Understanding barriers to the clinical breast exam in Telangana, India: A survey study of participants and non-participants in underserved rural and urban areas.

Abstract

1593 Background: In low-resource settings where mammography is not feasible, Clinical Breast Examination (CBE) performed by trained healthcare workers is an effective alternative for breast cancer early detection. Despite prior success of large-scale CBE programs in India, national uptake remains extremely low. This study evaluated knowledge, attitudes, beliefs, and structural barriers associated with participation in CBE screening among women in rural and urban Telangana, India and assessed factors influencing participation. Methods: We conducted a prospective, nested case-control study in October 2025, in which CBE participants and non-participants were drawn from the same source population. Women aged >35 years who were non-pregnant and able to consent were approached during home visits or at primary health centers (PHCs) to complete standardized surveys; participation in CBE was voluntary. Surveys captured sociodemographic factors, breast cancer knowledge, attitudes toward CBE, stigma, and treatment beliefs. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for factors associated with CBE participation, adjusting for relevant sociodemographic and belief-based covariates. Results: A total of 669 women were included (urban n=426; rural n=243), of whom 421 participated in CBE (participants) and 248 declined(non-participants). Among 403 CBE participants, 81.1% (n=327) reported never having had a prior breast examination. Belief that CBE is necessary even in the absence of symptoms was strongly associated with participation (81.1% vs 51.6%, p<0.001) as was belief that breast cancer is curable (80.6% vs 56.9%, p<0.001). There was no difference in fear of stigma between participants and non-participants (62.2% vs 65.3%, p=0.61). Fear of losing the breast was highly prevalent among non-participants (72%) and independently associated with lower participation (OR 0.49, 95% CI 0.28–0.87). After adjustment, urban residence was associated with lower odds of participation compared with rural residence (adjusted OR 0.28, 95% CI 0.14–0.56) as was higher household income (>₹100,000 vs ≤₹15,000; adjusted OR 0.24, 95% CI 0.12–0.46). Among non-participants, the most cited facilitators for future participation were examination by a doctor (33.5%), clinic-based exams (28.2%), and convenient timing (28.2%). Conclusions: Participation in CBE is influenced by modifiable belief-based and structural barriers that vary by setting. Addressing fears related to diagnosis and treatment of breast cancer and tailoring CBE delivery strategies may improve uptake and enhance early detection of breast cancer in low-resource settings.