The study was concentrated to lower socio-economic area catered by Prabhadevi maternity home and health post which comes under Municipal Corporation of Greater Mumbai (MCGM). Mumbai has a mixed health care system, inclusive of services provided by local bodies, the government of Maharashtra and public trusts and private service providers. The MCGM runs a network of primary, secondary and tertiary level facilities through medical college and hospitals, municipal general hospitals and speciality hospitals, maternity homes, dispensaries and health posts. The primary healthcare services are provided by health posts and dispensaries whereas maternity home provides specialized delivery care. The health posts were established to provide primary health services mainly in slum areas. The Prabhadevi maternity home and health post provides both primary healthcare services and maternal health care to lower socio-economic population in the Prabhadevi area of Mumbai.
The data used for the current study came from primary data collected for baseline survey of a breast cancer intervention study. The tertiary cancer specialized hospitals bear most of the burden of screening and treatment of breast cancer in India. The primary healthcare facilities in India is not well equipped with required human resources and training for cancer screening leading to late detection of cancer. So, this intervention was to test screening of breast cancer at primary care level for early detection of breast cancer cases with the available resources at present. The Prabhadevi facility was chosen for this study because it is both women centric and provides primary health care services. The cross-sectional baseline survey was conducted during November 2018 to March 2019.
The details of inclusion and exclusion criteria, sample size, sampling procedure, data collection and analysis are given below:
Women between 18 and 55 years of age were included in the study.
Women who were already diagnosed with breast cancer and under treatment, pregnant women and lactating women were excluded from the study.
About 80% of women aged 30–50 years were aware of breast cancer in Vikhroli, Mumbai . However, our study focused on women 18–55 years of women. One of the study in similar settings at Delhi found around half (53%) of the women (aged 14–75 years) were aware of breast cancer . Thereby considering 53% prevalence, 5% level of significance and 20% non-response rate, the required sample size was calculated as 478. Information was collected from 480 women participants.
The complete area under Prabhadevi maternity home and health post was identified through the map available with Municipal Corporation of Greater Mumbai (MCGM). This health post is located at G-South ward of Mumbai. With the help of MCGM record, the low-income group housings based on criteria set by Maharashtra Housing and Area Development Authority (MHADA) were identified. Around 76 thousand low income group community population (according to MHADA, Government of Maharashtra) is catered by Prabhadevi Maternity Home under Municipal Corporation of Greater Mumbai. The whole area with around 19 thousand households was divided into 16 sections of around 1000–1400 households based on areas covered by 16 Community Health Volunteers at the health post. Mapping and house listing of the selected area/community was done to prepare a list of households having eligible women. Systematic random sampling was used to select the 480 eligible women from the list. Kish grid method was used to select women in case more than one woman was found eligible in the selected household .
Data collection tools (baseline)
The tools were divided into two sections a) socio-economic background of the participants b) knowledge about breast cancer with questions related to awareness and practices (See supplementary file). The socio-economic background section focused on collecting individual level information like age, education, religion, caste, marital status of the participants. The second section was used to assess the women’s knowledge regarding breast cancer, sign and symptoms, risk factors, Breast Self-Examination (BSE), and Clinical Breast Examination (CBE) using a structured questionnaire. Women participants were asked whether they had ever heard of breast cancer. Those who have heard of breast cancers were further asked about knowledge of breast cancer signs and symptoms, risk factors and current practices using closed response questions. The questionnaire was prepared using existing literature and in consultation with the study team as well as experts constituting of oncologists, gynaecologist, public health, and social scientist. The tools were translated to both Hindi and Marathi languages for the convenience of participants. These questions were pilot tested with 20 participants (10 Hindi and 10 Marathi questionnaires each) at a similar socio-economic setting of Mumbai. The results from this pilot testing were used for modification of the words for easy comprehension of the participants. The content validity was ensured through expert consultation and pilot testing of the questionnaire. The field investigators were trained for 1 day and made familiar with the questions and ways of asking the questions. The data was collected through face to face interview with participants. Regular back-checks were conducted at the office to ensure data quality. The response rate was 96% for this baseline study.
Univariate and bivariate analysis were performed using percentage and median to know the profile of study participants, proportion of women who were aware of symptoms, risk factors and screening methods and socio-economic differential in those symptoms and risk factors. Multivariate logistic regression was used to know the socio-demographic predictors of breast cancer awareness among women in the study area. The data were analysed using IBM SPSS 26.0 packages.
Women were asked ‘Have you ever heard of breast cancer?’. The response ‘Yes’ is coded as 1 and response “No” was coded as 0. This is used as a proxy variable for breast cancer awareness. Bivariate and multivariate binary logistic regression analysis was performed to see the differential and predictors of awareness of breast cancer. The other dependent variables used were specific symptoms, signs and risk factors of breast cancer to see differential socio-economic characteristics.
Different socio-economic variables like age, religion, caste, working status, marital status, and years of schooling of women were used as independent variables in this study.
The Indian Council of Medical Research-National Institute for Research in Reproductive Health (ICMR-NIRRH) Ethics Committee for clinical studies, Mumbai has approved this study in compliance with the Helsinki declaration. Written consent from the participants was obtained during data collection. The confidentiality of the data was maintained during all the stages of research- data collection, data cleaning, and dissemination of research results.