1. Factors associated with abnormal PAP Smears in a health center X – Costa Rica, 2009 Leandra Abarca 1, Julia Freer 1, Maricela Salas 2 1, MD, MsC, FETP, Caja Costarricense de Seguro Social, 2, MD, MsC, Caja Costarricense del Seguro Social

2. Background Incidence RateMortality Rate 1, Skin44,51, Breast13,4 2, Breast40,12, Stomach8,7 3, Cervical17,43, Colorectal5,5 4, Stomach16,94, Cervical4,9 5, Colorectal 9, 85, Lung3,2 Cervical cancer is among the leading causes of cancer in women globally In Costa Rica it is among the top five causes * * INEC: Incidence and Mortality Rate / 100 000 Hab- 2007

3. Background (II) Early detection of premalignant or malignant cells through PAP smears improves prognosis The PAP smears is part of the national screening guidelines, but the coverage in some areas of health is low

4. Cervical Cancer Screening in Costa Rica Social Security The medical care is public (CCSS) in 90% and a percentage of private medical establishments

5. Geographical location of health center X, Costa Rica Located in the heart of the capital Population:94,145 ( 47,958 women) This center heath sees an urban population Very good accessibility to health services Do not perform colposcopy

6. Objective Identify demographic and clinical factors associated with abnormal Pap Smears in this center during 2009 to improve prevention and control strategies

7. Methods Study Design: We conducted a health center-based case control study Data collection instruments: Questionnaire administered through personal interviews Questions included sociodemographic, medical history, sexual behavior and alcohol and tobacco use

8. Methods (II) Case definition: Case: was defined as any woman seeking care in a health center during 2009, having abnormal PAP smear We defined abnormal as PAP smear positive for either cells of undetermined significance (ASCUS), mild, moderate or severe dysplasia Control: was defined women seen at the same health centers in 2009 and having normal PAP smears

9. Methods (III) Sampling Selection : Simple random sampling Data analysis: Proportions, odds ratios 95% Confidence Intervals (CI) were calculated for associations between potential risk factors and abnormal PAP smears Software used : Epiinfo 3,3,2 & Stata 10,1

10. General characteristics as a group, Health Center, Costa Rica 2009 CaseControl Frequency n%n% Age group Less than 35 years20325137 35 years and older42688663 Civil Status Married29395843 Single16263425 Free Union12192317 Divorced58118 Widow58107 Frequency of PAP smears every 2 years477511382 Family history of cervical cancer711 8 Tobaco use30483929 Alcohol22363727

11. CaseControl Frequency n%n% Onset of sexual activity before 18 years old 40657152 after 19 years old 22356648 Number of sexual parthers > 3 sexual partners 36583727 < 3 sexual parthers 264210073 Contraceptive Methods Hormonal contraception 2544 32 Non-hormonal contraception 37605641 General characteristics as a group, Health Center, Costa Rica 2009 (II)

12. Distributions of the PAP Smears in the Health Center X, Costa Rica, 2009

13. Analysis of factors associated abnormal PAP smears health center X, Costa Rica, 2009 95%CI ORILSL Age group > 35 years old 1,250,632,47 Frequency of PAP smears every 2 years0,60,30,92 Family history of cervical cancer1,450,53,95 Tobaco use2,41,214,60 Vaginal delivery1,780,813,94 Onset of sexual activity before 18 years old1,951,043,85 Number of sexual parthers > 3 sexual partners 2,101,13,97 Contraceptive Methods Hormonal contraception1,60,93,1

14. Discussion Similarity between our results and those in the literature as onset of sexual activity before age 18 and having a history of > 3 sexual partners Smoking is considered a factor associated with abnormal Pap Smears

15. Discussion (II) PAP smears every 2 years would help early detection of precancerous lesions Delaying first age of sex or reducing # of partners may help to reduce risk of abnormal Pap in the future

16. Limitations Our study was limited by the failure to follow- up colposcopy results for final diagnosis No determination of HPV in all the health social security Population studied is not representative of all the population in Costa Rica

17. Recommendations Dissemination of the results to local and central health authorities to generate intervention strategies Improve strategies for not smoking in the population of the area studied Doing this nationwide study, to be more representative and thus create or strengthen health care policy

18. Actions Workshop development and reproductive health in schools in the area Inclusion in the National Survey of Risk Factors for Noncommunicable Diseases questions about risk factors associated with Cervical Cancer, representing all the population

19. Muchas Gracias!