SOCIO-ECONOMIC AND BEHAVIORAL RISK-FACTORS OF CERVICAL LESIONS IN ADJARA REGION (REPUBLIC OF GEORGIA)

Lela Bibileishvili 1 , Besarion Tkeshelashvili 1,2 , Tinatin Gagua 1,2 , David Gagua 1,2 and David Tananashvili 2 . 1. David Tvildiani Medical University; 2/6, Ljubljana str., 0159, Tbilisi, Georgia. 2. Gagua Clinic; 6, Javakhishvili str., 0159, Tbilisi, Georgia. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 14 July 2019 Final Accepted: 16 August 2019 Published: September 2019

2 nd stages in the incidence is only 55.3%, which was explained by low values of screening coverage: Tbilisi (capital of Georgia) -18% and other regions -11.5% (Georgian NCDC, 2016).
HPV infection and sexually transmitted diseases, oral contraception and intrauterine devices, obesity, immune system reduced functioning, many deliveries, age at first delivery, smoking and nutrition have been reported among the main reasons of cervical intraepithelial neoplasia (CIN) (Georgian NCDC, 2016; Si et al., 2017;Brennan et al., 2010).
There are a few information of the relationship of diet and nutritional pattern with HPV infection and cervical intraepithelial lesions compared to socio-economic and demographic data [5,6]. Sedjo et al. showed that lutein and lycopene may reduce the incidence of cervical cancer due to their antioxidant properties (Sedjo et al., 2002). Moreover, Barchitta et al. (2018) studied the relationship between nutritional pattern and HPV infection and concluded that women with "Mediterranean diet" (high content of fruit and vegetables) are characterized by lower risk of HPV infections of oncogenic types. It was also lower the risk of CIN development in these women compared to women with the "western diet" nutritional pattern (fast food).
Therefore, the aim of our investigation was the study of socio-economic, demographic and behavioral risk-factors in the development of cervical lesions in specific Region of the Republic of Georgia, Adjara, which is characterized by variety of food and meal intake habits, geographical locations [from urban (seaside) to rural (mountains)about 2,000 m above sea level) in comparable small area), the distance to healthcare units, etc.
Specific questionnaires have been used to evaluate nutritional and behavioral characteristics (meal intake frequency; breakfast skipping; nutritional pattern: lack of proteins, carbohydrate-and fat-rich; sweets and snacks); Sleep regimen (duration, continuity, late bedtime, late wake up, insomnia). From socio-economic parameters we assessed education level, family status, occupational status, family income, etc.
Statistical analyses were performed using SPSS software (version 22.0, SPSS, Chicago, IL, USA). Descriptive statistics were used to characterize the population using frequencies and means ± standard deviations (SDs). The two-tailed Chi-squared test was used for the statistical comparison of proportions, whereas continuous variables were tested using Student's t tests. Trends across demographic, socio-economic and behavioral risk-factors were analyzed using Chi-squared tests for categorical variables. The case-control study of age-adjusted data have been analyzed by estimation of Relative Risks (ORs) and corresponding 95% confidence intervals (95%CI). The case control ratio was 1:3. All statistical tests were 2-sided, and p-values less than 0.05 were considered statistically significant.

Results:-Population Study.
Cervical lesions have been identified in 89 cases. The distribution of these cases by groups is presented on Diagram #1. It is showed that the patients with cervical lesions in Group 1 (n=28, 14.43%) was significantly higher than in women from seaside region (n=54, 9.29%; RR=1.55, p=0.043).

Diagram 1:-Distribution of patients with cervical lesions by groups.
To find out the reasons of above mentioned significant difference the demographic, socioeconomic and behavioral characteristics have been investigated. The results of this study in groups are given in Table #1. Table #1 shows that the difference between age was not significant. Married women were significantly more in group 1 (mountain Adjara) compared to group 2 (seaside Adjara, p<0.001); the percentage of women with low family income and socially unprotected persons in group 1 was significantly higher than in group 2 (p<0.001).

Study of risk-factors (Case-Control Study)
The results of statistical assessment of risk-factors in whole population (see Table #2) showed that marital status was not significant; family income was not significant too. Disorders related with food and meal intake habits showed that only breakfast skipping was significant risk-factor for cervical lessions (RR=2.67; 95%CI -2.20÷3.23; p<0.001); it was also significant the disorders related with sleep: continuity (RR=1.61; 95%CI -1.02÷2.55; p=0.041); chronic insomnia (RR=9.24; 95%CI -4.83÷17.69; p<0.001); drowsiness (RR=34.68; 95%CI -12.01÷100.18; p<0.001).  Wen X et al. (2019) showed that the age-standardized incidence rate (ASIR) of cervical cancer in rural Shexian County (China) was 3 times higher than in Shijiazhuang city in 2012 (25.0 vs. 8.4 per 100,000 per year, p<0 .01) . This high value in rural region was partially explained by lack of access to screening centers. They also noted that it was not impossible to carry out cytologic studies in rural ambulatories.

Discussion:-
Some epidemiologic studies revealed that the some food or macro-and micronutrients may be used for the prevention of the progression from precancer-to cancer-state. "European Prospective Investigation into Cancer and Nutrients" (EPIC) has showed significant inverse correlation between cervical cancer and daily fruit intake (González CA, 2011). In particular, the intake of fruit and vegetables, vitamins A, C, and E, folates, carotinoids and minerals were associated with the decreased risk HPV infection, CIN and cervical cancer (Zhang X. et [18,20] during cervical cancer development. According very few data about the role of lifestyle on the cervical damages showed that alcohol overconsumption, the absence of adequate sleep and physical inactivity had significant association with CIN; however most significant risk-factor remains smoking (Lukac A. et al., 2018; Comparetto C. and Borruto F., 2015; Parada R. et al., 2010). We could not find out the data about the impact of sleep and meal intake habits (breakfast skipping, the frequency of meal intake) on the development of cervical lesions.

Conclusions:-
Rural mountain Adjara habitants have significantly high prevalence of cervical lesions compared to urban Adjara habitants. Family income is main socio-economic risk-factor for the development of cervical lesions in rural Adjara region. Food and meal intake habits, sleep disorders are associated with cervical lesions in whole region. Among of them are breakfast skipping (RR=2.67; p<0.001), sleep discontinuity (RR=1.61; p=0.041), insomnia (RR=9.24; p<0.001), and drowsiness (RR=34.68; p<0.001).