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Community Based Cancer Screening – The 12 “ I ”s Strategy for Success

Written By

Rajamanickam Rajkumar

Published: 02 March 2012

DOI: 10.5772/39233

From the Edited Volume

Topics on Cervical Cancer With an Advocacy for Prevention

Edited by Rajamanickam Rajkumar

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1. Introduction

Background of the study, in which the Editor has served as the Investigator at source 1.

Cluster Randomized Controlled Trial of Visual Screening for Cervical Cancer in Dindigul District, Tamil Nadu, India

Supported by the Bill & Melinda Gates Foundation through the Alliance for Cervical Cancer Prevention (ACCP)


  1. Christian Fellowship Community Health Centre (CFCHC), Ambillikai, India

  2. Cancer Institute (WIA), Chennai (Madras), India

  3. PSG Institute of Medical Sciences and Research (PSGIMSR), Coimbatore, India

  4. World Health Organization-International Agency for Research Cancer (WHO-IARC), Lyon, France

A communtiy based screening program was planned and the editor used the following strategies which ensured success:

The 12 “ I”s Strategy

“Our experience in a Community Based Cervical Cancer Screening Programme and the strategies which helped us to be successful”

The 12 “ I ” s













Figure 1.

Geographical location of the study area

Table 1.

Cancer Incidence in SE Asia: The need for screening is based on the following tables, showing high incidence of cervical cancer

Table 2.

Cancer Incidence Rates- World – Females

Table 3.

Cancer Incidence Rates – India – Females

Figure 2.

The women need education and empowerment


2. INITIATION – of cancer registry


  • There are Urban and Rural Population based Cancer registries

  • Cancer registry is important to know the cancer pattern

  • Priority for preventable cancers by screening, is an important use

  • Our Ambillikai Cancer Registry, was population based rural cancer registry in India started in 1995, and its an Associate Member of the International Association of Cancer Registries


3. INFERENCE – of the cancer pattern

  • Leads for the planning of control strategies

  • Ambillikai cancer registry recorded one of the highest ASR for cancer cervix (65.4/ 100 000)

  • This gave the lead for a community based cervical cancer screening programme

Supported by our publication:“Leads to cancer control based on cancer patterns in a rural population in South India”R.Rajkumar, R.Sankaranarayanan, A.Esmi, R.Jeyaraman, J.Cherian & D.M.Parkin, Cancer Causes and Control 2000; 11:433-39


4. IMBIBE – the appropriate technology

  • Developing countries can seek technical support from developed nations

  • Low resource settings need appropriate, affordable and accessible technologies

  • Technical & Financial constraints to be overcome by resource development

  • In rural India – Cervical Cancer Screening was not a health care priority

  • Hence we offered once a life time – VIA, Colposcopy

  • High risk approach is needed for selected population

  • 80% PARTICIPATION was targeted, and achieved

Supported by our publication:“Effective screening programmes for cervical cancer in low-and middle - income developing countries”Rengasamy Sankaranarayanan, Atul Madhukar Budukh, Rajamanickam Rajkumar, Bulletein World Health Organisation, 2001, 79(10) 954-962


5. INSTALL – resources

  • Political Will & Commitment

  • Manpower – train local health staff

  • Materials – locally available equipments and local maintenance expertise

  • Money – internal and/or external funds

Supported by our publication:“Early detection of cervical cancer with visual inspection methods, A summary of completed and on – going studies in India”.

R.Sankaranarayanan, IARC/WHO, B.M. Nene, K.Dinshaw, R.Rajkumar, S.Shastri, R.Wesley,P.Basu, R.Sharma, S.Thara, A.Budukh, D.M. Parkin, IARC/WHOPublic Health Journal of Mexico (Revista de Salud Publica de Mexico)

In commemoration with 80th Anniversary School of Public Health & 15th Anniversary NationalInstitute of Public Health, Mexico, July 2002

Figure 3.

Use local manpower


6. INSPIRE – personnel

  • Lighted to lighten, the health care providers play key role

  • Financial incentives, motivates them

  • Social recognition is very important in team work

  • Appreciation means a lot for the workers

  • Awards, titles, honours, cost little but the gain is big

Figure 4.

Inspiration and motivation of the Health care providers ensure success

Even in the Olympics it is a small “MEDAL” which matters



  • Involve both “ providers” & “recipients”

  • All levels of micro & macro planning

  • All levels of implementation

  • When we hear we forget

  • When we see we remember

  • When we do we know



  • It is humans’ innate desire to be invited for participation

  • Advertisements, Propaganda, Bombardment with information – may not work

  • Invitation with genuine Interest by Influencers works well

Methods of Invitation

  • Mass – Appeal to “Emotions” – Use the words “Mothers”, “ Wives”, “Sisters” instead of Women

  • Families – Appeal to “Responsibilities” of the family towards the motherhood and their duty for “ mother’s” health

  • Individuals – Appeal to their “self care and self esteem”

Who would invite ?

  • The “Influencers”

  • Medical personnel, village leaders, religious leaders, local healers, teachers

  • Satisfied Customers

  • Peer groups

  • Family members

  • Educating the school children have resulted in them bringing their mothers for screening – “tender roots split hard rock”


9. INSURE – holistic health

  • Rural community does not appreciate “organ specific approach”

  • Wholesome approach for holistic health is the demand

  • Do whatever possible for total care – even counseling and advice are well received

  • Health is a state of complete physical, mental and social well being and not merely an absence of disease or infirmity – Health for All

Figure 5.

A woman expects holistic health care from the provider



  • In thoughts, words and deeds

  • “Cancer” is scaring, terrifying and people are afraid to get diagnosed as to have cancer

  • Start from what they know and build from what they have

  • Address their common complaints like “wdpv”, “abnormal bleeding pv” and then explain about precancer and cancer.

  • Perform VIA, colposcopy and cryotherapy/LEEP and the “women get rid of their complaints” and we have done our “screening for cervical cancer”. Thus we have made the very “problem” as “indigenous”

Indigenous - Screening Environment

  • People in villages are reluctant to get in to the huge vans or buses for screening as these are unusual environments to them

  • Hence, screening clinics could be arranged in places which are frequently visited by the people, like health centre buildings, schools, ration shops, public utility buildings

Indigenous – Health personnel

  • Like begets like

  • Birds of the same feather flock together

  • Screening could be done by trained local nurses and health workers

  • Examination – Female to female and male to male

  • Identification with the people in all possible ways ensures good compliance

Indigenous in attitude

  • Never say that the other is wrong, only that they may not be right

  • Never call the local customs, beliefs, hopes, attitudes and practices as superstitions. It will hurt the feelings. Just guide them rightly.

  • Screening clinics should ensure privacy, confidentiality in a pleasant atmosphere.

  • All services under one roof and cordial relationship to be maintained

  • No outside prescriptions, referrals

  • Counsel the family as a whole, whenever possible

11. INSTITUTE – follow up

  • In rural India, people greet each other by asking “ How are you ? ”

  • People appreciate this gesture very much as it coveys one’s concern and regard

  • If this is done in a scientific way it is called the “ follow up ”, and it should be done meticulously and frequently. The possible outcomes of the screening should be well explained before hand and the need for passive follow up should be well understood by the beneficiaries and their families.

How we tackled some of the problems!

Post cryotherapy period

Long term serous discharge

Very distressing for women

Good sign of healing “Ice” melting


Post Cryo - LEEP period

Long period of sexual abstinence

Husbands’ uncooperative

Abstinence for religious reasons, Abstinence during jaundice


Problem Solving

  • Dialogues, Discussions would definitely Dissolve many of the Deterrent factors

  • Communication gap closes the doors

  • Careful and considerate listening are very important for community based programmes

  • Counseling increases the community’s compliance for the programme

Determinants of Participation

  • Educational level

  • Social status

  • Economic status

  • Type of family

  • Severity of the disease

  • Satisfactory services

Supported by our publication:“Determinants of participation of women in a cervical cancer visual screening trial in rural south India”Rengaswamy Sankaranarayanan, Rajamanickam Rajkumar, Silvina Arrossi, Rajapandian Theresa, Pulikattil Okkaru Esmy, Cerdric Mahe, Richard Muwonge, Donald Maxwell Parkin, Jacob CherianCancer Detection and Prevention 27 (2003) 457 – 465

12. ILLUSTRATE – study findings

    Supported by our publication: “Initial results from a randomized trial of Cervical Visual Screening in rural South India”.R. Sankaranarayanan. R. Rajkumar, et al.International Journal of Cancer 2004; 109, 461 – 467

    Figure 6.

    13. IMPROVE

    Successful completion of a program improves capabilities of the health care providers and it leads to further research, like our other studies:

    HPV Studies:

    Study 1

    Papillomavirus infection in rural women in southern IndiaFranceschi, R Rajkumar, PJF Snijders, A Arslan1, C Mahe, M Plummer, R Sankaranarayanan, J Cherian, CJLM Meijer and E Weiderpass, British Journal of Cancer (2005) 92, 601 – 606

    Study 2

    Worldwide distribution of HPV Types in Cytologically Normal Women: Pooled Analysis of the IARC HPV Prevalence SurveysG. Clifford (PhD), S. Gallus (ScD), R. Herrero (MD), N. Muñoz (MD), P.J.F. Snijders (PhD), S. Vaccarella (ScD), P.T.H Anh (MD), C. Ferreccio (MD), N.T Hieu (MD), E. Matos (MD), M. Molano (PhD), R. Rajkumar (MD), G. Ronco (MD), S. de Sanjosé (MD), H.R. Shin (MD), S. Sukvirach (MD), J.O. Thomas (MD), S. Tunsakul (MS), C.J.L.M. Meijer (MD), S. Franceschi (MD) and the IARC HPV Prevalence Surveys (IHPS) Study Group, Lancet 2005;366(9490):991-8.

    Study 3

    HPV vaccine trial“Preparation of a large, simple “phase IV” study of anti- HPV Vaccination in Asia”Silvia Franceschi IARC/WHO, Richard Peto, T.Rajkumar, R.Rajkumar, Rengaswamy Sankaranarayanan, Soina Pagliusi, Teresa Aguado & Thomas Cherian, Scientific Paper Submitted to the HPV International Conference – Floriano polis – June 2001.

    The editor is happy to enlist all his publications for further reference :



    1. 1. Wright Thomas C.BlumenthalPaul BradleyJanetDenny LynetteEsmyPulikattil OkkaruJayantKasturi NeneBhagwan M.PollackAmy E. RajkumarRajamanickam Sankaranarayanan Rengaswamy SellorsJohn W.Shastri Surendra S.SherrisJacquelin eTsuVivien 2007Cervical cancer prevention for all the world’s women: new approaches offer opportunities and promise”. Diagnostic cytopathology 35 12 8458 .
    2. 2. Sankaranarayanan RengaswamyEsmyPulikkottil OkkuruRajkumarRajamanickam MuwongeRichard SwaminathanRajaraman ShanthakumariSivanandam Fayette Jean-Marie Cherian Jacob 2007Effect of visual screening on cervical cancer incidence and mortality in Tamil Nadu, India: a cluster-randomised trial”. Lancet 370 9585 398406 .
    3. 3. SankaranarayananR.RajkumarR.EsmyP. O.FayetteJ. M.ShanthakumaryS.FrappartL.TharaS.CherianJ. 2007Effectiveness, safety and acceptability of ‘see and treat’ with cryotherapy by nurses in a cervical screening study in India”. British journal of cancer 96 5 73843 .
    4. 4. Franceschi SilviaHerrero RolandoClifford Gary M.Snijders Peter J.F.Arslan AnnieAnh Pham Thi HoangBoschF. XavierFerreccioCatterinaHieuNguyen TrongLazcano-Ponce EduardoMatos ElenaMolano MonicaQiao You-LinRajkumar RajRonco Guglielmode Sanjosé SilviaShin Hai-RimSukvirach SukhonThomas Jaiye O.Meijer Chris J.L.M.Muñoz Nubia2006Variations in the age-specific curves of human papillomavirus prevalence in women worldwide”. International Journal of Cancer. Journal international du cancer 119(11):2677-84.
    5. 5. Vaccarella SalvatoreHerreroRolando DaiMinSnijders Peter J.F. MeijerChris J.L.M. Thomas Jaiye O.Hoang Anh Pham Thi Ferreccio Catterina Matos Elena Posso Hector de Sanjosé SilviaShinHai-Rim Sukvirach SukhonLazcano-Ponce EduardoRonco GuglielmoRajkumar Raj Qiao You-LinMuñoz Nubia Franceschi Silvia 2006; “Reproductive factors, oral contraceptive use, and human papillomavirus infection: pooled analysis of the IARC HPV prevalence surveys”. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology 15(11):2148-53..
    6. 6. CliffordG. M.GallusS.HerreroR.MuñozN.SnijdersP. J. F.VaccarellaS.AnhP. T. H.FerreccioC.HieuN. SanjoséS.ShinH. R.SukvirachS.ThomasJ. O.TunsakulS.MeijerC. J. L. M.FranceschiS. 2005Worldwide distribution of human papillomavirus types in cytologically normal women in the International Agency for Research on Cancer HPV prevalence surveys: a pooled analysis”. Lancet 366 9490 9918 .
    7. 7. FranceschiS.RajkumarR.SnijdersP. J. F.ArslanA.MahéC.PlummerM.SankaranarayananR.CherianJ.MeijerC. J. L. M.WeiderpassE. 2005Papillomavirus infection in rural women in southern India”. British journal of cancer 92 3 6016 .
    8. 8. SankaranarayananR.RajkumarR.TheresaR.EsmyP. O.MaheC.BagyalakshmiKarur. R.TharaS.FrappartL.LucasE.MuwongeR.ShanthakumariS.JeevanD.SubbaraoT. M.ParkinD. M.CherianJ. 2004Initial results from a randomized trial of cervical visual screening in rural south India”. International Journal of Cancer. Journal international du cancer 109 3 4617 .
    9. 9. SankaranarayananR.NeneB. M.DinshawK.RajkumarR.ShastriS.WesleyR.BasuP.SharmaR.TharaS.BudukhA.ParkinD. M. 2003Early detection of cervical cancer with visual inspection methods: a summary of completed and on-going studies in India”. Salud pública de México 45 Suppl 3():S399407 .
    10. 10. SankaranarayananR.RajkumarR.ArrossiS.TheresaR.EsmyP. O.MahéC.MuwongeR.ParkinD. M.CherianJ. 2003Determinants of participation of women in a cervical cancer visual screening trial in rural south India”. Cancer detection and prevention 27 6 45765 .
    11. 11. SankaranarayananR.BudukhA. M.RajkumarR. 2001Effective screening programmes for cervical cancer in low- and middle-income developing countries”. Bulletin of the World Health Organization 79 10 95462 .
    12. 12. RajkumarR.SankaranarayananR.EsmiA.JayaramanR.CherianJ.ParkinD. M. 2000Leads to cancer control based on cancer patterns in a rural population in South India”. Cancer causes & control : CCC 11 5 4339 .


    • Experience and Evidence Based Recommendations for Health Care planners especially in developing countries who undertake Cervical Cancer Screening projects in limited resource settings

    Written By

    Rajamanickam Rajkumar

    Published: 02 March 2012