gco.iarc.who.int/today/en/dataviz/pie?mode=cancer&types=0&sexes=2&populations=900" rel="noreferrer noopener" target="_blank">most prevalent cancers among women globally, but preventative screenings can provide early detection that may lead to better outcomes. To work, though, women must get the screenings - which can be difficult in some areas of the world, especially if women have less autonomy to make their own health care decisions, according to a new study by researchers in the Penn State Department of Health Policy and Administration.
The team examined the relationships between married women's autonomy in making health-related decision for themselves, the presence of community effort in enhancing women's health, and breast and cervical cancer screening rates in Nepal. Their findings, published in World Medical & Health Policy, demonstrated that women who have the autonomy to make health-related decisions for themselves were more likely to get cervical cancer screening service. When examining the relationship between the presence of community effort and screening outcomes however, the researchers observed mixed results.
In Nepal, cervical and breast cancer are the two highest causes of cancer-related deaths in women, with the cervical cancer mortality rate in Nepal being about 2% higher than the global mortality rate of 7.1 per 100,000 women. While routine screenings are known to help detect cancers at an early stage, leading to reduced morbidity and mortality, the screening rate for both breast and cervical cancer remains low in Nepal.
Previous research found that only 8% of women in Nepal ages 30 to 49 had undergone cervical cancer screening, and only 6% of survey participants in rural Nepal had heard of cervical cancer. Another research team previously found that, in Nepal, gender norms such as women having low decision-making power may be a major barrier contributing to the lack of women utilizing health care services.
For this study, Young-ji Lee, a doctoral candidate in the Penn State Department of Health Policy and Administration, defined women's autonomy as a woman making health-related decisions for herself without input from her husband or other family members. According to Lee, this is an important distinction to make as many women follow traditional cultural norms, leading them to consult their husband or family members when making health-related decisions that, in some cases, may be classed as having autonomy.
"Other studies have looked at the low breast and cervical cancer screening rates in Nepal, but largely in the context of socio-demographic factors," said Yubraj Acharya, associate professor of health policy and administration at Penn State and senior author on this publication. "We focused on women's autonomy and the presence of community groups in relation to cancer screening rates, an area where little prior research exists."
Lee and Acharya performed a cross-sectional analysis of data from the 2022 Nepal Demographic Health Survey - a comprehensive survey on population, health and nutrition across low- and middle-income countries. Their sample consisted of married women ages 30 to 49.
In the analysis, the researchers found there was a positive association between autonomy to make health-related decisions and both the knowledge of and participation in cervical cancer screening, which involves an invasive physical examination. They did not find a positive association between women's autonomy and knowledge of and participation in breast cancer screening, which can still feel invasive but typically to a lesser extent than cervical cancer screening.
"This result is not surprising when we consider the stigma that typically follows cervical cancer, especially in low- and middle-income countries like Nepal," Lee said. "When making health decisions for themselves, women feel empowered to participate in cervical cancer screening, but when making decisions with their husbands or family members, they can often be made to feel shame and be dissuaded from having the screening due to the way the test is conducted."
This study also examined whether women's health groups were associated with breast and cervical cancer screening knowledge and participation.
According to Lee, the Female Community Health Volunteers (FCHVs) program - created in the 1980s and originally designed for female volunteers to support family planning and immunization efforts - is a key component of community efforts to enhance health care for women in Nepal. The program bridges the gap between women, families and communities, and the lack of access to adequate health care resources in Nepal.
FCHVs often works with Health Mother's Groups (HMG) to organize and lead meetings for women in rural Nepal. HMGs - community‐based groups designed to improve maternal and child health - typically organize meetings in accessible locations such as schools or clinics.
"The main role of these community groups is to provide critical health education to pregnant women, new mothers and mothers with young children, so they have the knowledge to make the best health care decisions for themselves and their families," Lee said. "In our study, we wanted to examine whether these community groups deliver health-related information efficiently to these women, and whether this was associated with women's participation in cancer screenings."
The researchers found an increase in knowledge of both breast and cervical cancer screening for women who attended an HMG meeting at least once in the last six months. They did not, however, find an association between attending an HMG meeting and participation in breast and cervical cancer screening.
"The HMG community efforts do work in delivering important health information to women and increasing their knowledge of these topics, but it's not leading to more women seeking breast and cervical cancer screening," Lee said. "More needs to be done to expand the role of HMGs past maternal health and family planning to enhance gender awareness and women's empowerment, which will hopefully lead to higher utilization of these services."
Lee noted there are other factors that need to be considered in future research, such as availability and accessibility of health resources. Lee said she hopes to continue this work in the future, with a more comprehensive analysis.
"I hope to travel to Nepal and collect primary data from FCHVs and women working in HMGs to determine, from their perspectives, what support is lacking and would be most beneficial," Lee said. "With that knowledge, I hope to design and implement interventions to raise women's participation in available screening services."
