IJG-08654; No of Pages 4

International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx

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International Journal of Gynecology and Obstetrics

journal homepage: www.elsevier.com/locate/ijgo

CLINICAL ARTICLE

Awareness and prevalence of cervical cancer screening among women

in Nepal
Anju Ranjit a,⁎, Shailvi Gupta b,c, Ritesh Shrestha d, Adam L. Kushner b,e,f,
Benedict C. Nwomeh b,g, Reinou S. Groen b,h
a
Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard School of Public Health, Boston, MA, USA
b
Surgeons OverSeas, New York, NY, USA
c
Department of Surgery, University of California, San Francisco, East Bay, CA, USA
d
Department of Surgery, Nepal Medical College Teaching Hospital, Kathmandu, Nepal
e
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
f
Department of Surgery, Columbia University, New York, NY, USA
g
Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA
h
Department of Gynecology and Obstetrics, Johns Hopkins Hospital, Baltimore, MD, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To estimate awareness and prevalence of cervical smear testing among women in Nepal. Methods: A
Received 13 July 2015 secondary analysis of data obtained as part of a nationwide household survey between May 25 and June 14,
Received in revised form 31 October 2015 2015, was undertaken. Information obtained from women aged 21–65 years was included. Multiple regression
Accepted 10 March 2016 analyses were performed to identify factors associated with having undergone cervical smear testing. Results: A
total of 829 women were included. Among 816 women who answered the relevant survey question, 710 (87.0%)
Keywords:
had no knowledge of cervical smear tests. Only 39 (4.7%) of the 829 women had ever undergone a cervical smear.
Cervical cancer
Cervical smear
In multivariate analysis, having undergone a cervical smear was associated with literacy (adjusted odds ratio
Nepal [aOR] 3.26, 95% confidence interval [CI] 1.25–8.51; P = 0.016) and living in rural areas (aOR 0.48, 95% CI
0.24–0.96; P = 0.038). Conclusion: Nepali women rarely undergo cervical smear screening, with the lowest
prevalence recorded among the illiterate and those living in rural areas. To boost screening rates, educational
campaigns and rural outreach are needed.
© 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction cervical cancer screening is limited; it is estimated that 95% have

never been screened [5].
Worldwide, more than 270 000 women die from cervical cancer an- In Nepal, cervical cancer is thought to be the leading cause of cancer-
nually, with the disease being the second most common cancer in related deaths among women aged 15–44 years, with 9.65 million
women [1]. In 2008, 86% of new cases and 88% of deaths from cervical women at risk [6]. Estimates suggest that, in 2008, there were 10,000
cancer occurred in low- and middle-income countries [2]. A routine cer- new cases of invasive cervical cancer and 26 000–45 000 women who
vical smear test—a well-known and widely implemented screening had a precancerous lesion in Nepal [7]. Nepali national cervical cancer
technique to identify women with precancerous cervical lesions—has screening guidelines recommend that all women aged 30–65 years be
been shown to be beneficial in many high-income countries, and has screened for cervical cancer [8], but because of poor awareness, scarce
significantly reduced the incidence, morbidity, and mortality of cervical screening resources, inadequate access to health care, and difficult geo-
cancer [3]. In the USA, current guidelines [4] recommend that all graphic terrain [9,10], most women never undergo screening, and most
women aged 21–29 years undergo cervical cancer screening every often present for care at a very late stage of the disease. This lack of
3 years and women aged 30–65 years should undergo a cervical test screening meant that only 2332 Nepali women were diagnosed with
every 5 years coupled with HPV testing, provided that all results are cervical cancer in 2013 [7].
normal. Nevertheless, for women in low-income countries, access to Despite the great need, few programs in Nepal raise awareness of
the necessity of cervical cancer screening or provide cervical smear
tests or HPV vaccinations [8]. To adequately assist program managers
and policymakers in the design and implementation of programs and
⁎ Corresponding author at: Center for Surgery and Public Health, Brigham and Women's
Hospital, One Brigham Circle, 1620 Tremont Street, 4-020, Boston, MA 02120, USA.
in the provision of resources to increase cervical cancer screening,
Tel.: +1 201 210 1214; +1 617 525 9281. an understanding of the baseline requirements is essential. However,
E-mail address: aranjit@bwh.harvard.edu (A. Ranjit). population-based data on cervical cancer screening rates in the Nepali

http://dx.doi.org/10.1016/j.ijgo.2015.11.019
0020-7292/© 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Please cite this article as: Ranjit A, et al, Awareness and prevalence of cervical cancer screening among women in Nepal, Int J Gynecol Obstet
(2016), http://dx.doi.org/10.1016/j.ijgo.2015.11.019
2 A. Ranjit et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx

context or on cervical cancer awareness and attitudes to screening Table 1 shows the demographic characteristics of the included
among Nepali women remain limited. Thus, the aim of the present women. The mean age was 38.12 ± 12.20 years, with most women
study was to estimate the awareness and prevalence of cervical smear aged 21–49 years. Almost half the women had never received any for-
testing among Nepali women eligible for cervical cancer screening. mal education, although almost 60% were literate. More than half had
no employment, most were married, and two-thirds were from rural
2. Materials and methods areas of Nepal.
Among 816 women for whom relevant information was available,
A secondary analysis of data obtained through a previous survey- 710 (87.0%) reported no awareness of cervical smear tests. Among the
based study was undertaken. Full methods of the previous study have 106 women who had some knowledge of these tests, 67 (63.2%) had
been reported previously [11]. Briefly, between May 25 and June 12, never undergone a cervical smear test. Indeed, only 39 (4.7%) women
2014, 1397 randomly selected households from 15 randomly selected included in the survey had ever undergone a cervical test. There were
districts in Nepal were visited. In each district, three clusters—two significant differences between women who had and had not under-
urban and one rural—were randomly chosen in proportion to the popu- gone a cervical smear test in literacy, employment, and area of residence
lation for a total of 45 clusters [12]. In each cluster, trained interviewers (P b 0.05 for all) (Table 2).
chose an agreed central geographic location and sampled every fifth In univariate analysis, literacy, employment, and rural area of resi-
household, sampling a total of 30 households per cluster. For each dence were associated with ever having had a cervical smear test
household visited, two members were chosen using a randomization (P ≤ 0.011 for all) (Table 3). In multiple logistic regression analysis,
calculator and interviewed. Only individuals with an intellectual dis- with adjustment for other variables, literacy and rural area of residence
ability were excluded. For the present analysis, only data for women
aged 21–65 years—i.e. those eligible for cervical smear testing—were in-
cluded. Ethical approval for the study was obtained from the Institu- Table 1
tional Review Board of Nationwide Children's Hospital, Columbus, OH, Demographic characteristics.
USA, and the Nepal Health Research Council, Kathmandu, Nepal. Characteristics Value a
The Surgeons OverSeas Assessment of Surgical Need (SOSAS)
Age, y (n = 829)
survey—which was developed by an international group of experts
21–49 648 (78.2)
and used in Sierra Leone and Rwanda to determine the prevalence of 50–65 181 (21.8)
conditions needing surgical care and the percentage of deaths possibly Education (n = 828)
averted through adequate access to such care [13]—was used. The None 365 (44.1)
SOSAS survey is composed of a head-of-household interview to deter- Primary school 148 (17.9)
Secondary school 188 (22.7)
mine household demographics and a head-to-toe verbal examination Tertiary level 111 (13.4)
of two, randomly chosen household members. Previous studies have Graduate degree 16 (1.9)
documented the method in detail [11,13–15]. Literacy (n = 828)
The tool was slightly modified for the Nepali context to include a vi- Illiterate 332 (40.1)
Literate 496 (59.9)
sual examination and additional questions on women's health needs
Occupation (n = 828)
[13,16]. To assess knowledge of cervical cancer, female participants Unemployed 92 (11.1)
were asked if they were aware of what a cervical smear test was and Homemaker 479 (57.9)
if they had ever had one. To assess for gynecologic comorbidities, fe- Domestic helpers 16 (1.9)
males were questioned about leucorrhea, urinary incontinence, and Farmers 76 (9.2)
Self-employed 124 (15.0)
symptoms of uterine prolapse. Government employee 21 (2.5)
The required sample size was estimated to be 753 women aged Non-government employee 20 (2.4)
21–65 years to detect a previously documented prevalence of 2% uptake Employment (n = 828)
of cervical smear tests for cervical cancer screening [7], with a 95% con- No 571 (69.0)
Yes 257 (31.0)
fidence interval and absolute precision of 1%.
Good general health (n = 829)
Univariate analysis (logistic regression) and χ2 tests were performed Yes 715 (86.2)
using Stata version 13.2 (StataCorp, College Station, TX, USA) to test the No 114 (13.8)
association between the dependent variable (history of cervical test) Village type (n = 829)
and independent variables such as age, area of residence (urban/rural), Urban 286 (34.5)
Rural 543 (65.5)
occupation, literacy, and travel time to or costs for treatment at primary, Marital status (n = 816)
secondary, and/or tertiary health centers. Women with any comorbid Married 704 (86.3)
condition such as prolapse, incontinence, or leucorrhea were catego- Unmarried 66 (8.1)
rized into a comorbid condition group and this category was used in a Divorced 4 (0.5)
Widow 42 (5.1)
multiple regression model. The Student t test was performed to assess
Knowledge of cervical smear (n = 816)
the associations between age, travel time to health center, cost of travel, No 710 (87.0)
and the dependent variable. A logistic regression analysis adjusted Yes 106 (13.0)
for variables, accounting for clustering, was performed along with for- Travel time to health facility, min
ward and backward selection of the variables. Co-linearity between Primary health center 46.46 ± 304.44
Secondary health center 173.75 ± 434.75
the variables was examined using variance inflation factors. P b 0.05
Tertiary health center 340.34 ± 1151.77
was considered significant for all statistical tests. Cost of travel to health facility, NPR b
Primary health center 27.44 ± 134.25
3. Results Secondary health center 623.01 ± 3025.81
Tertiary health center 1895.68 ± 6197.28
Other comorbid conditions
The response rate among the 1397 households randomized for the Symptoms of prolapse (n = 814) 42 (5.2)
survey was 96.6%, with 1350 households participating. Among 2695 White discharge (n = 791) 53 (6.7)
individuals interviewed, 1261 (46.8%) were female. Of the female inter- Incontinence (n = 789) 46 (5.8)
viewees, 829 (65.7%) were aged 21–65 years and were eligible for inclu- a
Values are given as number (percentage) or mean ± SD.
sion in the present analysis. b
1 Nepalese rupee = US$0.01.

Please cite this article as: Ranjit A, et al, Awareness and prevalence of cervical cancer screening among women in Nepal, Int J Gynecol Obstet
(2016), http://dx.doi.org/10.1016/j.ijgo.2015.11.019
 A. Ranjit et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx 3

Table 2 Table 3
Characteristics of participants according to cervical smear test status.a Univariate and multiple analyses of variables associated with having undergone a cervical
smear test.
Characteristics Never undergone Undergone P value
cervical smear cervical smear Variable Univariate analysis Multiple logistic
test (n = 790) test (n = 39) regression analysis

Age, y Unadjusted OR P value Adjusted OR P value

21–49 614/790 (77.7) 34/39 (87.2) 0.163 (95% CI) (95% CI)
50–65 176/790 (22.3) 5/39 (12.8) 0.510
Age, y
Education 0.059
21–49 1 – 1 –
None 356/789 (45.1) 9/39 (23.1)
50–65 0.51 (0.19–1.33) 0.17 0.86 (0.30–2.49) 0.79
Primary school 141/789 (17.9) 7/39 (17.9)
Literacy
Secondary school 175/789 (22.2) 13/39 (33.3)
Illiterate 1 – 1 –
Tertiary level 102/789 (12.9) 9/39 (23.1)
Literate 3.87 (1.60–9.34) 0.003 3.26 (1.25–8.51) 0.016
Graduate degree 15/789 (1.9) 1/39 (2.6)
Employment
Literacy 0.001
No 1 – 1 –
Illiterate 326/789 (41.3) 6/39 (15.4)
Yes 2.19 (1.15–4.19) 0.017 2.4 (0.90–5.10) 0.083
Literate 463/789 (58.7) 33/39 (84.6)
Good general health
Occupation 0.018
Yes 1 – 1 –
Unemployed 90/789 (11.4) 2/39 (5.1)
No 1.39 (0.60–3.24) 0.438 1.47 (0.60–3.57) 0.392
Homemaker 461/789 (58.4) 18/39 (46.2)
Village type
Domestic helpers 16/789 (2.0) 0/39
Urban 1 – 1 –
Farmers 73/789 (9.3) 3/39 (7.7)
Rural 0.43 (0.22–0.82) 0.011 0.48 (0.24–0.96) 0.038
Self-employed 114/789 (14.4) 10/39 (25.6)
Marital status
Government employee 18/789 (2.3) 3/39 (7.7)
Married 1 – 1 –
Non-government employee 17/789 (2.2) 3/39 (7.7)
Unmarried 0.56 (0.13–2.39) 0.437 0.40 (0.09–1.78) 0.233
Employment 0.014
Other comorbid conditions 2.05 (0.94–4.45) 0.06 2.15 (0.00–1.14) 0.062
No 551/789 (69.8) 20/39 (51.3)
Yes 238/789 (30.2) 19/39 (48.7)
Good general health 0.436
Yes 683/790 (86.5) 32/39 (82.1)
No 107/790 (13.5) 7/39 (17.9)
Area of residence 0.009
has established that there is a disparity between rural and urban
Urban 265/790 (33.5) 21/39 (53.8) areas: women in rural areas seem to have less access to and knowledge
Rural 525/790 (66.5) 18/39 (46.2) regarding cervical cancer screening.
Marital status 0.376 Previous studies [17,18] have shown that healthcare costs, a lack of
Married 667/777 (85.8) 37/39 (94.9)
awareness of cervical cancer and screening procedures, and individual
Unmarried 64/777 (8.2) 2/39 (5.1)
Divorced 4/777 (0.5) 0/39 and cultural barriers are the major obstacles to the uptake of cervical
Widow 42/777 (5.4) 0/39 smear testing in low-income countries. In the Nepali context, illiteracy,
Knowledge of cervical smear 0.410 inadequate access to health care, and a trend toward accessing health
No 710/777 (91.4) 0/39
care for curative rather than preventive purposes could explain the
Yes 67/777 (8.6) 39/39 (100.00)
Travel time to health facility, min
low uptake of cervical smear testing [8,19]. Other studies [20,21] have
Primary health center 48.13 ± 311.79 12.79 ± 10.88 0.479 also shown that support from husbands, engaging men in cervical can-
Secondary health center 180.05 ± 444.01 46.71 ± 89.03 0.060 cer awareness programs, and screening facilities in close proximity to
Tertiary health center 352.00 ± 1177.77 98.06 ± 103.45 0.185 women's residences increases the uptake of cervical smear screening.
Cost of travel to health facility,
Laboratory services and pathologists trained to evaluate cervical
NPR b
Primary health center 27.60 ± 136.29 24.17 ± 84.17 0.876 smears are practically nonexistent in rural parts of Nepal, and women
Secondary health center 648.17 ± 3097.68 118.53 ± 276.30 0.286 in these areas must travel to secondary or tertiary centers to receive ap-
Tertiary health center 1948.91 ± 6301.86 802.97 ± 3261.65 0.265 propriate testing, which severely limits uptake. Even in urban settings—
Other comorbid conditions
where laboratory facilities and trained pathologists are available—
Symptoms of prolapse 38/775 (4.9) 4/39 (10.3) 0.140
White discharge 50/753 (6.6) 3/39 (7.7) 0.763
increased case burden and the associated costs limit cervical smear
Incontinence 40/752 (5.3) 6/39 (15.4) 0.006 screening of eligible women. Because geographic, cultural, and econom-
a ic barriers to appropriate health care limit the uptake of the recom-
Values are given as number/total number (percentage) or mean ± SD, unless indi-
cated otherwise. mended cervical smear screening routine in Nepal, alternative cervical
b
1 Nepalese rupee = US$0.01. cancer screening and service delivery methods should be considered
in these settings. Indeed, visual inspection of the cervix with acetic
acid or Lugol iodine can be adopted as a cost-effective alternative to
remained significantly associated with having had a cervical test cervical smear testing in low-resource settings [22]. Furthermore, a
(P = 0.016 and P = 0.038, respectively) (Table 3). one-time screening for cervical cancer at the age of 35 years has been
shown to significantly lower the lifetime risk of cervical cancer [23].
4. Discussion Offering cervical smears at prenatal care visits or with periodic mobile
services might also increase the uptake of the cervical smear, especially
The results of the present analysis show that only approximately 5% in rural settings where access to pathology laboratories is limited. Addi-
of Nepali women aged 21–65 years have ever had a cervical test. The tionally, screening for HPV with a self-administered swab could be
Nepali national cervical cancer screening guidelines [8] indicate that implemented in addition to cervical smear testing for cervical cancer
all women aged 30–65 years should have a cervical test; only 31 prevention [24]. Liquid-based preparation for evaluation of cervical cy-
(5.4%) of the 579 women in the present analysis eligible for testing ac- tology and HPV DNA detection could also be implemented in healthcare
cording to the guidelines were screened. These values are higher than centers where resources are available. Furthermore, primary preven-
previous estimates indicating that only 2% of Nepali women have ever tion via HPV vaccination should assist in decreasing the burden of
undergone a cervical smear test [8]. Therefore, the present findings cervical cancer [25]. Nevertheless, considering both the sociocultural
might reflect an improvement in the awareness of, and possibly im- and economic barriers against the implementation of vaccines, this
proved access to, cervical smear testing. However, the present study needs to be executed through awareness and information campaigns.

Please cite this article as: Ranjit A, et al, Awareness and prevalence of cervical cancer screening among women in Nepal, Int J Gynecol Obstet
(2016), http://dx.doi.org/10.1016/j.ijgo.2015.11.019
4 A. Ranjit et al. / International Journal of Gynecology and Obstetrics xxx (2016) xxx–xxx

A resource-poor country like Nepal could benefit from adopting the [7] Johns Hopkins Program for International Education in Gynecology and Obstetrics.
Cervical Cancer Prevention Program (CECAP) Situational Analysis of Awareness,
above strategies to decrease the burden of cervical cancer deaths. Services, Referral and Policies in Nepal. Baltimore, MD: Jhpiego; 2008.
The sampling technique used in the present study represents a [8] Ministry of Health and Population. National guideline for cervical cancer screening
limitation; although the study sample was a random selection with and prevention in Nepal. http://whonepal.healthrepository.org/bitstream/
123456789/498/1/National%20Guideline%20for%20CCSP.pdf. Published 2010.
stratification according to the rural/urban composition of the Nepali Accessed May 3, 2015.
population, undersampling or oversampling of certain demographic [9] Joy T, Sathian B, Bhattarai C, Chacko J. Awareness of cervix cancer risk factors in
areas cannot be excluded. Additionally, the survey was limited in the educated youth: a cross-sectional, questionnaire based survey in India, Nepal, and
Sri Lanka. Asian Pac J Cancer Prev 2011;12(7):1707–12.
number of questions related to cervical cancer and did not assess the [10] Pradhan N, Giri K, Rana A. Cervical cytological study in unhealthy and healthy
number of sexual partners, age at first intercourse, or the number of cer- looking cervix. Nepal J Obstet Gynaecol 2007;2(2):42–7.
vical smears performed. Further studies should assess these variables, as [11] Gupta S, Shrestha S, Ranjit A, Nagarajan N, Groen RS, Kushner AL, et al. Conditions,
preventable deaths, procedures and validation of a countrywide survey of surgical
well as women's perception of cervical smears, gynecologic examina-
care in Nepal. Br J Surg 2015;102(6):700–7.
tions, and the acceptability of HPV self-sampling. [12] Bennett S, Woods T, Liyanage WM, Smith DL. A simplified general method for
The findings of the present study indicate that only 5% of Nepali cluster-sample surveys of health in developing countries. World Health Stat Q
women aged 21–65 years have ever had a cervical smear test. Because 1991;44(3):98–106.
[13] Groen RS, Samai M, Stewart KA, Cassidy LD, Kamara TB, Yambasu SE, et al. Untreated
literate women are more likely to undergo screening, educational cam- surgical conditions in Sierra Leone: a cluster randomized, cross-sectional, country-
paigns would be beneficial. Furthermore, outreach programs for rural wide survey. Lancet 2012;380(9847):1082–7.
areas are warranted. [14] Groen RS, Samai M, Petroze RT, Kamara TB, Yambasu SE, Calland JF, et al. Pilot testing
of a population-based surgical survey tool in Sierra Leone. World J Surg 2012;36(4):
771–4.
Acknowledgments [15] Groen RS, Solomon J, Samai M, Kamara TB, Cassidy LD, Blok L, et al. Female health
and family planning in Sierra Leone. Obstet Gynecol 2013;122(3):525–31.
[16] Gupta S, Ranjit A, Shrestha R, Wong EG, Robinson WC, Shrestha S, et al. Surgical
Funding for logistics and transportation was provided by the 2014 needs of Nepal: pilot study of population based survey in Pokhara, Nepal. World J
Global Surgery Research Fellowship Award granted by the Association Surg 2014;38(12):3041–6.
for Academic Surgery and Surgeons Overseas. [17] Lyimo FS, Beran TN. Demographic, knowledge, attitudinal, and accessibility fac-
tors associated with uptake of cervical cancer screening among women in a
rural district of Tanzania: three public policy implications. BMC Public Health 2012;
Conflict of interest 12:22.
[18] Perng P, Perng W, Ngoma T, Kahesa C, Mwaiselage J, Merajver SD, et al. Promoters of
and barriers to cervical cancer screening in a rural setting in Tanzania. Int J Gynecol
The authors have no conflicts of interest. Obstet 2013;123(3):221–5.
[19] Bhatla N, Gulati A, Mathur SR, Rani S, Anand K, Muwonge R, et al. Evaluation of
References cervical screening in rural North India. Int J Gynecol Obstet 2009;105(2):145–9.
[20] Gan DE, Dahlui M. Cervical screening uptake and its predictors among rural women
[1] World Health Organization. WHO Guidance Note: Comprehensive cervical cancer in Malaysia. Singapore Med J 2013;54(3):163–8.
prevention and control: a healthier future for girls and women. http://apps.who. [21] Garrett JJ, Barrington C. ‘We do the impossible’: women overcoming barriers to
int/iris/bitstream/10665/78128/3/9789241505147_eng.pdf?ua=1. Published 2013. cervical cancer screening in rural Honduras–a positive deviance analysis. Cult Health
Accessed May 3, 2015. Sex 2013;15(6):637–51.
[2] Arbyn M, Castellsague X, de Sanjose S, Bruni L, Saraiya M, Bray F, et al. Worldwide [22] Nessa A, Nahar KN, Begum SA, Anwary SA, Hossain F, Nahar K. Comparison between
burden of cervical cancer in 2008. Ann Oncol 2011;22(12):2675–86. visual inspection of cervix and cytology based screening procedures in Bangladesh.
[3] Bastos J, Peleteiro B, Gouveia J, Coleman MP, Lunet N. The state of the art of cancer Asian Pac J Cancer Prev 2013;14(12):7607–11.
control in 30 European countries in 2008. Int J Cancer 2010;126(11):2700–15. [23] Goldie SJ, Gaffikin L, Goldhaber-Fiebert JD, Gordillo-Tobar A, Levin C, Mahé C, et al.
[4] Committee on Practice Bulletins—Gynecology. Practice Bulletin No. 157: Cervical Cost-effectiveness of cervical-cancer screening in five developing countries. N Engl
Cancer Screening and Prevention. Obstet Gynecol 2016;127(1):e1-20. J Med 2005;353(20):2158–68.
[5] World Health Organization Department of Reproductive Health and Research and [24] Wigle J, Coast E, Watson-Jones D. Human papillomavirus (HPV) vaccine implemen-
Department of Chronic Diseases and Health Promotion. Comprehensive cervical can- tation in low and middle-income countries (LMICs): health system experiences and
cer control: A guide to essential practice. Geneva: World Health Organization; 2006. prospects. Vaccine 2013;31(37):3811–7.
[6] ICO Information Centre on HPV and Cancer. Nepal. Human Papillomavirus and Related [25] Jit M, Brisson M, Portnoy A, Hutubessy R. Cost-effectiveness of female human papil-
Cancers, Fact Sheet 2015. http://www.hpvcentre.net/statistics/reports/NPL_FS.pdf. lomavirus vaccination in 179 countries: a PRIME modelling study. Lancet Glob
Updated 2015. Accessed May 3, 2015. Health 2014;2(7):e406–14.

Please cite this article as: Ranjit A, et al, Awareness and prevalence of cervical cancer screening among women in Nepal, Int J Gynecol Obstet
(2016), http://dx.doi.org/10.1016/j.ijgo.2015.11.019