Novel educational training of para medical professionals in cervical cancer screening.

Background: Cervical cancer is a public health problem in India due to weak national screening policy compounded by lack of resources including scarcity of trained personnel to carry out community-based screening program. Para medical professionals (PMPs) are closely related to women in local communities. Hence, training PMPs by incorporating novel technology and reduced time duration to achieve adequate competence in screening is an area underutilized and needs to be explored. Materials and methods: A pilot cross sectional analytical study was conducted at a tertiary referral cancer center using a shorter version of educational intervention of 2 weeks duration (EI2W) involving PMPs. Pre- and post-training assessment of knowledge, attitude, and practice (KAP) was done using questionnaires consisting of 5 domains viz. awareness of cervical cancer, awareness of cervical pre-cancer, practical screening methodology (practice oriented), data management and aspects of human papilloma virus (HPV). Wilcoxon signed-rank test was used for comparison and the degree of change was measured using analysis of covariance (ANCOVA). A p value of <0.05 was considered significant. Results: 118 PMPs were included. There was a significant improvement in scores of all domains (except cervical pre-cancer domain), following introduction of EI2W. Knowledge scores, post EI2W was better in Auxiliary Nurse Midwives (ANMs) than other participants. Awareness regarding cervical cancer was higher with more years of experience. The KAP analysis showed excellent interrater reliability in the practice 0.726 (0.649-0.792) followed by knowledge domain 0.711 (0.626-0.783). Conclusion: EI2W was effective in significantly improving the competence of PMPs, thus reducing human resource constraints in cervical cancer prevention and elimination.

Behavioural interventions for tobacco cessation in India: A systematic review and meta-analysis.

Tobacco consumption is an area of public health concern in India. One of the unmet needs of many low-resource countries is to provide cost-effective tobacco cessation interventions for reducing tobacco-related mortality. This article reviews studies on non-pharmacological interventions for tobacco cessation in India. A systematic review by PICO (population, intervention, comparison, outcome) of behavioural intervention-based tobacco cessation studies that met the inclusion criteria, with a minimum 1-month follow-up, reporting outcomes in terms of frequencies or percentages published between 2010 and 2020 was performed. Following the review stages, 16 studies comprising 9,613 participants were included in the review. A pooled estimate was derived using both fixed-effects and random-effects models. The intervention showed good overall efficacy for any tobacco user (relative risk [RR] = 1.73 [95% confidence interval [CI]: 1.58-1.90) (fixed-effect model)] and (RR = 2.02 [95% CI: 1.64-2.48] [random-effects model]). Behavioural intervention studies targeted towards only smokers (RR of 1.81 [95% CI: 1.55-2.11] and 1.96 [95% CI: 1.52-2.53]) and combined smoking and smokeless tobacco users (RR of 1.69 [95% CI: 1.50-1.90] and 2.12 [95% CI: 1.49-3.01]) were equally efficacious. The review provides the effectiveness of behavioural interventions in quitting tobacco among users of both smoking and smokeless forms of tobacco. The review findings are of particular significance to inform health policy decisions on the integration of cost-effective brief behavioural intervention into existing health care services in resource-constrained countries.

Screening for breast cancer: Cost-effective solutions for low- & middle-income countries.

Low- and middle-income countries (LMICs) have limited financial resources and proportionately smaller portions allocated for health budget. With competing health priorities, treatment of the diagnosed cases and establishment of treatment facilities are the main concerns in LMICs. Infectious diseases, reducing infant, child and maternal mortality may seem crucial as compared to early cancer detection. LMICs that are committed to providing comprehensive cancer care, will need to judiciously choose the screening tool depending on specifics of how the tool is expected to perform in the population and the cost-effectiveness with respect to the number of lives expected to be saved. Increasing awareness about breast health in general and common cancers and non communicable diseases (NCDs), in particular, may lead to symptomatic women approaching the healthcare facilities at an earlier stage. When the limited available resources are mobilized towards cancer screening, increasing awareness would lead to greater acceptability of the programme. The reach of the programme to achieve good population coverage, the establishment of the diagnostic referral linkages and the availability and accessibility of treatment facilities, will all decide the outcome of the screening programme.

Evaluating the Performance of Hybrid Capture 2 Test as a Primary Screening Test from Studies Conducted in Low and Middle-Income Country Settings- Special Focus India.

Among the screening tests for cervical cancer, advantages of screening with second generation molecular Hybrid Capture 2 (HC2) test is the high sensitivity and negative predictive value that makes it easy to implement as a cervical cancer screening policy necessitating less screening rounds. High income countries are now implementing HC2 test in their national cervical cancer screening program. Since the acceptance of any screening test depends on the sensitivity of the test, the current study was carried out to evaluate the sensitivity of HC2 test reported from Low- and Middle-income countries (LMIC) which share major burden of cervical cancer globally and to establish if HC2 test could be used as a primary screening test in India. MATERIALS AND METHODS: The population based cross sectional studies from LMICs which evaluated HC2 test as a primary screening modality to diagnose Cervical intraepithelial neoplasm grade 2 and above (CIN2+) lesions were included. RESULTS: A total of 18 studies from LMIC involving 1,13,086 women were reviewed for sensitivity of HC2 as a primary screening test. The overall average sensitivity and specificity to diagnose CIN2+ lesions were 79.84% (95% CI-71.01,86.73) and 85.63% (95% CI- 84.37,86.92) respectively. India demonstrated an average sensitivity and specificity of 65% (95% CI 57,77) and 93% (95% CI- 92,94) respectively. CONCLUSION: Results from LMIC demonstrate a comparably low sensitivity of HC2 test to diagnose CIN2+ lesions as compared to that reported from High income countries. Sensitivity of HC2 was substantially low for India. The current study discusses issues of HC2 assay and the role of untreated Reproductive tract infections as probable causes for low sensitivity of the test. This needs further research in an attempt to improve the sensitivity of the test in an era of self-sampling and low-cost HPV test on horizon to improve the coverage for cervical cancer.
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Determinants of Compliance to Population-Based Oral Cancer Screening Program among low Socioeconomic Women in Mumbai, India.

BACKGROUND: The use of tobacco, especially smokeless variety, is common and culturally accepted among Indian women. Hence, oral cavity cancers rank as the fourth most common cancers among Indian women. OBJECTIVES: The objectives of this study were to study factors determining compliance of women for oral cancer screening in a population-based program in Mumbai and to create awareness among women regarding ill effects of tobacco and importance of oral cancer screening. MATERIALS AND METHODS: This is a community-based organized service program for awareness and screening of oral cavity cancers among women residing in low socioeconomic areas of Mumbai, India. Screening was conducted by oral visual inspection by trained primary health workers (PHWs). Univariate and multivariate logistic regression analyses were conducted to identify predictors of participation in oral cancer screening. RESULTS: 138,383 population was surveyed, out of which 13,492 eligible women were enlisted for oral cancer screening. Among these, 12,495 were contacted and 11,895 (95.12%) women participated in a cancer awareness program and 11,768 (94.18%) participated in oral cancer screening. According to results of multivariate logistic regression analysis, women belonging to Hindu religion 94.57%, with mother tongue Marathi 94.76%, and with family history of cancer 95.84% complied significantly higher to oral cancer screening as compared to other women. CONCLUSION: This program has assisted in identifying predictors of compliance to oral cavity screening. Furthermore, it demonstrates that good compliance can be achieved through multiple household visits, personal invitation during camps, organizing well-planned Health Education Program, and the use of simple, low-cost visual inspection test performed by trained PHWs.

Effect of screening by clinical breast examination on breast cancer incidence and mortality after 20 years: prospective, cluster randomised controlled trial in Mumbai.

OBJECTIVE: To test the efficacy of screening by clinical breast examination in downstaging breast cancer at diagnosis and in reducing mortality from the disease, when compared with no screening. DESIGN: Prospective, cluster randomised controlled trial. SETTING: 20 geographically distinct clusters located in Mumbai, India, randomly allocated to 10 screening and 10 control clusters; total trial duration was 20 years (recruitment began in May 1998; database locked in March 2019 for analysis). PARTICIPANTS: 151 538 women aged 35-64 with no history of breast cancer. INTERVENTIONS: Women in the screening arm (n=75 360) received four screening rounds of clinical breast examination (conducted by trained female primary health workers) and cancer awareness every two years, followed by five rounds of active surveillance every two years. Women in the control arm (n=76 178) received one round of cancer awareness followed by eight rounds of active surveillance every two years. MAIN OUTCOME MEASURES: Downstaging of breast cancer at diagnosis and reduction in mortality from breast cancer. RESULTS: Breast cancer was detected at an earlier age in the screening group than in the control group (age 55.18 (standard deviation 9.10) v 56.50 (9.10); P=0.01), with a significant reduction in the proportion of women with stage III or IV disease (37% (n=220) v 47% (n=271), P=0.001). A non-significant 15% reduction in breast cancer mortality was observed in the screening arm versus control arm in the overall study population (age 35-64; 20.82 deaths per 100 000 person years (95% confidence interval 18.25 to 23.97) v 24.62 (21.71 to 28.04); rate ratio 0.85 (95% confidence interval 0.71 to 1.01); P=0.07). However, a post hoc subset analysis showed nearly 30% relative reduction in breast cancer mortality in women aged 50 and older (24.62 (20.62 to 29.76) v 34.68 (27.54 to 44.37); 0.71 (0.54 to 0.94); P=0.02), but no significant reduction in women younger than 50 (19.53 (17.24 to 22.29) v 21.03 (18.97 to 23.44); 0.93 (0.79 to 1.09); P=0.37). A 5% reduction in all cause mortality was seen in the screening arm versus the control arm, but it was not statistically significant (rate ratio 0.95 (95% confidence interval 0.81 to 1.10); P=0.49). CONCLUSIONS: These results indicate that clinical breast examination conducted every two years by primary health workers significantly downstaged breast cancer at diagnosis and led to a non-significant 15% reduction in breast cancer mortality overall (but a significant reduction of nearly 30%in mortality in women aged ≥50). No significant reduction in mortality was seen in women younger than 50 years. Clinical breast examination should be considered for breast cancer screening in low and middle income countries. TRIAL REGISTRATION: Clinical Trials Registry of India CTRI/2010/091/001205; ClinicalTrials.gov NCT00632047.

Evidence based appropriate triage strategies for implementing high risk HPV as primary technology in cervical cancer screening.

Primary cervical cancer screening by HPV testing for high risk human papillomavirus (hrHPV) is expected to replace cytology-based programs in many parts of the world. Its high sensitivity and negative predictive value permit longer screening intervals up to beyond five years. However, low positive predictive value can lead to unnecessary referrals and overtreatment since most hrHPV infections are transient and will not develop disease. Therefore risk stratification is needed to effectively triage and identify women among the hrHPV positives, who are at an increased risk of cervical (pre)cancer who need further diagnostic evaluation to decide on further management. Several triage strategies like HPV16/18 genotyping, p16/Ki67 dual staining and DNA methylation markers (CADM1, MAL and miR-124-2) have been evaluated to determine suitable triage options. Triage with p16/Ki-67 dual-stain provided better long-term risk stratification than cytology with significant reduction in cumulative 5 years CIN3+ risk in p16/Ki-67 negative women. DNA methylation assays have shown higher specificity than cytology and higher sensitivity than HPV16/18 genotyping with added advantages of reproducibility and application on self-collected samples. Based on current evidence, Pap cytology with or without additional HPV16/18 genotyping remains the most recommended triage strategies for primary HPV screening. Other strategies will need more longitudinal studies to provide evidence of risk reduction in test negative results. WHO recommends Visual Inspection with Acetic Acid (VIA) for triaging HPV-positive women in LMIC settings. An optimal triage strategy that can be integrated with primary HPV screening should be able to segregate and reassure the large majority of women who are at very low risk of cervical cancer.

Reliability of conventional Papanicolaou smear in diagnosing bacterial vaginosis among women with clinical genital infection.

OBJECTIVE: Bacterial vaginosis (BV) is a common reproductive tract infection (RTI) reported among Indian women. BV can influence the persistence of high-risk oncogenic human papillomavirus, a causative factor for cervical cancer. BV and cervical cancer are major public health issues in a developing country like India. It becomes important for a resource-constrained country like India with poor healthcare access to implement control measures to screen and treat RTI in an attempt to prevent the risk for cervical cancer. Papanicolaou (Pap) smear is an established screening tool for cervical cancer and the diagnosis of RTIs, forms a part of its evaluation. The present study explores the validity of conventional Pap smear in diagnosing BV. METHODOLOGY: Pap smear and Gram stain smear were collected for 254 women with clinically evident cervicitis/cervicovaginitis (genital infection). Using the Nugent score on Gram stain as a gold standard, we determined the sensitivity and specificity of Pap smear to diagnose BV. RESULTS: The overall prevalence of BV in the study population was 44% using the Nugent score. Pap smear showed sensitivity and specificity of 70.9%. (CI- 61.5% - 79.2%) and 56.8% (CI - 48.2%-65.2%), respectively. The positive predictive value of Pap smear to diagnose BV was 56.5% (CI - 47.8%-64.9%), and the negative predictive value was 71.2% (CI - 61.8%-79.4%). CONCLUSION: In the present study, conventional Pap smear demonstrates good accuracy to detect BV. Pap testing for cervical cancer screening can additionally serve as an effective screening tool for diagnosing BV among women with genital infection in healthcare settings.

Optimizing high risk HPV-based primary screening for cervical cancer in low- and middle-income countries: opportunities and challenges.

Disparities in the incidence and mortality due to cervical cancer between developed and developing countries continue to persist due to suboptimal health care systems in low- to middle-income countries (LMICs) that are unable to implement organized programs for screening which lack the technical, infrastructure and financial resources for adequate coverage and access to quality assured cervical cancer screening services that further reduce their effectiveness. The challenges in introducing quality cytology screening in LMICs led to the evaluation of alternative screening approaches such as visual inspection with acetic acid (VIA) and human papillomavirus (HPV) testing-based screening. Large-scale clinical trials have generated sufficient evidence of efficacy of HPV-based screening for the introduction as the primary technology in cervical cancer screening. Being more objective, automated with better sensitivity than cytology requiring fewer rounds of screening and opportunity for self-sampling, HPV testing is thus poised to be more cost-effective in providing opportunity for wider coverage, making it ideal for incorporating into primary screening programs of LMIC settings that could help reduce regional disparities. But its optimal implementation in public health programmatic settings in LMIC still faces barriers due to high operating cost and logistic challenges. This review summarizes and presents evidence for HPV primary screening leading to higher program efficiency in cervical cancer screening programs. Policy measures and strategies to overcome the resource limitations and weaknesses in health care service delivery in low resource settings need to be assessed and streamlined to leverage the initial high program costs with that of the long term potential benefits for HPV DNA testing to reach its full potential in reducing cervical cancer incidence and mortality.

Cervical Cancer Screening in Low Resource Settings: Cytology versus HPV Triage for VIA Positive Women.

BACKGROUND: The objective of the study is to comparatively evaluate performance of human papillomavirus (HPV) hybrid capture 2 (HC2) and cytology as triage tests among visual inspection after application of 3-5% acetic acid (VIA) screen positive women, thus aiming to reduce the referral burden. METHODS: The community-based cross sectional cervical cancer screening with VIA was conducted among women aged between 30 and 65, residing in selected low socio-economic areas of Mumbai, India, during October 2010-March 2017. After obtaining informed consent, delivering health education and collecting socio-demographic data, participants were offered VIA screening by trained primary health workers. The VIA screen positive women underwent cytology, HPV HC2 and diagnostic colposcopy at nodal hospital. Women with positive colposcopy underwent cervical biopsies. RESULTS: 231 VIA positive women underwent cytology and HPV HC2 test, followed by colposcopy. Cervical biopsies were obtained in 83 cases. The sensitivity and specificity in detecting ≥ CIN 2 were 77.8 and 92.3 for HC2 and 66.7 and 98.2 for cytology. The false positivity and negativity rates were 7.7 and 22.2 for HC2 and 1.8 and 33.3 for cytology. CONCLUSIONS: HPV HC2 reduces referrals to larger extent and misses fewer cases compared to cytology, thus appearing a better triage test among VIA positive women.

Smokeless tobacco use and oral neoplasia among urban Indian women.

OBJECTIVES: Oral cavity cancers are fourth most common cancers among Indian women. The objectives were to create cancer awareness (CA) and screen tobacco-using women for oral cavity cancers. MATERIALS AND METHODS: A community-based CA and screening programme was conducted among women in Mumbai, India. The tobacco-using women participated in CA and oral cavity screening by oral visual inspection (OVI). All screen-positive women were referred to nodal hospital and assisted for diagnostic confirmation and treatment completion. RESULTS: Twelve slum clusters comprising of 138,383 population and 13,492 tobacco-using women have been covered. Among them, 11,895 (88.2%) participated in CA and 11,768 (87.2%) in OVI. A total of 377 (3.2%) women were screened positive, 275 (72.9%) complied with referral and 207 oral precancers [173 leukoplakia, 9 erythroplakia, 3 erythroleukoplakia and 41 sub-mucus fibrosis (SMF) including 35 women with multiple precancers] and 7 oral cancers were diagnosed. The detection rate of oral precancerous lesions and oral cancers was 17.6 and 0.6 per 1,000 screened women. Thirty-five women had multiple oral precancerous lesions. The results of multivariate analysis indicate dose-response relationship between tobacco use and risk of oral precancers. CONCLUSION: Good participation rates (>85%) for cancer awareness and OVI were seen among urban slum women in India. Many oral precancer and cancer cases were detected and were managed at the nodal hospital.

Determinants of Compliance to Breast Cancer Screening and Referral in Low Socio-Economic Regions of Urban India.

BACKGROUND: Breast cancer (BC) is the most common cancer among women globally and also in India. Early detection by screening is likely to reduce mortality and improve survival. To study the determinants of compliance to BC screening and referral by women in a community based BC screening programme in urban India. METHODS: A community-based one-time cancer screening programme, implemented in the urban slums of Mumbai, India. The programme involves screening for breast cancer by Clinical Breast Examination (CBE) performed by trained primary health workers (PHWs), referral of screen-positive women to the nodal hospital for further investigations, confirmation of diagnosis and treatment. Univariate and multivariate logistic regression analysis in SPSS version 16 was used. RESULTS: The compliance to screening, referral and treatment were 90.58%, 74.22% and 100% respectively. The results of multivariate logistic regression analysis demonstrate literate women, having family history of cancer, with tobacco habit, being treated for breast abnormalities, being ever pregnant and having history of contraceptive use were positive predictors while, women belonging to Muslim religion or speaking mother-tongue other than Marathi or Hindi were negative predictors of participation to screening. Educational status was the only significant predictor of compliance to referral. Screen-positive women with education of secondary school level or more were more likely to comply with referral. CONCLUSIONS: The programme ensured good compliance with screening, referral and treatment indicating feasibility and acceptability of CBE based BC screening programme by the community.

Evaluation of cytology as secondary triage in visual inspection after application of 4% acetic acid-based cervical cancer screening program.

CONTEXT BACKGROUND: Visual-based screening techniques are low cost and have good sensitivity. Hence, they appear promising for primary screening in low-resource settings. However, to reduce referrals for diagnostic colposcopy, there is need to triage these screen-positive women with test with good specificity. AIMS: The study aims to evaluate the performance of cytology as triage for visual inspection after application of 4% acetic acid (VIA) screen-positive women. SETTINGS AND DESIGN: Community-based cervical cancer screening using VIA was implemented among socioeconomically disadvantaged women in Mumbai, India. METHODS: Cytology was performed on screen-positive women. All primarily screen-positive women underwent colposcopy. Directed biopsies were obtained among women with positive findings on colposcopy. The gold standard used for final disease status was histopathology or negative colposcopy. STATISTICAL ANALYSIS USED: Test characteristics of cytology as triage test. RESULTS: Among the 138,383 population, 16,424 eligible women were screened with VIA. 785 (4.78%) women were VIA positive and 580 women participated in triage with cytology. The sensitivity and specificity of cytology at threshold of atypical squamous cells of undetermined significance in detecting ≥cervical intraepithelial neoplasia (CIN) 2 were 75.0 and 94.7, respectively. The positive and negative predictive values of cytology as triage test were 23.1 and 99.4, respectively, and the false positivity and false negativity rates were 5.34 and 25.0, respectively. CONCLUSION: Cytology triage with VIA can reduce referrals for colposcopy to 4.97% of original referrals but may miss around 25%, of high-grade CIN. The substantial reduction in referrals has special implication for low-resource settings, wherein compliance to referral and availability of diagnostic facilities are poor.

Global strategies for cervical cancer prevention and screening.

Cervical cancer is highly preventable and can be easily treated if detected at early stages. However there is disproportionate high burden of cervical cancer incidence and mortality in low-middle income (LMIC) country settings that lack organized screening and prevention programs. Robust evidence for prevention and screening of cervical cancer is currently available. However there are barriers for country specific adoption and implementation. These pose unique challenges such as organizing prevention and screening services delivery through the current health infrastructure, access to screening facilities, follow-up management and adequate linkages for confirmatory diagnosis and subsequent treatment. Overall cervical cancer screening rates and cancer screening among women still remains suboptimal in many LMIC's. Considering the complexities involved in organization, service uptake and delivery of population based cervical cancer prevention and screening programs, this article aims to provide evidence based appropriate, affordable and effective standardized cervical cancer prevention and screening guidelines that are operationally feasible to help adopt best practices for uniform adaptation and implementation leveraging with the existing public health care settings. Cost-effective strategies and tools to reduce cervical cancer burden worldwide to mitigate the existing disparities in cervical cancer burden between low-resourced and high-resourced settings are needed. The current cervical cancer prevention and screening guidelines are drawn from the most robust evidence generated from the randomised trials and cross-sectional studies undertaken in the socioeconomic, cultural and health systems context of varied geographic settings and therefore conform towards applicability for wide-scale, sustainable and uniform implementation of population based cervical cancer screening and prevention program.

Compliance with point-of-sale tobacco control policies and student tobacco use in Mumbai, India.

BACKGROUND: We measured how student tobacco use and psychological risk factors (intention to use and perceived ease of access to tobacco products) were associated with tobacco vendor compliance with India's Cigarettes and Other Tobacco Products Act provisions regulating the point-of-sale (POS) environment. METHODS: We conducted a population-based cross-sectional survey of high school students (n=1373) and tobacco vendors (n=436) in school-adjacent communities (n=26) in Mumbai, India. We used in-class self-administered questionnaires of high school students, face-to-face interviews with tobacco vendors and compliance checks of tobacco POS environments. Logistic regression models with adjustments for clustering were used to measure associations between student tobacco use, psychological risk factors and tobacco POS compliance. RESULTS: Compliance with POS laws was low overall and was associated with lower risk of student current tobacco use (OR 0.48, 95% CI 0.26 to 0.91) and current smokeless tobacco use (OR 0.40, 95% CI 0.21 to 0.77), when controlling for student-level and community-level tobacco use risk factors. Compliance was not associated with student intention to use tobacco (OR 0.50; 95% CI 0.21 to 1.18) and perceived ease of access to tobacco (OR 0.73; 95% CI 0.53 to 1.00). CONCLUSIONS: Improving vendor compliance with tobacco POS laws may reduce student tobacco use. Future studies should test strategies to improve compliance with tobacco POS laws, particularly in low-income and middle-income country settings like urban India.

Prevention of Cervix Cancer in India.

Cervical cancer is the fourth most common cancer among women globally and the second most common cancer among Indian women. India alone bears 23% of the global cervical cancer burden. In India, population-based cervical cancer screening is largely nonexistent in most regions due to competing healthcare priorities, insufficient financial resources and a limited number of trained providers. Hence, most of the cases present in advanced stages of the disease, thus leading to increased mortality and reduced survival. Various screening options like cytology, visual-based screening and testing for high-risk HPV are available. Several cross-sectional studies have looked at the comparative efficacy of different screening tests. Three important randomized controlled trials from India have shown the efficacy of screening once in a life time with HPV DNA, one-time screening with VIA by trained nurses and four-time screening with VIA by trained primary health workers, reducing mortality due to cervical cancers. Prevention of cervical cancers with two-dose HPV vaccination and early detection of precancerous cervical lesions of the eligible population through screening and their appropriate treatment with a single-visit 'screen-and-treat' approach appear to be promising for low-middle-income countries including India.

Smokeless tobacco use in Urban Indian women: Prevalence and predictors.

CONTEXT: India is the second largest consumer of tobacco. Tobacco consumption in nonsmoking forms is culturally accepted even among women. AIMS: This study aimed at understanding the patterns and predictors of smokeless tobacco (SLT) use among the urban low-socioeconomic women in Mumbai, India. MATERIALS AND METHODS: This is a cross-sectional community-based survey of tobacco usage among women residing in seven low-socioeconomic communities in suburbs of Mumbai, India. Staff for the study was recruited, trained, clusters selected, accurately mapped, households identified, meetings held with community leaders, and household surveys conducted. Women using tobacco were invited to participate in the detailed survey and interviewed to document the various sociodemographic factors and in depth information on tobacco use. The data were computerized and analyzed. RESULTS: About 22.30% of the total female population consumed tobacco, mainly in the smokeless forms, with only 0.50% of the tobacco users using smoked tobacco. Masheri was the most common form of tobacco used, followed by chewing tobacco. The median frequency of use of different tobacco products varied from 2 to 4 per day. The mean age at initiation of tobacco was 26.23 years. According to the results of univariate and multivariate logistic regression analysis, illiterate women, with advancing age, belonging to Hindu, Muslim, or Buddhist communities, who were either manual laborers or housewives, divorced or separated, and speaking Marathi were at higher risk of being tobacco user. CONCLUSION: Patterns and predictors of SLT use among women have been identified in the present study. This will guide in planning prevention and control strategies.

Effect of VIA screening by primary health workers: randomized controlled study in Mumbai, India.

BACKGROUND: Cervical cancer is the leading cause of cancer mortality among women in India. Because Pap smear screening is not feasible in India, we need to develop effective alternatives. METHODS: A cluster-randomized controlled study was initiated in 1998 in Mumbai, India, to investigate the efficacy of visual inspection with acetic acid (VIA) performed by primary health workers in reducing cervical cancer mortality. Four rounds of cancer education and VIA screening were conducted at 24-month intervals in the screening group, whereas cancer education was offered once at entry to the control group. The study was planned for 16 years to include four screening rounds followed by four monitoring rounds. We present results after 12 years of follow-up. Poisson regression method was used to calculate the rate ratios (RRs); two-sided χ(2) was used to calculate the probability. RESULTS: We recruited 75360 women from 10 clusters in the screening group and 76178 women from 10 comparable clusters in the control group. In the screening group, we achieved 89% participation for screening and 79.4% compliance for diagnosis confirmation. The incidence of invasive cervical cancer was 26.74 per 100000 (95% confidence interval [CI] = 23.41 to 30.74) in the screening group and 27.49 per 100000 (95% CI = 23.66 to 32.09) in the control group. Compliance to treatment for invasive cancer was 86.3% in the screening group and 72.3% in the control group. The screening group showed a statistically significant 31% reduction in cervical cancer mortality (RR = 0.69; 95% CI = 0.54 to 0.88; P = .003). CONCLUSIONS: VIA screening by primary health workers statistically significantly reduced cervical cancer mortality. Our study demonstrates the efficacy of an easily implementable strategy that could prevent 22000 cervical cancer deaths in India and 72600 deaths in resource-poor countries annually.