Khordha district, Odisha, India
In the five villages served by health care provider Subhasini Dei, Thursdays are reserved for women and their families with heart conditions, high blood pressure, diabetes and other noncommunicable diseases (NCDs). An auxiliary nurse-midwife for 30 years, Dei has noted a growing incidence of these conditions among her clients, a worrisome trend with devastating consequences for families, she says.
“I have been observing a rapid increase in cases of diabetes, hypertension and cancer. I lost my own husband due to a complication of diabetes,” says Dei, 54, who was widowed last year. “Another person of this village died of liver cancer due to late detection.”
For women over 30, the focus for Dei is breast health. Breast cancer is the most common cancer among women in India, and more than 90,000 women died of it in 2020. Dei teaches her clients to conduct regular breast self-examinations. For women with complaints, she conducts a thorough clinical breast examination and ensures proper referral for further investigation.
Partnership with government
Dei has been well prepared to perform these examinations and to educate and counsel women about breast health through PRARAMBH, a Jhpiego program developed in partnership with the government of Odisha, a state in eastern India.
The program began in January 2020 to bring awareness, screening and diagnosis closer to the community, along with streamlining coordinated and continuous breast health care in Odisha. Supported by Novartis, the program seeks to address three major gaps in breast cancer care—late detection, low awareness and inadequate case management, especially at the primary and secondary levels of the public health system. More than 668 accredited social health activists (ASHAs), nurses and other health care providers have participated in the trainings.
“Women in my community are not very educated. Many are poor and anemic,” says Dei, whose responsibilities cover a range of services, from community health surveys to family planning services and antenatal care to child immunization. “Most come from farmer or laborer families. Many come from tribal communities. So my role becomes very important to build their awareness and detect cases on time.
A session on breast health and self-exam
Updated skills and counseling techniques
During her training with Jhpiego, Dei and other health care providers updated their knowledge on the risk factors for breast cancer as well as signs and symptoms to look for, such as discharge from nipples, pain or lumps, breast size changes and dimpling. They learned how to teach breast self-examination to women, acquired useful counseling techniques and honed their skills through demonstrations and practice on life-like models.
“I felt more confident in the technique by practicing on the model. The trainer used simple words that made it easy to understand and provided us with a much needed knowledge update,” says Dei.
In support of the Odisha-based program, Jhpiego developed and shared tools and job aids and helped produce radio jingles for a statewide awareness campaign. The organization is working to establish a strong referral system for diagnosis and management using patient navigation, ensuring resources for diagnosis and management are available at facilities. Jhpiego is also supporting the state to digitize the existing data reporting system to allow better access to patient information for timely action.
A client’s story
Upon completing her training, Dei integrated breast health care into her Thursday NCD sessions at the Anganwadi community center. She recalls a recent case: “This client has been coming to me regularly for blood pressure monitoring. This time, she complained of some pain (in her breast area). I conducted a clinical breast examination and noticed a lump in one of her breasts. She was scared and reluctant to get it investigated further.”
Dei counseled the woman and her husband, explaining the benefits of early detection in case the lump turned out to be cancerous, and how neglecting it would be wrong. With the help of the patient navigator, she ensured that the woman was referred to the district hospital, where fine needle aspiration cytology was conducted. To everyone’s relief, the tumor was diagnosed benign. The client returned to thank Dei, attributing her decision to follow up on her condition to Dei’s expert and compassionate counseling.
“The awareness has increased from before,” says Dei. “ASHAs are also very actively involved in the field to counsel the people. Some people are also getting aware from mass media and coming on their own. But there are some tribal populations who are not aware. I am working hard to counsel the people and increase their awareness.”
Also contributing to this article was Dr. Nochiketa Mohanty, state program manager in Odisha. Dr. Debasis Swain is a senior program officer and Indrani Kashyap is communications specialist, Asia Region.