Cancer screening barriers and facilitators for under and never screened populations: A mixed methods study

BackgroundCancer screening is below targets in Ontario, Canada. Our objective was to identify and quantify the barriers and facilitators for breast, cervical and colorectal cancer screening for under and never screened (UNS) residents living in Ontario between 2011 and 2013.MethodsWe used a multi-phased mixed methods study design. Results from thematic analysis of focus group discussions with health care providers and UNS community members were used to develop an on-line, province-wide, cross-sectional survey to estimate the prevalence of barriers and facilitators for the provincial population. Adjusted prevalence odds ratios and 95% confidence intervals were estimated for UNS compared to regularly screened participants using logistic regression.ResultsFour focus groups were held with health service providers and sixteen with UNS community members. Top barriers and facilitators themed around provider-patient communication, fear and embarrassment, history of physical or sexual abuse, social determinants of health (including low literacy, lack of awareness, and health insurance), symptoms appearing, and family and friends. 3075 participants completed the online survey. Compared to regularly screened participants, UNS had significantly higher odds of reporting: no regular health care provider; not feeling comfortable talking about screening; or the Doctor or Nurse Practitioner not suggesting screening. UNS also had significantly higher odds of reporting the facilitators: the test being less scary/painful or uncomfortable; friend/family insisting on getting screened; starting to have symptoms; or an easier test that could be done at home.ConclusionsInterventions addressing fear through individual, interpersonal and structural facilitators may increase cancer screening.     

Obese women's barriers to mammography and pap smear: the possible role of personality

Obese women are at increased risk of developing and dying from cancer, but are less likely than nonobese women to receive cancer screening examinations. Our qualitative study explores obese women's barriers to Pap smears and mammograms in greater depth than previous research. We also seek to understand why some obese women undergo screening whereas others do not. A purposive sample of moderately to severely obese women over age 40 was recruited from community-based organizations, health clinics, and retail establishments. Semi-structured in-depth interviews (N = 33) informed by the Theory of Care-Seeking Behavior and three prior focus groups of obese women (N = 18) were recorded and transcribed. Qualitative analysis was iterative, using a grounded theory approach involving a series of immersion/crystallization cycles. Participants verified many barriers to cervical and breast cancer screening previously identified in the general population, including fear, modesty, competing demands, and low perceived risk. Participants also highlighted several weight-related barriers, including insensitive comments about weight and equipment and gowns that could not accommodate them. Comparison of participants who were up-to-date with both Pap smears and mammograms with those not up-to-date with either screening showed no discernable differences in these barriers, however. Instead, we found that the participants who followed through on their cancer screenings may share certain personality traits, such as conscientiousness or self-regulatory ability, that allow them to complete difficult or feared tasks. Our research therefore suggests that personality may act as an important mediator in health behavior, and should be taken into account in future theoretical models and health behavior interventions, particularly for obese women.     

Engaging New Migrants in Infectious Disease Screening: A Qualitative Semi-Structured Interview Study of UK Migrant Community Health-Care Leads

Migration to Europe - and in particular the UK - has risen dramatically in the past decades, with implications for public health services. Migrants have increased vulnerability to infectious diseases (70% of TB cases and 60% HIV cases are in migrants) and face multiple barriers to healthcare. There is currently considerable debate as to the optimum approach to infectious disease screening in this often hard-to-reach group, and an urgent need for innovative approaches. Little research has focused on the specific experience of new migrants, nor sought their views on ways forward. We undertook a qualitative semi-structured interview study of migrant community health-care leads representing dominant new migrant groups in London, UK, to explore their views around barriers to screening, acceptability of screening, and innovative approaches to screening for four key diseases (HIV, TB, hepatitis B, and hepatitis C). Participants unanimously agreed that current screening models are not perceived to be widely accessible to new migrant communities. Dominant barriers that discourage uptake of screening include disease-related stigma present in their own communities and services being perceived as non-migrant friendly. New migrants are likely to be disproportionately affected by these barriers, with implications for health status. Screening is certainly acceptable to new migrants, however, services need to be developed to become more community-based, proactive, and to work more closely with community organisations; findings that mirror the views of migrants and health-care providers in Europe and internationally. Awareness raising about the benefits of screening within new migrant communities is critical. One innovative approach proposed by participants is a community-based package of health screening combining all key diseases into one general health check-up, to lessen the associated stigma. Further research is needed to develop evidence-based community-focused screening models - drawing on models of best practice from other countries receiving high numbers of migrants.     

Improving uptake of breast screening in multiethnic populations: a randomised controlled trial using practice reception staff to contact non-attenders.

OBJECTIVES: To determine whether a two hour training programme for general practice reception staff could improve uptake in patients who had failed to attend for breast screening, and whether women from different ethnic groups benefited equally. DESIGN: Controlled trial, randomised by general practice. SETTING: Inner London borough of Newham. SUBJECTS: 2064 women aged 50-64 years who had failed to attend for breast screening. Women came from 26 of 37 eligible practices, 31% were white, 17% were Indian, 10% Pakistani, 14% black, 6% Bangladeshi, 1% Chinese, 4% were from other ethnic groups, and in 16% the ethnic group was not reported. MAIN OUTCOME MEASURES: Attendance for breast screening in relation to ethnic group in women who had not taken up their original invitation. RESULTS: Attendance in the intervention group was significantly better than in the control group (9% v 4%). The response was best in Indian women--it was 19% in the intervention group and 5% in the control group. CONCLUSIONS: This simple, low cost intervention improved breast screening rates modestly. Improvement was greatest in Indian women--probably because many practice staff shared their cultural and linguistic background. This intervention could be effective as part of a multifaceted strategy to improve uptake in areas with low rates.     

An audit of cervical cytology in HIV‐positive women

O. E. O. Hotonu, J. Hussey, M. S. T. Basta, V. Wadehra, P. Cross and M. L. Schmid
An audit of cervical cytology in HIV‐positive women Objective: To investigate whether a cohort of human immunodeficiency virus‐positive (HIV+) women were having annual cervical cytology as recommended by the English National Health Service cervical screening programme (NHSCSP) guidelines. Methods: An audit of cervical cytology in an HIV+ cohort of 187 women by obtaining their last cervical cytology result and recall from local cytology services. Results: Of the 187 women in the audit, two were ineligible, leaving 185 women, 167 (90.3%) of whom were aged 25–64 years and eligible for screening. Of the 185 women, 126 (68.1%) had a cytology history, 50 (27%) had never had cervical cytology and nine (4.9%) had inadequate details to ascertain whether or not they had a cytology history. Of the 126 with a cytology record, 34 (27%) had a current cytological abnormality, which was low grade in 25 (19.8%) and high grade in nine (7.1%). Among women aged 25–64 years attending the clinic, these percentages were significantly higher than expected for England as a whole (P < 0.001). Of 126 women with a cytology record, 29 (23%) were overdue for their recall date and of these the previous test was abnormal in 14 (48.3%). Cytology tests were taken within the community setting in 61 (48.4%), whereas 65 (51.6%) were seen either at an HIV sexual health clinic or were under colposcopy follow‐up. Of 91 women with negative cytology only 50 (54.9%) were recommended for repeat in 12 months. Conclusion: This audit demonstrates a high rate of cytological abnormalities among HIV+ women compared with the screening population at large. Implementation of NHSCSP guidelines has been difficult and requires improved care pathways between HIV clinics, primary care and laboratories.     

Fair shares in health care? Ethnic and socioeconomic influences on recording of preventive care in selected inner London general practices. Healthy Eastenders Project.

OBJECTIVE--To describe the association of ethnic and socioeconomic status with recording of preventive care information by selected general practitioners. DESIGN--Random selection of people aged 20-64 registered with 43 general practitioners. Ethnic and social characteristics of stratified samples were determined at interview in the subject''s home. Recording of preventive information was ascertained from general practitioners'' medical records. SETTING--Inner London borough of Tower Hamlets. SUBJECTS--505 ut of 739 people confirmed as residents at their home address (190 white, 86 black, 112 Bangladeshi, 105 Chinese or Vietnamese, 12 other). MAIN OUTCOME MEASURES--Socioeconomic characteristics, consultation with general practitioner, and recorded preventive activities for ethnic groups. RESULTS--Minority ethnic groups were considerably more disadvantaged than white people and five times more likely to be overcrowded (31% v 6%), three times less likely to own their own home(11% v 37%), twice as likely to be in social classes IV and V (54% v 28%) and less likely to be employed (34% v 63%). There were no significant differences between white, black, Bangladeshi, and Chinese or Vietnamese subjects in recording smoking, blood pressure, alcohol consumption, weight, and height in the general practitioners'' medical records. White women were more likely to have a record of mammography (46% v 20%; P=0.03) and of cervical smears than women in minority ethnic groups. CONCLUSION--Despite major socioeconomic inequity, equitable recording of preventive activity for the major causes of death for white, black and Bangladeshi populations is possible. Chinese and Vietnamese people had lower levels of recording and consultation. Mammography and, to a lesser extent, cervical cytology are inequitably recorded and require additional support at practice level.     

Preliminary results of a district call scheme for cervical screening organised in general practice.

A recognised problem with the cervical screening programme in the United Kingdom is the failure to include women who have never had a cervical smear test, who are a high risk group. The implementation of a district based call scheme in East Berkshire in 1986 is described whereby women aged 20-64 with no record of a cervical smear test who were judged to be eligible for testing by their general practitioner were sent a personal invitation from their general practitioner to attend for a test. A list of high risk unscreened women was kept by each practice, and a duplicate sent to the cytology laboratory to update the central records. Six months after each batch of invitations had been sent the resulting number of women having a smear test was assessed. Forty three of 51 practices approached agreed to participate in the five year scheme. During the first year lists were sent to the 43 participating practices. The first list was returned to the cytology laboratory by 37 practices and the second by 33; practices varied in their responses, however, some needing considerable persuasion to return the lists. Of 972 identified unscreened women from the total 3757 women listed in the lists of the family practitioner committee, 247 (25%) had a cervical smear test in response to the invitation, representing an overall increase of 7% in the screened population. The preliminary findings of the five year study have shown that screening can be improved by a systematic call scheme. Coordinated support from the area health authority in health education, monitoring of screening, and feedback of data from the scheme to practices is required to reduce the proportion of unscreened women.     

Family Physicians' Barriers to Cancer Screening in Extremely Obese Patients

Extremely obese women are less likely than nonobese women to receive breast and cervical cancer screening examinations. Reasons for this disparity are unclear and may stem from patient and/or physician barriers. This sequential mixed‐methods study used individual in‐depth interviews of 15 family physicians followed by a mail survey of 255 family physicians (53% response rate) to understand the barriers they faced in performing cancer screening examinations in extremely obese women. Barriers fell into three main areas: (i) difficulty doing pelvic and breast exams; (ii) inadequate equipment; and (iii) challenges overcoming patient barriers and refusal. This led some physicians to avoid performing breast and pelvic examinations on extremely obese women. Having more knowledge about specific examination techniques was associated with less difficulty in palpating lumps on breast and pelvic examinations (P < 0.005). Physicians perceived that embarrassment, aversion to undressing, and avoidance of discussions related to their weight were the most frequent barriers extremely obese women had with getting physical examinations. Educating and/or motivating patients and addressing fears were strategies used most frequently when patients refused mammograms or Pap smears. Interventions focusing on physician barriers, such as educating them on specific examination techniques, obtaining adequate equipment and supplies, and providing resources to assist physicians in dealing with patient barriers and refusal, may be fruitful in increasing cancer screening rates in extremely obese patients. Future research studies testing the effectiveness of these strategies are needed to improve cancer outcomes in this high‐risk population.     

Evaluation of the cervical cytology screening programme in an inner city health district.

District health authorities have been instructed to operate a cervical cytology call and recall screening programme using the age-sex registers held by family practitioner committees. A detailed evaluation of implementation in an inner London district showed that 477 out of 687 (69%) invitation letters sent to women by the family practitioner committee were either inaccurate or inappropriate: almost half of the recorded addresses were incorrect and a further fifth of the women were not eligible for a test. Overall, 90 women had a smear, which is only 13% of the total but 43% of those found to be eligible. The findings did not differ significantly with age. The findings have major implications not only for the effectiveness of call and recall for screening for cervical cancer but also for the future development of screening for breast cancer in such areas.     

Laboratory performance measures: evidence against low-risk women explaining low detection rates of high-grade abnormalities

OBJECTIVE: When a laboratory has a low reporting rate of high-grade abnormality for its cervical cytology specimens, the question arises whether this is due to the laboratory screening a low-risk group of women. This study was undertaken to explore the hypothesis that a low-risk group of women were screened by Victorian laboratories not meeting the recommended minimum standard for the detection of high-grade abnormalities. METHODS: A cohort of 28 094 women was established comprising women whose cervical cytology was reported in 2000 by laboratories not meeting the recommended standard of 0.5% high-grade abnormalities in their reporting of community smears. Outcome measures included the prevalence of high-grade abnormality on the next cytology test for the women, the positive predictive value of the cytology reports of high-grade abnormality, and the standardized incidence ratio for a later diagnosis of cervical cancer. RESULTS: The prevalence of high-grade abnormality was 0.36% on the index cytology compared with 0.68% on the first subsequent cytology report. Sixty-nine per cent (60/87) of the index cytology reports of high-grade abnormality were confirmed as high-grade abnormalities on histology, compared with 70.8% (121/171) for the first subsequent reports of high-grade abnormality. During 70 015 person-years at risk, nine cases of cervical cancer were observed compared with 5.21 expected cases, giving a standardized incidence ratio of 1.73 (95% CI 0.79-3.28). CONCLUSIONS: These results do not support a hypothesis that the low detection rate for high-grade abnormalities is due to the women comprising a low-risk group for cervical neoplasia.     

HIV/AIDS in rural India: context and health care needs

Primary research on HIV/AIDS in India has predominantly focused on known risk groups such as sex workers, STI clinic attendees and long-distance truck drivers, and has largely been undertaken in urban areas. There is evidence of HIV spreading to rural areas but very little is known about the context of the infection or about issues relating to health and social impact on people living with HIV/AIDS. In-depth interviews with nineteen men and women infected with HIV who live in rural areas were used to collect experiences of testing and treatment, the social impacts of living with HIV and differential impacts on women and men. Eight focus group discussions with groups drawn from the general population in the four villages were used to provide an analysis of community level views about HIV/AIDS. While men reported contracting HIV from sex workers in the cities, women considered their husbands to be the source of their infection. Correct knowledge about HIV transmission co-existed with misconceptions. Men and women tested for HIV reported inadequate counselling and sought treatment from traditional healers as well as professionals. Owing to the general pattern of husbands being the first to contract HIV women faced a substantial burden, with few resources remaining for their own or their children's care after meeting the needs of sick husbands. Stigma and social isolation following widowhood were common, with an enforced return to the natal home. Implications for potential educational and service interventions are discussed within the context of gender and social relations.     

Implications of inflammatory changes on cervical cytology.

OBJECTIVE--To assess premenopausal women with inflammatory changes on cervical cytology for genital infections and cervical abnormalities. DESIGN--Prospective study of women attending general practice and family planning clinics who had a recent cervical cytology result with inflammatory changes. SETTING--Department of genitourinary medicine. PATIENTS--102 Premenopausal women with recent cytology result showing inflammatory changes and with no history of antibiotic or antifungal treatment since their smear. INVESTIGATIONS--Genital examination and microbiological screening for genital infections; colposcopic examination about six weeks later. MAIN OUTCOME MEASURES--Detection of genital infections, particularly those sexually acquired, and abnormalities on colposcopy. RESULTS--Genital infections were isolated in 77 patients, and one or more sexually acquired infections were found in 22. Prevalence of sexually acquired infections was significantly correlated with younger age (particularly being under 25), being single, separated, or divorced; using non-barrier contraception; and recent change of sexual partner. An abnormality on colposcopy was found in 36 women. There was a strong correlation of a sexually acquired infection with an abnormality at colposcopy; hence younger women were more likely to have a colposcopic abnormality. CONCLUSIONS--Inflammatory changes on cytology are often associated with the presence of a sexually acquired infection and premalignant disease of the cervix, particularly in younger, single women using non-barrier contraception.     

Chlamydia trachomatis detection in cervical PreservCyt specimens from an Irish urban female population

Objective:  The aim of this study was to determine the prevalence of cervical Chlamydia trachomatis infection by polymerase chain reaction (PCR) in urban women undergoing routine cervical cytological screening and to investigate the relationship with age, cytology, smoking status and concurrent human papillomavirus (HPV) infection.
Methods:  A total of 996 women (age range 16–69 years) attending general practitioners for routine liquid-based cervical smear screening in the Dublin area were recruited in the study of prevalence of C. trachomatis . Informed consent was obtained and liquid-based cytology (LBC) specimens were sent for cytological screening. DNA was extracted from residual LBC and tested for C. trachomatis by PCR using the highly sensitive C. trachomatis plasmid (CTP) primers and for HPV infection using the MY09/11 primers directed to the HPV L1 gene in a multiplex format.
Results:  The overall prevalence of C. trachomatis was 5.4%. Prevalence was highest in the <25 years age group (10%). Coinfection with HPV and C. trachomatis occurred in 1% of the screening population. A higher rate of smoking was observed in women positive for C. trachomatis , HPV infections or those with abnormal cervical cytology. Chlamydia trachomatis infection was not associated with abnormal cytology.
Conclusions:  Women (5.4%) presenting for routine cervical screening are infected with C. trachomatis . Opportunistic screening for C. trachomatis from PreservCyt sample taken at the time of cervical cytological screening may be a possible strategy to screen for C. trachomatis in the Irish female population.     

Multi-Level Factors Affecting Entry into and Engagement in the HIV Continuum of Care in Iringa,Tanzania

Progression through the HIV continuum of care, from HIV testing to lifelong retention in antiretroviral therapy (ART) care and treatment programs, is critical to the success of HIV treatment and prevention efforts. However, significant losses occur at each stage of the continuum and little is known about contextual factors contributing to disengagement at these stages. This study sought to explore multi-level barriers and facilitators influencing entry into and engagement in the continuum of care in Iringa, Tanzania. We used a mixed-methods study design including facility-based assessments and interviews with providers and clients of HIV testing and treatment services; interviews, focus group discussions and observations with community-based providers and clients of HIV care and support services; and longitudinal interviews with men and women living with HIV to understand their trajectories in care. Data were analyzed using narrative analysis to identify key themes across levels and stages in the continuum of care. Participants identified multiple compounding barriers to progression through the continuum of care at the individual, facility, community and structural levels. Key barriers included the reluctance to engage in HIV services while healthy, rigid clinic policies, disrespectful treatment from service providers, stock-outs of supplies, stigma and discrimination, alternate healing systems, distance to health facilities and poverty. Social support from family, friends or support groups, home-based care providers, income generating opportunities and community mobilization activities facilitated engagement throughout the HIV continuum. Findings highlight the complex, multi-dimensional dynamics that individuals experience throughout the continuum of care and underscore the importance of a holistic and multi-level perspective to understand this process. Addressing barriers at each level is important to promoting increased engagement throughout the continuum.     

Human papillomavirus DNA and liquid-based cervical cytology cotesting in screening and follow-up patient groups

OBJECTIVE: To compare the use of human papillomavirus (HPV) DNA and cervical cytology cotesting in screening and follow-up of patients with previous cervical abnormalities and to assess the significance of a positive HPV DNA test result in re-screening of cytologically normal cases. STUDY DESIGN: Cellular samples collected in liquid-based fixative were used for both cervical cytology and HPV DNA testing. The cervical cytology slides were manually screened by cytotechnologists followed by rapid re-screening by pathologists. The HPV DNA tests were performed using hybrid capture test kits. Statistical analyses of cervical cytology results and HPV DNA tests for high- and low-risk HPV from both patient groups were carried out. RESULTS: The prevalence of HPV DNA-positive cases was higher in younger patients. There was a poor correlation between cervical cytology results and HPV DNA tests for the screening group (kappa = 0.23), but a fair to good correlation was obtained for the follow-up group (kappa = 0.51). The false negative fraction of cytology negative/HPV DNA positive cases (0.1317), as compared with cytology negative/HPV DNA negative cases (0.0056), was statistically significant (p = 0.000001). CONCLUSION: The prevalence of HPV DNA decreased with increasing age in both the screening and follow-up patient groups. Virus clearance was delayed in the follow-up group as compared with the screening group. There was a poor correlation between cervical cytology and HPV DNA tests in the screening group but a fair to good correlation in the follow-up patient group. Cotesting of HPV DNA and cervical cytology increases the sensitivity and decreases the false negative fraction, suggesting that cotesting could be used to increase the interval of screening.     

Integrating Cervical Cancer Screening with HIV Care in Cameroon: Comparative Risk Analysis of Cervical Disease in HIV-Infected Women Receiving Antiretroviral Therapy to Women in the General Population

Background

While the effect of highly active antiretroviral therapy (HAART) on natural history of cervical lesions remains controversial, resource limited countries need to understand the relevance of their own data to their settings. We compared the risk of cervical disease in HAART-experienced women with that in women in the general population of Cameroon.

Methods

A retrospective cross sectional survey of women aged 35 years and above, attending a voluntary screening campaign for cervical cancer at the Nkongsamba Regional Hospital in Cameroon between February and May 2014. Squamous intraepithelial lesions (SIL) were determined by Pap smear. Multiple logistic regression was used to compare the odds of SIL in women on HAART to women from the community with unknown HIV status.

Results

Included were 302 women of whom 131(43.4%) were HIV-infected and receiving HAART on the site while 171 (56.6%) were women from the community. Cervical disease was observed in 51(16.9%) persons of whom 15 (11.5%) cases in the HAART group and 36 (21.1%) cases in the general group (p = 0.027). After controlling for age and other covariates, women in the HAART group had a 67% reduction in the odds of cervical lesions compared with the community group [adjusted odd ratio (aOR) = 0.33, 95%CI: 0.15–0.73, p = 0.006).

Conclusion

HIV-infected women receiving HAART have a lower risk of cancer than women in the general population. This finding may not be attributed to HAART alone but to all the health benefits derived from receiving a comprehensive HIV care.     

Cervical screening in Perth and Kinross since introduction of the new contract.

OBJECTIVE--To determine changes in the cervical screening service since the introduction of the new general practitioner contract on 1 April 1990. DESIGN--Analysis of computerised records of cervical screening both before and after introduction of the new contract. SETTING--General practices in Perth and Kinross Unit, Tayside. PATIENTS--A total of 30,071 women aged 21-60 on 26 general practitioner partnership lists. MAIN OUTCOME MEASURES--Percentage average of target population for cervical screening in each practice for first three quarters on introduction of the contract. RESULTS--Perth and Kinross Unit completed a computerised cervical screening call programme in July 1989, which produced an increase from 71% to 78% in the mean percentage of women aged 20-60 who had had cervical smear tests within 5.5 years. Six months after the introduction of the new general practitioner contract the mean population coverage was increased to 85% in women aged 21-60 and only four practices had not attained the 80% upper target compared with 10 on 1 April 1990. Detailed examination of randomly selected practices immediately before the new contract was introduced showed an average artificial list inflation of 4.3% in health board records when compared with practice records, a hysterectomy rate of 6.2%, and an additional 3% of women who were considered to be ineligible for smear testing due to putative virginity or illness or infirmity, or both. There was a considerable shift away from use of well woman clinics (2.7% of smears in 1990 compared with 5.6% in 1988) for taking cervical smears, potentially threatening the long term viability of the clinics. CONCLUSION--The introduction of the new contract for general practitioners has brought about a further sustained increase in population coverage for cervical screening in a small Scottish unit with a stable population, well motivated general practitioners, and a fully integrated computerised call and recall system based on the community health index. To optimise the screening service revision of the targets levels is necessary.     

Age as a factor in breast cancer knowledge,attitudes and screening behaviour.

OBJECTIVE: To determine whether there are age-related differences in knowledge, attitudes and behaviour with respect to breast cancer and whether the differences reflect the age-specific Canadian recommendations on breast cancer screening. DESIGN: Telephone survey. SETTING: Two cities and five towns and their surrounding areas in Alberta. PARTICIPANTS: The age-specific, randomly selected sample comprised 1284 women aged 40 to 75 years who did not have breast cancer. Of the 1741 eligible women who were contacted, 1350 (78%) agreed to participate; 66 were excluded because of age ineligibility or a history of breast cancer. MAIN OUTCOME MEASURE: Frequency of knowledge, attitudes and behaviour with respect to breast cancer, by age group. RESULTS: Knowledge of breast cancer risk factors was generally low and decreased with age. Few women were aware of the Canadian recommendations on breast self-examination, physical examination of the breasts by a health care practitioner and mammographic screening. Older women believed they were less susceptible to breast cancer than younger women and were less likely to have positive attitudes toward screening. Self-examination was performed 9 to 15 times per year by 424 women (33%), and 810 (63%) had been examined by a health care professional in the past year. Although 664 (52%) had undergone mammography, the proportion decreased with age after age 59. The main barriers to mammography were lack of physician referral and the woman''s belief that the procedure is unnecessary if she is healthy. CONCLUSIONS: Education is needed to increase breast cancer knowledge, promote the Canadian recommendations for early detection of breast cancer and decrease negative beliefs about the disease. Changes in the behaviour of women and physicians are needed to increase the use of breast self-examination, clinical breast examination by a health care professional and mammographic screening. Reaching women in the upper range (60 to 69 years) of the target group for mammographic screening should be a focus in promoting early detection of breast cancer.     

Health and social status of elderly Asians: a community survey.

A sample based on general practices was the starting point for a community survey of Asians aged 65 years and over to describe: family structure and social contact; aspects of lifestyle; language and communication; capacity for self care; and knowledge about and use of services. A total of 726 (95% of those approached) old people were interviewed in their own languages. Almost all had been born in India, mainly in Gujarat or the Punjab, but most had come to Britain via east Africa. Over half of the over 75s were not fully independent in basic activities of daily living, and a fifth were occasionally or often incontinent of urine, though these levels of incapacity were little different from those found in the indigenous elderly. Few elderly Asians were aware of social services, such as meals on wheels, home helps, social workers, and particularly chiropody. Language also excluded them: 37% of men and only 2% of women could speak English. Moreover, two thirds of elderly Asian women were illiterate in all languages. Health education initiatives directed at these people must understand these cultural and language barriers and perhaps use alternative methods, such as Asian radio programmes and home videos, in providing information on health and welfare services.     

Human papillomavirus infection in women with and without cervical cancer in Tbilisi, Georgia

Background: No accurate estimates of cervical cancer incidence or mortality currently exist in Georgia. Nor are there any data on the population-based prevalence of high-risk (HR) human papillomavirus (HPV) infection, which, in the absence of good-quality screening, is known to correlate with cervical cancer incidence. Methods: We obtained cervical cell specimens from 1309 women aged 18–59 years from the general population of Tbilisi, and also from 91 locally diagnosed invasive cervical cancers (ICC). DNA of 44 HPV types was tested for using a GP5+/6+-based PCR assay. Results: In the general population (of whom 2% reported a previous Pap smear) HPV prevalence was 13.5% (95% CI: 11.6–15.9), being highest in women aged 25–34 years (18.7%) and falling to between 8.6% and 9.5% for all age groups above 34 years. HR HPV prevalence was 8.6% overall, being 6.8% and 38.9% among women with normal and abnormal cytology, respectively. HPV45 (1.6%) was the most common type in women with normal cytology, whereas HPV16 predominated among women with cervical abnormalities (including 7 of 10 histologically confirmed cervical intraepithelial neoplasia 2/3) and among ICC (57.6%). The next most common types in ICC in Georgia were HPV45 and 18 (13.2 and 11.0%, respectively). Conclusions: We report a relatively high burden of HPV infection in Tbilisi, Georgia. Improving cervical cancer prevention, through screening and/or HPV vaccination, is an important public health issue in Georgia, where 70% of ICC are theoretically preventable by HPV16/18 vaccines.