Prajakta Adsul

Using photovoice to understand the context of cervical cancer screening for underserved communities in rural India

Cervical cancer is the second most common cancer diagnosed among women in India and current estimates indicate low screening rates. To implement successful population-based screening programs, there is an urgent need to explore the social and cultural beliefs among women residing in underserved communities. An innovative, community-based participatory approach called photovoice was used with 14 women aged between 30–51 years, residing in rural and tribal villages around Mysore, Karnataka, India. Each participant was trained in photovoice techniques, provided with a digital camera, and asked to photo document their everyday realities that could influence their intentions to undergo cervical cancer screening. Over 6 months, participants took a total of 136 photos and participated in 42 individual interviews and two group discussions. These data helped identify specific beliefs prevalent in the target population and were organized according to the Integrated Behavior Model. Some women reported a lack of perceived susceptibility to cervical cancer whereas others mentioned the fatal nature of cancer as a disease and believed that no screening exam could prevent death if they were destined to get cancer. Husbands, mothers-in-law, and their peers in the community had an important influence on the social identity of women and influenced their intentions to participate in the screening exams. Seeking healthcare was associated with an economic burden, not only in terms of out-of-pocket expenses for healthcare services but also in missing daily labor wages or taking unpaid leave from work to seek healthcare when they were asymptomatic. Several action steps were proposed including: identifying community liaisons or champions, repeated community activities to raise awareness of cervical cancer, and educating men and other family members about women’s health issues. Study findings can conceptually help design and develop educational efforts for mobilizing women to undergo screening and inform future research to help understand disparities.

Commentary: Advancing the Science of Implementation for Resource-Limited Settings through Bidirectional Learning Around Cervical Cancer Screening

In 2020, the highest rates of cervical cancer incidence and mortality were reported in Asian and African regions of the world. Across the globe, growing evidence confirms cancer disparities among racial and ethnic minorities, low socioeconomic status groups, sexual and gender minorities, uninsured individuals, and rural residents. Recognition of these stark disparities has led to increased global efforts for improv­ing screening rates overall and, in medically underserved populations, highlighting the urgent need for research to inform the suc­cessful implementation of cervical cancer screening. Implementation science, defined as the study of methods to promote the integration of research evidence into health care practice, is well-suited to address this challenge. With a multilevel, implementa­tion focus, we present key research direc­tions that can help address cancer dispari­ties in resource-limited settings. First, we describe several global feasibility studies that acknowledge the effectiveness of self-sam­pling as a strategy to improve screening cov­erage. Second, we highlight Project ECHO as a strategy to improve providers’ knowl­edge through an extended virtual learning community, thereby building capacity for health care settings to deliver screening. Third, we consider community health work­ers, who are a cornerstone of implement­ing public health interventions in global communities. Finally, we see tremendous learning opportunities that use contextually relevant strategies to advance the science of community engagement and adaptations that could further enhance the uptake of screening in resource-limited settings. These opportunities provide future directions for bidirectional exchange of knowledge between local and global resource-limited settings to advance implementation science and address disparities. Ethn Dis. 2022; 32(4):269-274; doi:10.18865/ed.32.4.269