Introduction

Cancer of the uterine cervix is the fourth most common cancer diagnosis among women, with an incidence of 528,000 new cases and an estimated death toll of 266,000 in 2012 worldwide. This condition is a major public health issue, mostly in low-income countries as in South America where it is the second most incident cancer an it ranks third for all casualties with rates of 11.5 and 9.3% respectively¹.

In Peru, cervical cancer ranks first for cancer incidence with a standardized incidence rate per age of 23.7 for every 100,000 women and second for mortality with a standardized rate of 12 cases for every 100,000 women².

The implementation of appropriate prevention measures, healthier diets and physical exercise can reduce the incidence of and mortality from cancer of the uterine cervix³. Primary prevention regards human papilloma virus (HPV) vaccination while secondary prevention regards screening methods such as the Papanicolaou test in high-risk populations such as imprisoned women^4-6. The later involves certain limitations such as a poor commitment of women towards their own healthcare, low social and economic conditions, rural isolation, illiteracy, type of health insurance and rejection of gynecologic examination⁷.

The National Department of Corrections (INPE in Spanish) is responsible for administering Peru’s correctional system and through its Sub-Department of Health it manages the provision of healthcare in prisons with diagnosis and prevention programs (mainly HIV/AIDS and tuberculosis)⁸.

Prevention measures against cervical cancer among prisoners in Peru have been scarcely addressed in research studies. International publications suggest that the imprisoned population is at a higher risk of developing this disease as well as of risk behaviours, poorer follow-up and impaired cytological monitoring when compared with the general population^{5 6 9 10}.

Moreover, it is highly probable that the deficiencies observed in the general population such as poor medical coverage, the inadequate quality of services, the lack of family and social support be greater among imprisoned women and lead them to daily survival activities, with prevention taking a secondary role^11-13.

The main objective of our study was to determine the prevalence rate and risk factors associated to cytological screening of cervical cancer in the imprisoned population of Peru in 2016.

Material and methods

Results

Out of the total of registered inmates, 4515 fulfilled inclusion criteria and were included in the study. Figure 1 and Table 2 depict the selection flow and this population’s characteristics respectively.

Figure 1 Women selected for the study on cervical cancer cytological screening in he imprieoned population in Peru, 2016. 

69.17% of cases (95%CI: 67.81-70.5) underwent cytological screening for cervical cancer during the previous year. By addressing this screening according to facilitators, it shows that women with public insurance are more likely to report this condition (73.50%; 95% CI, 72.22-7.,25) as well as those who pursue consultation in the correctional health services (7.79%; 95% CI 71.17-74.18) and those who engaged in sporting activities (70.66%; 95%, CI 68.86-72.4).

The prevalence of screening according to socio-demographic characteristics showed that the prevalence of cytological screening increased from the 18- 29 age group (60.63%; 95% CI 57.81-63.38) to the 40-49 age group (74.71%; 95% CI, 72.08-77.17), the dropping among women over 50 years old (71.05%; 95%CI: 67.68-74.19). The prevalence rate was lower among women with no children and it increased progressively with the number of children with higher results among women with four or more children (75.53%; 95% CI 72.22-78.64).

When the prevalence rate was analysed according to factors generating the need for the use of health services, a higher prevalence rate was observed among women with any kind of cancer (82.43%; 95% CI, 72.05-89.52), HIV/AIDS (78.72%; 95% CI: 64.78-88.15) and tuberculosis (72.55%; 95% CI: 58.82-83.02).

The analysis of prevalence according to the rest of variables is depicted on Table 2.

Multivariate analysis determined that the report of cytological screening for cervical cancer in imprisoned women is associated to having public (aPR: 1.28, 95%CI: 1.21-1.36) or private insurance policies (aPR: 1.32; 95%CI: 1.13-1.54), pursuing consultation in the correctional health services (aPR: 1.18; 95%CI: 1.12-1.24), being hosted in a female facility (aPR: 1.07, 95%CI: 1.03-1.11) and engaging sporting activities (aPR: 1.07; 95% CI: 1.02-1.11) (Table 3).

The age and number of children were also associated to cytological screening with the age group of women between 40 and 49 years old having a stronger association (aPR: 1.16; 95%CI: 1.09-1.24) while inmates over 50 years old showed lower degrees of association (aPR: 1.08; 95%CI: 1.01-1.17) when compared to the age group 20-29; and women with five or more children are more likely to have undergone cytological screening than those who have no children (aPR: 1,.3; 95%CI 1.12-1.34). A history of cancer (any type) would also be associated to reporting PAP in this population (aPR: 1.14; 95%CI 1.02-1.27) (Table 3).

Discussion

Our results show the prevalence rate and associated factors of reporting cytological screening for cervical cancer in a scarcely studied population at high risk of this condition: imprisoned women in Peru.

The prevalence rate of screening for cervical cancer in the imprisoned population in Peru is similar to that of the national coverage and lower that that described by Binswanger et al. in an imprisoned population in America (69% vs 83%)¹⁵.

In Peruvian prisons there are areas aimed at the recovery of health in charge of professional healthcare providers: mainly aimed at controlling tuberculosis, sexually transmitted diseases, pregnancy and family planning, without a specific approach for cancer of the uterine cervix, as seen in other countries^{4 16}.

The screening of cervical cancer could increase if intra-penitentiary policies aimed at controlling this condition were implemented and enforced since we face an environment were other publications show that an improved coverage is possible^{6 15}.

Women deprived of their liberty who have health insurance, pursue consultation and engage in sporting activities within the centre are more likely to have preventive behaviours against cervical cancer, as reported by Barrionuevo et al and Nijhawan et al in the general and imprisoned population respectively^{7 17}.

We should expect that prisoners with lower socio-demographical and educational backgrounds and impaired access to health insurance are less likely to undergo cytological screening. This can be changed by turning prison health centres into a suited environment where access to information on healthcare, on the detection of diseases such as cervical cancer be promoted, and where optimal quality healthcare be provided¹⁷.

Previous studies such as that by Binswanger et al show that the prevalence rate of cytological screening among imprisoned women increases with age, specially for women over 50 years old¹⁵. However this is not observed in Peruvian prisons, where although the prevalence increases until 50 it then slowly decreases: probably due to this group’s features: their educational level, beliefs and interest on their health with an increased difficulty to accessing quality healthcare, where information on cancer prevention be provided, when compared with younger women¹⁵.

Prisoners with children are more likely to having undergone cytological screening of cervical cancer. Even though this is not so among prisoners in other countries such as Canada¹⁵, it has also been observed in other countries in Latin America such as Peru or Mexico^18-20. This probably has to do with family planning services which are encouraged in high-income countries such as Canada. The opposite can be found in Latin America, where having children can make the difference between women who probably accessed these services and received information on the importance of cytological screening for the prevention of cervical cancer in comparison with women who did not have children or were never pregnant^18-19.

As expected, a previous history of cancer is associated with a higher prevalence rate of cytological screening²¹. In this sense, education from physicians who make the diagnosis or prescribe treatment is essential. Women should receive information on healthier lifestyles, risk factors such as alcohol or smoking and cancer prevention and follow-up^22-24.

Conclusions

We can conclude that the prevalence of cytological screening of cervical cancer in the imprisoned population in Peru is more common among women with health insurance, those aware of their health, with children or a previous history of cancer. Further research on the impact of prevention measures for this condition among imprisoned women compared with the general population are needed.