MEJFM - An Implementation for Integration of Cervical Smear Screening with Family Planning Services in the District of Diyarbakir Province of Turkey 2001

Almost 71.8% (361 women) of the 503 women were familiar with a family planning clinic. Twenty-eight percent of the women had never attended the family planning clinic previously.

Factors associated with previous Pap test are investigated in Table 2. According to univaried analyses, illiteracy, having no social security, not being employed and having more than 2 induced abortions were the factors associated with previous Pap test usage. Almost 96% of the illiterate women, 95% of those without health insurance and 93% of unemployed women had never had a Pap test. Women with more than 2 induced abortions were more likely to have had a Pap test with respect to women who had never induced abortion (odds ratio : 0.18, 95%CI: 0.06-0.58). This difference was statistically significant (p= 0,0003). Although most of the women attended a family planning clinic before (71.8%), only 7.4% of them had a Pap test.

After adjusting for all variables in the logistic regression model, two characteristics were found to be significantly associated with those having never used Pap test (Table 3). Illiteracy remained as the strong factor. Illiterate women were at greater risk than literate women (odds ratio: 2.80, 95% CI : 1.3-6.3). Women who had never induced abortion were at 3.9 (1.3-12.0) times at risk with respect to those who had never used a Pap test. Age was not a significant factor associated with use of a Pap test, but as the age increases, Pap test usage seems to increase.

In Table 4, the results of the Pap tests are shown. The most frequently screened result was infection reaction. Totally, 54.3% of the women were diagnosed to be normal. In 3 (0.6%) women, CIN-I, and in 2 (0.4%) women, CIN-II were detected, while chronic cervical squamous metaplasia was diagnosed in 7 (1.4%) women. Two women diagnosed as CIN-II were referred to colposcopy; CIN-II was confirmed by colposcopy. Women with CIN-I and higher grade were advised to re-screen annually.

The risk factors for cervical cancer were also investigated. Almost 39% (195 of 503 women) of the women had early marriages, 23% (117 women) of them had smoking habits and 6% (28 women) of women were using contraceptive pills. Genital warts were rarely diagnosed; only 0.8% (4 women) of the women had genital warts.

According to DHS of Turkey (5), adolescent marriages were 15.2%, ratio of women with high parity 16.4% and history with at least one induced abortion was 26.7%. Apart from induced abortion, those determinants were higher in our study group. These results indicate that our study group has a more traditional structure than other parts of Turkey. Besides, traditional methods were used less than the other parts of Turkey (6.8% in our study group and 25.5% in Turkish Demographic Health Survey 1998). IUD usage also was higher with respect to other parts of Turkey (52.1% versus 19.8%). Although they had traditional lifestyle, they had a tendency to use modern contraceptive methods. This may be explained by their familiarity with our clinic. This familiarity was the result of a community based family planning project implemented in the region. Although many of the women attended family planning clinics before, very few of them (7.4%) had a Pap test. An important finding was that 93% of women in the study had not had a cervical smear at a mean age of 32 years. These findings provided rationality of implementation of cervical cancer screening for the residential women. In Chinese women, attainment of family planning services was a major factor associated with history of at least one Pap test (6). Integration of family planning services with cervical cancer screening should avoid missed opportunities for early diagnosis of cervical cancer. In Turkey, there is no written strategy for cervical cancer control. Women can access cervical screening in gynaecology and obstetric clinics of University Hospitals and State Hospitals or in private gynaecology clinics but not in primary health centers like family planning clinics. In University hospitals, for all women who have gynaecological examinations, cervical smear is also performed. In private clinics, the cost of cervical smear examination is high for Turkish people (nearly 20 USD). In Turkey, generally, gynaecologists perform cervical smears on all women they examine, and advise routine annual screening to women over 18 years old. In the South-eastern region of Turkey, cervical screening is not routine in antenatal visits. However, it was reported that only 8% of the women had antenatal care in their last pregnancy (7).

These kind of implementations should be a good example for Turkey and many other countries that have no strategy for cervical cancer control. In the study area, most of the women had heard about cervical cancer, however services providing Pap tests are insufficient. It would be effective to extend cancer screening programs to primary health care units. In our study, we really tried to implement cervical screening in a primary health care unit. For acceptability of the screening, we used local women to communicate with the residential women who could not speak the Turkish language. We minimised the cost price of cervical smear (nearly 7 fold). Nurses were trained on the subject of performing cervical smear and developed their communication / counseling skills.

In the study, nurses working in family planning were educated and activated for cervical cancer screening. It was seen that, for reaching underscreened women, nurses could play an important role (8). Practices with male doctors had lower response rates with respect to female doctor or nurse, according to a study which examined aspects of organisation of a national screening program (9). Women are greatly affected by health care providers' attitudes, abilities to provide clear information, and abilities to establish reliable relationships (10). Educating healthcare personnel is an important component of reducing barriers to effective screening (11). In our study, all nurses were educated, and volunteer women were also familiar to residential women. Those factors might provide usage of screening program. From our study, it is not possible to tell whether or not female nurses are an important factor for encouraging women to undertake a cervical smear. By the project, of 503 women (92.6%), 446 had their first cervical smear.

According to another study conducted in the USA, one of the main barriers identified by non-regular Pap test screeners was "no health insurance" (12). In the present study, having no health insurance had an adverse effect on having at least one Pap test according to univaried analyses. However, in multivariate analyses, the main factors associated with having at least one Pap test were illiteracy and having an induced abortion history. Both of these are factors associated with the social development of women. In Turkey, induced abortion rate is higher in women with a high status (13). Women who had induced abortion are more likely to use modern medicine, and in this way, they have contact with doctors or nurses. However, abortion services also provide cervical cytology which might also affect the previous Pap test.

Pathologic reports indicated that 54.3% of women did not have cervical disease in the present study. Ninety-five percent of Pap tests were indicated as normal by cytopathology in Minnesota USA (14); in another study, 81.4% of the women were normal, 8% had (15). Infection/reaction ratio was higher than those results indicated in the above studies. Low socioeconomic levels of women and unhygienic behaviours may explain this higher infection ratio. In a study by Montes MA et al. it was reported that atypical metaplastic cells, especially those of the immature type, were associated with high grade squamous intraepithelial lesion (16). In our study, women with CIN-I or CIN-II should be regularly followed up by Pap testing. All women with CIN-I or higher grade were advised to screen annually.

Eighty-two percent of the rural women were found to be at high risk for cervical cancer, and high risk status was determined according to the presence of history of more than two sexual partners, age at first sexual intercourse under 18 years, history of sexually transmitted disease, and smoking (17). In the study, 38.8% of the women were at high risk for cervical cancer especially because of early age marriages. Early marriage is highly prevalent in the south-eastern region of Turkey. Median age for marriage is 18.1 in this region (5). In other parts of Turkey, median ages for the first marriage was 19. In another study conducted in the same area of Huzurevleri-Diyarbakir, in grand multiparious women, early marriages was found to be 86% (18).

The prevalence of other risk factors associated with cervical cancer was not very high in our study population. However, there are some latent risks of history of multiple sex partners.

Integration of cervical cancer screening with family planning services is a useful implementation. Many missed opportunities can be avoided by this integration. Volunteer women can play an important role in informing women with low socioeconomic status, and within this framework nurses may have an important role in performing Pap tests. Low socioeconomic levels including illiteracy may be the main factor affecting Pap test usage. Risk factors associated with cervical cancer should also be reported, and women with high risk be followed up.