|Year : 2021 | Volume
| Issue : 1 | Page : 96-102
An intervention-based study to assess the acceptability and effectiveness of a breast health awareness program among rural women of Southern Haryana, India
Avinash Surana1, Rakesh Tank2, DR Rajesh3, Abhishek Singh4, Vikas Gupta5, Deepika Agrawal6, Virender Kumar Chhoker7
1 Assistant Director Health, Rajasthan, India
2 Department of Internal Medicine, SHKM Government Medical College, Nalhar, Haryana, India
3 Department of Forensic Medicine, Indira Gandhi Medical College, Puducherry, India
4 Department of Community Medicine, SHKM Government Medical College, Nalhar, Haryana, India
5 Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh, India
6 Department of Community Medicine, Santosh Medical College, Ghaziabad, Uttar Pradesh, India
7 Department of Forensic Medicine, Santosh Medical College, Ghaziabad, Uttar Pradesh, India
|Date of Submission||28-May-2020|
|Date of Acceptance||19-Aug-2020|
|Date of Web Publication||09-Feb-2021|
Dr. Vikas Gupta
Department of Community Medicine, Government Medical College, Shahdol, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Breast cancer is among the most prevalent cancers in India and improving breast cancer awareness among women has shown to overcome the barriers related to diagnosis and treatment. Although breast self-examination (BSE) being quite easy and fast procedure, it a matter of debate that in limited-resource settings, it could be implemented or not, and hence, the present study was conducted to assess the acceptability and effectiveness of a breast health awareness program among rural women.
Methods: The present prospective interventional study was conducted for a duration of 12 months among 270 rural women in the age group of 30–59 years. A pretested questionnaire was used to collect data. The activity of the study was divided into three parts, i.e., pretest, intervention and posttest. McNemar's Chi-square was used to examine the association between each dependent variable at pretest and posttest and an association was statistically significant if the P < 0.05.
Results: Only 17.2% were aware of BSE and among them, not even single has ever practiced BSE. The pretest and posttest median awareness scores were 3 and 5, respectively, whereas the mean awareness score pretest and posttest were 2.76 ± 1.525 and 5.07 ± 1.598, respectively. Awareness regarding risk factors for breast cancer before training (11.1%) was increased significantly after training (35.2%) but to a little extent only (P < 0.001).
Conclusion: The present study highlights the levels of baseline awareness of breast cancer in rural women, which is unacceptably low, but educational intervention by field health workers having significantly improved their level of awareness, including the BSE practices. The study also found various barriers for not performing BSE among participants.
Keywords: Awareness, barrier, breast self-examination, effectiveness, rural, women
|How to cite this article:|
Surana A, Tank R, Rajesh D R, Singh A, Gupta V, Agrawal D, Chhoker VK. An intervention-based study to assess the acceptability and effectiveness of a breast health awareness program among rural women of Southern Haryana, India. Indian J Health Sci Biomed Res 2021;14:96-102
|How to cite this URL:|
Surana A, Tank R, Rajesh D R, Singh A, Gupta V, Agrawal D, Chhoker VK. An intervention-based study to assess the acceptability and effectiveness of a breast health awareness program among rural women of Southern Haryana, India. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Apr 17];14:96-102. Available from: https://www.ijournalhs.org/text.asp?2021/14/1/96/308947
| Introduction|| |
The breast cancer and its treatment, which is documented in historic literature and in the present world breast cancer, comprised 25% of all cancers (1.67 million new cases) as per GLOBOCAN 2012.,, In India, breast cancer is most prevalent among cancers, and annually, there is an estimated occurrence of around 80,000 cases and compared to cervical cancer, its mortality rates are still higher. It is expected that the number of new cases of cancer would increase from 10million/year in 2000 to 15 million/year in 2020. In various studies, it was revealed that breast cancer is being noticed by the person herself in more than 90% of cases.,Improving breast cancer awareness among women has shown to overcome the barriers related to diagnosis and treatment in several studies, and there is necessary evidence form the several on-going studies that in limited-resource settings, low-cost screening methods, such as breast self-examination (BSE) could be implemented., Being quite easy and fast procedure including free of cost, BSE practice in India is low and varies between 0% and 52%. Early-stage diagnosis and optimal treatment are the two factors which decide the survival period in breast cancer. Around 80% of breast cancer patients in India while approaching to seek care in hospitals are already in advanced stages. In developing countries, like India the existence of population-based breast cancer screening programs is lacking, so the objectives of this community-based study were to use trained female multipurpose health workers to educate rural women on breast health to increase their awareness regarding breast cancer for early diagnosis and to assess the impact of interventional measures on acceptance of BSE for early detection of breast anomaly along with to carry out proficient self-examination of the breast, to seek medical care at the earliest when necessary as well as to identify barriers if any to self-examination.
| Materials and Methods|| |
Study area and study period
The present study was conducted for a duration of 12 months during the months of March 2018 to February 2019 in the service area of a rural health center, Nagina which also happens to be field practice area under the aegis of Department of Community Medicine, SHKM Government Medical College, Nalhar, Haryana.
Ethical approval was obtained from the SHKM GMC Institutional Ethical Committee, Nalhar (Approval letter number: EC/OA-10/2018, dated 29/01/2018).
Study design and the participants
This prospective community-based educational intervention study includedwomen in the age group of 30–59 years as participants.
Study population and sample size
The rural health center covers a population of 91548 spread over 7 sub-centers and 42 villages of Nagina Taluk, in a Southern part of Haryana. Out of these 42 villages, 1 village was randomly selected for the present study, which had a total population of 13258 of and the proportion of females in that village was 53%. Among those females, the proportion of women belonging to the age group 30–59 years was 42%, i.e., 2950.
The sample size was calculated (n = 224) considering the proportion of rural women practicing BSE as 18% (Kumaraswamy et al.) with confidence level of 95% and 10% absolute allowable error by applying the following formula: N = (Z1-a/2) 2 × p (1-p)/d2; where Z = Standard normal variate for level of significance (at 5% Type I error [P < 0.05], Z = 1.96 for 2-sided test), a = level of significance (0.05), P = prevalence (proportion- 18%), d = absolute allowable error (5%), n = sample size.
As this study was novel to this field practice area and as it is being for the first time and being exploratory nature of the study, feasibility and acceptability of it was unsure, so expecting a drop out of 15%, a final sample size calculated was of 263 and which was rounded off to 270. A list of 30–59 years of age women was prepared, and every ninth of the study participants was selected through systematic random sampling technique to obtain a sample size of 270. Written informed consent from the study participants was obtained, and anonymity and confidentiality of the participants was maintained throughout the study. Women who were seriously ill were excluded from the study.
Before conducting the study in the practice field area, theMulti-Purpose Health Worker Female (MPHW-F) themselves were needed to be educated on breast cancer and to be trained in breast examination skills, so keeping this in mind, 7 Multi-Purpose Health Worker Female were educated and trained using a comprehensive lesson plan. The training was conducted by the investigator for two consecutive days for a duration of 3–4 h each day, and method used for training included didactic lecture followed by interactive sessions to clear the doubts or queries.
The training session was consisting of a powerpoint presentation, video-film, charts and posters, and hands-on experience for the skills learnt on a breast model at the clinical skills laboratory. This was followed by a micro-teaching session using micro-teaching lab method by theMPHW-Fs simulating the training sessions to be conducted in the practice field area and simultaneously the feedback regarding deficiencies if any were corrected. Following this, each MPHW-F was assigned area of the village and was held responsible for motivating and training the 40 women from the same area.
A pretested, predesigned, standardized questionnaire was prepared, which has two parts, i.e., pretest and posttest. The pretest questionnaire included demographic details such as age, sociodemographic characteristics; their baseline awareness regarding breast cancer, its risk factors, available screening modalities, andBSE. To assess the socioeconomic status revised B G Prasad scale was used. The posttest questionnaire was to again assess the awareness at 1st month only to observe the change in baseline awareness and to assess thecompetency in carrying out BSE at the 1st and 3rd months. Competence in carrying out BSE included self-reported frequency of performance (daily/weekly/monthly), observer-rated proficiency scores for technique and completeness of self-examination as well as lump detection scores in a breast model.
The questionnaire was first prepared in English. Then, it was translated into Hindi by an expert in that language keeping semantic equivalence. To check the translation, it was back-translated into English by two independent researchers who were unaware of the first English version. All efforts were made to keep the questions simple and unambiguous according to the objectives of the study.
Activity of study was divided into three parts.
During first part of activity the participants took part in the batches of 12–15 counts per session and pretest questionnaire for participants was administered by the investigator himself by face to face interview technique. The questionnaire required 10–15 min per participant to be completed. Furthermore, the filled questionnaires were then checked for completeness.
The second part of the activity consisted of 1–2 h training session of participants by MPHW-F under the supervision of the investigator. The MPHW-F briefed the women about breast cancer and followed by demonstration of BSE stressing on thoroughness and the recommended technique. Women were taught the mirror method for visual inspection of the breast and the lying down position for breast palpation. Tactile skills were emphasized using an indigenous breast model. Women were instructed to do self-examination on a daily basis for the first 1 month and on a weekly basis for the next so as to familiarize themselves with their breasts. Thereafter monthly BSE was advised depending on their menstrual status. The education was followed by an interactive session with the trainer to clarify doubts. At the end of the session, an illustrated booklet on the topic was distributed among the women, with an intention to reinforce what was being taught.
During the third part of the activity, the intervention was evaluated by the investigator by visiting house to house at an interval of 1st and 3rd month post-training session. A posttest questionnaire was administered to evaluate the change in thebaseline awareness at only 1st month and to assess the competency in carrying out self-examination at 1st and 3rd months. To find out the barriers among those who were not performing Self Breast-Examination, a modified Stillman scale for beliefs on the value of BSE was used. Ethical approval was obtained from the Institutional Ethical Committee.
Collected data were entered in the MS Excel spreadsheet, coded appropriately, and later cleaned for any possible errors. The analysis was carried out using IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp. Armonk, NY, USA). During data cleaning, more variables were created so as to facilitate the association of variables. Clear values for various outcomes were determined before running frequency tests. Categorical data were presented as percentages (%). Continuous data were presented as mean, median, and interquartile range and; pretest and posttest awareness scores were analyzed using paired t-test.Bivariate analysis using McNemar's Chi-square was used to examine the association between each dependent variable at pretest and posttest. All tests were performed at a 5% level of significance; thus, an association was significant if the P < 0.05.
| Results|| |
In the present study, a total of 270 participants were enrolled and out of them, only 223 were available for the final analysis showing a response rate of 80%. Among those participants who were lost to follow-up, nearly four-fifths (79.2%) of them belonged to the 50–59 years of age group and among them, more than two-fifth of them (41.6%) were illiterate.
The baseline characteristics of the study participants are shown in [Table 1]. It was surprising that very few (17.2%) were aware ofBSE, and among them, not even single has ever practiced BSE. The most common first-hand source of information among participants regarding BSE was media and health workers.
|Table 1: Sociodemographic profile and baseline characteristics of the study participants (n=223)|
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The total awareness score for each study subject was calculated based on their response to seven knowledge-based questions pertaining to the risk factors for breast cancer, the importance of early detection, available screening modalities and frequency of BSE. The pretest and posttest median awareness scores were 3 (interquartile range 2–4) and 5 (interquartile range 4–6), respectively, whereas mean awareness score? pretest and posttest were 2.76 ± 1.525 and 5.07 ± 1.598, respectively [Figure 1], which illustrates a significant increase in overall awareness regarding breast cancer and the various other aspects pertaining to it (paired t = 19.976, df = 222, P < 0.001).
|Figure 1: Distribution of pretest and posttest median awareness scores on a scale of 7 among study participants|
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Awareness regarding risk factors for breast cancer before training (11.1%) was increased significantly after training (35.2%) but to a little extent only (P < 0.001). Irrespective of their socio-demographic status, women were willing to be educated by the health worker, and the educational intervention was acceptable to them.About four-fifth of study participants (81.6%) were ever performing the BSE after 1 month of training session [Table 2], but there was a decrease in the percentage (75.3%) for performing BSE after 3 months of the training session, i.e., 6.3% reduction. This reduction was statistically significant for the women who were young, illiterate, Muslim, married, residing in joint family, and having children more than four.
|Table 2: Association of socio-demographic characteristics with the breast self-examination continuation among study participants (n=223|
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Among more than half of women who have not ever performed BSE, the common barriers were lack of privacy or embarrassing procedure, and time-consuming or overburdened with work [Figure 2].
|Figure 2: Distribution of barriers for breast self-examination among study participants|
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| Discussion|| |
In the present study, it was revealed that the median score for awareness has improved after education session as pretest and posttest were 2.76 ± 1.525 and 5.07 ± 1.598, respectively (P < 0.05). Furthermore, 81.6% of the study participants were ever performing the BSE after 1 month of the training session. In other similar studies done by Rao et al., Gupta et al., Bala et al., Shalini et al., Shankar et al., Srivastava et al., and Madhukumar et al., have also reflected the effectiveness of interventions in increasing the knowledge about breast cancer and improving BSE practices.,,,,,,
Although studies from developed countries by Bennett et al., suggested compliance was better for physician conducted educations and training, but the present study has showed a high acceptance of health workers too as educators and trainers, and it was supported in the studies conducted by Rao et al., Gupta et al., and Bala et al.,,, This is probably due to the better rapport that they have with the community, especially the women.
Studies in India by Shankar et al., Srivastava et al., and Madhukumar et al., revealed that even educated women were lacking in knowledge and practice for BSE and the present study was also in agreement with these findings.,, A similar scenario was been noticed in different studies done in developing countries by Odusanya et al., Gabriel et al., and Oluwatosin et al.,, Study by Friedman et al. showed the contrasting results where 90% of the women in the developed world are aware of BSE; nonetheless the practice varied from 15% to 40%.
The barriers to BSE noted in our study were similar to the ones reported elsewhere Rao et al., Shalini et al., and Sharma et al.,, The negative psychological impact of BSE such as fear to find something abnormal, was noticed in more than two-fifth of participants. As due to the apparent nonchalance nature of older women in rural India, they were of the opinion that having led a relatively disease-free life so far, they were unlikely to get the disease now and therefore felt it unnecessary to comply with the intervention. Even a study by Larkin et al. challenges the effectiveness of BSE, but it has its own merits, like it involuntarily improves and enhances the awareness and knowledge among women, empowers them to take care of their own health as well as inducing them to seek medical attention at the earliest.
| Conclusion|| |
The present study highlights the levels of baseline awareness of breast cancer in rural women, which is unacceptably low, but educational intervention by field health workers having significantly improved their level of awareness, including the BSE practices. The study also found various barriers for not performing BSE among participants.
The generalizability of the present study is an apparent limitation due to low literacy rates of study participants, and hence, the results are likely to be generalize in the similar settings. Furthermore, the age-specific intervention is the hour of need due to the apparent nonchalance nature of older women which reduces their compliance. This study does not answer whether heightened awareness regarding breast health leads to early detection and better prognosis, but however before finding out the outcomes in terms of early detection and better diagnosis, it is important to establish an appropriate method to create this awareness.
We recommend that there is urgent need for awareness programs at all health-care levels to improve knowledge about breast cancer. In addition, in India, doctor-to-patient ratio is very low, so it will be more appropriate and necessary to educate and train Multipurpose Health Workers (MPHW female) using module-based training to create this awareness and instruct women to carry out BSE proficiently.
Furthermore, we recommend that the repeated sessions are required to be kept at community level as in the present study a decline of 6.3% in proportion of participants performing BSE practices was seen in just 2 months of interval. Although BSE is not accepted as an early detection method for BC, this technique, if used diligently and skilfully, can serve as a useful adjunct in a resource-limited country like ours.
We recommend that female school teachers shall be also involved in such activity as it will lay foundation of breast cancer awareness among female students from the school level and they will have more acceptance toward such educational programs being organized in communities. Furthermore, they will help the others females at home or neighborhood.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]