Antidepressants for people with both schizophrenia and depression

BACKGROUND

Depressive symptoms, often of substantial severity, are found in 50% of newly diagnosed suffers of schizophrenia and 33% of people with chronic schizophrenia who have relapsed. Depression is associated with dysphoria, disability, reduction of motivation to accomplish tasks and the activities of daily living, an increased duration of illness and more frequent relapses.

OBJECTIVES

To determine the clinical effects of antidepressant medication for the treatment of depression in people who also suffer with schizophrenia.

SEARCH STRATEGY

We undertook electronic searches of the Cochrane Schizophrenia Group's Register (October 2000), ClinPsych (1988-2000), The Cochrane Library (Issue 3, 2000), EMBASE (1980-2000) and MEDLINE (1966-2000). This was supplemented by citation searching, personal contact with authors and pharmaceutical companies.

SELECTION CRITERIA

All randomised clinical trials that compared antidepressant medication with placebo for people with schizophrenia or schizoaffective disorder who were also suffering from depression.

DATA COLLECTION AND ANALYSIS

Data were independently selected and extracted. For homogeneous dichotomous data the fixed effects risk difference (RD), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, reviewers calculated weighted mean differences. Statistical tests for heterogeneity were also undertaken.

MAIN RESULTS

Eleven studies met the inclusion criteria. All were small, and randomised fewer than 30 people to each group. Most included people after the most acute phase of psychosis and investigated a wide range of antidepressants. The quality of reporting varied a great deal. For the outcome of 'no important clinical response' antidepressants were significantly better than placebo (n=209, 5 RCTs, summary risk difference fixed effects -0.26, 95% CI -0.39 to -0.13, NNT 4 95% CI 3 to 8). The depression score at the end of the trial, as assessed by the Hamilton Rating Scale (HAM-D), seemed to suggest that using antidepressants was beneficial, but this was only statistically significant when a fixed effects model was used (n=261, 6 RCTs, WMD fixed effects -2.2 95% CI -3.8 to -0.6; WMD random effects -2.1 95% CI -5.04 to 0.84). There was no evidence that antidepressant treatment led to a deterioration of psychotic symptoms in the included trials. Heterogeneous data on 'any adverse effect' are equivocal (n=110, 2 RCTs, RD fixed 0.11 CI -0.03 to 0.25, Chi square 7.5, df=1, p=0.0062). In one small study extrapyramidal adverse effects were reported less often by those allocated to antidepressant (n=52, 1 RCT, RD fixed -0.28 CI -0.5 to -0.04). Only about 10% of people left these studies by 12 weeks. There was no apparent difference between those allocated placebo and those given an antidepressant (n=426, 10 RCTs, RD fixed 0.04 CI -0.02 to 0.1).

REVIEWER'S CONCLUSIONS

Overall, the literature was of poor quality, and only a small number of trials made useful contributions. Though our results provide some evidence to indicate that antidepressants may be beneficial for people with depression and schizophrenia, the results, at best, are likely to overestimate the treatment effect, and, at worst, could merely reflect selective reporting of statistically significant results and publication bias. At present, there is no convincing evidence to support or refute the use of antidepressants in treating depression in people with schizophrenia. We need further well-designed, conducted and reported research to determine the best approach towards treating depression in people with schizophrenia.

The Hybrid III 10-Year-Old Dummy

This paper describes the design and development of the Hybrid III 10-year-old crash test dummy. The size of the dummy was chosen to fill the gap between the Hybrid III 6-year-old and the Hybrid III small adult female dummy which is also about the size of a 13-year-old teenager. Characteristic dimensions and segment weights of the dummy are based on the anthropometry of the average 10-year-old. Biofidelity response guidelines for forehead, sternum and knee impacts and for fore/aft neck bending are scaled from the midsize adult male biofidelity guidelines taking into account the effects of differences in size, mass and material properties due to the age difference. The dummy is similar in construction to the other Hybrid III dummies except it has an adjustable lumbar spine which allows the dummy to slouch and its neck structure is aligned with its thoracic spine. Data are given showing the responses of the prototype dummy relative to its biofidelity guidelines. The prototype dummy was evaluated in out-of-position air bag tests and three-point belt tests to evaluate its durability and ease of use. The prototype dummy has demonstrated acceptable biofidelity, repeatability and durability and the design has been approved by the SAE Hybrid III Dummy Family Task Group for production.

Development and Testing of a Prototype Pregnant Abdomen for the Small-Female Hybrid III ATD

A new prototype pregnant abdomen for the Hybrid III small-female ATD is being developed and has been evaluated in a series of component and whole-dummy tests. The new abdomen uses a fluid-filled silicone-rubber bladder to represent the human uterus at 30-weeks gestation, and incorporates anthropometry based on measurements of pregnant women in an automotive driving posture. The response of the new pregnant abdomen to rigid-bar, belt, and close-proximity airbag loading closely matches the human cadaver response, which is thought to be representative to the response of the pregnant abdomen. In the current prototype, known as MAMA-2B (Maternal Anthropomorphic Measurement Apparatus, version 2B), the risk of adverse fetal outcome is determined by measuring the peak anterior pressure within the fluid-filled bladder. Peak internal bladder pressures measured in a series of sled-test simulations of frontal crashes of different severities and occupant-restraint conditions have been correlated to the likelihood of adverse fetal outcome based on risk curves developed from in-depth investigations of real-world crashes involving pregnant occupants. Compared to the original pregnant abdomen, the new prototype has improved geometry and improved impact response to a range of potential in-vehicle loading conditions, However, additional instrumentation development and more rigorous testing are needed before the MAMA-2B can be confidently used to assess restraint system performance with regard to reducing the likelihood of adverse fetal outcome in motor-vehicle crashes.

The relation between mortality from malignant melanoma and early detection in the Cancer Research Campaign Mole Watcher Study

Between 1987 and 1989 the Cancer Research Campaign funded a health education programme for the early detection of cutaneous malignant melanoma in the general population in 6 health districts of England and 1 health board in Scotland (population of 3 million). The intervention was evaluated by studying its effects on annual and cumulative mortality rates for melanoma. Population-based data on mortality from melanoma were collected in the intervention areas, the health regions covering those areas, and 5 other health regions of England from 1981 to 1996. Deaths from melanoma in cases diagnosed after the start of the intervention were used to study cumulative mortality rates. The annual mortality rates for melanoma, 1981 to 1996, showed no significant difference in their trends between the intervention areas, and other areas of England and Wales. After adjustment for pre-intervention rates, there was also no significant reduction in cumulative mortality from melanoma in the intervention areas compared with the non-intervention areas: rate ratio 1.2 (95% Cl 0.9-1.7) in men, 0.9 (95% Cl 0.7-1.3) in females. The lack of a significant reduction in melanoma mortality associated with the intervention raises questions about this approach to early detection and emphasises the need for new strategies.

Survey of the rate of PSA testing in general practice

The use of prostate specific antigen (PSA) test could have a large impact on the incidence of prostate cancer in the UK. Over a period of 1 year (1999), 3.5% out of 160 015 men aged > 45 on a GP database, who had no previous record of prostate cancer, had a PSA test. Of the tested men, 21.3% had a PSA > 4 ng/ml. Future data need to distinguish between men with and without symptoms.

LiCB(11)Me(12): a catalyst for pericyclic rearrangements

[structure: see text] Benzene and 1,2-dichloroethane solutions of the Li(+) salt of the weakly coordinating anion CB(11)Me(12)(-) catalyze the rearrangement of cubane to cuneane, quadricyclane to norbornadiene, basketene to Nenitzescu's hydrocarbon, and diademane to triquinacene. The Claisen rearrangement of phenyl allyl ether is also strongly accelerated.

Is targeted early detection for melanoma feasible? Self assessments of risk and attitudes to screening

OBJECTIVES

To study the feasibility of developing targeted screening for those at high risk of melanoma by examining how attitudes relate to (a) acceptance of an invitation for a free skin check and (b) self assessed and clinically assessed risk factors for developing cutaneous melanoma.

DESIGN

A population based cross sectional survey.

SETTING

A general practice with a broad mix of socioeconomic groups in one district health authority.

SUBJECTS

A total of 1600 subjects aged 25-69 years stratified using the social deprivation score of wards were randomly selected from a population of 8000; 77% (1227) returned the questionnaire and 56% (896) attended for screening.

MAIN OUTCOME MEASURES

Questionnaire measures of confidence in own ability to self assess risk factors for melanoma, attitudes to seeking medical help for skin abnormalities, and self assessment of relative risk of developing melanoma.

RESULTS

Clinic attenders were less confident in their ability to self assess risk factors (p<0.005), more favourable towards seeking help (p<0.001), and more pessimistic about developing melanoma (p<0.001) than non-attenders. Those from more affluent wards were more willing to seek help (p<0.001). Those clinically assessed as at higher risk were more pessimistic about developing melanoma (p<0.001) but clinical assessments were inconsistently related to help seeking attitudes and self assessment confidence.

CONCLUSIONS

Barriers to the uptake of screening included greater optimism about not developing melanoma, confidence in self assessment, and reluctance to seek professional help. Such reluctance was greater in more deprived social groups. Targeting screening at high risk groups cannot depend on self identification and self referral.

Renomedullary interstitial cells in culture; the osmolality and oxygen tension influence the extracellular amounts of hyaluronan and cellular expression of CD44

Our previous studies have suggested a role for renomedullary interstitial cells (RMICs) and renal medullary hyaluronan (HA) in water homeostasis. In the present study, cultured rat RMICs were used to examine the relationship of osmolality and oxygen tension on the extracellular amount of HA in the culture and to the cellular immunoreactivity to CD44, a HA binding protein. Under isotonic (330 mOsm(.)kg(-1) H(2)O), normoxic (20% O(2)) conditions, supernatant from sub-confluent RMICs contained 120+/-37 pg 10(4) cells(-1) 24 h(-1) of HA. Under hyperosmotic conditions (630 mOsm kg(-1) H(2)O), HA in the supernatant was decreased by 42% and under hypoosmotic conditions (230 mOsm kg(-1) H(2)O) it was doubled. Under hypoxic, iso-osmolar conditions (5% and 1% O(2), 330 mOsm kg(-1) H(2)O) this HA content was decreased by 56 and 48%, respectively, compared with normoxic, iso-osmolal conditions. Expression of CD44 on sub-confluent cells increased with increasing osmolality, as shown by immunostaining and flow cytometric analysis. The increases in CD44 from 330 to 630, 930 and 1230 mOsm kg(-1) H(2)O amounted to 5, 142 and 212%, respectively. Low oxygen tension (5% O(2)) decreased the intensity of CD44 immunofluorescence by 31%. Cell viability was similar at all conditions studied. In summary, these data indicate that cultured RMICs produce HA and are immunoreactive to CD44. In the supernatant of RMICs, the HA content decreases under hyperosmotic, hypoxic conditions. Conversely, CD44 immunoreactivity increases under hyperosmotic conditions. These results may explain our previous in vivo findings of a decreased renal papillary HA content during anti-diuresis and an increased content during water diuresis. The results support the concept that RMICs play an important role in renal water handling.

An audit of psychiatric case notes in relation to antipsychotic medication and information giving

This paper reports upon a Welsh Office funded "clinical effectiveness" project. The project aimed to produce evidence-based practice guidelines for depot neuroleptic medication. An audit was conducted to establish current practice regarding the provision of illness and treatment specific information to out-patients and their informal carers. Sixty-five patients' case-notes, under the care of a single community mental health team were examined for evidence of the type, nature and frequency of information given to patients receiving typical depot neuroleptic medications. Service guidelines were produced and are presented.

BIOMED-MEROPE project: service provision for adults with intellectual disability: a European comparison

The aim of the present paper is to describe and compare services for adults with intellectual disability (ID) and mental health needs in five European countries: Austria, England, Greece, Ireland and Spain. A framework and structure for collecting information about service provision was designed. This information was collected through a mixture of interviews with service providers, questionnaires and a review of the research literature within each country. Information was collected on historical context, policy, legislation, assessment, treatment and the structure of services for people with ID and mental health problems. Overall, the needs of those with additional mental health needs have not been specifically addressed at a national level with perhaps the exception of England and Ireland, although there are still gaps in services in these nations. Normalization has been adopted in each of the five countries, and there are moves toward deinstitutionalization, integration and inclusion. Families and self-advocacy groups have grown. The pace of this change varies between and even within countries. The main findings of the study include: unclear policy, trends for legislative changes, increased prevalence of mental health problems, inadequate generic service provision, a need for specialist mental health services, a need for improved interconnections of services, and a need for training developments. Policy and legislation in the five European countries under consideration tend to separate the disability aspects of people with ID from their mental health needs. Consequently, the service needs of this group remain largely invisible. This might be a direct reflection of policy clarity and legislation, or could be the result of a failure to implement existing guidelines. This has a detrimental effect on the lives of people with ID, and their families and carers.

Psychiatric symptoms in adults with learning disability and challenging behaviour

BACKGROUND

In people with learning disability one of the most frequent reasons for psychiatric referral is challenging behaviour.

AIMS

To determine what proportion of people with challenging behaviour actually have psychiatric symptoms.

METHOD

Using an instrument specifically designed for use by informants, a sample of 320 people with administratively defined learning disability, with and without challenging behaviour, was surveyed for the presence of psychiatric symptoms.

RESULTS

Increasing severity of challenging behaviour was associated with increased prevalence of psychiatric symptoms, depression showing the most marked association. Anxiety symptoms were associated with the presence of self-injurious behaviour.

CONCLUSIONS

There is clearly the potential for reducing challenging behaviour by improved identification and treatment of coexisting psychiatric disorders. The possibility of modifying diagnostic criteria for depression in people with learning disability, by including aspects of challenging behaviour, merits attention.

Evaluation of primary prevention initiatives for skin cancer: a review from a UK perspective

To ensure effective primary prevention of skin cancer, aimed at changing behaviour in the sun, and ultimately at reducing the incidence and mortality rates from skin cancer, sufficient information needs to be known about the relationship between sun exposure and skin cancer, the effectiveness of sun protection measures, and the acceptability and uptake of protective measures by the general public. This review specifically addresses the quality and outcome of studies designed to evaluate the impact of primary prevention initiatives in the U.K. Four main areas of concern are highlighted: (i) teenage behaviour in the sun is difficult to change; (ii) fashion, in part, dictates adult and adolescent behaviour in the sun; (iii) there are practical problems related to response rates, follow-up and interpretation of self-reported behaviour; and (iv) a strategy for primary prevention in the U.K. may be falsely based on the experience and results of Australian and American programmes. Standardized methods for monitoring general population behaviour are needed in the U.K. Evaluation of interventions targeting specific groups, especially parents and young children, and the relative costs of different strategies should be reported. Primary prevention messages and strategies should be adapted to the type of ultraviolet radiation exposure experienced, and the overall low risk of melanoma, while addressing controversies on the health effects of sun exposure and sun screens.

Interleukin 10-induced thrombocytopenia in normal healthy adult volunteers: evidence for decreased platelet production

Recombinant human interleukin 10 (rhuIL-10) inhibits the production of proinflammatory cytokines and has shown promise in the treatment of inflammatory bowel disease. Clinical trials have been accompanied by a reversible decline in platelet counts. We conducted a randomized, double-blinded, placebo-controlled, parallel group trial in 12 healthy volunteers to investigate the aetiology of rhuIL-10-induced thrombocytopenia. Eight volunteers received 8 microg/kg/d of rhuIL-10 subcutaneously, while four subjects received a placebo alone for 10 d. A reversible decline in the platelet counts from a mean of 275 x 10(9)/l to 164 x 10(9)/l was observed in the IL-10-treated cohort (P = 0.012). A fall in the haemoglobin mean levels was also observed in the IL-10-treated cohort from 13.7 to 11.7 g/dl (P = 0.011). No significant change was observed in the bone marrow cellularity or myeloid/erythroid ratio or in the number of megakaryocytes per high-powered field (HPF). A fall was observed in the number of megakaryocyte colony-forming units (CFU-MKs) after the administration of IL-10 compared with those receiving the placebo (P = 0.068). No difference in the change in granulocyte-macrophage CFUs (CFU-GMs), mixed lineage CFUs (CFU-GEMMs) or erythroid burst-forming units (BFU-Es) was observed when comparing the IL-10- vs. placebo-treated groups (P > 0.465). Serum cytokine levels of thrombopoietin (TPO). IL-6 and granulocyte-macrophage colony stimulating factor (GM-CSF) were not decreased following IL-10 administration. In fact, both TPO and GM-CSF appeared to be slightly increased in the serum. All subjects underwent In111-labelled platelet survival studies with liver/spleen scans to assess splenic sequestration prior to and then on day 7 of treatment. A significant reduction in splenic sequestration of platelets (P =0.012) was observed in the IL-10-treated group, but not in the placebo-treated subjects.

Intranodal hemangioma of the oral soft tissues: a case report of a rare entity with review of the literature

The presentation of a primary vascular tumor in a lymph node is a rare occurrence. Only 16 documented cases have been reported to date, with none described in the oral soft tissues. This case report presents the first occurrence of an intra-nodal hemangioma of the oral soft tissue in an 11-year-old girl. A review of the literature is also presented.

A comprehensive program to improve safety for pregnant women and fetuses in motor vehicle crashes: a preliminary report

OBJECTIVE

A program was developed to study the mechanisms of abruptio placentae and pregnancy loss caused by motor vehicle crashes. The results were intended to be used to develop strategies to improve protection of the fetus in this setting.

STUDY DESIGN

Four integrated projects were conducted: (1) seated anthropometric measurements and belt fit determination during pregnancy, (2) development of new models of traumatic abruptio placentae, (3) investigations of crashes involving pregnant women, and (4) the development of the second-generation pregnant crash dummy from these data and others.

RESULTS

Twenty-two different pregnant subjects in five different height groups underwent serial measurements of abdominal surface contours, seat belt fit, and distances between the subjects and various landmarks in the automobile interior with a laboratory-designed "automobile seat" (seating buck). The abdomen was significantly closer to the steering wheel in the shorter stature group than among the taller women. Beginning at approximately 20 weeks' gestation the fundus of the uterus was above the lower rim of the steering wheel. Lap belts fit properly over the anterior superior iliac spine throughout gestation, but the lap belt overlapped the uterus in the midsagittal plane. Two separate mechanisms for traumatic abruptio placentae were tested: shear failure and tensile failure. In the shear failure model large circumferential strains in the uterine wall induce a shear strain across the uteroplacental interface, and the model predicts placental separation at a mean circumferential strain of -58% +/- 8%. By means of finite-element modeling, it was demonstrated that tensile failure might also be a mechanism that causes abruptio placentae during rapid deceleration of the uterus. Crash investigations were performed in 43 cases involving pregnant women beyond 20 weeks' gestation. There were a total of 8 fetal losses and 8 major complications (fetal survival with abruptio placentae, direct fetal injury, or preterm delivery before 34 weeks' as a result of the accident). The best predictors of fetal loss or adverse outcome were impact severity and proper seat belt use. With these newly acquired data a second-generation crash dummy, known as the Maternal Anthropomorphic Measurement Apparatus version 2b (MAMA-2b), is being developed. It incorporates strain gauges in the fundal region of the fluid-filled uterus plus pressure transducers in both the anterior and posterior uterus. Criteria are being developed to associate the likelihood of abruptio placentae with measurements from these instruments that correspond to the two major hypothesized mechanisms of abruptio placentae.

CONCLUSION

An improved understanding of the elements of automobile crashes that cause fetal loss and other major pregnancy complications has been gained through this series of investigations.

Feasibility of targeted early detection for melanoma: a population-based screening study

The feasibility of targeted screening for cutaneous malignant melanoma in the UK using a postal questionnaire and invitation to screening by a consultant dermatologist was investigated in a population based cross-sectional survey. A total of 1600 people aged 25-69 years, stratified by the social deprivation score of wards within one general practice, were randomly selected from a population of 8000.1227 (77%) returned the questionnaire and 896 (56%) attended the screening clinic. Uptake was lower for men (P<0.001), those aged under 50 (P<0.001), people from deprived areas (P<0.001) and skin types III and IV (men only, P<0.001). Twenty per cent of women and 10% of men felt nervous about attending the clinic, but only 4% were worried by the questionnaire. The level of agreement between the self- and dermatologist's assessments of risk factors was best for hair colour (Kappa = 0.67, sensitivity 73% and specificity 98%). People tended to under-report their level of risk. Over 95% knew about at least one major sign, but 54% reported incorrect signs of melanoma. Targeted screening for melanoma in the UK will be hampered by difficulties in accurately identifying the target population. Strategies to improve skin self-awareness rather than screening should be developed and evaluated.

The unreliability of clinical measures of muscle tone: implications for stroke therapy

BACKGROUND

the central tenet of the neurofacilitatory approach to stroke therapy is that muscle tone needs to be normal before normal movement can occur. A reliable clinical measure of the full spectrum of muscle tone is needed to test: (i) the purported relationship between muscle tone, other motor impairments and disability, and (ii) the effectiveness of stroke therapy to restore movement.

AIM

the purpose of the study was to test the inter-rater reliability of clinical categorization of muscle tone (spastic/normal/flaccid) and also a visual analogue scale with anchor points of 'lowest tone possible' (score 0) and 'highest tone possible' (score 100).

METHODS

four independent raters assessed tone of elbow flexors and knee extensors of 14 stroke rehabilitation inpatients using the categorical scale. Six independent raters assessed tone of elbow flexors and knee extensors of 25 chronic stroke patients and two healthy volunteers using the visual analogue scale. All assessment orders were randomized.

RESULTS

both scales were unreliable, with K coefficients for the categorical scale ranging from -0.046 to 0.56 for the categorical scale, and intra-class correlation coefficients for the visual analogue scale of 0.595 for elbow flexors and 0.451 for knee extensors. Assessment order effects for the visual analogue scale were non-significant for elbow flexors (P= 0.545) and knee extensors (P= 0.911).

CONCLUSIONS

these results, and those of earlier studies, suggest that clinical measures of muscle tone are consistently unreliable. Systematic investigation of the therapy rationale for planning and evaluating treatment is required before relevant clinical measures can be developed.

Mental health services for people with intellectual disability: a conceptual framework

The present paper discusses the application of the 'matrix model' to mental health services for people with intellectual disability. There is great variability between the service models in this area, which makes comparisons and conclusions difficult. The present model facilitates the breaking down of these complexities into understandable parts so that future directions for research, service planning and delivery can be logical, coherent and evidence-based.

A trial to study the effect on breast cancer mortality of annual mammographic screening in women starting at age 40. Trial Steering Group

OBJECTIVE

Although there is clear evidence from randomised trials of the effectiveness of mammographic screening in women over 50 in reducing mortality from breast cancer, the benefit of screening in younger women remains less certain. This paper describes a randomised controlled trial in progress to study the effect on breast cancer mortality of annual mammographic screening of women starting at age 40-41.

SETTING

Screening centres of the NHS Breast Screening Programme.

METHODS

In 1991 a national multicentre randomised controlled trial was set up by the United Kingdom Coordinating Committee on Cancer Research (UKCCCR). This trial (the "age" trial) aims at recruiting 195,000 women aged 40-41 such that 65,000 form a study group and the remaining 130,000 a control group. Women in the study group are invited for annual screening by mammography, and become eligible for the National Health Service Breast Screening Programme (NHSBSP) after age 50. Those in the control group are not offered any additional services, but will also join the national programme after age 50. All malignant breast histology in trial women is recorded.

ANALYSIS

The principal method of evaluation will be the comparison of cumulative breast cancer mortality rates in the study and control groups; interim analyses of prognostic factors of breast cancers will also be possible. Additional NHS screening costs incurred owing to lowering the age of screening will be assessed as part of an economic evaluation. The amount of unscheduled screening occurring in the control group of the trial will also be assessed.

[The factors that determine participation in cervical cancer screening in the state of Morelos]

OBJECTIVE

To determine the main factors associated to participation in an early detection program of cancer (DPC), in a population with a high cervical cancer (CC) mortality rate.

MATERIAL AND METHODS

A population-based, cross-sectional study was performed in the state of Morelos, which included 3,197 women aged between 15 and 49 years, randomly selected from a household sample frame of the 33 municipalities of the state.

RESULTS

Awareness of the utility of the Papanicolaou (Pap) test (OR 29.6, 95% CI 23.6-37) and a former history of gynecological symptoms (OR 1.7, 95% CI 1.2-2.4) predisposed to greater use of the DPC. Factors associated to the use of the Pap test were precedents of using one contraceptive (OR 1.4, 95% CI 1.1-1.8) or two or more contraceptives (OR 2.1, 95% CI 1.6-2.8).

CONCLUSIONS

In the state of Morelos, Mexico, screening for cervical cancer is offered opportunistically in the context of health care use. Therefore, the precedent of using health care services is the main determining factor for use of the DPC program. These results reveal the need to design alternative strategies to promote participation among women who have no access to health services, since they constitute the population group at highest risk of developing CC.