 Now, it's my pleasure to introduce Nancy Garigal. She's a midwife from Papua New Guinea who works in one of the provincial hospitals, Cundiyawa General. She has served as a clinical midwife for seven years before pursuing postgraduate studies in Australia this year. The average number of births per day at Cundiyawa is 6 to 10 newborns, which accounts for 30 to 50 babies per month on average. The ward capacity is limited with four delivery beds, 18 antenatal beds and 19 gynecology beds. The workload is very high for shift. Apart from Nancy's clinical work, she volunteers in the rural communities by providing basic health education such as hygiene, nutrition, family planning, cervical cancer education, antenatal care, and men's involvement in maternal child healthcare, family health, and more. Nancy has a special interest in the topic of her presentation because, apart from the pregnancy related complications faced by women in her country, cervical cancer is one of the most common causes of death in Papua New Guinea. There's no proper screening for cervical cancer and no pap smear services in most public hospitals and clinics. Many women are not aware of their cervical cancer status. It is further compounded by other related factors that prevent women from reaching the health facility early when they have early signs of cervical cancer. Therefore, Nancy was interested to know what the barriers were for individuals seeking medical health quickly. By discovering the possible factors, then how and what we as healthcare providers can address these issues to reduce the mortality rate. Nancy, I'm going to turn presentation over to you and you'll be able to move your slides. Thank you. Okay. You should be able to move your slides. Okay. I can start now. Yes, please. Hi, everyone. Thank you for tuning in around the world and thank you, Cecilia, for the introduction. My presentation this morning is about the risk factors and constraints to early detection of cervical cancer amongst Central Islands women, which is in Papua New Guinea. And this is a preliminary findings from an ongoing survey. The outline of my presentation entails a background followed by aim, the method used, and the results from the survey, a few discussions about the results, findings, and conclusion, and followed by a few recommendations and acknowledgement at the end. As we know, and maybe some of you may not know, Papua New Guinea is a small island country north of Papua New Guinea, and it's one of the developing countries with low income and poor resources, which trace states of health inequalities and increase bed and disease. And women in Papua New Guinea, most of them live in rural parts of the country. And there's a high rate of death of women, especially due to cervical cancer. A report in 2019 reveals that there was a high number of women diagnosed with cervical cancer that's around 1,024, of which 666 die per year. And also cervical cancer is also ranked the leading cause of female death ages from 15 to 24 in Papua New Guinea and maybe in other parts of the world, especially in developing countries. And the main virus that caused cervical cancer is human papillomavirus type 16, in which it's responsible for 70% of cervical cancer worldwide. Knowing that Papua New Guinea is one of the developing countries, most women are not accessible to good health services, and especially with cervical cancer, most women are able to do the necessary screening as early as possible, thus leading to symptoms, signs and symptoms being deteriorating, and most women present at the hospital with late stage of cancer. There are possible factors in timely presentation, early diagnosis and appropriate treatment for cervical cancer that the study seeks to find out. The aim of the study is to identify the common risk factors and constraints to early detection of cervical cancer, diagnosis and appropriate treatment. And from this study, the data and the results will be used to help in the preventative measures of addressing and combating cervical cancer. And also with the diagnosis process, appropriate therapeutic interventions at all levels of health facilities. The method of the survey is a cross sectional survey on 56 cervical cancer patients from 2017 to 2019. Using pre-prepared questionnaires, prospectively face-to-face interviews with cervical cancer patients with a consent. And retrospectively, patients information charts were retrieved from the medical records approved from the director medical service of the hospital. Ethical clearance were approved by the clinical research office of Kundiawa General Hospital, Simba Province in Papua, Nighini for the research in the hospital. From the 56 participants that were uh uh the the data that the results reveals that there were major major risk factors identified in these variables in their age. The parathy, previous history of sexual transmitted infections, polygamy, having been in a relationship where there has been as more than one sexual partners smoking, beetle not chewing, and also family history of cervical cancer. These were the major risk factors that that was identified in the survey. With the age the the bug graph shows the the age the bug shows the age distribution of cervical cancer patients by percentage. So between the age of 30 to 50 and towards 60 most patients were patient's age were between this range. Regarding the disability with the patients interviewed 29 percent of them were Nali Paras and 25 percent of them were at parathy the parathy five followed by 11 percent with parathy four and then nine percent were rather 11 percent with parathy two followed by parathy six. So there was apart from those who have a child who have had children there were the number of patients interviewed found to be those ones with have no children which will be further discussed in the discussion. Regarding the age when they have first child 33 percent of them have their first child at the age of 18 followed by 24 of them also reported that they have any children they were Nali Paras but there were 13 percent of them at the age of 19 and then nine percent were at the age of 17. Let's look at the previous history of STI. Almost modern half denied history of sexual trans previous history of sexual transmitted infections however 39 percent reported that they have history of sexual transmitted infections and also with polygamy was I number of high percentage reported with percentage of 82 percent that to have have been in a polygamous relationship and the smoking behavior more than half around 55 percent of them report to have been smoker or they have been smoking and 45 percent deny history of smoking. Now apart from the risk factors identified there were also other factors that also contribute to the delays that the mother when experienced or like the mothers were unable to read hospital as early as possible and these delay factors include their place of residence where they live the mode of transport that is commonly used to travel to reach the health and also the transportation costs and their previous cervical cancer screen history and also pepsmia, pepsmia screening whether the women had survived pepsmia screening done or not and the last delay factor is doctor's review some may have been seen by doctors but they didn't come back for doctor's review so this where the table shows the summary of the delay factors that that were experienced during the course of their disease condition. Now the delay factors is further graphed into this pie chart the common delay factor that that is seen is a lack of knowledge of which most women in Papua New Guinea and even in my province where I most of them live in rural parts of the province where the eye there is a high rate of illiteracy and their ability to access awareness and basic knowledge on the disease signs and symptoms and get help and what to do if they have any signs of symptoms most mothers found to lack that part of the knowledge about the disease pattern and also the other constraint effect that that is identified is financial constraint where most of the population live in rural parts of the country or province of which their income level is very low and if they have to come to the hospital then they have to pay a lot of money for the hospital fee and staff's financial constraint was another delay factor identified that and also the distance as I've said the geographical there's also also geographical strain and the distance they live is far and that also compounded here the delays of reaching the hospital on time for that for screening and diagnosis and treatment so it's more or less like the delay effect as a very the delay factor that each marriage varies with where they live their the economical income and their accessibility to know the information about cervical cancer and other related associated with it and also not only the distance financial constraint and lack of knowledge but also 18 percent of rather yeah 18 percent of them were reveals that due to distance but also lack of family support ignorance from them from the women and full fight when there is a fight between two tribes then there's road block and women cannot be able to travel to reach the hospital or the nearest health facility on time and most times diagnostic delay so a problem because of the lack of the necessary equipment and facilities available to have the right treatment and diagnostic tests and radiotherapy delay as well we only have one radiotherapy center in Papua, Nighini where that's also a delay for the payment for their cancer treatment so where they move on to the treatment modalities that were identified there were four treatment that were identified for matters with cervical cancer and that includes chemotherapy radiotherapy surgical intervention and other other alternative treatment as well as shown in the table looking at each of them respectively with the alternative treatment according to the results 50 46 percent of them were realized or said say that they have resort to other alternative treatment apart from the medical treatment offered and 54 percent of them denied having been resort to other alternative treatment and surgery only four percent of them found to have some form of surgery that may have been the stages of cancer that they experience if it was like cervical cancer stage 1 a b than it then there's possibility for surgical intervention however 96 percent of were found to have no surgical intervention because all of them presented the late stages of cervical cancer and with the radiotherapy as I've mentioned there's only one radiotherapy center in Papua all type of cancer patients access this service and with our matters with cervical cancer and geographical training the financial constraint and all these other factors really cause big struggle for them and most not many of them are able to access therapy so only five percent of them were able to access while 95 percent of them have not access radiotherapy treatment now as with our discussion the risk factors identified 85 percent of them were ages 33 to 60 at the age when they were interviewed and the the mean or the average age was around 43 evidence suggested all the black women status class present at late stage of cervical and breast cancer pregnant progression of cervical license is found to be aged around 34 and onwards and furthermore 50 percent of first child ages women very women's age at first child ages 17 to 19 and were at least parrotry at the time of interview early age at first sexual inter pregnancy or child birth also associated with the the vical cancer development owing to expose of cervical squamous column to junction in fact insult by HPV virus or human papilloma virus in teenage years in that it means that the development of malignant cervical listen may be due to degree of the degree of of squamous column junction of cervical epithelium during teenage years which has a susceptibility to infective human papilloma virus which subsequently affects the epithelium changes that undergo malignant transformation over time and with lead to cancer continue 82 percent in polygamous relationship and it is a common practice in male dominated provincial central islands or society in Papua Niqui where it significantly raises the chances for STI improvement although 61 percent of them denied previous history of cervical rather history of sexual transmitted infection including human papilloma virus the students indicate indicating that there's a association between oncogenic types of human papilloma and cervical cancer development which means that women who have polygamous relationship or their husband has been having more than one sexual partner they are highly at risk of contracting human papilloma virus with this possibility to further develop cancer and in the 1990s there was a survey in the central islands and nearby islands from Simbu where the survey is done in Goroka where 33 percent of women found to have HPV 16 and 18 amongst 113 women that were studied and type 16 18 31 and 33 was serotypes in cervical biopsies from 70 women in the region so the prevalence of HPV in relation to polygamous relationship is is a high risk factor for women who are exposed to history of and involving in polygamous relationship furthermore 24 percent of the parrots may conversely mean a lesser effect of parity on cervical cancer development that means that despite of the parity or regardless of the parity of cancer is predominant in any women as long as they are exposed to in papilloma virus through sexual intercourse and 55 percent of them were found to be and beetle natures and 56 and all of 56 women interviewed the history of cervical cancer of her or any other form of cancer so smoking and smoking is also a major contributing factor to cervical cancer or any other form of cancer because it reduces parity and also chewing of beetle nut beetle nut is a nut that is commonly grown in tropical and other is as well with along the tropics it is a nut that is chewed together with the I'm and another plant type called mustard so it changes the color to people find it more pleasurable to chew in most common lean polygony but in terms of when it comes to cancer or cervical cancer beetle nut is found to have mostly damages the DNA also can cause increased changes of cancer cells so women who would chew not also at risk of having cancer including cervix and the history of cervical cancer is also another factor of which 56 women interviewed denied any history of that now with the document as I've said most women found to have presented the hospital at late stage of cancer so found to have some surgical intervention whereas rather while therapy was not none of them had chemotherapy at the time of the interview and only five percent reported to have your therapy at the country's only radiotherapy as I've said we only have one chemotherapy in pulmonary kidney and since I think three or four years ago now the facility was not in operation because the machine was not working and while I'm speaking it's a set news for most patients and including cervical cancer mothers in pulmonary kidney who are dying away because there's no radiotherapy facility in the country at the moment furthermore 46 percent women interviewed they resort to other alternate forms of treatment including able and traditional medicine given availability of conventional treatment like radiotherapy or chemotherapy or even when surgical intervention is not possible they resort to other treatment modalities for their disease condition and most of them are found to be on palliative care only because most are presented at late stage of cervical cancer in conclusion as to sum up what I have just gone through 52 percent of women first child which was at early age at 17 to 19 and at least they were at the time of interview so early exposure to sex and as parity as as high risk of having cervical cancer followed by 82 percent of women interviewed were in polygamous relationship with their husbands having more than one partner which increases the chances of sexually transmitted infections including human papilloma virus which is responsible for cervical cancer however a polygamous relationship is very common and that can also implicate in the development of cervical cancer and 50 percent were found to be smokers and 24 percent were nulliparous at the time of interview common constraints or difficulties that were identified which have prevented the mothers from the health facility early include the lack of knowledge and understanding of cervical cancer financial constraint the distance they traveled not only that but also the delay in diagnosed and referral pathways at primary health facilities are also contributing to their delay in the hospital and most importantly their partner's involvement or the husband's support and involvement is also a factor identified and in in Papua Nighini we have tribal fights occasionally may be due to some election related or other factors tribal fights are also contributing factor to the delays and maybe the mothers also self-ignorance furthermore the lack of the ease of access to gynecologist review also impaired to earlier screening diagnosis and treatment as I'm speaking we have we we have no pepsumia screening facility in Papua Nighini at the moment especially in the public hospitals and sub hospitals the ones that are from the private hospitals with which are very costly for most mothers to pay and as the facility for screening so pepsumia screening is not available in the country at the moment we do have 2012 where there were some assistance from Marypath in Australia screening the smears but however in 2012 they stopped due to funding constraint and up till date pepsumia screening and that is a big factor that may may affect our mothers to know their cervical cancer status and finally unavailability of medical treatment modalities for cervical cancer women resort to alternate treatment like hairball medicine or other traditional medicine that which they find best for their disease condition there were some recommendations made from this in regard to the results identified this great need and health facility based education for on women's health awareness programs emphasizing the needs of fact recognition symptoms recognition and pepsumia screening and early presentation for gynecology review when when they are symptomatic is very important and also involved as much as possible in educational and awareness programs will to some extent help promote support for the women's for for the woman to access health facility daily stage and furthermore improving our well improve improve availability and accessibility of pepsumia screening facility and programs is of paramount importance at the moment as I've mentioned there's no smear screening and this is a great need and true true pepsumia screening it will help us to our mothers cervical cancer status and finally cancer treatment facilities by hospital provincial and national authorities is a struggle with only one radiotherapy center which is not in use at the moment so it is recommended it is a recommendation that this is this has to be in place in order to help our mothers and others or others who are also suffering from other forms of cancer in Papua Negini I would like to acknowledge the my study subjects the obstetric and gynecology team of said memory hospital kundia general hospital in Papua Negini and mr. James Francis and dr. Agua of research center centers of number hospital in kundia hospital for their support towards this survey thank you all for your listening and your attention towards my presentation that goes to the end of my presentation thank you all I'm going to keep the recording going while we ask Nancy some questions Nancy this is so interesting because the ability for women to receive screening and treatment in Papua Negini for cervical cancer is very different than North America or what I imagine it is in Europe Helen wanted to know more about alternate treatments can you tell us a little bit about those are they local herbs or are they other medications that women find and try thank you the other alternative treatments that women find some some they prefer like herbal herbal medication like more more herbal from plants while others have you some I think there's products that are sold to increase humidity and stuff like that there there's other medication or like I would say they've they call it like immune boosters or something there's like whiter plus an example like it's a some are sold in Papua Negini and other in Papua Negini where women who are able to buy they are there's good family support financially but otherwise most women take like some traditional medicine or herbal treatment to just ease their signs and symptoms so yep the alternative treatments revolve around this but it's on each individual patient whether they are able to afford to pay for those additional supplements supplement medication or if not if when they are unable then they resort to herbal and medicine depend on where they live yeah basically that thank you thank you so much Nancy um Anita asked do you think intervention by early education of adolescents in schools could be helpful uh that's very uh important and I appreciated that comment then because um unless um cervical cancer awareness and knowledge and even early child um teenage vaccination like it's done in other parts of the country if it can be roll out then it would be very um helpful to some degree and I think that's a helpful um way to prevent cervical cancer in the next generation. Anita was also asking if visual inspection using acetic acid could be done at primary health care facilities before seeking pap smear thank you Anita it is possible it is possible but um there is not much training done on that for our nurses or midwives at the um primary health facility and that's uh one of the one of the um specter that uh I am also taking note of that we have to uh in um the the gynecology specialists need to train more nurses and wives in the health uh primary health facility to do v i a so that uh at least um some um screening is done before pap smear thank you Anita that's uh well taken on board thank you Nancy I want to ask you when we talk about polygamy in North America that's marriage between one man and more than one woman when you were talking about polygamous relationships are those marriages where the man has one or more wives in the same household or or more than one family or are those informal relationships thank you Cecilia it's more or less informal relationship but sexually connected or it can be if the women at other other husbands prior to the current one so the it's like more than one sexual partner uh than the one they're living with so it's a vice versa between the men and women like predominantly we used to think that it's the male with more than one sexual partner and that's like when we support men having more than one wives like in in um in in in cultural context but then seeing the trend of this is it also um can be due to women exposed to other more than one um men who uh who have who may have probably have papilloma virus as well so it's like um polygamous relationship mean uh extra marriage relationship or extra uh more than one partners that have sexual contact yeah I understand um with time for one last question Anita has asked if the HPV vaccine is available for young people in Papua New Guinea uh thank you Anita there was a trial program uh done in the main uh city of Papua New Guinea which is in Port Mosby but I think it's more than five years now and the program has never been ruled out to most parts of Papua New Guinea and we're not sure whether this is uh uh continue or not but this is also a great need for um for a vaccination vaccinating young young girls so it was done but the the program was not sustained and it was carried out in almost all of uh all parts of Papua New Guinea thank you thank you Nelsie thank you so much