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Breast cancer in rural India: knowledge, attitudes, practices; delays to care and quality of life
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Cancer is a major public health problem globally. The incidence of cancer is increasing rapidly in many low- and middle-income countries like India due to the epidemiological transition. At present, breast cancer is the leading cancer in females in many countries including India. In spite of all of the epidemiological evidence pointing towards a surge in breast cancer cases, the National Cancer Control Programme of India has not yet taken sufficient measures to understand the disease burden and to plan a course of action to cope with the increasing cancer burden.

Aim: The aim of this thesis is to explore the knowledge, attitudes, and practices regarding breast cancer in a predominantly rural district of central India along with identifying the determinants of delays to care and quality of life (QoL) in breast cancer patients. This understanding may help to strengthen the health system by improving breast cancer control and management programmes and the delivery of care.

Methods: This thesis combines findings from two cross-sectional studies in the predominantly rural district of Wardha. The first study was a population-based crosssectional survey conducted on 1000 women, in which face-to-face interviews were conducted with the help of a questionnaire covering demographic and socio-economic information, knowledge, attitudes and practices regarding breast cancer screening and breast cancer. The Chi-square test for proportions and t-test for means were used and multivariable linear regression analysis was performed to study the association between socio-demographic factors and knowledge, attitude and practices. The second study was a patient-based cross-sectional study conducted in 212 breast cancer patients. All 212 breast cancer patients were included for patient delay. However, 208 female breast cancer patients could be included for system delay, quality of life and self-efficacy, as there was some information lacking in 4 patients. Information on socio-demographic characteristics, patient and system delays and also reasons for the delays were collected. The study also utilised WHOQOL–BREF for QoL and selfefficacy measurements in breast cancer patients. Socio-demographic determinants were examined by frequencies and means and multivariable logistic and linear regression analysis to assess the relationship between exposure and outcome variables.

Results: One third of the respondents had not heard about breast cancer, and more than 90% of women from both rural and semi-urban areas were not aware of breast self-examination. Patient delay of more than 3 months was observed in almost half of participants, while a system delay of more than 12 weeks was seen in 23% of the breast cancer patients. The late clinical stage of the disease was also significantly associated with patient delay. The most common reason for patient delay was painlessness of the breast lump. Incorrect initial diagnosis or late reference for diagnosis were the most common reasons for diagnostic delay while the high cost of treatment was the most common reason for treatment delay. Self-efficacy was positively associated with QoL, after adjusting for socio-demographic factors, patient delay and clinical stage of disease.

Conclusions: Our research showed poor awareness and knowledge about breast cancer, its symptoms and risk factors in women in rural India. Breast self-examination was hardly practiced, although the willingness to learn was high. Although The ideal is to have no delay in diagnosis and treatment, diagnostic and treatment delays observed in the study were not much higher than those reported in the literature, even from countries with good health facilities. However, further research is needed to identify access barriers throughout the process of cancer diagnosis and treatment. The quality of life was moderately good and its strong relationship with self-efficacy makes these two dimensions of breast cancer patients relevant enough to be considered for health workers and policy makers in the future.

Interventions focused on improving breast awareness in women and the breast cancer continuum of care should be implemented at a district level. The role of community social health activists in breast cancer prevention should be encouraged and the implementation of an operational national breast cancer program is urgently required.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2018. , p. 88
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1947
Keywords [en]
breast cancer, rural, India, knowledge, attitudes, practices, delay, quality
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health; Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-145427ISBN: 978-91-7601-842-2 (print)OAI: oai:DiVA.org:umu-145427DiVA, id: diva2:1187627
Public defence
2018-03-28, Room 135, Allmänmedicin, byggnad 9A, Norrlands universitetssjukhus, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2018-03-07 Created: 2018-03-05 Last updated: 2018-06-09Bibliographically approved
List of papers
1. Women's Knowledge, Attitudes, and Practices about Breast Cancer in a Rural District of Central India
Open this publication in new window or tab >>Women's Knowledge, Attitudes, and Practices about Breast Cancer in a Rural District of Central India
2015 (English)In: Asian Pacific Journal of Cancer Prevention, ISSN 1513-7368, Vol. 16, no 16, p. 6863-6870Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Breast cancer accounted for almost 25% of all cancers in women globally in 2012. Although breast cancer is the most prevalent cancer in India, there is no organised national breast cancer screening programme. Local studies on the burden of breast cancer are essential to develop effective context-specific strategies for an early detection breast cancer programme, considering the cultural and ethnic heterogeneity in India. This study examined the knowledge, attitudes, and practices about breast cancer in rural women in Central India.

MATERIALS AND METHODS: This community-based cross sectional study was conducted in Wardha district, located in Maharashtra state in Central India in 2013. The sample included 1000 women (609 rural, 391 urban) aged 13-50 years, selected as representative from each of the eight development blocks in the district, using stratified cluster sampling. Trained social workers interviewed women and collected demographic and socio-economic data. The instrument also assessed respondents' knowledge about breast cancer and its symptoms, risks, methods of screening, diagnosis and treatment, as well as their attitudes towards breast cancer and self- reported practices of breast cancer screening. Chi-square and t-test were applied to assess differences in the levels of knowledge, attitude, and practice (the outcome variables) between urban and rural respondents. Multivariable linear regression was conducted to analyse the relationship between socio-demographic factors and the outcome variables.

RESULTS: While about two-thirds of rural and urban women were aware of breast cancer, less than 7% in rural and urban areas had heard about breast self-examination. Knowledge about breast cancer, its symptoms, risk factors, diagnostic modalities, and treatment was similarly poor in both rural and urban women. Urban women demonstrated more positive attitudes towards breast cancer screening practices than their rural counterparts. Better knowledge of breast cancer symptoms, risk factors, diagnosis, and treatment correlated significantly with older age, higher levels of education, and being office workers or in business.

CONCLUSIONS: Women in rural Central India have poor knowledge about breast cancer, its symptoms and risk factors. Breast self-examination is hardly practiced, though the willingness to learn is high. Positive attitudes towards screening provide an opportunity to promote breast self-examination.

Place, publisher, year, edition, pages
Asian Pacific Organization for Cancer Prevention, 2015
Keywords
Breast cancer, screening, rural, KAP, India
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-117043 (URN)10.7314/APJCP.2015.16.16.6863 (DOI)26514458 (PubMedID)
Note

This work was partly supported by the Umeå Centre for Global Health Research, funded by FAS, the Swedish Council for Working Life and Social Research (Grant no. 2006–1512).

Available from: 2016-02-18 Created: 2016-02-18 Last updated: 2018-06-07Bibliographically approved
2. Prevalence and Risk Factors for Patient Delay Among Women With Breast Cancer in Rural India
Open this publication in new window or tab >>Prevalence and Risk Factors for Patient Delay Among Women With Breast Cancer in Rural India
Show others...
2016 (English)In: Asia-Pacific journal of public health, ISSN 1941-2479, Vol. 28, no 1, p. 72-82Article in journal (Refereed) Published
Abstract [en]

Delay in seeking health care by women with breast cancer increases mortality risk. This study was conducted in rural India to identify risk factors associated with patient delay. A total of 212 women with primary breast cancer diagnosed between 2010 and 2012 were interviewed. Sociodemographic characteristics, time interval between seeking medical attention and appearance of symptoms, and reasons for delay were inquired. Patient delay was defined as more than 3 months between date of first symptoms and medical consultation. Logistic regression was applied to assess associations between potential risk factors and patient delay. Almost half the women with breast cancer experienced patient delay. Age more than 60 years (odds ratio = 4.9, 95% confidence interval = 1.3-18.0) was significantly associated with patient delay. Only 6.6% of patients had heard about breast self-examination. Significantly higher number of patients with delay presented with advanced clinical stage (P = .000). Health education programs should be introduced with specific strategies to shorten patient delay.

Keywords
breast cancer, patient delay, screening, rural India
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-112841 (URN)10.1177/1010539515620630 (DOI)000368770300008 ()26658324 (PubMedID)
Available from: 2015-12-16 Created: 2015-12-16 Last updated: 2018-06-07Bibliographically approved
3. System delay of diagnosis and treatment experienced by women with breast cancer in rural India
Open this publication in new window or tab >>System delay of diagnosis and treatment experienced by women with breast cancer in rural India
(English)In: Article in journal (Refereed) Submitted
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-144516 (URN)
Available from: 2018-02-05 Created: 2018-02-05 Last updated: 2018-06-09
4. Quality of Life Determinants in Breast Cancer Patients in Central Rural India
Open this publication in new window or tab >>Quality of Life Determinants in Breast Cancer Patients in Central Rural India
2017 (English)In: Asian Pacific Journal of Cancer Prevention, ISSN 1513-7368, Vol. 18, no 12, p. 3325-3332Article in journal (Refereed) Published
Abstract [en]

Introduction: Breast cancer is the most frequently diagnosed cancer among women throughout world, with incidence rates increasing in India. Improved survival in breast cancer patients has resulted in their quality of life (QOL) becoming an important issue. Identifying determinants for QOL may provide insights into how to improve their living conditions. This study aimed to assess socio-demographic and clinical factors, as well as the role of self-efficacy, in relation to QOL among women with breast cancer in rural India. Methods: A total of 208 female patients with infiltrating carcinoma of the breast participated in the study. A questionnaire was administered that included sections for socio-demographic characteristics, clinical stage of the cancer and patient delay in seeking health care. A standardized instrument to measure self-efficacy was applied. To assess QOL, the WHOQOL – BREF instrument was used. Results: The overall mean score for QOL was 59.3. For domain 1 (physical health) the mean score across all groups was 55.5, for psychological health 58.2, for social relationships 63.2 and for environmental factors, 60.4. The environmental domain in QOL was negatively associated with lower education. Being divorced/widowed/unmarried had a negative association with the psychological health and social relationship dimensions, whereas higher income was positively associated with QOL parameters such as psychology, social relationships and environmental factors. Self-efficacy was positively associated with all four domains of QOL. Conclusions: The present study demonstrated a moderate QOL in women with breast cancer in rural India. Young age, lack of education and being without a partner were negatively related to QOL, and employment as casual and industrial workers, high monthly family income and higher self-efficacy were positively associated with QOL. A comprehensive public health initiative is required, including social, financial and environmental support, that can provide better QOL for breast cancer survivors.

Keywords
Breast cancer, QOL, self efficacy, rural India
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-143688 (URN)10.22034/APJCP.2017.18.12.3325 (DOI)29286227 (PubMedID)
Available from: 2018-01-05 Created: 2018-01-05 Last updated: 2018-06-09Bibliographically approved

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