A community health worker-led, population-based cancer education and screening strategy in a high-burden, resource-constrained setting in India: A retrospective cohort study

The proposed workshop organized by the Chronic Disease EPH section will start with an overview of the impact of a life course perspective on cancer prevention and screening strategies, in the context of aging populations and fear of increasing health inequity. It will be followed by three presentations to address issues of cancer screening inequalities, low-value cancer screening, and cancer surveillance bias due to screening. Key messages • Due to population aging, the burden of cancer increases and calls for new cancer prevention and screening strategies. • Cancer screening strategies must be adapted among older adults and designed to prevent inequities.

Colon Cancer Screening Models: Lessons and Challenges

Population based cancer screening was initiated in India in 2016 owing to an increased burden of cancers. A feasibility health system study was done by utilising community health workers (CHWs) to conduct the cancer screening. The current study is a qualitative study to elicit the barriers and facilitators in implementing population based cancer screening through CHWs. The study was conducted at three subcentres of Dholai block of Cachar district, Assam, India and Cachar Cancer Hospital and Research Center, Silchar. The participants of the study were CHWs, master trainer nurses and women from community. Three focus group discussions (FGDs) and one in-depth interview (IDI) were conducted at the provider level and seven IDIs of women from the community. The FGDs and IDIs were audio recorded after taking verbal consent from the participants. The verbatims were prepared following translation and transcription and data analysis using ATLAS ti ver 8. The major barrier faced by the community was a lack of motivation to get screened which stemmed from various factors such as personal beliefs, attitudes and fear. The major facilitators were accessibility of tests, family support and CHWs as screening service providers. The major barriers for CHWs were difficulty in motivating the community, lack of support from supervisors and lack of motivation to work. The major facilitators were convenience of screening during home visits, empowerment, skill enhancement and teamwork. Population based cancer screening was a new concept for the community under study. Cancer screening by CHWs was well accepted by the community. Awareness generation among the community was a major factor in improving screening coverage. The study highlights that training and motivation of CHWs can improve the uptake of cancer screening services. CHWs felt empowered with the new skills imparted and were able to carry out screening.

This article reviews the ongoing initiatives to prevent and control cardiovascular diseases (CVDs) and non-communicable diseases (NCDs) in India and analyses the role of primary health care (PHC) system. The authors note that in last 2 decades, there has been increasing policy recognition of the challenges posed by CVDs and NCDs in India. The review of ongoing government health program in India indicate that while the interventions to tackle CVDs and NCD have also been launched and scaled up, a majority of these initiatives continue to be delivered through district or sub-district levels. Though, there has been plans, the scale up through PHC system is at early stage only. There is sufficient scientific evidence that the effective prevention and control of CVDs need accessible health services and a series of public health interventions through strengthened PHC system. There are learnings from COVID-19 pandemic response in India (in areas such as private sector engagement, effective enforcement of health regulation, community engagement and the use of tele-consultations), which can be useful. The authors conclude that a strengthened and well-functioning PHC system can ensure increased access to CVD and NCD services. As India plans to scale up ongoing health programs and launch a few new initiatives, the learnings from the past, documented in this paper, could be useful. These steps would help India to accelerate progress towards universal health coverage.

Non-communicable diseases (NCDs) represent a major global health challenge, particularly in low- and middle-income countries like India, with significant gender disparities in mortality and disease burden. This study aims to investigate these disparities, using data from national health surveys, to inform gender-specific public health strategies and align with global health goals. The study uses data from the Longitudinal Aging Study in India (LASI) and National Family Health Surveys (NFHS-4 and NFHS-5). The results from the Longitudinal Ageing Study in India (LASI) and National Family Health Surveys (NFHS-4 and NFHS-5) indicate significant demographic and health-related variations among 65,562 participants. Key findings show gender disparities in lifestyle habits such as alcohol and tobacco use, and differences in health outcomes across age, education, and socioeconomic status. Notably, an increase in NCD prevalence, particularly hypertension and diabetes, was observed from NFHS-4 to NFHS-5, highlighting evolving health challenges in India. The study emphasizes the importance of gender in the prevalence and management of non-communicable diseases (NCDs) in India, advocating for public health strategies that address gender differences, socio-economic factors, and urban-rural disparities to achieve health equity.

India has one of the world's highest proportions of out-of-pocket expenditure (OOPE) payments. The low share of public health expenditure coupled with the double burden of disease (communicable and non-communicable) has a direct financial impact on individual OOPE and an indirect impact in the form of decreasing life expectancy, reduced productivity, and hence a negative impact on economic growth. This systematic review aims to compare and assess the estimated economic cost of non-communicable diseases (NCDs) in India and ascertain the methods used to derive these estimates. This paper reviews the past 12-year (2010-22) literature on the economic impact of health shocks due to NCDs. Three databases were searched for the literature: PubMed, Scopus, and Google Scholar. Thematic analysis has been performed to analyse the findings of the study. The OOPE was very high for NCDs. The increasing cost was high and unaffordable, pushing many people into financial distress measured by catastrophic payments and rising impoverishment. The results indicate both the direct and indirect impact of NCDs, but the indirect burden of loss of employment and productivity, despite its relevance, has been less studied in the literature. A robust economic analysis will allow an evidence-based policy decision perspective to reduce the rising burden of NCDs.

This compilation aims to explore the burden of non-communicable diseases (NCDs) in India and the potential role of the gut microbiome as a promising avenue for intervention. It focuses on understanding the unique Indian microbiome, examining the impact of microbiome interventions on general wellbeing and NCD management and outlining future directions for microbiome research in India.

The recent trends and distributional patterns of communicable diseases (CD) and non-communicable diseases (NCD) in India are analysed in this study. Utilising the unit-level health-specific data from three rounds (1995, 2004 and 2014) of the National Sample Survey Office, it is found that the incidence of CDs is declining while that of NCDs increasing over time. The state-wise pattern shows that both the least-developed states and relatively developed states have a high incidence of diseases. But the incidence of CDs is relatively high in backward states like Rajasthan, Odisha, Assam, Bihar and UP, whereas the prevalence of NCDs is high in advanced states like Kerala, Maharashtra, Tamil Nadu and others. The multinomial logistic regression results also confirm that income, sex and availability of safe drinking water are key determinants of the presence of diseases. Thus, the policy implication of the study calls for the availability and accessibility of adequate medical facilities at affordable costs, development of a strong network of public health facilities in rural India primarily. Bringing the rural as well as urban poor into the fold of health insurance schemes would ensure a huge benefit to the masses who struggle to get the basic treatment. The development of an effective ‘health information system’ can be a better policy instrument in arresting the rising incidence of NCDs. JEL Classification codes: C12, C51, I15, I18

Health literacy plays a crucial role in combating non-communicable diseases (NCDs) in India, where the prevalence of conditions such as cardiovascular diseases, diabetes, and cancer is rising significantly. Enhancing health literacy empowers individuals to make well-informed health decisions and adhere to treatment plans more effectively. This review provides a comprehensive evaluation of the current state of health literacy in India, emphasizing the notable regional and socioeconomic disparities that exist. It also explores various public health initiatives designed to improve health literacy and assesses their effectiveness in managing NCDs. The findings highlight that targeted educational and communication strategies can substantially enhance both disease prevention and management. To address these challenges, the review recommends strengthening health literacy by improving access to relevant information and supporting effective self-management of NCDs.

The paper emphasizes the vital need to address the rising burden of noncommunicable diseases (NCDs) in India with a health systems approach. The authors argue that adoption of such approach may soon be imperative. Applying the health systems framework developed by the WHO in 2000 to NCDs means in summary re-examining the planning and organization of the entire health system, from service provision to financing, from information generation to ensuring adequate supply of pharmaceuticals/technologies or human resources, from improving facility management to performance monitoring. Using this framework the authors seek to highlight core issues and identify possible policy actions required. The challenge is to ensure the best implementation of what works, aligning the service provision function with the financial incentives, ensuring leadership/stewardship by the government across local/municipal, state or regional and national level while involving stakeholders. A health system perspective would also ensure that action against NCD goes hand in hand with tackling the remaining burden from communicable diseases, maternal, child health and nutrition issues.

Cancer screening rates in Japan are much lower than those in Western countries. This study evaluated the relationship between cancer screening rates and strategies used to improve screening rates, and determined which strategy is the most effective. All municipalities are responsible for conducting gastric, lung, colorectal, cervical, and breast cancer screenings in Japan. Of the 1,746 municipalities in total, 92-99% were included in the analyses for each cancer screening. Using national data in 2009, the correlations between cancer screening rates and strategies for improving screening rates of all municipalities, both large (populations of over 30,000) and small (populations of under 30,000), were determined. The strategies used were as follows: sending personal invitation letters, personal visits by community health workers, use of a clinical setting for screening, and free screening. Of all four strategies used to improve cancer screening rates, sending personal invitation letters had the highest correlations with all screening rates, with the exception of breast cancer screening. The partial correlation coefficients linking this strategy with the screening rates in all municipalities were 0.28, 0.32, 0.30, and 0.26 for gastric, lung, colorectal, and cervical cancer screening, respectively. In large municipalities, the correlations between the number of examinees in a clinical setting and the screening rates were also relatively high, particularly for cervical cancer screening (r=0.41). Sending personal invitation letters appears to be particularly effective in improving cancer screening rates in all municipalities. All municipalities should implement a system that sends personal invitation letters for cancer screening. In large municipalities, increasing the availability of screening in a clinical setting is also effective in improving cancer screening rates.

Participants, Physicians or Programmes: Participants’ educational level and initiative in cancer screening

Objective: Cancer remains a leading cause of morbidity and mortality globally, with India experiencing a significant cancer burden. Effective population-based cancer screening is crucial for early detection and reduction of cancer-related deaths. This study aims to develop a mobile application-based Cancer Screening and Surveillance System (CSMS) to enhance the efficiency and effectiveness of population-based cancer screening by community health workers (CHWs). Methods:An applied research approach was employed, integrating traditional cancer screening procedures with a newly developed mobile application system. The CSMS includes an Android-based mobile application and a web portal designed for real-time data collection, monitoring, and rapid referral of screen-positive cases. The system was piloted in the Cachar district of Assam and training sessions were conducted to equip CHWs with traditional cancer screening procedures and the necessary skills to utilize the mobile application for cancer screening. 199 CHWs were trained and screened eligible population of 73,630 individuals. Results:The mobile application facilitated efficient data collection and synchronization with a central server, enabling timely referrals and follow-ups. The system supported comprehensive data management, ensuring patient privacy and data security. The pilot implementation demonstrated improved screening coverage and streamlined referral processes, highlighting the system’s potential to enhance cancer screening programs. Conclusion: Mobile application-based Cancer Screening and Surveillance System provides a cost-effective and robust solution for population-based cancer screening. The developed system can improve data accuracy, facilitate timely referral and aid in early detection of cancer. Further studies should be conducted to evaluate the impact of the developed system and its scalability in more diverse settings.

Background and context: Three most common cancers in India are breast, uterine cervix and oral cavity, together accounting for approximately 34% of all cancers. Ministry of Health and Family Welfare, India has released an operational guidelines for cancer screening last year and has urged all the states to roll out population based cancer screening at various health care levels. As per these guidelines, the existing health care providers (HCPs) at various facilities would be rolling out the population based cancer screening in the country. However, the existing HCPs lack the skills and are not trained in cancer screening. Considering the size of the country, it is neither a feasible nor economically viable to provide in-person training for all cadres of HCPs. The limitation is comprehensively overcome by ECHO (Extension for Community Healthcare Outcomes) model provides a cost effective way to exponentially expand the capacity to mentor and train these HCPs in cancer screening best practices. ECHO as per the motto to “move knowledge rather than patients or doctors”, uses widely available one to many video-conferencing technology, didactic presentations and case based learning techniques to mentor and support HCPs to implement best practices in the field. In teleECHO clinics expert teams at an academic “hub” partner with willing participants to participate in knowledge networks in which all teach and all learn. Aim: To train the health care providers in cancer screening through technology assisted learning. Strategy/Tactics: A structured training program was designed using ECHO platform for all HCPs in separate batches that included, gynecologists, dentists and community health workers (CHWs), by virtual training to address all issues while they roll out cancer screening in their communities. Program/Policy process: A structured course of 20 week-sessions' virtual (online) cancer screening training program for various cadres of health care providers was undertaken. A typical one hour of ECHO session consisted of 25-30 minutes of didactics by the expert followed by 2 case presentations by the spokes. A “Beginner´s program” was well received by the participants who requested us to take it ahead with “Advanced training program” for specialists. Outcomes: 58 participants completed the course in cancer screening. The pre- and posttraining knowledge evaluation demonstrated a significant increase in the knowledge gained by participants. What was learned: In a resource constrained environment it is feasible to develop a basic curriculum in cancer screening program and train and support, all cadres of HCPs. Rolling out a technology enabled model such as ECHO for teaching and training can enable the development of a population based cancer screening program.

ObjectiveNational Health Commission of the People’s Republic of China collaborated with many ministries and commissions government and initiated a population-based cancer screening program in high-risk area of rural China, targeting three types of cancer that are most prevalent in these areas, including esophageal, stomach and liver cancer. This study protocol was reported to show the design and evaluate the effectiveness of cancer screening and appropriate screening strategies of three cancers in rural China.Methods and analysisA two-step design with cancer risk assessment based on questionnaire interview, Hepatitis B surface antigen (HBsAg) test strip and subsequent clinical intervention for high-risk populations was adopted free of charge at the local hospitals designated in the program.Ethic and disseminationThis study was approved by the Institutional Review Board of Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. The results will evaluate the effectiveness of cancer screening and appropriate screening strategies in rural China.