A Survey of Ongoing Understanding, Boundaries and the Way of Thinking on Breast Cancer and Mammography in Gonda (U.P.)

Breast cancer is the most common cancer affecting women globally, and it has emerged as the leading cause of cancer-related deaths among Indian women, with an alarming rise in incidence, particularly in younger age groups. According to the Global Cancer Observatory (GLOBOCAN), India reported over 162,000 new cases of breast cancer and approximately 87,000 related deaths in 2018, placing it second only to the United States in mortality rates associated with breast cancer among women ^[1]. Unlike Western countries, where screening programs are widespread and early detection rates are high, India faces a critical challenge due to late-stage presentation, low awareness levels, and limited access to diagnostic tools like mammography in rural regions ^[2]. In rural districts such as Gonda in Uttar Pradesh, these challenges are compounded by cultural beliefs, gendered stigmas, financial barriers, and a dearth of trained medical personnel and infrastructure. Mammography, an essential imaging tool for early detection of breast cancer, is grossly underutilized in such areas due to both systemic and perceptual barriers. As the American College of Radiology (ACR) and the National Comprehensive Cancer Network (NCCN) emphasize, annual screening beginning at age 40 significantly reduces mortality by detecting tumors in earlier, more treatable stages ^[3]. However, despite its proven efficacy, the uptake of mammography screening in India remains limited to urban centers, leaving a vast rural population at higher risk of undetected disease progression. The World Health Organization (WHO) has stressed the importance of integrating breast cancer awareness and early detection strategies into national health agendas, particularly in low- and middle-income countries where the majority of deaths occur due to late diagnosis ^[4]. In the Indian context, sociocultural norms play a substantial role in shaping women’s health-seeking behavior. Topics related to breast health are often considered taboo, leading to a sense of shame or embarrassment that discourages women from discussing symptoms or seeking preventive care ^[5]. Moreover, studies have consistently shown that fear of cancer diagnosis, misconceptions about mammography, and a general lack of knowledge about breast cancer risk factors are significant deterrents to screening participation ^[6]. Many women remain unaware of basic signs such as lumps, nipple discharge, or changes in breast size and texture, which delays medical consultation until the disease has progressed to an advanced stage. In such settings, Breast Self-Examination (BSE) and Clinical Breast Examination (CBE) could serve as valuable early detection tools, particularly where mammography is inaccessible, yet the knowledge and practice of these methods remain critically low ^[7]. Research in India and other developing nations has demonstrated that educational level, socioeconomic status, and urban-rural divide are strongly associated with breast cancer awareness and screening uptake. For instance, a study conducted in Maharashtra found that educated women were significantly more likely to be aware of BSE and to undergo regular clinical check-ups ^[8]. Similar findings were reported in studies from Jordan ^[9], Uganda ^[10], and Saudi Arabia ^[11], where rural women exhibited lower participation in screening due to fear, lack of information, and limited access. In addition to these perceptual barriers, infrastructural limitations further constrain breast cancer detection in regions like Gonda. Most Primary Health Centers (PHCs) and Community Health Centers (CHCs) lack mammography machines, and even when equipment is available, trained radiology technicians and female healthcare workers are often in short supply ^[12]. The financial burden associated with travel, testing, and follow-up consultations further discourages low-income women from pursuing preventive care. For women who are already burdened with domestic responsibilities and childcare, setting aside time for medical appointments is often seen as a luxury rather than a necessity. This results in a paradoxical situation where the disease is common, deadly, and detectable—yet most cases continue to be diagnosed at a late, often incurable stage ^[13]. The introduction of government initiatives such as the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) has aimed to promote cancer awareness and screening, but implementation remains inconsistent and underfunded in rural belts ^[16]. Therefore, there is an urgent need to assess and address the existing gaps in knowledge, attitude, and accessibility to breast cancer screening in such areas. The present study seeks to explore the ongoing understanding, perceived barriers, and psychological perspectives surrounding breast cancer and mammography among women in Gonda district. Given the rising burden of breast cancer and the evident discrepancies between urban and rural screening practices, such localized studies are essential to develop region-specific health education models and intervention strategies. By identifying the core obstacles—whether informational, psychological, or infrastructural—this study aims to contribute actionable insights toward enhancing early detection efforts. The inclusion of structured questionnaires and statistical correlation with variables such as education, occupation, and family history of breast cancer helps paint a clearer picture of where awareness gaps exist and how best they can be targeted. Furthermore, understanding local perceptions allows healthcare providers to design culturally sensitive outreach programs that resonate with the community’s values and beliefs. In a district like Gonda, where medical resources are scarce and traditional beliefs are strong, public health initiatives must bridge the knowledge divide with empathy and pragmatism. Thus, this study not only aims to quantify awareness levels but also to humanize the data by exploring the lived experiences, fears, and aspirations of women dealing with the possibility of breast cancer. The long-term vision is to use these insights to inform policy, strengthen local health systems, and empower women to take charge of their breast health.

OBJECTIVES

• Assess understanding and knowledge regarding breast cancer.
• Evaluate awareness and usage of mammography and BSE.
• Identify barriers to breast cancer screening.
• Determine demographic associations with screening practices.
• Recommend strategies to improve early detection.

METHODS

This study employed a descriptive cross-sectional survey design to assess the level of understanding, perceived barriers, and attitudes regarding breast cancer and mammography among women in the Gonda district of Uttar Pradesh, India. The aim was to gather quantitative data on knowledge, beliefs, and practices surrounding breast health, with particular emphasis on mammography and breast self-examination (BSE). The research was conducted over a period of three months, following ethical approval from the institutional ethical review board of SCPM College of Nursing & Paramedical Sciences.

3.1 Research Approach

A quantitative, non-experimental research approach was adopted to collect structured responses from the target population. The design was chosen for its ability to capture measurable data and establish relationships between variables such as education, age, occupation, and knowledge about breast cancer.

3.2 Study Setting

The study was conducted in Gonda district, a predominantly rural area in the Indian state of Uttar Pradesh. The region is characterized by low literacy rates, traditional gender norms, and limited access to specialized healthcare services, making it an appropriate site for evaluating breast cancer awareness and screening barriers.

3.3 Population and Sampling

The target population comprised women aged 18 years and above residing in Gonda, regardless of their educational or marital status.

• Inclusion criteria:
  • Women aged 18 and above
  • Residents of Gonda district
  • Those who gave informed consent to participate
• Exclusion criteria:
  • Women who had previously been diagnosed with breast cancer
  • Women who were healthcare professionals
  • Women unwilling to participate or unable to provide informed consent

3.4 Sample Size and Sampling Technique

A sample of 420 women was selected through simple random sampling from various blocks and villages within the district. This sample size was determined using a standard formula for cross-sectional studies:

n=Z2×p×(1-p)d2

Where:

• n = required sample size
• Z = Z statistic for a 95% confidence level (1.96)
• p = expected prevalence of awareness (assumed to be 50% for maximum sample size)
• d = margin of error (0.05)

Using this, the sample size was calculated as approximately 384, rounded up to 420 to account for potential non-responses and ensure greater representativeness.

3.5 Variables Under Study

• Independent variables: Age, education, marital status, occupation, number of children, income, and area of residence
• Dependent variables: Level of knowledge about breast cancer, awareness and use of mammography, attitude toward BSE, perceived barriers

3.6 Data Collection Tool

A structured questionnaire was developed based on existing instruments such as Champion’s Health Belief Model Scale (CHBMS) and modified to suit the local population's literacy and cultural context. The questionnaire had four sections:

1. Demographic Information
2. Knowledge of Breast Cancer (Symptoms, Risk Factors, Prevention)
3. Awareness and Practice of Screening (BSE, Mammography)
4. Attitudes and Perceived Barriers

The tool was translated into Hindi, the local language, and back-translated to ensure linguistic consistency.

3.7 Pilot Study

A pilot test was conducted with 30 women from a neighboring village not included in the final study to assess the clarity, reliability, and cultural appropriateness of the tool. Minor modifications were made to question phrasing based on participant feedback.

3.8 Validity and Reliability

• Content validity was ensured by expert review from radiologists, public health professionals, and nursing faculty.
• Reliability was tested using Cronbach’s alpha, with a resulting value of 0.81, indicating good internal consistency.

3.9 Ethical Considerations

Ethical approval was obtained from the Institutional Ethics Committee of SCPM College of Nursing & Paramedical Sciences. Informed consent was obtained from each participant before administering the questionnaire. Participants were assured of confidentiality, anonymity, and the voluntary nature of their participation. No identifying personal data was collected.

3.10 Data Collection Procedure

Trained female field investigators conducted face-to-face interviews using printed questionnaires. Each interview lasted 20–30 minutes, and data collection was conducted in community centers, PHCs, and household settings. Measures were taken to ensure privacy and comfort, especially during sensitive questions related to breast health.

3.11 Data Analysis Plan

Data were entered into Microsoft Excel and analyzed using SPSS version 25.0. Descriptive statistics (frequency, percentage, mean, and standard deviation) were used to summarize demographic and response data. Inferential statistics were used to test hypotheses:

• Chi-square test: To assess association between demographic variables and knowledge/practices
• Pearson correlation: To evaluate the relationship between knowledge, attitude, and behavior
• Significance level: p<0.05 was considered statistically significant

RESULTS

Table 1: Descriptive Statistics for Age and Number of Children

Interpretation:

The average age of participants was 33.5 years, indicating a relatively young adult female population, predominantly within the reproductive and early middle-aged group. The standard deviation of 8.4 shows variability in age across participants. Most women had approximately 2 to 3 children, showing a demographic trend typical of rural India, where childbearing starts early. This data reflects a population likely responsible for family care, potentially limiting time or priority for self-health screening like mammography or BSE.