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ARGENTINA: Lack of Information Raises Risk of Cervical Cancer

BUENOS AIRES, Mar 29 2012 (IPS) - A novel research study in Argentina explored women’s knowledge and beliefs about cervical cancer, in the provinces with the highest mortality from this highly preventable form of cancer, to design more effective policies.

Although there are now effective tools to prevent cervical cancer, and vaccination against human papillomavirus (HPV) is free and mandatory for 11-year-old girls, the death rate from cervical cancer is not declining in Argentina, and the geographical distribution of the burden is extremely unequal.

This scenario was the starting point for the study titled “Lo que piensan las mujeres: Conocimientos y percepciones sobre cáncer de cuello de útero y realización del Pap” (What Women Think: Knowledge and perceptions about cervical cancer and the Pap test”, published by the Argentine Health Ministry and the Pan American Health Organisation (PAHO).

The study concluded that women have only a vague understanding of this health problem, and that most are unaware that HPV, a sexually transmitted disease, can cause cervical cancer.

Medical research has established that persistent infections with certain types of HPV cause nearly all cases of cervical cancer. Left untreated, invasive cervical cancer is almost always fatal, according to the World Health Organisation (WHO).

“They do not always know what the Pap smear is for,” say the authors, referring to women’s understanding of the Papanicolau screening test, which involves taking a small scraping of cells from the cervix – the narrow lower portion of the uterus where it joins with the top end of the vagina.

Examination of the sample in a laboratory can detect pre-cancerous lesions before they develop into cancer, a potentially life-saving step if it is followed by prompt treatment.

One of the authors, Dr. Silvina Arrossi, who is the scientific coordinator of the National Cervical Cancer Prevention Programme, told IPS the goal of the study was “to find out about women’s perceptions and knowledge about this type of cancer, in order to incorporate their views into prevention strategies at the design stage.”

In Argentina, cervical cancer is the second cause of deaths from cancer in women aged 35 to 64.

“We wanted to know if there were problems with the information women have about it, in order to design user-friendly educational materials that could help to overcome those difficulties,” Arrossi said.

The interviews were carried out with women in the eastern province of Buenos Aires – the most populous – and in the northern provinces of Jujuy, Salta, Misiones and Chaco, which have the highest cervical cancer mortality rates.

The national average for cervical cancer mortality is 7.5 deaths per 100,000 women. But in these four northern provinces, the mortality rate rises to as many as 15 deaths per 100,000, while in the city of Buenos Aires it falls to four deaths per 100,000 women, so the study examined both statistical extremes.

The interviews with the women were revealing. A considerable number believe the cancer lives in the body in a latent state, and “is awakened” by events like an abortion, rough intercourse, or insertion of an intra-uterine device (IUD).

“According to this view, the Pap smear, seen as an invasive procedure, could also ‘disturb’ or ‘awaken’ the dormant cancer,” the study says. One woman said her 52-year-old mother-in-law had never had a Pap test because of this fear.

Another mistaken idea that cropped up frequently in the interviews is that older women do not need to have Pap tests if they are no longer sexually active and are feeling well. “There’s nothing wrong with me, so why should I go to the doctor?” one woman remarked.

The women referred to other difficulties, related to their home-making role, that cause them to put off their own needs. “Who’ll serve your father his dinner?” one woman asked her daughter, when the younger woman urged her mother to go in for a Pap test.

The study also found that women are not always well enough informed about the continuing precautions they need to take to prevent the illness.

A 38-year-old mother of nine from Chaco has never had a Pap test in spite of the many times she has attended health clinics for antenatal care and childbirth. Evidently the health system is failing here, the authors said.

The women’s most common sources of information about cervical cancer are television, radio and other women. The health system, in contrast, was not frequently cited as a source of knowledge.

Several women call cervical cancer “la pudrición” (“rot” or putrefaction), because of the fetid odour of vaginal discharge when the cancer is in an advanced state. They are fatalistic and pessimistic about the disease, and in some cases they say directly that “there is no cure.”

Another worrying finding is that some women have a Pap test, but do not return for the test result. According to the authors, this would seem to indicate that they do not fully understand the importance of having the test and then following it up.

In general, the respondents also showed “a complete lack of knowledge” that untreated HPV infection is the main cause of cervical cancer.

In October 2011, the Health Ministry added HPV vaccination to the mandatory series of routine shots for 11-year-old girls. Arrossi believes the vaccination campaign will help spread knowledge of the association between the virus and cervical cancer.

The study, by Arrossi, Nina Zamberlin and Laura Thouyaret emphasises that in spite of these “highly effective and low cost” preventive measures, cervical cancer continues to be one of the main causes of cancer deaths among women in developing countries.

Experience in the industrialised world shows that screening women with the Pap test is effective in reducing incidence and mortality, the researchers point out. However, in Latin America incidence of cervical cancer has not declined because of the “low coverage” of screening, the study says.

“Mortality from cervical cancer in Argentina has not declined significantly in the last 40 years, and the distribution of the burden (of deaths) is extremely unequal,” it says.

In 2009, the Health Ministry found that only 46 percent of women aged 35 to 64 in the northeast and northwest of Argentina had had a Pap test in the two years prior to the survey.

Based on the information collected by Arrossi and her colleagues, a photo-novella has been designed in which a woman tells her daughter she (the mother) does not need to have Pap smears any more because of her age. But the daughter explains to her mother that, in fact, she really does need to keep having the test.

Training will be given to health centre personnel who offer women health advice, in order to ensure that they engage women in dialogue and exchange of information, rather than just send them away with a leaflet, Arrossi said.

Many of the women interviewed for the survey admitted that they felt embarrassed when they had Pap smears taken by male doctors. The study therefore recommends that health centre teams always have a woman available to take samples for the Pap test.

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