till ett användarcentrerat förhållningssätt som riktar sig till att designa för användaren. Även co-design tillämpas där användaren och designern samarbetar under delar av designprocessen. Denna studies användare är kvinnor i åldern 23–30 år som gör sina första cellprovsbesök.  För att undersöka studiens frågeställning samlades kvalitativ information genom en expertintervju, intervjuer med användaren och workshops med användaren. Dessa metoder analyserades och resulterade i önskemål på fysiska attribut i produkten. Delar av önskemålen togs med i beslut senare i designprocessen. Användarnas problem definierades i metoden Problem Definition. De problem som användarna angav i Problem Definition var att komforten i väntrummet är bristande, väntetiden är oviss samt rastlöshet i väntrummet. Metoden Problem Definition blir studiens grundställning i designprocessen där beslut tas utifrån att lösa de nyssnämnda problemen. Designprocessen bestod främst utav brainstorming, brainwriting och två delar av skissande och prototypande där slutkonceptet framställdes. Studiens frågeställning besvaras genom framtagandet av en interaktiv stol. Stolen syftar till att höja komforten i väntrummet samt uppmuntra till interaktion med användaren och därmed bidra till minskad stress och oro. Interaktionen sker genom att användaren gungar eller vaggar upp och ner när den sitter ner och lutar sig bakåt i möbeln. Slutsatsen är att produktdesign kan stötta en stressad och oroad patient genom att göra denne bekväm, skapa komfort och distrahera från väntetiden i väntrummet. Slutprodukten kom fram till det ovan beskrivna, men fortsatta användartester, funktionstester etc krävs för att framta en stol fullt fungerande för sitt syfte. / Going for a gynecological pap smear is something many women find uncomfortable. It is experienced as an uneasy and unpleasant meeting. The study therefore examines the following question; How can product design support a stressed/anxious patient in a waiting room before a Pap test? The purpose of the study is to improve women’s waiting room experiences in women’s health care and to investigate how design methods and product design can contribute to the development of a product that relieves the user’s stress and anxiety levels in the waiting room before a Pap test. The study relates to a user-centered approach, which focuses on the user’s needs in the design process. Co-design is also applied where the user and the designer collaborate during parts of the design process. The users of this study are women aged 23–30, i.e., women who are attending their first pap smear test appointment. In order to investigate the study's question, qualitative information was gathered through an expert interview, interviews with the user and workshops with the user. These methods were analyzed and resulted in requests for physical attributes in the product. Parts of the requests were included in decisions later in the design process. The users’ problems were defined in the method Problem Definition. The problems that the users indicated during this method were; a lack of comfort in the waiting rooms, unclear waiting times, and restlessness in the waiting room. The Problem Definition method becomes the basis of the study in the design process where decisions are made based on solving the problems just mentioned. The design process mainly consisted of brainstorming, brainwriting and two parts of sketching and prototyping where the final concept was produced. The study’s question is answered through an interactive piece of furniture. The chair aims to increase comfort in the waiting room and encourage interaction with the user, thus reducing stress and anxiety. The interaction takes place by the user rocking the chair up and down while sitting down and leaning back in the chair.  The conclusion is that product design can support a stressed and anxious patient by making them comfortable, creating comfort and distracting from the waiting time in the waiting room. The final product resulted in what was described above, but further user tests, functional tests, etc. are required to produce a chair fully functional for its purpose.

This study is a secondary analysis of survey data collected in fall 2000 from patients of a safety-net hospital and its eight community health outreach clinics in Fort Worth, Texas. The study examined three objectives. These include explaining the utilization of Pap smear tests among the sample who were low-income women, by ascertaining the determinants of using these services. Using binary logistic regressions analyses primarily, the study tested 10 hypotheses. The main hypothesis tested the race/ethnicity/immigration status effect on Pap smear screening. The remaining hypotheses examined the effects of other independent/control variables on having a Pap smear. Results from the data provide support for the existence of a race/ethnicity/immigration status effect. Anglos were more likely to have had a Pap smear, followed by African Americans, Hispanic immigrants, and finally, by Hispanic Americans. The persistence of the race/ethnicity/immigration status effect, even when the effects of other independent/control variables are taken into account, may be explained by several factors. These include cultural differences between the different groups studied. The race/ethnicity/immigration status effect on Pap smear screening changed with the introduction of age, usual source of care, check-up for current pregnancy, and having multiple competing needs for food, clothing and housing into the models studied. Other variables, such as marital status, employment status and health insurance coverage had no statistically significant effects on Pap smear screening. The findings of this study are unique, probably due to the hospital-based sample who has regular access to subsidized health insurance from a publicly funded safety-net healthcare network and its healthcare providers. Given the importance of race/ethnicity/immigration status for preventive Pap smear screening, public education efforts to promote appropriate Pap smear tests among vulnerable populations should target specific race/ethnicity/immigration status groups in the U.S. within the cultural context of each group. Furthermore, publicly funded health programs for underserved populations such as the John Peter Smith Connections and Medicaid should be maintained and strengthened.

Made available in DSpace on 2015-03-05T20:04:16Z (GMT). No. of bitstreams: 0 Previous issue date: 5 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior / Objetivo: Investigar o acesso de mulheres negras e brancas aos exames de detecção precoce de câncer, mama e citopatológico (CP), em duas cidades no sul do Brasil. Métodos: Estudo transversal de base populacional realizado a partir da junção de duas amostras representativas de mulheres dos 20 aos 60 anos, residentes em São Leopoldo e em Pelotas, cidades localizadas no sul do Brasil. As análises foram ajustadas por renda, escolaridade, classe econômica e idade para verificar a associação entre raça/cor e o acesso ao CP e ao exame de mama. Resultados: Foram entrevistadas 2030 mulheres, das quais 327 (16,1%) eram negras e 1703 (83,9%) brancas. Houve maior percentual de mulheres negras pertencentes aos estratos mais baixos de renda, de classe econômica e de escolaridade comparados com as mulheres brancas. A probabilidade das mulheres não realizarem os exames citopatológico e de mama foi significantemente maior nas negras. A desigualdade racial no acesso aos exames de detecção precoce de câncer persistiu após con / Objective: To investigate the access of both Black and White women to cancer early detection exams, breast and pap-smear, in two cities in Southern Brazil.Methods: A population based cross-sectional study that combines two representative samples of women aged from 20 to 60 years, from São Leopoldo and Pelotas, south Brazil cities. The analyses were adjusted according to income, education, economic class and age in order to verify the association of race/color with the access to pap-smear and breast exam. Results: Out of 2030 women interviewed, 327 (16.1%) were Black and 1703 (83.9%) were White. In comparison with White women, there were higher percentages of Black women in the lower strata of income, economic class and education. The probability of not accomplishing pap-smear and breast exam was significantly higher among Black women. Racial inequalities in access to cancer early detection exams persisted after controlling for age and other socioeconomic variables. In the previous year, Black women, regardl

Background Screening by cytology has been highly effective in reducing the incidence and mortality from squamous invasive cervical cancer (ICC), but the effectiveness is less established regarding non-squamous ICC and regarding women above screening ages and below 30 years of age. Cervical cancer still occurs despite the presence of an organised screening programme. A substantial proportion of screened women with ICC are reported to have had previous abnormal cytology findings. The significance of negative cytology with limited evaluation is not quite determined, the most effective management of women with low-grade abnormalities is controversial, and evaluation of long-term effect of different treatment methods is limited. Aims To identify possible areas of improvements in the prevention of cervical cancer by evaluating the effectiveness of the Swedish cervical screening programme, and by exploring risk factors for ICC in the cytological screening histories and in the management of women with abnormal cytology findings. Methods The screening histories of all ICC cases in Sweden 1999-2001 (n=1230) and of five population-based control women per case were reviewed, using data from the Swedish Cancer Registry, the national population register, the Swedish national cervical screening quality register, histopathological reports and questionnaires to clinicians. The risk of cervical cancer according to screening histories 0.5-6.5 years before cancer diagnosis was estimated as odds ratios (ORs) in logistic regression models with 95% confidence interval (CI) (Paper I). Risk related to different cytological reports was assessed in women below 67 years of age with cytology (n=572, n=3569) in Paper II. The initial follow-up of women with abnormal or unsatisfactory cytology reports (n=159, n=258) was evaluated in Paper III, and further investigation and treatment of abnormalities (n=143 cases, n=176 controls) in Paper IV. Results The cancer cases were above screening ages (31%), had not been screened according to recommendations (33%), had negative cytology (23%), or had previous positive screening tests (13%). No screening within the recommended interval increased the risk of squamous (OR 2.97, 95% CI 2.51-3.50) as well as non-squamous cancer (OR 1.59, 95% CI 1.20-2.11), and increased the risk in all ages. Negative cytology with partially obscuring factors and unsatisfactory cytology increased the risk of subsequent early stage ICC. All cytological abnormalities increased the risk of ICC, and women with glandular atypia or atypia in cells of uncertain origin carried a particularly high risk (OR 11.69, 95% CI 7.02-19.46). After a low-grade squamous abnormal smear finding, further investigation with biopsy was more effective than repeated cytology (OR 0.46, 95% CI 0.24-0.89). Lack of biopsy increased the risk in women with both low-grade and high-grade squamous abnormalities. Neither repeat cytology, nor biopsy, decreased the risk in women with glandular atypia or atypia in cells of uncertain origin. Treatment decreased the risk, even when the biopsy before treatment was negative or showed low-grade atypia only. Ablative therapy was less effective than excision and laser conisation was the most effective therapy. Conclusions Improved adherence to screening recommendations and including older women at increased risk in the programme would have significant cancer preventive gains. Women with negative cytology with limited evaluation and with unsatisfactory cytology may need further evaluation. Assessment with biopsy should be recommended for women with low-grade as well as high-grade squamous abnormalities. The diagnosing of precancer lesions and the identification of women in need of treatment warrant improvements, in particular in cases of glandular or “other” atypia in cytology. Treatment techniques need further evaluation.

Abstract Malignancy Associated Changes are subtle alterations in the morphology and nuclear texture of cells in the vicinity of a malignant lesion. The phenomenon was first described in 1959, and has been the subject of considerable research in the four intervening decades, due to its potential utility to cancer screening programs. In this thesis the history of research into malignancy associated changes is reviewed, and the major findings of previous workers summarized. Original work aimed at improving the accuracy of classification of Pap smear slides is described in detail. A novel algorithm, which incorporates a genetic algorithm for feature selection and training of a neural network, is described. The algorithm was tested upon a large artificial dataset consisting of points from nested spheres in multiple dimensions. It was able to select the most discriminatory features and classify data with 99% accuracy on 80% of runs for two dimensional data, and on 90% of runs for three-dimensional data. The algorithm was also tested on two real data sets from the UCI Machine Learning Repository, the “sonar” data and the “ionosphere” data. On both of these datasets the algorithm produced a classifier using a subset of features which performed as well as previously reported classifiers using the full feature set. This algorithm was then tested on a large dataset of cell images, and its performance compared with that of the standard stepwise linear discriminant analysis approach. Both of these approaches produced similar results, which are comparable to those of previous workers in this field. Interestingly, runs of the genetic algorithm with different random number seeds tended to select different feature subsets, which produced approximately equivalent performance. This finding indicates that amongst the features used, which were selected from those previously identified in the literature as useful for MACs detection, many subsets exist which are equally discriminatory.

O objetivo geral dessa pesquisa é demonstrar como uma Associação de Mulheres em uma entidade religiosa pode proporcionar um local favorável para a realização de educação em saúde com a finalidade de proporcionar conhecimento em um ambiente seguro vinculando a ação individual e coletiva de busca de vivências que melhore a saúde das mulheres e combatendo uma doença que no Brasil é a terceira causa de morte feminina em território nacional segundo o Ministério da Saúde. As associações de mulheres em entidades religiosas possuem estatutos próprios que estabelecem as diretrizes a serem seguidas pelas as mulheres. Através de um conhecimento prévio do estatuto das Associações de Mulheres em entidades religiosas, do Programa Atenção Integral a Saúde da Mulher (PAISM), conhecimento das Leis do Sistema Único de Saúde (SUS) e do programa de prevenção do câncer de colo uterino, os profissionais da saúde responsáveis por promover promoção, prevenção e reabilitação poderão ter um local propicio onde as mulheres de forma individual e coletiva se sintam seguras para obter conhecimento, estabelecer metas e realizar ações de promoção e prevenção para o Câncer de Colo Uterino e a superação das barreiras enfrentadas pelas mulheres na realização do exame citopatológico. A hipótese do trabalho é que os profissionais de saúde que trabalham com educação permanente em saúde podem e devem utilizar o ambiente religioso para realizar promoção, prevenção e reabilitação de todas as politicas de saúde preconizadas pelo Programa Atenção Integral a Saúde da Mulher. Trata-se de uma pesquisa qualitativa baseada no estudo fenomenológico-hermenêutico direcionado ao método de analise de estudos teóricos, documentos e textos. O fenômeno foi descrito pelo método descritivo através da escolha do tema, levantamento bibliográfico, formatação do problema, formulação das hipóteses, ficha de leitura do material e fichamento, delimitação da pesquisa, coleta de dados, discussão e conclusão. A pesquisa foi delineada através da analise do estatuto da Sociedade de Socorro que é uma associação de mulheres de A Igreja de Jesus Cristo dos Santos dos últimos Dias conjuntamente com uma analise das politicas do SUS do PAISM e do programa de promoção e prevenção do câncer de colo uterino vigente em território brasileiro. Uma associação de mulheres em uma entidade religiosa possui um extraordinário trabalho, estabelecendo como propósito dessa organização de mulheres preparadas para as bênçãos da vida eterna, ajudando-as a aumentar sua fé e retidão pessoal, fortalecer a família e o lar, e auxiliar os necessitados. A educação em saúde nesses locais fortalecerá os princípios do SUS e a melhoria na condição de saúde das mulheres como proposito primordial. O cumprimento desse propósito se dará por meio de aulas proporcionadas pelos profissionais de saúdes e reforçada nas aulas do evangelho aos domingos e de outras reuniões, do trabalho de professoras visitantes, do serviço de bem-estar e do serviço de solidariedade. Sendo assim, venho advogar pela inclusão ou manutenção da educação permanente em saúde nas associações de mulheres nas mais diversas religiões. / The overall goal of this research is to demonstrate how an Association of Women in a religious entity may provide a favorable location for conducting health education with the purpose of providing knowledge in a safe environment while linking individual action and collective research experience that improves women's health and fighting a disease in Brazil that is the third leading cause of death of women in the country according to the Ministry of Health. Women's associations in religious bodies have their own statutes that establish the guidelines to be followed by the women. Through a prior knowledge of the status in Womens Associations in religious entities, the Comprehensive Care Program for Women's Health (CCPWH), knowledge of the Laws of the Unified Health System (UHS) and the program for prevention of cervical cancer, the professionals responsible for promoting health promotion, prevention and rehabilitation may have a conducive place where women individually and collectively feel safe to obtain knowledge, set goals, and achieve promotion and prevention for cervical cancer and overcome barriers faced by women in the Pap smear testing. The hypothesis of the study is that health professionals who work with continuing health education can and must use this environment to perform religious promotion, prevention and rehabilitation of all health policies advocated by the CCPWH. This is a qualitative research study based on hermeneutic-phenomenological directed method for analysis of theoretical studies, documents and texts. The phenomenon was described by the descriptive method for choosing the topic, bibliography, formatting the problem, formulating hypotheses, form reading and cataloging the material, delimitation of the research, data collection, discussion and conclusion. This research was designed through analyzing the status of the Relief Society, the association for women of The Church of Jesus Christ of Latter-day Saints, in conjunction with an analysis of the policies of the UHS with the CCPWH a program for promotion and cervical cancer prevention currently in force in Brazil. An association of women in a religious entity has an extraordinary work; establishing the purpose of this organization of women prepared for the blessings of eternal life by helping them to increase their faith and personal righteousness, strengthen families and homes, and help the needy. Health education in these locations will strengthen the principles of the UHS and improve the health status of women as a primary purpose. The fulfillment of this purpose will be through classes offered by health professionals and enhanced gospel classes on Sundays and other meetings, also through visiting teaching, welfare service, and compassionate service to the poor and needy. Therefore, come advocate for inclusion or maintenance of continuing health education in women's associations in various religions.

Aim: The aim of this thesis was to investigate experiences of receiving notification of an abnormal Pap smear result and its impact on women’s health-related quality of life as well as to investigate women’s awareness of human papillomavirus.   Methods: In total, 176 women and 20 healthcare professionals participated. Data were collected through individual interviews (I, II) and a questionnaire (IV) including the instrument Functional Assessment of Chronic Illness Therapy – Cervical Dysplasia (FACIT-CD) and Hospital Anxiety and Depression Scale (HADS). For the translation and cross-cultural adaptation of the FACIT-CD, and for evaluation of its linguistic validity and reliability, cognitive debriefing interviews and a questionnaire consisting of the Swedish instrument FACIT-CD was used. Data were analysed by content analysis (I, II) and by using statistical analysis (III, IV), while one part (III) was analysed according to FACIT translation methodology.     Results: Women receiving notification of an abnormal Pap smear result have good overall HRQoL; they become anxious but not depressed. Reasons for anxiety were mainly that women misinterpreted the result as cancer, which could lead to lower attendance for further investigation, treatment and follow-up. To cope with the anxiety, women sought emotional support and information. They primarily used the Internet for information but also turned to healthcare professionals for information needs. Moreover, women had low awareness of HPV, its sexually transmitted nature, and its relationship to abnormal Pap smear results and cervical cancer. An awareness of HPV as a sexually transmitted infection did not lead to higher level of anxiety or more depression symptoms or worse HRQoL, compared to not being aware. Finally, the Swedish FACIT-CD is equivalent to the English version and linguistically valid and exhibited good internal consistency reliability.   Conclusion: Women have low awareness of HPV and abnormal Pap smear results, whereupon they misinterpret their test result as cancer. It is of importance that women understand their test result, in order to minimise anxiety as well as to maintain high attendance for investigation, treatment and follow-up of abnormalities.