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Community health is a crucial element in the society subject to the increased health problems. In the US health matters have gained a lot of concern in line with the quality and affordability of the service. In line with this, the paper will discuss the issue of EpiPen price increase. It is noted that EpiPen is an important drug in particular among the children having allergic conditions. Also, the paper will address the issue of HPV reduction as a result of vaccine among teenage girls. Then there is the problem of obesity whereby it is one of the controversial issues facing parents in the US.
Khazan (2016) adequately discusses the issue of EpiPen price increase is noting that it is a significant burden to most parents. The absurdity of the situation is adequately explained noting that parents will have to pay for more than $1,200 for four EpiPens. It is an important drug noting that is capable of reversing an allergic reaction when it hits a person too high. However, parents are struggling as the price continues to rise. It is a major challenge to the community health since today allergic conditions are common among most children. The prices that the drug is being sold is extremely high compared to that the same drug is being sold in France which is $85. The other concern is high-deductible insurance plans. It is explained that due to this people will be forced to pay full-price for EpiPens. The problem in such a situation is that most will not afford the drugs and this will deteriorate the health conditions of the allergic people.
Cancer has been identified as one of the most dangerous diseases in this era. Hoffman (2016) discusses that vaccine has reduced HPV among teenage girls tremendously. The (HPV) is a sexually transmitted disease and connected to various types of cancer. The reduced spreading of the virus in the society is a positive aspect in the community. There is a suggestion that the vaccine is given to children at the ages 11 and 12 since this age children immune response is more robust that at adolescent. The HPV is a significant problem in the US noting that it is estimated that 14 million people are infected each year. It is held that if the conditions persist one could suffer from throat, mouth, penile, anal, and cervical cancer. Besides the success of the disease, there is a large number yet to be vaccinated. The issue with sex activity whereby the drug is associated with reduced activeness. It is a social norm that even prevents the doctors from discussing and encouraging people to undertake the vaccination fully.
Brody (2016) analysis various studies conducted on childhood obesity and its impacts on health at a later age. Numerous studies indicate that among the notorious diseases as Type 2 diabetes, stroke, cancer and heart diseases are as a result of childhood consequences. A study conducted in Denmark reveals that becoming overweight at age thirteen heightens the risk of getting colon cancer by 9 percent. The another study noted is that of Danish people where it is held that danger of getting a clot-related stroke in early adults occurs when one starts to become overweight at the age of 13. Therefore, the article correctly presents a major issue being witnessed in the society today as more children continue to become obese. One of the elements contributing to obesity is the consumption of junk food since most parents are busy working and cannot get time to cook.
It is right to state that the three articles primarily reveal health conditions that affect children in the case of EpiPen if the prices continue to increase to the extent that the parents cannot afford then most children will suffer. It is problematic because allergic conditions also associate to other health problems. Thus, it would be right for the government to intervene this situation. Also, the case of HPV is a serious problem especially in this era where cancer continues to increase.
The challenge is to include more children in the vaccination bracket due to concern on sexual activeness. However, parents and teens require advice on the importance of being vaccinated. It would be right to emphasize the importance of preventing cases of cancer at an early age as possible. Also, children are the victims of the obese condition. The role in preventing the increase in obesity lies on the parent since; the situation starts to advance mostly at the age of 13 and at that age children are under the care of parents or guardians.
In conclusion, community health is a crucial element in the society. To achieve a healthy society calls for a contribution of various parties. The government is obliged in ensuring people get quality and affordable care while parents ensure that they seek conditions healthy for their children. The articles have revealed significant issue is affecting the Americans today. There is the need to ensure that health matters are properly and timely addressed especially in the case of children obese situation through healthy eating.
Jan Hoffman (22 February 2016). HPV Sharply Reduced in Teenage Girls Following Vaccine, Study Says.
Jane E Brody (5th July 2016). The Urgency in Fighting Childhood Obesity.
Olga Khazan (24th August 2016). Have You Ever Tried to Buy an EpiPen?
Breast cancer has led to huge loss of lives all across the world. The complexity of the disease has led to implementation of various policies to help the victims recover or increase their survival conditions. Breast cancer has shown prevalence on African-American women more than on Caucasian women. Physical adaptations and difference in genetic composition may cause the mortality disparity among race. However, the main cause of the mortality disparity is still unclear despite years of research.
The main objective of this essay is to create a Public Health National Assessment Tool (PHNAT) in order to assess the breast cancer mortality-disparity between women of different races. The Public Health Assessment Tool will evaluate all political, health and social aspects that may influence the mortality disparity between different races concerning breast cancer.
Breast cancer cases and mortality rates have declined in the past decade. However, the decline in breast cancer cases and mortality rates is higher in white women compared to black women in the American society. Health officials indicate that the disparity could have been caused by the biological factors, healthcare access and socio-economic factors between women of different races in America (Jatoi, Chen, Anderson & Rosenberg, 2007). In order to assess the disparity in breast cancer cases and mortality rates, this assessment examines the individual, family and population statistics disparity between the races.
Individual and Community Assessment
The impact of health care access and socio-economic factors at neighboring and individual levels could lead to racial disparities in mortality, breast cancer screening and survival rates. According to data provided by the Special Cancer Behavioral Risk Factor Survey, a regular healthcare provider insured the most vital predictors of sufficient breast cancer screening (Jatoi, Chen ,Anderson & Rosenberg, 2007). The survey examined the disparities between black and white women using the National Longitudinal Mortality Study (NLMS). The racial differences were cancelled out after adjusting for treatment variables and socio-demographic variables.
According to the Michigan Department of Community Health, there were racial differences reported in the annual breast cancer breast cancer mortality- rate and the percentage of late stage trends in Michigan (Michigan report, 2011). The report indicated that the rate of mortality was consistently higher among black women compared to white women. Further, the late stage of presentation among black women was higher compared to white women despite the socio-economic conditions and healthcare access. However, while comparing the annual breast cancer data, white women showed an increasing rate of late-stage breast cancer presentation. This may be caused by the low screening rates that result from lack of health insurance due to high unemployment rate in Michigan.
The Michigan report findings suggest that the improvement of the access to timely screening and adequate treatment of uninsured populations will improve the rate of breast cancer cases in the region. This would reduce the rate of breast cancer mortality caused by racial disparity and socio-economic status (Michigan report, 2011).
Comparing breast cancer disparity with international populations
In order to compare the racial differences between American citizens and immigrants, I compared breast cancer survival-rates between U.S born Asians and immigrant Asians (Baquet, Mishra, Commiskey, Ellison & DeShields, 2008). The data used in this case study was retrieved from the California Cancer Registry. The data insinuated that U.S born Asian women had similar mortality rates in breast cancer cases. On the other hand, U.S born Asian women had a higher cancer survival rate compared to immigrant Asian women (Jatoi, Chen, Anderson & Rosenberg, 2007). The differences in breast cancer mortality-rates among U.S born and immigrant Asian women may indicate variations in cancer treatment and socio-demographic factors between different countries.
The international breast cancer survival-variations imply that the American population is well supported with breast cancer treatment options. Moreover, the international disparities in breast cancer survival-rates are also similar when comparing U.S born and immigrant black populations. Therefore, the national differences may also influence the rate of breast-cancer mortality because of the healthcare infrastructures present in different countries.
Access to Healthcare
The National Cancer Institute explains that the cancer health disparities as the differences in new cancer cases, cancer prevalence, cancer mortality-rates and cancer survivors among specific population groups within the United States. Some population groups are characterized by age, education, geographic location, disability, ethnicity, race or income. Poor populations lack health insurance and they are medically under deserved. This limits their access to all levels of access to healthcare services (Baquet, Mishra, Commiskey, Ellison, DeShields, 2008). This is regardless of the ethnicity or racial background of the cancer patients. Therefore, there are high death statistics among cancer patients, despite their racial background, who are low-income earners compared to the general American population.
Nevertheless, interrelated complex factors contribute to the observed racial cancer disparities in the United States. The main factors that lead to the racial and ethnic cancer mortality disparity are lack of healthcare coverage and low socio-economic status.
Socio-economic factors include the per capita income, education level and job occupation among other factors. Further, the social status of the community where various cancer patients live indicate the mortality-rate disparity among cancer patients. Socio-economic factors lead to cancer disparity rates more than racial and ethnic differences of the cancer patients (Michigan report, 2011). This is because the socio-economic status of different populations affects their access to education, health insurance, certain occupations and living conditions. The living condition of various populations may predispose cancer patients to environmental toxins that increase their cancer-mortality rates compared to other populations.
Behavioral Risk Factors
Behavioral factors may also cause the racial disparities between black and white breast-cancer patients. Poor societal behaviors such as tobacco smoking, physical inactivity, drug abuse, obesity and health status lead to disparity in breast-cancer mortality rates. These unhealthy behaviors increase the prevalence of breast cancer among various populations compared to healthy populations. Furthermore, different health state policies may lead to disparity in cancer mortality-rates. For instance, some states have improved their cancer screening measures to all populations compared to other states. Thus, this leads to a disparity in cancer related cases among different inter-state communities.
Therefore, under deserved populations show high cases of patients diagnosed with late-stage cancer diseases (Jatoi, Chen, Anderson & Rosenberg, 2007). In comparison, other states show low breast-cancer mortality rates because of early cancer screening and diagnosis. Moreover, differences in cultural, physical and financial factors limit certain populations from obtaining effective health care access.
Analysis of health Status
Breast cancer is the most dominant female cancer in the United States. There are high rates of new cancer cases in the country. For instance, in 2012, there was a 29% increase in new cancer cases all across the United States. According to annual cancer reports, the median age of cancer diagnosis is 61 years. This is because most of the diagnosed cancer patients were aged between 55-64 years (Baquet, Mishra, Commiskey, Ellison, DeShields, 2008). Even though breast cancer mortality- rates and new cases have steadily reduced over the past decade, the decline was mostly caused by the decline of breast-cancer cases in young women. However, the reduction of breast cancer cases among young women may be influenced by the increasing prevalence of obesity. Obesity is considered as a protective risk factor for pre-menopausal breast-cancer patients.
Between 1999 and 2006, there was 89% breast-cancer survival rate. Stage diagnosis is considered as a vital determinant of breast cancer survival. The diagnosis of cancer in its early stages and use of appropriate treatment increased population survival rate. When breast cancer is diagnosed at its localized stage, the disease becomes confined to the primary site. For instance, a five-year relative survival rate was 98%, when the disease is diagnosed at its localized state when the disease is confined to the primary site. In comparison, the five-year relative survival rate was 84%, when the disease is at the regional stage and it has spread to the lymph nodes. On the other hand, a five-year relative survival was 23% when cancer is diagnosed at its distant stage where the cancer has metastasized (Baquet, Mishra, Commiskey, Ellison & DeShields, 2008).
In the United States, the breast-cancer cases and mortality rates showed differences when compared between racial groups. The white population of cancer patients was 126.5 per 100,000 and the mortality rate of the patients was 23.4 per 100,000 in 2003-2007. On the other hand, the black population of breast-cancer patients was 118.3 per 100,000 and the rate of mortality among these patients was 32.4 per 100,000 in 2003-2007. Breast-cancer mortality cases have consistently reduced since 1990’s. However, the reduction is uneven when comparing the black and white racial groups. Breast cancer mortality reduced by 2.4% annually for the white women population, whereas the disease declined by 1.1% annually for the black women population in the United States (Baquet, Mishra, Commiskey, Ellison & DeShields, 2008).
Prioritize Public Health Issues
When breast cancer patients receive mammography screening at early stages of the disease, treatment is more effective, further, when screening is done early enough the survival rate is high for breast cancer patients. According to health records, the mammography utilization rates between white and black women populations were almost similar over the last decade (Baquet, Mishra, Commiskey, Ellison & DeShields, 2008). Despite the similarity in mammography utilization between the two races, racial disparity in early cancer detection was still present. There were high levels of black women in the breast cancer mortality and survival rates. Thus, it is crucial to examine the factors that contribute to the racial breast-cancer disparity in the United States.
According to health reports, healthcare access is the intermediary factor between socio-economic factors and poor breast cancer outcomes (Jatoi, Chen, Anderson & Rosenberg, 2007). Low socio-economic status influences poor breast cancer outcomes because of the limited access to healthcare services. This is evident by the low numbers of mammography screening observed in poor women. Further, lack of adequate or timely diagnosis is caused by lack of health insurance and other competing priorities for the poor populations. Improving the rate of timely and adequate cancer patient-care services could improve the breast cancer cases for populations with poor socio-economic status among black women.
According to a research conducted by Andersen, prioritizing public healthcare access will reduce the breast-cancer disparity (Jatoi, Chen, Anderson & Rosenberg, 2007). A comprehensive behavioral model, which incorporates healthcare utilization concerning predisposing, enabling and need factors for the breast cancer patients, is necessary. These predisposing factors that influence individual access to health care system include age, gender and race. Consequently, the government should also prioritize enabling factors such as income, travel time to facility, waiting time at facility and health insurance.
A review of the report by Andersen shows that behavioral models include individual level predisposing factors such as race, marital status, household size and income (Jatoi, Chen, Anderson & Rosenberg, 2007). In addition, behavioral models should also include individual level enabling factors such as health insurance and routine physical examination on breast cancer patients. On the other hand, the government should also focus on the behavioral model in order to improve the neighborhood level enabling factors for breast cancer patients. These neighborhood level enabling factors include the number of physicians, number of mammography centers, number of healthcare centers and designation of certain under deserved areas as Health professional Shortage Areas.
Plan and Implementation Using Minnesota Intervention Wheel Strategies
The nursing professional has played a primal role in the management of breast-cancer in the United States. Historically, nurses have enabled the public health sector to provide patient-centered care. The shortage of the nursing profession workforce insinuates an obstacle in the management of breast-cancer. Further, the aging nursing workforce and low unemployment levels in the United States shows a possible workforce shortage in the future. In order for the public health infrastructure to accommodate sufficient nurses, various changes are essential in the education, policy, regulations, and healthcare delivery systems.
The complex nature of how patients are cared for in a properly managed health center calls for increased nursing services. Nursing services are needed in order to reduce lengthy hospital stays and acute primary care in the community setting. Therefore, this insinuates the need for highly skilled nurses. The supply of nurses needs to be increased rather than being redistributed. The shortage of the nurses’ workforce is deemed to worsen in the next decade when more nurses retire. Thus, this calls for major structural changes within the nursing profession. The past economic solutions to increase the nurses’ workforce such as sign-on bonuses, new premium packages or relocation coverage need to be restructured as they only relocate nurses rather than increase the number of nurses.
Some of the structural changes that may help increase the nurses’ workforce include time over money. Time over money insinuates that employees seek more personal time compared to overtime-financial compensation they receive for overtime. Further, nurses are burdened by the increasing working hours and few hours of personal time. Thus, nurses should be given adequate professional and personal consideration. There is a rising trend of new employees seeking for less stressful jobs that offer more personal time (Baquet, Mishra, Commiskey, Ellison, DeShields, 2008). This has led to a low rate of application for the nursing role among young American citizens. The government should consider offering incentives for the nursing profession in order to encourage more nurses. Moreover, collaborative management is the ideal team structure for the current nursing role. Collaborative management rules out the traditional hierarchal decision making process. Thus, collaborative management is the future of nursing as nurses are given the freedom and efficiency of working together as team when implementing health policies.
Tracking and Evaluation
The recruitment of nursing students should be adjusted to accommodate more students. Further, the education of these nurses should be streamlined to meet the new changes in the health sector. New approaches to the diagnosis of breast-cancer should be initiated in the early nursing education stages. For example, music therapy is a new therapy used with conventional treatment to reduce pain and other side effects. These new therapies should be initiated at an early nursing education stage, in order for the new nurses to adequately provide patient-centered primary care.
Moreover, retention of nurses already in the health sector is vital to reduce the shortage of the nurses’ workforce. The government should look for ways of negotiating with these nurses in order to increase their productivity. Breast cancer requires more acute care, increased screening services and patient education. Increasing and improving the quality of nurses in the country will lead to a quantitative and qualitative improvement in the breast-cancer management program.
Jatoi I, Chen BE, Anderson WF, Rosenberg PS, (2007). Breast cancer mortality trends in the
United States according to estrogen receptor status and age at Diagnosis. J Clin Oncol. May 1;25(13):1683-90
Baquet CR, Mishra SI, Commiskey P, Ellison GL, DeShields M, (2008). Breast cancer
epidemiology in blacks and whites: Disparities in incidence, mortality, survival rates and histology. J Natl Med Assoc. 2008 May;100(5):480-8
The cancer burden in Michigan: Selected statistics (1993-2011) www.michigancancer.org/PDFs/MCCReports/CancerBurden Sept2011/AllSections.pdf
Malignant melanoma is a cancerous skin disease that affects the epidermal layer of the skin. However, the disease also affects various organs in inside the body such as the small intestines. Malignant melanomas are caused by the spread of melanocytes, which are normally found in the basal layer of the epidermis. The patient presentation of the disease includes cancerous lesions that produce melanin and non-cancerous melanocytes cause the formation of freckles and moles (Porth & Matfin, 2009).
On the other hand, benign skin lesions are infectious lesions caused by the growth of seborrheic keratoses that grow on the outer layer of the skin. Benign skin lesions are limited to growth on the skin surface. The patient presentation of the disease involves appearance of skin lesions that have different colors and sizes. The lesions are either flat or inflammatory (Porth & Matfin, 2009).
The major difference in patient presentation of the two infections is that malignant melanoma is more severe than benign skin lesions. Benign skin lesions are limited to the outer skin whereas malignant melanoma can spread to other body parts. Benign lesions clinical presentation suggests that it is a pre-malignant disease. These is because they may resemble malignant melanoma is patient presentation because of the similarity in patient presentation such as colored lesions (Pelengaris & Khan, 2013).
Normal melanocytes are present in the epidermis basal layer. They are equal in number in white skin and black skin. However, in black skins melanocytes produce more melanin than in white skins. This makes people of Caucasian race more prevalent towards ultraviolet radiation than people of African-American origin. When the melanoma has only developed in the epidermal layer, it is treated by excision. However, when melanoma spreads to the epidermis it is referred as invasive melanoma (Pelengaris & Khan, 2013).
The major risk factors causing malignant melanoma include family history, race, weakened immunity and exposure to ultraviolet rays. Family history may replicate the disease through parent-offspring genetic presentation. Further, the disease is more prevalent to individuals of the Caucasian race than people of African-American race. Consequently, weakened immunity may lead to infection of the disease. Malignant melanoma is a cancerous disease mostly caused by the effect of ultraviolet rays to the skin. Thus, individuals prone to the disease should wear sun protective lotions to prevent the disease from emerging on their skins (Porth & Mattfin, 2009).
Atopic eczema is an infant related disease that presents itself first in a series of allergic reactions. Atopic eczema is a chronic disease, which spreads within many parts of the body. However, the presentation of the disease may vary between patients. The disease may lead to xerosis, lichenification and secondary infections (Porth & Mattfin, 2009).
Contact dermatitis occurs in two forms namely contact irritant eczema and contact allergic dermatitis. Contact allergic dermatitis is caused by an allergic reaction when the body is exposed to allergic substances such as plants, cobalt and rubber. On the other hand, contact irritant eczema is triggered by frequent contact of the body with the same substance. For instance, constant contact of the hand with detergents and shampoos may lead to contact irritant eczema. The disease is caused by chemical irritation and not allergy (Patterson, 2013).
The two disorders can be differentiated in a clinical practice with history of the disease and physical examination of the disease. The major difference between the two disorders is the age of the patients. Atopic eczema affects children more than adults and it is less severe as most children grow out of it. On the other hand, contact dermatitis is triggered by the patient’s environment mostly work. Contact dermatitis patient history may date to the day when the skin encountered the allergen. Apparently, the patient history for atopic eczema depicts the disease as a first disease in a series of allergic diseases (Patterson, 2013).
Patterson, J. W. (2013). Practical skin pathology: A diagnostic approach. Philadelphia, PA: Elsevier/Saunders.
Pelengaris, S., & Khan, M. (2013). The molecular biology of cancer: A bridge from bench to bedside. New York: Wiley.
Porth, C.M., & Matfin, G. (2009). Pathophysiology: Concepts of altered health states. (Eight ed.) Philadelphia, PA
A risk factor can be described as any factor that alters one’s chance of acquiring a disease like cancer. The various types of cancer have different risk factors. Smoking is, however, a risk factor for many cancers. Regardless, having a risk factor does not necessarily mean that one will get the disease. Various risk factors increase the chance of acquiring cervical cancer (Moyer, 2012). For this reason, women who do not have such risk factors rarely get cervical cancer. The cervical cancer risk factors include Human papillomavirus infection, smoking, immunosuppression, Chlamydia infection, long-term use of oral contraceptives, and intrauterine device use among others.
Almost all cervical cancer cases are brought about by HPV. HPV is a common virus that can be transferred from one person to the other during sexual intercourse. Being that there are various types of HPV, some types tend to cause changes in a woman’s cervix which in turn leads to cervical cancer in the long-run (Guan et al., 2012). Other types can lead to genital warts or skin warts. Being that HPV is quite common, many people end up getting it at a particular point in their lives. It has no definite symptoms so one can hardly tell if they have it. For many women, the HPV infection usually goes away on its own. In the event that it doesn’t, there is always likeliness that in the long run it might cause cervical cancer. Other factors include having a family medical history of cervical cancer, poor living standards, Diethylstilbestrol, which is a hormonal drug given to some women to avoid miscarriage (Schuiling, and Likis, 2013). Having multiple full-term pregnancies as well as being younger than 17 at the first full term pregnancy are also risk factors that contribute towards getting cervical cancer.
Gardasil vaccine, also known as the HPV vaccine has been approved by the FDA and helps in preventing infections of four types of HPV. About 14 million people, including teens, get infected with HPV every year. HPV vaccine is recommended for both males and females from age 9 to 25. However, the vaccine is recommended to be administered at a young age to prevent people from getting infected at later ages (Schuiling, and Likis, 2013). Teens ranging from 11 to 13 are most encouraged to take up the vaccine as it is better to get it before exposure to HPV. Another reason is that the vaccine produces a higher immune response in younger people as compared to older teens as well as young women. Boys are also recommended to take the vaccine as it helps in preventing the types of HPV which can lead to cancers of the penis, anus, and throat. The vaccine also prevents genital warts (Moyer, 2012). A booster for the vaccine is not recommended. Other recommendations are such that all the three shots of the vaccine should be administered in a period of over six months. Even in the event that one has already engaged in sexual activities, one can and should still get the HPV vaccine. This is because the vaccine can prevent some types of the HPV virus from affecting the infected person.
The vaccine is also recommended for bisexual as well as gay young men. This extends to any young man who engages in sexual intercourse with other men. The vaccine is also recommended for young men with a compromised immune system including that cased by HIV through to age 26. However, the recommendations insist that the vaccine should be administered when the people are younger and most preferably when they have not yet started engaging in sexual activities (Moyer, 2012). However, if they have already began having sex, then the vaccine will still be effective for holding out other types of HPV.
Being that there are over 40 types of HPV, the Gardasil vaccine can only be used to contain about for types of the virus (Guan et al., 2012). These types are the high-risk HPV types 16 and 18 which are associated with genital cancers as well as low-risk HPV types 6 and 11 which bring about genital warts. The vaccine was approved for use by males and females aged 9 to 26 and was licensed in 2006.
The differential diagnosis for non- tender mass in the lower left quadrant is an acceptable differential diagnosis being that it has applied the main steps and ruled out other possible diagnoses. The physician has gathered all the symptoms and placed them in a list. This helps in knowing all the symptoms and then relating them to any relevant causative factors (Schuiling, and Likis, 2013). All the causes of the symptoms found have also been listed, thereby enabling the physician to identify the candidate conditions in this case. The physician has also prioritized the list by having to place the most urgently dangerous possible causes at the beginning of the list. Looking at the differential diagnosis, the physician has also ruled out possible causes, beginning with the most dangerous and the most urgent ones. “Ruling out” entails using the tests as well as other scientific methods to determine that a specific candidate condition has a medically negligible probability of being the main causative factor.
Looking at the diagnosis, the physician has started by evaluating the patient by asking questions that will reveal the patient's history. After that the physician has analyzed the history and sent the patient for an ultrasound and a pregnancy test being that these will help in making a proper diagnosis (Schuiling, and Likis, 2013). The physician has then proceeded to rule out weaker causative factors and remained with the final diagnosis. This, therefore, is a good and an acceptable diagnosis being that the steps and methods have been followed and credible results obtained.
Guan, P., Howell‐Jones, R., Li, N., Bruni, L., de Sanjosé, S., Franceschi, S., & Clifford, G. M. (2012). Human papillomavirus types in 115,789 HPV‐positive women: A meta‐analysis from cervical infection to cancer. International journal of cancer, 131(10), 2349-2359.
Moyer, V. A. (2012). Screening for cervical cancer: US Preventive Services Task Force recommendation statement. Annals of internal medicine, 156(12), 880-891.
Schuiling, K.D., Likis, F.E. (2013). Women's Gynecologic Health. Burlington, MA. Jones & Bartlett Learning.
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