Women's perceptions and social barriers determine compliance to cervical screening: Results from a population based study in India

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Abstract

Background: Success of cervical screening initiatives depends on high participation of the target population, which in turn is determined by the women's perceptions, health orientation and other socio-cultural issues. The present study identifies the immediate social and cultural barriers that prevent women to attend cervical screening facilities. Methods: Women non-compliant to a community-based cervical screening program were identified. From them 500 were randomly selected for interview using a structured questionnaire that was designed on the basis of feedbacks received from several focused group discussions. Questionnaire listed 24 possible reasons for non-compliance. The women were asked to select the most pertinent reason(s) for her non-attendance or to reveal if they had any reason other than the listed ones. Results: A total of 469 non-compliant women were interviewed. They had significantly lower literacy rate compared to the compliant women (OR = 2.25; 95% CI: 1.23–4.13). Nearly half of the interviewed women responded that they themselves opted to stay away from the program. Most common reasons cited for non-attendance in this group were reluctance to go for medical test in the absence of any symptoms and apprehension to have a test that detects cancer. Second major group of responders comprised of women who were willing, yet could not attend due to various hurdles. Most common hurdles were inability to leave household chores, pre-occupation with family problems and lack of approval from husbands. Conclusions: Modification of health behavior through education and social empowerment of women are essential for a population based cervical screening program to succeed in India.

Introduction

Cervical cancer is the most common cancer and the leading cause of cancer deaths among Indian women. There were 126,000 new cases of cervical cancer and 71,000 deaths from the disease in India in the year 2000 [1]. Unfortunately, in India, despite the public health importance that cervical cancer deserves, there are no effective screening programs either at the state level or at the national level [2]. For this reason, majority of the cases are diagnosed only at an advanced stage of the disease when therapeutic intervention offers limited success. The situation is similar in other less developed countries that have not yet been able to initiate organized screening programs.

The results from public health intervention programs in different diseases have shown that perceptions and spontaneous participation of the target population are critical determinants of success of such efforts. This is particularly true in the context of cervical cancer screening where the rate of coverage of the target population is more important than the frequency and the accuracy of the screening tests [3].

As per the latest Indian National Cancer Control Program guidelines, pilot cervical screening programs will soon be initiated in multiple small geographic areas under the direct supervision of the government supported cancer centers and the medical schools [4]. Ensuring spontaneous participation of the target women by making the program acceptable to them will be a major challenge that the program planners will have to overcome. This key determinant of success of the screening program is influenced by the perceptions, knowledge and health behavior patterns of the population [5], [6].

Some of the previous studies have shown that women may have more pressing issues and social circumstances that prevent them from being concerned about a disease that is apparently not causing any problem to them [7], [8]. Cancer is synonymous to death to many of the women and the possibility of obtaining a positive result from a test that detects such a dreadful disease is a strong deterrent [9]. Many perceive the test to be painful and avoid going for it [10]. Even in United Kingdom where cervical screening program is running for decades, the main reasons for non-compliance cited by the women themselves were fear and dislike of the test itself [11].

Few studies have been done on the level of knowledge and awareness of the Indian women about cervical cancer and its prevention through screening [12]. In the absence of any organized screening program, hardly any studies have looked into the viewpoints of the women who had access to screening but did not participate. One population based study done in South India observed that age, education, income and contraceptive methods were independent predictors of participation in screening [13]. However, the study did not highlight the direct and immediate reasons that prevented nearly one-third of their women to participate.

To identify the barriers related to women's awareness and perceptions of cervical screening and those related to the socio-cultural issues, the present study systematically interviewed the women who did not participate in a small scale population based cervical screening program. Women residing in the rural areas and the urban indigent areas were selected for the study as they comprise the vast majority of the Indian population. The feedbacks received directly from the women who were invited to a cervical screening program for the first time, yet did not attend, gave us a good insight into the problem of non-compliance. The study identified the immediate and direct reasons for non-attendance to cervical screening, information regarding which is almost non-existent in an Indian context.

Section snippets

Materials and methods

Women aged 25–65 years were screened by visual inspection after application of acetic acid (VIA), visual inspection after application of Lugol's iodine (VILI) and HPV DNA testing (Hybrid Capture II) as part of a research project to evaluate these screening tests. The details of the study design and the results of test evaluation have already been reported [14]. Women were recruited from a defined geographic area adjacent to the city of Calcutta in Eastern India. The study participants included

Results

Of the 500 women randomly selected for the interviews, 16 refused to respond and 15 could not be traced. A total of 469 completed questionnaires were obtained.

The age distribution (64% below 40 years), marital status (99% ever married) and the socio-economic status (86% in low socio-economic strata) of the non-compliant women were not significantly different from those of the compliant women. However, the lower literacy rate among the non-attendees (49%) as compared to the attendees (59.5%) was

Discussions

Cervical cancer screening is a preventive health strategy that needs high level of motivation for the women to participate. Such motivation comes from appreciation of the beneficial effects of the intervention and a preventive health seeking behavior of the target population. The compliance rate of 62.7% observed in our study is considered to be low. Information on rate of compliance to cervical screening in Indian population is rare. The only other recent study in Indian population that

Acknowledgement

The screening study was funded by Bill and Melinda Gates Foundation through Alliance for Cervical Cancer Prevention.

References (15)

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