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1.  Suicide in South India: A community-based study in Kerala 
Indian Journal of Psychiatry  2009;51(4):261-264.
Studies from Tamil Nadu, South India, have reported the world's highest suicide rates. As per official reports, Kerala, another South Indian state has the highest suicide rate among the major states in India.
The purpose of this analysis is to estimate the rates and age-specific incidence of suicide in a rural community in Kerala, under continuous observation for the last five years.
Settings and Design:
The study setting comprised of seven contiguous panchayats constituting a development block in Kerala. A prospective cohort study design was used.
Materials and Methods:
Through regular home visits, every death that occurred in the community was captured by local resident health workers and the cause of death assigned.
Statistical Analysis:
Suicide rates by age and sex and relative share of suicide deaths to all-cause deaths in men and women were calculated.
During the five-year period from 2002 to 2007, 284 cases of suicide were reported. The suicide rates were 44.7/100,000 for males and 26.8/100,000 for females. Male to female suicide ratio was 1.7. Among females aged between 15 and 24, suicides constituted more than 50% of all deaths. Male to female ratio of suicide varied from 0.4 in children aged 14 years or less to 4.5 in the 45-54 year age group.
Our analysis shows that the level of under-reporting of suicides in rural Kerala is much less than that reported in Tamil Nadu.
PMCID: PMC2802372  PMID: 20048450
Kerala; South India; suicide
2.  Assessing perceptions about malaria among the elected representatives in rural India 
Tropical Parasitology  2011;1(2):83-87.
The short-term objective of our endeavour was to understand the perception of Grama panchayat presidents and secretaries on the issues related to malaria and its control, being the key leaders of the Panchayat Raj Institutions (PRIs) at a Grama panchayat level. This was necessary to achieve the long-term objective of the role of PRIs in malaria control and their enhanced participation/partnership with the public health sector.
Materials and Methods:
Grama panchayat presidents and secretaries representing all the 28 Grama panchayats of Chikkanayakanahalli taluk Tumkur district in Karnataka were invited for a 1-day workshop. Deliberations with the participants (n = 32) shed light on their perceptions with respect to knowledge, attitude and practice vis-a-vis malaria and its control strategies.
Their knowledge of malaria as a disease was fairly good as they were well aware of it being a communicable disease and its transmission by mosquitoes. However, knowledge about the breeding sources of malaria mosquitoes (Anophelines) was very poor. Many practices in vogue to control mosquitoes at the community level were unscientific. There was a general negative attitude toward the government's handling of the malaria problem and the credibility of the health care system.
Existence of health committees in every Grama panchayat coupled with their jurisdiction and responsibilities toward sanitation, water supply and health care resources makes PRIs a natural partner to the health sector. While health education and public health intervention strategies should be based on generic principles of science, the implementation and operational specifics should definitely be based on a sociological perspective of the stakeholders.
PMCID: PMC3593494  PMID: 23508083
Grama panchayat; intersectoral; KAP; malaria; social factors; rural governance
3.  Experiences of Junior Public Health Nurses in Delivery of Maternal Healthcare Services to Tribal Women in Kerala 
The maternal health care indicators are better in Kerala even in the tribal districts than the national averages. The tribal population scattered in hilly areas or other difficult terrains heavily constraints the MPHW female (Junior Public Health Nurse in Kerala) from providing services. The study was intended to describe the experiences of the Junior Public Health Nurses (JPHN) in delivery of maternal health care services to tribal women in Kerala.
Materials and Methods:
JPHNs posted in Thariode panchayat under the sub centers of CHC Thariode in Wayanad district of Kerala. This is a Qualitative study with in-depth interview of the JPHNs using an interview guide.
Results and Inferences:
The various difficulties experienced by JPHNs in delivering the services in tribal areas were lack of sufficient time for field work, travel difficulties faced due to the hilly terrain and lack of public transport facilities, more time spent on travel than actual time spent for field work, cultural and language barriers and extra inputs put up in service delivery to tribal women.
Conclusion and Recommendations:
The JPHNs serving in tribal areas overcame various constraints in service delivery like hilly terrain, limited public transport facilities, long hours spent in travelling, cultural and language barriers by putting in extra effort, time and personal money to fulfill their responsibilities. It is suggested that the JPHNs be given compensatory off to complete records and extra remuneration to cover their out of pocket expenditure on travelling to difficult areas.
PMCID: PMC3894011  PMID: 24479046
Difficulties; maternal health; multi purpose health worker female; tribal areas
4.  Women's health in a rural community in Kerala, India: do caste and socioeconomic position matter? 
To examine the social patterning of women's self‐reported health status in India and the validity of the two hypotheses: (1) low caste and lower socioeconomic position is associated with worse reported health status, and (2) associations between socioeconomic position and reported health status vary across castes.
Cross‐sectional household survey, age‐adjusted percentages and odds ratios, and multilevel multinomial logistic regression models were used for analysis.
A panchayat (territorial decentralised unit) in Kerala, India, in 2003.
4196 non‐elderly women.
Outcome measures
Self‐perceived health status and reported limitations in activities in daily living.
Women from lower castes (scheduled castes/scheduled tribes (SC/ST) and other backward castes (OBC) reported a higher prevalence of poor health than women from forward castes. Socioeconomic inequalities were observed in health regardless of the indicators, education, women's employment status or household landholdings. The multilevel multinomial models indicate that the associations between socioeconomic indicators and health vary across caste. Among SC/ST and OBC women, the influence of socioeconomic variables led to a “magnifying” effect, whereas among forward caste women, a “buffering” effect was found. Among lower caste women, the associations between socioeconomic factors and self‐assessed health are graded; the associations are strongest when comparing the lowest and highest ratings of health.
Even in a relatively egalitarian state in India, there are caste and socioeconomic inequalities in women's health. Implementing interventions that concomitantly deal with caste and socioeconomic disparities will likely produce more equitable results than targeting either type of inequality in isolation.
PMCID: PMC2465509  PMID: 17108296
5.  Debt, shame, and survival: becoming and living as widows in rural Kerala, India 
The health and well-being of widows in India is an important but neglected issue of public health and women’s rights. We investigate the lives of Indian women as they become widows, focussing on the causes of their husband’s mortality and the ensuing consequences of these causes on their own lives and identify the opportunities and challenges that widows face in living healthy and fulfilling lives.
Data were collected in a Gram Panchayat (lowest level territorial decentralised unit) in the south Indian state of Kerala. Interviews were undertaken with key informants in order to gain an understanding of local constructions of ‘widowhood’ and the welfare and social opportunities for widows. Then we conducted semi-structured interviews with widows in the community on issues related to health and vulnerability, enabling us to hear perspectives from widows. Data were analysed for thematic content and emerging patterns. We synthesized our findings with theoretical understandings of vulnerability and Amartya Sen’s entitlements theory to develop a conceptual framework.
Two salient findings of the study are: first, becoming a widow can be viewed as a type of ‘shock’ that operates similarly to other ‘economic shocks’ or ‘health shocks’ in poor countries except that the burden falls disproportionately on women. Second, widowhood is not a static phenomenon, but rather can be viewed as a multi-phased process with different public health implications at each stage.
More research on widows in India and other countries will help to both elucidate the challenges faced by widows and encourage potential solutions. The framework developed in this paper could be used to guide future research on widows.
PMCID: PMC3517387  PMID: 23126457
6.  A Population Based Case Control Study on Breast Cancer and the Associated Risk Factors in a Rural Setting in Kerala, Southern India 
Introduction: The incidence of breast cancer is increasing in developing countries over three decades. Despite good health indicators breast cancer is a public health problem in Kerala with an annual incidence of 14.9/100000 population. Identifying the risk factors helps to reduce the incidence in future.
Method: A Population based case control study was conducted among all the breast cancer cases in the Arpookara Panchayat of Kottayam district in Kerala. 20 cases of breast cancer were paired with age matched controls from the same geographic area (ratio 1:4) with a total of 100 study participants. Data were collected by interviewing the participants using a pre tested structured questionnaire.
Analysis was done by the authors using SPSS version 16.0
Results: Age group of participants ranged from 32-70 years with mean age of 49.7 + 10.39. Early menarche < 13 years [Odds Ratio =3.2, p= 0.03], being unmarried and single, family history of breast cancer [Odds Ratio = 3.5, p = 0.02], previous history of benign breast tumours [Odds Ratio =8.14, p= 0.04], breast feeding less than 2 years [Odds Ratio = 2.28, p = 0.01 ] were found to be the risk factors for the breast cancer and the birth of first child before 30 years [Odds Ratio =0.302, p = 0.03 ] was found to be a protective factor for breast cancer. 60% of cases belonged to lower socioeconomic status [Odds Ratio = 14.47, p = 0.03]. Despite high literacy status, significantly lower awareness about symptoms of breast cancer and self examination of the breast were noted [Odds Ratio =11.6, p= 0.03].
Conclusion: Awareness about symptoms of breast cancer and self examination of the breast were lacking in the study population. Health care personnel should be trained to spread the awareness of breast cancer in the community and to identify the vulnerable groups at the primary care settings itself. The policy makers can consider encouraging community participation by involving the non-governmental organizations, women self help groups and Public Private Partnerships in spreading the awareness of breast cancer.
PMCID: PMC3809635  PMID: 24179896
Arpookara Panchayat; Kottayam; Case control study; Odds ratio
7.  Knowledge, attitude and practice of cervical cancer screening among market women in Zaria, Nigeria 
Cervical cancer is the most common genital cancer and one of the leading causes of death among female population. Fortunately, this cancer is preventable by screening for premalignant lesions but this is rarely provided and hardly utilised. We assessed the knowledge, attitude and utilisation of cervical cancer screening among market women in Sabon Gari, Zaria.
Materials and Methods:
This was a cross-sectional study to evaluate the knowledge, attitude and practice of cervical cancer screening among market women. A total of 260 women were administered with questionnaires which were both self and interviewer administered. These were analysed using SPSS version 11.
Respondents exhibited a fair knowledge of cervical cancer and cervical cancer screening (43.5%); however, their knowledge of risk factors was poor. There was generally good attitude to cervical cancer screening (80.4%), but their level of practice was low (15.4%).
There was a fair knowledge of cervical cancer and cervical cancer screening among Nigerian market women in this study, their practice of cervical cancer screening was poor.
PMCID: PMC3883231  PMID: 24403709
Cervical; cancer; screening; Zaria
8.  Assessment of Status of Patients Receiving Palliative Home Care and Services Provided in a Rural Area—Kerala, India 
Indian Journal of Palliative Care  2012;18(3):213-218.
For the first time in India, a Pain and Palliative Care policy to guide the community-based home care initiatives was declared by the Government of Kerala state. In Kerala, majority of the panchayats (local self-governments) are now conducting home-based palliative care as part of primary health care. National focus domain areas in palliative care research are structure and process, the physical aspects, and also the social aspects of care.
The study was conducted to assess the patient's status and the services provided by palliative home care.
Settings and Design:
The descriptive study was conducted at Mavoor panchayat—Kozhikode district of Kerala, India by collecting information from the case records, nurses diary notes of all enrolled patients.
Materials and Methods:
Collecting information from the case records, nurses diary notes of all enrolled patients.
Statistical Analysis:
The data were entered using Microsoft excel for Windows XP and analyzed using SPSS 16.0 (Statistical Package for Social Sciences; SPSS Inc., Chicago, IL, USA).
Totally, 104 patients were enrolled. Diagnosis wise major category was degenerative diseases. There were 27% persons suffering from cerebrovascular accidents, 15.3% with malignancies, 8.7% with coronary artery disease, 5.8% with complications of diabetes, and 8.7% were with fracture of bones. The major complaints were weakness (41.3%), tiredness (31.7%), and pain (27%). Twenty-five percent persons complained of urinary incontinence, 12.5% complained of ulcer, 10.6% of edema, and 9.6% of mental/emotional agony. The activity of daily living status was as follows. Twenty-five percent subjects were completely bed ridden. 5.8% were feeding through Ryles tube, 16.3% had urinary incontinence, 9.6% were having no bowel control.
The service could address most of the medical, psychosocial, and supportive needs of the patients and reduce their pain and symptoms. The interface between institutional-based care and home care needs more exploration and prospective studies.
PMCID: PMC3573477  PMID: 23440060
Activity of daily living; Community nurse; Home-based palliative care; Primary care; Quality of life
9.  Knowledge, attitudes and practices on cervical cancer screening among the medical workers of Mulago Hospital, Uganda 
Cervical cancer is the commonest cancer of women in Uganda. Over 80% of women diagnosed in Mulago national referral and teaching hospital, the biggest hospital in Uganda, have advanced disease. Pap smear screening, on opportunistic rather than systematic basis, is offered free in the gynaecological outpatients clinic and the postnatal/family planning clinics. Medical students in the third and final clerkships are expected to learn the techniques of screening. Objectives of this study were to describe knowledge on cervical cancer, attitudes and practices towards cervical cancer screening among the medical workers of Mulago hospital.
In a descriptive cross-sectional study, a weighted sample of 310 medical workers including nurses, doctors and final year medical students were interviewed using a self-administered questionnaire. We measured knowledge about cervical cancer: (risk factors, eligibility for screening and screening techniques), attitudes towards cervical cancer screening and practices regarding screening.
Response rate was 92% (285). Of these, 93% considered cancer of the cervix a public health problem and knowledge about Pap smear was 83% among respondents. Less than 40% knew risk factors for cervical cancer, eligibility for and screening interval. Of the female respondents, 65% didn't feel susceptible to cervical cancer and 81% had never been screened. Of the male respondents, only 26% had partners who had ever been screened. Only 14% of the final year medical students felt skilled enough to use a vaginal speculum and 87% had never performed a pap smear.
Despite knowledge of the gravity of cervical cancer and prevention by screening using a Pap smear, attitudes and practices towards screening were negative. The medical workers who should be responsible for opportunistic screening of women they care for are not keen on getting screened themselves. There is need to explain/understand the cause of these attitudes and practices and identify possible interventions to change them. Medical students leave medical school without adequate skills to be able to effectively screen women for cervical cancer wherever they go to practice. Medical students and nurses training curricula needs review to incorporate practical skills on cervical cancer screening.
PMCID: PMC1413529  PMID: 16509979
10.  Women's perspectives on illness when being screened for cervical cancer 
International Journal of Circumpolar Health  2013;72:10.3402/ijch.v72i0.21089.
In Greenland, the incidence of cervical cancer caused by human papillomavirus (HPV) is 25 per 100,000 women; 2.5 times the Danish rate. In Greenland, the disease is most frequent among women aged 30–40. Systematic screening can identify women with cervical cell changes, which if untreated may cause cervical cancer. In 2007, less than 40% of eligible women in Greenland participated in screening.
To examine Greenlandic women's perception of disease, their understanding of the connection between HPV and cervical cancer, and the knowledge that they deem necessary to decide whether to participate in cervical cancer screening.
Study design
The methods used to perform this research were 2 focus-group interviews with 5 Danish-speaking women and 2 individual interviews with Greenlandic-speaking women. The analysis involved a phenomenological-hermeneutic approach with 3 levels of analysis: naive reading, structural analysis and critical interpretation.
These revealed that women were unprepared for screening results showing cervical cell changes, since they had no symptoms. When diagnosed, participants believed that they had early-stage cancer, leading to feelings of vulnerability and an increased need to care for themselves. Later on, an understanding of HPV as the basis for diagnosis and the realization that disease might not be accompanied by symptoms developed. The outcome for participants was a life experience, which they used to encourage others to participate in screening and to suggest ways that information about screening and HPV might reach a wider Greenlandic population.
Women living through the process of cervical disease, treatment and follow-up develop knowledge about HPV, cervical cell changes, cervical disease and their connection, which, if used to inform cervical screening programmes, will improve the quality of information about HPV, cervical cancer and screening participation. This includes that verbal and written information given at the point of screening and diagnosis needs to be complemented by visual imagery.
PMCID: PMC3753123  PMID: 23984277
cervical cancer; HPV; Greenland; interview; nursing; perceptions of health and disease; public health programming; screening
11.  Socio-Economic-Political-Cultural Aspects in Malaria Control Programme Implementation in Southern India 
Objective. A Socio-economic-political-cultural (SEPC) study was undertaken under the Roll Back Malaria (RBM) initiative to understand the process of programme implementation and how far in the changing malaria context, the broader environment has been understood and programme components have undergone changes. Material and Methods. Two studies were carried out; first in four villages under the primary health unit (PHU) Banavaralu in Tiptur Taluka in September 2002 and the second one in April 2003 in four villages in Chitradurga district, namely, Kappagere, Kellodu in Hosadurga Taluka, and Vani Vilas Puram and Kathrikenhally in Hiriyur Taluka. Focus group discussion and key interviews were adopted to collect the qualitative data. Results. Gender discrimination and lack of empowerment of women came out strongly in social analysis. In the rural elected bodies called Panchayats, the concept of health committees was not known. Health committees as one of the important statutory committees under every Panchayat were nonexistent in reality in these villages. Financial difficulties at Grama Panchayat level and also meager budget allocation for health have led to indifferent attitude of Panchayat members towards health. It was observed that there were generally no specific cultural practices in relation to malaria cure. Cultural and traditional practices in malaria-related issues were not predominant in the community except for some sporadic instances. Conclusion and Recommendation. SEPC study is an important indicator in malaria control programme. It is ultimately the community that takes the major decision directly or indirectly and the health authority must guide them in right direction.
PMCID: PMC3371745  PMID: 22701778
12.  Understanding Cervical Cancer Prevention and Screening in Chuukese Women in Hawai‘i 
Hawaii Medical Journal  2010;69(6 Suppl 3):13-16.
Cervical cancer is the primary cause of death due to cancer in women in Chuuk State, Federated States of Micronesia. The Chuukese population is the fastest growing segment of the Micronesian community in Hawai‘i. Little is known about the health beliefs or practices of this population in Hawai‘i. The purpose of this project was to describe the knowledge, attitudes, and beliefs of Chuukese women in Hawai‘i regarding cervical cancer prevention and screening.
Research assistants from the Chuukese community were recruited and trained as members of the research team. A culturally sensitive survey tool was developed and piloted by the research team and used to interview ten key informants from the Chuukese community in Honolulu, Hawai‘i.
There is limited knowledge about cervical cancer, especially the association with human papillomavirus (HPV). This may be indicative of a lack of health information in general. Fear, privacy concerns, lack of awareness and cultural beliefs represent the main barriers mentioned when discussing cervical cancer. Education, done in a group setting with other women, is the most recommended method of informing this community and improving preventive and screening services for cervical cancer in these women.
PMCID: PMC3123140  PMID: 20539995
13.  Knowledge, attitude and practice about cancer of the uterine cervix among women living in Kinshasa, the Democratic Republic of Congo 
BMC Women's Health  2014;14:30.
Cervical cancer is the most frequent cancer of women in the Democratic Republic of Congo (DRC). Nevertheless, the level of women’s awareness about cervical cancer is unknown. Knowledge, attitude and practice (KAP) are important elements for designing and monitoring screening programs. The study purpose was to estimate KAP on cervical cancer and to identify associated factors.
A cross-sectional study was conducted in Kinshasa, DRC, including 524 women aged 16–78 years (median age 28; interquartile range 22–35). The women were interviewed at home by trained field workers using a standardized questionnaire. The women’s score on knowledge, attitude and practice were dichotomized as sufficient or insufficient. We used binary and multiple logistic regression to assess associations between obtaining sufficient scores and a series of socio-demographic factors: age, residence, marital status, education, occupation, religion, and parity.
The women’s score on knowledge was not significantly correlated with their score on practice (Spearman’s rho = 0.08; P > 0.05). Obtaining a sufficient score on knowledge was positively associated with higher education (adjusted odds ratio (OR) 7.65; 95% confidence interval (95% CI) 3.31-17.66) and formal employment (adjusted OR 3.35; 95% CI 1.85-6.09); it was negatively associated with being single (adjusted OR 0.44; 95% CI 0.24-0.81) and living in the eastern, western and northern zone of Kinshasa compared to the city centre. The attitude score was associated with place of residence (adjusted OR for east Kinshasa: 0.49; 95% CI 0.27-0.86 and for south Kinshasa: 0.48; 95% CI 0.27-0.85) and with religion (adjusted OR 0.55; 95% CI 0.35-0.86 for women with a religion other than Catholicism or Protestantism compared to Catholics). Regarding practice, there were negative associations between a sufficient score on practice and being single (adjusted OR 0.24; 95% CI 0.13-0.41) and living in the eastern zone of the city (adjusted OR 0.39; 95% CI 0.22-0.70). Although 84% of women had heard about cervical cancer, only 9% had ever had a Papanicolaou (Pap) smear test.
This study shows a low level of knowledge, attitude and practice on cervical cancer among women in Kinshasa. Increasing women’s awareness would be a first step in the long chain of conditions to attain a lower incidence and mortality.
PMCID: PMC3937079  PMID: 24548698
14.  Can microcredit help improve the health of poor women? Some findings from a cross-sectional study in Kerala, India 
This study examines associations between female participation in a microcredit program in India, known as self help groups (SHGs), and women's health in the south Indian state of Kerala. Because SHGs do not have a formal health program, this provides a unique opportunity to assess whether SHG participation influences women's health via the social determinants of health.
This cross-sectional study used special survey data collected in 2003 from one Panchayat (territorial decentralized unit). Information was collected on women's characteristics, health determinants (exclusion to health care, exposure to health risks, decision-making agency), and health achievements (self assessed health, markers of mental health). The study sample included 928 non elderly poor women.
The primary finding is that compared to non-participants living in a household without a SHG member, the odds of facing exclusion is significantly lower among early joiners, women who were members for more than 2 years (OR = 0.58, CI = 0.41–0.80), late joiners, members for 2 years and less (OR = 0.60, CI = 0.39–0.94), and non-participants who live in a household with a SHG member (OR = 0.53, CI = 0.32–0.90). We also found that after controlling for key women's characteristics, early joiners of a SHG are less likely to report emotional stress and poor life satisfaction compared to non-members (OR = 0.52, CI = 0.30–0.93; OR = 0.32, CI = 0.14–0.71). No associations were found between SHG participation and self assessed health or exposure to health risks. The relationship between SHG participation and decision-making agency is unclear.
Microcredit is not a panacea, but could help to improve the health of poor women by addressing certain issues relevant to the context. In Kerala, SHG participation can help protect poor women against exclusion to health care and possibly aid in promoting their mental health.
PMCID: PMC2254417  PMID: 18186918
15.  Determinants of acceptance of cervical cancer screening in Dar es Salaam, Tanzania 
BMC Public Health  2012;12:1093.
To describe how demographic characteristics and knowledge of cervical cancer influence screening acceptance among women living in Dar es Salaam, Tanzania.
Multistage cluster sampling was carried out in 45 randomly selected streets in Dar es Salaam. Women between the ages of 25–59 who lived in the sampled streets were invited to a cervical cancer screening; 804 women accepted and 313 rejected the invitation. Information on demographic characteristics and knowledge of cervical cancer were obtained through structured questionnaire interviews.
Women aged 35–44 and women aged 45–59 had increased ORs of 3.52 and 7.09, respectively, for accepting screening. Increased accepting rates were also found among single women (OR 2.43) and among women who had attended primary or secondary school (ORs of 1.81 and 1.94). Women who had 0–2 children were also more prone to accept screening in comparison with women who had five or more children (OR 3.21). Finally, knowledge of cervical cancer and awareness of the existing screening program were also associated with increased acceptance rates (ORs of 5.90 and 4.20).
There are identifiable subgroups where cervical cancer screening can be increased in Dar es Salaam. Special attention should be paid to women of low education and women of high parity. In addition, knowledge and awareness raising campaigns that goes hand in hand with culturally acceptable screening services will likely lead to an increased uptake of cervical cancer screening.
PMCID: PMC3551792  PMID: 23253445
Cervical cancer; Screening acceptance; Demographic characteristics; Knowledge; Tanzania
16.  Prevalence of coronary artery disease and coronary risk factors in Kerala, South India: A population survey – Design and methods 
Indian Heart Journal  2013;65(3):243-249.
There is paucity of reliable contemporary data on prevalence of coronary artery disease (CAD) and risk factors in Indians. Only a few studies on prevalence of CAD have been conducted in Kerala, a Southern Indian state. The main objective of the Cardiological Society of India Kerala Chapter Coronary Artery Disease and Its Risk Factors Prevalence Study (CSI Kerala CRP Study) was to determine the prevalence of CAD and risk factors of CAD in men and women aged 20–79 years in urban and rural settings of three geographical areas of Kerala.
The design of the study was cross-sectional population survey. We estimated the sample size based on an anticipated prevalence of 7.4% of CAD for rural and 11% for urban Kerala. The derived sample sizes for rural and urban areas were 3000 and 2400, respectively. The urban areas for sampling constituted one ward each from three municipal corporations at different parts of the state. The rural sample was drawn from two panchayats each in the same districts as the urban sample. One adult from each household in the age group of 20–59 years was selected using Kish method. All subjects between 60 and 79 years were included from each household. A detailed questionnaire was administered to assess the risk factors, history of CAD, family history, educational status, socioeconomic status, dietary habits, physical activity and treatment for CAD; anthropometric measurements, blood pressure, electrocardiogram and fasting blood levels of glucose and lipids were recorded.
PMCID: PMC3861304  PMID: 23809375
Population survey; Coronary artery disease; Coronary risk factors; Kerala
17.  Evaluation of visual inspection as a screening test for cervical cancer. 
British Journal of Cancer  1997;75(3):436-440.
Visual inspection of the uterine cervix by paramedical personnel has been proposed for the early detection of cervical cancer, as an alternative to routine cytology screening in developing countries. We evaluated the performance of this procedure in detecting precursor lesions and cancer in a study involving 2843 married women in Kerala, India. Two thresholds were used to define a positive test. In the lower one, any abnormality was considered as positive. The cut-off point for the high threshold was one or more of the high-risk findings: bleeding on touch, suspicious growth/ulcer and hard, irregular, oedematous cervix. A Pap smear was performed on all subjects, and a biopsy was done for those with moderate dysplasia and above. A combination of cytology and histology findings was used as the 'gold standard'. Using the low threshold, 1279 (45%) women were positive on visual inspection, and with the higher threshold 179 (6.3%) were positive. There were six moderate dysplasias, nine severe dysplasias, ten carcinomas in situ and 13 invasive carcinomas. With the lower threshold, sensitivity and specificity to detect moderate dysplasia and above were 65.8% and 55.3% respectively; the values for severe dysplasia and above were 71.9% and 55.3% respectively and for invasive cancer were 92.3% and 55.2% respectively. With the higher threshold, the sensitivity decreased considerably (28.9% to detect moderate dysplasia lesions, 31.3% for severe dysplasia and 53.8% for clinical cancer) and the specificity increased to approximately 94%. At a lower threshold, the sensitivity was not satisfactory, and the test was highly non-specific; at a higher threshold sensitivity was even lower. Thus, the test characteristics of visual inspection are not very promising either as a preselection procedure for cytology or as a low-technology measure for cervical cancer screening in developing countries.
PMCID: PMC2063368  PMID: 9020493
18.  Characteristics of 44 Cervical Cancers Diagnosed Following Pap-Negative, High Risk HPV-Positive Screening in Routine Clinical Practice 
Gynecologic oncology  2011;121(2):309-313.
To characterize the cervical cancers diagnosed following a Pap-negative, high risk human papillomavirus (HPV)-positive (Pap−/HPV+) screen in routine clinical practice.
Using data from Kaiser Permanente Northern California, we investigated the cases of cervical cancer diagnosed between January, 2003 through January, 2009 following Pap−/HPV+ screen. Two cervical specimens were routinely collected for cervical cancer screening, one for conventional cytology and the other for high risk HPV testing using Hybrid Capture 2 (Qiagen).
Forty-four women (median age at diagnosis = 44 years) were diagnosed with primary invasive cervical cancer with a recent history of one or more Pap−/HPV+ screens. Twenty-six women had one Pap−/HPV+ screen preceding the diagnosis of cancer, 15 had two, and three had three. There were 16 squamous cancers, one small cell cancer, 24 adenocarcinomas, 2 adenosquamous carcinomas, and one case with separate invasive squamous and adenocarcinoma. FIGO Stage was IA in 11 women, IB in 31 women and IIA in 2 women. Treatment included a pelvic node dissection in 230, 2 (6.7%) of whom had positive nodes.
HPV testing contributes to early cervical cancer diagnosis detection in women with negative Pap tests. Most women in this cohort have early stage, node negative, treatable and potentially curable disease. Adenocarcinoma predominated as might be expected because cytology misses these cancers and their precursors. The majority of cancers were diagnosed following a single Pap−/HPV+ screen, suggesting that effective triage to colposcopy of women with a Pap−/HPV+ screen would be preferable to retesting in one year as currently recommended.
PMCID: PMC3081890  PMID: 21276605
cytology; cervical cancer; human papillomavirus (HPV); HPV testing
19.  Awareness and knowledge of cervical cancer and its prevention among the nursing staff of a tertiary health institute in Ahmedabad, Gujarat, India 
ecancermedicalscience  2012;6:270.
Carcinoma of the cervix is the second most common cancer in women worldwide, while it is the commonest cancer among Indian women. Awareness regarding cervical cancer and its prevention is quite low amongst Indian women. The Pap test is a simple and cost effective technique for early diagnosis of cervical cancer. It is necessary to make nursing staff aware of cervical cancer, so that they can impart knowledge regarding cervical cancer and its prevention to the general public.
Aims and objectives:
(1) To assess the knowledge level regarding symptoms, risk factors, prevention and screening of cervical carcinoma among nursing staff. (2) To find out the behaviour of respondents regarding prevention and screening of cervical carcinoma.
Materials and methods:
A cross-sectional interview-based survey regarding knowledge levels about cervical carcinoma was conducted among the nursing staff from one of the tertiary health institutes of Ahmedabad, India. A structured questionnaire with multiple choices was used for data collection. Provision for open-ended responses was also made in the questionnaire. Department-wise stratification was carried out, and thereafter 15% of the total nursing staff from all departments were selected randomly so as to include a total of 100 nurses in the current study. Data entry was done in Microsoft Excel. SPSS statistical software was used to generate statistical parameters like proportion, mean, standard deviation, etc. The Z test was used as a test of significance, and a P value of <0.05 was considered as the level of significance.
PMCID: PMC3437739  PMID: 23008746
cervical cancer; knowledge; nursing staff; PAP test
20.  Traditional knowledge on zootherapeutic uses by the Saharia tribe of Rajasthan, India 
The present zootherapeutic study describes the traditional knowledge related to the use of different animals and animal-derived products as medicines by the Saharia tribe reside in the Shahabad and Kishanganj Panchayat Samiti's of Baran district of Rajasthan, India. A field survey was conducted from April to June 2006 by performing interview through structured questionnaire with 21 selected respondents, who provided information regarding use of animals and their products in folk medicine. A total of 15 animal species were recorded and they are used for different ethnomedical purposes, including cough, asthma, tuberculosis, paralysis, earache, herpes, weakness, muscular pain etc. The zootherapeutic knowledge was mostly based on domestic animals, but some protected species like the peacock (Pavo cristatus,), hard shelled turtle (Kachuga tentoria), sambhar (Cervus unicolor) were also mentioned as medicinal resources. We would suggest that this kind of neglected traditional knowledge should be included into the strategies of conservation and management of faunistic resources. Further studies are required for experimental validation to confirm the presence of bioactive compounds in these traditional remedies and also to emphasize more sustainable use of these resources.
PMCID: PMC1892771  PMID: 17547781
21.  Expenditure and resource utilisation for cervical screening in Australia 
The National Cervical Screening Program in Australia currently recommends that women aged 18–69 years are screened with conventional cytology every 2 years. Publicly funded HPV vaccination was introduced in 2007, and partly as a consequence, a renewal of the screening program that includes a review of screening recommendations has recently been announced. This study aimed to provide a baseline for such a review by quantifying screening program resource utilisation and costs in 2010.
A detailed model of current cervical screening practice in Australia was constructed and we used data from the Victorian Cervical Cytology Registry to model age-specific compliance with screening and follow-up. We applied model-derived rate estimates to the 2010 Australian female population to calculate costs and numbers of colposcopies, biopsies, treatments for precancer and cervical cancers in that year, assuming that the numbers of these procedures were not yet substantially impacted by vaccination.
The total cost of the screening program in 2010 (excluding administrative program overheads) was estimated to be A$194.8M. We estimated that a total of 1.7 million primary screening smears costing $96.7M were conducted, a further 188,900 smears costing $10.9M were conducted to follow-up low grade abnormalities, 70,900 colposcopy and 34,100 histological evaluations together costing $21.2M were conducted, and about 18,900 treatments for precancerous lesions were performed (including retreatments), associated with a cost of $45.5M for treatment and post-treatment follow-up. We also estimated that $20.5M was spent on work-up and treatment for approximately 761 women diagnosed with invasive cervical cancer. Overall, an estimated $23 was spent in 2010 for each adult woman in Australia on cervical screening program-related activities.
Approximately half of the total cost of the screening program is spent on delivery of primary screening tests; but the introduction of HPV vaccination, new technologies, increasing the interval and changing the age range of screening is expected to have a substantial impact on this expenditure, as well as having some impact on follow-up and management costs. These estimates provide a benchmark for future assessment of the impact of changes to screening program recommendations to the costs of cervical screening in Australia.
PMCID: PMC3548768  PMID: 23216968
22.  HPV infection, cervical abnormalities, and cancer in HIV-infected women in Mumbai, India: 12-month follow-up 
HIV-infected women are at a higher risk of cervical intraepithelial neoplasia (CIN) and cancer than women in the general population, partly due to a high prevalence of persistent human papillomavirus (HPV) infection. The aim of the study was to assess the burden of HPV infection, cervical abnormalities, and cervical cancer among a cohort of HIV-infected women as part of a routine screening in an urban overpopulated slum setting in Mumbai, India.
From May 2010 to October 2010, Médecins Sans Frontières and Tata Memorial Hospital Mumbai offered routine annual Pap smears and HPV DNA testing of women attending an antiretroviral therapy (ART) clinic and a 12-month follow-up. Women with abnormal test results were offered cervical biopsy and treatment, including treatment for sexually transmitted infections (STIs).
Ninety-five women were screened. Median age was 38 years (IQR: 33–41); median nadir CD4-count 143 cells/μL (IQR: 79–270); and median time on ART 23 months (IQR:10–41). HPV DNA was detected in 30/94 women (32%), and 18/94 (19%) showed either low-grade or high-grade squamous intraepithelial lesions (LSIL/HSIL) on Pap smear. Overall, >50% had cervical inflammatory reactions including STIs. Of the 43 women with a cervical biopsy, eight (8.4%) had CIN-1, five (5.3%) CIN-2, and two (2.1%) carcinoma in situ. All but one had HPV DNA detected (risk ratio: 11, 95% confidence interval: 3.3–34). By October 2011, 56 women had completed the 12-month follow-up and had been rescreened. No new cases of HPV infection/LSIL/HSIL were detected.
The high prevalence of HPV infection, STIs, and cervical lesions among women attending an ART clinic demonstrates a need for routine screening. Simple, one-stop screening strategies are needed. The optimal screening interval, especially when resources are limited, needs to be determined.
PMCID: PMC3746789  PMID: 23976867
HIV/AIDS; HPV; women’s health; cervical cancer; operational research; India
23.  Problems of cervical cancer screening programmes 
The feasibility of using an age-sex register as a basis for a cervical cancer screening programme was investigated in a London practice serving both inner city and suburban populations. Only about 25% of 810 women aged 35-59 years who had not recently been screened responded to an invitation to attend a practice well woman clinic for a cervical smear. Nearly 30% of the invitations were returned `not known at this address' and there was no reply from the remaining 45%. A high proportion of incorrect addresses considerably reduces the effectiveness of a cancer screening programme based on an age-sex register covering an area with a mobile population and also makes it difficult to follow up women with abnormal smears adequately. Opportunistic screening remains essential and every effort should be made to encourage women to be responsible for their own cancer screening programmes.
PMCID: PMC1711357  PMID: 3255814
24.  Prevalence of HPV Infection And Cervical Intraepithelial Neoplasia And Attitudes towards HPV Vaccination among Chinese Women Aged 18-25 in Jiangsu Province 
Few data are available on the epidemiology of HPV and cervical cancer among Chinese women younger than 25 years old. This study aimed to estimate the HPV infection rate and the prevalence of cervical intraepithelial neoplasia (CIN) in women aged 18-25, as well as their knowledge of and attitudes towards HPV vaccination.
A population-based cervical cancer screening study was conducted on women aged 18-25 in Jiangsu province in 2008. Participants provided socio-demographic, reproductive and behavioral information and completed a survey about their knowledge of and attitudes towards HPV vaccination. Women then underwent a gynecologic exam to provide two cervical exfoliated cell samples for high risk HPV DNA testing and liquid-based cytology (LBC) as well as visual inspection with acetic acid (VIA). Women testing positive for any test were referred to colposcopy and biopsy. The gold standard for diagnosis of cervical lesions was directed or random biopsies.
Within the sample of 316 women, 3.4% of them were diagnosed with CIN grade 2 or worse lesions and 17.1% were found to be positive for HPV DNA. Among these young women, extra-marital sexual behavior of them (OR=2.0, 95%CI: 1.1-3.8) or their husbands (OR=2.6, 95%: 1.4-4.7) were associated with an increased risk of HPV positivity. Although overall HPV awareness was low, after a brief educational intervention, 98.4% reported they would electively receive HPV vaccination and would also recommend that their daughters be vaccinated. However, most urban and rural women reported their ideal maximum out-of-pocket contribution for HPV vaccination to be less than 500 RMB and 50-100 RMB, respectively.
Our study indicates cervical disease burden is relatively high among sampled Chinese women aged 18-25. Appropriate educational interventions for female adolescents and strategies to subsidize vaccine costs are definitely needed to ensure the effectiveness of vaccination campaigns in China.
PMCID: PMC3587523  PMID: 23467401
Cervical cancer; Cervical intraepithelial neoplasia; Human papillomavirus; Knowledge; Attitude
25.  Pap smear screening in the primary health care setting: A study from Turkey 
Cervical cancer is one of the ten most frequent cancers in Turkey. It is well known that cervical cancer morbidity and mortality could be significantly reduced with an active cervical smear screening (Pap smear) program.
The aims of this study were: 1) to evaluate the knowledge and attitudes of women about cervical smear testing; 2) to establish a cervical smear screening program and to evaluate the cervical cytological abnormalities that were found; 3) to determine the applicability, limitations and effectiveness of this screening in a primary health care unit.
Patients and Methods:
A total of 332 married women were included in our study. We collected data concerning socio-demographic and fertility characteristics, and knowledge about Pap smear testing was determined through printed questionnaires. A gynecological examination and Pap smear screening was performed on every woman in our study group.
Over ninety percent of our study group had never heard of and had not undergone Pap smear screening before. Of the 332 smears evaluated, 328 (98.8%) were accepted as normal, whereas epithelial cell anomalies were seen in 4 (1.2%), infection in 59 (17.7%), and reactive cell differences in 223 (67.2%) of the smears.
The frequency of epithelial cell anomalies in our study group was less than the frequencies reported from Western countries. Knowledge regarding cervical cancer and Pap smear screening was very low. Pap smears can be easily taken and evaluated through a chain built between the primary health care unit and laboratory, and this kind of screening intervention is easily accepted by the population served.
PMCID: PMC3339109  PMID: 22558549
Cervical smear; cervical intraepithelial lesion; cervical cancer screening

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