Dissertations / Theses on the topic 'Cervix uteri Cancer Victoria Diagnosis'

Cervical cancer is the ninth leading cause of female cancer deaths in Hong Kong. In 2011, 391 new cases of cervical cancer were diagnosed and the age-standardized incidence rate was 7.2 per 100,000 standard populations. In 2012, 133 women died from this cancer, accounting for 2.5% of female cancer deaths. The age-standardized death rate of cervical cancer was 2.1 per 100,000 standard populations. Human papillomavirus (HPV) infection is an established cause of cervical cancer. HPV vaccines offer more than 70% protection for women against HPV types 16 and 18 infections and their related cervical precancerous lesions and cervical cancer. As there are usually no symptoms in high-risk HPV infection, it is often diagnosed at a late stage. Regular cervical smears can offer early detection of pathological changes and pre-cancerous stage for a timely medical treatment to prevent progression to cervical cancer. The Cervical Screening Programme (CSP) of Department of Health (DH) was launched on 8 March 2004. It is a voluntary program with the objectives to increase the population coverage of cervical screening among women and to reduce the incidence and mortality of cervical cancer in Hong Kong. Women participating in the programme are encouraged to have cervical smears in the medical centres of their own choices and to provide their cervical smear information through their health care providers to the central registry of the CSP - The Cervical Screening Information System (CSIS). As at 31 December 2013, 491,674 women have registered with CSP. When DH implemented CSP in March 2004, a report was published in the same year showing evidence that an organized screening compared with the opportunistic screening could substantially increase benefits and reduce costs. Another local study conducted early this year supported by the Health Services Research Fund also highlighted the importance and urgency in enhancing the current screening protocol. It is of public health interests to study and compare the programme outcomes with countries like Finland, Australia, UK and Japan where different policy was adopted for the prevention of cervical cancer. Information gathered from research papers on epidemiological studies has been collected and analyzed on population benefit (outcome, access, disparities), cost (cost benefit, efficiency, cost containment), equity, feasibility and constituency perspectives in formulation of the policy alternatives. In conclusion, strengthening what is already in place with better allocative efficiency could protect the female population against cervical cancer. From the education perspective, emphasis on the risk of HPV infection in the sex education curriculum would raise the awareness on the precaution of HPV infections amongst young females. Additionally, vaccination at the age of 12 can provide protection against most types of HPV. It is strongly recommended that a cervical screening and HPV co-testing strategy at a triennial interval could provide the best cost and benefit effectiveness. Together they can enhance protection coverage of women at 12 through immunization and from 25 - 64 through active population screening. The ultimate objectives to reduce incidence, mortality and increase coverage could be achieved.
published_or_final_version
Public Health
Master
Master of Public Health

In cervical screening programmes, Papanicolaou test (Pap test) is the key screening tool. However Pap test is difficult to implement in low-resource region. Introduction of an economic, cost-effective and less skill demanding equipment is hence a potential direction of advance in cervical screening methodology. 　　Cervical carcinogenesis involves genetic instability which leads to chromosomal aneuploidy. Evaluation of aneuploidy may hence provide information for identifying cancer and precursor cells. An automated DNA-image-cytometry system (DNA-imager) capable of quantitating the DNA content of cells has recently been developed. 　　To evaluate the efficacy of DNA-imager in cervical cancer screening, a total of 483 residual ThinPrep liquid-based cytology (LBC) samples after diagnosis were retrieved and evaluated by the DNA-imager. The high risk human papillomavirus (HPV) status of the atypical squamous cells of undetermined significance (ASC-US) samples has been tested as a parallel study. According to established criteria, 423 out of the 483 samples were satisfactory for downstream analysis. The samples were designated “Normal”, “Suspicious” or “Abnormal” according to their DNA aneuploidy and proliferation activity. 　　Significantly more high grade lesion samples (HSIL and SCC) were designated as “Abnormal” by DNA-imager than were lower grade lesion samples (Negative, ASC-US, AGC, ASC-H, and LSIL) (94.19% vs 51.04%, p<0.0001). For detecting ≥HSIL, DNA-imager achieved high sensitivity and specificity (94.19% and 48.96%) using “Abnormal” as cut off. Adopting a more stringent definition of “Suspicious” or “Abnormal” would increase the sensitivity to 100% but decreased the specificity to 24.33%. 　　 　　Regarding ASC-US triage, DNA-imager achieved a sensitivity and specificity of 80.00% and 71.29% respectively when “Abnormal” was used as test positive to predict cases with ≥HSIL follow-up in the next two year. The sensitivity increased but the specificity decreased to 90.00% and 34.65% respectively if “Suspicious or above” was used as indicator of undesirable follow-up. HR-HPV test, on the other hand, was able to identify all cases with ≥HSIL upon follow-up (sensitivity = 100%) but the specificity was only 15.84%. Among these ASC-US sample, test positivity of the two tests showed poor concordance with each other (Cohen’s κ = 0.062 and 0.074 respectively for “Suspicious or above” or “Abnormal”, respectively). 　　Our findings suggested that DNA-imager may be a useful tool for automated primary screening of cervical cancer 3
published_or_final_version
Pathology
Master
Master of Medical Sciences

Background: Human papillomavirus (HPV) DNA test is more sensitive and can detect more high-grade cervical intraepithelial lesions than cytology test in cervical cancer screening. There are studies confirming HPV test being more effective in cervical cancer screening by detecting the persistence of HPV infection that could lead to cancer. However, the costs associated with a HPV test is higher than a cytology test. Moreover, HPV test is less specific which could subject more women to further triage tests or unnecessary invasive diagnostic procedures. Therefore healthcare costs could possibly increase if primary HPV screening is to be adopted. Study objective: The aim of the study is to systematically review the cost-effectiveness of primary HPV testing in cervical cancer screening Method: Electronic search was performed in three biomedical databases (PubMed, Medline, Cochrane Library) and one economic evaluation database to identify relevant studies. Studies were selected according to the explicit inclusion and exclusion criteria defined. Only those studies carried out in high-income countries were included so that result could be better applied to Hong Kong. Results: A total of 19 studies were included in this systematic review. Cytology-only method is generally not cost-effective. To be cost-effective, it has to be performed in a longer screening interval which would reduce not only the screening costs but also a reduction in the health outcomes. Among the different options in HPV-based primary screening, HPV testing with cytology triage is the most cost-effective strategy in many of the studies. Combined HPV/cytology co-screening could achieve the biggest health benefit but is also most costly. HPV-based screening is more cost-effective for those >30 years of age and is usually less cost-effective if applied to young women. From the result in sensitivity analysis, HPV-based screening is sensitive to an increase in the costs of the HPV test, a low HPV test sensitivity and a low screening compliance rate. Conclusion: Primary HPV screening is cost-effective and generally performs better than cytology screening. The result of this systematic review guides the future direction of developing an optimal cervical screening strategy in Hong Kong. Local context has to be considered when examining the cost-effectiveness of primary HPV testing for cervical screening. Good quality local epidemiological data on HPV infection and cervical cancer and screening would be required to aid future research on the application of HPV test for cervical cancer screening in Hong Kong.
published_or_final_version
Public Health
Master
Master of Public Health

Thesis (MFamMed)--Stellenbosch University, 2014.
OBJECTIVE: The purpose of the study was to assess the safety, acceptability and feasibility of Visual Inspection with Acetic Acid and Cervicography (VIAC) followed by Cryotherapy or Loop Electrical Excision Procedure (LEEP) at a single visit for prevention of cancer of the cervix in Bulawayo, Zimbabwe. STUDY DESIGN: The study was descriptive using retrospective data extracted from electronic medical records of women attending the VIAC clinic at United Bulawayo Hospital in the period 1st February2010 to 31st December2012.Over 24 months 4641 women visited the clinic and were screened for cervical cancer using VIAC. If positive and eligible, cryotherapy or LEEP was offered immediately. Treated women were followed up at 3months and 1 year. RESULTS: The VIAC test positive rate was 10.8%.Of those eligible,17.0% received immediate cryotherapy, 44.1%received immediate LEEP, 1.9% delayed treatment and 37.0% were referred to a gynaecologist. No major complications were recorded after cryotherapy or LEEP. Among those treated99.5% expressed satisfaction with their experience. Only 3.2% of those treated at the clinic were VIAC positive one year later. The service was shown to be feasible to sustain over time with the necessary consumables. There were no service-related treatment postponements and the clinic staff and facility were able to meet the demand for the service. CONCLUSION: A single visit approach using VIAC, followed by cryotherapy or LEEP proved to be safe, acceptable and feasible in an urban African setting in Bulawayo, Zimbabwe.
AFRIKAANSE OPSOMMING: Geen opsomming beskikbaar.

Cervical cancer is a common gynaecological malignancy worldwide, with more than 450,000 incidences every year. Its etiology has been well documented to be associated with persistent infection with high-risk genotypes of human papillomavirus (HPV). The carcinoma can be screened by convention Pap smear and liquid-based cytology. Although preventable, cervical cancer remains a primary cause of death from cancer in developing countries where cytological screening is not so available. In the past decades, many studies have been carried out to explore molecular screening or diagnosis of cervical cancer, such as HPV DNA testing, histological or cytological biomarkers. Micro RNAs, small non-coding RNA molecules of 18-25 nucleotides in length, areaberrantly expressed in various cancers. MiR-143 was reported consistently downregulated in cervical cancer tissues and cell lines, but its functional roles in cervical carcinogenesis has not been clearly illustrated. Ten miR-143 downstream target genes were chosen and their expression levels in five cervical cancer cell lines (HeLa, SiHa, CaSki, C4-I and C33A) were investigated. In general, the gene expressions of candidates are upregulated in our cell lines with lowmiR-143 level. To further identify specific miR-143 targets in cervical cancer for biomarkers, protein expressions of TARDBP, ERK5, KRAS and PHF6were significantly downregulated upon miR-143 overexpression. Hence, miR-143 level is inversely correlated with the mRNA and protein expressions of these target genes. Immunohistochemical study of ERK5 and TARDBP on FFPE samples including normal cervix, CINs and SCC cases showed that both ERK5 and TARDBP were positively stained in SCC samples, whereas weaker staining was found in CINs (both LSILs and HSILs) for both antigens. Thus, the intensity of positive staining ascended with the histological grading: LSIL, HSIL and SCC samples. Such differential expression pattern supports ERK5 and TARDBP as specific markers for high grade cancerous lesions. In summary, two targets of miR-143, ERK5 and TARDBP, could be specific markers for high-grade lesion of cervical cancer. This is supported by their transcript and protein expressions inversely associated with miR-143 level, and that their strong immunohistochemical positivity in SCC samples. Their underlying molecular mechanisms involved in carcinogenesis and possible future applications require more in-depth researches.
published_or_final_version
Pathology
Master
Master of Medical Sciences

The purpose of this study is to investigate specific contributing factors affecting quality assurance in the diagnosis of conventional cervical smears. More than half of South- African women fail to have one cervical smear in their lifetime and +/- 50 percent of those who do have cervical smears taken, are lost to follow-up. Since cervical cancer is the most common malignancy amongst women in developing countries, the medical profession will have to endeavor to screen a higher rate of women and ensure a 100 percent quality assurance with every patient treated in order to reduce the unacceptable high incidence of cervical carcinoma. At this stage it seems like an impossible task to screen all women in South Africa, due to far-off rural areas, shortage of medical professionals and the lack of knowledge of some women of the necessity of cervical smears. Many newly qualified South-African doctors leave the country to go and work elsewhere. South Africa then in turn has to recruit doctors from other countries to staff the State hospitals and clinics. Some areas have one doctor to thousands of patients, insufficient nursing personnel and inadequate equipment. Doctors in some areas cannot cope with the volume of work and the long hours. One has to accept that the quality of the management of some patients is affected negatively. There are a number of medico-legal issues (world wide) in relation to aspects of cervical cancer prevention practices which are controversial and are of particular concern to all of those involved in cervical cancer prevention. Various countries have therefore formed different national organizations to address the medico-legal issues in screening for the prevention of cancer. These organizations monitors procedures, internal quality control as well as external quality control. In South Africa, medico-legal cases are not so prevalent, but may become so shortly. The South-African medical professionals therefore have to ensure that their quality of work conforms to accepted good practice in all circumstances. State hospitals serve thousands of patients per month and it is an every day occurrence to see long queues of patients sitting waiting for doctors and who often have to come back the following day. The situation appears to be much improved in private practice and since patients have medical cover and accessible medical facilities. Since cervical cancer is the most common malignancy amongst women in developing countries, the medical profession will have to endeavor to screen a higher rate of women and ensure a 100 percent quality assurance with every patient treated in order to reduce the unacceptable high incidence of cervical carcinoma. At this stage it seems like an impossible task to screen 100 percent of women in South Africa, due to far-off rural areas, the shortage of medical professionals and ignorance of patients. Quality assurance is therefore of paramount importance to every medical professional for every patient treated. Laboratories all worldwide have been, or are in the process of being accredited by their specific accreditation authorities. The main reason for this is improvement of quality control and therefore quality assurance. The South African National Accreditation Society (SANAS) now accredits various laboratories in South Africa with the view of accreditting all laboratories within a certain time limit. The Ampath laboratory Port Elizabeth was successfully accredited during 2001. Accredited laboratories have to uphold a very high degree of quality to remain accredited. A team of professionals inspects the laboratory every 2 years and other quality assurance staff inspects the laboratories every few months. All aspects of the laboratory are checked, e.g. the qualification of staff, their registration with the Health Professions Council of South Africa (HPCSA), their curriculum vitaes, equipment, safety of the laboratory etc. Since the laboratory chosen for this study, is accredited, the author evaluated every cervical smear that was received in the laboratory since the year 2000, with the following objectives in mind: · Whether the presence or absence of an endocervical component has an effect on the adequacy of cervical smears · To determine the effect of using smaller coverslips on quality assurance in the cytology laboratory · Evaluate the effect that manual re-screening of smears has on quality assurance in the cytology laboratory. As there is a shortage of cytotechnologists and pathologists worldwide, several countries make use of automated screening devices as primary screening or secondary screening for quality assurance. These devices were tested in some laboratories in South Africa but were found to be very expensive and sensitivity and specificity were not up to standard. Sensitivity is a measure of the ability of a test to detect the abnormal - Sensitivity is the ratio of true positives to true positives + false negatives. Specificity is a measure of the ability of a test to correctly identify the negative - Specificity is the ratio of true negative to true negatives + false positives. The automated screening machines failed to identify abnormal cells amongst inflammatory cells, as well as in very blood stained smears. Several other problems also occurred and an increasing number of smears had to be manually rescreened, thus making this exercise costly and not helpful as a quality assurance instrument. The slides used for this thesis, have been retrieved from the archives of the Ampath laboratory in Port Elizabeth. Fourteen specific contributing factors affecting quality assurance in the diagnosis of cervical smears are also discussed and conclusions and recommendations given.

First Nations women face nearly three times the risk of cervical cancer and mortality rates of up to six times higher than their non-Aboriginal counterparts. While cervical cancer is almost completely preventable, Southern Alberta First Nations women seldom access cervical screening services. The purpose of this qualitative focused ethnography was to gain an understanding of the cervical screening needs of un- and under-served First Nations women living off-reserve. Thirteen purposefully selected First Nations women participated in three focus groups utilizing semi-structured interviews. Personal self-worth and cervical screening awareness and relevance are essential to the pursuit of cervical screening. Barriers and incentives for screening and opportunities for acceptability and sustainability are explored. A holistic approach, intersectoral collaboration and cultural safety are described by focus group participants as foundational for optimal service delivery.
xii, 223 leaves ; 29 cm.

The purpose of this thesis is to study the attitudes, practices and knowledge of Greek women in Perth, Western Australia, regarding cervical cancer screening. This is important because no study has yet examined the cervical screening pattern of this group, despite their low participation rate in screening programs. Qualitative semi-structured interviews among 15 Greek women in Perth were used for data collection. Interviews were conducted both in English and Greek. Eight out of the 15 women interviewed did not participate in frequent screening and many had had only one Pap test in their life. Culture and religion influenced negative attitudes towards cervical screening; these combined with strong emotions of fear towards the disease and lack of knowledge about the purpose of Pap tests, to create powerful barriers to screening. Preoccupation with morality and misconceptions about heredity and the symptomatology of cervical cancer also influenced attitudes towards Pap tests. Further, women's decisions to screen were influenced by the negative behaviour of General Practitioners. A preference was expressed for specialists/gynaecologists and an unwillingness to attend women's health centres.

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

This dissertation explores a diagnostic image analysis framework using multispectral digital colposcopy for real-time in vivo detection of cervical cancer. In the first part of the dissertation, the clinical feasibility of a previously developed multispectral digital colposcope (MDC) is demonstrated using a hamster cheek pouch model of carcinogenesis. Various studies on MDC applications to cervical cancer detection in human subjects are then presented. First, an automated diagnostic image analysis algorithm for cervical cancer using white light reflectance images is presented. The algorithm can identify pre-neoplastic tissue areas from an entire cervix based on intensity changes feature in the reflectance images induced by acetic acid treatment. Then, the information about tissue type is incorporated into the diagnostic image analysis framework. For this purpose, a Markov Random Field (MRF) model is adopted and the results are discussed. One of the practical difficulties of utilizing a MRF model in unpolarized white light reflectance imaging is the specular reflection problem since the effect of specular reflection extends into surrounding tissue areas. Through the use of cross polarized imaging, the effects of specular reflection reduced and the ability to segment images based on tissue types is enhanced, leading to better diagnostic performance. The diagnostic performance of polarized imaging is compared to that of unpolarized imaging. In order to assess the performance of the proposed approach, a gold standard for the entire cervical image is constructed using histopathology results from a whole cervix specimen. The results presented in this dissertation indicate that an automated diagnostic image analysis framework for early detection of cervical cancer has the potential to be clinically applied as a low cost alternative screening technique in developing countries. Advances in imaging technology as well as in image analysis algorithms will continue to reduce the cost of diagnostic imaging systems and improve the imaging and diagnostic capability, leading to an inexpensive, real-time, minimally-invasive alternative to conventional screening techniques for early detection of cervical cancer in developing countries.
text

Cervical cancer is the most common malignancy after breast cancer in women worldwide. It accounts for 83% of all new cases and 85% cancer death in developing countries. In South Africa, cervical cancer is the common cancer in women with an annual crude incidence rate of 30.2 per 100,000 women and the highest rate were found to be in women between the ages of 66-69 years. Approximately 6800 women in S.A face new case of cervical cancer while accounting for 3700 cancer death annually. Because of unequal access to the health facilities, socio-economic differences, HPV and HIV infection, the rate of cervical cancer in black women is higher (42.1%) compared to the low rate in white women. Because of the name “cancer bush’ given to Sutherlandia Frutescence(S.F) plant by the traditional healers as well as Xhosas, Zulu, Sotho and cape Dutch for its anti-cancer activity, the plant was in this study to confirm its cytotoxic effect on the cervical cancer cell lines. Aim of the study: to evaluate the methanolic extracts of Sutherlandia Frutescens on cervical cancer cell lines. Materials and Methods: The MTT assay was performed to evaluate SiHa cell lines treated with methanolic extract of S.F (50μg/ml, 100μg/ml, 150μg/ml and 200μg/ml). The three compounds (Canavanine, GABA and Pinitol) were also evaluated for its anti-tumour activity. The cell growth was then showed in real time using Xcilligence. Flow cytometry was employed to determine the mode of action. Caspase 3/7 assay was performed to confirm if cell death was via caspase-dependent or independent and ATP was done to assess the ATP level in S.F treated cells. Results: MTT shows a significant decline in cells treated with 50μg/ml, 100μg/ml and 200μg/ml of the extract and 50μg/ml was concluded to be the concentration at which 50% of the cells die. The ATP results are inconsistent with MTT result; the ATP level increased in S.F treated cells. Cell index which represents the quantitative measure of cell growth in real time decline upon treatment with 50μg/ml. Flow cytometry showed cells are dying by apoptosis and the cell cycle arrest is mostly in the S phase. The cell death was caspase-dependent as it shows an increased luminescence which is proportional to the number of caspase. The concentrations of the compounds used, Canavanine (1000μM, 1500μM and 2500μM), GABA (100μM, 300μM and 500μM) and Pinitol (30μM, 90μM and 120μM) induce cell death and cell death shows to decrease after the maximum concentration. Conclusion: Sutherlandia Frutescence has proven with number of research that it induces cell death via apoptosis. After evaluating its cytotoxicity, the plant shows to be a promising anti-tumor agent that needs to be clinically proven.
Life Sciences
M. Sc. (Life Science)

Despite the availability, accessibility and affordability of cervical cancer screening (CCS) in Malawi, many women do not utilize the CCS services. This research was conducted in Blantyre district, Malawi. The main objective of the study was to identify factors that act as barriers to the uptake of cervical cancer screening programs among urban and rural women in the Blantyre district of Malawi. A quantitative design was used and convenience sampling was applied in selecting a sample of 196 women from the population of women aged 18 and over in two Reproductive Health clinics, one urban clinic at Queen Elizabeth Central Hospital and one rural clinic at Mlambe hospital in Blantyre district, Malawi. A structured questionnaire was used to collect data. The questionnaire was translated from English into the local Chichewa language so that respondents were interviewed and responded in a language that they were able to comprehend. Analysis and discussion of findings are presented in five sections. Data were processed into numeric values using SPSS version 15.0 and Microsoft Excel to give meaning to the findings of the study. In order to test for statistically significant associations between variables, the Pearson correlation was applied. The study revealed that the main barrier to CCS was that women lack knowledge and information about cervical cancer and there is a lack of publicity about CCS services. Lack of knowledge was found in relation to - risk factors, prevention of, detection of and benefits of cervical cancer screening with a greater knowledge deficit being found in the rural women. Higher levels of education in both the urban and rural groups did not have a positive influence on the screening behaviours of the women. Commencing sexual intercourse at ages 15 to 19 years and having multiple sexual partners were the main risk factors to cervical cancer among the women in the study. It was also found that although rural women perceived themselves being very likely to be at risk of cervical cancer, this perception did not translate into CCS behaviour. v
Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2009.

Indiana University-Purdue University Indianapolis (IUPUI)
In this study we compared the distribution of HPV types in cervical cancer specimens from women living in either Indiana or Botswana. Paraffin-embedded blocks of formalin-fixed cervical cancer specimens were identified from women living in Indiana (n=51) or Botswana (n=171)

A model was developed in this study to understand women's cervical screening behaviour. It revealed that the interaction among institutional factors, risk appraisal, coping appraisal, and health beliefs and cultural factors contributed to the complex nature of screening behaviour among Chinese women. The institutional component provided the contextual factors within which women perceived the risk of cervical cancer, perceived the practice of cervical screening, and decided to take or not to take cervical screening. Risk appraisal provided the premise factor that induces women to seek coping strategies to reduce or remove the risk. During the process of coping appraisal, women's motivation to have cervical screening could be increased or decreased as the perceived benefits and costs of screening interacted with each other. The importance of the women's health beliefs and cultural factors was reflected in the way that they were affected by their notions of health behaviour and their cultural beliefs about cervical cancer risk and cervical screening participation. Commitment to participate in screening was a reinforcing factor inducing women to take up an offer of cervical screening.
Aim: To explore the knowledge and the perception of the risk of cervical cancer, identify the factors determining cervical screening behaviour, and develop a model to understand cervical screening behaviour among women in mainland China.
Background: Cervical cancer is the most common type of cancer, and is the second most common cause of cancer death in women in mainland China. Cervical screening is the most important intervention for the secondary prevention of cervical cancer. Theories of health behaviour and empirical research highlight risk perception as a significant factor motivating people to opt for cancer screening. However, little is known about the risk perception of cervical cancer and the factors influencing the screening participation of women in mainland China.
Conclusion: This study provides evidence of the complex factors influencing cervical screening behaviour and contributes new knowledge to the understanding of cervical screening behaviour within the Chinese cultural context. It further informs programmes for the promotion of cervical screening among this population.
Methods: A mixed method design consisting of two phases was used, employing both quantitative and qualitative methods of data collection. First, a cross-sectional survey was conducted to collect a baseline assessment of women's knowledge of cervical cancer and screening, their perceptions of the risk of cervical cancer, and the relationship between these factors and their cervical screening behaviour. Findings from this phase also guided the purposive sampling of participants in phase two.
Results: The findings from phase one demonstrated that the availability of an organized screening programme was a major motivator for women to opt for cervical screening. Multivariate analysis shows that having children (OR=2.57, p=0.026), a perception that visiting doctors regularly is important for health (OR-2.66, p=0.025), average (OR-4.84, 1)=0.006) and high levels of knowledge about cervical screening (OR-9.66, p=0.001) were significantly associated with having been screened in the previous three years.
Then in phase two, qualitative research was conducted using semi-structured interviews of 27 women, 16 of whom had been screened and 11 had not. The interview structure was based on an initial analysis of the data from phase one and from a review of the related literature. The data from the interviews were analyzed using latent content analysis, involving an interpretative reading of the symbolism underlying the surface structure in the text. The audio recordings of the interviews were transcribed verbatim in Chinese, and then the key phrases which were important for the objectives of the study were identified. The key phrases and words were grouped according to their commonality of meaning. Then, these groups of data were sorted and classified to create categories and sub-categories, which were mutually exclusive, explicit and accurate without overlapping.
Two themes emerged from the qualitative data from phase two. Theme I was that perceptions of cervical cancer and cervical screening included five categories: the perceived effects of suffering from cervical cancer; the perception of cervical screening; a lack of understanding about cervical cancer and screening; the perceived risk of cervical cancer; and factors related to the cultural beliefs system. Theme II was that the institutional and health care practitioner system included two categories: availability of an organised physical examination programme and the role of the health care practitioner in encouraging cervical screening utilization.
Gu, Can.
Adviser: Chan, Carmen.
Source: Dissertation Abstracts International, Volume: 73-02, Section: B, page: .
Thesis (Ph.D.)--Chinese University of Hong Kong, 2010.
Includes bibliographical references (leaves 244-267).
Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web.
Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [201-] System requirements: Adobe Acrobat Reader. Available via World Wide Web.
Abstract also in Chinese.

研究背景：
2009年起，中國政府發起並資助了一項覆蓋全國31個省221個鄉村、針對100萬名農村婦女的細胞學及肉眼觀察宮頸癌篩查試點項目。國家及地方政府需要對可行的篩查策略進行衛生經濟學評估，為下一步擴大規模的篩查提供政策依據。
研究目標：
應用人群特異性Markov模型，對巴氏塗片及肉眼觀察的宮頸癌篩查策略進行成本效果及成本效用兩方面的衛生經濟學評估，進而為中國農村婦女宮頸癌篩查政策的制定提供依據。
研究方法：
本論文工作建立了Markov人群動態擬合模型，該模型能夠整合與中國農村宮頸癌流行情況相吻合的成本及健康狀況的數據，進而用於擬合20年內35-59歲中國農村婦女在有/無篩查幹預下的成本、效用和效果。本文分析的八個備選篩查策略包括：採用醋酸染色肉眼觀察（VIA）或傳統細胞學（巴氏塗片）分別進行10年，5年，3年及1年一次的篩查。
本文從社會學角度出發，成本數據涵蓋篩查、診斷及治療過程中產生的直接及間接成本。模型在結構上綜合了已被廣泛認可的宮頸癌自然發展史模型，以及宮頸癌及其癌前病變（CIN）在中國農村進行篩查和治療的標準臨床路徑。模型輸入參數盡可能地使用了能夠反映中國農村婦女人群特異性的數據。通過對比國家報告數據與模型預測結果，本文從全死因死亡率、宮頸癌死亡率及宮頸癌發病率三個方面驗證了模型的可信度。
模型的結局變量包括：累計成本、累計生命年(LYs)、累計質量調整生命年(QALYs)、預期宮頸癌死亡率及發病率降低百分比(%)、CIN 相對風險、宮頸浸潤癌相對風險，增量成本效用比(ICUR, 表述為每挽救一個質量調整生命年消耗的成本)及增量成本效果比(ICER, 表述為每挽救一個生命年消耗的成本)等。與無篩查幹預相比，我們界定ICUR及ICER小於三倍人均國內生產總值（76,824元，2009年)的優勢策略為‘具有成本效益’的選擇，並將其中ICUR和ICER最低的策略，定義為‘最具成本效益’的策略，將具有最大健康效益的策略（挽救最多質量調整生命年或生命年的策略），定義為‘最有效’的策略。同時，我們對可能影響決策的不確定因素進行了敏感性分析。
結果：
與無篩查幹預相比，肉眼觀察及巴氏塗片篩查均能夠減少宮頸癌患病例數，進而顯示出一定的健康效益。較短的篩查間隔具有更高的健康效益。模型預測在不同的篩查策略幹預下，宮頸癌死亡率和發病率分別有望降低6.67-31.95%和5.12-24.71%，預期CIN發病相對風險為0.89-0.98，預期宮頸癌發病相對風險為0.73-0.95。篩查幹預對健康的保護作用在本研究中得到了證實。
成本效用分析顯示，10年一次的肉眼觀察策略最具成本效益，其次為5年一次、3年一次、1年一次的肉眼觀察篩查策略及1年一次的巴氏塗片篩查策略。與無篩查幹預相比，如上策略每挽救一個質量調整生命年消耗的成本為11,921至26,069元（1,892-4,138美元，2012年）。同時成本效果分析也顯示，10年一次的肉眼觀察策略最具成本效益，其次為5年一次的肉眼觀察策略及5年一次的巴氏塗片篩查策略。同樣與無篩查幹預相比，如上策略每挽救一個生命年消耗的成本為37,211至68,226元（5,906-18,830美元，2012年）。
對於某一既定策略，相應的ICUR和ICER受當地經濟狀況相關因素的影響最大，這些因素包括治療成本、篩查成本和成本貼現率。從檢測技術水平上看，肉眼觀察對分析結果的影響小於巴氏塗片，原因是前者敏感度範圍較小。篩查覆蓋率、初篩陽性隨訪率、診斷陽性治療率也都與相應的ICUR和ICER呈負相關性。敏感性分析結果顯示本文中模型對於健康結局的預測，及相關的衛生經濟學分析，受自然史模型中HPV感染和CIN之間轉移概率的不確定性的影響最大。HPV感染與CIN間的進展和逆轉概率是該項模型研究的核心參數。
結論：
本文中成本效用和成本效果分析均顯示，相較於傳統的細胞學篩查策略，採用間隔時間較長（10年或5年）的肉眼觀察篩查策略，對一般發病地區的35-59歲的農村婦女來說，是更具‘成本效益’的選擇。對於宮頸癌高發地區，其篩查頻率可以提高到1年一次。1年一次的巴氏塗片篩查策略，是最有效的篩查策略，可以挽救最多的生命。但採用該策略時，應在財政預算允許的前提下，確保篩查技術和項目完成的質量。
篩查項目的高覆蓋率，對篩查陽性患者良好的隨訪和診治，初篩檢測技術平均水平以上的表現，以及較低的篩查和治療成本是確保篩查項目具備成本效益優勢的核心因素。本文完成的成本效用及成本效果分析，能夠為公共衛生決策提供重要的輔助作用。
Background:
A Chinese government-sponsored cytology/visual inspection pilot cervical cancer screening program covered 10 million rural women in 221 counties of 31 provinces was initiated in 2009. Both the local and national governments in China need health economic evaluations of feasible strategies so as to make better policies for the next-step enlarging screening.
Objectives:
To perform health economic evaluations of Pap smear and visual inspection cervical cancer screening strategies using population-specific Markov modeling cost-utility (CUA) and cost-effectiveness (CEA) analyses, in order to assist screening policy making for women in rural China.
Methods:
Markov simulation models were developed to synthesize the evidence on costs and health outcomes related to cervical cancer epidemiology in rural China, and applied to predict the long-term utility, effectiveness and costs for hypothetical cohorts of 35-59 years old rural Chinese women, with or without the presence of screening over 20 years. The eight alternative screening strategies assessed were visual inspection with acetic acid (VIA) or traditional cytology (Pap smear) each with ten-year, five-year, three-year and one year screening intervals.
The study was conducted from the societal perspective, thus both directed and non-direct costs related to screening, diagnosis and treatment interventions were considered. The model structures incorporated with the well-accepted the natural history model of cervical cancer and the standard clinical pathway of screening and treatment interventions for precancerous lesions (CIN) and cervical cancer in real practice in rural China. Population-specific data were used as much as possible to be the model inputs. The model estimates were validated by comparison of our predictions of all-cause mortality, cervical cancer mortality and cervical cancer incidence with the national reported data.
Outcome variables included cumulative cost, life years (LYs), quality-adjusted life years (QALYs), predicted reduction(%) in cervical cancer mortality and incidence, relative risk of CIN, relative risk of cervical cancer, incremental cost-utility ratio (ICUR, presented as cost per QALY saved) and incremental cost-effectiveness ratio (ICER, presented as cost per life year saved). Compared with no screening, not-dominated strategies with ICUR and ICER less than three times China’s GDP per capita (76,824 CNY, 2009) were considered to be ‘cost-effective’ options. Among the identified ‘cost-effective’ options, the strategy with lowest ICUR or ICER was defined as the most cost-effective strategy, and the strategy with the highest health benefit (largest QALY saved or life year saved) was defined as the most effective strategy. Sensitivity analyses were conducted to test the effect of uncertainties on decision making.
Results:
All of the VIA and Pap smear screening strategies of showed certain benefits due to the decreased number of women developing cervical cancer, when compared with no screening. A trend for shorter screening interval to have greater benefit was also found. Cervical cancer mortality and incidence were expected to be reduced by 6.67-31.95% and 5.12-24.71% with different screening strategies. And the predicted relative risks of CIN and invasive cervical cancer of 0.89-0.98 and 0.73-0.95, respectively, also demonstrated the protective effect of screenings.
Modeling cost-utility analysis identified ten years VIA screening as the most cost-effective strategy followed by VIA screening with five-, three- and one year interval and Pap smear screening with a one year interval. Compared with no screening, the incremental costs per QALY saved of these strategies ranged from 11,921 to 26,069 Yuan (1,892-4,138 US dollars, 2012). In the meanwhile, modeling cost-effectiveness analysis also identified ten-years VIA screening as the most cost-effective strategy followed by VIA screening with five-year intervals and Pap smear screening with five-year intervals. Compared with no screening, the incremental costs per life year saved of these strategies ranged from 37,211 to 68,226 Yuan (5,906-18,830 US dollars, 2012).
Both ICUR and ICER of a selelected strategy were greatest influnced by factors related to variations in local economies , including treatment cost, screening cost and discounting rate of the cost. The influence of primary test performance of VIA was rather less than that of Pap smear due to the narrower ranges of the VIA sensitivities. Screening coverage, follow-up rate and treatment rate were also negatively associated with ICUR and ICER. Health outcome predictions and health economic analyses were mostly influenced by the uncertainties in HPV infection and CIN transitions in the natural history. Progression and regression probabilities between HPV infection and CIN were considered to be the key parameters of the simulation models.
Conclusions:
Baseline CUA and CEA results suggested that in comparison with traditional cytology screening strategies, organized VIA screening with long intervals (ten or five years) were more cost-effective options than for 35-59 years old women in normal incidence areas of rural China. The VIA screening interval can be shorten to one year in high incidence areas. Pap smear strategy with one year interval can be utilized as the most effective strategy with most lives saved when budget allows and the performances of program and test are ensured.
High coverage of the screening program, good management of screening positives, average or above performance of primary test, and lower screening and treatment costs are key elements for a cost-effective screening program. Cost-utility and cost-effectiveness analyses, such as the one conducted in this thesis study, can be considered important adjuncts to policy decision-making about public health objectives.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Detailed summary in vernacular field only.
Li, Xue.
Thesis (Ph.D.)--Chinese University of Hong Kong, 2013.
Includes bibliographical references (leaves 388-401).
Abstracts also in Chinese; appendixes includes Chinese.
Abstract of thesis --- p.i
中文摘要 --- p.v
ACKNOWLEDGEMENTS --- p.viii
TABLE OF CONTENTS --- p.1
LIST OF TABLES --- p.8
LIST OF FIGURES --- p.11
ABBREVIATIONS --- p.12
Chapter CHAPTER 1 --- INTRODUCTION --- p.14
Chapter 1.1 --- Epidemiological patterns and disease burden of cervical cancer --- p.14
Chapter 1.1.1 --- Cervical cancer incidence and mortality worldwide --- p.14
Chapter 1.1.2 --- Risk factors for cervical cancer --- p.15
Chapter 1.1.2.1 --- Human Papillomavirus (HPV) --- p.15
Chapter 1.1.2.2 --- Parity --- p.16
Chapter 1.1.2.3 --- Smoking --- p.16
Chapter 1.1.2.4 --- Human Immunodeficiency Virus (HIV) --- p.17
Chapter 1.1.2.5 --- Contraception --- p.17
Chapter 1.1.2.6 --- Sexual behavior, nutrition and other factors --- p.18
Chapter 1.1.3 --- Disease burden of cervical cancer in China --- p.18
Chapter 1.1.3.1 --- Epidemiology of Cervical Cancer in China --- p.18
Chapter 1.1.3.2 --- Cervical cancer in different geographic areas of China --- p.20
Chapter 1.2 --- The need for cost-effectiveness analysis of cervical screening strategies in China --- p.21
Chapter 1.2.1 --- Cervical cancer prevention in China --- p.21
Chapter 1.2.2 --- Why do we need a modeling cost-effectiveness analysis? --- p.23
Chapter 1.3 --- Natural history of cervical cancer --- p.25
Chapter 1.3.1 --- Terminology --- p.25
Chapter 1.3.2 --- Natural history of cervical cancer --- p.27
Chapter 1.4 --- Secondary prevention strategies of cervical cancer --- p.29
Chapter 1.4.1 --- Screening tests --- p.29
Chapter 1.4.1.1 --- Cervical cytology --- p.29
Chapter 1.4.1.2 --- Visual Inspection --- p.32
Chapter 1.4.1.3 --- HPV testing --- p.36
Chapter 1.4.2 --- Summary of different screening strategies all over the world --- p.37
Chapter CHAPTER 2 --- LITERATURE REVIEW --- p.40
Chapter 2.1 --- Background --- p.40
Chapter 2.2 --- Objectives of the literature review --- p.41
Chapter 2.3 --- Search strategies and results --- p.41
Chapter 2.3.1 --- Search strategies --- p.41
Chapter 2.3.2 --- Inclusion and exclusion criteria --- p.42
Chapter 2.4 --- Literature results summary --- p.44
Chapter 2.4.1 --- Methodology, target population and analytical perspective --- p.44
Chapter 2.4.2 --- Screening test and program performance --- p.47
Chapter 2.4.3 --- Cost and utility estimation --- p.49
Chapter 2.4.4 --- Model parameter sources and validation --- p.53
Chapter 2.4.5 --- Alternatives and identified cost-effective strategies --- p.58
Chapter 2.5 --- Conclusions --- p.63
Chapter CHAPTER 3 --- OBJECTIVES --- p.64
Chapter 3.1 --- General Objectives --- p.64
Chapter 3.2 --- Alternative cervical cancer screening strategies in this study --- p.64
Chapter 3.3 --- Decision rules for recommended cost-effective options --- p.65
Chapter 3.4 --- Analytical perspective and time horizon --- p.65
Chapter 3.5 --- Objectives --- p.66
Chapter 3.6 --- Analytical scenario in this study --- p.66
Chapter 3.6.1 --- Patterns of cervical screening program delivery in rural China --- p.67
Chapter 3.6.2 --- Demographic profile of the simulated hypothetical cohort --- p.67
Chapter 3.6.3 --- Summary of model assumptions --- p.68
Chapter 3.6.3.1 --- Assumptions related to screening performance and clinical practice --- p.68
Chapter 3.6.3.2 --- Assumptions related to epidemiological characteristics of cervical cancer --- p.68
Chapter 3.6.3.3 --- Assumptions related to economic evaluation --- p.69
Chapter CHAPTER 4 --- METHODOLOGY --- p.70
Chapter 4.1 --- Alternative strategies in this study --- p.70
Chapter 4.2 --- Markov Model Developments and Applications --- p.72
Chapter 4.2.1 --- General introduction of Markov Transition Model --- p.72
Chapter 4.2.2 --- Structure of Markov models --- p.76
Chapter 4.2.2.1 --- Natural history model of cervical cancer --- p.76
Chapter 4.2.2.2 --- Structure of Pap smear and Visual Inspection screening models --- p.82
Chapter 4.2.2.3 --- Structure of precancerous lesion and invasive cancer treatment models --- p.83
Chapter 4.2.2.4 --- Interaction of the models --- p.85
Chapter 4.2.3 --- Demographic profile of the hypothetical cohort --- p.86
Chapter 4.2.4 --- Probabilities --- p.88
Chapter 4.2.4.1 --- Identification and converting between rate and probability --- p.89
Chapter 4.2.4.2 --- Initial probabilities --- p.90
Chapter 4.2.4.3 --- Transition probabilities --- p.91
Chapter 4.2.5 --- Screening, diagnosis and treatment characteristics --- p.101
Chapter 4.2.5.1 --- Screening program characteristics --- p.101
Chapter 4.2.5.2 --- Diagnosis test performance --- p.104
Chapter 4.2.5.3 --- Precancerous lesions treatment characteristics --- p.104
Chapter 4.2.5.4 --- Invasive cancer and treatment characteristics --- p.106
Chapter 4.2.6 --- Model validation --- p.111
Chapter 4.3 --- Cost data collection --- p.112
Chapter 4.3.1 --- Perspective of study --- p.112
Chapter 4.3.2 --- Selection of study sites --- p.113
Chapter 4.3.3 --- Screening cost data collection --- p.113
Chapter 4.3.4 --- Treatment cost data collection --- p.115
Chapter 4.4 --- Cost-utility analysis and cost-effectiveness analysis --- p.117
Chapter 4.4.1 --- General introduction of these two analyses --- p.117
Chapter 4.4.2 --- Utility Estimates --- p.118
Chapter 4.4.3 --- Screening utility and effectiveness evaluation --- p.120
Chapter 4.4.4 --- Cost-effectiveness and cost-utility analysis method --- p.122
Chapter 4.5 --- Time horizon and discounting rate --- p.125
Chapter 4.6 --- Summary of modeling assumptions --- p.126
Chapter 4.6.1 --- Assumptions related to screening performance and clinical practice --- p.126
Chapter 4.6.2 --- Assumptions related to epidemiological characteristics of cervical cancer --- p.127
Chapter 4.6.3 --- Assumptions related to economic evaluation --- p.128
Chapter 4.7 --- Sensitivity analysis --- p.128
Chapter 4.8 --- Ethical approval --- p.129
Chapter CHAPTER 5 --- RESULTS --- p.130
Chapter 5.1 --- Model validation --- p.130
Chapter 5.2 --- Cost analysis results --- p.134
Chapter 5.2.1 --- Screening costs results --- p.134
Chapter 5.2.2 --- Treatment cost results --- p.136
Chapter 5.2.3 --- The proportional costs breakdown for different screening strategies --- p.139
Chapter 5.3 --- Utility estimation results --- p.141
Chapter 5.4 --- Cost-utility analysis results --- p.144
Chapter 5.4.1 --- Baseline analysis --- p.144
Chapter 5.4.2 --- Influence of screening program performance --- p.148
Chapter 5.4.2.1 --- Coverage of the screening program --- p.148
Chapter 5.4.2.2 --- Follow up rate and treatment rate of positives --- p.155
Chapter 5.4.3 --- Influence of screening test performance --- p.159
Chapter 5.4.4 --- Influence of costs --- p.165
Chapter 5.4.4.1 --- Influence of screening costs --- p.165
Chapter 5.4.4.2 --- Influence of treatment costs --- p.168
Chapter 5.4.5 --- Influence of discounting --- p.171
Chapter 5.4.6 --- Summary of factors and their influences on the baseline CUA results --- p.174
Chapter 5.5 --- Cost-Effectiveness analysis results --- p.180
Chapter 5.5.1 --- Baseline analysis --- p.180
Chapter 5.5.1.1 --- Life year saved --- p.181
Chapter 5.5.1.2 --- Cervical cancer mortality reduction --- p.185
Chapter 5.5.1.3 --- Cervical cancer incidence reduction --- p.187
Chapter 5.5.1.4 --- Relative risk of CIN and cervical cancer --- p.189
Chapter 5.5.1.5 --- Effectiveness summary of alternative screening strategies on the hypothetical 100,000 rural Chinese women --- p.191
Chapter 5.5.2 --- Factors that influence the CEA results --- p.195
Chapter 5.5.2.1 --- Best scenario analysis --- p.196
Chapter 5.5.2.2 --- Worst scenario analysis --- p.201
Chapter 5.5.2.3 --- Summary of the possible ranges of costs and effectiveness in different scenarios --- p.206
Chapter 5.6 --- Sensitivity analysis --- p.209
Chapter 5.6.1 --- Sensitivity analysis of Cost-Utility analysis results --- p.209
Chapter 5.6.1.1 --- Tornado analysis --- p.209
Chapter 5.6.1.2 --- One-way sensitivity analysis --- p.213
Chapter 5.6.2 --- Sensitivity analysis of Cost-Effectiveness analysis results --- p.220
Chapter 5.6.2.1 --- Tornado analysis --- p.220
Chapter 5.6.2.2 --- One-way sensitivity --- p.224
Chapter 5.6.3 --- Summary of sensitivity results --- p.236
Chapter CHAPTER 6 --- SUMMARY, DISSICUSSION AND CONCLUSIONS --- p.240
Chapter 6.1 --- Summary of Markov model development and validation --- p.240
Chapter 6.1.1 --- Category and source summary of input parameters --- p.240
Chapter 6.1.2 --- Model validation --- p.244
Chapter 6.2 --- Summary of modeling results --- p.245
Chapter 6.2.1 --- Summary of Cost-Utility Analysis --- p.245
Chapter 6.2.1.2 --- Baseline analysis findings --- p.245
Chapter 6.2.1.2 --- Influential factors on the cost-effective manner of alternative strategies --- p.246
Chapter 6.2.2 --- Summary of Cost-Effectiveness Analysis --- p.250
Chapter 6.2.2.1 --- Baseline analysis findings --- p.251
Chapter 6.2.2.2 --- Possible ranges for cost and effectiveness of alternative strategies under different scenarios --- p.253
Chapter 6.2.3 --- Summary of CUA and CEA findings --- p.257
Chapter 6.2.4 --- Summary of sensitivity analysis --- p.259
Chapter 6.2.4.1 --- Important variables on health outcome predictions --- p.259
Chapter 6.2.4.2 --- Sensitive variables to the baseline CUA and CEA recommendations --- p.260
Chapter 6.2.4.3 --- Overview of the sensitivity analysis --- p.263
Chapter 6.3 --- Discussion --- p.264
Chapter 6.3.1 --- Alternative strategies of cervical cancer screening in rural China --- p.264
Chapter 6.3.1.1 --- Target ages --- p.265
Chapter 6.3.1.2 --- Screening intervals --- p.266
Chapter 6.3.1.3 --- Feasible primary screening tests --- p.267
Chapter 6.3.1.4 --- Service delivering patterns --- p.269
Chapter 6.3.1.5 --- Time horizon of this thesis study --- p.270
Chapter 6.3.2 --- Transition probability estimation --- p.271
Chapter 6.3.3 --- Screening and treatment cost estimation --- p.276
Chapter 6.3.3.1 --- Representativeness of the selected counties --- p.276
Chapter 6.3.3.2 --- Screening costs of VIA and Pap smear --- p.277
Chapter 6.3.3.3 --- Treatment costs --- p.279
Chapter 6.3.4 --- Utility estimation --- p.280
Chapter 6.3.4.1 --- Instrument selection --- p.280
Chapter 6.3.4.2 --- Utility estimation between studies --- p.281
Chapter 6.3.5 --- Baseline cost-utility and cost-effectiveness analyses --- p.283
Chapter 6.3.6 --- Sensitivity Analysis --- p.284
Chapter 6.3.7 --- Strengths and limitations --- p.286
Chapter 6.3.7.1 --- Limitations --- p.286
Chapter 6.3.7.2 --- Strengths --- p.288
Chapter 6.4 --- Policy implications --- p.289
Chapter 6.4.1 --- How to manage a cost-effective cervical cancer screening program? --- p.289
Chapter 6.4.2 --- How can VIA screening be adopted? --- p.290
Chapter 6.4.3 --- How can Pap smear screening be adopted? --- p.291
Chapter 6.4.4 --- Framework for policy decision making --- p.292
Chapter 6.5 --- Conclusions --- p.295
Chapter APPENDIX --- p.300
Chapter Appendix 1-1 --- The 2001 Bethesda System* --- p.300
Chapter Appendix 1-2 --- The FIGO Staging for cervical cancers* --- p.301
Chapter Appendix 1-3 --- Cervical Cancer Screening Program in different countries --- p.302
Chapter Appendix 4-1 --- WHO World Standardized Population Distribution (%) --- p.305
Chapter Appendix 4-2 --- Summary of transition probabilities literature review --- p.306
Chapter Appendix 4-3 --- Price Indices from 1978 to 2010 --- p.326
Chapter Appendix 4-4 --- Screening Cost Questionnaire --- p.327
Chapter Appendix 4-5 --- Programmatic Cost Survey Questionnaire --- p.339
Chapter Appendix 4-6 --- Treatment Cost Survey Questionnaire --- p.342
Chapter Appendix 4-7 --- EQ-5D Algorism (UK) --- p.344
Chapter Appendix 4-8 --- Chinese Version of EQ5D----HQOL score questionnaire --- p.345
Chapter Appendix 5-1 --- Calibrated variables and its final settings --- p.348
Chapter Appendix 5-2 --- Cervical cancer new cases and deaths all over the world in 2008 --- p.349
Chapter Appendix 5-3 --- Data distribution of CIN2-3 and cervical cancer treatment costs --- p.350
Chapter Appendix 5-4 --- Relative risk of CIN and cervical cancer by age groups of alternative screening strategies --- p.361
Chapter Appendix 5-5 --- Influence of discounting rate of life years on the CEA results --- p.363
Chapter Appendix 5-6 --- Tornado analysis results based on the effect on QALYs predictions --- p.367
Chapter Appendix 5-7 --- Tornado analysis results based on the effect on life-year predictions --- p.372
Chapter Appendix 6-1 --- Summary of Markov Model Inputs and Sources --- p.377
REFERENCE --- p.388

Cervical cancer is reported to be the first among the five leading cancers affecting women in South Africa and the leading cancer among Black females. There is a high incidence and mortality rate among underserved and under-screened women presenting with cervical cancer as they are often unable to access screening facilities. Very little has been done to establish the factors in private health care provision that influence the implementation of cervical screening programmes. The study investigates factors influencing cervical cancer screening programme implementation among private medical practitioners in Soshanguve to establish whether private practitioners assume their roles in cervical screening. The intention is to provide guidelines for a screening programme that could be implemented in private health facilities. The study is qualitative, explorative, descriptive and contextual, using interviews and observation as the main data-collection methods. Lack of awareness and interest, failure to inform patients about cervical screening, age and gender of medical practitioners were among the factors identified. The study concluded that awareness programmes about cervical screening and materials containing information on cervical cancer and predisposing factors should be designed. The utilization of cheaper laboratory service providers could increase participation by making the test affordable and accessible to cash patients. The establishment of a private Pap clinic within medical practices or even as an independent entity is also recommended.
Health Studies
M.A. (Public Health)

Text in English
Cervical cancer remains the leading cause of cancer mortality among women worldwide, a burden in the developing countries and commonly detected through symptoms at later invasive stages. The study aimed at establishing knowledge and awareness of the importance of cervical cancer screening in the Makhuduthamaga Sub-district by exploring the perceptions of women and professional nurses and through the review of the National Cervical Cancer Screening Policy (2013). Recommendations to address the gap in knowledge and to inform the National Cervical Cancer Screening Policy were developed based on the study findings. A mixed-method approach was used in this study through a sequential explanatory design, which is quantitatively driven was used. Quantitative data were obtained by using a researcher developed checklist. The checklist was developed from variables stated in the National Cervical Cancer Screening Policy and was used to review its implementation. Qualitative data was obtained through in-depth interviews with individual women and focus group discussions with professional nurses. The study was conducted in ten randomly selected clinics of Makhuduthamaga Sub-district. Purposive sampling was done to obtain qualitative data. An average score of 9.7 was obtained for all ten clinics that participated in the study with regard to the evaluation of the implementation of the National Cervical Cancer Screening Policy. Only 6 (60%) clinics implemented the policy whereas 4 (40%) clinics did not implement the policy. Women and professional nurses perceived cervical cancer screening as important. Lack of knowledge among women regarding cervical cancer screening contributed to the majority of women not screening for cervical cancer. Lack of resources, the 10 year interval of normal cervical cancer screening, the use of disposable vaginal speculums and brushes, lack of standardized cervical cancer screening training, centralization of cytology laboratories came out as factors that negatively influence the uptake of cervical cancer screening. Cervical cancer screening awareness campaigns, availability of resources and standardized in-service trainings on cervical cancer screening were recommended to enhance the cervical cancer screening uptake. Key concepts:
Health Studies
D. Litt. et Phil. (Health Studies)

M.Cur. (Nursing Management)
Transformational leadership involves the creation of a motivating climate that enhances growth, development, commitment, goal achievement and enjoyment which encourages behaviour based on a set of shared values (Price, 2006:124). In this study transformational leadership referred to concepts of motivation, and change management with regard to the implementation of the Cervical Cancer Screening Programme in a PRe setting. During support visits in Ekurhuleni Health District, the researcher observed a lack of transformational leadership among facility managers in Primary Health Care Clinics to transform the Cervical Cancer Screening Program in line with relevant health care legislation. It was apparent that the problems in implementing the Cervical Cancer Screening Programme were related to poor motivation and lack of implementation of change management principles in the PHC clinics. From the problem statement the following research questions emerged: To what extent is the facility manager perceived as a transformational leader to implement the Cervical Cancer Screening Programme in a PHC clinic? Which actions should the facility manager take to implement the Cervical Cancer Screening Programme in PHe? From the findings guidelines for the facility managers were described to enable them to implement a Cervical Cancer Screening Programme in a Primary Health Care clinic within legal requirements...

Background Cervical cancer is one of the common cancers worldwide. Despite the available screening services, the uptake of cancer of the cervix is very low. The incidence and mortality in western countries has reduced greatly due to the introduction of cervical cancer screening programmes. However, this is not the same in Africa where cervical cancer is more prevalent in lower resource countries to lack of access to effective screening and services that enhances early detection and treatment. Purpose/Aim of the study The purpose of this research is to determine knowledge of cervical cancer and the level of awareness of screening regimes/routines among HIV positive women in Swaziland. The study was conducted at one hospital specifically at the HIV Care Unit and Public Health Unit between January and June 2015. Methods The questionnaire was administered to collect data and consisted both open and close-ended questions. The questionnaire comprises of three sections: Section A: Socio-demographic data and Section B: Awareness on Cervical Cancer. Section C: Awareness/knowledge on cervical cancer screening. The sample consisted of 123 HIV positive who are on antiretroviral therapy (ART) or ART naive. The mean age for the respondents was 35 years. Results From this study, N=28 (23%) out of 123 (77%) reported to have received annual Pap smear for cervical cancer screening. A low proportion of the respondents (45%) had knowledge on cervical cancer screening. In addition, 63% of those who got information about cervical cancer screening through the radio perceived themselves to be at risk of getting cervical cancer. Only 4% heard about cervical cancer at the ART clinic, despite having been followed up for their care at the HIV clinic. Those who screened for cervical cancer were younger in age 25-34 years (80%). This study also revealed that education increased the changes of a woman to be screened for cervical cancer. If a woman had a university or high school education, she perceived herself to be at risk of getting cervical cancer. Conclusion Knowledge is power, cervical cancer campaigns should be conducted at national level in order to promote prevention through screening. Cervical cancer screening should be fully integrated into HIV services
Health Studies
M.A. (Public Health)

Text in English
The purpose of the study was to explore perceptions, knowledge and attitudes of women undergoing cervical cancer screening in Omaheke, Namibia. A qualitative exploratory study was conducted. Data were collected from a purposive sample of eight participants using a self-developed interview guide. Data were analysed using Tesch’s descriptive method of open coding. Three themes were identified namely; cervical cancer as a disease, perception of cervical cancer and service delivery at the facility. The findings also revealed some suggestions for the facility that could improve screening uptake. The study proposes a community education programme on cervical cancer and related topics to be covered during health education sessions. In addition the study recommends the Omaheke directorate to look into operational issues in order to facilitate access to cervical cancer screening.
Health Studies
M.P.H.