Awareness of female malignancies among women and their partners in Southern Sri Lanka and implications for screening: a cross sectional study

The overall cancer incidence in females in Sri Lanka shows a gradual rise after age 30, reaching a peak in the age group of 50–60 years [1]. Breast and cervical malignancies are two of the most common malignancies affecting women of reproductive and postmenopausal age groups and have crude incidence rates of 19 and 7.3 per 100,000 of population, respectively [1, 2]. Ovarian and uterine malignancies (e.g., endometrial carcinoma) are placed fifth and ninth in the list of common female malignancies [1].

The treatment costs of female reproductive system malignancies (including breast cancer) is a considerable burden to government healthcare expenditure and premature deaths of females are an irreplaceable loss to their families and workforce. Recognizing the importance of early detection and treatment of female reproductive tract cancers, successive governments in Sri Lanka have initiated and funded community based health education and early detection/screening programmes mainly through “well woman clinics” [3]. While the positive impact of these interventions are obvious (early detection via standard screening measures such as Papanicolaou (Pap) smear for cervical cancer), the numbers of female reproductive system malignancies in Sri Lanka are still significant and increasing [4].

Against this background it is important to assess secondary factors that may influence the health seeking behaviours of females with respect to screening and early detection. One significant yet, unassessed area in this regard is the knowledge, attitudes and practices of males regarding female reproductive tract malignancies. We hypothesize that given the traditional male dominated gender norms in Sri Lankan society, better awareness by male partners will have a significant positive impact on health seeking behaviours of females (e.g., attending voluntary screening). We also hypothesize that other confounding factors such as level of education of partners, family income, permanent employment, having a relative affected by cancer will also be associated with better awareness and positive health seeking behaviours of females. It has been shown previously that better education, age greater than 50 years, past history of hysterectomy and several other factors to be significantly associated with attending breast cancer screening in Sri Lanka [5]. However, this sample was selected from women attending a mammography centre and is not representative of the community. Another clinic based study demonstrated very low uptake for Pap smear screening among eligible women in Sri Lanka [4]. The reasons for this observation including that of gender roles and partner attitudes have not been evaluated so far.

The objectives of this study were a) to assess the awareness of symptoms, risk factors and available screening facilities for three common female malignancies, namely; breast, cervical and uterine malignancies among women and their male partners, b) to assess the percentage utilization of screening services and self-examination strategies for early detection by women, c) to correlate utilization of health services by women with awareness, level of education and acceptance of screening by male partner, and d) to correlate utilization of health services by women with level of education, family income and employment status of women.

A total of 282 (n-282) couples were interviewed. The basic demographic characteristics of the sample are summarized in Table 1. The mean age of the male and female partners in the sample was 44 and 43 years respectively. The majority were of Sinhala ethnicity. Approximately, 80 % of the sample had completed at least 11 years of school education. There were few instances of non-consent (less than 15) and in all situations the respondents were too busy to fill the questionnaire.

The most noteworthy observation in this study is that the awareness of all three common female malignancies was unsatisfactory in the sample for both sexes. Understandably, the awareness of females was slightly better than that of males. This is not surprising given the fact that there is no formal communal education on any of these malignancies. Even the school curricula do not address the signs and symptoms of these female malignancies. Even if the topics were to be covered in school, the target group would be an age group least affected by any of these malignancies. Well woman clinics do educate women on these malignancies but only women above 45 years of age are eligible to attend these clinics (service is not available to men). In short, there is no formal community-wide educational programme targeting women in sexually active reproductive age groups. The education and awareness on these malignancies are sporadically picked up by the general public from newspapers, magazines, internet and televised healthcare programmes. These are by no means a substitute for an organized all inclusive centrally coordinated community based health awareness programme.

Previous studies, both local and international have noted the poor level of awareness of women with regard to these malignancies. A school based study in the metropolitan Colombo district of Sri Lanka (in which the national capital is located), showed that awareness of common signs and symptoms of breast cancer to be grossly inadequate [2]. One third of the sample did not have any satisfactory knowledge on signs, symptoms, screening and treatment modalities of breast cancer. Only 36 % of the sample had heard about mammography. Similarly, another study on awareness of pap smear as a screening method for cervical cancer showed that out of 188 women interviewed, only 111 (59 %) were aware of pap smear and only 34 (18.1 %)had ever undergone screening [4]. Again this study was conducted in the capital, Colombo. The hypotheses raised in both studies were that level of awareness can be even lower in more peripheral and rural areas of Sri Lanka. That assumption appears to be correct at least when considering the Galle district in the Southern province as the percentage uptake of Pap smear was even lower in our data.

There are several international studies which have assessed certain aspects studied in this survey. A cross sectional survey in Qatar of 1063 participants showed that only 29 and 25 % of women (aged 35 or older) knew about SBE and mammography, respectively [9]. Only 14 % admitted to practicing SBE monthly and only quarter of the eligible population has had regular mammography. A study in Lagos, Nigeria recorded that out of 218 women screened, 156 (72 %) were aware of breast cancer but the sample bias was obvious with the entire sample coming from a breast cancer treatment clinic [10]. The awareness is also better in certain groups of women such as healthcare workers. However, evidence suggests that even in healthcare workers, awareness doesn’t convert well in to practice. A survey of nursing students in Turkey showed that 81 % of the sample had a satisfactory level of awareness of breast cancer due to their training but only 64 % of the sample practiced regular SBE [11]. There are numerous other studies from low and middle income countries showing unsatisfactory level of awareness of these key malignancies and low uptake of screening practices [12, 13]. The surveys from high income countries report better numbers with regard to awareness [14, 15], but findings differ depending on different socioeconomic and occupational groups interviewed [16]. On the topic of cervical cancer, studies have noted similar deficiencies [17]. A review found that compared to high income countries the effect of pap smear in reducing cervical cancer related mortality is less in low and middle income countries due to poor coordination of screening, unsatisfactory public participation, limited access to healthcare and lack of quality assurance [18].

It is notable that in both females and their male partners, better awareness of all three malignancies showed a consistent strong association with having a better education, family income and permanent employment in univariate analysis. Socio-economic stability may increase the opportunity for better education and proper health seeking behaviour. It also increases the buying power to access media and internet plus formal health educational programmes. They are also more likely to have health insurance schemes supported by employers that fund routine check-ups and screening. Having a relative affected by cancer showed a strong association with better awareness in males but not in females. This is probably because women are more likely to be aware of these malignancies regardless of having an experience of a relative having cancer. However males are more likely to be knowledgeable about this group of malignancies that does not affect them when a relative falls victim to a similar illness.

Despite scarcity of data from Sri Lanka, there is evidence from other countries that better socio-economic standing and better education is associated better awareness of malignancies considered. The previously mentioned study in Qatar noted that better education (secondary or tertiary) was strongly and significantly associated with better awareness of breast cancer (p < 0.001) [9]. However being employed did not confer such an advantage. Still, it is observed that unlike our sample where a majority of women were employed, in this study, almost two third of the sample were unemployed. Income disparity and socioeconomic standing at a national level is shown to be related to successful utilization of screening services for cervical cancer with countries with better socioeconomic standing having better organized screening facilities and more detection rates (which is partly dependent on customers being knowledgeable and accessing these services) [18]. It is also noted that all female malignancies are increasing in low and middle income countries compared to high income countries [19]. Unlike the more popular breast and cervical cancers, studies on awareness of endometrial cancer are limited. From the data available, even in high income countries, the knowledge on this type of cancer is considered to be unsatisfactory [20, 21].

Awareness does not always convert in same numbers to practice. In Sri Lanka, it has been demonstrated previously that most people who are aware of screening procedures for breast cancer do not undergo screening [2]. Agreeing with that observation, in this sample also, the overall numbers of women actually attending well woman clinics, undergoing mammography or Pap smear were small. Nevertheless, there was a significant positive association of being aware of malignancies and attending well woman clinics. Whether attendance improved knowledge or vice versa is difficult to establish from this study. In addition, better socio-economic standing, better educational background, better awareness of female malignancies by male partner and active encouragement by male partner was also significantly and positively associated with female partner attending well woman clinics or performing SBE. It is a plausible hypothesis that better awareness by males will eventually lead to better female participation in screening services. Males can play an active role in coaxing women to participate in screening programmes especially in countries like Sri Lanka where subtle male dominant gender norms are prevalent.

Despite being considered as independent variables for univariate analysis; educational level, employment status and family income are not mutually exclusive. Obviously a better income leads to better employment and educational opportunities and vice versa. Considering these confounding effects we carried out a binary logistic regression of all variables that were significantly associated with better utilization of screening services in the univariate analysis. While the results varied according to the screening service studied, for attending well woman clinics, only permanent employment status of women remained significant. This highlights the importance of female empowerment, especially by financial means that may lead to positive health seeking behaviours. While there were some significant associations in the final output for other screening services studied (mammography, SBE) numbers utilizing these services were few to make any valid conclusions.

The traditional approach of only targeting women in health educational programmes on female malignancies needs to change. In Ghana, it has been shown that as a result of female targeted awareness programmes, the level of knowledge on breast cancer among men was unsatisfactory. However, when educated on the problem, they were willing to encourage female partners to attend screening services or perform SBE [22]. Similarly a qualitative study with focus group discussions in Mexican immigrants in United States showed less awareness about breast and cervical cancer among men compared to females. However, males had very positive attitudes towards screening once educated on the topic [23]. The education of males is even more important when it comes to cervical cancer as now a vaccine is available against Human Papilloma Virus (HPV). Fathers, husbands and male partners being educated on the topic can increase the vaccine uptake in target adolescent female population. In addition, the vaccine also protects against HPV induced cancers in males. A study in Japan showed that knowledge about HPV vaccine among fathers to be poor (small sample size, n −27) but once educated, the acceptability for the vaccine was high [24]. These observations suggest that health education on female malignancies for both sexes is a better way forward in reducing cancer related morbidity and mortality.

This cross sectional survey of women of reproductive and post-menopausal age groups and their male partners in Southern Sri Lanka showed that level of awareness of breast, cervical and endometrial carcinoma to be unsatisfactory in both sexes. Overall, males had a lower level of awareness compared to women. Better socioeconomic standing, being permanently employed and having a higher family income were positively and significantly associated with better awareness of malignancies for both sexes. Some of these variables remained significantly associated with better utilization of certain screening tests by women in both univariate analysis and in binary logistic regression.

Female malignancies are on the rise in low and middle income countries and several studies including those in Sri Lanka have shown that the level of awareness of these malignancies to be unsatisfactory among women. This study showed that awareness is comparatively worse among men. Furthermore, studies including this have derived evidence in support of educating and harnessing support of male partners to increase the uptake of screening services by women. Educating males is also important as breast cancer can also affect men and the availability of HPV vaccine prevents HPV induced malignancies in both sexes. There should be an organized community based healthcare and educational programme that invites participants from both sexes and it is recommended to have an alternative other than well woman clinics (which currently targets women over 45 years of age) for this purpose. It is also important to start health education in early adulthood as several screening methods such as SBE and Pap smear are relevant to women from this age group onwards.