Public Health

Factors associated with advanced-stage diagnosis of cervical cancer in Estonia: a population-based study

Cervical cancer (CC) remains a crucial public health issue in Estonia, with high incidence and late diagnosis. The aim of this study was to examine time trends of stage-specific CC incidence in Estonia and factors associated with advanced-stage diagnosis of CC. This was a nationwide population-based retrospective study. Data on CC cases diagnosed in Estonia in 2007-2018 were obtained from the Estonian Cancer Registry, including tumour, nodes, metastases stage at diagnosis. Sociodemographic data were obtained from the Population Registry. To estimate the risk of advanced-stage diagnosis (stages II-IV vs stage I) associated with sociodemographic factors, Poisson regression with robust variance was used to calculate univariate and multivariate prevalence ratios (PR) with 95% confidence intervals (CIs). Time trends of stage-specific CC incidence for 2005-2019 were examined with joinpoint analysis. Incidence of stage I CC showed a significant decline of 4.9% per year since 2007, whereas no change was seen for other stages. Of the 2046 women diagnosed in 2007-2018, 1137 (55.6%) were diagnosed at an advanced stage; this proportion increased from 51% in 2007-2009 to 58% in 2015-2018 (P = 0.004). Multivariate regression analysis showed that advanced-stage diagnosis was associated with age (PR 2.16, 95% CI 1.87-2.49 for women aged ≥75 years compared with those aged 30-44 years), educational level (PR 1.32, 95% CI 1.15-1.51 for women with basic/primary education compared to university education) and marital status (PR 1.14, 95% CI 1.01-1.29 for single women compared to married/cohabiting women). No associations were observed by region of residence or nationality. To reduce CC mortality, it is crucial to improve prevention and early diagnosis of CC in Estonia through human papillomavirus vaccination and effective and quality-assured screening particularly targeting high-risk groups as well as encouraging symptom awareness and regular check-ups among older women.

Fighting cervical cancer in Africa: a cross-sectional study on prevalence and risk factors for precancerous lesions in rural Uganda

To identify risk factors for precancerous cervical lesions and factors associated with treatment delay among women in the rural Busoga Region, Uganda. A retrospective cross-sectional study from a regional cervical cancer screening program and from cervical cancer patients enrolled in a region-wide palliative care program. Logistic regression analysis was conducted to assess risk factors for screening positive for precancerous lesions. In a separate analysis, factors associated with treatment delay were assessed among women enrolled in the palliative care program. Three thousand nine hundred forty-six women were included from the screening program and 334 from the palliative care program. In total, 7.6% of screening participants had precancerous lesions. Within Busoga Region, the highest positivity rate was found in Bugweri and Namayingo Districts. Abnormal vaginal bleeding (adjusted odds ratio [aOR] 1.60; 95% confidence interval [CI] 1.15-2.21; p = 0.005) and older age at first menstrual period (aOR 1.08; 95% CI 1.01-1.16; p = 0.03) were associated with having a precancerous lesion. Among palliative care patients, a history of previous contact with the health care system was associated with a delay in enrolment (≥12 months from first symptom presentation until commencement in palliative care; aOR 5.23; 95% CI 1.16-36.54; p = 0.047). The results underline an unmet need for broad-scale cervical cancer screening focusing on all women in the reproductive age. Abnormal bleeding was the only substantial risk factor for precancerous lesions, indicating that specific algorithms to identify high-risk populations may not be applicable in this population. Increased awareness, resources, and funding are still necessary to achieve global cervical cancer elimination.

Conventional cytology scheme: adherence and associated factors

This study analyzed adherence rates to conventional cytology and associated factors in a cohort of women at a health service provider institution in Medellin, Colombia. Observational cohort study with repeated measures. Clinical and sociodemographic data were obtained from databases for screenings between January 2018 and December 2022. Adherence, defined as undergoing 1, 2, or 3 cytology tests according to national guidelines, was the outcome. Statistical analysis involved a Poisson model with robust errors to identify factors associated with adherence. In total, 26,445 women were included, with a median age of 25 years (IQR: 22-27). Adherence rate was 20.4%. Having just high school education (RR = 0.51; 95% CI: 0.49-0.55), a history of pregnancy (RR = 0.63; 95% CI: 0.54-0.75), and a history of sexually transmitted infections (RR = 0.88; 95% CI: 0.78-0.99) decreased adherence. Conversely, the human papillomavirus (HPV) vaccination history increased adherence (RR = 2.11; 95% CI: 1.60-2.80). It is vital to monitor cytology programs to improve demand-induced and spontaneous consultations. Diligent follow-up, focusing on patients with factors linked to low adherence, along with appointment reminders, can enhance adherence to the screening protocol.

Educational inequalities in cervical cancer screening participation in 24 European countries

Cervical cancer screening (CCS) is an important public health measure for early detection of cervical cancer and prevents a large proportion of cervical cancer deaths. However, participation in CCS is relatively low and varies substantially by country and socio-economic position. This study aimed to provide up-to-date participation rates and estimates on educational inequalities in CCS participation in 24 European countries with population-based CCS programmes. This was a cross-sectional study. Using data from the European Health Interview Survey (EHIS) conducted in 2019, 80,479 women aged 25-64 years were included in the analyses. First, standardized participation rates and standardized participation rates by educational attainment were calculated for all 24 countries based on each country-specific screening programme organization. Second, a series of generalized logistic models was applied to assess the effect of education on CCS participation. Screening participation rates ranged from 34.1% among low-educated women in Romania to 97.1% among high-educated women in Finland. We observed that lower-educated women were less likely to attend CCS than their higher-educated counterparts. Largest educational gaps were found in Sweden (odds ratio [OR] = 6.36, 95% confidence interval [CI] = 3.89-10.35) and Poland (odds ratio = 5.80, 95% CI = 4.34-7.75). Population-based screening initiatives have successfully reduced participation differences between women with medium and high educational attainment in some countries; however, persistent disparities still exist between women with low and high levels of education. There is an urgent need to increase participation rates of CCS, especially among lower-educated women.

The application value of low-risk human papillomavirus testing in cervical cancer prevention and treatment in low- and middle-resource areas

To assess the application value of low-risk human papillomavirus (lrHPV) detection in the prevention and treatment of cervical cancer in low- and middle-resource areas (LMRAs). A retrospective cross-sectional study. Cervical HPV typing results were collected from 2019 to 2023, utilizing fluorescence PCR technology. An adjusted logistic regression model was used to assess the relative risk (OR) and 95 % confidence interval (CI) for co-infection with lrHPV and high-risk HPV (hrHPV). Out of 113,883 women included in the study, the overall lrHPV positivity rate was 1.9 %. In total, 47.7 % (1033/2167) of lrHPV positive women also had hrHPV co-infections. Multivariate analysis identified 12 hrHPV subtypes (T-hrHPV) significantly associated with co-infection risk, including HPV16, 31, 33, 39, 51, 52, 53, 56, 59, 66, 68, and 73. The risk of T-hrHPV infection was 3.77 times higher (95 % CI: 3.44-4.12) for women with a single lrHPV infection and 9.71 times higher (95 % CI: 4.72-19.99) for those with two lrHPV infections. Women screened in the gynecological outpatient clinic faced a T-hrHPV infection risk 2.64 times higher (95 % CI: 2.54-2.74) than those in the general health check department. lrHPV positivity significantly increases the risk of T-hrHPV co-infection, particularly under multiple infections, highlighting the importance of comprehensive HPV screening in LMRAs. The notable differences in T-hrHPV infection risks across various screening settings highlight their critical role in cervical cancer prevention and offer new insights into optimizing vaccination strategies to enhance effective prevention and treatment in LMRAs.

Prioritizing performance and outcome indicators for quality assessment of cancer screening programs in the EU

A key element in ensuring appropriate balance of harms and benefits in cancer screening is to develop a priority set of performance and outcome indicators to be used in screening data evaluation systems. These indicators need to be equity-focused, aligned to new screening approaches and broad-based to cover possible opportunistic screening, but at the same time as limited as possible. Indicators for breast, colorectal and cervical cancer screening programs were chosen through a consensus building Delphi methodology involving a panel of cancer screening experts. The list of indicators was developed using a multistage process. First, a systematic search was performed along with an extensive grey literature search to identify all potential existing indicators. Next, these indicators were refined by two expert groups, definitions and calculations were agreed upon, redundant indicators removed. A final list of 38 indicators was put forward into a Delphi study. 33 cancer screening experts were invited to take part. The Delphi study consisted of two rounds of an online survey and an online facilitated discussion between the cancer screening experts. 23 indicators were chosen covering 10 predefined indicator categories with detection rate, examination coverage and interval cancer rate deemed most important. Outcome indicators such as crude incidence rate and time from screen to result notification, while ultimately reaching consensus were deemed of less importance. 23 priority indicators cover the entire screening pathway including harms, barriers and inequalities. These indicators have been piloted by the CanScreen-ECIS project.

Adherence to the EAT-Lancet diet reduces the risk of renal cancer: Results from a population-based prospective study

Positive associations between dietary potential acid load and renal cancer incidence and mortality: Results from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening trial

Knowledge that HPV can cause oropharyngeal cancer and cervical cancer among adults in the United States: A comparison of prevalence and predictors

To compare prevalence and predictors of knowledge that human papillomavirus (HPV) can cause oropharyngeal cancer (OPC) and cervical cancer among U.S. adults. Cross-sectional. Using Health Information National Trends Survey-5 cycles 1-4 (2017-2020), we estimated weighted prevalence of knowledge that HPV can cause OPC and cervical cancer, overall and by sex. Predictors were identified using logistic regression adjusting for age, sex, race and ethnicity, and education. Females vs. males had greater OPC knowledge (22.3 % vs. 17.1 %) [adjusted odds ratio (aOR) = 1.4; 95 % confidence interval (95 % CI) = 1.2-1.6] and cervical cancer knowledge (59.4 % vs. 40.0 %) (aOR = 2.6; 95 % CI = 2.2-3.0). Females with notably greater OPC knowledge were White vs. Black (aOR = 2.0; 95 % CI = 1.5-2.7), and had a college degree or higher vs. high school or less (aOR = 2.8; 95 % CI = 2.1-3.7). Males with greater OPC knowledge had a college degree or higher vs. high school or less (aOR = 3.1; 95 % CI = 2.2-4.4) and visited a provider 1-2 times within the past year (aOR = 1.7; 95 % CI = 1.1-2.6). Females with greater cervical cancer knowledge were White vs. Black (aOR = 2.1; 95 % CI = 1.6-2.6), had a college degree or higher vs. high school or less (aOR = 5.6; 95 % CI = 4.5-6.9), and visited a provider within the past year (aOR = 2.2; 95 % CI = 1.7-2.9). Males with greater cervical cancer knowledge were White vs. Black (aOR = 1.6; 95 % CI = 1.1-2.4), had at least $75,000 vs. $34,999 or less annual income (aOR = 1.8; 95 % CI = 1.3-2.4), had a college degree or higher vs. high school or less (aOR = 4.7; 95 % CI = 3.5-6.2), and visited a provider within the past year (aOR = 1.5; 95 % CI = 1.1-2.2). HPV-related cancer knowledge is limited, especially for OPC. Knowledge disparities exist across many social and healthcare engagement factors, emphasizing need for broader dissemination of HPV education.

Mortality due to cervical and breast cancer in health regions of Brazil: impact of public policies on cancer care

This analysis assessed the association between regional income, screening coverage for cervical and breast cancer, and temporal trends in mortality from these cancers in different Brazilian health regions. Spatiotemporal ecological study across 450 health regions of Brazil. Data from 2010 Demographic Census were used to assess income. Variations in income distribution within health regions were measured using the Gini index. Data on screening coverage were obtained from the Ambulatory Information System (SIA/SUS). Mortality was assessed from the Global Burden of Disease Study 2019 data. The average annual percentage change (AAPC) in cervical and breast cancer mortality rates, 2010-2018, was calculated by health regions. Results were presented in regional maps. The associations between income, screening coverage and mortality changes were estimated by bivariate spatial correlation. Health regions located in the South and Southeast regions of Brazil had the greatest percentages of screening coverage and highest per capita incomes with the lowest Gini index values. From 2010 to 2018, mortality rates for cervical cancer were highest in the North and Northeast health regions. Breast cancer mortality rates were highest in the South and Southeast health regions. The AAPC in breast and cervical cancer mortality had a negative association with per capita income and screening coverage, and a positive association with the Gini index. There are large regional variations in income, screening coverage, and mortality rates for women with breast and cervical cancer. These inequities could be mitigated by policies to address income disparities and improved access to screening.

Measuring the societal burden of cancer: a case of lost productivity in Nepal

The global patterns of cancer incidences and mortality rates are slowly shifting towards low- and middle-income countries. Through our article, we highlight the societal cost associated with premature mortality and morbidity of cancer in Nepal. The monetary loss is indicative of the severity of the issue and it serves to motivate the policymakers realize the urgency in devising appropriate cancer control strategies. The study design is a cross-sectional study using the GLOBOCAN 2012 data. Using the human capital approach, we measure the number of years of life lost (YLL) and the number of years of productive life lost (YPLL) due to cancer in Nepal. We found that following diagnosis, a Nepali patient with cancer is likely to lose out on 19.64 years of their life; the average number of YLL is higher for females (22.2 years vs 16.8 years in males). After adjusting for labor force participation rate and predicted growth rate of the economy, we found that cancer led to a total productivity loss of $149 million (males) and $121 million (females) in 2012. The burden of the top five cancers accounted for almost half of the total productivity loss in both the genders. Cervical and lung cancer incur the maximum cost to society, respectively, for females and males. The article highlighted the severity of the cancer issue and emphasized the urgency needed in devising cancer control policies in Nepal.

Young adults' human papillomavirus–related knowledge: source of medical information matters

Few studies examine the influence that different sources of medical information has on human papillomavirus (HPV)-related knowledge. We examined the relationship between the primary source of medical information and knowledge about HPV in young adults aged 18-26 years. This study used cross-sectional data from the Health Information National Trends Survey. Respondents (n = 404) self-reported their knowledge about HPV-related diseases and vaccinations and their sources of medical information. Sources of medical information included electronic/print media, family/friends, or a healthcare provider. Bivariate and multivariate analyses were used to examine the association between the source of information and HPV knowledge. Fifty-six percent of respondents used electronic or print media as their primary source of medical information. A greater proportion of Hispanic (40.0%) and black (36.0%) respondents received medical information from their family/friends than white respondents (20.0%). Respondents who received medical information from family/friends had 4.34 (95% confidence interval [CI]: 2.14, 8.79), 4.06 (95% CI: 2.05, 8.04), and 2.35 (95% CI: 1.10, 5.04) times higher odds than those who received information from healthcare providers of not knowing that HPV causes cervical cancer, knowing HPV is a sexually transmitted infection, and hearing about the HPV vaccine, respectively. Source of medical information was significantly associated with knowledge of HPV. Receiving medical information from family/friends negatively influenced young adults' HPV knowledge. These findings may guide future interventions to target peer and familial influence on medical decisions.

Reasons for non-participation in public oncological screening programs in the Italian region Friuli Venezia Giulia

In the Italian region Friuli Venezia Giulia, public screening is offered for cervical cancer, breast cancer, and colorectal cancer. Participation of the target population is lower than 70%. Our aim was to investigate reasons for non-participation. This is a qualitative survey. A telephone survey was conducted in 2018 on a random sample of persons not adhering in 2017. Only one question about the reason for non-participation was asked. The answers were transcribed verbatim with no personal identifiers and no additional information. The transcribed anonymous answers were then read and classified into mutually exclusive macrocategories and subcategories. A total of 4456 non-adhering persons were surveyed. Personal practical issues were the most common type of barrier reported in all three screening programs, followed by personal beliefs. Program-related issues were more common in cervical cancer screening than in the others. Almost half of the women not participating in the public breast cancer screening and 40% of those not adhering to the public cervical cancer screening had mammography or Pap test out of the public program. In this region, practitioners should work to overcome practical barriers and discuss personal beliefs. Surveys of non-participants in other geographic areas would be important to adequately inform local policymaking.

Awareness, knowledge, and attitude toward cervical cancer screening and prevention in Uganda

Cervical cancer is the most prevalent cancer in Uganda, posing a significant burden with high mortality rates. Early detection through screening is crucial to reduce cervical cancer mortality. This study aimed to investigate the awareness, knowledge, and attitudes toward cervical cancer and its screening among residents in the central and western regions of Uganda. Cross-sectional study. A cross-sectional study was conducted through face-to-face interviews using a structured questionnaire, during October and November 2023 in Kampala City, Mbarara City, and Mbarara District. A total of 2000 men and women aged ≥20 years participated in the study. Among the respondents, 95 % were aware of cervical cancer, 85.1 % knew about cervical cancer screening, 37.8 % had heard of the human papillomavirus (HPV), and only 18.9 % recognized HPV as a major risk factor. Among females, 35 % had undergone cervical cancer screening. The most significant barrier preventing access to screening was a lack of knowledge (74.1 %). More than half of the respondents considered cervical cancer to be a fatal disease (52.9 %), and 93.7 % of females expressed willingness to undergo screening if provided for free. While awareness of cervical cancer and its screening was high, knowledge of HPV and actual cervical cancer screening rates were low, despite a high willingness to undergo screening. Increased investment in education and awareness campaigns, along with an organized cervical cancer screening program, is warranted to promote screening and reduce the cervical cancer burden in Uganda.

Resilience of the Dutch HPV-based cervical screening programme during the COVID-19 pandemic

Organisation of a screening programme influences programme resilience to a disruption as COVID-19. Due to COVID-19, the Dutch human papillomavirus-based cervical screening programme was temporarily suspended. Afterwards, multiple measures have been taken to catch-up participation. This study aimed to investigate programme resilience by examining the effect of COVID-19 and programme measures taken on participation in cervical screening. Observational cohort study. Data from the national screening registry and Dutch nationwide pathology databank (Palga) were used on invitations and follow-up in 2018/2019 (pre-COVID) and 2020 (COVID). Sending invitations, reminders and self-sampling kits were suspended from March to July 2020. Main outcome measures include distribution of participant characteristics (age, region and screening history), participation rates by age and region, time between invitation and participation (i.e. response time) and self-sampling use per month. Participation rate was significantly lower in 2020 (49.8%) compared to 2018/19 (56.8%, P < 0.001), in all ages and regions. Compared to 2018/19, participation rates decreased most in women invited from January to March 2020 (-6.7%, -9.1% and -10.4%, respectively). From August, participation rates started to recover (difference between -0.8% and -2.7%). Median response time was longer in February and March (2020: 143 and 173 days; 2018/19: 53 and 55 days) and comparable from July onwards (median difference 0-6 days). Self-sampling use was higher in 2020 (16.3%) compared to 2018/19 (7.6%). The pandemic impacted participation rates in the Dutch cervical screening programme, especially of women invited before the programme pause. Implementation of self-sampling in national cervical screening programmes could increase participation rates and could serve as an alternative screening method in times of exceptional health care circumstances, such as a pandemic. Due to the well-organised programme and measures taken to catch-up participation, the impact of COVID-19 on the screening programme remained small.

Women's initial preferences for self-sampling tests at home for cervical cancer screening in the UK: A mixed-methods analysis of demographic and behavioural factors

To identify the demographic and behavioural factors associated with cervical screening preferences if a choice of test, health professional-collected samples or self-sampling at home, is implemented in the UK; and the behavioural barriers to self-sampling at home. A mixed-methods study of secondary data. We used data from the Cancer Research UK CAM + survey (February 2023) and performed a quantitative regression analysis to examine the associations between demographics, behavioural factors, screening behaviours, and screening preferences of the UK population aged 25-64. Unadjusted and multivariable adjusted logistic regression models were used. Qualitative content analysis was used for free text comments on behavioural barriers to self-sampling and mapped onto the Theoretical Domains Framework. Analytical sample (n = 906). Test preference: Self-sampling (45.4 %); health professional-collected samples (41.1 %); and no test preference (13.6 %). Preference for self-sampling was significantly associated with older groups and psychosocial barriers (motivation and physical opportunity) regarding health professional-collected samples. Individuals with no test preference were the youngest and older groups, from low social grade and living with a partner. Behavioural barriers included test reliability and ability to do the test (motivation) and information needs (capability). Home seems a suitable setting for self-sampling, and it could alleviate many barriers faced to health professional-collected samples. Yet introducing test options did not allow all individuals a compelling basis for preference. Specific behaviour change techniques for identified barriers are proposed for this group. Ultimately, if choice is offered, future screening guidelines should consider how to address individuals with no test preference.

Socioeconomic inequalities in cervical cancer mortality in Canada, 1990 and 2019: a trend analysis

It is increasingly recognized that those of lower socioeconomic status (SES) are disproportionately affected by cancer mortality. The association between cervical cancer mortality and SES have been reported; however, it remains poorly understood in the Canadian population. Thus, this study investigates trends in income and education inequalities in cervical cancer mortality in Canada over the last three decades. Trend analysis. A dataset constructed at the census division level (n = 280), comprising the Canadian Vital Statistics Death Database, the Canadian Census of Population, and the National Household Survey was used to measure cervical cancer mortality in Canada. Income and education inequalities in cervical cancer mortality were measured using age-standardized Concentration index (C). Crude cervical cancer mortality rates decreased significantly during the study period. Age-standardized C values were negative for the majority of years for income and education inequalities, reaching significance in some years. Trend analyses indicated an increasing concentration of cervical cancer mortality amongst those with lower education levels. Despite recent decreases in cervical cancer mortality rates, socioeconomic inequalities in cervical cancer mortality in Canada are persistent. Notably, those of lower income and education levels are disproportionately affected, underscoring an opportunity to improve clinical outcomes by addressing these inequalities.

The impact of social media on guideline-concordant cervical cancer–screening: insights from a national survey

Cervical cancer is one of the leading causes of cancer mortality in women, yet routine screenings lead to early detection and sometimes even prevention. Screening is an effective way to prevent cervical cancer, and it has been implemented in many countries and regions worldwide, especially in developed countries. However, the incidence of cervical cancer remains a public health problem due to screening disparities in the population. Social media engagement and overloading of online health information may be the cause of this disparity. Cross-sectional study. Data from the Health Information National Trends Survey (a national survey conducted by the National Cancer Institute) was used to characterise cervical cancer screening into two dimensions; namely, high-frequency screening and guideline-concordant screening. The differences between these two screening frequency behaviours were compared by applying ordered logistic regression and binary logistic regression, and the mechanisms of guideline-concordant screening were explored. The factors influencing high-frequency screening and guideline-concordant screening were different. Only self-efficacy (odds ratio [OR] = 1.16; 95% confidence interval [CI] = 0.98, 1.37) had a significant positive association with the high-frequency screening behaviour. Social media engagement (OR = 0.57; 95% CI = 0.33, 0.96) was shown to have a significant negative impact on guideline-concordant screening. A theory-based mechanism of screening behaviour found that traditional health perception factors no longer influence guideline-concordant screening behaviour, whereas environmental factors (e.g., social media) significantly reduce guideline-concordant screening behaviour. The results from this study indicate that while the internet has become the main channel through which women acquire health resources, and social media has become a main platform for people to obtain health information, online information cannot guide people to engage in appropriate healthy behaviours. Overloading of online health information and the digital divide may lead to excessive screening. Consequently, it is important to address the screening disparity caused by health behaviours as a result of environmental factors and the digital divide.

Variation in insurance-mortality relationship amid macroeconomic shifts: a study of SEER female-specific cancer patients in USA

Health insurance availability and affordability are vital elements in diagnosis and treatment of patients with cancer and thus constitute clinical significance as well. Although past studies have explored the disparity in mortality figures for patients with different insurance statuses, this population-based study is pioneering in analyzing the changes in cancer mortality risks over time amid macroeconomic shifts. The study uses Surveillance Epidemiology and End Results (SEER) data of 424,889 non-elderly patients with breast, cervical, ovarian, and uterine cancer diagnosed during 2007-2010 and 2011-2015. In addition to discussing incidence figures and insurance patterns, the study uses Kaplan-Meier and Cox's proportional hazard models to examine the changes in survival probability and mortality risks for insurance-stratified patients with female-specific cancer across the two time periods. Patients without insurance have an increased risk of mortality over time relative to insured patients. Moreover, uninsured patients face this heightened risk more than Medicaid patients. Despite public policy measures as well as advancements in diagnostic facilities and treatment technology, the increased relative mortality of patients without insurance limits the long-term affordability of cancer treatment for economically vulnerable patients in comparison with insured patients.

Cervical screening coverage in England before and during COVID-19

Spatial evaluation of prevalence, pattern and predictors of cervical cancer screening in India

To investigate the social determinants of cervical cancer screening and report the locations vulnerable to poor utilization of cervical cancer screening services. An ecological study with the data derived from fourth round of the National Family Health Survey conducted in India in the period 2015-2016. The study focused on the percentage of women who have never undergone cervical cancer screening across 639 districts in India. Moran's I statistic was used to investigate the overall clustering of location. The Getis-Ord Gi* statistic was used for the detection of significant local clusters. Spatial error, spatial lag, spatial Durbin and spatial Durbin error models were compared, and the model with best fit was reported. ArcGIS, GeoDa and R software were used for the analysis. The existence of spatial autocorrelation (Moran's I = 0.61) necessitates the consideration of spatial component while studying the screening data. A significant clustering of districts with poor screening has been observed in the North-Central and North-Eastern regions of India. The geographic arrangement of the percentage of women who have undergone cervical cancer screening was associated with the percentage of women with poor wealth index (P < 0.001), not using a modern method of contraception (P < 0.001), residing in rural areas (P = 0.033) and never heard of sexually transmitted infection (P = 0.014). The range of percentage of women getting cervix screened for cancer was 0.5-68.4%, presenting the heterogeneity among the population elements. A higher risk of poor cervical cancer screening is observed in the districts where most of the women have poor wealth index, reside in urban area, have never heard of sexually transmitted infection and do not use a modern method of contraception.

The impact of community-based multimedia intervention on the new and repeated cervical cancer screening participation among South Asian women

The objectives of this study were to reveal the screening uptake of South Asian women who had participated in the community-based multimedia intervention and to identify the reasons among those women who remained unscreened after receiving the intervention. This was a cross-sectional study. South Asian women (Indian, Pakistani and Nepalese) who had attended a community-based multimedia intervention and who agreed to participate in a follow-up telephone survey were contacted. A structured telephone survey was conducted to collect data on their screening uptake status. There were altogether 371 women who completed the survey. Before attending the intervention, 220 of them had never had a Pap test. After the intervention, 75 of those 220 women (34.1%) decided to attend screening, of which 43 underwent their first Pap test, while 32 made their first Pap test appointment. Among those 151 women who previously underwent screening, 76 of them completed the screening or had scheduled a repeated test. Perceived barriers to screening such as lack of time, language barriers and perception that it was unnecessary to attend screening remained the major reasons for women who were not screened. Some South Asian women started to have their first Pap test, while some continued to attend screening after the intervention. As barriers that affect women's screening participation still exist, continuous and sustainable efforts should be made to improve the overall screening uptake.

Adherence to the EAT-Lancet diet reduces the risk of head and neck cancers in 101,755 American adults: a prospective cohort study