Table 1 report the demographic characteristics of the study sample stratified by professional category. Results for cancer related Knowledge (Table 2), Attitude (Table 3), and Practice (Table 4) are also reported by professional category. Table 5 and 6 report descriptive and multivariate logistic regression analysis of respondents’ KAP scores.
Table 1: Demographic characteristics of HAs and CHCPs
Characteristics
|
CHCPs%
|
HAs%
|
p-value&
|
Age
|
21-30
|
55 (43.31)
|
26 (13.13)
|
0.000
|
31-40
|
69 (54.33)
|
94 (47.47)
|
41-50
|
2 (1.57)
|
43 (21.72)
|
51-60
|
1 (0.79)
|
35 (17.68)
|
Sex
|
Male
|
61 (48.03)
|
102 (51.52)
|
0.540
|
Female
|
66 (51.97)
|
96 (48.48)
|
Education
|
SSC
|
2 (1.57)
|
19 (9.60)
|
0.000
|
HSC
|
28 (22.05)
|
69 (34.85)
|
Diploma
|
3 (2.36)
|
9 (4.55)
|
Honors
|
22 (17.32)
|
49 (24.75)
|
Masters
|
72 (56.69)
|
52 (26.26)
|
Marital Status
|
|
|
|
|
|
Single
|
16 (12.60)
|
18 (9.09)
|
0.313
|
Married
|
111 (87.40)
|
180 (90.91)
|
Duration of employment
|
<10 years
|
114 (89.76)
|
80 (40.40)
|
0.000
|
11-20 years
|
12 (9.45)
|
51 (25.76)
|
>20 years
|
1 (0.79)
|
67 (33.84)
|
Religion
|
Islam
|
96 (75.59)
|
132 (66.67)
|
0.086
|
Others
|
31 (24.41)
|
66 (33.33)
|
Smoking
|
No
|
116 (91.34)
|
177 (89.39)
|
0.566
|
Monthly Income
|
<15000
|
11 (8.66)
|
19 (9.60)
|
0.000
|
15001-20000
|
109 (85.83)
|
87 (43.94)
|
20001-25000
|
2 (1.57)
|
45 (22.73)
|
>25000
|
5 (3.94)
|
47 (23.74)
|
Cancer in the family
|
No
|
122 (96.06)
|
182 (91.92)
|
0.138
|
Workplace Location
|
Moulvibazar, Sylhet
|
11 (8.66)
|
40 (20.20)
|
0.000
|
Barisal, Barisal
|
18 (14.17)
|
17 (8.59)
|
Cumilla, Chattogram
|
37 (29.13)
|
32 (16.16)
|
Lalmonirhat, Rangpur
|
21 (16.54)
|
27 (13.64)
|
Natore, Rajshahi
|
15 (11.81)
|
12 (6.06)
|
Khulna, Khulna
|
1 (0.79)
|
29 (14.65)
|
Netrokona, Mymensingh
|
15 (11.81)
|
18 (9.09)
|
Gopalganj, Dhaka
|
9 (7.09)
|
23 (11.62)
|
Notes: % N (%); & Chi-square tests
Socio-demographic characteristics
Table 1 shows that that there was statistically significant association between professional category and age, education, duration of employment, religion, monthly income, and workplace location. We found that a majority of CHCPs were younger in age whereas the age of HAs was more evenly spread over the 4 age categories. Most of the CHCPs had a shorter duration of employment than the HAs. We saw that both CHCPs and HAs had an even mix of males and females. Most HAs and CHCPs were married (HA - 90.91%; CHCP - 87.40%) and non-smokers (HA - 89.39%; CHCP - 91.34%). Islam was the dominant religion for most participants. 8.08% HAs and 3.94% CHCPs had a cancer affected family member.
Table 2: Cancer related knowledge of CHCPs and HAs
Knowledge Items
|
Correct Answers
|
CHCP%
|
HA%
|
p value
|
Who can be affected by Cancer?
|
Anyone
|
188 (94.95)
|
123 (96.85)
|
0.118
|
Is Cancer contagious?
|
No
|
175 (88.38)
|
118 (92.91)
|
0.405
|
Is Cancer a hereditary disease?
|
A few types
|
78 (39.39)
|
45 (35.43)
|
0.183
|
What is/are the risk factor(s) for Cancer? ^
|
13 categories
|
Can Cancer be prevented?
|
Yes
|
128 (64.65)
|
87 (68.50)
|
0.694
|
How can Cancer be prevented? ^
|
7 categories
|
What is/are the warning sign(s) of Cancer? ^
|
15categories
|
What is/are the treatment option(s) for Cancer? ^
|
11 categories
|
Can Cancer be completely cured?
|
Yes
|
68 (34.34)
|
34 (26.77)
|
0.322
|
Can Cancer be prevented through Vaccination?
|
Some are preventable
|
121 (61.11)
|
76 (59.84)
|
0.431
|
What types of Cancer are preventable through Vaccination? ^
|
5 categories
|
What are the consequences of incomplete treatment for a Cancer patient?
|
Patient will deteriorate
|
171 (86.36)
|
111 (87.40)
|
0.326
|
Are all treatment options for Cancer available in Bangladesh?
|
Yes
|
41 (20.71)
|
32 (25.20)
|
0.616
|
What is the diagnostic test for Cancer? ^
|
3 categories
|
Is there any Cancer Screening Program in govt. hospitals which is free of cost?
|
Yes
|
101 (51.01)
|
62 (48.82)
|
0.901
|
What types of Cancer are screened as part of this program? ^
|
4 categories
|
Do you have enough training to treat Cancer?
|
No
|
194 (97.98)
|
125 (98.43)
|
0.771
|
Have you received any govt. training on Cancer?
|
No
|
180 (90.91)
|
122 (96.06)
|
0.077
|
Where can you treat Cancer? ^
|
4 categories
|
Notes: % N (%); ^ Details of the categories can be found in the attached additional file 1
Assessment of knowledge about cancer
In the knowledge section of the study, the results were mixed (Table 2). In response to items on risk factors or warning signs of cancer, respondents answered correctly for some categories but not for others. Most respondents were not acquainted with advanced cancer treatment options such as - targeted therapy, hormone therapy or immunotherapy. They knew about chemotherapy (HA-86.36% and CHCP-90.55%) but not so much about radiotherapy (HA-54% and CHCP-51.18%). A positive aspect is that most respondents answered correctly about diagnostic tests for cancer. In terms of knowledge about cancers preventable through vaccination, the respondents did not know well about liver cancer (HA-32.83% and CHCP-25.2%).
Only 20.71% HAs and 25.2% CHCPs knew about the availability of all treatment options in Bangladesh and were also unsure about whether such treatments were available at public facilities or not. They knew poorly about govt. screening program for breast, cervical and lung cancers or that these programs were free of cost in govt. hospitals (HA - 51.01%; CHCP - 48.82%). 97.98% HAs and 98.43% CHCPs responded that they did not have enough training to treat cancer. A majority also reported not receiving any training on cancer from the govt.
Multivariate analysis in table 6 shows that being married (OR 3.3, SE 1.46), having cancer in the family (OR 2.48, SE 1.32) and working in specific locations led to significantly higher odds of obtaining a good knowledge score. CHWs from Moulvibazar, Sylhet were almost 6 times (OR 5.72, SE 3.23) and Barisal, Barisal were 4 times (OR 4.50, SE 2.52) more likely to score above average than respondents from Gopalganj, Dhaka. Respondents with a longer duration of employment had lower odds of getting a good score (11-20 years - OR 0.94, SE 0.39; >20 years – OR 0.91, SE 0.64) than those who were employed for a shorter duration (<10 years). We observe that female CHCPs and HAs have slightly higher odds (OR 1.15, SE 0.30) of scoring above average than their male counterparts. Also, high income and smoking resulted in lower odds of scoring well in the knowledge section.
Table 3: Cancer related attitude of CHCPs and HAs
Attitude Items
|
Correct Answers
|
CHCP%
|
HA%
|
p value
|
Do you feel sympathy towards Cancer affected patients?
|
Yes
|
188 (94.95)
|
115 (90.55)
|
0.304
|
What type of Cancer patients do you feel more sympathetic to?
|
Do not differentiate
|
163 (82.32)
|
114 (89.76)
|
0.216
|
Are you afraid of Cancer patients?
|
No
|
164 (82.83)
|
106 (83.46)
|
0.987
|
Do you feel hesitant to speak with Cancer patients?
|
No
|
180 (90.91)
|
118 (92.91)
|
0.595
|
Do you think that Cancer patients are socially marginalized?
|
No
|
177 (89.39)
|
110 (86.61)
|
0.736
|
Do you think that Cancer patients are avoided by their friends?
|
No
|
140 (70.71)
|
93 (73.23)
|
0.055
|
Do you think Cancer patients face administrative discrimination in terms of receiving govt. benefits?
|
No
|
118 (59.60)
|
87 (68.50)
|
0.048
|
Do you think a patient is responsible for his own disease/fate?
|
No
|
122 (61.62)
|
74 (58.27)
|
0.072
|
If you realize a patient has Cancer, will you disclose that information to others?
|
No
|
103 (52.02)
|
68 (53.54)
|
0.899
|
If you realize a patient is receiving treatment for Cancer, will you disclose that information to others?
|
No
|
79 (39.90)
|
51 (40.16)
|
0.999
|
Do you think Cancer patients should think less of themselves due to their condition?
|
No
|
56 (28.28)
|
43 (33.86)
|
0.562
|
Do you think Cancer patients should be ashamed of themselves due to their condition?
|
No
|
183 (92.42)
|
120 (94.49)
|
0.760
|
Would you be ashamed of yourself if diagnosed with Cancer?
|
No
|
154 (77.78)
|
109 (85.83)
|
0.197
|
How serious of a disease is Cancer?
|
Very
|
168 (84.85)
|
98 (77.17)
|
0.196
|
In your opinion, how prevalent is Cancer in Bangladesh?
|
High
|
90 (45.45)
|
43 (33.86)
|
0.088
|
Notes: % N (%)
Assessment of attitude towards cancer
Table 3 shows that the respondents did not fare well in some items of the attitude section. The most notable deficiency (HA-39.9% and CHCP-40.16%) was seen in response to the question about confidentiality of cancer patients. Few (HA-28.28% and CHCP-33.86%) thought that cancer patients should not think less of themselves due to their condition. A large percentage of respondents (HA-45.45% and CHCP-33.86%) also did not know about the severity of cancer in Bangladesh.
From multivariate analysis (Table 6) we observe that, compared to less than 10 years of employment, those employed for 11-20 years had a much lower odds (OR 0.40, SE 0.16) and those employed for more than 20 years have a much higher odds of scoring above average (OR 2.34, SE 1.49). Higher monthly income (>25000 bdt) had lower odds of scoring good (OR 0.29, SE 0.20) than those with low income (<15000 bdt). Our analysis shows that Muslim respondents had higher odds of scoring above average (OR 1.64, SE 0.48) than those belonging to other faiths. Respondents from Moulvibazar, Sylhet (OR 3.11, SE 1.72) and 51-60-year-olds had higher odds (OR 2.09, SE 1.48) of scoring good; while CHCPs had lower odds (OR 0.75, SE 0.24) of doing good than HAs. Respondents with a cancer affected family member had higher odds (OR 1.56, SE 0.88) of good attitude than those without such experience.
Table 4: Cancer related practice of CHCPs and HAs
Practice Items
|
Correct Answers
|
CHCP%
|
HA%
|
p value
|
If you realize a patient has cancer, will you try to treat by yourself?
|
No
|
189 (95.45)
|
125 (98.43)
|
0.148
|
If you realize a patient has Cancer, do you refer him/her to the UHC or any other specialist physician?
|
Yes
|
183 (92.42)
|
121 (95.28)
|
0.308
|
If referred, does a patient actually go to the UHC?
|
Yes
|
147 (74.24)
|
102 (80.31)
|
0.207
|
If you realize a patient has Cancer, do you advise the patient to take Homeopathic or Ayurvedic treatment?
|
No
|
196 (98.99)
|
121 (95.28)
|
0.035
|
Do you educate people on Cancer during fieldwork or activities at CC?
|
Yes
|
186 (93.94)
|
119 (93.70)
|
0.930
|
Do you follow-up on a Cancer patient once identified during fieldwork?
|
Yes
|
169 (85.35)
|
107 (84.25)
|
0.787
|
Notes: % N (%)
Assessment of practice regarding cancer
The respondents did well in the practice section of our survey (Table 4). The lowest percentage (HA-74.24% and CHCP-80.31%) of correct answers was in response to the question - “If referred, does a patient actually go to the Upazilla Health Complex?”. Importantly, most respondents (HA-99% and CHCP-95.28%) did not advise Ayurvedik or Homeopathic treatment to cancer patients. Most HAs (93.70%) and CHCPs (93.94%) educated people about cancer during their field visits.
Table 6 shows that those working in Moulvibazar, Sylhet (OR 7.24, SE 4.37), Lalmonirhat, Rangpur (OR 3.99, SE 2.29) and Natore, Rajshahi (OR 3.53, SE 2.35) had higher odds of scoring well than Gopalganj, Dhaka. Respondents with cancer in their family had higher odds (OR 3.80, SE 2.67) and higher income (>25000 bdt) had lower odds (OR 0.17, SE 0.14) of scoring well. CHCPs had higher odds (OR 1.21, SE 0.44) of having good practices than HAs. Those aged 31-40 had slightly lower odds (OR 0.80, SE 0.29) of scoring well than those aged 21-30. However, the odds increased with the age group of 51-60 (OR 1.10, SE 0.90).
Table 5: Knowledge, Attitude, and Practice scores of CHCPs and HAs
|
Knowledge Score%
|
Attitude Score%
|
Practice Score%
|
Total score
|
74
|
15
|
6
|
Average Score
|
46.77 (6.57)
|
9.67 (2.18)
|
5.43 (.93)
|
Above Average
|
176 (54.15)
|
189 (58.15)
|
213 (65.54)
|
Below Average
|
149 (45.85)
|
136 (41.85)
|
112 (34.46)
|
N
|
325
|
325
|
325
|
Notes: % N (%)
Overall Scoring
Table 5 shows that the knowledge section had a total score of 74 and the mean score was 46.77 (SD - 6.57). We found that 54.15% of the respondents had good or above average score in the knowledge section. Out of 15, the mean score was 9.67 (SD 2.18) and 58.15% CHCPs and HAs had above average score in the attitude section. The respondents had a mean of 5.43 (SD 0.93) out of 6 in the practice section and 65.54% of respondents scored above the average score.
Table 6: Multivariate Logistic Regression Models for Above/Below Average of Knowledge, Attitude and Practice Scores
|
Above Average Knowledge Score$
|
Above Average Attitude Score$
|
Above Average Practice Score$
|
CHCP (Ref.: HA)
|
1.13 (0.35)
|
0.75 (0.24)
|
1.21 (0.44)
|
Age (Ref.: 21-30)
|
31-40
|
1.07 (0.35)
|
1.23 (0.41)
|
0.80 (0.29)
|
41-50
|
0.91 (0.62)
|
1.03 (0.63)
|
0.93 (0.64)
|
51-60
|
1.41 (1.12)
|
2.09 (1.48)
|
1.10 (0.90)
|
Sex (Ref.: Male)
|
1.15 (0.30)
|
1.08 (0.28)
|
0.98 (0.27)
|
Education (Ref.: HSC)
|
SSC
|
1.01 (0.55)
|
1.02 (0.52)
|
1.10 (0.61)
|
Diploma
|
1.53 (1.16)
|
0.88 (0.58)
|
1.19 (0.89)
|
Honors
|
0.98 (0.36)
|
1.18 (0.44)
|
0.59 (0.26)
|
Masters
|
1.19 (0.37)
|
0.99 (0.33)
|
0.91 (0.33)
|
Marital Status (Ref.: Single)
|
3.30*** (1.46)
|
0.68 (0.30)
|
0.92 (0.43)
|
Duration of employment (Ref.: <10 years)
|
11-20 years
|
0.94 (0.39)
|
0.40** (0.16)
|
1.12 (0.53)
|
>20 years
|
0.91 (0.64)
|
2.34 (1.49)
|
1.02 (0.79)
|
Religion (Ref.: Others)
|
0.75 (0.23)
|
1.64* (0.48)
|
1.61 (0.54)
|
Smoking (Ref.: No)
|
0.68 (0.28)
|
0.67 (0.27)
|
2.45* (1.19)
|
Monthly Income (Ref.: <15000)
|
15001-20000
|
0.53 (0.27)
|
0.99 (0.50)
|
0.34 (0.23)
|
20001-25000
|
0.73 (0.43)
|
0.83 (0.48)
|
0.65 (0.45)
|
>25000
|
0.59 (0.36)
|
0.29* (0.20)
|
0.17** (0.14)
|
Cancer in the family (Ref.: No)
|
2.48* (1.32)
|
1.56 (0.88)
|
3.80* (2.67)
|
Workplace Location (Ref.: Gopalganj, Dhaka)
|
Moulvibazar, Sylhet
|
5.72*** (3.23)
|
3.11** (1.72)
|
7.24*** (4.37)
|
Barisal, Barisal
|
4.50*** (2.52)
|
2.13 (1.18)
|
1.39 (0.79)
|
Cumilla, Chattogram
|
1.66 (0.88)
|
1.29 (0.72)
|
0.54 (0.32)
|
Lalmonirhat, Rangpur
|
1.46 (0.74)
|
1.26 (0.67)
|
3.99** (2.29)
|
Natore, Rajshahi
|
1.13 (0.69)
|
2.93 (1.99)
|
3.53* (2.35)
|
Khulna, Khulna
|
2.34 (1.38)
|
0.66 (0.39)
|
0.63 (0.36)
|
Netrokona, Mymensingh
|
0.87 (0.50)
|
1.69 (0.99)
|
1.84 (1.15)
|
Notes: $ Odds Ratios; Standard errors in parentheses; * p < 0.10, ** p < 0.05, *** p < 0.01