Translating Evidence into Practice in Low Resource Settings: Cervical Cancer Screening Tests are Only Part of the Solution in Rural India

  • Isaac, Rita (RUHSA Department, Christian Medical College) ;
  • Finkel, Madelon (Weill Cornell Medical College) ;
  • Olver, Ian (Cancer Council Australia) ;
  • Annie, I.K. (RUHSA Department, Christian Medical College) ;
  • Prashanth, H.R. (RUHSA Department, Christian Medical College) ;
  • Subhashini, J. (Dept of Radiotherapy, Christian Medical College) ;
  • Viswanathan, P.N. (RUHSA Department, Christian Medical College) ;
  • Trevena, Lyndal J. (Sydney School of Public Health, University of Sydney)
  • Published : 2012.08.31


Background: The majority of women in rural India have poor or no access to cervical cancer screening services, although one.quarter of all cervical cancers in the world occur there. Several large trials have proven the efficacy of low-tech cervical cancer screening methods in the Indian context but none have documented the necessary components and processes of implementing this evidence in a low-resource setting. Methods: This paper discusses a feasible model of implementation of cervical cancer screening programme in low-resource settings developed through a pilot research project carried out in rural Tamilnadu, India. The programme used visual inspection of cervix after acetic acid application (VIA) as a screening tool, nurses in the primary care centres as the primary screeners and peer educators within Self-Help Women groups to raise community awareness. Results: The uptake of screening was initially low despite the access to a screening programme. However, the programme witnessed an incremental increase in the number of women accessing screening with increasing community awareness. Conclusions: The investigators recommend 4 key components to programme implementation in low-resource setting: 1) Evidence-based, cost-effective test and treatment available within the reach of the community; 2) Appropriate referral pathways; 3) Skilled health workers and necessary equipment; and 4) Optimisation of health literacy, beliefs, attitudes of the community.



  1. Bhatla N, Gulati A, Mathur SR, Rani S, et al (2009). Evaluation of cervical screening in rural North India. Int J Gynaecology & Obstetrics, 105, 145-9.
  2. Chhabra S, Bhavani M, Mahajan N, Bawaskar R (2010). Cervical cancer in Indian rural women: trends over two decades. J Obstetrics & Gynaecology, 30, 725-8.
  3. Christe DM, Mohanambal M, Ramamurthy V, Snehaa NB (2008). A study of cervical cancer screening for prevention of carcinoma cervix. J Indian Med Assoc, 106, 779-80.
  4. Craig P, Dieppe P, Macintyre S, et al (2008). Developing and evaluating complex interventions:the new Medical Research Council guidance. BMJ, 337, ?-?.
  5. Cuzick J, Arbyn M, Sankaranarayanan R, et al (2008). Overview of human papillomavirus-based and other novel options for cervical cancer screening in developed and developing countries. Vaccine, 26, 29-41.
  6. Dinshaw K, Mishra G, Shastri S, et al (2007). Determinants of compliance in a cluster randomised controlled trial on screening of breast and cervix cancer in Mumbai, India. 1. Compliance to screening. Oncology, 73, 145-53.
  7. Garland SM, Cuzick J, Domingo EJ, et al (2008). Recommendations for cervical cancer prevention in Asia Pacific. Vaccine, 26, 89-98.
  8. Gozum S, Karayurt O, Kav S, Platin N (2010). Effectiveness of peer education for breast cancer screening and health beliefs in eastern Turkey. Cancer Nursing, 33, 213-20.
  9. IARC. GLOBOCAN (2008): Cancer Incidence, Mortality and Prevalence Worldwide in 2008. Available from:
  10. Juneja A, Sehgal A, Sharma S, Pandey A (2007). Cervical cancer screening in India: strategies revisited. Indian J Med Sci, 61, 34-47.
  11. Kaku M, Mathew A, Rajan B (2008). Impact of socio-economic factors in delayed reporting and late-stage presentation among patients with cervix cancer in a major cancer hospital in South India. APJCP, 9, 589-94.
  12. Karwalajtys T, McDonough B, Hall H, et al (2009). Development of the volunteer peer educator role in a community Cardiovascular Health Awareness Program (CHAP): a process evaluation in two communities. J Community Health, 34, 336-45.
  13. Kerner JF, Cazap E, Yach D, et al (2009). Comprehensive cancer control-research & development: knowing what we do and doing what we know. Tumori, 95, 610-22.
  14. Maticka-Tyndale E, Barnett JP (2010). Peer-led interventions to reduce HIV risk of youth: a review. Evaluation & Program Planning, 33, 98-112
  15. Mittra I, Mishra GA, Singh S, et al (2010). A cluster randomized, controlled trial of breast and cervix cancer screening in Mumbai, India: methodology and interim results after three rounds of screening. Int J Cancer, 15, 976-84.
  16. Nandakumar A, Anantha N, Venugopal TC (1995). Incidence, mortality and survival in cancer of the cervix in Bangalore, India. Bri J Cancer, 71, 1348-52.
  17. Nene BM, Hiremath PS, Kane S, et al (2008). Effectiveness, safety, and acceptability of cryotherapy by midwives for cervical intraepithelial neoplasia in Maharashtra, India. Int J Gynaecology & Obstetrics, 103, 232-6.
  18. Patra S, Panda D (2010). Cervical cancer screening in developing countries. Indian J Cancer, 47, 344-5.
  19. Rema P, Suchetha S, Thara S, et al (2008). Effectiveness and safety of loop electrosurgical excision procedure in a lowresource setting. Int J Gynaecol Obstetrics, 103, 105-10.
  20. Sankaranarayanan R, Esmy PO, Rajkumar R, et al (2007). Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial. Lancet, 4, 398-406.
  21. Sankaranarayanan R, Rajkumar R, Esmy PO, et al (2007). Effectiveness, safety and acceptability of 'see and treat' with cryotherapy by nurses in a cervical screening study in India. Br J Cancer, 12, 738-43.
  22. Sankaranarayanan R, Bhatla N, Gravitt PE, et al (2008). Human papillomavirus infection and cervical cancer prevention in India, Bangladesh, Sri Lanka and Nepal. Vaccine, 19, 43-52.
  23. Sankaranarayanan R, Thara S, Esmy PO, Basu P (2008). Cervical cancer: screening and therapeutic perspectives. Med Principles Practice, 17, 351-64.
  24. Sankaranarayanan R, Nene BM, Shastri SS, et al (2009). HPV screening for cervical cancer in rural India. New Engl J Med, 2, 1385-94.
  25. Sankaranarayanan R, Boffetta P (2010). Research on cancer prevention, detection and management in low-and mediumincome countries. Ann Oncol, 21, 1935-43.
  26. Singh AA (2009). India can do more for breast and cervical cancer control. Asian Pac J Cancer Prev, 10, 527-30.
  27. Swaminathan R, Selvakumaran R, Esmy PO, et al (2009). Cancer pattern and survival in a rural district in South India. Cancer Epidemiol, 33, 325-31.

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