# Does the empowerment of women and their socioeconomic status affect the acceptance of breast cancer screening? Findings from NFHS-5, India – BMC Women’s Health

Study setting: This ecologic study is based on the fifth wave of the National Family Health Survey (NFHS-5), for which data was collected during the 2019-2020 year. This regular survey is conducted by the Ministry of Health and Family Welfare (MoHFW), Government of India, with the International Institute of Population Sciences (IIPS), Mumbai as the nodal agency to conduct the survey. [19]. The NFHS is a nationally representative multi-stage survey comprising a representative sample of households from all 36 states and union territories (UTs) of India. The survey is conducted to measure various indicators related to population, health, and nutrition with the goal of providing reliable and comparable data sets on health, family well-being, and related topics. The state summary reports from this survey provide data on indicators such as household and population characteristics, socioeconomic conditions, maternal and child health and nutrition parameters, and adult health problems, including cancer screening. A total of 610,000 households were surveyed in the fifth wave of the NFHS.

Data source: This study considered all the states of India as the unit of analysis (N = 36). Breast cancer detection rates for women aged 30-49 in the 36 states and UTs in India were taken to explore the association between socioeconomic status (SES) and women’s empowerment status (WES) with acceptance of breast cancer detection. A total of 364,556 women in this age group were interviewed.

The Indian government issued operational guidelines and advocated for cancer screening risk factor screening in all states simultaneously in 2016 and then gradually scaled up. [6]. These NFHS-5 survey reports do not provide specific information about screening uptake in state or central government-run screening programs, but only mention the percentages of women who have been screened by governmental, non-governmental or other agencies.

Study endpoints: Clinical breast examination has been the recommended approach for screening and early detection of breast cancer in India as per the operational guidelines of the Government of India. [20]. Therefore, this paper used “percentage of women who have ever had a breast examination” as a broad marker for acceptance of screening. State and UT breast cancer screening rates for women ages 30 to 49 years were considered as a dependent variable. SES and WES were taken as independent variables. State-specific SES and WES were derived from household profile and women’s empowerment indicators as reported in NFHS-5 state reports [21]. Additional File 1: Table S1 elaborates the individual indicators/components used to calculate the SES and WES.

Statistical methods: We used dimension indices developed by Iyengar and Sudarshan for this study. [22].

Dimension Index (DI): The DI is a statistical measure used to estimate the level of development of a region. We calculated dimension indices for all states and union territories for each indicator using the percentage for each indicator provided in the NFHS State Summary Reports. The value of DI is between 0 and 1, with a higher value indicating better performance, while a value closer to 0 indicates poorer performance.

DI was calculated as follows:

$$Dimension \,Index \left( {DI} \right) = \frac{ Value \,real \,of \,the \,indicator \,for \,a \,state – Value \,minimum \,of \ ,the \,indicator\,in\,all\,the\,states/UTs}{{Maximum – Minimum\,values\,of\,the\,indicator\,in\,all\,the\,states/ UTs}}$$

For example, DI for the state of Maharashtra for breast cancer screening is calculated as:

$$DI\_Maharashtra = \frac{BCa \,Projection \,\% \,for \,Maharashtra – Minimum \,BCa \,Projection \,\% \,in \,all states \,and \,UTs} { {Maximum – Minimum \,values ​​\,of \,the \,test \,BCa \,in \,all \,states \,and \,UT}}$$

BCa = breast cancer

Composite Scores: A composite score for SES and WES was calculated by summing the ID values ​​of their respective component indicators. Table 1 shows various components of the SES and WES indicators from the NFHS-5 State Summary Reports. ID values ​​for breast cancer detection were classified as low, medium, and high using the 33rd and 66th percentile marks in the range of index values. Similarly, SES and WES were ranked based on the weighted composite score according to their respective 33rd and 66th percentile values. SES and WES categories were cross-tabulated with uptake of breast cancer screening.

First, the article correlated the SES and WES composite scores for each state with the ID values ​​of the selection using Spearman’s rank coefficient method. He followed the standard Dancey and Reidy convention for interpreting Spearman’s coefficient values ​​and grouped the association as weak, moderate, or strong. [23]. Second, we plotted the detection acceptance levels of the states for their SES and WES using a bubble chart. Third, he used a simple linear regression model to estimate the determinants of uptake of breast cancer screening using the ID values ​​of each component indicator. The effects of the variables SES and WES on detection in all states were examined separately.

Statistical analysis was carried out using SPSS Version 25 (SPSS Inc, Chicago, IL, USA) for Windows, R Studio, and Microsoft Excel 2020. A p value below five percent was considered statistically significant.

Data quality and ethics review: Informed consent was obtained from all respondents before beginning the survey. The privacy of the data and the confidentiality of the respondents were maintained during the conduct of the survey. This document is based on secondary data and summary indicators from the NFHS-5 survey collected by the IIPS and therefore does not require any ethics clearance. All analyzes and results are presented with an unbiased intent.

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