Introduction
Cervical cancer is a major public health problem among Indian women. India accounts for quarter of the world’s cervical cancer; 96,922 new cases and 60,078 deaths occurred in 2018.[1 2 prevention of the disease.[3 - 5 prevention programme is the low participation of women.[5 - 10
Menstrual pad can be a convenient tool for HPV testing in cervical cancer screening. In the rural area the women who are mostly daily wage earners, would not want to lose their daily earning by taking out time to visit the screening clinic. Rural Indian women generally use old cloths as a menstrual device.[11 - 13 12 , 14 , 15 16 - 19
The objective of this research paper is to study the factors that influence women to provide menstrual pads as a cervical cancer screening tool in spite of restrictions put on them.
Ethics
The project was approved by the Scientific and Ethics Committee of our hospital.
Methods
The study was conducted in two different populations of two districts of Maharashtra state. Two villages from Jamkhed tehsil of Ahmednagar district (Population A) and 16 villages from Mulshi tehsil of Pune district (Population B) were covered. In population A, the study was carried out between January 2013 and July 2013 while it was conducted during November 2014 to February 2016 in population B. Population A was selected for the reason that the villagers were aware of the cancer prevention activities carried out by our hospital in collaboration with local hospital in the neighbouring district. Population B was unaware of the cancer control activities carried out by our hospital.
In this study, women health workers, selected from the study villages, were provided relevant training at local hospital as well as at our hospital. A house-to-house enumeration was carried out to identify the eligible population. The eligible women were in the age group of 30-50 years with no history of cervical intraepithelial neoplasia (CIN) lesion, were physically and mentally fit, were menstruating regularly and were permanent residents of the villages. During the house-to-house survey, the health worker explained the objective of the project and provided information on the available diagnostic test along with use of menstrual pad as a cervical cancer screening tool. After obtaining the consent of the eligible participant, the health worker gathered the required information of the participants including the mobile number of the head of the family or a close family member. The socio-demographic history, reproductive history, facility of bathroom, toilet facilities and the kind of menstrual device used by the women were documented. The last menstruation date and the probable date of next menstruation were also recorded. The health worker, a well-recognized resident of the area, shared her contact details with each participant. She requested them to contact her by phone on the first day of menstruation so that she could visit them to collect the sample. The women were taught to store the first day used menstrual pad in a zip-lock bag placed in a simple polythene bag provided to them. The privacy of the women was maintained so that they were not embarrassed while providing the sample.
The strategies we used in motivating women for their participation were person-to-person contact, involving the village leaders, social workers and family members in the project activities, and also by providing comfortable and time-saving services. The eligible women were provided health education and easy access to health workers to give their menstrual pads. In the health education programme, we explained the objective of the study as well as the risk factors and preventive measures for the disease. Health worker, a well-known female face in the community, was involved in all project-related activities. The eligible participants were only needed to call the health worker on her mobile phone so that she would visit the participant’s house to collect the menstrual pad. The health worker also contacted the eligible participants on the mobile to enquire about the menstrual period. In few villages, we were unable to appoint health workers. In such circumstances, the neighbouring village health worker collected the menstrual pad samples from the participating women. The collected menstrual pad samples were kept in the −20°C freezer at the local primary health centre. The collection of the menstrual pad and follow-up were similar in both the populations. Population A women underwent Hybrid Capture 2 (HC2) test and they provided menstrual pad for HPV testing by Polymerase Chain Reaction (PCR); on the other side, population B women provided menstrual pad and not every participant underwent for HC2 testing. Only those positive on PCR and 10% randomly selected negative underwent for HC2 testing. The details about the testing of the sample in both populations have been published.[12
Statistical analysis
Data analysis was carried out using Stata Software Version 15.0 (StataCorp LLC, College Station, Texas, USA).[20
The covariates which were found to be associated with the outcome variable were tested for univariate logistic regression as initial model with independent factors: tehsil (population), age group, education, house type, drinking water facility, availability of mobile phone, number of times napkins changed per day, every day new napkin, age at first menstruation, tobacco use and health worker present. Further, multivariate logistic regression model (final model) was fitted with the independent factors: age group, education, mobile phone available, number of times napkins changed per day, every day new napkin, age at first menstruation, tobacco use and health worker present. As income and type of napkin were not found to be significant in the univariate analysis, they were not considered respectively for univariate and multivariate logistic regression.
The regression analysis gave the odds ratio (OR) with a 95% confidence interval (95% CI) that the effect of each influencing factor over the outcome variable. The model uses an entry criterion of P ≤ 0.05 and removal criterion of P ≥ 0.05.
Results
In population A, there were 258 eligible women, out of which 192 provided menstrual pad and in population B there were 687 eligible women, out of which 365 provided menstrual pad. The compliance was 74% in population A and 53% in population B. Of the total 945 women who participated in the study, 557 (58.9%) gave menstrual pads as a cervical cancer screening tool despite several obstacle faced by women.
Table 1 shows the socio-economic characteristics of the women who provided menstrual pads and those who did not provide the same. Women of age group less than 34 years and age group of 35–44 years, with the house having a steel roof, income above 5000 Indian rupees (not mentioned in statistical analysis), and education above secondary level had a higher proportion of providing their menstrual pads for HPV testing. We also observed that population A women were more likely to provide menstrual pads as compared to women from the population B (OR: 2.6; 95% CI: 1.9-3.5).
Table 1: Socio-economic characteristics of women who have given menstrual pad for cervical cancer screening and who have not provided
Table 2 , multivariate analysis shows the factors that influenced the women in providing their menstrual pads for cervical cancer screening. Women less than 34 years of age were more likely to provide their menstrual pads compared to women with aged 45 years and above (OR: 2.6; 95% CI: 1.4–4.9), also women in the age group 35–44 years were also more likely to provide menstrual pad in comparison to women with aged 45 years and above (OR: 1.9; 95% CI: 1.1–3.4). Women with education more than secondary level had the higher probability of giving their samples compared to women who had no education at all or had less education (OR: 1.4; 95% CI: 1.0-1.9).
Table 2: Univariate and multivariate analysis of predictors of women’s participation in giving menstrual pad for human papillomavirus (HPV) testing as a tool for cervical cancer screening
The women or their close family members who had mobile phones with them had higher probability of providing their menstrual pads as compared to the women who did not have access to mobile phones (OR: 1.4; 95% CI: 1.0-2.0). Women who had the practice of using a new cloth during menstruation had a higher probability of providing menstrual pads as compared to the women who did not have (OR: 8.5; 95% CI: 5.0-14.3).
Women who were changing their napkins two or more times a day showed the higher probability of giving the sample compared to the women who were changing once a day (OR: 1.3; 95% CI: 0.9–1.9) under univariate analysis while in multivariate it was found to be insignificant.
Women had the higher probability of giving their menstrual pads if a health worker was stationed at their village compared to the women for whom a health worker was not available in their village (OR 1.8; 95% CI: 1.4–2.5). Women with no consumption of tobacco were found to have a higher probability of giving their menstrual pads compared to women who had the habit of consumption of tobacco (OR: 1.4; 95% CI: 1.1-1.9). The model was found to be best fit as the model error was found to be 0.16.
In the multivariate analysis, we have seen higher correlation between factor tehsil (Population A and B) and everyday new napkin; hence, tehsil was removed from the final model as this study does not deal with the comparison of two.
Discussion
This paper deals with identifying the factors that influenced the rural women in providing their menstrual pads for HPV detection as a screening tool for cervical cancer. Highly educated women were more responsive in providing their menstrual pads as compared to women who were less educated. The different studies carried out in India have also supported that educated women were more responsive in the screening programme as compared to less-educated women.[6 , 21 , 22
Poor genital hygiene is an important risk factor for cervical cancer and this point should be focused in the health education programme. It is reported that HPV infection is associated with reproductive and genital health.[23
Women with no tobacco habit were more responsive in providing menstrual pads as compared to those with tobacco habit. It is reported that women with smokeless tobacco habit are at higher risk of developing cervical lesions.[24 prevention programme, we need to motivate women having tobacco habit to participate in screening test. This factor is many times related to the coexisting poor socio-economic status among smokeless tobacco using women.
Women or close relative having mobile phone were more likely to provide menstrual pads as compared to those who did not have the mobile phones. The mobile phone was an important medium of communication; it was easy for the health worker to contact a woman, as well as to motivate and to request her to hand over her menstrual pad for screening. Women who had the accessibility of using mobile phones were able to contact health worker and vice versa. Studies have reported that the mobile phone is an effective way of communication in the screening programme.[25 prevention programme should document mobile number of the participant during enumeration. The mobile phone facility should be used to contact the eligible women, as it is an effective way of communication.
Increasing age was associated with decreased participation by providing used menstrual pads. It was found that older women were less responsive to awareness activities because they believed that detection and treatment would make no difference to them. Therefore, awareness strategies need to be focused on the older age group. Older women may be more concerned about the social taboo about the menstrual cloths which exist in India from time immemorial. Previous studies also reported that old aged women were more reluctant to participate in the cancer screening programme.[21 , 26 , 27
Cervical cancer screening programme should include special strategy for less educated, older women and those having tobacco habit so that they can come forward to participate in the cervical cancer prevention programme. The screening organization needs to focus on the health education programme about using clean cloths/napkins during the menstrual periods.
In developing countries, women die due to cervical cancer because of poor access to preventive services. The public health department should design a cervical cancer prevention or screening programme as per the local situation which should be comfortable and convenient to the participants so that we can save the lives of women. A good health education programme, an easy access to sample collection, communication with the help of local health worker, and time-saving and comfortable services can help the women to participate in the cervical cancer screening programme.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for clinical and sociodemographic information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This project was funded by the Ministry of Science and Technology, Department of Biotechnology, Government of India (No/BT/PR4824/SPD/11/1389/2012).
Conflict of Interest
There was no conflicts of interest.
Key Message
Effective interaction with participants by the local health workers - a known face in the community, non-invasive, and time-saving examination will influence women to participate in the cervical cancer screening .
Acknowledgement
The authors gratefully acknowledge the financial support provided by the Department of Biotechnology. They also acknowledge the health authorities of Pune and Ahmednagar district for their co-operation in running this project. They also thank all the participants, their families, and the village administrators for their support.
References
1. Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global Cancer Observatory: Cancer Today (2018). Lyon, France: International Agency for Research on Cancer. Available from:
https://gco.iarc.fr/today . Last accessed on 2020 Oct 22.
2. Jemal A, Vineis P, Bray F, Torre L, Forman D. The Cancer Atlas 2nd ed [Internet]. Available from:
http://publications.iarc.fr/Non-Series-Publications/Other-Non-Series-Publications/The-Cancer-Atlas-2nd-Edition-2014 . Last accessed on 2020 Oct 22.
3. Sankaranarayanan R, Nene BM, Dinshaw KA, Mahe C, Jayant K, Shastri SS, et al. A cluster randomized controlled trial of visual, cytology and human papillomavirus screening for cancer of the cervix in rural India. Int J Cancer 2005;116:617–23.
4. Schmeink CE, Bekkers RLM, Massuger LFAG, Melchers WJG. The potential role of self-sampling for high-risk human papillomavirus detection in cervical cancer screening. Rev Med Virol 2011;21:139–53.
5. Srivastava AN, Misra JS, Srivastava S, Das BC, Gupta S. Cervical cancer screening in rural India: Status & current concepts. Indian J Med Res 2018;148:687–96.
6. Budukh A. Cervical Cancer Control in Rural India. Tampere: Tampere University Press; 2007. Available from:
https://trepo.tuni.fi/bitstream/handle/10024/67760/978-951-44-7090-5.pdf?sequence=1&isAllowed=y . Last accessed on 2020 Sep 03.
7. Basu P, Sarkar S, Mukherjee S, Ghoshal M, Mittal S, Biswas S, et al. Women's perceptions and social barriers determine compliance to cervical screening: Results from a population based study in India. Cancer Detect Prev 2006;30:369–74.
8. Lim JNW, Ojo AA. Barriers to utilisation of cervical cancer screening in Sub Sahara Africa: A systematic review. Eur J Cancer Care (Engl) 2017;26:e12444.
9. Islam RM, Bell RJ, Billah B, Hossain MB, Davis SR. Lack of understanding of cervical cancer and screening is the leading barrier to screening uptake in women at midlife in Bangladesh: Population-based cross-sectional survey. Oncologist 2015;20:1386–92.
10. Jain N, Halder A, Mehrotra R. A mixed method research to identify perceived reasons and solutions for low uptake of cervical cancer screening in urban families of Bhopal region. Scientifica (Cairo) 2016 2016. 5731627.
11. Budukh A, Maheshwari A, Palayekar V, Bagal S, Purwar P, Deodhar K, et al. Prevalence and nonsexual transmission of human papilloma virus (HPV) in the adolescence girls from rural area of Maharashtra state, India. Indian J Cancer 2018;55:336.
12. Budukh A, Palayekar V, Maheshwari A, Deodhar K, Purwar P, Bagal S, et al. Menstrual pad, a cervical cancer screening tool, a population-based study in rural India. Eur J Cancer Prev 2018;27:546–52.
13. Singh AJ. Place of menstruation in the reproductive lives of women of rural North India. Indian J Community Med 2006;31:10.
14. Wong SCC, Au TCC, Chan SCS, Chan CML, Lam MYY, Zee BCY, et al. Human papillomavirus DNA detection in menstrual blood from patients with cervical intraepithelial neoplasia and condyloma acuminatum. J Clin Microbiol 2010;48:709–13.
15. Adamson PC, Huchko MJ, Moss AM, Kinkel HF, Medina-Marino A. Acceptability and accuracy of cervical cancer screening using a self-collected tampon for HPV messenger-RNA testing among HIV-infected women in South Africa. PLoS One 2015;10:e0137299.
16. Thakur H, Aronsson A, Bansode S, Stalsby Lundborg C, Dalvie S, Faxelid E. Knowledge, practices, and restrictions related to menstruation among young women from low socioeconomic community in Mumbai, India. Front Public Health 2014;2:72.
17. Caruso BA, Clasen TF, Hadley C, Yount KM, Haardörfer R, Rout M, et al. Understanding and defining sanitation insecurity: Women's gendered experiences of urination, defecation and menstruation in rural Odisha, India. BMJ Glob Health 2017;2:e000414.
18. Kaur R, Kaur K, Kaur R. Menstrual hygiene, management, and waste disposal: Practices and challenges faced by girls/women of developing countries. J Environ Public Health 2018 2018. 1730964.
19. Kuhlmann AS, Henry K, Wall LL. Menstrual hygiene management in resource-poor countries. Obstet Gynecol Surv 2017;72:356–76.
20. StataCorp. Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC; 2017.
21. Nene B, Jayant K, Arrossi S, Shastri S, Budukh A, Hingmire S, et al. Determinants of women's participation in cervical cancer screening trial, Maharashtra, India. Bull World Health Organ 2007;85:264–72.
22. Sankaranarayanan R, Rajkumar R, Arrossi S, Theresa R, Esmy PO, Mahé C, et al. Determinants of participation of women in a cervical cancer visual screening trial in rural south India. Cancer Detect Prev 2003;27:457–65.
23. Shaw E, Ramanakumar AV, El-Zein M, Silva FR, Galan L, Baggio ML, et al. Reproductive and genital health and risk of cervical human papillomavirus infection: Results from the Ludwig-McGill cohort study. BMC Infect Dis 2016;16:116.
24. Priyanka R, Hariprasad R, Kumar V, Danasekaran K, Sharma S, Sriram L, et al. Relationship between smokeless tobacco and cervical premalignant and malignant lesions among the patients screened for cervical cancer in the health promotion clinic, Noida. J Glob Oncol 2018;4 Suppl 2:32s.
25. Lee HY, Koopmeiners JS, Rhee TG, Raveis VH, Ahluwalia JS. Mobile phone text messaging intervention for cervical cancer screening: Changes in knowledge and behavior pre-post intervention. J Med Internet Res 2014;16:e196.
26. Dinshaw K, Mishra G, Shastri S, Badwe R, Kerkar R, Ramani S, et al. Determinants of compliance in a cluster randomised controlled trial on screening of breast and cervix cancer in Mumbai, India. Oncology 2007;73:145–53.
27. Bradley J, Risi L, Denny L. Widening the cervical cancer screening net in a South African township: Who are the underserved?. Health Care Women Int 2004;25:227–41.
