Perspective of females from a rural community in India towards the knowledge, screening, and treatment of breast and cervical cancer, and preventive vaccination

doi:10.21203/rs.3.rs-4867364/v1

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Research Article

Perspective of females from a rural community in India towards the knowledge, screening, and treatment of breast and cervical cancer, and preventive vaccination

https://doi.org/10.21203/rs.3.rs-4867364/v1

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Purpose

The success of a preventive oncology program depends upon the general population's awareness of the disease, its magnitude, and the screening and prevention process. The objective of our study was to study the situational analysis of the awareness of a rural community population towards the most common cancers in females.

Methods

We conducted a cross-sectional study in the rural community of Uttarakhand, recruiting 589 participants from Pauri Garhwal. We developed a questionnaire comprising sociodemographic information, knowledge of the disease, early detection, and the attitude toward breast and cervical cancer treatment. We also registered the participant's knowledge and enthusiasm towards vaccination against cervical cancer. Local Non-Governmental Organization (Uttarakhand Manav Seva Samiti, Delhi) collaborated to conduct door-to-door interviews.

Results

Among the participants, 38% and 79% had never heard about breast and cervical cancer, respectively. The knowledge about various signs and symptoms of breast cancer varied from 14–50%. Only 36.1% (132) and 11.5% (42) of the participants having heard about breast cancer were aware of breast examination and mammography including its utility to diagnose early breast cancer. The knowledge about various signs and symptoms of cervical cancer varied from 11–55%. Only 6.5% of them have heard about preventive vaccination. Nearly 57% and 56% of the participants expressed eagerness to participate in cancer screening programs. Younger (< 40 years) and literate participants were likelier to have statistically significant knowledge, awareness, and a positive attitude toward the disease.

Conclusion

A forbidding lack of awareness in the rural community has been observed towards breast and cervical cancers. Strengthening educational activities in the rural community against these cancers seems to be an indispensable step toward a preventive oncology program.

Preventive oncology

Screening and prevention

Breast cancer

Cervical cancer

India

The estimated number of cancer cases in India for the year 2022 as per the National Cancer Registry Program (NCRP), National Center for Disease Informatics and Research (NCDIR) of the Indian Council of Medical Research (ICMR-NCDIR) was 14,61,427, with a greater proportion of female cases compared to that in males. Not surprisingly, breast cancer (28.8%) and cervix cancer (10.6%) are the leading cancers in females, and this burden continues to increase [1]. The incidence of breast cancer is increasing as per the data from the last two decades. The rapid rise in incidence in India is due to many factors and socio-economic changes like delayed marriage and childbirth, fewer children, and increasing obesity. The demography of breast cancer in Indian women differs significantly from that in Western women. Breast cancer–affected Indian women are of younger age group and present with advanced stage of disease. Younger patients tend to have aggressive disease, a larger size of the tumor, worse tumor grade, a more significant number of positive lymph nodes, more hormone receptor-negative status, and early recurrence with poorer prognosis. Cervical cancer is a unique cancer as it is preventable and starts mainly as an infectious disease, leading to a non-communicable disease cancer. It is the second leading cause of cancer-related death in Indian females [2]. Numerous studies have suggested screening programs for the early detection and timely treatment of cancer as a requisite approach to decrease the burden of mortality and improve the prognosis. This impulsively, will decrease the surplus burden on our healthcare system as the curative treatment is often simple, short duration and economically more feasible vis a vis palliative treatment [3]. The situation is precisely the opposite in developing countries, including India, where lack of awareness about cancer, social disgrace, and poor healthcare resources contribute as a barrier to the abysmal screening rate and adverse cancer-related outcomes [4–5].

The National Cancer Control Program was launched by the Government of India in 1975, and the strategies were revised during 1984-85, from providing Cobalt machines to prevention and early detection of cancer. The Ministry of Health & Family Welfare of India (MOHFW), in 2016, recommended screening for cervical cancer by visual inspection with acetic acid (VIA) and breast cancer by clinical breast examination (CBE) in the age group 30–65 years once every 5 years [6]. However, the wide heterogeneity in the cancer awareness programs, mostly confined to urban areas, has resulted in abysmal screening rates for these cancers.

The majority of the cancers in India are diagnosed at locally advanced (breast, cervix, head, and neck) or advanced stage (lung) [7, 8]. It Is imperative to know that effective screening is available for all of these cancers, yet the lack of awareness regarding the cancer and poor attitude towards early detection and treatment of cancer pose major hindrance for a successful screening program.

Uttarakhand, being a hill state with heterogeneous rural demographic characteristics in the form of population density, access to health care, and resource availability, it becomes crucial to know about the level of awareness regarding breast and cervical cancer in rural females. This study was conducted with the objective of knowing the level of awareness in rural females of Uttarakhand regarding female cancers (breast and cervical), which can be detected at earlier stages by screening programs and can be prevented (cervical cancer) by means of an effective vaccination.

This study was a community-based cross-sectional survey carried out in the 4 rural blocks of Pauri Garhwal district in Uttarakhand. Females aged 18-65 years from the exact geographical location were included in the study. Those currently or previously diagnosed with breast or cervical cancer were excluded. A cluster sampling method was used to calculate the sample size for the study. Population of women residing in the rural areas of Pauri Garhwal was 306539 as per 2011 census [9]. We assumed that total number of women residing in the rural areas currently will be 500000. As per a previous study in rural areas, 63% of the women had heard about breast cancer. [10]. Keeping a 95% confidence interval, 10% relative precision, and design effect of 2, the sample size was calculated as 498, rounded off to 500. We assumed a 10% non-response rate; hence, the final sample size was kept at 560.

Questionnaire development

Content and domain specification & Item generation: Items were generated from the literature review from a pubmed search to identify publications that evaluated knowledge regarding awareness, early diagnosis, treatment and attitude towards breast and cervical cancer. A total of 41 unique questions were included in the preliminary version of the questionnaire.
Instrument construction: The preliminary questionnaire version was sent to an advisory committee for opinion. A three-member committee was asked to evaluate the questionnaire's overall format, domains, and items. The committee comprised a breast cancer specialist, gynae-oncologist, and community and family medicine expert. The questionnaire was revised as per the recommendations of the committee. Each domain and item was reviewed for structure and clarity, redundant inquiries were eliminated, and ambiguous wording was modified.
Content Validity: It was tested using index of content validity(CVI) using the Item-CVI (I-CVI) and Scale-CVI (S-CVI). I-CVI is computed as the number of experts rating "very relevant" for each item divided by the total number of experts. Values range from 0 to 1 where I-CVI > 0.79, the item is relevant, between 0.70 and 0.79, the item needs revisions, and if the value is below 0.70, the item is eliminated. Similarly, S-CVI is calculated using the number of items in a tool that have achieved a rating of "very relevant ."There are two methods for calculating S-CVI: one is the Universal Agreement (UA) among experts (S-CVI/UA), and the second is the Average CVI (S-CVI/Ave). S-CVI/UA is calculated by adding all items with I-CVI equal to 1 divided by the total number of items, while S-CVI/Ave is calculated by taking the sum of the I-CVIs divided by the total number of items. A S-CVI/UA ≥ 0.8 and a S-CVI/Ave ≥ 0.9 have excellent content validity. The questionnaire was circulated among seven subject experts with the content validity survey explaining why experts were invited to participate, along with clear and concise instructions on how to rate each item. A 4-point Likert scale was used, and responses include: 1 = not relevant, 2 = somewhat relevant, 3 = relevant, and 4 = very relevant. Ratings of 1 and 2 were considered content invalid, while 3 and 4 were considered content valid. The final questionnaire was prepared in English and Hindi and contained 39 items.

The study was explained in detail to the participants. Informed consent was taken. The help of a local non-governmental organization (Uttarakhand Manav Seva Samiti, Delhi) was taken for carrying out the door-to-door interview. This was accomplished through field workers/supervisors who were trained in detail regarding the study and questionnaire. The Institutional Research Review Board and Ethics Committee approved the study.

Statistical analysis

Results were expressed in frequency and percentage for categorical variables while mean and standard deviation for categorical variables. Comparative analysis between qualitative variables was done using Chi-square test.

Six-hundred and twenty -four females were recruited into the study, out of which 35 were excluded due to withdrawal of consent and providing incomplete information. Five hundred and eighty-nine participants were included in the study analysis. The mean age of the participants was 38.6 ± 10.7 years. This suggests a relatively younger population, as 340(57.7%) participants were under 40 years of age. The mean age at marriage and first childbirth were 19.7 ± 2.1 and 21.7 ± 2.4 years, respectively, suggesting an inclination towards these life events at an early age. One hundred and thirteen (19.2%) females were illiterate or had no formal education (Table 1).

Table 1: Socio-demographic characteristics

Parameter

Number of participants (%)

(n=589)

Mean age (years)

38.6 ± 10.7

Age (years)

≤ 40

>40

340 (57.7)

249 (42.3)

Marital status

Married

Unmarried

Widow

542 (92.0)

25 (4.2)

22 (3.7)

Mean age at marriage (years)

[n=564]

19.7 ± 2.1

Mean age at first childbirth (years)

[n=541]

21.7 ± 2.4

Occupation

Housewife

Student

Government job

Private job

Farmer

492 (83.5)

23 (3.9)

10 (1.7)

9 (1.5)

55 (9.3)

Education level

Illiterate*

Read and write*

Primary

Middle

High school

Inter college

Graduate

Postgraduate

49 (8.3)

64 (10.9)

52 (8.8)

101 (17.1)

132 (22.4)

139 (23.6)

39 (6.6)

13 (2.2)

*Those who could only read and write were clubbed together with illiterate as having no formal education.

Awareness and knowledge about the symptoms and signs of breast cancer

Thirty-eight percent (224) of the participants had never heard about breast cancer. Amongst those who have heard about breast cancer (365 out of 589), only 26.3%(96) knew it as the most common cancer in women in India. The positive family history as a risk factor for breast cancer was known to only 7.6%(28) of the participants who had heard about breast cancer. Presentation of breast cancer as a painless lump(usual), armpit lump, nipple discharge, breast pain, puckering and redness of the skin, crusting of the nipple, and change in size/swelling of the breast was known to only 49.8%(182), 43.5%(159), 28.2%(103), 33.4%(122), 19.7%(72), 13.9%(51), and 17.5%(64) of the participants who had heard about breast cancer [Table 2(a)]. Participants aged 40 years and younger were more likely to have (statistically significant) knowledge and awareness regarding the symptoms and signs of breast cancer.

Table 2 (a). Awareness and knowledge about the symptoms & signs of breast cancer (responses stratified as per age groups)

Parameter

Age

Responses

(n = 589)

Responses

(n = 365)

P value

≤ 40 (n=340)

>40

(n=249)

Knowledge about breast cancer

Have you ever heard of breast cancer?

Yes

224 (65.9)

116 (34.1)

141 (56.6)

107 (43.3)

365 (62)

224 (38)

0.025

Breast cancer is the most common cancer among women in India

Yes

No/No information

69 (20.3)

271 (79.7)

27 (10.8)

222 (89.1)

96 (16.3)

493 (83.7)

96(26.3)

269 (73.7)

0.002

If a family member has been affected by breast cancer at any time in life, then the chances of breast cancer in themselves increase

Yes

No/No information

26 (7.6)

314 (92.3)

2 (0.8)

247 (99.1)

28 (4.8)

561 (95.2)

28 (7.6)

337 (92.4)

0.000

Knowledge about the symptoms/signs of breast cancer

Breast cancer usually occurs as a painless lump

Yes

No/No information

123 (36.2)

217 (63.9)

59 (23.7)

190 (76.2)

182 (30.9)

407 (69.1)

182 (49.8)

183 (50.2)

0.001

Breast cancer can occur as an armpit lump

Yes

No/No information

110 (32.4)

230 (67.6)

49 (19.7)

200 (80.3)

159 (27)

430 (73)

159 (43.5)

206 (56.4)

0.000

Watery discharge from the nipple can be a sign of breast cancer

Yes

No/No information

72 (21.2)

268 (78.9)

31 (12.4)

218 (87.5)

103 (17.5)

486 (89.4)

103 (28.2)

262(71.8)

0.005

Breast cancer may present as breast pain

Yes

No/No information

83 (24.4)

257 (75.5)

39 (15.7)

210(84.2)

122 (20.7)

467 (79.2)

122 (33.4)

243 (66.6)

0.009

Breast cancer may present as shrinking skin of the breast or maybe in the form of redness

Yes

No/No information

51 (15)

289(85)

21 (8.4)

228 (91.6)

72 (12.2)

517 (87.7)

72 (19.7)

293 (80.3)

0.016

Excoriation or crust formation on the nipple can be a sign of breast cancer

Yes

No/No information

34 (10)

306 (90)

17 (6.8)

232 (93.1)

51 (8.7)

538 (91.2)

51 (13.9)

314(86.1)

0.176

Change in the size of the breast or swelling in the breast can be a sign of breast cancer

Yes

No/No information

42 (12.4)

298 (87.5)

22 (8.8)

227 (91.1)

64 (10.9)

525 (89.1)

64 (17.5)

301 (82.5)

0.175

Knowledge about early detection, treatment, and attitude regarding breast cancer

Only 36.1% (132) and 11.5% (42) of the participants had heard about breast cancer had also heard about breast examination and mammography, including its utility in diagnosing early breast cancer (EBC), respectively. Only 22.7% (83) of the participants were educated enough to know breast examination's beneficial role in diagnosing EBC. The fact that early detection and treatment can lead to cure of EBC was known to only 21.3%(78) of the participants.

Near to half of the participants having heard about breast cancer agreed with the fact that it was not shameful to get diagnosed (48.2%) with and subsequently treated (53.2%) for the breast cancer.

The fact that breast cancer treatment is a long process and it can be cured if the patient undergoes timely and complete treatment was known to 31.5% and 39.1% of the participants respectively [Table 2(b)].

Enthusiasm towards participation in the breast cancer screening program was noted in 57.9% of the total participants.

Table 2 (b). Knowledge about early detection, treatment, and attitude regarding breast cancer (responses stratified as per age groups)

Parameter

Age

Responses

(n = 589)

Responses*

(n = 365)

P value

≤ 40 (n=340)

> 40 (n=340)

Knowledge about early detection and treatment of breast cancer

Have you heard about breast examination?

Yes

No/No information

88 (25.9)

252 (74.1)

44 (17.7)

205 (60.2)

132 (22.4)

457(77.5)

132(36.1)

233(63.9)

0.000

Have you heard of mammography?

Yes

No/No information

29 (8.5)

311 (91.4)

13 (5.2)

236 (94.8)

42 (7.1)

547 (92.8)

42(11.5)

323(88.5)

0.123

Mammography screening can detect breast cancer at an early stage

Yes

No/No information

29 (8.5)

311 (91.4)

13 (5.2)

236 (94.8)

42 (7.1)

547 (92.9)

42(11.5)

323(88.5

0.123

Regular breast examination can detect breast cancer at an early stage

Yes

No/No information

57 (16.8)

282 (82.9)

26 (10.4)

221 (88.8)

83 (14.1)

503 (85.4)

83(22.7)

82(77.3)

0.029

Complete cure of breast cancer is possible with early detection and treatment

Yes

No/No information

51 (15)

289 (85)

27 (10.8)

222 (89.1)

78 (13.2)

511(86.8)

78(21.3)

287(78.7)

0.141

Attitude regarding breast cancer

Being diagnosed with breast cancer is not shameful

Agree

Don’t agree/Cannot say

124 (36.5)

216 (63.4)

52 (20.9)

197 (79.1)

176 (29.9)

413 (70.1)

176(48.2)

189(51.8)

0.000

Breast cancer treatment is a long process

Agree

Don’t agree/ Cannot say

82 (24.1)

258 (75.9)

33 (13.3)

216 (86.6)

115 (19.5)

474 (80.4)

115(31.5)

250(68.5)

0.001

Breast cancer treatment is helpful in all patients, not just young patients

Agree

Don’t agree/Cannot say

60 (17.6)

280 (82.3)

26 (10.4)

223 (89.6)

86 (14.6)

503 (85.3)

86(23.5)

279(76.4)

0.014

Breast cancer treatment is not shameful

Agree

Don’t agree/Cannot say

101 (29.7)

239 (70.2)

45 (18.1)

204 (81.8)

146 (24.8)

443 (75.1)

146(40)

219(60)

0.001

A woman undergoing treatment for

breast cancer can lead a normal life

Agree

Don’t agree/Cannot say

81 (23.8)

259 (76.1)

37 (14.9)

212 (85.1)

118 (20)

471(79.9)

118(32.3)

247(67.6)

0.007

Breast cancer can be cured if the patient undergoes complete and timely treatment

Agree

Don’t agree/Cannot say

100 (29.4)

240 (70.5)

43 (17.2)

206 (82.9)

143 (24.3)

446 (75.6)

143(39.1)

222(60.8)

0.000

I will participate in the breast cancer screening program

Agree

Don’t agree/Cannot say

203 (59.7)

137 (40.2)

138 (55.4)

111 (45.5)

341 (57.9)

248 (42.1)

341(93.4)

24(6.5)

0.299

Awareness and knowledge about the symptoms and signs of cervical cancer

In contrast to breast cancer, only 20.9%(123) of the participants have ever heard about cervical cancer. Out of these, only 7.3% were aware of the fact that it is one of the common cancer causing death in Indian females. Inter-menstrual bleed, foul-smelling vaginal discharge, bleeding after menopause, and intercourse as a sign of cervical cancer were known to only 37.3%, 30.8%, 55.2%, and 11.38% of the participants, respectively [Table 2(c)].

Table 2 (c). Awareness and knowledge about the symptoms and signs of cervical cancer (responses stratified as per age groups)

Parameter

Age

Responses

(n = 589)

Responses*

(n = 123)

P value

≤ 40

(n=340)

> 40

(n=249)

Knowledge about cervical cancer

Have you ever heard of cervical cancer?

Yes

80 (23.5)

260 (77.4)

43 (17.3)

206(82.6)

123 (20.8)

466 (79.1)

0.0648

Cervical cancer is one of the most common cancer-causing death among Indian women

Yes

No/No information

17 (5)

323 (95)

10 (4)

239 (96)

27 (4.6)

562 (95.4)

27(21.9)

96(78.0)

0.572

Knowledge about the symptoms/signs of cervical cancer

Bleeding between periods can be a sign of cervical cancer

Yes

No/No information

30 (8.8)

310 (91.1)

16 (6.4)

233 (93.5)

46 (7.8)

543 (92.2)

46(37.3)

77(62.6)

0.285

Foul-smelling vaginal discharge (watery discharge) could be a sign of cervical cancer

Yes

No/No information

25 (7.4)

315 (92.6)

13 (5)

236 (94.9)

38 (6.5)

551 (93.4)

38(30.8)

85(69.1)

0.299

Bleeding after menopause could be a sign of cervical cancer

Yes

No/No information

47 (13.8)

293 (86.2)

21 (8.4)

228 (91.5)

68 (11.5)

521 (88.4)

68(55.2)

55(44.7)

0.043

Bleeding after intercourse could be a sign of cervical cancer

Yes

No/No information

7 (2.1)

333 (97.9)

7 (2.8)

242 (97.2)

14 (2.4)

575(97.5)

14(11.3)

109(88.6)

0.553

Awareness and knowledge about early detection, prevention, treatment, and attitude towards cervical cancer

Knowledge about screening tests for cervical cancer and their ability to detect cancer in the very early stage was known to 55.2% and 47.1% (out of 123) of the participants, respectively. Only 8 (6.5%) have heard about preventive vaccination for cervical cancer. The role of screening and vaccination in near total prevention of cervical cancer was known only to 13% of them. Out of the total participants, 23.1% and 18.8% agreed that being diagnosed with cervical cancer and getting treated for it, respectively, was not shameful. About 56% of the participants expressed willingness to participate in the cervical cancer screening program [Table 2(d)].

Table 2 (d). Awareness and knowledge about early detection, prevention, treatment, and attitude towards cervical cancer (responses stratified as per age groups)

Parameter

Age

Responses

(n = 589)

Responses*

(n = 123)

P value

≤ 40

(n=340)

> 40

(n=249 )

Knowledge about early detection, prevention, treatment, and attitude towards cervical cancer

Have you ever heard of screening for early detection of cervical cancer? (Pap smear test, VIA, etc.)

Yes

47 (13.8)

293(86.2)

21 (8.4)

228 (91.5)

68 (11.5)

521 (88.4)

68(55.2)

55(44.7)

0.043

Cervical cancer can be detected in the pre-cancerous stage by screening

Yes

42 (12.4)

298(87.5)

16 (6.4)

233 (93.5)

58 (9.8)

531(90.2)

58(47.1)

65(52.8)

0.017

Is there a vaccine to prevent cervical cancer?

Yes

No/No information

3 (0.9)

337 (99.1)

5 (2)

244 (98)

8 (1.4)

581 (98.6)

8(6.5)

115(93.5)

0.244

Cervical cancer can be prevented by screening and vaccination in 90-100% of the cases

Yes

No/No information

10 (2.9)

330 (97.1)

6 (2.4)

243 (97.6)

16 (2.7)

573 (97.2)

16(13)

107(87)

0.695

With early detection and treatment, a complete cure of cervical cancer is possible

Yes

No/No information

34 (10)

306 (90)

14 (5.6)

235 (94.4)

48 (8.1)

541 (91.8)

48(39)

75(60.9)

0.055

Attitude about cervical cancer

It is not shameful to be suffering from cervical cancer

Agree

Don’t agree/Cannot say

99 (29.1)

241 (70.9)

37 (14.9)

212 (85.1)

136 (23.1)

453(76.9)

0.000

Treatment of cervical cancer is helpful in all patients, not just young patients

Agree

Don’t agree/Cannot say

35 (10.3)

305 (89.7)

13 (5.2)

236 (94.8)

48 (8.1)

541 (91.8)

48(39)

75(60.9)

0.026

Treatment of cervical cancer is not shameful

Agree

Don’t agree/Cannot say

78 (22.9)

262 (77.0)

33 (13.3)

216 (86.7)

111 (18.8)

478 (81.1)

111(89.4)

12(9.7)

0.002

A woman who is treated for cervical cancer can lead a normal life

Agree

Don’t agree/Cannot say

37 (10.9)

303 (89.1)

14 (5.6)

235 (94.4)

51 (8.7)

538 (91.3)

51(41.4)

72(58.5)

0.024

Cervical cancer can be cured if the patient completes the treatment

Agree

Don’t agree/Cannot say

48 (14.1)

292 (85.9)

15 (6)

234 (94)

63 (10.7)

526 (89.3)

63((51.2)

60(48.8)

0.001

I will participate in a cervical cancer screening program

Agree

Don’t agree/Cannot say

199 (58.5)

141 (41.5)

130 (52.2)

119 (47.6)

329 (55.9)

260 (44.1)

0.127

On stratifying the study population according to the literacy status, similar results were obtained, literate participants were more likely to have (statistically significant) the knowledge awareness, and a positive attitude towards the disease [Table 3(a,b,c,d)].

Table 3 (a). Awareness and knowledge about the symptoms & signs of breast cancer (responses stratified as per the literacy status)

Parameter

Age

Total

P value

Illiterate (n=113)

Literate

(n=476)

Knowledge about breast cancer

Have you ever heard of breast cancer?

Yes

51 (45.1)

62 (54.9)

314 (66)

162 (34)

365 (62)

224 (37.9)

0.000

Breast cancer is the most common cancer among women in India

Yes

No/No information

3 (2.7)

110 (97.3)

93 (19.5)

383 (80.4)

96 (16.3)

493 (83.6)

0.000

If a family member has been affected by breast cancer at any time in life, then the chances of breast cancer in themselves increase

Yes

No/No information

113 (100)

28 (5.9)

448(94.1)

28 (4.8)

561 (95.1)

0.008

Knowledge about the symptoms/signs of breast cancer

Breast cancer usually occurs as a painless lump

Yes

No/No information

12 (10.6)

101 (89.3)

170 (35.7)

306 (64.2)

182 (30.9)

407 (69.1)

0.000

Breast cancer can occur as an armpit lump

Yes

No/No information

9 (8)

104 (92)

150 (31.5)

326 (68.4)

159 (27)

430 (73)

0.000

Watery discharge from the nipple can be a sign of breast cancer

Yes

No/No information

4 (3.5)

109 (96.5)

99 (20.8)

377 (79.2)

103 (17.5)

486 (82.5)

0.000

Breast cancer may present as breast pain

Yes

No/No information

8 (7.1)

105 (92.9)

114 (23.9)

362 (76.4)

122 (20.7)

467 (79.3)

0.000

Breast cancer may present as shrinking skin of the breast or maybe in the form of redness

Yes

No/No information

4 (3.5)

109 (96.5)

68 (14.3)

408 (85.6)

72 (12.2)

517 (87.8)

0.001

Excoriation or crust formation on the nipple can be a sign of breast cancer

Yes

No/No information

1 (0.9)

112 (99.1)

50 (10.5)

426 (89.4)

51 (8.7)

538 (91.3)

0.001

Change in the size of the breast or swelling in the breast can be a sign of breast cancer size

Yes

No/No information

2 (1.8)

111 (98.2)

62 (13)

414 (87)

64 (10.9)

525 (89.1)

0.000

Table 3 (b). Knowledge about early detection, treatment, and attitude regarding breast cancer (responses stratified as per literacy status)

Knowledge about early detection and treatment of breast cancer

Parameter

Age

Total

P value

Illiterate (n=113)

Literate

(n=476)

Have you heard about breast examination?

Yes

6 (5.3)

107 (94.6)

126 (26.5)

350 (73.5)

132 (22.4)

457 (77.6)

0.000

Have you heard of mammography?

Yes

113 (100)

42 (8.8)

434 (99.2)

42 (7.1)

547(92.8)

0.000

Mammography screening can detect breast cancer at an early stage

Yes

No/No information

113 (100)

42 (8.8)

433 (91.2)

42 (7.1)

547 (92.9)

0.000

Regular breast examination can detect breast cancer at an early stage

Yes

No/No information

4 (3.5)

109 (96.5)

79 (16.6)

397 (83.3)

83 (14.1)

506 (85.9)

0.000

Complete cure of breast cancer is possible with early detection and treatment

Yes

No/No information

3 (2.7)

110 (97.3)

75 (15.8)

401 (84.2)

78 (13.2)

511 (86.8)

0.000

Attitude regarding breast cancer

Being diagnosed with breast cancer is not shameful

Agree

Don’t agree/Cannot say

31 (27.4)

82 (72.6)

145 (30.5)

331 (69.5)

176 (29.9)

413 (70.1)

0.527

Breast cancer treatment is a long process

Agree

Don’t agree/Cannot say

12 (10.6)

101 (89.4)

103 (21.6)

373 (78.3)

115 (19.5)

475 (80.3)

0.007

Breast cancer treatment is helpful in all patients, not just young patients

Agree

Don’t agree/Cannot say

4 (3.5)

109 (96.5)

82 (17.2)

394 (82.7)

86 (14.6)

503 (85.3)

0.000

Breast cancer treatment is not shameful

Agree

Don’t agree/Cannot say

25 (22.1)

88 (77.9)

121 (25.4)

353 (74.5)

146 (24.8)

443 (75.2)

0.452

A woman undergoing treatment for

breast cancer can lead a normal life

Agree

Don’t agree/Cannot say

12 (10.6)

101 (89.4)

106 (22.3)

391 (77.6)

118 (20)

471 (80)

0.009

Breast cancer can be cured if the patient undergoes complete and timely treatment

Agree

Don’t agree/Cannot say

18 (15.9)

95 (84.1)

125 (26.3)

351 (73.6)

143 (24.3)

446 (75.6)

0.021

I will participate in the breast cancer screening program

Agree

Don’t agree/Cannot say

69 (61.1)

44 (38.9)

272 (57.1)

204 (42.9)

341 (57.9)

238 (42.1)

0.448

Table 3 (c). Awareness and knowledge about the symptoms and signs of cervical cancer (responses stratified as per literacy status)

Knowledge about cervical cancer

Parameter

Age

Total

P value

Illiterate (n=113)

Literate

(n=476)

Have you ever heard of cervical cancer?

Yes

10 (8.8)

103 (91.2)

113 (23.7)

363 (76.3)

123 (20.9)

466(79.1)

0.000

Cervical cancer is one of the common cancer-causing death among Indian women

Yes

No/No information

113 (100)

27 (5.7)

449 (94.3)

27 (4.6)

562 (95.4)

0.000

Knowledge about the symptoms of cervical cancer

Bleeding between periods can be a sign of cervical cancer

Yes

No/No information

113 (100)

46 (9.7)

430 (90.3)

46 (7.8)

543 (92.2)

0.000

Foul-smelling vaginal discharge (watery discharge) could be a sign of cervical cancer

Yes

No/No information

113 (100)

38 (8)

438 (92)

38 (6.5)

551 (93.4)

0.000

Bleeding after menopause could be a sign of cervical cancer

Yes

No/No information

4 (3.5)

109 (96.5)

64 (13.4)

412 (86.5)

68 (11.5)

521(88.4)

0.003

Bleeding after intercourse could be a sign of cervical cancer

Yes

No/No information

113 (100)

14 (2.9)

462 (97.1)

14 (2.4)

575(97.5)

0.097

Table 3 (d). Awareness and knowledge about early detection, prevention, treatment, and attitude towards cervical cancer (responses stratified as per age groups)

Knowledge about early detection, prevention, and treatment of cervical cancer

Parameter

Age

Total

P value

Illiterate (n=113)

Literate

(n=476)

Have you ever heard of screening for early detection of cervical cancer? (Pap smear test, VIA, etc.)

Yes

1 (0.9)

112 (99.1)

67 (14.1)

406 (85.9)

68 (11.5)

521 (88.4)

0.000

Cervical cancer can be detected in the pre-cancerous stage by screening

Yes

No/No information

113 (100)

58 (12.2)

416 (87.8)

58 (9.8)

531 (90.2)

0.000

Is there a vaccine to prevent cervical cancer?

Yes

No/No information

113 (100)

8 (1.7)

468 (98.3)

8 (1.4)

581(98.5)

0.359

Cervical cancer can be prevented by screening and vaccination in 90-100% of the cases

Yes

No/No information

113 (100)

16 (3.4)

460 (96.5)

16 (2.7)

573 (97.3)

0.000

With early detection and treatment, complete cure of cervical cancer is possible

Yes

No/No information

113 (100)

48 (10.1)

428 (89.9)

48 (8.1)

541 (91.9)

0.000

Attitude about cervical cancer

It is not shameful to be suffering from cervical cancer

Agree

Don’t agree/Cannot say

25 (22.1)

88(77.9)

111 (23.3)

365 (76.7)

136 (23.1)

453 (76.9)

0.786

Treatment of cervical cancer is helpful in all patients, not just young patients

Agree

Don’t agree/Cannot say

2 (1.8)

111 (98.2)

46 (9.7)

430 (90.3)

48 (8.1)

541(91.9)

0.005

Treatment of cervical cancer is not shameful

Agree

Don’t agree/Cannot say

19 (16.8)

94 (83.2)

92 (19.3)

384 (80.6)

111 (18.8)

478 (81.2)

0.539

A woman who is treated for cervical cancer can lead a normal life

Agree

Don’t agree/Cannot say

2 (1.8)

111 (98.2)

49 (10.3)

427 (89.7)

51 (8.7)

538 (91.3)

0.003

Cervical cancer can be cured if the patient completes the treatment

Agree

Don’t agree/Cannot say

3 (2.7)

110 (18.7)

60 (12.6)

416 (87.3)

63 (10.7)

526 (89.2)

0.002

India is looking at the steep demographic transition to an alarming increase in the number of patients with cancer over the next 25 years. Community-level screening programs for the most common and lethal cancers can control the situation, saving lives and improving quality of life. The success of preventive oncology or a cancer control program depends mainly upon cancer awareness for early detection and better health-focused behavior among the general population. The lack of awareness regarding the most common and lethal cancers among women poses an effective barrier that ultimately determines the acceptance of such a program in a geographical area. The screening programs for the early detection of breast and cervical cancer have been in place since 2016; the screening rates are low, the reason being poor knowledge about cancer awareness, symptoms, risk factors, diagnosis, and treatment. In India, most of the individuals being diagnosed with cancer, report to the healthcare facilities for the first time at advanced stage of the disease.

Two-thirds of the Indian population resides in rural areas, where accessibility to healthcare IEC activities is limited. We conducted this rural community-based study in remote, hilly areas of Uttarakhand as they represent areas with unmet needs. Thirty-eight percent of the participants in our study had never heard about breast cancer. Among these, the knowledge about various signs and symptoms of breast cancer varied from 14–50%. Our study also revealed a poor knowledge of participants regarding the early diagnosis of breast cancer using breast examination and mammography. However, 57.9% of the participants showed enthusiasm towards joining a screening program. A study conducted in Delhi (urban area) by Dahiya N et al. revealed that the knowledge of risk factors associated with breast cancer among women varied from 35% - to 60%. Unmarried and younger (< 30 years) females registered higher knowledge. The role of breast examination and mammography in the early detection of breast cancer was known to 75% and 48% of the females, respectively. [10] Similar studies had been conducted in institutional settings (hospitals, college teachers, school or college students) or in urban community areas where availability and access to information, education, and communication (IEC) activities and healthcare facilities are more straightforward than in rural areas. [10, 11, 12, 13, 14, 15].

Only a few community-based studies have been conducted in rural or combined urban-rural areas. Gangane N et al. conducted a community-based cross-sectional study in Maharashtra's rural and urban districts regarding the knowledge, attitudes, and practices about breast cancer. While two-thirds of the rural and urban women had heard about breast cancer, less than 7% of the women knew about breast examination and early detection of cancer. However, most of the females (more than 95%) showed enthusiasm towards participation in the breast cancer screening program. In their study. [16]

A similar rural community-based study conducted across Northeast states (Assam, Nagaland, and Meghalaya) included 1400 participants, revealing that only 50% of the participants had heard about breast cancer and its risk factors. Only 34% of the participants registered knowledge related to cancer screening and early detection. The authors cited a limitation with cancer related IEC campaigns, access to screening centers, and the government screening programs. Overall, the community participants exhibited a low health-seeking behaviour and the awareness regarding cancer prevention and early detection. [17] A similar study conducted in the rural and peri-urban areas of Andhra Pradesh recruited 300 community-dwelling women. The study revealed a low level of awareness (21.4%) regarding the awareness of breast cancer, with less than 5% having knowledge about breast examination as a screening procedure. [18]

We obtained even poorer results regarding the awareness and knowledge of cervical cancer, as only 20.9% of the participants had ever heard about the disease. Among these, the knowledge about various signs and symptoms varied from 11–55% of the participants. Only 56% of the participants expressed their willingness to participate in the cervical cancer screening program. Previous studies have cited similar results, which have been attributed to poor IEC activities and correlated well with the participants' education status and income level. [17]

It has been demonstrated previously that educated and young participants register more uptake and enthusiasm towards any screening program (16, 19). Similar to the previous studies, our results also show that literate and younger participants (< 40 years) exhibited more knowledge, awareness, and a positive attitude toward the disease.

In total, the results of our study are alarming as they highlight a noteworthy lack of awareness towards the most common and lethal form of female cancers. The foremost priority towards the successful implementation and promotion of a cancer screening program should be the stake holdings in the IEC activities based on a comprehensive understanding of the socio-cultural factors, more apt for the rural and remotely accessed geographical areas. These have been appropriately designated as community-level pull priorities. This will only enable the females to know where to go and whom to approach for screening and vaccination services. Simultaneously, there is a need for the scrupulous monitoring and evaluation of these IEC activities, including through the inclusion of cancer knowledge questions in large-scale surveys [20]. The recognition that breast and cervical cancer can be diagnosed at an early stage with a high possibility of cure and that cervical cancer is preventable needs to be established and further strengthened in the rural community.

Funding information

This study was supported with a research grant from Uttarakhand State Council for Science & Technology (UCOST), however, they did not have any role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Ethics statement

The study was approved from the institutional research review board and ethics committee (AIIMS/IEC/21/532)

Acknowledgements

We are thankful to the Non-Governmental, apolitical organization, Uttarakhand Manav Seva Samiti, Delhi (UKMSSD), for collaborating and providing the necessary support for carrying out the study.

Contributors

Deepak Sundriyal, Shalini Rajaram, Yogesh Bahurupi: Conceptualisation, methodology, validation, writing original draft, data collection, and editing.

Amit Sehrawat, Sweety Gupta, Pradeep Aggarwal: Data collection, supervision, and critical analysis.

Mahendra Singh, Preeti Antil: Writing original draft and editing.

All authors: Final approval.

Data sharing statement

The study data will be made available upon a reasonable request over email to the corresponding author.

Conflict of interest statement

The authors declare no conflict of interest.

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No competing interests reported.

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Perspective of females from a rural community in India towards the knowledge, screening, and treatment of breast and cervical cancer, and preventive vaccination

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