Cervical cancer screening status and implementation challenges: Report from selected states of India

DOST: A consolidated health behavior model that maps factors influencing cancer screening uptake

BACKGROUND

Cancer is a leading cause of death worldwide, particularly in low- and middle-income countries (LMICs), where preventive interventions like screening and vaccination face challenges due to limited resources. Despite the availability of user-friendly screening methods, uptake remains poor. Psychological theories are recommended to identify and address determinants of screening participation; however, existing models often focus on a limited range of domains and overlook critical belief-related factors needed to encourage screening uptake. A comprehensive, integrated model addressing these gaps could significantly improve the identification of barriers to screening.

METHODS

This conceptual paper proposes a model that maps potential barriers to cancer screening uptake through the lens of beneficiaries. The 'Determinants Of Screening upTake' (DOST) model was systematically developed through a series of steps integrating three existing health behavior theories that have been successfully used previously to improve screening uptake: the Health Belief Model (HBM), the Theory of Planned Behavior (TPB), and the Theory of Care-Seeking Behavior (TCSB).

RESULTS

The DOST model integrates dimensions represented in existing health behavior models, presenting a detailed map of potential barriers in real world, faced by beneficiaries of screening. These barriers are categorized systematically to enhance understanding and facilitate its use among non-experts in empirical research.

CONCLUSION

By integrating multiple models, the DOST model offers a comprehensive framework that combines theoretical robustness with practical guidelines. It highlights psychosocial barriers that influence screening attitudes, intentions, and uptake. The model can guide the assessment of screening determinants in populations and support the design of educational messages or interventions aimed at increasing screening uptake.

Living in the Minds of Others: How Pudor and Social Judgements Affect Women's Cervical Cancer Screening Uptake in Mozambique?

Mozambique introduced its cervical cancer screening programme in 2009, but only 3.5% of the target women participate in screening annually. While previous research has focused on provision and access to service, and women's cognitive barriers to screening, this study explores the emotional factors, particularly pudor, that affect women's acceptance of screening. Using an institutional work perspective, we conducted an explanatory case study involving documental analysis and primary data collection through semi-structured interviews, focus group discussions, direct observations, and informal conversations with 121 participants, including women, health professionals, and family members from Xai-Xai in Southern Mozambique. Our findings reveal that pudor, an emotion tied to a deep-seated sense of reserve rooted in patriarchal culture and masculine dominance, plays a significant role in limiting women's motivation to participate in screening. This emotion, shaped by social and cultural norms around privacy, intimacy, and sexuality, leads women to view cervical cancer screening as culturally unacceptable, often responding with attitudes emphasising modesty and avoidance. These findings underscore the importance of addressing emotional factors in health care strategies and considering the sociocultural context that influences health behaviours.

A scoping review of evidence on routine cervical cancer screening in South Asia: investigating factors affecting adoption and implementation

NEED: Cervical cancer is a major global public health issue, particularly affecting low and middle-income countries, distinctly in the South Asian region. This geographical region lacks a well-organized routine cervical screening program. Consequently, this scoping review aimed to investigate the evidence on factors influencing the adoption and implementation of routine cervical cancer screening in South Asia.

METHODS

Adopting the "Arksey and O'Malley and Levac et al." methodology, databases such as PubMed, CINAHL, Web of Science, and Scopus were scrutinized in the pursuit of relevant studies. Subsequently, the collected data were synthesized by adopting the Consolidated Framework for Implementation Research (CFIR) model.

RESULTS

A total of 837 records were initially identified and screened for eligibility, including 55 studies. The successful adoption and implementation of cervical cancer screening in South Asia encounter numerous obstacles within the health system, including the absence of a comprehensive program protocol for screening, inadequate health infrastructure, and the presence of multiple sociocultural factors, such as social stigma, low levels of education, and concerns related to modesty.

CONCLUSION

To optimize adoption and implementation, it is imperative to construct a customized policy framework that incorporates a risk communication strategy tailored to the specific contexts of these nations. Drawing insights from the experiences of South Asian countries in executing cervical cancer screening programs can inform the formulation of policies for similar healthcare initiatives aimed at facilitating the expansion of HPV vaccination efforts.

Sister partnership to overcome the global burden of cancer

Emerging countries are currently facing an increasing burden of cancer while they do not have adequate prevention, monitoring, and research capabilities to tackle the disease. Cancer outcomes are influenced by several factors, including different cancer patterns, national cancer screening guidelines, current stage of disease, and access to quality care and treatments. Discrepancies in cancer care between emerging and developed countries require actions to achieve global health equity. The process of pioneering a sister relationship in the oncology field can thwart the global burden of cancer. The objective of such cooperation programs should include research and training programs, evidence-based oncology practice, and quality cancer. Building global connections will therefore be the novel approach to addressing the global burden of cancer.

Supply-Side Barriers in Accessing Human Papillomavirus Screening for Cervical Cancer Prevention in Rural India: Evidence From a Cross-Sectional Study

BACKGROUND

Cervical cancer is a leading cause of cancer-related mortality among women worldwide, particularly in low- and middle-income countries. In India, rural areas face a disproportionate burden of cervical cancer cases. Effective screening methods, such as Human Papillomavirus (HPV) testing, are recommended by the World Health Organization (WHO) for early detection and prevention. However, the uptake of these screening methods in rural India is significantly low due to various supply-side barriers. This study aims to evaluate the readiness and capacity of PHCs in rural India to conduct HPV screening tests.

MATERIALS AND METHODS

This cross-sectional study in Pondicherry, India, examined cervical cancer screening and management at 15 primary health centers (PHCs) through a structured questionnaire. It assessed personnel training for HPV screening, availability of screening tests, healthcare infrastructure functionality, supply chain efficiency, infection prevention practices, medicine and diagnostic supply availability, referral protocols, data management practices, policy adherence, and equipment availability.

RESULTS

Visual inspection with acetic acid was available in all PHCs, while more advanced tests like cytology, HPV testing, loop electrosurgical excision procedure (LEEP), colposcopy, and histology/pathology were generally absent. Only one PHC had personnel trained for cytology processing, with none trained for other advanced procedures or HPV testing. The study identified significant gaps in healthcare infrastructure, trained personnel, and supply chain logistics.

CONCLUSION

Enhancing cervical cancer screening and treatment in PHCs necessitates investments in infrastructure, training, and data systems. Key priorities include upgrading equipment like colposcopes and implementing a robust Health Management Information System (HMIS). Collaboration with stakeholders is essential for effective resource allocation and capacity building.

Improving access to cancer care among rural populations in India: Development of a validated tool for health system capacity assessment

BACKGROUND

Cancer burden in India is rapidly growing, with oral, breast, and uterine cervix being the three most commonly affected sites. It has a catastrophic epidemiological and financial impact on rural communities, the vast majority of whom are socio-economically disadvantaged. Strengthening the health system is necessary to address challenges in the access and provision of cancer services, thus improving outcomes among vulnerable populations.

OBJECTIVE

To develop, test, and validate a health system capacity assessment (HSCA) tool that evaluates the capacity and readiness for cancer services provision in rural India.

METHODS

A multi-method process was pursued to develop a cancer-specific HSCA tool. Firstly, item generation entailed both a nominal group technique (to identify the health system dimensions to capture) and a rapid review of published and gray literature (to generate items within each of the selected dimensions). Secondly, tool development included the pre-testing of questionnaires through healthcare facility visits, and item reduction through a series of in-depth interviews (IDIs) with key local stakeholders. Thirdly, tool validation was performed through expert consensus.

RESULTS

A three-step HSCA multi-method tool was developed comprising: (a) desk review template, investigating policies and protocols at the state level, (b) facility assessment protocol and checklist, catering to the Indian public healthcare system, and (c) IDI topic guide, targeting policymakers, healthcare workforce, and other relevant stakeholders.

CONCLUSIONS

The resulting HSCA tool assesses health system capacity, thus contributing to the planning and implementation of context-appropriate, sustainable, equity-focused, and integrated early detection interventions for cancer control, especially toward vulnerable populations in rural India and other low-resource settings.

Socio-cultural and financial issues against breast cancer screening behaviour among eligible Indian women: evidence for action

PURPOSE

Breast cancer, a common malignancy in Indian women, is preventable and curable upon early diagnosis. Screening is the best control strategy against breast cancer, but its uptake is low in India despite dedicated strategies and programmes. We explored the impact of socio-cultural and financial issues on the uptake of breast cancer screening behaviour among Indian women.

METHODS

Breast cancer screening-uptake and relevant social, cultural, and financial data obtained from the National Family Health Survey (NFHS) round 5 were used for analysis. We studied 399,039 eligible females to assess their breast cancer screening behavior and determine the impact of socio-cultural and financial issues on such behavior using multivariable logistic regression.

RESULTS

Most participants were 30-34-year-old (27.8%), educated to the secondary level (38.0%), and 81.5% had bank accounts. A third (35.0%) had health insurance, and anaemia was the most common comorbidity (56.1%). Less than 1.0% had undergone breast cancer screening. Higher age, education, urban residence, employment, less privileged social class, and access to the Internet and mass media were predictors of positive screening-uptake behavior (p < 0.05). Mothers of larger number of children, tobacco- and alcohol-users, the richer and having health insurance had negative uptake behavior (p < 0.05).

CONCLUSION

A clear impact of socio-cultural and financial factors on breast cancer screening behavior is evident among Indian women. Therefore, apart from the ongoing health system strengthening efforts, our findings call for targeted interventions against prevailing misconceptions and taboos along with economic and social empowerment of women for the holistic success of India's cancer screening strategy.

Screening Guidelines and Programs for Cervical Cancer Control in Countries of Different Economic Groups: A Narrative Review

Screening guidelines and practices differ according to resource availability and continually update as scientific developments take place. In this article, we have reviewed screening guidelines and programs for cervical cancer prevention in selected countries belonging to different economic groups viz high income, middle income, and low income. We have selected six countries - the United States of America (USA), the United Kingdom (UK), India, South Africa, Bangladesh, and Malawi. Considerable differences are observed across the health systems. Countries with established screening guidelines complemented by organised nationwide programs or insurance practices have much better screening rates. Human Papilloma Virus (HPV) DNA testing is currently the test of choice in the majority of settings for cervical cancer screening due to its higher sensitivity (up to 90-100%) and longer screening intervals (three to five years). It is also cost-effective, less dependent on operator expertise, and suitable for all settings as compared to a Pap smear test or visual inspection with acetic acid (VIA). Self-sampling of HPV can further help to improve screening coverage by increasing opportunities of reaching to women who would otherwise not participate in screening programs. Resource-constrained countries recommend VIA-based screening in their national programs due to its low cost. The share of cervical cancer is higher in middle and low-income countries as they have lower screening coverage, compared to high-income countries. The main barriers faced in the implementation of the program in low-income countries (LICs) are pertaining to the health system, patient-specific challenges, and healthcare provider-specific challenges.

Factors explaining men's intentions to support their partner's participation in cervical cancer screening

BACKGROUND

Cervical cancer represents a high burden of disease. Many women in low- and middle-income countries face opposition from their partners and families to undergo cervical cancer screening. Identifying the social, cultural, and psychological factors that underly the opposition to screening by male partners is an important step towards reducing barriers for men to support their wives' participation in cervical screening. This study explored the role of structural and psychological factors deriving from theoretical models as determinants of Indian men's opposition to their partners being screened for cervical cancer.

METHODS

A survey among 500 sexually active males was conducted between April 2020 and August 2020 to measure knowledge of cervical cancer and screening, awareness of screening possibilities, attitude towards screening, perceived barriers to screening, and health literacy. Regression analysis was performed to assess which of the potential factors contributed to the intention to support their wives' screening.

RESULTS

The majority of participants had very poor knowledge and awareness about cervical cancer and screening procedures, tended towards a negative attitude towards screening, and perceived several structural barriers. Attitude towards the screening procedure and routine participation in general screening significantly predicted their intention to support their wives' screening for cervical cancer. Education moderated the association between knowledge and awareness and the intention to support their wives' screening.

CONCLUSION

As women often rely on their spouses' financial and emotional support of cervical screening, there is a need for men to be encouraged to support their wives' screening participation. Programs to encourage men to support their wives' cervical screening should focus on their attitude towards screening, educate about cervical cancer and screening procedures, and reduce perceived barriers.

A comparison of behavioural models explaining cervical cancer screening uptake

BACKGROUND

Cervical cancer represents a very high burden of disease, especially in Low- and Middle-income economies. Screening is a recommended prevention method in resource-poor settings. Cervical cancer screening (CCS) uptake is influenced by various psycho-social factors, most of which are included in behavioural models. Unlike demographic characteristics, these factors are modifiable. While few studies have compared these models in terms of their capacity to predict health behaviour, this study considers three health behaviour theories to assess and compare the predictors of CCS behaviour and intention.

METHODS

A survey was conducted among 607 sexually active women in the South Indian state of Karnataka. Data was collected regarding socio-demographic factors, health literacy, knowledge on CCS, and the socio-cognitive factors related to CCS that are represented in the Health Belief Model (HBM), Theory of Planned Behaviour (TPB) and Theory of Care-Seeking Behaviour (TCSB). Logistic regression analyses tested to what extent each of the theoretical models explained cervical cancer screening (CCS) intention and regular screening behaviour, comparing the variance explained by each of the models.

RESULTS

CCS intention was best explained by the TPB, followed by the HBM. Of the constructs included in these models, positive attitude towards the screening procedure and perceived benefits contributed most significantly to screening intention, followed by fear, anxiety or embarrassment related to the disease or screening procedure, and context specific barriers.

CONCLUSION

Health behavioural models such as the TPB and HBM can help to identify the main socio-cognitive factors explaining the intention of women to participate in CCS. As such, they can inform interventions to target specific determinants of screening intention and behaviour, and enhance their effectiveness by addressing women's screening attitude, perceived benefits, and emotions as well as reducing context specific barriers to screening.