|Ahead of print
Screening practices for breast and cervical cancer and associated factors, among rural women in Vellore, Tamil Nadu
Shubhashis Saha1, S Mohana Priya1, Anu Surender1, Rohan Chacko Jacob1, Michael Philip George1, Namitha Mary Varghese1, Nishant Kumar1, Noel Eappen1, Prabhas Ranjan Kumar1, Riya Raymond1, Ashna Christine Phillips1, Reuben Thomas Mathew1, Miji M Vijayan1, Christina Sukhadhan1, Bincy Mary Thomas1, Sam David Marconi1, Kulandaipalayam Natarajan Sindhu2, Anu Mary Oommen1, Sushil Mathew John1
1 Department of Community Health, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
2 The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu, India
|Date of Submission||31-Jan-2020|
|Date of Decision||22-Jun-2020|
|Date of Acceptance||16-Jul-2020|
|Date of Web Publication||19-Sep-2021|
Anu Mary Oommen,
Department of Community Health, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: Population-based screening coverage for breast and cervical cancer screening in the community is inadequately reported in India. This study assessed screening rates, awareness, and other factors affecting screening, among rural women aged 25–60 years in Vellore, Tamil Nadu.
Methods: Women aged 25–60 years, from five randomly selected villages of a rural block were included in this cross-sectional study in Vellore, Tamil Nadu. Households were selected by systematic random sampling, followed by simple random sampling of eligible women in the house. A semi-structured questionnaire was used to assess screening practices, awareness, and other factors related to cervical and breast cancer.
Results: Although 43.8% and 57.9% were aware of the availability of screening for cervical and breast cancer respectively, screening rates were only 23.4% (95% confidence interval [CI]: 18.4-28.4%) and 16.2% (95% CI: 11.9-20.5%), respectively. Adequate knowledge (score of ≥50%) on breast cancer was only 5.9%, with 27.2% for cervical cancer. Only 16.6% of women had ever attended any health education program on cancer. Exposure to health education (breast screening odds ratio [OR]: 6.89, 95% CI: 3.34-14.21; cervical screening OR: 6.92, 95% CI: 3.42-14.00); and adequate knowledge (breast OR: 4.69, 95% CI: 1.55-14.22; cervix OR: 3.01, 95% CI: 1.59-5.68) were independently associated with cancer screening.
Conclusion: Awareness and screening rates for breast and cervical cancer are low among rural women in Tamil Nadu, a south Indian state with comparatively good health indices, with health education being an important factor associated with screening practices.
Keywords: Awareness, breast cancer, cervical cancer, rural, screening coverage
Key Message: Screening rates for cervical and breast cancer screening were low among rural women in Vellore, Tamil Nadu, despite availability of screening services, with exposure to health education highly influencing screening.
|How to cite this URL:|
Saha S, Priya S M, Surender A, Jacob RC, George MP, Varghese NM, Kumar N, Eappen N, Kumar PR, Raymond R, Phillips AC, Mathew RT, Vijayan MM, Sukhadhan C, Thomas BM, Marconi SD, Sindhu KN, Oommen AM, John SM. Screening practices for breast and cervical cancer and associated factors, among rural women in Vellore, Tamil Nadu. Indian J Cancer [Epub ahead of print] [cited 2021 Oct 28]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=326251
| » Introduction|| |
Cancer is rapidly emerging as a public health concern among women in developing countries such as India, with breast cancer contributing to 27.7% and cervical cancer 16.5% of all new cancer cases in 2018. Breast cancer has become the single largest cause of death due to cancer, whereas cervical cancer ranks second, with an increase in incidence of breast cancer and decreasing incidence of cervical cancer. Cervical cancer is high in countries with low levels of the sociodemographic index, an indicator based on income, education, and fertility, with a 1 in 40 odds of lifetime risk for women in these countries.
A major contributor to the high rate of mortality in cancer is late case detection due to inadequate screening, which allows the disease to progress such that intervention is no longer effective or efficient. A randomized controlled trial using trained health workers who performed visual inspection after application of acetic acid (VIA) showed a 31% reduction in mortality due to cervical cancer in 12 years.
Although community-based screening programmes in settings where dedicated primary health workers involved only in cancer control have shown excellent coverage rates of 90%, in programmes which rely on primary care personnel who have other tasks in addition to cancer screening or referrals, the initial coverage achieved is much lower, for example, 16% using nurses and 10.2% using multipurpose health workers in rural areas of Vellore, Tamil Nadu.
The National Family Health Survey NFHS-4 (2015) reported the proportion of women who had undergone cervical (22%) and breast examination (10%), but was not specifically targeted to assess screening rates for cervical and breast cancer. The National Program for Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS) which initially started with opportunistic screening in public healthcare services, has now expanded its scope to population-based screening for women aged 30 years and above through Accredited Social Health Activists (ASHAs). However, current screening coverage and its variations has not been reported across the country.
This study aimed to assess screening practices and factors affecting screening for breast and cervical cancer, amongst women aged 25–60 years, in a rural block in Vellore, Tamil Nadu.
| » Methods|| |
A cross-sectional survey was conducted in five clusters (villages) of Kaniyambadi block of Vellore district, chosen by simple random sampling from 82 villages, in 2018. Kaniyambadi block, a rural administrative block in Tamil Nadu houses a population of 116,241. Government primary health centres, a government medical college hospital, and a secondary hospital (private not-for-profit) are the major healthcare providers for this rural population, offering screening for breast and cervical cancer, in addition to private clinics. Health education for various topics including cancer has been provided in some areas as part of the primary services of these health facilities.
The sample size was calculated as 294, with a design effect of 1.2, based on expected prevalence of 29% screening (NFHS-4, women aged 30–49 years). In each of the five selected villages, a random direction was selected, followed by systematic random sampling of households. In each household one woman aged 25–60 years was selected by simple random sampling (lots).
A semi-structured, pilot-tested questionnaire created using expert opinion and previous studies was used to collect sociodemographic details, knowledge and practices regarding cervical and breast cancer, including breast self-examination (BSE), mammography, and clinical breast examination (CBE). Socioeconomic status was assessed using the updated modified BG Prasad scale. Knowledge was scored as adequate or inadequate based on a cut off score of 50% of the total score.
The study was carried out according to the recommended ethical standards for research in human subjects and was approved by the institutional review board (IRB) and ethics committee of Christian Medical College (CMC) Vellore (IRB Minutes Number 11466). Written informed consent was obtained from each participant.
Data was entered in EpiData version 3.1 and analyzed using SPSS version 13.0. Categorical variables were analyzed as frequencies and continuous variables as mean with standard deviation (SD) or median. The knowledge questionnaire was scored by giving one point to each correct answer about awareness of risk factors, symptoms, and screening (score out of 27 for breast cancer and 19 for cervical cancer), with 50% cut-off used to define adequate knowledge. Chi-square test of significance and odds ratios with 95% confidence intervals (CIs) were calculated to study associations of screening with knowledge, and sociodemographic characteristics. Logistic regression was performed using independent factors which were significantly associated (P < 0.05) with screening in the unadjusted analysis.
| » Results|| |
The survey was conducted among 290 women from five villages. The majority (181, 62.4%) were in the reproductive age (25–44 years), with mean age of 40.3 (SD: 9.9, range: 25-60) years. Only 7 (2.4%) were single, while the remaining were either currently married (260, 89.7%) or separated/widowed (23, 7.9%). While 55 (19%) were illiterate, 91 (31.4%) were educated to eighth standard or above. Most 201 (69.3%) women were homemakers, while 42 (14.5%) were manual laborers. Around two-thirds (192, 66.2%) belonged to upper and upper-middle rural social classes.
Breast cancer awareness and screening practices
Regarding knowledge about breast cancer, 66 (22.8%) women had never heard of breast cancer. Knowledge of risk factors (one or more of: age, family history, early menarche, early age of first childbirth, nulliparity, lack of breast feeding, obesity, oral contraceptive pills) was present only in 35 (12.1%) [Table 1]. Only 66 (22.8%) were aware of at least one symptom, with 63 (21.7%) aware that a painless breast lump was a possible symptom of breast cancer. Of all the interviewed participants, 168 (57.9%) were aware of at least one screening method for breast cancer. While 54 (18.6%) were aware of BSE as a screening method, 151 (52.1%) and 79 (27.2%) were aware of CBE and mammography respectively, [Table 1]. Majority (191, 65.9%) were aware that cure was determined by early diagnosis. Overall, only 17 (5.9%, 95%CI: 3.1-8.7%) had adequate knowledge (score of ≥50%) on breast cancer.
Overall 47 (16.2%, 95%CI: 11.9 - 20.5%) reported having been screened for breast cancer in the past, 10 (3.4%, 95%CI: 1.3-5.5%) having undergone mammography and 37 (12.8%, 95%CI: 8.9-16.7%) screened by CBE alone. BSE was being practised by 35 (12.1%, 95%CI: 8.3-15.9%).
Regarding knowledge about cervical cancer, 110 (37.9%) women had never heard of cervical cancer. Awareness of symptoms (abnormal vaginal discharge or bleeding) was present only in 51 (17.6%) and only 39 (13.4%) were aware of at least one risk factor. Overall, only 79 (27.2%, 95%CI: 22-32.4%) had adequate knowledge on cervical cancer.
While 127 (43.8%) were aware of the availability of cervical cancer screening, only 68 (23.4%, 95%CI: 18.4-28.4%) had undergone screening at least once in the past. The rate of screening in the age group 30–49 years was 24.5%. On asking an open-ended (unprompted) question on what methods are used to screen for cervical cancer, only 29 (10%) answered that screening is done by internal examination, with only 4 (1.4%) women mentioning a specific test (VIA), despite 68 (23.4%) having undergone cervical screening, indicating possible hesitation and low confidence in answering questions that test knowledge, in this sample of rural women. Awareness of a vaccine for cervical cancer was present only in 27 (9.3%, 95%CI: 5.9-12.7%). While 120 (41.4%) believed that cervical cancer was curable, 140 (48.3%) agreed that cure was determined by early diagnosis.
Exposure to health education programs on cervical and breast cancer was recorded in 48 (16.6%). Irrespective of their knowledge regarding either cancers, 258 (88.9%) women felt it was important for all women to undergo regular screening for these cancers and 231 (81%) expressed willingness to be screened regularly if it was free of cost.
Exposure to cancer-related health education (adjusted OR: 6.89, 95% CI: 3.34–14.21) and having adequate knowledge on breast cancer (adjusted OR: 4.69, 95% CI: 1.55–14.22) were independently associated with having been screened (by CBE or mammography), [Table 2].
Health education exposure (OR: 6.92, 95% CI: 3.42–14.00) and adequate knowledge (OR: 3.01, 95% CI: 1.59-25.68) were also the factors significantly influencing screening for cervical cancer [Table 3].
| » Discussion|| |
Awareness of breast and cervical cancer and screening for these cancers was found to be very low among rural women in Vellore, Tamil Nadu, a state known for its high level of health and educational achievements, and strength of healthcare services, both public and private. This was also seen in a survey from Villupuram district, Tamil Nadu, among women attending Primary health Centres, where only 20% and 18% had ever heard of cervical and breast cancer screening, respectively. However, a secondary care referral hospital-based study in Andhra Pradesh showed higher knowledge among women attending an obstetrics and gynecology clinic, with 61% awareness of cervical cancer screening prevention, showing that awareness levels vary considerably in the population and that studies among those attending hospitals are likely to report higher awareness than the general population.
There was better overall knowledge about cervical cancer (27.2%) than breast (5.9%) in our study, possibly indicating more emphasis on the same in health education programmes in rural communities. In this rural block, besides educational efforts by the government's village health nurses as part of the national program, small group health education sessions are also being conducted in various villages, by medical social workers of the private medical college situated in the block (CMC Vellore), to motivate women for screening for cervical and breast cancer, through primary care services. Women who attend such educational sessions, which are arranged in common village buildings (e.g., schools) or even at worksites, are advised to motivate their neighbours and co-workers for screening camps. However, only 16.6% of the interviewed women in this study reported having attended any educational sessions.
The screening rates of cervical cancer was 23.4% among 25–60-year-old women, similar to 24.4% among women aged 15–49 years in rural Tamil Nadu (NFHS-4). Secondary analysis of NFHS-4 data also showed that 31.0% of women aged 30–49 years in Tamil Nadu had ever undergone cervical examination (the indicator used as a proxy for cervical cancer screening), compared to 24.5% in our study from rural Vellore. Unlike the NFHS-4 where there was a possibility of over reporting due to women reporting cervical examinations which were not done for cervical cancer screening, our reported screening rate is more specific for cancer screening. A review of information captured by various health information systems around the world also showed inadequate capture of information on cancer screening and awareness in national surveys.
Breast cancer screening in rural Vellore (16.2%) was similar to the 16.9% reported breast examination rate in rural Tamil Nadu, from the NFHS-4. The lower rate of breast cancer screening despite cervical and breast cancer being offered at the same visit under the national program, as found in our study, as well as the NFHS-4, points to greater lapses in breast cancer screening and is also worrying as breast cancer incidence is increasing across the country, while the incidence of cervical cancer is decreasing. The survey in Villupuram district, Tamil Nadu had found that willingness to undergo screening for breast and cervical cancer among women attending primary health centres was only 35% and 29%, respectively, indicating that acceptance of screening was low even when offered free of monetary costs. Although our study was limited by the fact that it was done only in one rural block in Tamil Nadu and among a small sample, the findings of low screening and awareness in even settings with high program inputs, points to the need for greater efforts in this direction.
A community-based screening programme in KV Kuppam block, Vellore found that increasing awareness in the community led to greater uptake of screening among women.
This successful program by the Rural Unit for Health and Social Affairs (RUHSA) department, Christian Medical College, Vellore, included health education sessions in villages targeting local leaders and male members of the community, as well as sessions organised for target women, through self-help groups. Training of women self-help group members as peer educators, and use of innovative tools for community evening education sessions, such as hand puppet shows, were instrumental in increasing the uptake of screening in the RUHSA program. An evaluation of the pink chain cancer awareness program among college teachers also showed sustained increase in awareness of breast and cervical cancer 6 months and 1 year after intervention, with increase in screening practices. Non-governmental organizations such as the CAPED (Cancer, Awareness, Prevention and Early Detection) trust, have used multipronged strategies to increase community awareness, through workshops and special events in schools, colleges, worksites, as well as utilizing online platforms. A systematic review of interventions to improve screening uptake in lower socioeconomic groups found that effective interventions included using lay health advisors to provide both education (face-to-face and/or printed material) and practical logistical support for screening, telephone calls to invite women for screening appointments, as well as switching to human papillomavirus (HPV) self-testing kits for screening. Another systematic review of interventions among Asian women also reported greater effectiveness of educational interventions when combined with logistical support such as assistance for scheduling screening appointments or providing mobile clinic services. Our current study also found a significant association of knowledge regarding these cancers and specifically exposure to health education in the community, with having undergone screening, better communication strategies are needed in rural India with respect to common cancers, so that the burden of deaths due to late diagnosis can be reduced. To increase the effectiveness of educational interventions, in addition to opportunistic screening, outreach camps in villages as well as referral of women by ASHAs, as envisaged in the population-based screening guidelines for the NPCDCS need to be implemented more effectively and monitored. In addition to providing opportunities for screening, the health system needs to be prepared in terms of competent health personnel, resources and coordinated services, to facilitate women through the continuum of services from screening, diagnostic work up, initiation of screening, as well as supporting curative or palliative treatment.
| » Conclusions|| |
There is a need for more efforts for primary and secondary prevention of breast and cervical cancer among rural women, even in states with good government healthcare services for cancer control, as awareness and screening practices remain suboptimal. It is also necessary to evaluate the coverage and implementation challenges of screening for common cancers as part of the NPCDCS, across the country, to increase current screening rates. Clear indicators to capture the World Health Organization's indicator for cervical cancer control, the proportion of women aged 30–49 years screened for cervical cancer at least once, and similar information for breast cancer screening, need to be incorporated into routine nationwide surveys such as the NFHS.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]