Well-woman Clinics Research Articles

Arthralgia in midlife Singaporean women: the Integrated Women’s Health Program (IWHP)

Objective Arthralgia is a common menopausal complaint in midlife women, and its causes remain unclear. We examined the prevalence of menopausal arthralgia with various factors including sleep quality, depression/anxiety, muscle strength and physical performance among midlife Singaporean women. Methods The Integrated Women’s Health Program (IWHP) comprised 1120 healthy, community-dwelling women of Chinese, Malay or Indian ethnicities (aged 45–69 years) attending well-women clinics at the National University Hospital, Singapore. Sociodemographic, menopausal, reproductive and health data were obtained with validated questionnaires. Muscle strength, physical performance and dual-energy X-ray absorptiometry were measured. Women with moderate to very severe symptoms using the Menopause Rating Scale were classified as having arthralgia. Multivariable logistic regression analyses examined risk factors for arthralgia. Results One-third of the participants reported arthralgia, and 12.7%, 16.2% and 71.2% were in the premenopausal, perimenopausal and postmenopausal period, respectively. Menopausal symptoms, such as vaginal dryness (adjusted odds ratio [aOR]: 2.64, 95% confidence interval [CI]: 1.64, 4.24) and physical/mental exhaustion (aOR: 2.83, 95% CI: 1.79, 4.47), were independent risk factors for arthralgia. Poor muscle strength (aOR: 2.20, 95% CI: 1.29, 3.76), obesity (aOR: 1.94, 95% CI: 1.13, 3.32) and rheumatoid arthritis (aOR: 7.73, 95% CI: 4.47, 13.36) were also independently associated with arthralgia after adjustment for confounders. Conclusions Arthralgia in midlife Singaporean women was associated with menopausal symptoms of vaginal dryness and physical and mental exhaustion. Women with poor muscle strength were more likely to experience menopausal arthralgia.

Menopausal symptoms in midlife Singaporean women: Prevalence rates and associated factors from the Integrated Women's Health Programme (IWHP).

Menopausal symptoms can substantially impact quality of life. We studied somatic, psychological, and urogenital symptoms and their associated factors. Cross-sectional study of healthy midlife Singaporean women from three major Asian ethnic groups. In 2014-16, women aged 45 to 69 attending well-woman clinics at the National University Hospital Singapore completed the Menopause Rating Scale (MRS). Sociodemographic, reproductive, medical, anthropometric, body composition, and physical performance characteristics were assessed using validated questionnaires and strict protocols. We analysed sub-scales and total scores by median split, and adjusted odds ratios using multivariable logistic regression. Of the 1054 eligible women, 62.6% reported at least one moderate to extremely severe symptom. The top five menopausal symptoms were joint and muscle discomfort, sleep problems, vaginal dryness, physical and mental exhaustion, and hot flushes. Higher total scores on the MRS were associated with moderate disability (adjusted odds ratio: 9.80, 95% confidence interval: 2.88-33.34), poorer self-rated health status (2.18, 1.60-2.97), menstrual irregularity at 25years (1.63, 1.07-2.49), and slower chair stands (1.49, 1.09-2.03). Age ≥65 (0.54, 0.30-0.94) and a lower level of education (0.45, 0.26-0.76) had significant inverse associations with total MRS score. Menopausal symptoms were associated with disability, poorer health status, and weaker lower-body muscle strength. These data add to the limited Asian evidence and raise the profile of this important area of health.

Healthy lifestyle practices: Evidence from clinic attending mothers in the northern province, Sri Lanka

Healthy lifestyles are known to reduce noncommunicable disease-related mortalities and morbidities. Public health initiatives should encourage healthier lifestyles to prevent the risk of noncommunicable diseases. This study aimed to determine healthy lifestyle practices and their associated factors among clinic-attending mothers (mothers attending antenatal clinics, postnatal clinics, well-baby clinics, family planning clinics, well-women clinics, and polyclinics) in the Chavakachcheri Medical Officer of Health (MOH) area. We conducted a clinic-based cross-sectional study in 19 centers covering 28 Public Health Midwives (PHM) areas. Healthy lifestyle practices, such as regular exercise, consumption of recommended servings of fruits and vegetables, measuring their own BMI, and average salt consumption, were poor. In the multivariate analysis, we found only three factors that had higher odds of affecting healthy lifestyle practices that were statistically significant: attributes of higher level of perceptions about healthy lifestyle practices (AOR = 4.36, 1.32–14.39), participating in Mothers’ Support Groups (AOR = 7.97, 2.17–29.27) and BMI value of < 23 kg/m2 (AOR = 4.47, 1.35–14.73). Effective targeted healthy lifestyle-related educational programs instead of regular training during clinic visits and promoting participation in peer groups at the community level may benefit clinic-attending mothers.

A Descriptive Study of Different Methods of Cervical Cancer Screening among Ever-Married Women in 35-Year and 45-Year Cohorts in Kalutara District, Sri Lanka.

Screening for cervical cancer in Sri Lankan females with Pap smears (conventional cytology) has shown no marked reduction in cervical cancer incidence over the past two decades. The study aims to compare the efficacy of Pap smear, with other screening tools such as Liquid Based Cytology (LBC) and Human Papilloma Virus/deoxyribonucleic acid (HPV/DNA) (using cobas 4800) in detection of underlying cervical intraepithelial neoplasia (CIN) and cervical cancer among 35 and 45 year old ever married women in Kalutara districtin Sri Lanka. Women from 35-year cohort and 45-year cohort were selected from all Public Health Midwife areas (n=413) in Kalutara district by random sampling. Pap smear, LBC, and HPV/DNA specimen were collected s from women who attended the Well Woman Clinics (WWC) . Women with positive results from any method were confirmed by colposcopy. Results: Of the, 510 and 502 women in the 35-year cohort and 45-year cohort, respectively, included in the analysis, nine women among 35-year cohort (1.8%) and 7 women among 45-year cohort (1.4%) had cytological abnormality (positive results) with Pap smears. Thirteen women among 35-year cohort (2.5%) and 10 women among 45-year cohort (2%) age groups had cytological abnormality (positive results) with Liquid Based Cytology reports. Total of 32 women among 35-year cohort (6.2%) and 24 women among 45-year cohort (4.8%) were positive for HPV/DNA test. Of the women tested positive on screening, colposcopy revealed that HPV/DNA method was superior to Pap and LBC for detecting CIN while the results of latter two were comparable. The CIN detection rate by colposcopy was high with HPV/DNA screening with cobas 4800, whereas the detection rate by LBC was insignificantly higher than Pap smears.

Factors associated with poor sleep quality in midlife Singaporean women: The Integrated Women’s Health program (IWHP)

ObjectiveTo examine factors associated with poor sleep quality in community-dwelling midlife women. MethodsHealthy women (aged 45–69 years) of Chinese, Malay and Indian ethnicities attending well-women clinics at the National University Hospital, Singapore, completed the Pittsburgh Sleep Quality Index (PSQI). A PQSI score >5 denoted poor sleep quality. The women filled out validated questionnaires covering menopausal and genito-urinary symptoms, and mental health. Physical performance was measured. Bone mineral density and visceral adiposity were assessed by dual energy X-ray absorptiometry. Binary logistic regression analyses assessed independent factors for poor sleep. ResultsPoor sleep quality was reported in 38.2% of women (n = 1094, mean age: 56.4 ± 6.2 years). Indian women had higher sleep disturbance scores than Chinese women (mean ± SD: 1.33 ± 0.58 vs 1.17 ± 0.49). Malays experienced more daytime dysfunction (0.54 ± 0.60 vs 0.33 ± 0.55) and had a higher overall PSQI score (6.00 ± 3.31 vs 5.02 ± 2.97) than the Chinese. A low education level (aOR: 1.76, 95% CI: 1.01–3.05), feelings of irritability (2.67, 1.56–4.60) and vaginal dryness (1.62, 1.03–2.54) were associated with poor sleep quality in the adjusted multivariable model. Women with moderate to severe disability were ∼3 times (2.99, 1.20–7.44) more likely to experience less than ideal sleep quality, while urinary incontinence (1.53, 1.08–2.17) and breast cancer history (2.77, 1.36–5.64) were also associates of poor sleep quality. ConclusionSelf-reports of education level, irritability, vaginal dryness, disability, urinary incontinence, and breast cancer history were independently related to poor sleep. Ethnic differences suggest the need for targeted interventions among the ethnic groups.

Acceptability, simplicity, and relevance of the new human papillomavirus/DNA test among 35-year-old ever-married women in a district of Sri Lanka: focus group discussions

BackgroundTwo major drawbacks of the present cervical cancer screening programme in Sri Lanka are, the suboptimal sensitivity of the pap smear and the low coverage. The sensitivity of the HPV/DNA screening test is high. The objective of the study was to explore the acceptability relevance and simplicity of the new HPV/DNA screening implementation among ever-married women in a district of Sri Lanka.MethodsFocus group discussions (FGD) (n = 3) in the public health divisions of the Kalutara district were used to collect data during December 2018. The study population comprised of ever-married women 35 years old, who, carried out an HPV/DNA test at a community Well Woman Clinics (WWCs) (n = 89). A list of WWCs was prepared according to an alphabetical order under urban, rural, and estate sector categories and allocated a number. One WWC was selected from each sector randomly for the three FGDs representing the estate, rural, and urban clinics. A convenient sampling technique was used to select participants for each FGD (n = 8). The information collected at each interview was summarized at the end of each interview. The analysis was done with manual content.ResultsMost of the participants were Sinhalese (n = 17, 70.9%), Buddhist (n = 18, n = 75%), and non-working (n = 18, n = 75%). The community awareness of HPV/DNA screening and field staff performance were highly appreciated by most of the participants. Most were aware of the high sensitivity of the HPV/DNA test, therefore the early detection rate of cervical cancer precursors is high. Most of the participants expressed the HPV/DNA test as a convenient and neutral test. Most were mentioned the necessity of repeated clinic visits for the pap test and colposcopy in HPV/DNA screened positive follow-up but there was marked acceptability (n = 23, 95.8%) for HPV/DNA test.ConclusionsAcceptability of the new HPV/DNA screening test was high. Most of the participants perceived the HPV/DNA test to be simple and also relevant. Therefore, the HPV/DNA screening test can be recommended to be incorporated into the National Cervical Cancer Screening Programme as its suitability was well explored in the Sri Lankan setting.

Cervical Cancer: The outcomes of liquid-based cytology vs conventional cytology among HPV/DNA screening test positives of ever married 35 and 45 years old women in Kalutara district and unit cost estimation of colposcopy and biopsy

Background: One major drawback of the present National Cervical Cancer Screening programme is, the suboptimal sensitivity (53%) of the pap smear to detect Cervical Intraepithelial Neoplasia (CIN). HPV/DNA test is highly sensitive (92.9%) for CIN II viral load and the feasibility of HPV/DNA screening with conventional cytology for screen positive follow-up was successfully attempted. The sensitivity of Liquid Based Cytology (LBC) to detect CIN II+ is 79.1%. Objective: To describe the results of LBC vs conventional cytology among HPV/DNA screen positives of 35 and 45 year old ever-married women in MOH areas of Kalutara district. Methods: There are 15 Medical Officer of Health areas in Kalutara district and the Public Health Midwife area (n=413) is taken as a cluster. Three clusters were randomly selected in each MOH area (n=45) by the lot method. Eligible family registers were the sampling frame. Nine subjects in the 35 and 45 age cohort each from all 45 clusters were selected by consecutive sampling technique. The total number of 393 and 390 subjects from 35 and 45 age cohorts were subjected to cervical specimen collection at community Well Woman Clinics (WWC) after applying exclusion criteria at field and clinic setting. HPV/DNA screen positives were subjected to both LBC and pap smear. HPV/DNA screen positive with either conventional cytology or LBC≥ Atypical Squamous Cells of Undetermined Significance (ASCUS) were referred for colposcopy. The incremental cost of the pap smear was calculated. The Scenario-Building technique was used to calculate the per- procedure cost of colposcopy and biopsy. Results: The response rate of 35 and 45 age cohorts women was 97.5% and 96.5% respectively. The number of 25 (6.36%) among 35 and 18 (4.61%) among 45-year- old women were positive for HPV/DNA test. The number of 7 (1.78 %) among 35 year and 5 (1.28%) among 45 year old women had ≥ASCUS in conventional cytology, while the number of 10 (2.54%) among 35 years and 8 (2.05%) among 45 years old women had ≥ASCUS in LBC. Prevalence of CIN by colposcopy among 35 years and 45 years women for LBC vs conventional cytology were 1.53%, 1.28% and 1.53%, 1.03% respectively and there was no significant difference. No invalid results were reported for LBC and the treatment adherence for colposcopy was 86.7%. The incremental cost of pap smear was Rs. 626.18, while the per-procedure cost of colposcopy and biopsy was Rs.1528.15 and Rs.681.16. Conclusions and recommendations: To improve the quality and coverage of the programme HPV/DNA PCR test as a primary cervical cancer screening method with LBC for only screen positive follow-up can be recommended.

Modelling the Use of Traditional Family Planning by Women in Sri Lanka

Family planning plays a crucial role in enhancing the health of the mother and the child. Contraceptives are used by most women in the reproductive age span (15-49 years). Sri Lanka has been named as one of the countries with high usage of traditional family planning (TFP) methods than the other Asian countries. However, the reasons for that have not been investigated. Therefore, this study is carried out to identify the significant factors influencing on usage of TFP by using data from Sri Lanka Demographic and Health Survey in 2016 with a sample size of 10835. The percentages of women using TFP is 16.3% compared to 83.7% of using modern family planning (MFP). Among TFP users, the withdrawal method and the rhythm method are 35% and 57% respectively. The balance 8% uses both methods. A binary logistic regression model was developed to capture the factors influencing the use of TFP by considering all variables simultaneously. The fitted model was invariant on the type of selection method and selection criteria. The overall predictive power is 82.9%. The knowledge on family planning, having advice from public health midwives, attendance to well-women clinics, religion, ethnicity, decision to use family planning, husband’s occupation, women’s age, women’s occupation, women’s education level, number of children, and wealth quantile are the significantly associated factors with the usage of TFP. The odds of the usage of TFP among the women having no children and women having 1 or 2 children are respectively 1.4 and 4.0 times higher than the women having 3 or more children. The factors identified are geared towards providing robust evidence based on data driven decision making (DDDM) and therefore the key population groups in need of contraceptive services can be targeted more effectively and efficiently. Organizing counselling programmes and promotions on family planning and conducting media awareness programmes to avoid some myths on modern contraceptives can be suggested.

Family Planning Advice in State-Socialist Poland, 1950s-80s: Local and Transnational Exchanges.

This paper scrutinises the relations between different models of family planning advice and their evolution in Poland between the mid-1950s and the late 1980s, focusing on their similarities and dissimilarities, conflicts and concordances. From 1956 onwards, the delivery of family planning advice became a priority for both the Polish Catholic Church and the party-state, especially its health authorities, which supported the foundation of the Society of Conscious Motherhood and aspired to mainstream birth control advice through the network of public well-woman clinics. As a consequence, two systems of family planning counselling emerged: the professional, secular family planning movement and Catholic pre-marital and marital counselling. We argue that reciprocal influence and emulation existed between state-sponsored and Catholic family planning in state-socialist Poland, and that both models used transnational organisations and debates relating to contraception for their construction and legitimisation. By evaluating the extent to which the strategies and practices for the delivery of birth control advice utilised by transnational birth control movements were employed in a 'second world' context such as Poland, we reveal unexpected supranational links that complicate and problematise historiographical and popular understandings of the Iron Curtain and Cold War Europe.

Evaluation of p16/Ki-67 dual-stain cytology performed on self-collected vaginal and clinician-collected cervical specimens for the detection of cervical pre-cancer

ObjectivesTo compare the performance of dual immunostaining of p16INK4a and Ki-67 proteins performed on self-collected vaginal specimens and clinician-collected cervical specimens, and to evaluate the performance of this technique in predicting high-grade disease. MethodsWomen aged 30–59 years (n = 1005) were recruited at two well-women clinics in Papua New Guinea. Each woman provided both cervical and vaginal specimens that were tested for high-risk human papillomavirus (hrHPV) DNA using the Xpert HPV Test (Cepheid) at point of care. A subset of paired cervical and vaginal specimens (n = 243) were selected to undergo CINTec® PLUS (Roche) p16/Ki-67 dual-stain cytology and liquid-based cytology (LBC). ResultsFifty-five pairs (22%) were excluded from further analysis because the smears were not assessable. Of the 189 remaining paired specimens, 74 pairs (39.1%) were positive for one or more hrHPV genotypes. When comparing results of the dual stain, the overall percent agreement, positive and negative percent agreements and κ value between the cervical and vaginal specimens were 87.8% (CI 82.3–92.1%), 64.6% (CI 49.5–77.8%), 95.7% (CI 91.0–98.0%) and 0.65 (CI 0.51–0.79%) respectively. The sensitivity of the dual stain performed on the cervical specimen to predict high-grade disease, determined by LBC, was superior to that of the dual stain performed on the vaginal specimen: 100% (CI 84.6–100%) versus 68.2% (CI 45.1–86.1%). ConclusionAlthough further evaluation may be warranted, these findings indicate that dual-stain testing of vaginal specimens cannot be advocated as part of cervical screening programmes in low- and middle-income countries. However, dual-stain cytology performed on cervical specimens may have a role in quality assurance in such settings.

Is Cancer Screening a Priority among Adult Females in Sri Lanka?

We assessed the use of well women clinics (WWC) screening services for cervical and breast cancer prevention in a sample of females attending the largest religious festival in Sri Lanka. Of the 3,116 women studied, 2, 874(92.2%) were aware on breast cancer and 2, 609(83.7%) on cervical carcinoma. Of them only 1,895 (60.8%) were aware of the WWC services, but only 578 (18.5%) had ever used the services. Of the 217 professionals or associate professionals in the study sample, 190 (87.6%) were aware of the WWC compared to only 58.8% among the 2,899 women falling under the categories of other occupations and housewives. Clinic attendance was also significantly higher amongst professionals and associate professionals compared to women in other occupational categories and housewives (40.1% versus 16.9%). Use of cancer screening services are low and new strategies needed to improve the secondary prevention of these cancers in Sri Lanka.

Low uptake of Pap smear testing among medical clinic attendees in a tertiary care hospital in Sri Lanka.

The Papanicolaou (Pap) smear test is a safe and effective screening test for pre-invasive cervical cancer. The test is offered free of charge through well-woman clinics in Sri Lanka, but previous studies have shown poor awareness and uptake. We used an interviewer administered validated questionnaire to conduct a cross sectional survey among ever-married women between the ages of 25 and 65 years attending a medical clinic at the National Hospital of Sri Lanka. We obtained data on socio-demographic characteristics, awareness/knowledge and uptake status of Pap smear testing. A total of 188/280 eligible women were interviewed (67.1%). Participant ages ranged from 29-65 years. Awareness about Pap smear testing was found in 111 (59.0%) women of whom 41 (36.9%) did not know that the Pap smear was used to detect pre-cancerous lesions. Only 34 (18.1%) subjects had ever had a Pap smear taken. Univariate associations related to Pap smear uptake were: prior awareness of the test (p<0.001), higher parity (p=0.022), and knowing someone with cervical carcinoma (p<0.001). Multivariate regression analysis confirmed the same as independent associations of test uptake (p<0.001, p=0.012, p=0.013 respectively). Knowledge regarding Pap smear testing was poor. Pap smear uptake was very low, and did not parallel prior knowledge, although knowledge did influence uptake. Parity and contact with patients with cervical cancer correlated with uptake. There is an urgent need to increase uptake through a multi-pronged campaign.

Quality of Breast Cancer Early Detection Services Conducted by Well Woman Clinics in the District of Gampaha, Sri Lanka

Breast cancer is the most common cancer diagnosed in females in Sri Lanka and early detection can lead to reduction in morbidity and mortality. To evaluate selected aspects of breast cancer early detection services implemented through well woman clinics (WWCs) in the Gampaha District. The study consisted of two components. A retrospective descriptive arm assessed clinical breast examination (CBE) coverage of target age group women (TGW) of 35-59 years in all the WWCs in Gampaha district over 2003- 2007. A cross sectional descriptive study additionally assessed quality of breast cancer early detection services. The Lot Quality Assurance Sampling (LQAS) technique was used to decide on the lot size and threshold values, which were computed as twenty and six clinics. Checklists were employed in assessing coverage, physical facilities and clinic activities. Client satisfaction on WWC services was assessed among 200 TGW attending 20 WWCs using an interviewer-administered questionnaire. CBE coverage in the Gampaha district increased only from 1.1-2.2% over 2003-2007. With regard to physical facilities, the number of clinics that were rated substandard varied between 7-18 (35- 90%). The items that were lacking included dust bins, notice boards, stationary, furniture and linen, and cleanliness of outside premises and toilets. With regard to clinic activities, punctuality of staff, late commencement of clinics, provision of health education, supervision, CBE and breast self-examination (BSE) were substandard in 7- 20 clinics (35-100%). Client satisfaction for WWC services was 45.2% (IQR: 38.7-54.8%) and only 11% had a score of ≥70%, the cut off set for satisfaction. Breast cancer early detection service coverage in the Gampaha district remained low (2.2%) in 2007, 11 years after commencing WWCs. All 20 clinics were substandard for overall CBE and BSE.

Evaluation of Cervical Screening Coverage in Kalutara District

Objective: To determine the cervical screening coverage of women 40-60 years in Kalutara District since the inception of the programme in 1996. Methodology: Cervical screening which is conducted in Well Woman Clinics (WWC), involves both visual inspection of the cervix and Pap smear testing. A descriptive cross sectional survey was conducted to assess the cervical screening coverage achieved since the inception of the programme and to assess the quality of services. The area investigated was the Kalutara district and individual MOH (Medical Officer of Health) areas within it. Data of screened females between 33 to 63 years were obtained from the records maintained in the WWClinics Results The results were expressed as a percentage of the total 40-60 females in the District and individual MOH areas. The cervical screening coverage in Kalutara District was 2.2% since the inception of the programme. Although the cover-age was low, a rising trend of cervical screening from 1996 was observed particularly after the year 1998. Only three MOH areas out of 7 conducted more than 4 WWClinics per month, which is the recommendation of Ministry of Health. Seventy four percent (1135) of total screenings (1535) were performed in those three clinics. Only one MOH area conducted an out-reach clinic. Five MOH areas conducted the clinics in combination with Maternal and Child Health/Family Planning (MCH/FP) clinics, while the other two MOH areas conducted separate WWClinics. The highest cumulative coverage was observed in Bulathsinhala MOH area (9.3%) where there were more than 4 WWclinics per month and clinics were conducted separately. Conclusion The low cervical screening coverage of 2.2% over a 5 year period in Kalutara District resembled the cervical screen-ing coverage pattern in other developing countries. Cervical screening coverage could be increased by increasing fre-quency and number of clinics especially in the periphery and conducting WWClinics separately without combining with MCH/FP Clinics. Key words: Cervical screening; Well Woman Clinics; evaluation; coverage DOI: 10.4038/jccpsl.v14i1.2946 Journal of the College of Community Physicians of Sri Lanka Vol.14(1) 2009 33-38

Shining a torch for Islands screening

Julie Stevenson tells why she is known as the ‘lady with the torch’ for her Falkland Islands well-woman clinics. She spoke in Belfast to Liam Benison.

Midwives' views on redefining midwifery 2: public health

This is the second of four papers focusing on the expanding role of midwives. The first paper published last month, explored midwives' views of their role in health promotion. This paper focuses on midwives' views of their contribution to the public health strategy. The main findings suggest that, generally, midwives recognise and support a public health role. Over half of the midwives surveyed said they had a role in child protection; promoting effective parenting skills, informing young people about healthy lifestyle choices, providing well-women clinics, targeting vulnerable groups and promoting sexual health. Many midwives acknowledged the need for multiprofessional collaborations. Training was an important and consistent issue.

'You don't do it for nothing': women's experiences of volunteering in two community WELL WOMAN CLINICS.

Despite the fact that approximately 11.5 million women each year participate in formal voluntary activity, little is known about their experiences of volunteering in the National Health Service (NHS) and in particular, their experiences of working together with paid workers in direct client care. Arguably, this is because of the sensitive nature of voluntarism and concerns regarding the potential for exploitation. Much of women's voluntary activity is within the health and personal social services. Recently, volunteering in the NHS has been promoted as providing an added dimension to professional care. The study reported here seeks to bring to public attention women's experiences of volunteering and their relationships with paid workers within two community WELL WOMAN CLINICS. The findings are based on an 18-month period of participant observation which included in-depth interviews with 26 volunteer and paid workers and a review of the clinics' operational policy documents. Applying the concepts of balanced reciprocity and equity theory, the relationships between the volunteers and between the volunteers and paid workers are illuminated. Volunteers gain from their participation in the clinics as well as giving of their time and effort. However, in order for volunteers to view their volunteering positively and to sustain their interest there needs to be a balance between giving and taking. Within the context of the clinics, volunteering need not necessarily be exploitative and can be empowering for some women.

Women users' views on the role and value of the practice nurse.

Aspects of the views of women aged 16-65 years on practice nurses in the primary health care setting are explored. The extent to which women consult practice nurses and the reasons for consultation are first identified. Women's assessments of practice nurses are then examined. The findings are from a 3-year research project where 1251 women completed a postal questionnaire and 70 women were interviewed in depth about issues concerning women's perceptions and experiences of both general practitioners (GPs) and practice nurses. Two thirds of the sample had consulted the practice nurse; 22% about specific women's health issues (including 13% for cervical screening). For most women's health issues, more women expressed a preference to be seen by a general practitioner (GP) than a practice nurse, except for breast examination among women aged 49 to 65 years where 57% expressed a preference for a practice nurse compared with 43% for a GP. Women gave similarly positive evaluations of the approachability of practice nurses and GPs. Positive views of practice nurses were high among older women, women who saw practice nurses in well-women clinics and women who saw practice nurses in relation to women's health issues. Among women who had not consulted a practice nurse, there was both a lack of awareness of the level and range of expertise of practice nurses, and a perception that in the main they offered only minor routine services. Health promotion, disease prevention and family planning do not appear to feature centrally in women's expectations of services provided by the practice nurse.

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Do general practitioners facilitate the breast screening programme?

Mammography uptake has been discouragingly low since the introduction of breast cancer screening in Northern Ireland. This questionnaire survey was undertaken to appraise the views of participating general practitioners (GPs) about mammography and the extent to which they followed good practice in facilitating the screening programme. Of 173 GPs, 152 returned a questionnaire. Approximately three-quarters of these GPs believed the screening programme was worthwhile for the eligible women on their list. When sent the prior notification lists from the screening unit, less than half of the GPs always checked the accuracy of patients' addresses. Fifty-five per cent of the GPs said they routinely took opportunities (as they arouse) during normal surgeries to counsel women about mammography and 90% did so in health promotion or well-woman clinics. Despite this, only 56% routinely recorded non-attendance in patients' case notes and less than 20% contacted non-attenders to advocate mammography. Such a pro-active approach was more commonly adopted with women who had not attended when invited for a cervical smear. There was no significant difference in mammography uptake among the women on the lists of GPs with differing views or whose doctors differed in their degree of active commitment to the programme. The results point to a need for the screening unit to evaluate its own advocacy role to GPs and for Health Board to devise effective appraisal strategies for health promotion clinics in primary care.