Comparison of Pap Smear Screening Results between Akha Hill Tribe and Urban Women in Chiang Rai Province , Thailand

decrease in invasive cervical cancer incidence has been recorded (Twinn and Cheng, 1999; Idestrom et al., 2002; Lonky, 2002a; 2002b). In Thailand, Ministry of Public Health proposed the Pap smear screening of the entire population of women 5 yearly intervals in 35-60 years. However, this program can not cover some ethnic groups as Karen, Hmong (Meo), Lahu, Akha, Yao, H’ tin and other hill tribes, because some of them do not obtain Thai citizenship. In addition, these ethnic groups may refuse to have Pap smear screening because of lacking knowledge, poor economic condition and/or prohibition by their religion. Akha is one of ethnic groups; the population about 6.9% of total six main ethnic groups residing in northern Thailand including Chiang Mai, Chiang Rai, Mae Hong Sorn province and others (Aguettant, 1996). Akha hill tribe has the socio-economic life and their


Introduction
Cervical cancer is the second among gynecologic developing countries.It has high mortality unless early diagnosis (Morris et al., 1996).In countries where active decrease in invasive cervical cancer incidence has been recorded (Twinn and Cheng, 1999;Idestrom et al., 2002;Lonky, 2002a;2002b).In Thailand, Ministry of Public Health proposed the Pap smear screening of the entire population of women 5 yearly intervals in 35-60 years.However, this program can not cover some ethnic groups as Karen, Hmong (Meo), Lahu, Akha, Yao, H' tin and other hill tribes, because some of them do not obtain Thai citizenship.In addition, these ethnic groups may refuse to have Pap smear screening because of lacking knowledge, poor economic condition and/or prohibition by their religion.Akha is one of ethnic groups; the population about 6.9% of total six main ethnic groups residing in northern Thailand including Chiang Mai, Chiang Rai, Mae Hong Sorn province and others (Aguettant, 1996).Akha hill tribe has the socio-economic life and their

Comparison of Pap Smear Screening Results between Akha Hill Tribe and Urban Women in Chiang Rai Province, Thailand
Onanong Kritpetcharat 1 , Wiwat Wutichouy 2 , Suchat Sirijaichingkul 3 , Panutas Kritpetcharat 4 * culture distinct from general Thai people, such as no/ low education, young aged marriage, high birth rate, religion, hygienic situation, etc.Most of them do not have knowledge about cervical cancer and Pap smear screening, so that the prevalence of abnormal Pap smear screening results of Akha hill tribe women are expected to be higher than of urban women.
Our study aimed to compare the Pap smear screening results between Akha hill tribe and urban women who live in Chiang Rai province, Thailand.

Materials and Methods
A cross-sectional Pap smear screening was conducted in 1,100 Akha hill tribes and 1,100 urban women who came to have Pap smear screening at Chiangrai Prachanukroh Hospital and 1 private cytology laboratory, Chiang Rai province from January to June 2008.
Abnormal Pap smears were defined according to the Bethesda system 2001(Solomon et al., 2002)

Results
The age gorup distributions of 1,100 Akha women and 1,100 urban women were shown in Table 1.The residences of these urban and Akha women are shown in Figure 1.All of the urban women reside in Mueang district; Ahka women reside in Doi Mae Fah Luang (Mae Fa Luang district), Doi Mae Salong (Mae Fa Luang district), Doi Tung (Mae Sai district) and Doi Wawee (Mae Suai district), Chiang Rai province, Thailand.
The Pap smear screening results of Akha and urban women were summarized in Table 1.The overall prevalence of abnormal Pap smear screening results in Akha women was 12.2% (134/1,100) results in urban higher (p<0.05 by two proportion Z test) of ASCUS, ASC-H, LSIL-HPV and HSIL-CIN III observed in Akha women than urban women.
The highest prevalence of abnormal Pap smear screening results in both groups was found in 41-50 years age group, 49/1100 (4.5%) in Akha and 19/1100 (1.7%) in urban women.The lowest age group of the Akha and urban women that found the abnormal Pap smear screening results was <21 years age group (2/1100 and 5/1100) (Table 1).
From questionaires, characteristics of both women group were shown in Table 2. Most Akha women had no and primary school education (90.8%), whereas urban women had high school or higher education (84.9%).intercourses (AFI) between 14-17 years, whereas all urban women were higher.47.6% of Akha women had 3 and more parities, whereas most of urban women had 2 or fewer parities.8.3% of Akha women had abortion urban women (p<0.05 by two proportion Z test).45.1% of Akha women used oral contraception; the remainder used injected contraception, but 85.2% of urban women used oral contraception.74.9% of urban women had 4 times or more Pap smear screening history, but most of

Discussion
Among hill tribes in Chiang Rai province, Akha women were major group who had Pap smear screened, whereas few Karen, Hmong, Lahu, Yao and others were screened.
The risk factors for precancerous lesions of cervix were grouped into genital, sexual, chemical, dietary and life factors.Human papilloma virus (HPV) infectious etiological agent associated with the development of precancerous lesions of cervix.Other important risk factors were early AFI, multiple sexual partners of male and female.Oral contraceptive usage, nutritional as co-risk factors (Murthy and Mathew, 2000).
The data from this study showed that Akah women had several risk factors for precancerous lesion and cervical carcinoma which differed from urban women such as early AFI.There were several studies supported that early AFI was important risk factor for these abnormal Pap smear screening.Recently, Plummer et al. ( 2012) reported that Odds ratios (OR) for invasive cervical cancer was intercourse (exponent 1.95, 95%CI: 1.76-2.15) up to age to HPV.Pereira et al. (2007) showed that high-risk HPV infections were strongly associated to AFI (OR=7.10)and Sauvaget et al. ( 2011) also showed that high-risk HPV infection was associated to AFI.
High frequently pregnancies and high parities were also risk factors among Akha women.Pereira et al. (2007) reported that HPV infection was also strongly associated to three or more parities (OR=3.05),abortion episodes of Pap smear screening in Camerunian women found that there was high prevalence of precancerous lesions in early age groups (11-15 years) and found that many factors were related to this high prevalence such as young age 2001).No or low education level might be a risk factor in Akha women as previously reported a large cohort study in India (Thulaseedharan et al., 2012), showed that cancer and the study in Italy (Damiani et al., 2012) also more likely to use cancer screening.The high history of Pap smear screening in urban women revealed that urban women has more awareness or knowledge about cervical By these results, the cervical cancer control will be effective in these women groups by giving more knowledge about cervical cancer and the way of early detection by Pap smear screening.It should be setting more units to service Pap smear screening in order to increase the coverage in the risk group women who got ethnic groups should be encouraged to be Pap smear screened and to perceive about cervical cancer.