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O iginal A icle J Clin Gynecol Obs e . 2015;4(4):290-296
ess
Elme
Su i al o Pa ien s Wi h Ce ical Cance in Ru al India
Jissa Vinoda Thulaseedha ana, b, Nea Malilab, c, Raja aman Swamina hand, Puliko il Oku u Esmye,
Ma i Hakamab, c, Richa d Muwonge , g, Rengaswamy Sanka ana ayanan
Abs ac
Backg ound: Pa ien s’ su i al a e diagnosis o ce ical cance is
indi ec ly in luenced by socio-economic ac o s. We e alua ed his
su i al and i s socio-economic de e minan s in a u al popula ion in
sou h India.
Me hods: We assessed 165 women diagnosed wi h ce ical cance
om he ou ine ca e con ol a m o a andomized sc eening ial
conduc ed in u al sou h India. Kaplan-Meie cu es we e plo ed
o illus a e he obse ed su i al o cance pa ien s. The e ec o
socio-economic ac o s was assessed using Cox p opo ional haza ds
eg ession analysis.
Resul s: The 5-yea obse ed su i al was 32.5%, anging om 9%
o s age IV o 78% o s age I cance s. Women wi h poo socio-
economic s a us (SES) had up o a 70% highe isk o dea h. Highe
household income was signi ican ly associa ed wi h poo e su i al.
Howe e , mos women in he highe income g oup we e ma ied
women and housewi es, hence wi h no pe sonal income.
Conclusion: Ce ical cance su i al was disappoin ingly low in
hese u al popula ions o India and s age o disease a diagnosis was
he s onges de e minan . A highe household income is no always
associa ed wi h women being empowe ed in e ms o seeking heal h-
ca e. The s udy indings u he s ess he impo ance o s eng hen-
ing p e en ion and sc eening oppo uni ies o women in u al popula-
ions.
Keywo ds: Ce ical cance ; Su i al; Ru al India; Socio-economic
de e minan s
In oduc ion
Incidence and mo ali y es ima es a e used o measu e he
bu den o cance in a popula ion and su i al es ima es a e
ideal o e alua ing he ou come o cance con ol ac i i ies
[1]. Su i al s udies e alua e he quali y and quan i y o li e
o a g oup o pa ien s a e diagnosing he disease [2]. Long-
e m su i al, usually o mo e han 5 yea s, e lec s cu e and
is conside ed a posi i e measu e o e alua e he e iciency o
he heal h sys em [3].
Globally, ce ical cance su i al a ies widely be ween
coun ies. The 5-yea su i al a es o women diagnosed wi h
ce ical cance du ing 1995 - 1999 in de eloped coun ies a -
ied om 50% o 70% [4]. Fo A ica, Asia, and Cen al Ame i-
ca, he lowes su i al a es du ing 1990 - 2001 we e obse ed
in Uganda and Gambia wi h a 5-yea age s anda dized ela i e
su i al (ASRS) o 19% and 23%, espec i ely, and he high-
es su i al a es we e epo ed in China, Singapo e, Sou h
Ko ea, and Tu key, whe e he ASRS a ied om 63% o 79%
[5]. The median 5-yea ASRS o ce ical cance in India was
46% anging om 34% o 60% [5].
The ema kable inequali y in cance su i al be ween and
wi hin coun ies is la gely due o he di e ences in gene al
awa eness, a ailabili y o ea ly de ec ion p ac ices, ained hu-
man esou ces, and accessibili y o cance se ices, diagnosis
and ea men [3]. Age a diagnosis, agg essi eness and clini-
cal ex en o cance , willingness and de e mina ion o he pa-
ien o comple e his/he ea men and socio-economic ac o s
also in luence su i al om cance [1]. E en hough ce ical
cance is conside ed an eminen ly p e en able cance , la e
s age diagnosis and delay in ge ing ea men lead o educed
ce ical cance su i al in low esou ces se ings [6]. Thus, he
inequali y in ce ical cance su i al is ela ed o he di e -
ences in medical, biological, cul u al, gene ic, geog aphic, and
socio-economic ac o s [7-9].
To assess he socio-economic ac o s ha a ec ce ical
cance su i al in a u al popula ion o sou h India, we used
Manusc ip accep ed o publica ion Oc obe 21, 2015
aAchu ha Menon Cen e o Heal h Science S udies (AMCHSS), S ee Chi a
Ti unal Ins i u e o Medical Sciences and Technology (SCTIMST), T i an-
d um, India
bSchool o Heal h Sciences (HES), Uni e si y o Tampe e, Tampe een Ylio-
pis o, Finland
cFinnish Cance Regis y, Pieni Roobe inka u, Helsinki, Finland
dBios a is ics and Cance Regis y, Cance Ins i u e (WIA), Chennai, India
eCh is ian Fellowship Communi y Heal h Cen e (CFCHC), Ambillikai, Tamil
Nadu, India
Sc eening G oup, In e na ional Agency o Resea ch on Cance (IARC),
Lyon, F ance
gCo esponding Au ho : Richa d Muwonge, Sc eening G oup, In e na ional
Agency o Resea ch on Cance , 150 Cou s Albe Thomas, 69372 Lyon Ce-
dex 08, F ance. Email: [email p o ec ed]
doi: h p://dx.doi.o g/10.14740/jcgo367w
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Thulaseedha an e al J Clin Gynecol Obs e . 2015;4(4):290-296
he ma e ial consis ing o 165 women diagnosed wi h ce ical
cance du ing 2000 - 2006 om a coho o 31,000 women in
he con ol a m o a la ge VIA sc eening ial.
Ma e ials and Me hods
The de ails o he base popula ion and he sc eening ial we e
desc ibed in ea lie pape s [10-12]. This ial aimed o e alua e
he e ec o a single ound o VIA sc eening on ce ical cance
incidence and mo ali y. The ial p o ocol was e iewed and
app o ed by he ins i u ional scien i ic and e hical commi ees
o Ch is ian Fellowship Communi y Heal h Cen e (CFCHC)
and he In e na ional Agency o Resea ch on Cance (IARC).
Clus e s o eligible women aged 30 - 59 yea s, wi h an in ac
u e us and no his o y o cance , we e andomized in o in e -
en ion and con ol a ms du ing 2000 - 2003. Be o e en ol-
men , he ial was explained o he pa icipan s in he local
language and a signed in o med consen was ob ained. A s uc-
u ed ques ionnai e was used o ob ain he pa icipan s’ demo-
g aphic and socio-economic cha ac e is ics. Women in he
in e en ion a m we e o e ed sc eening wi h VIA, whe eas
hose in he con ol a m we e in o med abou sc eening, symp-
oms and isk ac o s o ce ical cance , whe e he sc eening,
ea ly diagnosis and ea men acili ies a e a ailable, and ad-
ised o u ilize such ou ine heal hca e acili ies.
The ial popula ion was ollowed annually un il Decem-
be 2006 o collec in o ma ion on dea h, mig a ion and ce i-
Table 1. Cha ac e is ics and Su i al Expe iences o Women Diagnosed Wi h Ce ical Cance F om he Con ol
A m Du ing 2000 - 2006 and Followed Un il Decembe 31, 2011
Women’s cha ac e is ics Numbe o women
wi h cance n (%)
Obse ed su i al (%) a P- alue
1-yea 3-yea 5-yea
To al 165 67.3 40 32.5
Indi idual
Age a diagnosis
30 - 39 37 (22.4) 70.3 45.9 37.3
40 - 49 53 (32.1) 66.0 39.6 34.0
50+ 75 (45.5) 66.7 37.3 29.1 0.5458
S age o disease
S age I 18 (10.9) 88.9 83.3 77.6
S age II 32 (19.4) 68.8 37.5 21.4
S age III 62 (37.6) 69.4 35.4 25.3
S age IV 11 (6.7) 36.4 9.1 9.1
Unknown 42 (25.5) 61.9 38.1 35.7 0.0023
Educa ion*
No schooling 145 (87.9) 66.9 37.9 30.9
Some schooling 17 (10.3) 82.4 64.5 51.6 0.1794
Occupa ion
House wi e/o he s 60 (36.4) 73.3 48.3 36.4
Manual 105 (63.6) 63.8 35.2 30.3 0.3117
Ma i al s a us
Cu en ly ma ied 146 (88.5) 66.4 39.7 31.3
Widowed/sepa a ed 19 (11.5) 73.7 42.1 42.1 0.4668
Household
Type o house
Tha ched 27 (16.4) 48.2 29.6 25.9
Tiled/conc e e 138 (83.6) 71.0 42.0 33.8 0.2588
Income (INR)
< 2,000 117 (70.9) 69.2 43.5 38.2
2,000+ 48 (29.1) 62.5 31.3 18.8 0.0143
*The in o ma ion on educa ion is missing o h ee obse a ions. INR: Indian Rupees. 50 INR was equi alen o 1 US dolla
du ing 2000 - 2003.
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Su i al A e Ce ical Cance Diagnosis J Clin Gynecol Obs e . 2015;4(4):290-296
cal cance s. The Dindigul Ambillikai Cance Regis y (DACR)
s a ac i ely collec ed in o ma ion on women diagnosed wi h
ce ical cance om he en i e Dindigul dis ic [13] and sub-
sequen ly ma ched he in o ma ion wi h he s udy da abase on
a case-by-case basis o ob ain all he inciden ce ical cance
cases diagnosed du ing 2000 - 2006 om he s udy popula ion.
In he inal analysis, he e o e, we used he upda ed in o ma-
ion o 165 women diagnosed wi h ce ical cance du ing 2000
- 2006 om he con ol a m. The ial base popula ion was
again ollowed in 2011 - 2012 o collec in o ma ion on dea h
and mig a ion.
The women’s cha ac e is ics s udied we e age a diagno-
sis (ca ego ized in 30 - 39, 40 - 49 and 50+), s age o disease
(s age I, II, III, IV and unknown) and he baseline in o ma-
ion on socio-economic ac o s such as o mal educa ion (no
schooling and some schooling), occupa ion (housewi e/o he
and manual wo ke s), ma i al s a us (cu en ly ma ied and
widowed/sepa a ed), ype o house ( ha ched and iled/con-
c e e), and household income (ca ego ized in < 2,000 and
2,000+ Indian Rupees (INR)).
Da a analysis was done using he S a a/IC 11.2 so wa e
package (S a a Co p LP, TX, USA). The p ima y endpoin was
dea h om ce ical cance . To gi e each o he included pa-
ien s a chance o ha ing a leas 5 yea s o su i al, Decem-
be 31, 2011 was used as he la es da e o ollow-up. Fo he
de ini ion o he s udy ou come, he i al s a us o all included
pa ien s by Decembe 31, 2011 was es ablished as dead, ali e
o los o ollow-up. Su i al ime was calcula ed om he da e
o diagnosis o da e o dea h, o he pa ien s who had died, o
Decembe 31, 2011 o hose who we e s ill ali e o da e o las
seen o hose los o ollow-up. Only wo women we e los o
ollow-up. Kaplan-Meie cu es we e plo ed o illus a e he
obse ed su i al o cance pa ien s and he log- ank es was
used o es he equali y o su i o unc ions. The e ec o
socio-economic ac o s was assessed using Cox p opo ional
haza ds eg ession analysis. Adjus men was made by includ-
ing all he ac o s s udied in a single eg ession model.
Resul s
Cha ac e is ics and su i al expe ience o 165 women diag-
nosed wi h ce ical cance a e p esen ed in Table 1. O e all,
54.5% o he women we e diagnosed wi h ce ical cance un-
de he age o 50 yea s. Mos women (63.6%) we e diagnosed
in s age II o wo se wi h a la ge numbe o women (37.6%)
in s age III and one-qua e o hem had unknown s age a di-
agnosis. Only 10.3% o he women had had some educa ion
and 70.9% o women had low household income (i.e., < 2,000
INR).
Kaplan-Meie su i al cu e o he o e all su i al o he
165 women wi h ce ical cance is shown in Figu e 1. O e
hal o he pa ien s did no su i e o 2 yea s a e diagnosis.
The obse ed 1-, 3- and 5-yea su i al es ima es we e 67.3%,
40% and 32.5%, espec i ely (Table1). Su i al es ima es by
age a diagnosis we e 37.3% o 30 - 39 yea s, 34% o 40 -
49 yea s and 29.1% o women aged 50 yea s and abo e (P =
0.5458). Women wi h o mal educa ion had a 20% highe di -
e ence in 5-yea su i al han women wi hou o mal educa-
ion (P = 0.1794; Table 1). The su i al es ima es di e ences
wi hin he di e en ca ego ies o occupa ion, ype o house and
ma i al s a us also a ied om 6% o 11% (Table 1).
The e was a signi ican educ ion in 5-yea su i al wi h
he inc easing s age a diagnosis; he su i al es ima es o
s ages I, II, III and IV we e 77.6, 21.4, 25.3 and 9.1, espec-
i ely (P = 0.0023; Table 1). These es ima es esul ed in he
Figu e 1. Kaplan-Meie o e all su i al cu e o 165 women diagnosed wi h ce ix cance om he con ol a m.
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Thulaseedha an e al J Clin Gynecol Obs e . 2015;4(4):290-296
adjus ed haza d a ios o s ages II, III and IV cance s compa ed
wi h s age I cance s o 3.81 (95% CI: 1.54 - 9.40), 3.67 (95%
CI: 1.56 - 8.64) and 6.74 (95% CI: 2.34 - 19.02), espec i ely
du ing he 12 yea s o ollow-up (Table 2).
Su i al a e ce ical cance diagnosis was no signi i-
can ly associa ed wi h age a diagnosis, educa ion, occupa ion,
ma i al s a us and ype o house. Con a y, he 5-yea su i al
es ima e o women wi h highe household income was signi i-
can ly lowe compa ed o he su i al o hose wi h low house-
hold income (18.8% s. 38.2%; Table 1) showing an adjus ed
haza d a io o 1.59 (95% CI: 1.05 - 2.41; Table 2).
Discussion
Su i al es ima es o pa ien s wi h ce ix cance ob ained
om popula ion-based da a a e sca ce in low- and middle-in-
come coun ies because cance egis a ion is no common and
mainly due o p oblems in ollow-up o pa ien s. In a coun-
y wi h limi ed esou ces, he su i al es ima es a e ob ained
om only a ac ion o he cance pa ien s. This p oblem is
agg a a ed u he o u al popula ions. He e we epo ed he
ce ix cance su i al in a u al popula ion co e ed by a can-
ce egis y and wi h e y ew losses o ollow-up.
Ou obse ed su i al expe ience o women diagnosed
wi h ce ical cance was poo , wi h o e a hal o he women
dying wi hin he i s 2 yea s and only abou 30% s ill ali e
a e 5 yea s o ollow-up. S age o disease was he s onges
de e minan o su i al. The obse ed 5-yea su i al (32.5%)
in his s udy is qui e simila o ha epo ed by DACR (35%)
o he ce ical cance cases egis e ed in 2003 om u al Ta-
mil Nadu [14]. The 5-yea obse ed su i al o women diag-
Table 2. C ude and Adjus ed Haza d Ra ios o Assess he E ec o Women Cha ac e is ics on Su i al A e Ce ical
Cance DiagnosiS
Women’s cha ac e is ics C ude haza d a io (95% CI) Adjus ed* haza d a io (95% CI)
Indi idual
Age a diagnosis
30 - 39 1 1
40 - 49 1.13 (0.68 - 1.90) 1.24 (0.73 - 2.14)
50+ 1.29 (0.80 - 2.08) 1.38 (0.83 - 2.32)
S age o disease
S age I 1 1
S age II 3.15 (1.36 - 7.31) 3.81 (1.54 - 9.40)
S age III 3.12 (1.40 - 6.91) 3.67 (1.56 - 8.64)
S age IV 6.77 (2.56 - 17.91 6.74 (2.34 - 19.02)
Unknown 3.00 (1.31 - 6.83) 3.51 (1.44 - 8.54)
Educa ion
No schooling 1 1
Some schooling 0.64 (0.33 - 1.23) 0.71 (0.35 - 1.40)
Occupa ion
House wi e/o he s 1 1
Manual 1.21 (0.83 - 1.77) 1.11 (0.74 - 1.68)
Ma i al s a us
Cu en ly ma ied 1 1
Widowed/sepa a ed 0.80 (0.44 - 1.45) 0.68 (0.35 - 1.32)
Household
Type o house
Tha ched 1 1
Tiled/conc e e 0.75 (0.47 - 1.22) 0.68 (0.39 - 1.18)
Income (INR)
< 2,000 1 1
2,000+ 1.60 (1.09 - 2.33) 1.59 (1.05 - 2.41)
*All a iables we e included in he eg ession model. CI: con idence in e al; INR: Indian Rupees. 50 INR was equi alen o 1 US
dolla du ing 2000 - 2003.
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294
Su i al A e Ce ical Cance Diagnosis J Clin Gynecol Obs e . 2015;4(4):290-296
nosed wi h ce ical cance du ing 1990 - 1999 in he Chennai
u ban PBCR in Tamil Nadu was 54%, and 62% in he Chennai
HBCR da a o women who ecei ed ea men du ing 2000 -
2001 [14]. Be e cance heal h se ices wi h mo e accessibil-
i y o diagnosis and ea men esul in la ge a ia ions in su -
i al be ween di e en egions o India, pa icula ly in u ban
s. u al a eas [5]. Delays in ea men due o lack o acili ies,
suppo echnology, ained pe sonal, inancial esou ces and
social o amily suppo a ec su i al o ce ical cance pa-
ien s in low- esou ce se ings [6].
S udies om Eu ope [7, 15] and India [8, 9] showed no
associa ion be ween socio-economic s a us (SES) and ce i-
cal cance su i al, bu p esence o co-mo bid condi ions, se -
e al clinical and/o pa hological ac o s such as s age we e o
p ognos ic impo ance. These s udies also sugges ha i may
no be possible o clea ly es ablish he ole o socio-economic
ac o s in ce ical cance su i al wi hin a g oup o pa ien s
who had simila socio-economic cha ac e is ics and/o access
o ea men and/o inaccessibili y o cance ea men acili-
ies. Howe e , one hospi al-based egis y s udy om Sou h
India showed ha socio-economic ac o s p edic ce ical can-
ce su i al along wi h pe o mance s a us and clinical s age
o disease [1]. Socio-economic ac o s a e in ac no di ec ly
linked o su i al, bu i is di ec ly ela ed o a pe son’s gene al
s a e o heal h, nu i ional s a us, a i udes, belie s and heal h
beha io . I can a ec he chances o being ea ly de ec ed, ac-
cess o o comple ion o ea men and ollow-up and pe haps
su i al is media ed by all hese ac o s [1].
In addi ion, he su i al analysis by socio-economic ac-
o s is p oblema ic by many ways. In ou s udy, we used he
baseline in o ma ion o socio-economic ac o s. A su i al
s udy equi es long- e m ollow-up, and a pe son’s SES can
a y o e ime and i may in luence he su i al es ima es. In
his su i al analysis, educa ion ( o mally educa ed o no ) is
he mos eliable socio-economic indica o because i does no
change o e ime. The a ailable scales o assessing he SES
o amilies in India usually de i e om a single piece o in-
o ma ion using many componen s o socio-economic ac o s
[16-18]. The analysis o su i al using such single in o ma ion
on SES can only gi e he a ia ion acco ding o SES in gene al
and ha may no be help ul o unde s and he mechanism o
indi idual componen s o socio-economic ac o s which de e -
mine he es ima es di e en ly. Also, i is possible ha he le el
o indi idual ac o s can ha e di e en di ec ions o associa-
ion o di e en ou comes; o ins ance educa ion is nega-
i ely associa ed wi h ce ical cance incidence, bu posi i ely
associa ed wi h b eas cance incidence [19]. Fu he mo e, he
ac o s which de e mine he SES o one popula ion may no
be applicable o ano he . Consequen ly, he assessmen o SES
should be a ied acco ding o he popula ion unde s udy and
pu pose o he s udy.
Acco dingly, in ou s udy we ocused on he a ia ion in
su i al by di e en componen s o SES using se e al indi-
idual and household cha ac e is ics. Old age, no schooling,
manual occupa ion, li ing in ha ched houses, and low house-
hold income indica ed poo SES. When we conside he a i-
able “ ype o house”, we canno say ha he women who li ed
in iled/conc e e houses had a e y high SES; howe e , we can
say ha e y poo people li ed in ha ched houses and peo-
ple whose ci cums ances we e a li le be e in iled/conc e e
houses in u al a eas. Howe e , he ac ha only 4% (1/27) o
women li ed in ha ched houses we e o mally educa ed and
had a highe household income, and 78% (21/27) o women
who li ed in ha ched houses we e manual wo ke s u he
suppo s he e iciency o his a iable o measu e poo SES in
his popula ion. Today, howe e , i has become imp ac ical o
Figu e 2. Kaplan-Meie su i al cu es showing su i al o ma ied women wi h di e en le els o income and occupa ion.

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Thulaseedha an e al J Clin Gynecol Obs e . 2015;4(4):290-296
use such a a iable o measu e SES because ha ched houses
a e g adually disappea ing om u al a eas h ough he ini ia-
i es o he s a e and cen al go e nmen s o p o ide conc e e
houses o he poo .
Ma ied women and hose wi h an income mo e han 2,000
INR pe mon h had poo su i al. In ac , he di e ence in su -
i al by income was he only s a is ical signi ican esul by
he SES a iables. This seems o be in con adic ion wi h he
poo SES hypo heses. As pa icipan s p o ided in o ma ion on
hei income g oup o he in e iewe a he ime o baseline
in e iew, his opens he possibili y o in o ma ion bias. Only
29% (48/165) o he women epo ed o ha e income g ea e
han 2,000 INR and because o his small sample, chance ob-
se a ions (dea hs) a e also possible.
I was obse ed om he da a ha 31.5% (46/146) o ma -
ied women epo ed a household income 2,000+ INR e sus
10.5% (2/19) o single women. Con e sely 96% (46/48) o he
women epo ed ha ing household income 2,000+ INR we e
cu en ly ma ied. Fu he , we ound ha 38% (55/146) o he
ma ied women we e housewi es compa ed o 26% (5/19) o
he single women. The emaining ma ied and single women
we e manual wo ke s (62% s. 74%) ha ing hei own ea n-
ings. I is common in u al India ha he ma ied women a e
no ee o spend money wi hou he pe mission o hei hus-
bands, e en hough hey ha e hei own ea nings. The house-
wi es epo ed he income gene a ed by hei amily mem-
be s and depend on hei husbands/ amily membe s o ge he
money necessa y o access heal hca e acili ies. Howe e , his
inancial ins abili y o en leads o igno ance o heal h needs.
I his is ue, he housewi es a e a poo su i al g oup. To
demons a e his, we u he made ou ca ego ies o ma ied
women wi h di e en combina ions o income and occupa ion
and we could clea ly illus a e ha hose housewi es who e-
po ed ha ing a highe household income we e he poo es su -
i al g oup (Fig. 2). Hence hese indings sugges ha a highe
household income may no always be a suppo ing ac o o
imp o ed su i al.
A majo limi a ion o ou s udy was ha we did no ha e
in o ma ion on clinical ex en o disease and ea men de ails
o women on a ou ine basis. Also, he es ima es do no ake
in o accoun dea hs due o o he causes. Howe e , we ha e
comple e and accu a e in o ma ion o all inciden cance cases
diagnosed du ing 2000 - 2006 o he s udy popula ion, and an
adequa e and ac i e ollow-up o he cance cases by DACR
and mo ali y egis a ion sys em and he ollow-up o he base
popula ion in 2011 - 2012. We had a e y minimal numbe o
women wi h incomple e ollow-up s a us, so we did no ha e
o adjus he es ima es o losses. Also we ook only hose
women diagnosed wi h cance du ing 2000 - 2006 o a oid
bias in ou selec ion c i e ia since ce ical cance sc eening
was p o ided o all 30 - 59 yea s old women om he con ol
a ea du ing 2007 - 2010.
In ou s udy, he a ia ion in haza d wi h espec o socio-
economic cha ac e is ics was no s a is ically signi ican p ob-
ably due o small numbe o pa ien s. We ound ha he poo
socio-economic cha ac e is ics had up o 70% highe isk o
dea h. Fo example, he e was a 30% educ ion in mo ali y o
a 70% be e su i al among hose wi h some schooling com-
pa ed o no schooling. E en i he di e ence is no s a is ically
signi ican , i should no be conside ed o be ze o di e ence
in mo ali y o su i al among he wo schooling ca ego ies.
In addi ion, he non-signi ican su i al a ia ion by SES may
seem less han expec ed. One explana ion may be he gene al
lack o heal h se ices in u al India. Specialized se ice migh
be oo a away o no e icien o cance diagnosis and ea -
men .
In conclusion, he ce ical cance su i al is likely o be
poo also in u al popula ions o o he a eas in India and in
low- and middle-income coun ies in gene al. The only s ong
de e minan was he s age o umo a diagnosis. Ou esul s
u he s ess he impo ance o p o iding p e en ion and
sc eening oppo uni ies o he women in low- esou ce se ings,
and he need o s eng hen he quali y o heal hca e acili ies
in u al a eas.
Acknowledgemen
We acknowledge he Bill & Melinda Ga es ounda ion o hei
inancial suppo o ou s udy h ough he Alliance o Ce ical
Cance P e en ion.
Con lic o In e es
None o he au ho s ha e any con lic ing in e es .
Financial Disclosu es
All au ho s ha e no inancial disclosu es o make.
G an Suppo
The o iginal s udy was inancially suppo ed by he Bill &
Melinda Ga es ounda ion.
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