Cervical Cancer Screening in the Municipality of Nicosia, Cyprus - Coverage and Association with Socioeconomic Determinants

Research Article

Austin J Public Health Epidemiol. 2016; 3(1): 1032.

Cervical Cancer Screening in the Municipality of Nicosia, Cyprus - Coverage and Association with Socioeconomic Determinants

Papapetrou I1,2, Charalambous G1,3, Sissouras A1,4 and Jelastopulu E1,5*

¹Postgraduate Program Health Management, Frederick University of Nicosia, Cyprus

²Strovolos Health Centre of Nicosia, Frederick University of Nicosia, Cyprus

³General Hospital of Athens “Hippocratio” of Athens, University of Patras, Greece

4Department of Operational Research and Management, University of Patras, Greece

5Department of Public Health, University of Patras, Greece

*Corresponding author: Eleni Jelastopulu, Department of Public Health, Medical School, University of Patras, 26500 Rio Patras, Greece

Received: October 12, 2015; Accepted: December 30, 2015; Published: January 04, 2016


The aim of the present study is to determine the prevalence of Pap smear use among the women in Nicosia and to identify the factors associated with Pap test’s performance. A cross-sectional study was carried out on a representative sample of 525 women living in the municipality of Nicosia in 2014. Prevalence Ratios (PR) of Pap smear use were calculated. Information about demographic, socioeconomic and lifestyle factors was collected. About 81% had at least one Pap test in their life, with 70% having been tested in the previous three years. Women aged 25-64 were more likely to have had a recent Pap test than women aged 20-24. Furthermore, married/partnered women, employed women, women with higher education were more likely to have had a recent Pap test. Compared to women with a monthly household income of >1000€, those with lower income were less likely to have had a recent Pap test. Finally non-Cypriot women are less likely to have had a recent Pap test than Cypriot females. The prevalence of Pap testing in Nicosia is high. However, efforts to establish a cervical cancer screening in Cyprus should be planned and implemented in the framework of a comprehensive cancer control program taking into account overall health care needs and priorities emphasizing mainly in women with socioeconomic disadvantages.

Keywords: Cervical cancer screening; Prevalence of pap test


The Health Profile of the city of Nicosia, Cyprus, was conducted in 2013-2014, within the Healthy Cities Programme, with the aim to collect and analyse information about the current socioeconomic and demographic situation of its citizens, their living conditions and health status as well as health related behaviors and to evaluate and implement preventive programmes, including cervical cancer screening. The ultimate purpose was to conduct a Health Action Programme of the City of Nicosia.

Cervical cancer is one of the world’s most common cancer among women, but at the same time one of the most preventable and treatable forms if detected early and managed effectively [1].

It is estimated that over one million women worldwide currently have cervical cancer. Most of these women have not been diagnosed, nor do they have access to treatment that could cure them or prolong their lives [1]. There is an unequal burden of cervical cancer [2]. In 2012, 528,000 new cases of cervical cancer were diagnosed worldwide and 266,000 women died of the disease, nearly 90% of them in lowto middle-income countries. Without urgent attention, deaths due to cervical cancer are projected to rise by almost 25% over the next 10 years [1].

Although significant advances are being made in the fight against cervical cancer, the disease remains a key public health concern and a tremendous burden on European societies. In the European Union (EU) 34,000 new cases and more than 16,000 deaths due to cervical cancer are reported annually [3,4]. The highest annual worldstandardized mortality rates are currently reported in Romania and Lithuania (13.7 and 10/100,000, respectively) and the lowest in Finland (1.1/100,000) [5].

Among all malignant tumours, cervical cancer is the one that can be most effectively controlled by screening [6]. It has been predicted that by implementing 100% population coverage of cervical cancer screening every 3-5 years, an estimated reduction of over 94% of life years lost could be attained, and for every 152 Pap smear tests performed, one life year could be gained [7]. In countries that have established such programs – mainly countries of developed world - cervical cancer incidence has shown a marked decrease. In times of financial instability, it is all the more important to maintain investments in health, in particular through preventive actions [8].

The EU Council recommends implementation of populationbased cervical cancer screening programs with identification and personal invitation of each woman in the eligible target population to the EU member states, with quality assurance at all levels [5]. Based on these recommendations most Member States (MS) have implemented population based organized cervical cancer screening programs either nationally or regionally. The highest screening rates are achieved in the United Kingdom, Norway and Sweden (80%) while the lowest ones are observed in Hungary (36%), the Slovak Republic (23%) and Romania (14%) [9].

In Cyprus in 2012 the incidence rate for cervical cancer was 5.2 per 100,000 women and the crude mortality rate was 2.5 per 100,000 women, while the age-standardized mortality rate was 7.2 per 100,000 women [10].

Cyprus is among the few European countries that have not yet establish both a national screening program for cervical cancer and a vaccination program against Human Papilloma Virus (HPV) that is causally linked with cervical cancer. However, from 2012, a regional pilot screening program was implemented in some communities in Nicosia district area, that includes women aged 25-65 under the care of the Ministry of Health. A private organisation of women in cooperation with the governmental health services organised this screening programme in which the Ministry of Health offers all the supplies and the health centers and the women organisation the doctors, the information and invitation of the eligible target population to performance of the screening test.

Cyprus has not established yet a National Health System (NHS), thus cervical screening in Cyprus is opportunistic and can be conducted in public or private hospitals or clinics. Several private clinics, mainly in Nicosia and Limas sol, have very well organized programs but no reliable data on the percentage of women covered are available. The majority of private gynaecologists also perform Pap tests in their private practices, not free of cost. There are no reliable data on the percentage of women who perform Pap tests privately. There are plans to establish a national organized population based screening program for cervical cancer as mentioned in the National Action Plan for Cancer which has been in effect since 2008.

Materials and Methods

Study design, data collection and study population

The data were collected between May 2013 and April 2014 through a research-administered survey. An interviewer addressed the questions to a representative sample of 525 women aged 20 to 74 years old, residents of Nicosia, who were selected by stratified sampling based on the census data of Cyprus.

The outcome variable of interest for this analysis was the proportion of women who have ever had a Pap-test and the proportion of women who had had a Pap-test within the last 3 years before the study. Independent variables included demographic and socioeconomic characteristics, such as age in years, marital status, educational level, household income, house ownership, health care coverage and occupational status. Secondary characteristics included body mass index (BMI categorized as underweight [18.5-19.9 kg/m2], within acceptable limits [20-24.9 kg/m2], overweight [25-29.9 kg/m2], obese [> = 30kg/m2]), tobacco exposure (expressed in pack-years and defined as 1 pack-year corresponding to twenty cigarettes smoked every day for one year) and alcohol consumption.

Statistical analysis

The statistical analysis was conducted by using IBM SPSS Statistics for Windows, Version 22.0. (IBM SPSS Statistics for Windows, Released 2013. Armonk, NY: IBM Corp.). The relationship between cervical cancer screening behaviour and demographic, clinical, and lifestyle factors was assessed by using Pearson’s chi square tests. In addition, binary logistic regression models, using the forced entry method, were used to further assess these relationships, where the prevalence odds ratios and their 95% Confidence Intervals (CI) were estimated to determine the magnitude of the association between the specific factors and cervical cancer screening behaviour. The accepted levels of significance were 0.05 or less.


The main demographic and socioeconomic characteristics of the study population are presented in (Table 1).