Browsing by Author "Adanu, R.M.K."
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Item Announcing the winner of the John J. Sciarra IJGO Prize Paper Award for 2016(International Journal of Gynecology and Obstetrics, 2018-01) Adanu, R.M.K.Item Announcing the winner of the John J. Sciarra IJGO Prize Paper Award for 2018(International Journal of Gynecology and Obstetrics, 2019-05) Adanu, R.M.K.Item Cervical cancer knowledge and screening in Accra, Ghana.(Journal of Women's Health and Gender-Based Medicine, 2002-07) Adanu, R.M.K.; Johnson, T.R.B.No abstractItem Clinic Visits and Cervical Cancer Screening in Accra(Ghana Medical Journal, 2010-06) Adanu, R.M.K.; Seffah, J.D.; Duda, R.; Darko, R.; Hill, A.; Anarfi, J.Objective: To determine the factors that increase the chances of a woman in Accra having a Pap smear and whether women who have recently visited clinics have higher chances of having had Pap smears. Design: A cross-sectional study Methods: A representative sample of women in Accra, Ghana was interviewed and the clinical and demographic factors influencing cervical cancer screening was assessed. Results: Out of 1193 women with complete data, only 25 (2.1%) had ever had a Pap smear performed though 171 (14.3%) had their last outpatient clinic visit for either a gynaecological consultation or a regular check up. Simple logistic regression showed that a high educational level, high socioeconomic status and a history over the past month of postmenopausal or intermenstrual bleeding significantly increased the odds of ever having a pap smear. Neither monthly income nor last clinic visit for a gynaecological consultation or regular check up increased the odds of having a pap smear. Multiple logistic regression showed that a high educational level and experiencing postmenopausal or intermenstrual bleeding were the most important determinants of ever having a Pap smear. Conclusion: While we wait for a national program for cervical cancer screening, there is a need for clinicians to put more individual effort into ensuring that asymptomatic women are screened for cervical cancer.Item A comparison of women with induced abortion, spontaneous abortion and ectopic pregnancy in Ghana.(Contraception, 2011-07) Schwandt, H.M.; Creanga, A.A.; Danso, K.A.; Adanu, R.M.K.; Agbenyega, T.; Hindin, M.J.Background Despite having one of the most liberal abortion laws in sub-Saharan Africa, complications from induced abortion are the second leading cause of maternal mortality in Ghana. Study Design The sample is composed of patients with pregnancy termination complications in Ghana between June and July 2008. The majority of patients report having had a spontaneous abortion (75%; n=439), while 17% (n=100) and 8% (n=46) report having had an induced abortion or an ectopic pregnancy, respectively. Factors associated with women in each of the three groups were explored using multinomial logistic regression. Results When compared to women with spontaneous abortions, women with induced abortions were younger, poorer, more likely to report no religious affiliation, less likely to be married, more likely to report making the household decisions and more likely to fail to disclose this pregnancy to their partners. Within the induced abortion subsample, failure to disclose the most recent pregnancy was associated with already having children and autonomous household decision making. Conclusion Identifying the individual and relationship characteristics of induced abortion patients is the first step toward targeted policies and programs aimed at reducing unsafe abortion in Ghana.Item Condom use by Senior High Technical School Students in Sandema, Upper East Region, Ghana(University of Ghana, 2015-07) Kona, E.T.; Adanu, R.M.K.; University of Ghana, College of Health Sciences, School of Public HealthFor over a decade now, adolescent sexual and reproductive health and more especially condom use, has increasingly been on national agendas. In many countries especially in Sub-Saharan Africa, this concern has been driven by the high prevalence of HIV and AIDS among young people. Other driving forces of comparable magnitude have been the following; - 800 women died every day in 2013 due to pregnancy related causes. A chunk of it occurred in Sub – Saharan Africa (SSA). - One in 5 women has a child by age 18. Again, the worse scenario is in SSA. - One million STIs occur every day. The developing world is still the worse affected. In Ghana, both government and non – governmental organisations have made frantic efforts at improving adolescent sexual and reproductive health. Unfortunately, however, many adolescents still do not use condom or use it wrongly during sex. This thus predisposes them to unplanned / unwanted pregnancy, unsafe abortion, sexually transmitted diseases including HIV and AIDS among others. This study assessed the level of condom use among Sandema Senior High Technical School students in Sandema to inform evidence based adolescent health programming. The study was a cross – sectional design and it employed quantitative data collection approaches. A sample size of 427 SSHTS students was selected using multi – stage sampling technique. A structured questionnaire was used to collect the data and Stata (version 12) used to analyse the data. The findings revealed that 71.2% of the students use condom (69.3% for females and 72.2% for males). A bivariate analysis indicated that age group of the students, having received training on condom use, condom use at first and last sex, fear of the consequences of not using a condom (pregnancy, STIs, etc), partner/friends influence, source of condoms to students, ability to afford, and ethnicity were significant determinants of condom use (p<0.0001). Multiple logistic regression however, revealed that only age group of respondents, condom use at sexual debut, last sexual encounter, having received training on condom use and fear of the consequences of not using a condom (pregnancy, STIs, etc) were the main correlates of condom use among the students. Condom use was not consistent among the respondents. This predisposes them to unintended pregnancy and STIs including HIV. A multi-sectorial approach involving the ministries of Health, Education and Local Government as well as NGOs, Faith-based organizations and families of young people should collaborate in implementing adolescent friendly programmes aimed at taking the attention of the youth off sexual activity. Where this is not feasible, condom use should be greatly emphasized.Item Contemporary issues in women's health(International Journal of Gynecology and Obstetrics, 2005) Johnson, T.R.B.; Adanu, R.M.K.The editors of Contemporary Issues in Women’sHealth solicit reporters and correspondents fromthroughout the world to make contributions tothis section. Beginning with this issue, we will bemaking editorial changes. Dr. S. Arulkumaran,Secretary General of FIGO and a founding editorof this section, will be departing as one of ourauthors and we will be adding colleagues fromaround the world to provide broad correspon-dence. This month, Richard M.K. Adanu, FWACS,MPH, Lecturer in the Department of Obstetricsand Gynecology at the University of GhanaMedical School, will be joining as a full-timecontributor. Dr. Adanu qualified in Medicine atthe University of Ghana, completed his trainingin Obstetrics and Gynecology in the well knownCarnegie Ghana Training Program, and has re-cently completed the Masters of Public Health atthe Johns Hopkins University as a Gates Scholar.We look forward to his participation. Please feelfree to email or otherwise contact ProfessorTimothy Johnson at trbj@umich.edu or DoctorRichard Adanu at rmadanu@yahoo.com if you havereports or items that you would like to haveincluded. We would be happy to attribute theitems to those reporters and correspondents whogive permission in their transmittal. Otherwise, wewill share those reports that we think are ofthe greatest interest to our readership withoutattribution.Item Contemporary issues in women's health.(International Journal of Gynecology and Obstetrics, 2006-01) Johnson, T.R.B.; Adanu, R.M.K.No abstractItem Contemporary issues in women's health.(International Journal of Gynecology and Obstetrics, 2006) Adanu, R.M.K.; Boama, V.; Guinto V.T.; Sosa C.G.No abstractItem Contraceptive use by women in Accra, Ghana: results from the 2003 Accra Women's Health Survey(African journal of reproductive health, 2009-03) Adanu, R.M.K.; Seffah, J.D.; Hill, A.G.; Darko, R.; Duda, R.B.; Anarfi, J.K.The study was to determine the predictors of use of modern contraception among women in Accra, Ghana. Data were collected by trained interviewers using questionnaires. Complete data for 2199 women were analysed using Stata 8.2. The study showed that educational status was the most significant predictor of contraceptive use. Women with no formal education had a 48% reduction in the odds of having ever used contraception and a 66% reduction in the odds of currently using contraception. Regular use of health facilities did not affect contraceptive use. Female education should continue to be a priority of the Ghanaian government. Education about family planning and the effects of having large families should be integrated into the school curriculum. Ghanaian health workers need to be active in promoting the use of modern contraceptive methods.Item Determinants of induced abortion among women of reproductive age: evidence from the 2013 and 2019 Sierra Leone Demographic and Health Surve(BMC Women’s Health, 2023) Sesay, F.R.; Anaba, E.A.; Manu, A.; Maya, E.; Torpey, K.; Adanu, R.M.K.Background Worldwide, pregnancy termination due to unintended pregnancy is crucial in maternal health, par ticularly in settings where abortion laws are restrictive. Presently, there is a paucity of literature on determinants of induced abortion among women of reproductive age in Sierra Leone. The study fndings could be used to improve the country’s maternal mortality indices and inform health programs and reproductive health policies geared toward tackling induced abortion. Methods We analyzed secondary data from the 2013 and 2019 Sierra Leone Demographic and Health Surveys. The surveys were nationally representative, with weighted samples comprising 16,658 (2013) and 15,574 (2019) women of reproductive age. Descriptive statistics, including frequencies and percentages, were computed, while Chi-square and Binomial Logistics Regression were employed to identify correlates of induced abortion. Results The results showed that a minority (9%) of the participants had induced abortion in both surveys. Abor tion was signifcantly associated with age, marital status, employment status, education, parity, and frequency of listening to the radio and watching television (p<0.05). For instance, women aged 45–49 years (AOR=7.91; 95% CI: 5.76–10.87), married women (AOR=2.52; 95% CI: 1.95–3.26), and working women (AOR=1.65; 95% CI: 1.45–1.87) had a higher likelihood of induced abortion compared to their counterparts. Moreover, women with primary educa tion (AOR=1.27; 95% CI:1.11–1.46) and those who watch television once a week (AOR=1.29; 95% CI: 1.11–1.49) were more likely to terminate a pregnancy. Women with six or more children (AOR=0.40; 95% CI: 0.31–0.52) were less likely to terminate a pregnancy compared to those with no child. Conclusion The study revealed that a minority of the women had induced abortions. The prevalence of induced abortion did not change over time. Induced abortion was infuenced by age, marital status, employment status, edu cation, parity, and exposure to mass media. Therefore, policies and programs to reduce unwanted pregnancies should focus on increasing access to modern contraceptives among women of lower socio-economic statusItem Determinants of induced abortion among women of reproductive age: evidence from the 2013 and 2019 Sierra Leone Demographic and Health Survey(BMC Women’s Health, 2023) Sesay, F.R.; Anaba, E.A.; Manu, A.; Maya, E.; Torpey, K.; Adanu, R.M.K.Background Worldwide, pregnancy termination due to unintended pregnancy is crucial in maternal health, particularly in settings where abortion laws are restrictive. Presently, there is a paucity of literature on determinants of induced abortion among women of reproductive age in Sierra Leone. The study findings could be used to improve the country’s maternal mortality indices and inform health programs and reproductive health policies geared toward tackling induced abortion. Methods We analyzed secondary data from the 2013 and 2019 Sierra Leone Demographic and Health Surveys. The surveys were nationally representative, with weighted samples comprising 16,658 (2013) and 15,574 (2019) women of reproductive age. Descriptive statistics, including frequencies and percentages, were computed, while Chi-square and Binomial Logistics Regression were employed to identify correlates of induced abortion. Results The results showed that a minority (9%) of the participants had induced abortion in both surveys. Abortion was significantly associated with age, marital status, employment status, education, parity, and frequency of listening to the radio and watching television (p<0.05). For instance, women aged 45–49 years (AOR=7.91; 95% CI: 5.76–10.87), married women (AOR=2.52; 95% CI: 1.95–3.26), and working women (AOR=1.65; 95% CI: 1.45–1.87) had a higher likelihood of induced abortion compared to their counterparts. Moreover, women with primary education (AOR=1.27; 95% CI:1.11–1.46) and those who watch television once a week (AOR=1.29; 95% CI: 1.11–1.49) were more likely to terminate a pregnancy. Women with six or more children (AOR=0.40; 95% CI: 0.31–0.52) were less likely to terminate a pregnancy compared to those with no child. Conclusion The study revealed that a minority of the women had induced abortions. The prevalence of induced abortion did not change over time. Induced abortion was influenced by age, marital status, employment status, education, parity, and exposure to mass media. Therefore, policies and programs to reduce unwanted pregnancies should focus on increasing access to modern contraceptives among women of lower socio-economic status.Item Determinants of Obesity among Basic School Pupils in the Ga-East Municipality(University of Ghana, 2014-07) Alangea, D.O.; Adanu, R.M.K.; Aryeetey, R.; Laar, A.K.; University of Ghana, College of Health Sciences , School of Public Health , Department of Community Health; University of Ghana, College of Health Sciences , School of Public Health , Department of Community HealthBackground: Overweight and obesity among children is a major public health concern globally. Childhood obesity is likely to persist into adulthood. Little is known about the prevalence and determinants of overweight and obesity among school-age children in Ghana. Knowing the determinants of overweight/obesity among basic school pupils is important for obesity intervention design. Objective: To determine overweight and obesity prevalence and its risk factors among basic school pupils in the Ga-East Municipality of Ghana. Methods: A cross-sectional study involving 24 private and public basic schools in the Ga-East Municipality; 487 pupils aged 9 - 15 years and 340 parents. Data collection involved interviews with pupils, parents and head teachers, a school environmental scan and an audit of school feeding and physical activity facilities. Dietary data was collected using a one-time 24 – hour meal recall and a 7–day Food Frequency assessment. Body weight and height of pupils and their parents were measured. Physical activity level of pupils was determined using the physical activity questionnaire for children. Associations between home and school food environments and child BMI and overweight status were tested using linear and logistic regressions respectively. Results: Total overweight prevalence among basic school pupils in the Ga-East Municipality was 17.7%; 8% were obese. Overweight prevalence among parents was 59.2%. Frequency of beverage consumption (p<0.01), least physical activity level (p<0.01) and being in the middle household wealth tertile (p=0.03) significantly predicted higher child BMI after controlling for parental BMI, age, sex, and calories consumed. None of the schools assessed had a written policy on eating at school and physical activity of pupils. Over 77% of all pupil purchases made during break time were from within the school compound. Foods associated with obesity formed 46.6% of all purchases. Schools which highly promoted healthier food options had over 5 times increased odds of child overweight [AOR=5.55; 95% CI = 1.430 – 21.511, p=0.013] than schools that least promoted. Schools‘ exerting moderate control over the food options available to pupils compared to those who had least control had 84.3% reduced odds of having overweight pupils. Parental use of snacks and sweetened drinks as reward from the least to the moderate category was associated with reduced odds of child overweight (AOR = 0.282, 95% CI = 0.105 – 0.759, p<0.05). High provision of a supporting environment for physical activity (open spaces, sports field) in a school was associated with an 80.2% reduced likelihood of pupils being overweight compared to the least provision. Conclusions: The school and home environments have significant influences on child weight status beyond the individual child behavioural and background factors. The school environment offers an opportunity to reach a large child population and changes made to improve physical activity and access to healthy food can have positive impacts on child weight status.Item Development and Validation of a Scale to Measure Adolescent Sexual and Reproductive Health Stigma: Results From Young Women in Ghana(Journal of Sex Research, 2018-01) Hall, K.S.; Manu, A.; Morhe, E.; Harris, L.H.; Loll, D.; Ela, E.; Kolenic, G.; Dozier, J.L.; Challa, S.; Zochowski, M.K.; Boakye, A.; Adanu, R.M.K.; Dalton, V.K.Young women’s experiences with sexual and reproductive health (SRH) stigma may contribute to unintended pregnancy. Thus, stigma interventions and rigorous measures to assess their impact are needed. Based on formative work, we generated a pool of 51 items on perceived stigma around different dimensions of adolescent SRH and family planning (sex, contraception, pregnancy, childbearing, abortion). We tested items in a survey study of 1,080 women ages 15 to 24 recruited from schools, health facilities, and universities in Ghana. Confirmatory factor analysis (CFA) identified the most conceptually and statistically relevant scale, and multivariable regression established construct validity via associations between stigma and contraceptive use. CFA provided strong support for our hypothesized Adolescent SRH Stigma Scale (chi-square p value < 0.001; root mean square error of approximation [RMSEA] = 0.07; standardized root mean square residual [SRMR] = 0.06). The final 20-item scale included three subscales: internalized stigma (six items), enacted stigma (seven items), and stigmatizing lay attitudes (seven items). The scale demonstrated good internal consistency (α = 0.74) and strong subscale correlations (α = 0.82 to 0.93). Higher SRH stigma scores were inversely associated with ever having used modern contraception (adjusted odds ratio [AOR] = 0.96, confidence interval [CI] = 0.94 to 0.99, p value = 0.006). A valid, reliable instrument for assessing SRH stigma and its impact on family planning, the Adolescent SRH Stigma Scale can inform and evaluate interventions to reduce/manage stigma and foster resilience among young women in Africa and beyond.Item Differences in age-specific HPV prevalence between self-collected and health personInfectious Agents and Cancernel collected specimen in a cross-sectional study in Ghana(Infectious Agents and Cancer, 2017) Awua, A.K.; Adanu, R.M.K.; Wiredu, E.K.; Afari, E.A.; Severini, A.Background: Solid medical waste (SMW) in households is perceived to pose minimal risks to the public compared to SMW generated from healthcare facilities. While waste from healthcare facilities is subject to recommended safety measures to minimize risks to human health and the environment, similar waste in households is often untreated and co-mingled with household waste which ends up in landfills and open dumps in many African countries. In Ghana, the management of this potentially hazardous waste stream at household and community level has not been widely reported. The objective of this study was to investigate household disposal practices and harm resulting from SMW generated in households and the community. Methods: A cross-sectional questionnaire survey of 600 households was undertaken in Ga South Municipal Assembly in Accra, Ghana from mid-April to June, 2014. Factors investigated included socio-demographic characteristics, medication related practices, the belief that one is at risk of diseases associated with SMW, SMW disposal practices and reported harm associated with SMW at home and in the community. Results: Eighty percent and 89% of respondents discarded unwanted medicines and sharps in household refuse bins respectively. A corresponding 23% and 35% of respondents discarded these items without a container. Harm from SMW in the household and in the community was reported by 5% and 3% of respondents respectively. Persons who believed they were at risk of diseases associated with SMW were nearly three times more likely to report harm in the household (OR 2.75, 95%CI 1.15-6.54). Conclusion: The belief that one can be harmed by diseases associated with SMW influenced reporting rates in the study area. Disposal practices suggest the presence of unwanted medicines and sharps in the household waste stream conferring on it hazardous properties. Given the low rates of harm reported, elimination of preventable harm might justify community intervention. © 2017 The Author(s).Item Drivers of Anaemia Reduction Among Women of Reproductive Age in the Eastern and Upper West Regions of Ghana: A Secondary Data Analysis of the Ghana Demographic and Health Surveys(African Journal of Food, Agriculture and Development, 2023) Tetteh, A; Adanu, R.M.K.Anaemia among women of reproductive age (WRA) increases the risk of pregnancy-related morbidity, mortality, and poor pregnancy outcomes. Globally, there is growing interest to reduce anaemia among WRA. In Ghana, anaemia among WRA declined at the national level between 2008 (59%) and 2014 (42%). There were also important declines at the sub-national level. The Eastern region (in the south) and Upper West region (in the north) provide an interesting opportunity to understand the decline. Identifying the drivers of anaemia reduction among WRA in Ghana provides important implementation science evidence for designing effective interventions. This current study examined the drivers of reduced anaemia prevalence in women of reproductive age using data from the Ghana Demographic and Health Surveys for 2008 and 2014. Anaemia was diagnosed as haemoglobin<12.0g/dl. Data were summarized using proportions and 95% confidence intervals. A weighted binary logistic-based multivariate decomposition technique was used to identify the potential drivers of anaemia across surveys for 2003, 2008 and 2014. Sensitivity analysis was carried out to test the robustness of the results of the decomposition analysis using haemoglobin concentration. The results of the decomposition analysis were presented as endowment and coefficient effects. Statistical analysis was carried out using Stata version 15. There was an improvement in access to water and sanitation, health services, family planning, and health insurance across surveys. Drivers of anaemia reduction over time at the national level included wealth index and maternal age, education, use of hormonal contraception and body mass index (BMI). In the Eastern region, the drivers of change were household wealth index, maternal age, hormonal contraceptive use and BMI. The drivers of change in the Upper West region, were household access to water, maternal education and BMI. The findings suggest that multi-level interventions are needed across sectors to further reduce anaemia among WRA.Item Dysfunctional labor: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data(Vaccine, 2017-12) Boatin, A.A.; Eckert, L.O.; Boulvain, M.; Grotegut, C.; Fisher, B.M.; King, J.; Berg, M.; Adanu, R.M.K.; Reddy, U.; Waugh, J.J.S.; Gupta, M.; Kochhar, S.; Kenyon, S.Item Effects of Parents Training on Parents' Knowledge and Attitudes about Adolescent Sexuality in Accra Metropolis, Ghana(Reproductive Health, 2017-08) Baku, E.A.; Agbemafle, I.; Adanu, R.M.K.Abstract Background Attitudes of parents about discussing sexuality issues with adolescents may or may not be influenced by their level of knowledge on such issues. This study seeks to examine parents’ training and its effects on parent knowledge and attitudes about sexuality in Accra Metropolis, Ghana. Methods This was an intervention study consisting of 145 parents who were recruited through their wards from 12 public junior high schools in Accra Metropolis. Parents were randomized equally into intervention and control groups and the intervention group received a 4 weeks training on adolescent sexuality topics. At pre-intervention and 3 months after parent training, parents answered questions on knowledge and attitudes about adolescent sexuality. Changes in baseline and follow-up within and between groups were compared using the difference- in-difference model and logistic regression. Results The ages of the parents ranged from 26 to 63 years and 44.1% of them completed middle school. There were 69.9% and 59.7% mothers in the intervention and control groups respectively. At pre-intervention, 21.9% of parents in the intervention group had very good knowledge but this increased significantly to 60% three months after the training. Knowledge about sexuality increased to a lesser degree from 18.1% to 34.7% in the control group. Parents’ positive attitudes towards adolescents’ sexuality increased by 50% in the intervention group compared to 20% in the control group. There were significant differences in knowledge on adolescent sexuality as parents in the intervention group had a greater positive effect than parents in the control group (28.7%, p-valueItem Electronic Learning and Open Educational Resources in the Health Sciences in Ghana(Ghana medical journal, 2010-12) Adanu, R.M.K.; Adu-Sarkodie, Y.; Opare-Sem, O.; Nkyekyer, K.; Donkor, P.; Lawson, A.; Engleberg, N.C.Objectives: To determine whether a group of Ghanaian students are able to easily use electronic learning material and whether they perceive this method of learning as ac-ceptable. Setting: The University of Ghana Medical School (UGMS) and the School of Medical Sciences (SMS), Kwame Nkrumah University of Science and Technology (KNUST) Participants: One hundred and fifty third year medical students at SMS and nineteen fifth year medical students at UGMS Methods: Two e-learning materials were developed, one on the polymerase chain reaction and the other on total abdominal hysterectomy and these were distributed to selected medical students. Two weeks after the distribu-tion of the programmes, a one-page, self-administered questionnaire was distributed to the target groups of stu-dents at the two institutions. Results: Ninety three percent (139) of respondents at KNUST and 95% (18) at UG report having access to a computer for learning purposes. All of the UG students viewed the TAH programme; 82% (130) of the KNUST students viewed the PCR animations. All students who viewed the programmes at both institutions indicated that the e-learning pro-grammes were “more effective” in comparison to other methods of learning. Conclusion: Computer ownership or availability at both medical schools is sufficient to permit the distribution and viewing of e-learning materials by students and the medical students considered both programmes to be very helpful.Item Eradicating cervical cancer(International Journal of Gynecology & Obstetrics, 2019-12-02) Adanu, R.M.K.Cervical cancer is one of the most common causes of death for women in low-and middle-income countries.1 This situation is unacceptable because cervical cancer has been shown to be one of the preventable cancers. Cervical cancer is caused by human papilloma virus (HPV), which is an infectious agent. The pathogenesis of cervical cancer begins with HPV infection and then slowly progresses to a premalignant disease of the cervix, before developing into an invasive disease. This pathogenesis clearly shows that there are many stages and enough time to detect the disease at an early stage and thereby prevent the development of invasive cancer. There are also proven methods of curing cervical cancer if it is detected at the earliest stages of the disease. Cervical cancer is neither a common disease nor a leading cause of death in high-income countries because their health systems have effective measures in place to prevent, detect, and treat the condition. These facts are part of the reason why the World Health Organization (WHO) is leading a campaign to eradicate cervical cancer.2 FIGO is playing an active role in furthering this campaign, and in 2018 launched a joint global declaration on the elimination of cervical cancer with WHO and UNFPA.3 Infectious diseases such as polio have been successfully eradicated from many parts of the world,4 and there are some low-and middle-income countries (LMICs) that have been able to eradicate malaria.5 It is therefore understandable that WHO should take on the task of eliminating cervical cancer, which could be considered an infectious disease.