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Insufficient use of Well Women Clinics show poor reproductive health awareness: Study

16 May 2022

BY Ruwan Laknath Jayakody Due to the inadequate use of Well Women Clinic services, more awareness on reproductive malignancies is needed in order to motivate more women to seek out the services that are readily available to them, noted a local study on cancer screening with a sample representing 22 Districts in the country. This finding and observation were made in a brief report on “Is cancer screening a priority among adult females in Sri Lanka?”, which was authored by Y.P.J.N. Warnasekara, M.K. Gamakumbura, S.D. Konthota, L.S.K. Liyanage and B.A.D. Lakpriya (attached to the Rajarata University’s Medicine and Allied Sciences Faculty), and S.B. Agampodi (attached to the same Faculty’s Community Medicine Department) and published in the Anuradhapura Medical Journal 11(1) in September, 2018. The concept of the Well Women Clinic was first introduced to Sri Lanka in 1996 in order to screen females for non-communicable diseases (NCDs), including reproductive system malignancies such as breast and cervical cancers. This was done, per S.A. Cohen and C.L. Richards’ “The Cairo (Egypt) consensus: Population, development, and women”, as part of a reproductive health programme promoted by international agencies at the International Conference on Population and Development in Cairo in 1994. At present, Well Women Clinics are operating throughout the country, at all Medical Officer of Health areas, on a fortnightly or monthly basis. At these clinics, women over 35 years of age are screened for cervical and breast cancers, hypertension, and diabetes mellitus. Breast and cervical cancers are the most common malignancies among females in Sri Lanka. According to the National Cancer Control Unit data, in 2010, the estimated age-adjusted annual incidence for breast and cervical malignancies in Sri Lanka was 23 and 8.4 per 100,000, respectively. The lifetime risk of having breast cancer among Sri Lankan females is 2.1%. "Screening for breast cancer is considered effective in low- and middle-income countries where the size of the tumour is considerably large at presentation. Unlike other malignancies, the survival rates of cervical cancer patients are high when identified at the early stages," Warnasekara et al. explained. While the Well Women Clinic services are available for early detection, more than 30% of breast cancers diagnosed in Sri Lanka in 2007 were in the stage IIIA or later, thus showing a late presentation.  These females, Warnasekara et al. observed, were either not using or not aware of cancer screening services. Hence, Warnasekara et al. sought to determine the awareness and utilisation of breast and cervical cancer and Well Women Clinic services among females over the age of 35 years. This study was conducted in June 2012, in the City of Anuradhapura on Poson Poya day. The researchers conducted a rapid spot survey using a short questionnaire with a convenient sample, while the pilgrims were waiting to enter one of the places of worship. The survey was conducted as a part of a health promotion and awareness programme on breast and cervical cancers initiated by the medical undergraduates of the aforementioned faculty. The target group included females who were 35-year-old and above, similar to the target group of the Well Women Clinics. A total of 3,116 females from 22 districts were interviewed. The mean (average) age of the study sample was 52.6 years. All districts, except Jaffna, Kilinochchi and Mullaitivu, were represented in the study sample. Of the 3,116 females studied, 2,874 (92.2%) reported that they have at least heard of the condition “breast carcinoma” and 2,609 (83.7%)  of “cervical carcinoma”. Although a majority of females expressed awareness of these malignancies, only 1,150 (36.9%) were aware that they belonged to the high-risk age group for breast cancer while for cervical cancer, it was 1,011 (32.4%). Of the females surveyed, 1,895 (60.8%) were aware of the Well Women Clinic services, but only 578 (18.5%) had ever used it. Of the 217 professionals or associate professionals in the study sample, 190 (87.6%) were aware of the Well Women Clinic compared to only 58.8% among the 2,899 females falling under the categories of other occupations and housewives. Clinic attendance was also significantly higher among the professionals and associate professionals compared to females in other occupational categories and housewives (40.1% versus 16.9%).  Females who were 50-years-old or younger (1,349) had a significantly higher awareness of the Well Women Clinic programme (67.1%) while only 56% of females over 50 years of age (1,767) reported awareness. A slightly higher percentage of younger females have attended the Well Women Clinics compared to older females (20.2% versus 17.45%). This study shows that less than 20% of females over the age of 35 years have ever participated in screening for breast and cervical cancers through the Well Women Clinics. There was also a significant difference in the awareness and usage of Well Women Clinics by social class and age.  The findings of this study show that Well Women Clinics do not have the expected coverage. P.V. Vithana, M. Ariyaratne, and P. Jayawardana’s “Quality of breast cancer early detection services conducted by Well Woman Clinics in the District of Gampaha” showed that only around 2.2% of females had ever undergone clinical breast examination in 2007. R.I. Nilaweera, S. Perera, N. Paranagama, and A.S. Anushyanthan’s “Knowledge and practices on breast and cervical cancer screening methods among female health care workers: A Sri Lankan experience” reported the use of cancer screening services among health care workers as being less than 20%.  P.V. Vithana, N.N. Hemachandra, Y. Ariyaratne, and P.L. Jayawardana’s “Qualitative assessment of breast cancer early detection services provided through Well Woman Clinics in the District of Gampaha” elaborated that one reason for this underutilisation would be the substandard services provided through these clinics, and the need for the training of health care workers.  The current study found probable social disparity on awareness and the use of Well Women Clinic services. S.B. Agampodi and D.A. Amarasinghe’s “Private sector contribution to childhood immunisation: Sri Lankan experience”, on the use of public health services in Sri Lanka, shows that there was no social disparity on using public health services. The finding in the instant study, according to Warnasekara et al., may be due to the lack of knowledge on malignancies in the lower socio-economic group. Even though Sri Lankan females possess high health literacy and participation in maternal and child health services is nearly 100%, NCD prevention, Warnasekara et al. point out, is yet to develop as a priority among them. However, they noted, this should be a priority in Sri Lankan settings, especially due to the epidemiological and demographic transitions that the country is going through.


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