Why Is Cervical Cancer a Problem of Increasing Magnitude Among Women of Low Socioeconomic Standing?
Cervical cancer is a problem of increasing magnitude in less developed countries. The prevalence of this disease is especially evident in poorer parts of less developed societies. Could there be a nexus between poverty and the rising incidence of cervical cancer among women in these societies? Drawing upon sociological and medical secondary sources, this paper utilizes a qualitative approach to explore whether socioeconomic factors including poverty, education level, income, language and acculturation, single-parenthood, etc., are associated with the health of women. Of particular interest is women’s health status with respect to cervical cancer. Factors such as accessibility to health care, inadequate health services, women’s knowledge, attitudes, and practices regarding cervical cancer will also be discussed. The paper suggests that improving the availability and accessibility of cervical cancer education and free Pap smears for women of low socioeconomic standing may be the most direct ways to improve their health.
It is widely established that whatever the actual causes of disease and illness, poor people suffer more. Because women are a significant percentage of this social group, they are predisposed to many life-threatening diseases, of which cervical cancer is one. Despite all of the advances in medicine and the remarkable progress made in reducing the incidence of certain types of cancers, Goldman and Hatch (2000) state that malignancy of the cervix is widespread in less developed countries and is the second highest ranking gynecological cancer among women (p. 932). The World Health Organization (WHO) (2007) reports that “in 2005, cervical cancer was responsible for up to 500,000 new cases and up to 257,000 deaths, more than 90% in low- and middle-income countries where access to cervical cancer screening and treatment and palliative-care services is often nonexistent or insufficient” (p.4). WHO further projects that “deaths from cervical cancer will rise to 320,000 in 2015 and to 435,000 in 2030” (p. 4).
During my practice as an operating room nurse in an underdeveloped country, I observed that almost all of the women undergoing surgery for cervical cancer were diagnosed with the disease in the late stage. Therefore, the surgical procedure of radical hysterectomy was naturally the wisest option of treatment. This form of treatment is by no means curative.
In addition to belonging to underprivileged communities where health services are greatly lacking, many of these women were from the indigenous groups residing in the hinterland region with language and acculturation practices that posed barriers to them accessing health services. Other women I saw were from urban communities, but they too were poor, and although they had better access to health services, they made little use of them for preventative care. This observation suggests that social factors may also serve as barriers to women seeking cervical care. The above stated observation is not novel. The literature does mention a correlation between cervical cancer and the socioeconomic status of women; however, more often than not, the socioeconomic factors are treated as less important. Yet the Cancer Treatment Centers of America (n.d.) state that “socioeconomic status is a major risk factor for cervical cancer, since a lack of access to medical care often eliminates the opportunity for early diagnosis by Pap test screening.”
In addition to providing a brief understanding of the disease from a medical perspective, this paper aims to provide a situational understanding of cervical cancer as a social condition affecting the lives of women. In this regard, the paper is particularly intended to capture women readers. It also speaks to policy makers and health care workers. The first section of this paper will provide a brief definitional understanding of cervical cancer/dysplasia, its causes/risk factors, signs and symptoms, screening (Pap smears), and treatment. The latter section of the paper attempts to provide a situational analysis of cervical cancer and to examine the social factors, particularly in less developed countries, that contribute to the high number of women developing cervical cancer.
Questions that will be answered in this paper include: What is the relationship between low socioeconomic status and cervical cancer? How do women’s socioeconomic, economic and child rearing responsibilities, single parenthood, and education levels serve as barriers to health seeking practices and contribute to behaviors that increase their likelihood for cervical cancer? What role do culture, language, fear and gender play in deterring women from obtaining cervical cancer screening? What governmental barriers do women in less developed countries face in obtaining cervical cancer screening? How would routine cancer screening and education, along with lifestyle changes reduce the incidence of cervical cancer? As much as possible, attempts will be made to provide a brief descriptive understanding of the disease in some developed and less developed countries. A brief examination of health services in some developing countries, particularly the Caribbean, will be done to determine their adequacy and effectiveness. Recommendations will be made in an attempt to effect change at both the individual and state levels.
What is Cervical Cancer and what Causes/Risk Factors are Associated with Cervical Cancer?
The Gale Encyclopedia of Cancer defines cervical cancer as a harmful condition which causes atypical and unregulated increase of cervical cells that develop into abnormal tissue (Thackery, 2002, p. 215). It is established that the sexually transmitted human papillomavirus (HPV) is the main infectious agent most closely associated with cervical cancer (New York City Department of Health and Mental Hygiene, 2006). In a survey coordinated by the International Agency for Research on Cancer, HPV was identified in more than 90% of the specimens of invasive cervical cancer obtained from 22 countries (Goldman & Hatch, 2000, pp. 934-935). In addition to HPV, “lack of regular Pap tests, smoking, weakened immune system, sexual history, using birth control pills for a long time, having many children, and DES (diethylstilbestrol)” are also cited as causes for cervical cancer (National Cancer Institute, 2008).
What are the Signs and Symptoms of Cervical Cancer?
According to Smeltzer and Bare (2004), cancer of the cervix is usually asymptomatic in the early stages. The passing of a colorless liquid after coitus or vaginal cleansing may be the only sign, which is rarely noticed (p. 1429). According to an article titled: “Cervical Cancer” cited in Merck Manual Home Edition (2003), cervical cancer:
[M]ay cause spotting or heavier bleeding between periods, bleeding after
intercourse, or unusually heavy periods. In later stages, such abnormal bleeding is common. Other symptoms may include a foul-smelling discharge from the vagina, pain in the pelvic area or lower back, and swelling of the legs.
Why is Cervical Cancer Screening Important?
There is substantive evidence from observational studies that screening can reduce mortality from cervical cancer. According to the Center for Disease Control (1997):
[T]he Papanicolaou test—or Pap smear test—is one of the most effective cancer screening tests available, and its ability to detect premalignant conditions has contributed to the decline in cervical cancer morbidity and mortality in the United States since its development in 1941. (p. 1)
The American Cancer Society (2008), has also recognized Pap screening as a major contributor in the decrease of the cervical cancer death rate in the United States, citing a seventy-four percent decline in the mortality rate over a thirty-seven year period, and a continued approximate four percent yearly mortality decline.
What Treatments are Available?
As pointed out by Thackery (2002), therapy for cancer lesions depends on the extent of abnormal cellular changes. In cases of mild dysplasia, cells usually return to normal and only careful follow-up is recommended. “Cold knife cone biopsy, LEEP, cryosurgery (freezing the cells with a metal probe), cauterization or diathermy (burning off the cells), and laser surgery (burning off the cells with a laser beam)” are treatment procedures for superficial carcinomas and other beginning phase cervical malignancies in would be pregnant women (p. 217). Treatment of cervical cancer ranges from “simple to radical hysterectomy, radiation therapy, chemotherapy, and alternative and complementary therapies” and such factors as the “clinical stage of the disease, a woman’s age, general health, and preferences may influence the choice of treatment” (pp. 217-219). However, these measures address the effects of the disease and not its cause. Given the fact that the HPV is recognized as a public health problem for its role as a sexually transmitted disease, and also as a critical factor in the development of cervical cancer, it becomes clear that therapeutics against HPV must be tried. To this end, the Gardasil vaccine promises to keep young girls and women who have not yet engaged in sex from contracting HPV types 16 and 18, which give rise to the majority of cases of malignancy of the cervix (Weeg, 2008).
What is the Relationship Between Low Socioeconomic Status and Cervical Cancer?
“Low socioeconomic status is an important determinant of access to health care” say Becker and Newsom (2003, p. 742). In countries such as the United States, which treat health care as a commodity distributed according to the client’s ability to pay, rather than as a service to be offered according to the patient’s health needs, socioeconomic status is especially important. Becker and Newsom (2003) sum up the U.S health situation by stating that “persons with low incomes are more likely to be Medicaid recipients or uninsured, have poor-quality health care, and seek health care less often; when they do seek health care, it is more likely to be for an emergency” (p. 742).
In less developed countries, the incidence and mortality rates of cervical cancer are very much related to the overall economic standing and the inability of the health systems to make screening programs available and sustainable. According to Lingam (2007), structural adjustment programs in several developing countries saw the erosion of their national health care systems “and the proliferation of the private health sector [which] augment[s] inequities in health care” (p. 3). Women in less developed countries lack access to cervical cancer screening services available in developed countries. My observations as a nurse in my own country, Guyana, were that screening services are largely limited to urban communities or are even nonexistent in some areas of the country. In those areas where there are screening programs, they are often haphazard, with insufficient personnel and inadequate mechanisms in place to provide diagnostic and treatment services. Additionally, women in poorer settings lack basic health education and often have to travel great distances for services. Accordingly, Lewis (2004) aptly states that new cases and deaths from cervical cancer are intertwined “with poverty, poor access, rural living and low education levels” (p. 8).
While it is beyond the scope of this paper to provide comprehensive statistical data for cervical cancer in all developing countries, statistics and specific examples drawn from some Caribbean countries and other less developed countries will call attention to the health woes that women face with respect to cervical cancer. These problems suggest that cervical cancer might be construed as more than just a health issue. Recent data on incidence and mortality rates for cervical cancer are scarce in many Caribbean countries. The 2002 Global Cancer Statistics report shows that less developed countries account for eighty-three percent of cervical cancer cases, with rates in the Caribbean at 32.6 new cases, and 16.0 deaths per 100,000 women. (Parkin, Bray, Ferlay, & Pisani, 2005, p. 91, 93). These rates are relatively high when compared to North America, which has only 7.7 new cases and 2.3 deaths per 100,000 women (p. 91, 93).
Advanced screening undertakings in developed countries have given rise to significant reductions both in new cases of cervical cancer and deaths from the disease (Parkin, Bray, Ferlay, & Pisani, 2005, p. 93). Yet, the opposite holds in developing countries. In 2004 the Pan-American Health Organization (PAHO) reported that screening measures for cervical cancer in Latin American and Caribbean countries are unsuccessful in reducing incidence and deaths “largely because of inadequacies in treatment and follow-up” (“Cervical Cancer,” 2004).
In the twenty-first century, cervical cancer continues to be a public health problem that warrants new and modified approaches in less developed countries. The director of PAHO, Dr. Mirta Roses (2004), in a press release states that “eighty percent of cervical deaths occur in developing countries where 600 women a day die from this cause.” In pointing the way forward, Roses, further states that “it is especially critical to improve poor women’s access to detection services to control this disease and save thousands of lives each year.” In this regard, “the best solution, therefore, is to increase early detection and prevent cervical cancer from developing” (Roses). It is evident that reductions in incidence and mortality from cervical cancer have plummeted in countries with intensified screening programs. For example, the Scandinavian countries with high rates of “nationwide screening programs” report significant declines in invasive cervical cancer incidence and mortality rates (Day, 1984).
A similar pattern can be seen in the United States and other developed countries where Pap tests are seemingly widely available and readily accessible. This evidence strongly suggests the need for increased availability and accessibility of effective screening programs for women in developing countries and also signals to international health organizations, as well as health agencies in these respective countries, that the implementation of health policies and sustained cervical cancer screening programs is timely. It also demonstrates the need not only for international assistance in providing long-term screening programs, but also for public health education programs at the local level because knowledge of the disease plays a role in determining women’s receptiveness to, and pursuit of screening.
How do Women’s Socioeconomic Status, Responsibilities, and Education Levels Affect their Ability to Access Cervical Cancer Screening?
Other barriers at the individual level may also be crucial factors that warrant collaborative consideration with cervical cancer screening programs. Within the Caribbean context, for example, we can understand how the various roles that women undertake as household heads can impact their personal health. Smith (1996), a prolific Caribbean writer, sees undertaking domestic functions and economic maintenance as the more important tasks for Caribbean women. He describes the woman as fully occupied with child rearing and “economic … decision-making,” regardless of the male presence. In this context, one can see much of the family earnings and quality time going towards basic physiological needs such as providing food, love, and shelter for the family unit. This leaves very little time and money for accessing and paying for preventative health care. In most instances, household expenses surpass the meager family income; therefore, preventative health is forgotten.
In addition to the financial barrier, the absentee father phenomenon in the Caribbean serves as a barrier to good health care practices for Caribbean women. As a social worker in Guyana, I saw many women take on the role of single parent and lone caregiver for her family. In many cases, most, if not all, of the woman’s attention is channeled towards taking care of the health and well being of her family first. In doing so, her health is neglected, and she is less likely to seek regular Pap testing. Such behavior increases her likelihood of developing cervical cancer. Additionally, the absence of the male partner and his economic support for the family creates further health problems for the woman. In seeking the much needed financial help to support the family, the woman is vulnerable, and she may enter into another relationship, which in itself adds to the number of her sexual partners. This behavior may arise out of the need for love, companionship, and a sense of financial security, but it further increases the likelihood for contracting HPV and subsequently, cervical cancer.
The education level of women is another barrier that warrants attention. Lewis (2004) speaks to the education barrier when she cites an example from Mexico in which she notes that women who are highly educated and economically stable were more inclined to access cervical cancer screening than poor, less educated women (p. 14). These poor and less educated women are the very ones who most often present with cervical cancer in its advanced stage. Therefore, it behooves us as a global community to concentrate our efforts on providing health education along with cervical cancer care to all women, particularly those who are poor and vulnerable.
What Role do Culture, Language, and Fear Play in Deterring Women from Obtaining Cervical Cancer Screening?
Cultural beliefs, customs, and cultural practices are other important factors that can become barriers to women’s access to Pap tests. In the Caribbean, as in many other cultures, traditional therapies—sometimes called bush medicine—are used as cures for many physical illnesses, especially by older household heads. This practice is often informally passed on to the younger generation through socialization. As a young woman, I recall being taught by my maternal grandmother (in most cases) to take care of my gynecological health using herbs. For example, after menstruating, I was encouraged to use herbal potions to clean out all the impurities from my womb. It is within this context that the head “older woman” will influence the kind of health care practices undertaken by the younger women, many of whom have come to believe that once the bush medicine is taken all is well, and there is no need for medical intervention let alone cervical cancer screening.
In Guyana, language poses problems, especially among indigenous women. I have observed that these women mainly communicate in their native dialect and that some have never attended formal school; therefore, relating to health care professionals is difficult and oftentimes serves as a barrier to obtaining cervical cancer screening and other preventative health care. Many of these women turn to herbal remedies in an effort to take care of their own health needs. It is within the above stated context that cultural practices and cultural differences need to be considered when educational strategies are implemented and health care services are offered by health care personnel.
Apart from language and cultural barriers, psychosocial factors also affect women’s receptiveness to preventative procedures. According to Lewis (2004), fear, among other factors such as “awareness, values, and attitudes,” also poses barriers (p. 14). Lewis further mentions that the perception of cervical cancer as being linked with death creates reluctance in women accessing screening. Some women also fear “a lack of information about possible treatments” (p. 14).
Of added significance is the role that gender plays in deterring women from obtaining cervical cancer screening. Mentore (2007) provides an explanation of how gender affects participation in cervical cancer screening when he states:
Consider … an Amerindian woman [from Guyana] whose body knows only the passionate looks and tender caresses of her lovers and husband and nothing of the clinical gaze and objective handling of medical practitioners. Now imagine, as part of a government campaign to eradicate cervical cancer among her high risk group, this same woman being asked by a total stranger to spread her legs for an intrusive pap smear. (p. 63)
Most Amerindian women have never had any gynecological examinations outside of giving birth, which is usually done at home with only their relatives present, or on rare occasions, at the hospital where they would be attended by female nurses who understand the culture. Their cultural way of life is best described in the words of Mentore (2007), when he says that “different and workable principles of social being governed their [Amerindian] lives” (p. 63). Lewis (2004) also speaks to the issue of gender as a barrier to cervical cancer screening when she mentions that “women were hesitant to access screening because they were conscious of the fact that ‘male health care providers’ were performing health checks” (p. 14).
What Governmental Barriers do Women in Less Developed Countries Face in Obtaining Cervical Cancer Screening?
In terms of adequateness of resources and accessibility to Pap smears, many underdeveloped countries cannot afford to manage the growing burden of health care needs and simply do not have the resources in their health systems to offer continuous, free Pap screening to women. A case in point is Guyana. The Guyana Cancer Society continues its efforts in the fight against cervical cancer through its educational programs, cancer survivor’s group sessions, and Pap smear testing, among other cancer services. But as I saw while working as a nurse in Guyana, this organization is financially limited. Only with the help of volunteers, non-governmental organizations (NGOs), and governmental assistance, can services be offered at a low cost. As a way of encouraging women, Pap testing is offered free of charge for one week during November, which is designated Cancer Awareness month.
The national health care system offers a free Pap smear service, but this service can only be accessed at the main public hospitals, which are few, and are situated mainly in the urban areas. Furthermore, a woman cannot access a Pap smear upon her own request. A Pap smear is done at the discretion of a specialist who may see the need and request such a test, at which point cervical cancer may only be remedied. Women located in rural communities are at a greater disadvantage since the commute makes it difficult for many to access public hospitals. This situation is alarming and not only warrants governmental intervention, but also requires a multimodal approach with community, international organizations, NGOs (including religious and women’s organizations), and women themselves becoming proactively involved in seeking ways to provide Pap smears on a nationwide basis.
Social networking between developed and developing countries should be initiated through personnel training, advice sharing, and donating of equipment and resources to aid in the reduction of cervical cancer in poor countries. Additionally, education must accompany any effort; this need exists especially in the hinterland communities where a large number of young women have been known to be involved in prostitution in the gold mining areas. This act may contribute to a higher number of cervical cancer among these women. As pointed out by the New York City Department of Health and Mental Hygiene (2006), having sex with multiple partners is a risk factor for cervical cancer (p. 7).
Despite the occurrences of false-positive lab reports in cervical cancer screening, and the airing of uncertainty about the Gardasil vaccine, greater access to routine Pap smears and HPV vaccination is undeniably important to early detection and prevention of cervical cancer.
For women in the Caribbean and other less developed countries, cervical cancer screening programs remain the key medical intervention. The Gardasil vaccine will no doubt take years to reach those shores and more years to be effective. However, even with the availability of these services, it is important to note that access to medical care is only partially responsible for what is generally considered good health. Behavior and life style changes, as well as improvements in socioeconomic factors, along with basic public health education are all critical to every aspect of cervical cancer decline, from the prevention of the HPV transmission, to screening, treatment, and rehabilitation. Efforts to address cervical cancer should therefore take a concerted approach not only in policy formulation and program implementation, but also at the personal level where personal responsibility in terms of practicing healthful behaviors is the duty of the individual.
Exploring the relationship between women’s health status and socioeconomic/psychosocial factors strengthens the point that poverty is related to inaccessibility and underutilization of cervical cancer screening among women. After examining cervical cancer from a health and social perspective, my research establishes that the disease is also a problem of increasing magnitude among women of low socioeconomic standing, especially in developing societies. These women experiencing systemic, economic, cultural, and psychosocial barriers are oftentimes the ones who seek medical assistance for cervical cancer at a time when the disease is far beyond cure. In addition to the overriding economic conditions, I opine that social barriers do influence women’s attitude towards preventative health care. As such, heightened attention must be paid to these factors that are invariably tied to the disease, and that pose barriers to cervical cancer screening. I believe that women’s poor response to cervical cancer screening is also augmented by psychological barriers that are related to culture and belief systems, insufficient knowledge about the disease, and impoverishment. To fail to take into account these factors is to fail to see the cervical cancer problem in all its complexity.
Because cervical cancer is a preventable and curable disease, the high incidence and mortality rate still being experienced in less developed countries not only can be, but must be reduced through immediate interventions at all levels. Further, studies have shown that the economic benefits of preventative care far outweigh the costs incurred for cervical cancer treatment. According to Helms and Melnikow (1999), “detailed resource-based estimation suggests that prevention costs are generally lower than those previously published in the literature, whereas, the costs of cervical cancer treatment are generally higher” (p. 652). This being the case, there must be greater technical, financial, and infrastructural assistance for poorer countries to deliver much needed preventative cervical cancer screening to women. I suggest that international organizations, with national and community involvement, undertake to ensure that adequate and affordable screening programs are available and are utilized. Further, well trained personnel and adequately equipped facilities need to be in place, and educational programs about the disease need to be made available to empower women so that they can make informed decisions about their health care.
The poor health of women is tied in with the systemic poverty experienced in less developed countries. The poverty situation also impacts the availability of free health care services, educational programs, and the economic wellbeing of the family. Many women assume single parenthood with added financial and family responsibility, which renders them financially powerless and vulnerable to behaviors that put them at greater risk for contracting HPV and hence cervical cancer. To this end, I believe that social spending should be concentrated towards essential services such as health care education, and health care programs. Various forms of education for women, especially for young girls, should begin at the school level and involve school-based sex education programs. Other methods of education could take a community-based approach and involve community groups, clubs, organizations and religious bodies to disseminate education through printed materials, art, talks, video, etc. Lewis (2004) looks at education on a wider front and suggests the use of mass media, the private sector as well as women’s organizations and other groups. She further states that “a systematic, linguistically appropriate and consistent approach is required, using technically accurate and culturally sensitive information, tailored for the specific audience and environment” (p. 25).
The high cervical cancer rates in less developed countries can be reduced when women gain mastery of their lives through economic empowerment, access to health education, and free Pap smears upon individual request.
American Cancer Society (2008). What are the key statistics about cervical cancer? Retrieved November 13, 2008, from http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_cervical_cancer_8.asp
Becker, G., & Newsom, E. (2003). Socioeconomic status and dissatisfaction with health care among chronically ill African Americans. American Journal of Public Health, 93(5), 742-748. Retrieved November 5, 2008, from www.ajph.org/cgi/reprint/93/5/742
Cancer Treatment Centers of America. (n.d.). What are the risk factors for cervical cancer? Retrieved November 11, 2008, from http://www.cancercenter.com/landing-pages/cervical-cancer/default.cfm?source=googphi
Centers for Disease Control (1997). Regulatory closure of cervical cancer cytology laboratories: Recommendations for a public health response. Morbidity and Mortality Weekly Report, 46(17). Retrieved November 13, 2008, from http://www.cdc.gov/mmwr/preview/mmwrhtml/00050479.htm
Cervical cancer (2003). Merck manual of medical information (2nd home ed.). Retrieved November 20, 2008, from http://www.merck.com/mmhe/print/sec22/ch252/ch252d.html
Day, N.E (1984). Effect of cervical cancer screening in Scandinavia. Obstetrics & Gynecology,63, 714-718. Retrieved November 19, 2008, from http://www.greenjournal.org/cgi/content/abstract/63/5/714
Goldman, M., & Hatch, M. (Eds.). (2000). Women and health. San Diego: Academic Press.
New York City. Department of Health and Mental Hygiene. (2006). Pap tests save lives: Get checked for cervical cancer. Health Bulletin 41.
Helms, L., & Melnikow, J. (1999). Determining costs of health care services for cost-effectiveness analysis: The case of cervical cancer prevention and treatment. Medical Care, 37(7) 652-661. Retrieved December 16, 2008, from http://www.lww-medicalcare.com/pt/re/medcare/abstract.00005650-199907000-00005.htm
Lewis, M. (2004). A situational analysis of cervical cancer in Latin America and the Caribbean. Retrieved November 13, 2008, from http://www.paho.org/English/ad/dpc/nc/pcc-cc-sit-lac.htm
Lingam, L. (2007, October 29-November 2). Gender and health: Emergent issues beyond equitable access. Conference paper presented at Forum 11. Beijing, People’s Republic of China. Retrieved November 13, 2008, from http://www.globalforum.org/filesupLd/forum11/f11cdpub/papers/Lingam%20L%20- %20rf.pdf
Mentore, G. (2007). Guyanese amerindian epistemology: The gift from a pacifist. Insurgence. Race & Class, 49(2),57-70. Retrieved November 25, 2008, from http://rac.sagepub.com
National Cancer Institute (2008, November 20). What you need to know about cancer of the cervix. Retrieved November 25, 2008, from http://www.cancer.gov/cancertopics/wyntk/cervix/page5
Cervical cancer kills almost a quarter- million women worldwide each year. (2004, December 20). Retrieved December 15, 2008, from http://www.news-medical.net/?id=6937
Parkin, D., Bray, F., Ferlay, J., & Pisani, P. (2005). Global cancer statistics, 2002. CA: A Cancer Journal for Clinicians 55, 74-108. Retrieved November 25, 2008, from http://caonline.amcancersoc.org/cgi/reprint/55/2/74
Roses, M. (2004). Prevention and control of cervical cancer. Retrieved November 25, 2008, from http://www.guy.paho.org/press.html
Smeltzer, S., & Bare, B. (2004). Brunner and Suddarth’s textbook of medical surgical nursing (10th ed.). Philadelphia: Lippincott.
Smith, R. T. (1996). Family, household, & gender: Some quotes. Retrieved November 13, 2008, from http://instruct.uwo.ca/anthro/211/family.htm
Thackery, E. (Ed.). (2002) Gale encyclopedia of cancer: A guide to cancer and its treatments. (Vol. 1) Detroit: Gale Group.
Weeg, C. (2008, July 25). A lifesaving tool against cervical cancer remains underused. The NewYork Times. Retrieved on November 11, 2008, from http://health.nytimes.com/ref/health/healthguide/esn=cervicalcancer-ess.html
World Health Organization (2007). Implementation of resolutions: Progress reports. Retrieved November 13, 2008, from http://www.who.int/phi/B120_35_Add1-en.pdf