University of Florida Thesis Or Dissertation

A SYSTEMATIC SCOPING REVIEW OF COMMUNICATION-BASED STUDIES ON CANCER PREVENTION AND DETECTION IN BANGLADESH

AANTAKI RAISA

A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN MASS COMMUNICATION

UNIVERSITY OF FLORIDA

2019

To my mom, sister and mentor, whose unconditional love, support and guidance have brought me where I am today, including the completion of this thesis

ACKNOWLEDGMENTS

I would like to take this opportunity to thank Dr. Janice Krieger, my mentor, my advisor, who has taught me to be my best version, and inspired me to try relentlessly to excel. My gratitude is extended towards my thesis co-chair Dr. Carma Bylund, who has been my North Star, providing me directions in the very maze-like world of systematic reviews. I could not thank Dr. Frank Waddell enough, who took the time and effort to guide me through my thesis with his feedback, challenging insights and positivity.

I would also like to take this opportunity to thank Mr. Reza Salim. I am forever in debt to him as he had introduced me to the world of translational science and to Dr.

Krieger, where it all started for me.

Finally, I would like to thank Taylor Thelander, a fellow master’s student, who came into my rescue to co-code within a short notice. I would also like to thank Dr.

Alyssa Jaisle, who kept me accountable with my daily writing goals. Last but definitely not the least, I want to shout out to my STCC family, who has been a pillar of strength, support and love in my journey.

TABLE OF CONTENTS

page

ACKNOWLEDGMENTS ...... 4

LIST OF TABLES ...... 8

LIST OF FIGURES ...... 9

LIST OF ABBREVIATIONS ...... 10

ABSTRACT ...... 12

CHAPTER

1 INTRODUCTION ...... 14

2 BACKGROUND AND NEED ...... 17

Country Overview ...... 17 Healthcare Infrastructure in Bangladesh ...... 18 Health Policy Infrastructure in Bangladesh ...... 20 Burden of Cancer in Bangladesh ...... 21 Burden of Cancer Based on Cancer Types ...... 21 Environmental and Other Systemic Factors Contributing to the Risk of Cancer...... 21 Resources Available to Reduce the Risk of Cancer ...... 23 Implementing Policies Based on Research ...... 24 Knowledge-to-Action (KTA) Model ...... 25 Cancer Communication ...... 27 Systematic Literature Reviews ...... 30 Theoretical Underpinnings ...... 32

3 METHOD ...... 36

Eligibility Criteria ...... 36 Inclusion Criteria ...... 37 Exclusion Criteria ...... 38 Information Sources ...... 38 Search Strategy ...... 39 Study Records ...... 39 Data Items ...... 40 Risk of Bias in Individual Studies ...... 40 Data Synthesis ...... 41 Meta-Bias ...... 42

4 RESULTS ...... 44

Articles ...... 44 Receiver ...... 46 Population ...... 47 Female-only participants ...... 47 Male and female participants combined ...... 48 Other ...... 50 Breast Cancer ...... 50 Knowledge ...... 51 Misconceptions ...... 52 Predictors of knowledge/awareness ...... 52 Attitude ...... 53 Barriers to screening ...... 53 Risk factors ...... 55 Cervical Cancer ...... 55 Knowledge ...... 56 Knowledge about symptoms ...... 57 Misconceptions ...... 57 Attitude ...... 58 Perceived severity ...... 59 Barriers to screening ...... 59 Risk factors ...... 60 Tobacco Control ...... 60 Knowledge ...... 61 Attitude and perceived severity of tobacco consumption ...... 62 Barriers to and predictors of cessation ...... 62 Risk factors ...... 63 Sender ...... 63 Trust in Sender ...... 64 Source/Channel of Information ...... 64 Breast cancer studies ...... 65 Cervical cancer studies ...... 65 Tobacco control studies ...... 66 Message ...... 67 Other Cancers ...... 71 Lung Cancer ...... 71 Oral Cancer ...... 71 Testicular Cancer ...... 72

5 DISCUSSION ...... 87

Audience Analysis ...... 87 Knowledge about Cancer ...... 87 Perceived Barriers to Cancer Prevention ...... 88 Low perceived susceptibility to cancer...... 89 Low perceived self-efficacy of cancer screening...... 89 Poor healthcare infrastructure...... 90 Literacy...... 91

Gender Differences ...... 91 Geographic Differences ...... 92 Theoretical Implications ...... 93 Practical Implications ...... 95 Limitations & Future Research ...... 97

6 CONCLUSION ...... 101

APPENDIX

A ARTICLE SEARCH STRATEGY ...... 103

B QUALTRICS SURVEY ...... 105

LIST OF REFERENCES ...... 109

BIOGRAPHICAL SKETCH ...... 119

LIST OF TABLES

Table page

3-1 Journal impact factor...... 73

3-2 Review articles by cancer type...... 74

3-3 Articles about Breast Cancer Prevention and Detection...... 74

3-4 Articles about Cervical Cancer Prevention and Detection...... 78

3-5 Articles about Tobacco Control and Prevention...... 83

3-6 Articles on other types of cancers...... 86

LIST OF FIGURES

Figure page

2-1 Knowledge to action process ...... 35

3-1 Flowchart of systematic scoping review process...... 43

LIST OF ABBREVIATIONS

BSE Breast Self-Examination

CIA Central Intelligence Agency

COPD Chronic Obstructive Pulmonary Disease

CBE Clinical Breast Exam

CHW Community Health Worker

CMMU Construction Maintenance and Management Unit

DHHS Department of Health and Human Services

DDT Dichlorodiphenyltrichloroethane

DGFP Directorate General of Health Services

DDA Directorate of Drug Administration

DNS Directorate of Nursing Services

EPPM Extended Parallel Process Model

HMN Health Metrics Network

HNAP Health National Adaptation Plan

HDI Human Development Index

HPV Human Papillomavirus

HRW Human Rights Watch

IF Impact Factor

IAEA International Atomic Energy Agency

ITC Internaitonal Tobacco Control

KTA Knowledge-to-Action

LMIC Low to Middle Income Countries mHealth Mobile Health

MOHFW Ministry of Healthand Family Welfare

NCCP National Cancer Control Program

NNP National Nutrition Programme

NGO Non-Governmental Organization

PLoS Public Library of Science

RCT Randomized Controlled Trial

SJR SCImago Journal Rank

SES Socioeconomic Status

SDG Sustainable Development Goals

TSE Testicular Self-Examination

TPB Theory of Planned Behavior

VIA Visual Inspection with Acetic Acid

WHO World Health Organization

Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Arts in Mass Communication

A SYSTEMATIC SCOPING REVIEW OF COMMUNICATION-BASED STUDIES ON CANCER PREVENTION AND DETECTION IN BANGLADESH

Aantaki Raisa

August 2019

Chair: Janice Krieger Cochair: Carma Bylund Major: Mass Communication

The aim of this systematic scoping review is to review all the peer-reviewed journal articles on communication-based studies for cancer prevention and detection conducted in Bangladesh. By doing so, this study aims to synthesize and aggregate the primary research on cancer communication in a low-to-middle income country (LMIC), in order to create second-generation knowledge, proposed by the Knowledge-to-Action

(KTA) model. A systematic scoping review method was applied to synthesize review articles from three academic databases: PsycINFO, Academic Search Premier, and

PubMed. Out of 985 citations resulting from the initial search, 35 were selected for inclusion. Analysis of these articles found that uneducated, rural, slum-dwelling people are more vulnerable to cancer due to their lack of knowledge, awareness, and access to care than the urban, educated people. Overall, the samples in the articles showed high perceived severity of different types of cancer, and high perceived response efficacy of different screening methods. However, due to the low perceived susceptibility of cancer, and low perceived self-efficacy of screening, overall screening uptake is low. While major barriers to seeking care differs based on cancer type, common ones include lack

of symptoms, lack of knowledge regarding the screening process, and lack of access.

Additioanlly, social and infrastructural barriers persist. Social barriers include stigma, misconceptions, fear of being screened positive, as well as fear of being abandoned by family. The main infrastructural barriers are lack of access and low priority of women’s health in the family. Culturally sensitive (i.e. language, gender and race concordant) and environmentally appropriate (effective channel of message dissemination) interventions are required for increasing knowledge and awareness of cancer and cancer care.

CHAPTER 1 INTRODUCTION

Globally, one in six people die of cancer (Cancer, 2018) making cancer the second leading cause of death worldwide with 9.6 million cancer deaths in 2018.

Seventy percent of cancer deaths occur in Low-to-Middle-Income countries (LMICs), such as Bangladesh (Cancer, 2018). Healthcare disparities are influenced by geography (Ndiaye et al., 2008), race/ethnicity (Krieger, 2003), economy (Lown &

Banerjee, 2006), and religious beliefs (Padela & Curlin, 2012). Seven and a half trillion

U.S. dollar is spent annually on healthcare worldwide. Of this only 20% is spent in

LMICs where 80% of the world population reside (Xu et al., 2018). Being a LMIC,

Bangladesh has internal factors which make its population vulnerable to cancer. For example, a healthcare infrastructure that is inadequate for supporting the 160 million people residing in the country, especially in the rural areas; the absence of a national cancer registry; primary care that lacks cancer screening; unavailability of expert oncologists; and an overall low level of cancer literacy among the general population

(Hussain & Sullivan, 2013; Hussain, 2013).

Only one in five LMICs have the necessary data to drive cancer policy (Cancer,

2018). According to the last published health policy of Bangladesh in 2011, there is no specific plan for cancer control (National Health Plan, 2011). Proposed by the World

Health Organization (WHO), the Bangladesh Health-National Adaptation Plan (HNAP) is still pending and thereby lacks cancer-specific prevention plans (HNAP, 2018). The

National Cancer Control Strategy and Plan of Action (2008) finalized by the government of Bangladesh expired in 2015 and has not been updated.

Countries like Bangladesh are also vulnerable to external factors which increase the risk of cancer among its populations. According to the WHO, the most important risk factors for cancer are tobacco use, obesity, and unhealthy diet such as excessive consumption of processed food (Cancer, 2018). While high income countries are implementing strict policies to restrict companies from exploiting their citizens by pushing these products, LMICs have yet to catch up with such policies (What ministries of information and communication need to know, 2016). As a result, companies producing tobacco, processed food, and sugar/beverages are targeting LMICs, taking advantage of the lack of policies to protect their citizens.

Implementing evidence-based policies for cancer control can be an effective step for Bangladesh. According to the knowledge-to-action (KTA) model, the translation of empirical evidence into policies can be achieved in two basic steps: knowledge creation and action (Graham, 2006). The knowledge is created in three phases: inquiry or first- generation knowledge, synthesis or second-generation knowledge, and knowledge tools/products or third-generation knowledge. Local cancer researchers, along with researchers in collaboration with foreign partners have conducted numerous studies to evaluate the cancer scenario in Bangladesh. Therefore, the first step in the KTA model, creation of first-generation knowledge, is present and continuing. The second step is to synthesize this available eclectic knowledge of various cancers, and various strategies among different population groups within the country to obtain a comprehensive and systematic overview of cancer beliefs, preventive interventions, and awareness in

Bangladesh. This synthesized knowledge helps inform the third generation of knowledge, such as policies, frameworks and health promotion campaigns. Usually,

systematic reviews, such as, scoping reviews are conducted to accomplish the goals of the second step in the KTA knowledge creation model, i.e. synthesizing existing first- generation knowledge. This thesis conducts a systematic scoping review to synthesize the existing knowledge of cancer communication in Bangladesh.

This systematic scoping review maps the available literature on cancer communication in Bangladesh to delineate the existing knowledge on various aspects of cancer communication and to inform policies and suggest future research. The review focuses on prevention and detection because preventive measures such as screening, early detection, and cancer awareness can offer the most feasible and affordable ways to control cancer risks in low resource countries like Bangladesh (Thun et al, 2009).

According to the cancer control continuum, prevention for cancer includes tobacco control, diet, physical activity, sun protection, the HPV vaccine, limited alcohol use and chemoprevention. Detection includes, pap/HPV testing, mammography, fecal occult blood tests, colonoscopy and lung cancer screening (Cancer Control Continuum, 2017).

This thesis focuses on the communication aspect of cancer prevention and detection because, by definition, health communication aims to prevent diseases, promote health, inform policy, and enhance the quality of life and health of individuals within the community (Parrot, 2006). Since, health communication aims to achieve these preventive approaches, along with informing policies, this systematic scoping review focuses on preventive cancer communication in Bangladesh.

CHAPTER 2 BACKGROUND AND NEED

In the following sections, a country profile of Bangladesh is presented to review the limited healthcare infrastructure and policies, along with the country-specific socioeconomic and socio-cultural factors that contribute to the health disparities in

Bangladesh. Following this`, the burden of cancer is reviewed to present the need for research in the area of cancer prevention and detection in the country. Finally, literature on health communication, the KTA model, and systematic scoping review methods are detailed, to provide a rationale for this study, and to formulate the research question.

Country Overview

Bangladesh is a LMIC with a burgeoning population and limited resources. It is a small country in South Asia with an area of 56,000 square miles. With a population of

160 million, it is the tenth most densely populated country in the world (The World Bank,

2016). For reference, the state of Florida in the United States is 65,000 square miles,

9,000 square miles larger than Bangladesh, while its population is 21 million, one eighth of Bangladesh. However, while there are 260.4 active physicians per 100,000 population in Florida (Florida Physician Workforce Profile, 2017), there are only 3.6 physicians for the same number of people in Bangladesh (Hussain & Sullivan, 2013).

This acutely low provider-to-patient ratio alludes to the scarcity of healthcare resources available in Bangladesh and the demands placed on the limited healthcare resources.

Bangladesh gained independence from then West Pakistan in 1971, making it a relatively recent democracy. Its struggles with its political and cultural identity as a nation makes it harder still to develop and solidify policies to improve healthcare. It is a

Muslim majority nation with 89.1% of the population adhereing to Islam (CIA, 2018).

Research suggests that practicing Muslims tend to believe their religious practices have healing qualities, which makes healthcare seeking perceived as unimportant or unnecessary (Carroll et al., 2007). This socially collectivist agrarian nation has 70% of its population living in the rural areas. Rural areas are less likely to receive healthcare services and high-quality physicians, compared to urban areas (DHHS, 2008).

Bangladesh has been a member of the United Nations since 1974. One of the seventeen Sustainable Development Goals (SDG) of the United Nations is to ensure good health and well-being of its 157 member nations by 2030. The United Nations has ranked the countries based on scores of these seventeen goals. Bangladesh ranks

120th, and its score in the 14 measures of health and well-being is alarmingly poor.

Bangladesh scores 4.6 out of 10 in the subjective well-being measure, 52.4 out of 100 on the Universal Health Coverage Index, and 42.1 out of 100 on the Proportion of Births

Attended by Skilled Personnel scale. Each of these scores falls far below the acceptable standards set by the SDG. Like other LMICs, Bangladesh is struggling with handling non-communicable diseases, such as cancer, diabetes, cardiac diseases, and mental health.

Healthcare Infrastructure in Bangladesh

According to the World Health Organization (WHO), Bangladesh suffers from a shortage and a geographic mal-distribution of Human Resource for Health (Global

Health Workforce Alliance, 2018). There are 3.6 physicians per 100,000 population and

2.2 nurses per 100,000 people (NIPORT, 2014). While 70% of the 160-million population lives in the rural areas, health workers are concentrated in urban secondary and tertiary hospitals (Hussain & Sullivan, 2013). Bangladesh also lacks any type of universal health insurance policy, which makes the health disparities between the rich

and the poor more severe. Even though there are community clinics in rural areas, they are not equipped with machineries and services of fully-fledged hospitals. Moreover, lack of affordable and expedited transportation to the nearest hospital makes health access much difficult for the rural population (The World Bank, 2016).

There are 59 medical colleges, of which 41 are private, 13 nursing colleges including seven private ones, 69 nursing institutes (22 private), and 17 medical assistant training schools (13 private) in Bangladesh (Hussain & Sullivan, 2013). Ninty-one percent of all types of pharmaceutical products, and 100% of that for essential drugs are met from the local market (Husain & Sullivan, 2013). The health financing system in

Bangladesh is mostly supply-side to ensure better access to essential healthcare services for poor households in the country. More than two-thirds of the total expenditure in health is privately financed through out-of-pocket payments. The remaining one-third is financed publicly, 60% of this is subsidized by the government with tax revenues or other developments outlays and 40% of it is through international development assistance. A few NGOs have started a health insurance component within their package of microcredit programs (Hussain & Sullivan, 2013). Blankart et al.

(2012) reported that the lack of accessible healthcare infrastructure can delay early diagnosis of cancer, and higher physician density can reduce this delay. Both of these are unavailable in the rural parts of Bangladesh, which makes the rural population even more vulnerable. The urban poor, such as slum dwellers, are also deprived of accessible healthcare, and continue to have poor access to basic determinants of g health (Banarjee et al., 2012).

Health Policy Infrastructure in Bangladesh

Policy and planning in the health sector is managed by the Ministry of Health and

Family Welfare (MOHFW). The country's health infrastructure is divided into national government, divisional administration, district administration, upazila (sub-district) administration, union administration, and ward administration. Bangladesh has eight divisions, 64 districts, 482 upazilas, 4,498 unions, and 40,482 wards. According to the health information system assessment of Bangladesh by the Health Metrics Network

(HMN, 2009), the MOHFW implements its policies through five authorities. The

Directorate General of Health Services (DGHS) is responsible for the implementation of all health-related programs on behalf of the MOHFW by providing technical guidance.

The Directorate General of Family Planning (DGFP) implements the family planning and part of maternal and child health related programs under the MOHFW. The other three authorities are, the Construction Maintenance and Management Unit (CMMU), the

Directorate of Drug Administration (DDA), and the Directorate of Nursing Services

(DNS).

Besides, these five executing authorities, the country has a large-scale nutrition program covering almost two-thirds of the country called National Nutrition Programme

(NNP). Even though it comes down to the policymakers to create environments for people and communities that are conducive to improving cancer prevention (Policy

Action for Cancer Prevention), according to the HMN report, the overall status of policy and planning for health in Bangladesh is not adequate at all. In the seven measures of policy and planning Bangladesh scored five out of 21 (24%).

Burden of Cancer in Bangladesh

In the following sub-sections, the burden of cancer in Bangladesh is presented to depict the population’s vulnerability to various types of cancer. The statistical prevalence of the burden is followed by reviews on the environmental and other systemic factors contributing to the risk of cancer, and the resources available to reduce the risk of cancer.

Burden of Cancer Based on Cancer Types

Cancer is the sixth leading cause of death in Bangladesh preceded by geriatric complications, asthma/COPD, fever, heart disease, and accidental injuries (Hussain &

Sullivan, 2013). According to a study published in 2013, there are 1.3 to 1.5 million cancer patients in Bangladesh with 200,000 patients newly diagnosed each year (Uddin et al.). For the past five years, lung (13.1%) and oral (11.9%) cancer have been the top two most prevalent cancers in Bangladeshi men. Other frequently occurring cancers among men are pharynx (8.2%), colorectal (6.5%), stomach (4.7%), esophageal (4.1%), non-Hodgkin lymphoma (4.7%), Hodgkin lymphoma (2.2), bladder (3.4), prostate

(2.3%), liver (1.5%), and leukemia (0.6%). For women, the top two most prevalent cancers in the past five years have been breast (32.8%) and cervical (26.1%). Others are oral (6.5%), ovarian (3.3%), colorectal (2.7%), lung (2%), esophageal (1.9%), stomach (1.8%), non-Hodgkin lymphoma (1.3%), Hodgkin lymphoma (0.8%), and liver

(0.6%) cancers.

Environmental and Other Systemic Factors Contributing to the Risk of Cancer

Regular use of carcinogenic chemicals in daily foods as preservatives makes the

Bangladeshi population vulnerable to cancer to a greater extent. Formalin, a colorless water-based solution of formaldehyde, is predominantly used to preserve fruits,

vegetables, and many other food products openly sold in the markets. Besides causing nausea, skin irritation, burning eyes, nose, and throat, formalin has been shown to cause stomach cancer in laboratory experiments (American Cancer Society, 2014).

Dichlorodiphenyltrichloroethane (DDT), which is banned in many countries including the

United States, is commonly used in processing dryfish (locally known as ‘shutki’- a famous delicacy in the country). DDT exposure is directly related to increasing the risk of in utero breast cancer (Cohn et al., 2015). Textile dyes and other unauthorized food colors are used in food manufacturing and processing. A literature review on the relationship between cancer risk and exposure to chemical textile dyes showed that exposure to different sets and combinations of these chemicals increase the risk of lung, bladder, breast, and colorectal cancers (Singh & Chadha, 2016).

Another hazard Bangladeshis frequently are exposed to is arsenic poisoning. It has been causing chronic skin and liver cancers among Bangladeshis for over two decades (Hussain & Sullivan, 2013). According to an 111-page report published by the

Human Rights Watch (HRW), 20 million people in Bangladesh drink water with dangerously high arsenic levels (>50 ppb; Nepotism and Neglect, 2016). Most of these

20 million are the rural poor. Arsenic poisoning of ground water in Bangladesh was first detected back in 1993 (Uddin & Huda, 2011). It has been more than 25 years and still one-eighth of the population, mostly poor and marginalized, is at risk of it.

Tobacco consumption is also severely unchecked in Bangladesh, despite the presence of policies and healthcare to control this major cause of oral, pharyngeal, and lung cancers. While WHO recommends a minimum 70% excise tax on retail price for cigarettes, Bangladesh enforces only 62%. This makes cigarettes cheap, and affordable

to people from a wide range of socio-economic status (SES). Moreover, unlike the

United States, one can easily buy cigarettes without buying the whole pack, popularly known as “loosies.” According to the World Tobacco Atlas, every year 161,200

Bangladeshis are killed by tobacco-related diseases. More than 172,000 children between the ages of 10 and 14 years as well as 24,880,000 adults over the age of 15 years continue to use tobacco every day. Thirty-nine point eight percent more men smoke tobacco in Bangladesh than on average in medium Human Development Index

(HDI) countries, 25.54% more men die in Bangladesh than on average in medium-HDI countries, while the percentage of tobacco-related death among women is 9.68% more.

31.5% more people use smokeless tobacco in Bangladesh than on average in medium-

HDI countries (The Tobacco Atlas: Bangladesh, 2019).

Resources Available to Reduce the Risk of Cancer

Despite the prevalence of cancer, there is no national cancer registry in

Bangladesh. However, according to the WHO’s Cancer Country Profiles (2014),

Bangladesh does have an operational action plan to monitor and surveil cancer. But the specifics of the action plans such as scope, coverage, and data from previous years, are not delineated. Bangladesh also has some preventive measures in relation to tobacco use. These include: a ban on direct and indirect tobacco commercial, a plan to make public places completely smoke free, 51-75% taxation on retail price, among others. Futhermore, there are operational policies to reduce physical inactivity and to promote physical activity, as well as efforts to reduce harmful use of alcohol. The country also has a 97% Hepatitis B vaccination coverage among infants.

This is the extent of Bangladesh’s effort to reduce risks of cancer (WHO Cancer

Country Profile, 2014). There are no action plans to reduce obesity and primary

healthcare does not include any kind of screening, such as for breast cancer, cervical cancer, or colorectal cancer. The International Atomic Energy Agency (IAEA) recommends two teletherapy machines and one brachytherapy machine for every one million people in a country (IAEA, 2008). For the 160 million people in Bangladesh, there is only 17 radiotherapy and 12 brachytherapy machines.

There is one oncologist for every 10,000 cancer patients compared to one for every 1600 in India (Hussain & Sullivan, 2013), and one for every 137 in the United

States (Mathew, 2018). Additioanlly, there are appromixmately150 qualified clinical oncologists and 16 pediatric oncologists working in the different parts of the country.

Regular cancer treatment is available in 19 hospitals and 465 hospital beds are attached as indoor or day care facilities for chemotherapy in the oncology/radiotherapy departments (Hussain, 2013).

Implementing Policies Based on Research

Based on the discussion so far, it is evident that Bangladeshis are at risk of cancer and the existing environmental, cultural, and socio-economic issues contribute heavily to the risk-factors. While there are policy efforts, they are either not effectively implemented, or are not at all implemented. There is also a lack of evaluating the effectiveness of policies. In some cases, there are not even any existing policies.

The WHO recommends each country to have a National Cancer Control Program

(NCCP) and provides a basic framework to implement such a program. The NCCP aims to implement four basic components of cancer control that can be achieved irrespective of a country’s resources: prevention, early detection, diagnosis and treatment, and palliative care (Cancer Control: Knowledge into Action. WHO Guide for Effective

Programmes, 2006). However, as a LMIC, a large proportion of cancers in Bangladesh

are diagnosed at advanced stages, resulting in increased morbidity, poor options of survival, and drainage of economic resources of the affected family (Sloan FA). Hence, cancer prevention and early detection through screening are the most important goals for the governments in LMICs like Bangladesh (Sivaram et al., 2018). Implementation of

NCCP for prevention and early detection requires systematic, equitable, and evidence- based strategies. Hence, to implement an effective NCCP, Bangladesh requires translating the available knowledge on cancer into actionable policies in the context of the country’s culture and available resources. The Knowledge-to-Action Model (KTA) provides guidelines to achieve this.

Knowledge-to-Action (KTA) Model

It is estimated that cancer outcomes can be improved by 40% with the effective application of what is known (Refreshing Canada’s National Cancer Control Strategy,

2018). The knowledge-to-action gap needs to be minimized so that research findings

(i.e. what is known) can make their way into practice in a timely manner. Minimizing this gap also makes healthcare policies evidence-based, cost-effective, and accountable.

Graham et al. (2006) proposed a knowledge-to-action framework where knowledge can be translated into practice or action in two basic processes: knowledge creation and action cycle (Figure 2-1). In their conceptualization, knowledge could be both empirically derived, and experiential (Graham et al., 2006). However, the scope of this study is empirically derived knowledge, i.e. research based knowledge, rather than the experiential knowledge of cancer practitioners, patients, and other stakeholders.

The first phase in the three phases of the knowledge creation, known as first generation of knowledge, is basic inquiry about an issue. This can be viewed as unrefined diamonds which are valuable but scattered and need to be refined

systematically to make use of them. Creating the second generation of knowledge is what this thesis focuses on, which is synthesizing the existing first generation of knowledge. The process includes applying explicit and reproducible research methods to identify, appraise, and synthesize studies or information specific to relevant questions

(Graham et al., 2006). The third generation of knowledge, or knowledge tools/products consist of guidelines, decision aids, rules, and care pathways. These tools can present knowledge in clear, concise and user-friendly formats to provide precise recommendations that would influence the stakeholders (Graham et al., 2006).

The action cycle, the second part of the KTA model, is where knowledge gets implemented. This cycle consists of seven phases which are dynamic and can influence each other (Graham et al., 2006). Ideally, after the knowledge creation, the action cycle starts with identifying a problem that needs addressing; identifying, reviewing and selecting the knowledge to the problem (i.e. third generation of created knowledge such as guidelines) identified in the first phase of the action cycle; adapting the identified knowledge to the local context; assessing barriers to using the knowledge; selecting, tailoring and implementing interventions to promote the use of knowledge; monitoring knowledge; using evaluate outcomes of engaging the knowledge; and finally, sustaining ongoing knowledge use. Each of these phases is influenced by its preceding phase and the succeeding phase can work as a feedback for the preceding one. For example, in the monitoring phase, if knowledge is seemingly not acted upon, change-makers can review the implementation phase to make the transition of knowledge to action more effective (Graham et al., 2006).

This study is situated in the knowledge creation part of the KTA model, specifically in the creation of second-generation knowledge, i.e. knowledge synthesis.

As Graham et al. (2006) specified, this knowledge takes the form of systematic reviews such as scoping reviews, meta-analysis or meta-synthesis; the chapter utilizes the method of systematic scoping review to synthesize the existing knowledge on preventive cancer communication in Bangladesh. The aim of producing this second generation of knowledge is to aid and create tools or guidelines, i.e. third generation of knowledge, which can then be utilized to inform policies in the action cycle of the KTA model. This formulates the research question for this study.

RQ: What is known about cancer communication studies on prevention and screening in Bangladesh?

Cancer Communication

It is important to mention that KTA is distinct from translational research, i.e. translating basic science into clinical practices (Graham et al., 206). KTA rather focuses on broader stakeholders and the social process of translating knowledge into action and practice. In a way KTA provides a framework to communicate knowledge to its stakeholders so that they can make use of it. This systematic scoping review focuses on the communication aspect of cancer prevention. As mentioned in the introduction, the aim of health communication is to prevent diseases and promote healthy behavior to inform policy. According to the WHO, 40% of all cancers can be prevented through screening and early diagnosis (Cancer Control: Knowledge into Action. WHO Guide for

Effective Programmes, 2006). Hence, the focus of this systematic scoping review is only the communication-based interventions to prevent cancer. This may also include the non-clinical (e.g. socio-economic, cultural, environmental) factors that can help inform

the populations’ cancer beliefs, attitude, or vulnerability to the disease. Moreover, this chapter will not cover clinical interventions or treatment, such as diagnosis or palliative care for cancer. Furthermore, it will not include basic science (biological, genetic, chemical, etc.) factors that may influence cancer vulnerability or preventive measures among Bangladeshis. Through this synthesis of cancer communication interventions, this chapter aims to produce refined knowledge on cancer communication that can inform policy and programs.

It is also important to identify the type of communication under evaluation in this study. Health communication can be categorized into five types: intrapersonal, interpersonal, organizational, community, and public/mass communication (Corocan,

2007). This systematic scoping review is focused on the literature that is concerned with community and mass communication. Hence, studies that concern the three components (sender, message, receiver) of the communication model where the method is mass or community (i.e. community-based interventions, assessment of geography-specific populations, public programs such as vaccination or cancer screening) were reviewed. Intrapersonal methods (i.e. inner voices, thoughts), interpersonal methods (i.e. patient-provider communication, family communication), and organizational communication (i.e. workshop for doctors and nurses, lectures on cancer prevention) were excluded from the review.

Health communication in itself is a science and needs to be well-defined for the purpose of this chapter. Health communication is defined as the study and use of communication strategies to inform and influence individuals and communities in their decisions so that their health outcomes are improved (Making health communication

programs work, 2004). Applying health communication sciences in the development of cancer intervention has numerous benefits including: an increase in the intended audience’s knowledge and awareness of a health issue and problem or solution; influence on perceptions, beliefs, and attitudes that may change social norms, prompt action, demonstration or illustration of healthy skills; reinforcement of knowledge, attitudes, and behavior; showing the benefit of behavior change; advocacy of a position on a health issue or policy; an increase in demand or support for health services; refutiation of myths and misconceptions; and strengthening organizational relationships

(Making health communication programs work, 2004).

On the other hand, not having the communication sciences backing the development of an intervention can have negative impacts on the intended outcomes.

Cho and Salmon (2007) found that health campaigns can have eleven different unintended effects, namely: obfuscation, dissonance, boomerang, epidemic of apprehension, desensitization, culpability, opportunity cost, social reproduction, social norming, enabling, and system activation. These effects may be individual or societal, as well as long or short term. Hence, it is important to design cancer prevention campaigns, programs, messages and policies based on empirical studies.

In order to do so, different components of health communication need to be evaluated in the context of Bangladesh. These components are: receivers of the preventive messages (i.e. general public, target audience), sender of the messages (i.e. channel such as news media, edutainment, word-of-mouth, or source such as producers of knowledge), and the health message itself (i.e. content of the message).

This systematic scoping review evaluates preventive cancer communication studies that

produce empirical findings regarding the potential receivers of future health messages/campaigns/programs (awareness, knowledge, attitude, perceived fear, perceived efficacy, risk factors related to cancer and its prevention), channel/medium of disseminating the messages (common and preferred medium of disseminating preventive cancer messages among the receivers), and sources of the messages

(producers of campaigns, messages such as researchers, and experts).

Systematic Literature Reviews

As mentioned earlier, this chapter aims to produce second generation knowledge on preventive cancer communication in Bangladesh, which is to map and aggregate existing unrefined first-generation knowledge. The most commonly used way of synthesizing knowledge is systematic reviews. Gough et al. (2017, pp. 2) defines a systematic review as ‘a review of existing research using explicit, accountable rigorous research methods.’ Systematic reviews can be of various types depending on the particular perspective, aims, resources, time, and context of research in the issue

(Gough et al., 2017). Systematic reviews also vary depending on the extent of the research problem addressed by the issue, such as the breadth of the question asked, the depth of detail in which the question is addressed and the rigor with which that detail is addressed.

Based on the aim of this review, which is to map and aggregate the existing literature on communication based interventions to prevent cancer among Bangladeshis in Bangladesh, a systematic scoping review is the best method for this purpose. A systematic scoping review is a type of systematic review that is limited in time and resource, while requiring narrow breadth, little depth, and/or other restrictions to achieve speed of review (Gough et al., 2017). Many refer this kind of review to just ‘scoping

review’, such as Arksey and O’Malley (2005). However, Gough et al. (2017) differentiated scoping reviews from a systematic scoping review. According to Gough et al. (2017), a scoping review is unsystematic and conducted by policymakers to inform policies. On the other hand, Systematic scoping reviews abides by the primary concern of systematic reviews which is to following a rigorous method of conduction.

A systematic scoping review deems the most appropriate method for this research question when compared to other reviews as it focuses on the mapping of literature, allows adequate breadth of available literature and answers broader questions (Arksey & O’Malley, 2005). Though Arksey & O’Malley (2005) refer to the systematic scoping review as scoping review, the method proposed by them is practically the same as a systematic scoping review. From this point forward, the term

‘scoping review’ will be used to mean ‘systematic scoping review’.

Scoping Review. Proposed by Arksey and O’Malley (2005), scoping review is a way of conducting a literature search on a particular field to obtain a comprehensive breadth of knowledge in that particular area. Aim of a scoping study might be “to map rapidly the key concepts underpinning a research area and the main sources and types of evidence available.” A scoping review can be a stand-alone project, especially as a way to understand an area that has not been reviewed comprehensively (Mays,

Roberts, & Popay, 2001, p. 194). Arksey and O’Malley identified four common reasons for conducting a scoping review: examining the extent, range, and nature of a research activity; determining the value of undertaking a full systematic review; summarizing and disseminating research findings; and finally, identifying research gaps in the existing

literature. The purpose of this study falls under the third and fourth categories and hence the choice of scoping review as the methodology.

As detailed earlier, developing countries like Bangladesh lack the data to inform policy to control cancer, and the aim of this study is to aggregate the scattered scientific research available in the field of cancer communication in Bangladesh to map what has been done in the topic. It is necessary to know which types of cancer are most studied, and which are neglected, in order to create campaigns that resonate with the necessity of information about different types of cancer. It is also necessary to know what communication channels are most effective or desired and which are most used, so that the messages reach the target audience.

Finding the perceived barriers and facilitators for cancer prevention and screening among the target audience is also an important factor to evaluate for designing effective campaigns. To find the answers to these queries, this study asks the aforementioned broad research question. Since a systematic scoping review tends to answer a broad research question in limited time and with limited resources, this was the review method selected, over other review methods such as meta-analysis, which tend to answer more specific research questions, or unsystematic scoping reviews, which are not systematic, and consequently are not reproducible in nature.

Theoretical Underpinnings

The selected articles for the scoping review were coded based on the constructs of several health communication theories to better understand the cancer prevention related phenomenon in Bangladesh. To code the available information in the articles regarding the receivers, constructs from the Extended Parallel Process Model (EPPM,

Witte, 1992) and the Theory of Planned Behavior (TPB, Ajzen, 1991) were used. For

example, Witte’s (1992) Extended Parallel Process Model (EPPM) stipulates that, if a message invokes more threat of a disease (e.g. “cancer is a deadly disease, it will kill you”) than the efficacy of its prevention (e.g. screening, information about screening facilities or affordability), the message recipient will reject the message and the solutions provided in the message to prevent the disease.

Perceived threat is composed of the message recipient’s perception of susceptibility (e.g., “You could get breast disease someday.”), and severity (e.g.,

“Breast disease that is not detected early is a serious threat to your health.”). Perceived efficacy is the message recipient’s perception of self-efficacy (e.g., “It is simple for you to go to a local health center if you have a breast problem.”), and response-efficacy

(e.g., “Going to the local health center is a good way to find out if you have a breast problem.”). Therefore, results of the studies on their respective participants, who were the recepients of the message provided in the study, were coded with perceived severity and susceptibility of cancer, perceived self and response efficacy of screening, and intention to get screened.

Ajzen’s (1991) Theory of Planned Behavior (TPB) stipulates that a person’s behavioral change for better health outcome is determined by three major factor:- attitude towards a disease (e.g. cancer) and the behavior change (e.g. screening), subjective norm (e.g. perception of the societal acceptance of cancer screening), and perceived behavioral control (e.g. perception of the ease or difficulty of getting screened for cancer). The received information from the studies were thus coded with attitude towards screening subjective norms. Perceived behavioral control and behavioral

intention were not coded since they are the same as perceived response efficacy and intention to screen, respectively.

Information on the source was coded with the concepts from the source credibility model (Hovland & Weiss, 1951). According to this model, the effectiveness of a message depends on the perceived expertise and trustworthiness of the source.

Hence, study participants trust in their source of cancer prevention information (e.g. physicians, community health workers) and perceived expertise of them, if reported, were coded.

Figure 2-1. Knowledge to action process (Graham et al., 2006)

CHAPTER 3 METHOD

The Preferred Reporting Items for Systematic review and Meta-Analysis protocols (PRISMA-P) 2015 statement provides a checklist for conducting a systematic review (Moher et al., 2015). In the PRISMA-P checklist, the method of a systematic review should include eligibility criteria, information sources, search strategy, study records, data items, risk of bias in individual studies, data and meta-bias. This chapter discusses these items.

Eligibility Criteria

Study eligibility criteria were informed by the aim of the review. First, the review focuses on studies that are about prevention and detection of cancer. The Population-

Intervention-Objective (PIO) structure for selecting studies was utilized for eligibility.

Population for the study was defined as Bangladeshis living in Bangladesh, or in

Bangladeshi enclaves. Even if the broader sample included other demographics, studies which contained such a sample, were deemed as eligible. Conversely, studies with population samples of non-Bangladeshis, such as Rohingya refugees or foreigners temporarily staying in Bangladesh, were considered ineligible. Migrant Bangladeshis living in other countries were also excluded.

The “intervention” part for this study was defined as anything that focused on cancer prevention, such as tobacco control, diet and the HPV vaccine, as well as detection such as screening. It is worth mentioning that the PIO structure was primarily developed for clinical studies and hence intervention was used to identify clinical trials.

However, since systematic reviews are now being widely used in the social sciences, the definition of intervention is also being used broadly, and can mean “intentionally

implemented change strategies which aim to impede or eradicate risk factors, activate and/or mobilize protective factors, reduce or eradicate harm, or introduce betterment beyond harm eradication” (Sundell & Olsson, 2017). For this study, any article that included such strategies for the eligible population, was included. However, the interventions needed to have a communication aspect to it, instead of being clinical or public health focused. As the review aims to focus on health communication based studies and interventions, studies that included at least one part of the health communication model (Corocan, 2007), i.e. health message sender, message, or receiver, were included.

The “objective” for the study was defined as, increasing awareness of cancer prevention and detection, as well as, evaluating cancer awareness, literacy, knowledge, beliefs, and practices among the eligible population. Hence, any study conducting surveys, interviews or experiments to obtain such objective, was considered eligible.

Eligibility for selection also included being published in peer-reviewed journals, and written in English. No time limits were put on the publication of the articles. The study design was also not limited to any partcular method. Since it is a scoping review, both quantitative and qualitative studies were selected. The following is the inclusion and exclusion criteria at a glance.

Inclusion Criteria

Primary and secondary formative and summative studies were selected if they were related to studies conducted in Bangladesh among Bangladeshis, published in a peer-reviewed journal, published in English, and were related to communication interventions regarding cancer prevention and detection.

Exclusion Criteria

Studies were excluded if they were related to intervention(s) conducted outside of Bangladesh, or in Bangladesh but among foreigners residing in Bangladesh; not published in peer-reviewed journals; not published in English; and were related to interventions that were not for cancer or were clinical in nature, instead of being communication-based. Studies were also excluded if they solely focused on training/communicating among medical health professionals instead of raising awareness among the general people, or communicating with the masses about cancer.

Information Sources

As scoping reviews primarily aim to have a comprehensive view of a particular field, the search for relevant studies needs to be as comprehensive as possible. To search for relevant published and peer reviewed literature, the researcher conducted a preliminary search in several databases with the keywords and MeSH terms for the three concepts: “Bangladesh,” “Cancer,” and “Communication.” Details of the terms used for the search can be found in Appendix A. A preliminary search was conducted in various communication and public health databases. Based on the quantity of the relevant results, PubMed, PsycINFO, and Academic Search Premier were selected as the databases to identify relevant articles. The preliminary search also failed to find any articles written in Bengali in the topic. Hence, for the study, only English-language articles were considered eligible.

Since the focus of the review is to identify evidence-based research, only peer- reviewed journals were selected. Preliminarily, whitepapers, such as government documents, hospital reports and NGO reports about cancer control in Bangladesh were reviewed. However, most of them did not include a detailed method of conducting their

research which produced the reports. Hence, for the final study, only peer-reviewed articles were selected. Due to the scarecity of relevant content and the scarecity of time, unpublished dissertations, theses, and conference papers were also not included for review.

Search Strategy

The study search was conducted in the three databases (PsyINFO, PubMed, and

Academic Search Premier). The searches were conducted on May 20, 2019 and May

21, 2019. Details of the search strategy is attached in Appendix A. The PubMed search terms are detailed here:

(("bangladesh"[MeSH Terms] OR "bangladesh"[All Fields]) AND

("neoplasms"[MeSH Terms] OR "neoplasms"[All Fields] OR "cancer"[All Fields])) AND

(("prevention and control"[Subheading] OR ("prevention"[All Fields] AND "control"[All

Fields]) OR "prevention and control"[All Fields] OR "prevention"[All Fields]) OR

("awareness"[MeSH Terms] OR "awareness"[All Fields]) OR ("communication"[MeSH

Terms] OR "communication"[All Fields]) OR ("methods"[MeSH Terms] OR "methods"[All

Fields] OR "intervention"[All Fields]) OR program[All Fields] OR campaign[All Fields])

Study Records

The article titles, along with their abstracts, were imported to the proprietary software “Covidence” for screening. After the removal of 124 duplicates, the 861 titles and abstracts were screened. Besides the author of this manuscript, another reviewer coded 100 of these articles with 82% agreement. The process starting from title and abstract screening to finalizing studies for review is detailed in Figure 3-1. The 12 preliminary articles which were used to develop the Qualtrics questionnaire for charting, are included in the final 35 articles that were reviewed.

Data Items

Based on the inclusion and exclusion criteria, 12 articles were preliminarily selected to develop a data charting guide. These articles were reviewed in an effort to uncover the most dominant factors covered in the articles and also to develop a

“questionnaire” that would ask questions about this information in the articles. A

Qualtrics survey was then created with those questions (Appendix B). The survey contained 17 questions that were used to chart standard information from each article.

This information includes:

 Authors  Publication information (year and journal)  Type of study (qualitative/quantitative)  Type of cancer  Study population sample (location- rural/urban, gender, size, age, SES,)  Methodology used  Study aims  Outcome measures  Results  Conclusions drawn by the authors  Any additional information perceived important by the coder

Risk of Bias in Individual Studies

Since each article was coded in Qualtrics with the same 17 questions, the risk of over or undercoding any particulat artcle is considered minimal. However, some studies were exclusively focused on Bangladeshi populations, and about cancer prevention and detection communication. As they were deemed more relevant to the aim of the study, they might have been given more attention than the articles which had populations other than Bangladeshis (i.e. developing countries in general), or had reported the communication aspects of cancer prevention and detection as a by-product.

Data Synthesis

A total of 35 articles were selected for review after the full text screening. Each article was reviewed to answer the 17 questions formulated in Qualtrics. From the charting, information about method of the study, study population, cancer type, and prevention type was directly extracted. Articles were coded for the population being studied in order find out which populations are given more attention and which ones are neglected in scientific research on cancer communication in Bangladesh. The types of cancer being studied were also categorized for a similar reason to find gaps in the literature regarding particular types of cancer. Intervention type and methodology used in each article were considered to understand the patterns and effectiveness of those interventions and methods.

The 35 articles were then categorized based on the type of cancer they focused on. The categories are: breast, cervical, lung, oral, testicular, and general. The general cancer category was further sub-categorized into three different types: generic cancer study, tobacco control, and cervical & breast. Smoking is considered to be the cause of

12 different types of cancer and according to the WHO, tobacco control is the foremost preventive measure to reduce the risk of cancer in any population (Simon, 2015; What ministries of information and communications need to know, 2016). Hence, tobacco control was given its own sub-category, despite it not being a type of cancer.

The ‘results’ section of each study under each cancer type category (and further, under each sub-category) was analyzed for in-depth knowledge about cancer communication in Bangladesh, using a thematic summary technique (Thomas et al.,

2017). Due to the choice of including quantitative, qualitative, and mixed method articles, a thematic summary technique was chosen since it allows combining

quantitative and qualitative data (Thomas et al., 2017). “Data” in this synthesis is defined as everything reported in each study in their result section. Thematic summary was the choice of synthesis also because of the deductive nature of coding the result sections. Each result section was coded based on several health communication theories discussed in the theoretical underpinnings section, along with other codes, such as: knowledge, perceived barriers, risk factors, and preferred/common channels of information dissemination.

Meta-Bias

As mentioned earlier, only 10.15% (100 out of 985) of the article abstracts were screened by two researchers. The rest of the articles were screened and then finally coded by a single researcher. There might be a bias here, but as most of the information coded was observed and not latent, the bias is considered minimal. The selection of articles published only in peer-reviewed journals also migh have created a file-drawer effect. Details of this is discussed in the limitations section.

Figure 3-1. Flowchart of systematic scoping review process.

CHAPTER 4 RESULTS

In this section findings of the systematic scoping review are detailed. The chapter is organized first by a general overview of the articles that were reviewed. Then the rest of the section is structured in framework of the transactional model of communication.

The findings in this structure are provided in categories of sender, message and receiver.

Articles

All of the articles were published between 2008 and 2019. Eleven articles were about breast cancer, ten were about cervical cancer and screening, one was about oral cancer, one was about lung cancer, and one was about testicular cancer. There were eight articles that focused on tobacco control, two that discussed general sentiments regarding cancer in Bangladesh, and one looked at both cervical and breast cancers.

Notably, no studies focused on colorectal cancer. Out of the 35 studies, 25 were primary research, six were secondary data analysis, and four did not mention any particular methodology.

Twenty six studies, out of the 35, were exclusively about Bangladeshi population.

Seven were conducted under the umbrella of “developing” or “low-to-middle-income” countries, where Bangladeshi participants were included, and two were exclusively about Indian and Bangladeshi populations. Twenty studies were quantitative (statistical data analysis), three were mixed-method, and twelve were qualitative studies

(observational, focus group discussions, long interviews). Tables 3-3 to 3-6 show the journals and years the articles were published in along with some key findings.

The articles were published in 25 different peer-reviewed journals. Asian Pacific

Journal of Cancer Prevention, which has an impact factor (IF) of 2.52 as of 2014 (About

Asian Pacific Journal of Cancer Prevention) had the highest frequency of publication

(n=7). Two articles were published in the Oncologist (IF= 5.306, The Oncologist, 2017), the PloS ONE (IF= 1.95, PLoS ONE, 2019), Health Care of Women International (IF=

0.850, Health Care for Women International, 2017) and the International Journal of

Environmental Research and Public Health (IF= 2.608, International Journal of

Environmental Research and Public Health, 2019). Two journals, each publishing one article, were Bangladeshi Mymensingh Medical Journal (Scimago Journal & Country

Rank, SJR= 0.15, Mymensingh medical journal, 2018) and Bangladesh Medical Journal

(IF= 0.09, Bangladesh medical journal, 2018).

If IF score is not available, impact factors or SJR scores of the other 19 journals are listed in Table 3-1. The information in the table was collected through Google searches. Sources such as the journal’s own website; publishing websites such as

Springer and ResearchGate, and Scimago Journal & Country Rank were used to collect the scores. The impact factor over five years was chosen to report if available, otherwise the latest available score was mentioned.

None of the journals in the sample were communication based. The journal with the highest IF score (4.151) is the Tobacco Control; Wakefield et al.’s (2013) study on smokers’ responses to television advertisement regarding tobacco induced harms, conducted in ten LMICs including Bangladesh was published in this journal. The second highest rated (3.315) journal was Maturitas; Islam et al.’s (2016) study about breast cancer awareness was published in it. The third best journal was the Vaccine (3.285);

Sankaranarayanan et al.’s (2008) study on HPV prevention and cervical cancer conducted in four South Asian countries, including Bangladesh, was published in it. Five of the remaining journals did not have an IF score, and one of the journal’s IF scores could not be found despite an extensive Google search.

Thirty out of the 35 articles were authored by at least one Bangladeshi. None of those five articles were exclusively about Bangladesh. All of them contained

Bangladeshi samples as part of an LMIC/international study. One of the articles was a global survey analysis of breast and cervical cancer combined, written by a cancer epidemiologist working at the Duke University in North Carolina (Akinyemiju, 2012). One was on tobacco use, an analysis of the Global Adult Tobacco Survey, conducted by two

Indians (Gupta & Kumar, 2014). Two articles, one about testicular cancer (Petzer &

Pengpid, 2015) and another about breast cancer (Pengpid & Peltzer, 2014) were written by the same authors. The fifth article, which contained no Bangladeshi author was the study on smokers’ responses to advertisement (Wakefield et al., 2013).

The rest of this chapter is structured according to the transactional model of communication and is divided into receiver, message, and sender segments. Even though the flow in the communication model starts from sender and ends in receiver, the result section is reported in the reverse order due to the overwhelming abundance of information on the receivers and the scarcity of information on sender and message.

Receiver

Receivers in this study are the participants/population sample that have been studied. Receiver information includes demographic characteristics, knowledge and awareness levels, attitude towards cancer and preventive methods, literacy, risk factors,

perceived barriers, and predictors of screening. In the following section, ‘population’ provides information on the sex and age of the participants. Following that, information about the receivers is categorized by the tye of cancer.

Population

Studies reported either male or female participants. No study mentioned intersex, or transgender participants. Studies also excluded any mention of the sexual orientation of the participants and hence homosexuals, bisexuals, and people of other sexual orientations seemed not to be included or identified. Most studies also reported either rural, urban, or sub-urban (upazillas or small towns) localities. There was no mention of the hill tracts where the majority of the tribal Bangladeshis reside.

Female-only participants

Sixteen of the 35 studies (45.71%) had only female participants. Nine of them were about breast cancer, five were about cervical, one about the HPV infection, and one was about breast and cervical cancer combined. Five of the studies, conducted exclusively on females, had urban only populations; two were exclusively centered on rural women; and five were on mixed populations from rural, urban, and sub-urban areas of the country. Four studies did not specify the locality of their sample. One study did not define its sample age, and only two included minor participants. The two that included under-age participants, contained women between the ages of 13 and 15.

However, the inclusion of under-age participants was not to understand cancer in the pediatric population, rather it was due to Bangladesh’s social context, where under-age women are comparatively highly likely to be married, especially in the rural, lower SES population.

The age range of the 16 studies was 13-69 years. One study did not mention the size of its sample. The largest sample size was an evaluation of the national cervical cancer screening program conducted by Basu et al. (2010), and included 135,735 women. Smallest sample size was 100 and the study was conducted on urban women seeking breast health care by Ahmad et al. (2017). Three studies did not provide any

SES indicator of their sample. Two additional studies did not specify sample SES but they were both conducted on rural women. Out of the 12 studies that reported sample

SES, five were conducted on women mostly with secondary (high school) or higher education, five had majority participants with none to primary-level education, and two studies had mixed education (homogenous distribution of literate to illiterate participants) samples.

Ten studies reported employment status of the participants; four of them had a majority of the participants earning a salary with jobs outside of home. Six studies had a majority participants as unemployed/housewives. Only one study, on HPV infection, reported garments workers, and house maids. No study reported on sex-workers, women living in slums in the city areas, or homeless women. A majority of the participants were married women; no study specified the relationship status of non- married women, such as, single, widowed, and divorced women.

Male and female participants combined

Thirteen of the 35 studies (37.14%) included both male and female participants.

Seven of them were on tobacco cessation, two were about breast cancer, two were about cervical, one was about oral, and one was about lung cancer. Five of the studies were conducted exclusively on urban residents; one of these was about oral cancer, one was about breast cancer, and three were on smoking cessation. Only one study

was conducted exclusively on rural residents and it was about cervical cancer. The rest of the studies included residents of urban, rural, and sub-urban areas. All 13 studies at least mentioned whether the sample was adult, or had both adult and youth. All seven tobacco cessation studies included both minors and adults. The reasoning was thatbeing minors already put them at high risk of tobacco consumption. The minimum age of the participants reported in these studies was 15, and the maximum age was not reported. While these studies included both male and female minors almost equally, the adult participants were mostly males.

One of the two breast cancer studies reported to have adults only, and the other had an age range of 16-30. One of the two cervical cancer studies had a sample size aged between 20 and 49, and the other study was 32 and 40. In both cases of the cervical cancer studies, only female age was reported. Eighty-nine-point one percent of the oral cancer study samples aged between 19 and 24. While the mean age of the lung cancer study was 56.99 years. Sample size varied among 176 participants in a cervical cancer study and 9,619 participants in a tobacco cessation ITC survey study.

Three studies did not mention the SES of their samples; one of them was conducted among urban residents though. All four studies that reported income, had low income

(household income less than 10,000 taka per month) participants.

Nine studies mentioned education. Of them two had college students as their samples, and both studies were conducted in Dhaka city. One mentioned 1-8 years of education, one reported 26% of the sample having more than nine years of education.

Two studies reported 55% of the sample as having moderate education (middle school or lower), and two mentioned none or primary-level education. One of the studies had

an eclectic sample ranging from unemployed rural women to medical practitioners in the suburban areas adjacent to the rural areas in the Khulna division. The only studies to include slum residents were those on tobacco cessation.

Other

Two studies had exclusively male samples while four did not mention the gender of their sample. Of the two male-only studies, one focused on testicular self-examination

(TSE) and the other looked at smokers’ responses to television advertisement about the serious harms of tobacco use. The TSE study was conducted among the urban population in Dhaka city, while the smoking cessation study had a mixed population.

Age range was reported 16-30 for the TSE study (sample size 448, university students in Dhaka), and 18-34 for the tobacco advertisement study (sample size 192, SES not mentioned). The four studies that did not specify gender included two reports on general cancer scenario in Bangladesh, one on the ethical issues concerning the HPV vaccination, and the other one on cervical cancer prevention and HPV vaccination in four South Asian countries including Bangladesh. None of them included age, size,

SES, and locality of the sample. Now that the demographic characteristics of the participants in the studies have been described, the following segment is categorized by cancer type.

Breast Cancer

Ten out of the eleven studies were conducted exclusively on Bangladeshi participants. Two focused exclusively on rural women; three concentrated on urban women; two studies focused on women from rural, urban, and/or sub-urban areas. Two studies focused on women but did not specify whether they were rural or urban. Two studies had both male and female populations, one, dealing withurban populations, and

the other one consisting of mixed (rural, and sub-urban) populations. Two studies that exclusively focused on rural women were part of a similar research endeavor. One of them was a pilot study to assess the feasibility of implementing a mobile-based cancer screening by community health workers in a rural area in Bangladesh, while an earlier one was a randomized control trial (RCT) study conducted in the same area to test a mHealth model. Four studies focused on the knowledge and attitude towards breast cancer and screening among Bangladeshi women. One study was about the effect of educational level on knowledge and use of breast cancer screening, two on risk factors of breast cancer, and one about breast care seeking behavior. The other study was a mix of knowledge, attitude, breast care seeking behavior, and socio-demographic risk factors of breast cancer.

Knowledge

Three studies mentioned the percentage of the population that had knowledge

(i.e. having heard) of breast cancer. In the study conducted by Islam et al. (2016),

81.9% of their sample had heard of breast cancer, while Rasu et al. (2011) found 89% of their sample to have heard of breast cancer, and Hossain et al. (2014) found 41% of

175 women had not even heard of it. Four studies reported statistics on knowledge regarding some form of breast cancer screening, i.e. unspecified screening method,

BSE, or mammogram. Of the participants who had heard of breast cancer, 64.2% had heard of screening (Islam et al., 2016), 77% were unaware of screening (Hossain et al.,

2014), 72% did not know about any diagnosis, and 60% did not know anything about screening (Begum et al., 2019) while only 46% knew of BSE (Pengpid & Peltzer, 2014).

One qualitative study mentioned that in rural Bangladesh there is no word for breast cancer and talking about breast is not permissible in public (Story et al., 2011). Two

studies mentioned knowledge about symptoms. Chowdhury found that 65% of the sample had no knowledge of symptoms and signs (Chowdhury et al., 2008). Begum et al. (2019) reported mass in breast to be the most known (330, 66%) early symptom of breast cancer among its sample.

Misconceptions

Along with the lack of knowledge stated in the previous section, many misconceptions were also reported in the breast cancer related articles. Chowdhury et al. (2008) explored these reporting94% of its sample did not think breast cancer is a disease of old age, 54% thought it’s not inherited, 52% said it was caused by evil spirit, and 54% thought it cannot be cured. Story et al. (2011) also reported fatalistic beliefs and myths about how breast cancer is caused as misconceptions.

Predictors of knowledge/awareness

Reported predictors of knowledge about breast cancer included: women being aged between 40 and 59 years of age, being overweight or obese, and having less than three children (Islam et al., 2016). The same study reported the predictors for lack of awareness about breast cancer, which included being residents of rural areas, having only primary or no education, being aged between 30 and 39 years, having normal BMI, and having more than three children. However, Love et al. (2011) found younger women in rural areas were more aware of the severity of breast cancers. Rasu et al.

(2011) found statistical significance between more than twelve years of education and hearing about breast cancer, knowing about screening practices, and acting to perform a BSE or have a mammogram. It was discovered that 72% of their participants who knew about breast cancer reported positive family history of breast cancer.

Attitude

Several studies reported attitude towards screening and early detection.Ninety two percent of participants mentioned they would seek care if breast problems were found (Hossain et al., 2014). Rural women were eager to participate in breast examination if they were given the opportunity to see a doctor who was accessible to them (Story et al., 2011). Ginsburg et al. (2014) found in their RCT that no woman who had breast symptom declined CBE. In their pilot study for mHealth intervention feasibility, Chowdhury et al. (2018) found that contrary to their expectation women in the predominantly Muslim Khulna division showed very low level of unwillingness to report their breast symptoms, and to be examined.

However, none of the breast cancer cases are detected through organized screening, and more than 90% of patients seek medical attention in late stages (stage

III or IV) of cancer (Hossain et al., 2014). Ahmad et al. (2017) found in their study that despite having family physicians, 68% participants did not go for routine breast exams.

Pengpid & Peltzer (2014) found that less than 2% Bangladeshi women perform BSE on a monthly basis, 64% never performed BSE, and only 1.2% performed BSE more than

10 times in 12 months.

Barriers to screening

Five studies reported barriers to breast cancer screening and/or seeking any type of breast care. Islam et al. (2016) reported that women who knew about screening but did not screen reasoned having no symptoms (92.4%), not knowing screening was needed (40.1%), and possible expense associated with screening (7.2%). Modesty

(4.7%) and religion (1.7%) were the lowest rated barriers. Hossain et al. (2014) reported high cost of treatment, fear of social stigmatization, inadequate diagnosis facilities, and

lack of trust in the healthcare system for not seeking medical help for breast problems.

Rasu et al. (2011) found that 51% of their participants, who were urban and educated, did not perceive any barriers to having mammograms, which means 49% did. The most commonly mentioned barriers by their study participants were deeming screening unnecessary and self-blame (not practicing good health behavior).

Cost was also an issue in their study. While 86% of the participants were willing to pay for mammograms, only 11% were willing to pay more than 1000 taka ($11.83

USD) while a mammogram costs 3000 taka. Ahmad et al. (2017) found three major barriers reported by their urban study participants: concerns about time burden on family members (needing another family member to accompany them for doctor’s visit), concerns about house-hold chores (having to make time for herself), and concerns about having a female physician. They also found age, income, and education to be significantly associated with the likelihood to seek care.

Story et al. (2011) found that, despite the knowledge of importance of screening, the rural participants in their study chose not to seek care due to mistrust in doctors, lack of female doctors, preferring alternative medicine, feeling too much responsibility to the family to leave for her own care, and fear of being diagnosed with cancer and being left by the husband. The study also found that social perception of women with cancer as “bringing curse to the family,” financial constraints of the family, malnourishment of family members, priority of the survival of other family members over the woman’s being other barriers to seek breast care such as screening. Most of their participants also perceived not to have access to care for breast cancer as most of them believed there was no such facility. Road condition, weather, and permission from the family were the

other common barriers reported in the study. Women in the study reported that they believed their family would not or could not pay for the transportation cost to go to a breast care facility.

Risk factors

The focus of the study conducted by Ahmed et al. (2015) was to assess the risk factors for cancer in Bangladesh. They found early menarche and late menopause women to be at high risk. Abortion, having taken hormone therapy, having affected family members, and high BMI were also found to be statistically significant risk factors.

Cervical Cancer

Two of the studies were exclusively about the HPV vaccination. One of them was about the ethical concerns regarding the vaccination program in Bangladesh and the other was on the prevalence of HPV among Bangladeshis. Six studies emphasized knowledge and/or awareness of breast cancer, attitude towards screening/HPV vaccination, and barriers to getting screened. One study evaluated the role of media surrounding cervical cancer prevention. Another evaluated a national cancer cervical screening program. Nine of the ten studies had a Bangladeshi population. Two studies had urban female populations. Still, only one study was conducted among rural population and it had both male and female participants. Three studies were conducted on females from urban, rural, and/or sub-urban areas (mixed area). One study was conducted on men and women from mixed areas. Two studies did not mention either the gender or the locality of their samples. One study was conducted on females, but their locality was not specified.

Knowledge

Six studies reported knowledge about cervical cancer and screening, and one of them discussed knowledge about HPV vaccination. Ansink et al. (2008) reported cervical cancer to be colloquially known as “ulcer of the womb.” Islam et al. (2015) found 81.3% of their participants had heard of cervical cancer and, of them, 59.8% had heard of screening. They also found that women were less likely to know about cervical cancer if they lived in rural areas or had no education or only primary education.

Furthermore, women between the ages of 40-49 were more likely to know about cervical cancer than women aged 30-39. Obese women were also more likely to be aware of cervical cancer compared to women with normal body mass indices.

Contrary to previous findings, Islam et al. (2018) found that significantly more women in rural areas had heard of cervical cancer compared to urban women. They also found education was associated with knowledge and attitude towards cervical cancer and screening only among urban women. Urban women, aged 35–44 years, were most likely to have heard of cervical cancer when compared to those aged less than 24 years. In rural women, the odds of having heard of cervical cancer were significant only for the age group 25–34 years when compared to those aged less than

24 years.

Ferdous et al. (2016) found knowledge about cervical cancer screening to be poor in 17.7%, average in 41.4%, and good in 40.9% of the participants. In the urban study population, they found a significant relationship between knowledge and age.

Women above 41 had better knowledge of cervical cancer compared to women between 30-40. Furthermore, knowledge level increased with age. Bhuiyan et al. (2018) found 98% of their participant had heard of cervical cancer, and 50% of the participants

had heard of HPV. Sankaranarayanan et al. (2008) found that knowledge about HPV infection was not only low among the general population but also among policymakers and healthcare professionals. Men in a study of rural and sub-urban populations also reported to have proper knowledge about cervical cancer screening (Ansink et al.,

2008).

Knowledge about symptoms

Ansink et al. (2008) found men and women both had accurate knowledge about the symptoms of cervical cancer, but the causes of it were not accurate. In another study, only 21.7% of the participants could identify at least one symptom when they were provided with a list (Islam et al., 2015). Bhuiyan et al. (2018) found, 50% of their sample could identify HPV as a sexually transmitted infection.

Misconceptions

General misconceptions about screening included, assuming screening itself was a cure (Ansink et al., 2008), regular check-ups not even being considered a way of prevention among rural women (Islam et al., 2018). The study also found misconceptions about perceived causes of this cancer. For instance, urban participants thought sexual intercourse was the main cause of cancer, while rural participants thought it was lack of hygiene during menstruation. Sexual relationship with anyone other than the husband was the second most common perceived cause among both rural and urban women in the study. In a study, women reportedly blamed themselves for not knowing enough (Bhuiyan et al. 2018). In the same study, one woman reported that she believed her infertility was caused by HPV vaccination.

Attitude

Islam et al. (2018) found that only 16% of urban, and 5% of rural women perceived vaccination to be a preventive measure for cervical cancer. However, when they were asked if they would take vaccines to prevent cancer, 94% of urban and 99% of rural women said yes. Similarly, 92% of urban and 99% of rural women also were willing to recommend vaccination to others. Bhuiyan et al. (2018) reported 56% of their participants had taken measures to prevent cervical cancer and the most common measures were regular checkup (30%), and the use of HPV vaccines (29). The other two measures were using condoms and regular pap smears. Only 3% of the participants correctly chose all four preventive measures. In the same study, women who had daughters were more likely to want their daughters to be vaccinated but they wanted more information about the efficacy and safety of the HPV vaccines. Almost all women in the study had a positive attitude towards raising awareness about HPV and cervical cancer. The study also found that the decision to be vaccinated was influenced by personal experience such as a family member being diagnosed with cervical cancer.

The high cost of vaccination (15,000 taka) did not prevent one of the participants whose mother was diagnosed with cervical cancer from getting screened. In the study conducted by Islam et al. (2015), only 8.3% of their sample had ever been screened.

Nessa et al. (2013) found that both men and women had positive attitude towards the

Visual Inspection with Acetic Acid (VIA) test and perceived no resistance from the family. However, there was a strong preference for female doctors among the husbands. Basu et al. (2010) reported in their evaluation of screening facilities that screening was predominantly opportunistic as women with existing symptoms of genital tract infection or cervical malignancies were referred for screening. Only 8.6% women

who took VIA tests, did so spontaneously in the facilities evaluated. Ansink et al. (2008) reported that adolescent girls found screening “modern” but acceptable if done in proper privacy. The same study found men to be accepting of screening. However, they placed the burden of getting screend on women, despite, women’s financial and social dependence (transportation/being accompanied by a man for safety) on men to receive healthcare.

Perceived severity

Although Ansink et al. (2008) reported there was a general awareness about the lethality of cervical cancer if left untreated, a main consequence perceived by their female participant was being exiled by family and for men, it was the physical impact the diagnosis would have on their wives and their relationship. No other articles directly reported perceived severity.

Barriers to screening

Barriers to screening included: low priority given to seeking care of symptoms, lack of appropriate services at close proximity, lack of money, lack of appropriate care, referral of wrong, and unnecessary tests such as blood test, X-ray or ultrasound despite the problem being gynecological (Ansink et al. 2008). In a study that evaluated the role of media in raising awareness about a VIA program found that many women could not avail the test due to crowds and several did not go due to hesitation, shyness, and fear

(Nessa et al., 2013). The study exploring the ethical aspects of HPV vaccination found that adolescent girls were being vaccinated without parents’ consent, and due to the lack of administrative infrastructure for health information storage, follow-up vaccination was not possible (Salwa & Munim, 2018). Islam et al. (2015) reported reasons among their study participants for not getting screened. These include: lack of symptoms

(86.1%), lack of knowledge concerning the need of screening (37.5%), and possible expense associated with screening (11.5%).

Risk factors

Sankaranarayanan et al. (2008) found that one in four female cancer patients in

Bangladesh had cervical cancer, resulting in 13,000 annual cases and 6,600 deaths of cervical cancer annually based on cancer registries. Of their 120-sample cases of cervical cancer, 96.7% were HPV positive and low SES people were seven times more likely to develop cervical cancer compared to higher SES people. Nahar et al. (2014) found no rural-urban difference in the prevalence of HPV infection. Education had no effect on urban women but having primary, secondary, or higher education decreased the risk of any HPV infection among rural women. Occupation had the largest impact on

HPV infection among urban women. Garments workers and housemaids were at a higher risk compared to housewives. Urban women with two or more sexual partners were four times more likely to have HPV infection and there was no association between the number of husband’s sexual partners with the risk of any HPV infection.

Rural women whose husbands were abroad were twice as likely to get HPV infection compared to those whose husbands lived with them.

Tobacco Control

Four out of the eight studies were secondary data analysis of the International

Tobacco Control (ITC) survey, which is the first ever international cohort study of tobacco use, and was conducted in 25 countries. Two studies were experimental, testing the effects, perceived credibility, and health effects of warning messages on tobacco product packaging; one was for smokeless products, and another was for cigarette packaging. A mixed method study evaluated the smokers’ response on

television advertisementsconcerning serious harms of cancer. It evaluated

Bangladeshis among the citizens of nine other countries. The last study evaluated under tobacco control quantitatively evaluated the patterns of use and perceptions of harm of smokeless tobacco among Bangladeshis and Indians. One out of the eight studies focused only on men, and three of the studies focused only on urban populations, exclusively in Dhaka city.

Knowledge

Two of the eight studies reported knowledge of the effects of tobacco consumption among its participants. Gupta & Kumar (2014) in their ITC data analysis found that a large number of adults believed that tobacco consumption, i.e. smoking

(cigarettes) or smokeless tobacco (most consumed smokeless tobacco in Bangladesh reported by Mutti et al., 2016 were: gul which is similar to creamy snuff, betel leaf, zarda which is a form of flavored tobacco, tobacco leaf which is locally known as sadapata in

Bangla language, and noshshi which is known as snuff in English language), in addition to second hand smoking caused serious illness. In fact, awareness about the harmful effects of smokeless tobacco was exceptionally high in Bangladesh (92.7%) compared to other countries evaluated in the study. It also reported that rural Bangladeshis sowed higher awareness. Driezen et al. (2016b) reported that slum residents and illiterate

Bangladeshis had significantly lower odds of being aware of the harms of cigarette smoking than urban residents, and people having more than nine years of formal education. The study also found that a significantly higher percentage of slum residents knew that smokeless tobacco caused oral cancer (97%) compared to the non-slum residents in the sample (87%). The authors attributed this difference to the higher prevalence of smokeless tobacco use among slum residents.

Attitude and perceived severity of tobacco consumption

In their study, Mutti et al. (2016) reported that respondents with low education had more positive attitudes and beliefs about smokeless tobacco consumption compared to those with moderate levels of education. No other study directly reported attitude towards smoking or smoking cessation. Gul was ranked as the most harmful smokeless tobacco product among adult and minor Bangladeshis (Mutti et al., 2016).

However, perceived harm of a smokeless tobacco product varied significantly based on the participants’ utilization of a product. For example, gul users did not rank gul as the most harmful product. Similiarly, paan users did not perceive paan to be the most harmful product.

Barriers to and predictors of cessation

Abdullah et al. (2015) found that attempts to quit was significantly related to residing outside of Dhaka, being 40 years or older, having a household monthly income of 10,000 taka, having intention to quit in the future, and working indoors. Those who had successfully quit smoking were 40 years or older, self-rated to have good or excellent health, and reported increased levels of self-efficacy. In fact, the study found that one point increase in self-efficacy increased the odds of successful cessation by

80%. In their evaluation of determinants of intentions to quit smoking among adult smokers in Bangladesh, Driezen et al. (2016) found that smokers who believed there was great benefit in quitting had 2.1 times higher odds of planning to quit compared to smokers who had lower perceived benefits. Smokers who were highly concerned about their health had 8.7 times higher odds of quitting than smokers who were not at all worried. Similar to Abdullah et al. (2015), this study found that smokers employed in indoor areas where smoking is banned were two times more likely to quit compared to

smokers who worked outdoors. Knowledge of harmful effects of second-hand smoking was associated with increased intention to quit. Smokers with children of five years or younger living at home were also significantly more likely to have intentions to quit compared to those who had no children. Knowledge about harmful effects of smoking on one’s own health was not associated with intentions to quit. Advice from doctors to quite smoking, and partial ban in indoor office environment were also associated with intentions to quit.

Risk factors

Driezen et al. (2016a) reported the most vulnerable groups to the effects of consumption were the ones who were least knowledgeable of the dangers of tobacco, i.e. illiterate Bangladeshis. Complete smoking bans, which is a predictor of quitting or at least intention to quit, were least prevalent among urban slums (39%), while just under two-thirds of urban (non-slum) and rural residents reported having complete smoking bans in their homes; however, this difference was not significant.

Sender

Data from the articles showed two major aspects of the sender component in the communication model. First was the source, or channel of information, such as relatives or news media. The second aspect was trust in the source of cancer-related information or screening related recommendations, such as trust in physicians or the hospital. In the following section, these two aspects of the sender component in the communication model is discussed. First, trust in sender is discussed, and then common/preferred sources/channels of cancer information is detailed, categorized by the cancer type.

Trust in Sender

Only three out of the 35 articles, reported trust, and both of them were about trust in physicians. Story et al. (2011) in their study about breast cancer outcomes improvement, conducted among a mixed sample (rural, and sub-urban) reported that the participants had a mistrust in the doctors due to having experienced or seen examples of bad treatment in the past. They also reported that participants who get screened positive for breast cancer often seek second opinions. They usually get manipulated by brokers in the hospitals who suggest seeing another doctor for ‘better’ results. These brokers, in return, get commissions from other doctors. Hossain et al.

(2014), in their breast cancer perspective study, also mentioned lack of trust in existing healthcare systems as a barrier to seeking medical care.

Ansink et al. (2008), in their study of community perceptions of cervical cancer and screening, also reported issues with physicians among the mixed (rural and sub- urban) sample of men and women. Participants mentioned being referred for wrong and unnecessary tests, despite the symptoms of their illness being gynecological. Patients with cervix problems reported refervals for blood tests, X-rays, and ultrasound but not speculum exams. Chowdhury et al. (2018) and Ginsburg et al. (2014) found that community health workers (CHWs) are also trusted sources of information among rural women.

Source/Channel of Information

Four of the 35 studies reported on the participants preferred and common sources/channels of information about cancer and screening. Two studies tested the effectiveness of an emerging technology in the dissemination of cancer-related

information. The findings have been detailed in the following, categorized by cancer type.

Breast cancer studies

Chowdhury et al. (2008) reported that 43% of their sample that had heard of breast cancer had heard from their relatives. Rasu et al. (2011) reported that most of their urban women learned about breast cancer through the news media over physicians, friends, or family. Two studies investigated implementing mHealth technology to screen for breast cancer in rural Bangladesh (Ginsburg et al., 2014;

Chowdhury et al., 2018). The first study found cellphones act as an effective medium to collect breast cancer related (e.g. symptoms, other health information) messages from rural women while also providingthem with pre-cancer diagnosis, recommendations, and navigation information to get treatment in nearby healthcare facilities. Chowdhury et al. (2018) also found that cellphones were effective in raising awareness about breast cancer by showing relevant videos to the participants. Along with cellular technology,

CHWs were found to be effective in communicating with the participants about breast cancer and screening in both studies.

Cervical cancer studies

Nessa et al. (2013) specifically tested the role of media in cervical cancer prevention and evaluated how their target population heard about a VIA test program in their vicinity. The researchers found that 25.5% of those who came to the program camp heard about it in cable television, 21.4% from mike announcements (a common way of announcements in rural Bangladesh where an announcer travels around a community on a van with a microphone and a megaphone and reads out loud an announcement), 20.4% from front-yard meetings/focus group discussions, and 18.8%

from neighbors. According to the participants in the study, television was the best method for raising awareness among the general people (34.7%), mike announcements

(28.6%), and front-yard meetings (23.2%) were the two next most popular channels for dissemination of information about cervical cancer and screening. Women preferred discussion settings where they could ask questions. Both men and women preferred door-to-door health workers over going to the doctor. Disseminating cervical cancer related information through announcements and posters in school, college, mosques, temples, incorporation of cervical cancer prevention program in education curriculum, placement of billboard at important places, and hospital were suggested by the stakeholders to improve communication about cervical cancer.

Bhuiyan et al. (2018) reported in their urban population based study that 52% of the participants heard of cervical cancer from newspapers or magazine, 36% from friends or family, and 29% from television. Less than one-fifth of the 157 respondents heard of cervical cancer from their doctors. More than half of the women in the study recommended reaching out to women through mass media such as television commercials, and house-to-house visit, or mass campaigns by healthcare workers.

Islam et al. (2018), in their mixed population (urban, rural, etc.) study reported, 66% of their population heard of cervical cancer from neighbors, 45% from relatives, 14% from television, 7.7% from doctors, 7.7% from other health professionals, 0.5% from newspapers, 0.7% from colleagues, 0.6% from radio, 0.1% from friends, and 0.1% from husbands.

Tobacco control studies

Reid et al. (2017) found that their urban participants wanted more information on cigarette packages. Driezen et al. (2016a) found that tobacco users living in the urban

slums thought that all forms of tobacco packaging should contain more health information. According to the researchers this finding was counter-intuitive since most of the slum dwellers are illiterate. They rationalized that slum dwellers are aware of their relative disadvantage in terms of receiving health information and healthcare; warnings on cigarette packaging might be the most accessible way for them to receive some type of information to improve their health. The authors also recommended making such warnings pictorial, so that illiteracy does not become a barrier in receiving that information.

Message

Only seven studies reported on messages used to disseminate information about cancer and prevention. Details about the messages utilized and described are below.

Out of the 11 studies about breast cancer, two involved developing, implementing, and assessing culturally appropriate, communication-based interventions. Ginsburg et al. (2014) developed an mHealth model to increase clinic attendance for breast symptoms among rural Bangladeshis. It was a randomized control trial (RCT) where they trained community health workers (CHW) in a rural area to use mobile phones to record data from patients and help those with positive breast cancer symptoms navigate to nearby breast care clinic. The study found more than 99% of the

22,337 participants approached accepted to be interviewed by the CHWs, and women in the experiment group that provided navigation and cellphone record storage were significantly more likely to attend for care. The communication, and message utilized in the study was made culturally appropriate by using local CHWs.

The other study (Chowdhury et al., 2018) was a feasibility test of case finding for breast cancer by CHWs in rural Bangladesh. It was conducted in the similar locality of

the other study and used mHealth technology. This one included technology to not only collect data from its 4,649 participants, but also securely safe them in an online storage.

The study included a culturally tailored motivational video to raise awareness about breast cancer and screening. The video portrayed rural Bangladeshi women’s personal testimonials on getting screened for breast cancer, and receiving care. Both studies included some components of being culturally appropriate such as including community leaders and health workers in the development phase of the intervention, making them in colloquial language, and portraying demographically concordant people.

One study (Nessa et al., 2013) out of the 10 about cervical cancer developed, implemented, and evaluated the effectiveness of an intervention. The primary study, conducted in the rural Bangladesh, among 176 men and women, aimed to find out the most effective way to disseminate cervical cancer awareness. The mixed method designed developed messages through focus group discussions, delivered the message for a three-week time span, and through surveys and post-intervention focus group discussions evaluated the most preferred and most effective ways of receiving such messages. However, the only detail about the message contain provided was

“cervical cancer is a common cause of death of Bangladeshi women.” Other details on the message content was not provided in the article. The intervention was deemed effective as participants’’ knowledge about cervical cancer, and VIA increased post- intervention. 1021 VIA tests were performed, 47 of the results came positive. The authors concluded, availability of screening services influence awareness level of screening.

Another study (Basu et al., 2010) evaluated the effectiveness of a national program to increase cervical cancer screening in Bangladesh. How the information about the program was disseminated among the public was not reported in the study.

However, the campaign itself can be considered as a ‘message.’ The observational study conducted among 135,735 participants found that screening facilities were predominantly opportunistic, and 28% of the women evaluated through screening were under the recommended age. The uptake of the program after four years was low

(target of 20 million screening in three years vs. achieved 135,735 screening in four years). Non-compliance, and non-adherence were also found to be predominant among those who were screened and diagnosed with symptoms. The authors recommended expanding the scope of the screening program to rural areas to increase coverage, along with utilizing mass media, and utilizing community health workers to promote the screening program for better outreach.

Two experimental studies were conducted to test the effectiveness of health warnings on tobacco packaging. Reid et al. (2017) conducted an experiment on 1018 urban men and women to test the influence of health warnings on beliefs about the health effects of cigarette smoking. The health warnings on cigarette packaging included both text-only and pictorial messages; texts were in Bangla, and the images were tailored to Bengali ethnicity. Health warnings for impotence were effective on adults in terms of acknowledging smoking caused impotence but had no effect on minor participants. Health warnings regarding aging of the skin were effective on the minors in acknowledging that smoking caused aging of skin, but had no effect on the adult participants.

Mutti et al. (2017) examined the potential mediating role of negative emotions and the moderating role of message credibility in perceived effectiveness of smokeless tobacco warnings on 1081 urban men and women in Bangladesh. The between- subjects study found that both adults and youth who viewed any of the three types of pictorial messages (symbolic, graphic, testimonial) had greater levels of negative affects compared to text-only group. Greater levels of negative emotions elicited greater perceived message effectiveness. Message credibility moderated the perceived effectiveness among the adults but not among the minors. The authors attributed this lack of effect to the fact that pictorial warnings using graphics and personal testimonials included older looking people and the minor participants did not relate to them.

Wakefield et al. (2013) conducted a mixed-method study to assess the comprehension, acceptability, and potential effectiveness of five television advertisement in communicating anti-smoking message and motivating cessation among 192 adult males in Bangladesh. The study found that, portrayals of visible external damage as a result of smoking, and serious internal damage were perceived powerful and motivating. Some of the ads portrayed females and the male participants perceived those were for women and the issues discussed in the advertisements did not concern them. Participants also failed to comprehend the message when medical jargon was used. Bangladeshi participants in general showed lower odds of positive ad ratings than the participants from other countries in the study. The authors concluded that, advertisements made in high-income countries can be effective in low-income countries with minor adaptation, but did not provide any details about what type of adaptation.

Other Cancers

Three studies were conducted focusing about lung (Mukti et al., 2014), oral

(Chowdhury et al., 2010), and testicular cancer (Peltzer & Pengpid, 2015). Not much information on the sender-message-receiver was reported in the studies. Hence these other types of cancers are reported in the following sections separately.

The studies about lung and testicular cancers were quantitative studies, and the one about oral cancer was a qualitative one. The lung cancer study was conducted among both men and women from both rural and urban areas. The oral cancer study was also conducted among both men and women but only from Dhaka city, the capital of the country. The testicular cancer study was conducted among urban men. The oral and lung cancer studies were conducted exclusively among Bangladeshis, while the testicular cancer study was part of an international study.

Lung Cancer

Mukti et al. (2014) assessed the risk factors of lung cancer among the

Bangladeshis. Smoking was found to be the most significant risk factor among men, while previous lung cancer was significant risk factor among both men and women.

Socio-demographic factor associated with lung cancer among Bangladeshis are annual income, residential area, occupation, and educational level. Poverty, rural residency, and low education level were the most prevalent predictors of lung cancer.

Oral Cancer

Chowdhury et al. (2010) assessed the knowledge, attitude, and behavior towards oral cancer and tobacco control among urban Bangladeshi men and women. There were significantly more male tobacco users than females in their study sample (47.7% vs. 4%). Being dental students themselves, 97.3% of them had a positive attitude

towards playing a role in giving advice on tobacco cessation but 73.7% of them felt their advice will have no effect on the patients. Female dental students were significantly more likely to support receiving specific tobacco cessation training and routinely advising their patients to quit tobacco use, compared to male participants.

Testicular Cancer

Peltzer & Pengpid (2015) assessed the knowledge, attitudes, and practice of testicular self-exam (TSE) among male university students in Bangladesh, and four other countries. They found only 20% of their Bangladeshi sample were aware of TSE,

84% never conducted TSE in 12 months, and only 16.3% of the participants had conducted TSE more than 10 times in 12 months. Average rating of the importance of

TSE was 6.3.

Table 3-1. Journal impact factor. Journal Impact Factor/Scimago Journal &

Country Rank

Indian Journal of Community Medicine 0.39*

South Asian Journal of Cancer 0.58

Journal of Family and Reproductive Health 0.61*

BioResearch Open Access 0.76*

International Journal of Breast Cancer 1.04*

Cancer Epidemiology 1.33*

Journal of Cancer Education 1.547

Journal of Family Planning and Reproductive Health Care 2.027

Tobacco Induced Diseases 2.092

BMC Medical Ethics 2.106

Japanese Journal of Clinical Oncology 2.140

BMC Women’s Health 2.151

Transactions of the Royal Society and Tropical Medicine and 2.184

Hygiene

Addictive Behaviors 2.686

Vaccine 3.285

Maturitas 3.315

Tobacco Control 4.151

Global Health Research and Policy N/A

* denotes SJR scores

Table 3-2. Review articles by cancer type. Cancer Type/Preventive Scope Number of Articles Breast 11 Cervical 10 Lung 01 Oral 01 Testicular 01 General 02 Tobacco Control 08

Table 3-3. Articles about Breast Cancer Prevention and Detection. Title Authors Publication Journal Study Sample Key Findings Year Published in Feasibility Touhidul Imran 2018 Asian Pacific Rural women Cellphones can be an effective way to find breast Study of Chowdhury, Journal of cancer patients; culturally appropriate video can Case-Finding Richard Reed Love, Cancer motivate patients with ymptoms to seek care for Breast Mohammad Prevention Cancer by Touhidul Imran Community Chowdhury, Abu Health Saeem Artif, Hasib Workers in Ahsan, Anwarul Rural Mamun, Tahmina Bangladesh Khanam, James Woods, Reza Salim

Table 3-3. Continued. Title Authors Publication Journal Study Sample Key Findings Year Published in An mHealth Ophira M. Ginsburg, 2014 The Rural women Every woman with symptoms wanted CBE. Participants Model to Mridul Chowdhury, Oncologist were more likely to seek care if CHWs helped them with Increase Wei Wu, Md the navigation to get help from a near-by clinic Clinic Touhidul Imran Attendance Chowdhury, Bidhan for Breast Chandra Pal, Rifat Symptoms in Hasan, Zahid H. Rural Khan, Dali Dutta, Bangladesh: Arif Abu Saeem, Can Bridging Raiyan Al-Mansur, the Digital Sahin Mahmud, Divide Help James H. Woods, Close the Heather H. Story, Cancer Reza Salim Divide?

Knowledge, Supa Pengpid, Karl 2014 Asian Pacific Female 64% of the participants never performed BSE, 46% Attitude and Peltzer Journal of college knew of BSE, importance of BSE was rated 7.1. Practice of Cancer students Breast Self- Prevention examination Among Female University Students from 24 Low, Middle Income and Emerging Economy Countries

Table 3-3 Continued. Title Authors Publication Journal Study Sample Key Findings Year Published in Knowledge, Begum SA, Mahmud T, 2019 Mymensingh Adult female Mass in breast was the most well-known Attitude and Rahman T, Zannat J, Medical Journal patients at symptom of BCa, 72% did not know anything Practice of Khatun F, Nahar K, hospital about diagnosis of BCa, 60% did not know Bangladeshi Towhida M, Joarder M, anything about screening, expenditure Women towards Harun A, Sharmin F. problem was the biggest reason for not Breast Cancer: A seeking prevention for BCa, 32% did not Cross Sectional have knowledge about this type of medical Study advice, 60% never practiced BSE

Association Kawsar Ahmed, Sayed 2015 Asian Pacific Patients with early menarche and late Assessment among Asaduzzaman, Mamun Journal of menopause, hormone therapy, having Risk Factors and Ibn Bashar, Goljar Cancer affected family member and abortion were at Breast Cancer in a Hossain, Touhid Prevention high risk, Low-Income Bhuiyan No association was found between risk and Country: food habits and alcohol consumption. Bangladesh

Awareness on Shahanaz Chowdhury; 2008 Journal of Population 51% of the participants thought BCa is Breast Cancer M.P.H, Shaila Sultana; Family and representative curable if detected early, 64% knew BCa to among the Women Reproductive adult females be common. 94% mentioned BCa does not of Reproductive Health occur in old age, 54% thought it's not Age. inherited, 52% told cancer is caused by evil spirit, 54% told BCa cannot be cured. 65% had no knowledge of symptoms and signs of Bca.

A study with Farah Ahmad, Syeda F. 2017 Health Care for Urban, Despite most participants had family Bangladeshi Kabir, Nabila H. Purno, Women medium to physician (FP,67%), most (68%) did not have women: Seeking Saima Islam, and Internaitonal high SES routine check up. Three sociocultural items care for breast Ophira Ginsburg adult females (i.e. concerns about time-burden on family health members, concerns about completing the household chores, and having a female FP) along with age, income, and education were significantly associated with the likelihood to seek care.

Table 3-3. Continued. Title Authors Publication Journal Study Sample Key Findings Year Published in Improving H. L. Story, R. R. 2011 International Rural women No word for breast cancer in local language, talking Outcomes Love, R. Salim, A. Journal of about female body is not permissible in the public from Breast J. Roberto, J. L. Breast sphere, most participants believed they had no access Cancer in a Krieger, and O.M. Cancer to breast care, reasons not to seek care included, Low-Income Ginsburg mistrust in physicians, lack of female physicians, Country: preference for alternative medicine, family burden, fear Lessons from of being a social outcast Bangladesh

Effect of Rasu, R.S., Rianon, 2011 Health Care Urban 12+ years of education is significantly associated with Educational N.J., Shahidullah, for Women working knowledge about BCa, most common source of Level on S.M., Faisel, A.J., & International women at a knowledge about BCa is news media, while 89% of the Knowledge Selwyn, B.J. university participants knew about BCa and Use of Breast Cancer Screening Practices in Bangladeshi Women

Breast Hossain, M.S., 2014 Cancer N/A Unlike the high-income countries, Bangladeshi BCa cancer in Ferdous, S., & Epidemiology cases are predominantly premenoposal. None of the South Asia: A Karim-Kos, H.E. breast cancer cases is detected by organized screening Bangladeshi in Bangladesh. Almost all breast cancer cases are perspective detected clinically. most of the patients (more than 90%) seek medical attention at advanced stages: i.e., stages III and IV.

Table 3-3 Continued. Title Authors Publication Journal Study Sample Key Findings Year Published in Awareness of Islam, R. M., Bell, 2016 Maturitas N/A 81.9% heard of BCa, of that 64.2% had ever heard of breast cancer R. J., Billah, B., screening, 29.1% had ever had a mammogram. The and barriers Hossain, M. B., & corresponding figure for women who had ever heard of to breast Davis, S. R. CBE was 8% (n = 66). 9 predictors of BCa awareness: screening place of residence, age, marital status, education, uptake in occupation, husband's occupation, BMI, parity (number Bangladesh: of children). Women less likely to be aware of BCa if: A population lived in rural area, only primary or no education, aged based survey 30-39, normal BMI, had more than 3 children.

Table 3-4. Articles about Cervical Cancer Prevention and Detection. Title Authors Year of Journal Study Sample Key Findings Publication Published Knowledge and Afsana Bhuiyan, 2018 BioResearch High educated Most common source of information about cervical Acceptance of Farhana Sultana, Open Access urban adult cancer is newspaper or magazines. Knowledge of Human Jessica Yasmine women prevention was poor. Reasons to not get HPV Papillomavirus Islam, Mohiuddin vaccines were, not knowing enough about the Vaccine for Ahsanul Kabir vaccine, not being recommended by their doctors, Cervical Cancer Chowdhury, and worries about the safety of the vaccine, and Prevention Quamrun Nahar perceiving themselves as too old for vaccination. Among Urban Professional Women in Bangladesh: A Mixed Method Study

Table 3-4. Continued Title Authors Year of Journal Study Sample Key FIndings Publication Published in Attitude and Ferdous J, Khatun 2016 Bangladesh Female Knowledge was significantly associated with age. practice of S, Ferdous NE, Medical doctors Participants aged 30-40 years had poor knowledge cervical cancer Sharmin F, Akhter Journal score (24.2%) than the participants between 41-50 screening among L, Keya KA years age group (4.9%) and between 50-60 years the female age group (6.7%). Most commons reason for not doctors of getting screened was not being referred by a Bangabandhu doctor. Those who got screened, almost all of them Sheikh Mujib were referred by a doctor. Medical University

Knowledge of Jessica Yasmine 2018 BMC Population In the sample, significantly more women in rural cervical cancer Islam , Fatema Women's representative areas heard of cervical cancer compared to urban and HPV vaccine Khatun , Anadil Health adult females women. But, there were significantly more women in Bangladeshi Alam , Farhana in the urban area who underwent cervical cancer women: a Sultana, Afsana screening compared to their rural counterpart. Top population based, Bhuiyan , Nazmul perceived causes of cervical cancer: urban women- cross-sectional Alam , Laura sexual intercourse, rural women- poor hygience study Reichenbach , during menstruation. "sexual relationship other than Lena Marions , husband. Most believed cervical cancer was not Mustafizur Rahman preventable. Participants were open to getting and Quamrun vaccinated. Education was not associated with Nahar knowledge among rural women. Most common source of knowledge was neighbors, relatives and television.

Table 3-4. Continued Title Authors Year of Journal Study Sample Key Findings Publication Published in Lack of Rakibul M. Islam, 2015 The Population Women were less likely to have heard of CCa if Understanding of Robin J. Bell, Baki Oncologist representative they were living in a rural area, had primary or no Cervical Cancer Billah, Mohammad adult females education. Women aged 40–49 years were more and Screening Is B. Hossain, Susan likely to know about CCa compared with women the Leading R. Davis aged 30–39 years. obese women were more likely Barrier to to be aware of CCa compared with women of Screening Uptake normal body mass index. the reasons given for not in Women at undergoing screening included having no symptoms Midlife in (86.1%), not knowing screening was needed Bangladesh: (37.5%), and possible expense associated with Population-Based screening (11.5%). Cross-Sectional Survey

Ethical issues Marium Salwa and 2018 BMC Medical Adolescent No guidelines to get consent from parents to get related to human Tarek Abdullah Al- Ethics girls, parents, their children vaccinated. To make vaccination papillomavirus Munim policymakers communication culturally sensitive, risk of sexual vaccination intercourse is not talked about; hence, the programs: an information provided is ethically and technically example from incomplete. However, this strategy has worked well Bangladesh for LMICs.

Table 3-4. Continued Title Authors Year of Journal Study Sample Key Findings Publication Published in Genital Human Quamrun Nahar, 2014 PLOS One Rural and While no effect of education was seen on HPV Papillomavirus Farhana Sultana, urbam adult infection in urban women, having primary, Infection among Anadil Alam, women secondary or higher education significantly Women in Jessica Yasmine decreased the risk of any HPV infection in rural Bangladesh: Islam, Mustafizur women. Occupation had the strongest effect on Findings from a Rahman, Fatema HPV infection for urban women. Rural women Population-Based Khatun, Nazmul whose husband lived overseas were almost twice Survey Alam,, Sushil Kanta as likely to have any HPV infection compared to Dasgupta, Lena those women whose husbands lived with them. The Marions, number of lifetime sex partners of urban women Ashrafunnessa, was significantly associated with detection of any Mohammed Kamal, HPV infection. Alejandro Cravioto, Laura Reichenbach

Role of Print and Ashrafun Nessa, 2013 Asian Pacific Rural and only 10-12% women pre-intervention knew that Audiovisual Media Muhammad Anwar Journal of semi-urban early detection of cancer can save lives but that in Cervical Hussain, Cancer adult men and 81uadrupled post intervention. Among men Cancer Mohammad Harun Prevention women however, the awareness early detection and Prevention in Ur Rashid, Nargis treatment of cervical cancer did not improve post Bangladesh Akhter, Joya Shree intervention. Participants’ knowledge about VIA and Roy, Romena Afroz pre-cancer cervix increased post-intervention. Besides the media used in the intervention, people learned about it through family members and neighbors. Women said people can be informed about VIA by television (drama serials, advertisement through cable line), mike announcement and health education/discussion sessions at Uthan Baithaks/EPI meetings/community clinics.

Table 3-4. Continued Title Authors Year of Journal Study Sample Key Findings Publication Published in Human Sankaranarayanan, 2008 Vaccine N/A Data is outdated. Papillomavirus R.; Bhatla, N.; Infection and Gravitt, P.; Basu, Cervical Cancer P.; Esmy, P.; Prevention in Ashrafunnessa, K.; India, Ariyaratne, Y.; Bangladesh, Sri Shah, A.; Nene, B. Lanka and Nepal

Evaluation of the Basu, P., Nessa, 2010 Journal of Adult women Screening was predominantly opportunistic as National Cervical A., Majid, M., Family women with existing symptoms of gential tract Cancer Screening Rahman, J. N., & Planning & infection or cervical malignancies were referred for Programme of Ahmed, T. Reproductive screening. Only 8.6% women who got VIA did so Bangladesh and Health spontaneously in the facilities evaluated. 28% of the the formulation of women in the centers evaluated were under the quality assurance recommended age. The uptake of the program guidelines even after 4 years of initiation was very low and the coverage achieved of the target population

Cervical cancer in Ansink, A.C., 2008 Transactions Rural and Strong preference for privacy and female doctors. Bangladesh: Tolhurst, R., of the Royal semi-urban Burden to get screened was put on women by the community Haque, R., Saha, Society of adult men and men, despite women’s difficulties to take perceptions of S., Datta, S., & Van Tropical women independent decisions about their health. Perceived cervical cancer den Broek, N.R. Medicine and consequence of getting cervical cancer differed and cervical Hygiene among men and women. While women perceived cancer screening being abandoned by family, men perceived the inconvenience it would cause in the family due to the physical inability of the affected women to perform her duties.

Table 3-5. Articles about Tobacco Control and Prevention. Title Authors Publication Journal Study Sample Key Findings Year Published A Cross-Country Bhawna Gupta, 2014 Asian Pacific Population Awareness about the harmful effects of Comparison of Narinder Kumar Journal of representative tobacco consumption was significantly high Knowledge, Cancer among Bangladeshis compared to others Attitudes and Prevention countries; rural Bangladeshis were also Practices about highly aware of the harmful effects Tobacco Use: Findings from the Global Adult Tobacco Survey

The role of negative Seema Mutti- 2017 Addictive Urban adult men Message effectiveness was influenced by the affect and message Packer, Jessica L. Behaviors and women personal relevance and identity of the credibility in Reid, James F. participants. Identity (age, gender, ethnicity) perceived Thrasher, Daniel concordance increased effectiveness of the effectiveness of Romer, Geoffrey T. cessation message. Pictorial warnings on smokeless tobacco Fong, Prakash C. cigarette packaging were more effective than health warning Gupta, Mangesh S. text-only warnings. labels in Navi Pednekar, Nigar Mumbai, India and Nargis, David Dhaka, Bangladesh: Hammond A moderated- mediation analysis

Patterns of Use and Seema Mutti, 2016 Indian Journal Urban men and Despite knowledge of the harmful effects of Perceptions of Harm Jessica L. Reid, of Community women both smokeless tobacco, 94% of the participants of Smokeless Prakash C. Gupta, Medicine young and adult used it on a daily basis. Respondents with Tobacco in Navi Mangesh S. low level of education were more likely to Mumbai, India and Pednekar, Gauri have a positive attitude towards smokeless Dhaka, Bangladesh Dhumal, Nigar tobacco. Nargis, AKM Ghulam Hussain, David Hammond

Table 3-5. Continued Title Authors Publication Journal Study Sample Key Findings Year Published in Influence of Health Jessica L. Reid, 2017 International Urban young and 50.4% of the youth participants were Warnings on Beliefs Seema Mutti- Journal of adult men, urban females. Adults who viewed the health about the Health Packer, Prakash C. Environmental young women warnings for impotence were more likely to Effects of Cigarette Gupta, Qiang Li, Research and say that smoking caused impotence. While Smoking, in the Jiang Yuan, Nigar Public Health there was no effect for youth. In contrast, Context of an Nargis, A. K. M. Bangladeshi youth who viewed the health Experimental Study Ghulam Hussain warnings for aging were more likely to say in Four Asian and David that smoking caused aging of the skin while Countries Hammond there was no effect for adults

Smokers’ responses Melanie Wakefield, 2013 Tobacco Adult males The portrayals of external visible damage as to television Megan Bayly, Control urban, rural and a result of smoking, and serious damage to advertisements Sarah Durkin, Trish semi-urban internal organs, were considered powerful about the serious Cotter, Sandra and motivating. Some ads were perceived harms of tobacco Mullin, Charles targeted towards females since the use: pre-testing Warne characters in the ad were females. Use of results from 10 low- Jargon in the ad such as emphysema was a to middle-income barrier to comprehension. countries

Determinants of Pete Driezen, Abu 2016 Global Health Urban, rural and Smokers employed in indoor areas where intentions to quit S. Abdullah, Anne Research and semi-urban men smoking is banned had 2.0 times higher odds smoking among C. K. Quah , Nigar Policy and women from of 84lanning to quit compared to smokers adult smokers in Nargis and age of 15 years who worked outdoors. Even partial bans Bangladesh: Geoffrey T. Fong and above. were associated with intentions to findings from the quit. Smokers living in homes with children International aged 5 or younger had significantly higher Tobacco Control odds of planning to quit compared to (ITC) Bangladesh smokers having no children in the home. wave 2 survey Awareness of the harmful effects of smoking on one’s own health was not associated with intentions to quit

Table 3-5. Continued Title Authors Publication Journal Study Sample Key Findings Year Published in Awareness of Pete Driezen, Abu 2016 International Population Slum residents had significantly lower odds Tobacco-Related S. Abdullah, Nigar Journal of representative of of being aware of the harms of cigarette Health Harms Nargis , A. K. M. Environmental young and adult smoking than urban residents. Most among Vulnerable Ghulam Hussain , Research and men and women vulnerable groups were least knowledgeable Populations in Geoffrey T. Fong, Public Health of the dangers of cigarette smoking. Illiterate Bangladesh: Mary E. Thompson Bangladeshis had significantly lower odds of Findings from the , Anne C. K. Quah being aware of the harms than Bangladeshis International and Steve Xu having nine or more years of formal Tobacco Control education. Interestingly, significantly higher (ITC) Bangladesh percentage of slum residents knew that Survey smokeless tobacco causes mouth cancer compared to non-slum residents. This result might be due to the higher prevalence of smokeless tobacco use among slum residents. Predictors of Abu S. Abdullah, 2015 Tobacco Population One point increase in self efficacy increased smoking cessation Pete Driezen, Anne Induced representative of the odds of successful cessation by 80%. behavior among C. K. Quah, Nigar Diseases young and adult Attempts to qiut was significantly related to: Bangladeshi adults: Nargis and men and women residing outside of Dhaka, aged 40 or older, findings from ITC Geoffrey T. Fong having a household monthly income Bangladesh survey >10,000taka, having intention to quit smoking in the future, working indoors.

Table 3-6. Articles on other types of cancers. Title Authors Publication Journal Study Sample Key Findings Year Published Score Based Risk Roushney Fatima 2014 Asian Pacific Urban and rural The socio-demographic conditions of lung Assessment of Lung Mukti, Pratul Dipta Journal of adult men and cancer were correlated with respect to Cancer and its Samadder, Cancer women annual income, residential area, occupation Evaluation for Abdullah Al Prevention and their educational level. Inability to afford Bangladeshi People Emran, Farzana early diagnosis. Smoking a significant risk Ahmed, Iqbal Bin factor for lung cancer among men. Previous Imran, Anyanna lung disease significant risk factor for both Malaker, Sabina men and women. Yeasmin

Knowledge, Attitudes Karl Peltzer, Supa 2015 Asian Pacific Urban college 20% aware of TSE, 84% never conducted and Practice of Pengpid Journal of students TSE in 12 months, 16.3% condected more Testicular Cancer than 10 times in 12 months, importance Selfexamination Prevention rating 6.3. Knowledge proportion more than among Male 20%. University Students from Bangladesh, Madagascar, Singapore, South Africa and Turkey

Bangladeshi Dental Chowdhury, 2010 Journal of Urban college Female respondents were significantly more Students’ Knowledge, M.T.H., Pau, A. & Cancer students likely to support receiving specific tobacco Attitudes and Croucher, R. Education cessation training and routinely advising their Behaviour Regarding patients to quit tobacco use. Nearly all Tobacco Control and (97.3%) would support the dentist having a Oral Cancer role in giving advice on tobacco cessation, the need for specific training on tobacco cessation (91.9%) and the routine provision of advice to patients to quit smoking (90.9%). Fewer respondents (73.7%) felt their advice would increase a patient’s chances of quitting even though 78% of respondents felt they should serve as role models.

CHAPTER 5 DISCUSSION

In the following sections, the implications of this study are detailed. The discussion is categorized in three parts. First, an audience analysis is provided where the different demographic characteristics in Bangladesh pertaining to cancer prevention is discussed. The aim of this part is to provide information that can be taken into account while tailoring and targeting future cancer prevention messages towards the

Bangladeshi populations. The other two parts of the discussion sections are, the theoretical and the practical implications of the study.

Audience Analysis

Developing effective health campaigns and messages require analysis of specific audience (Kopfman & Smith, 1996). Hence, differences based on the target audiences’ knowledge & literacy level, gender, and geographic location are important factors to consider before designing a campaign. Health campaigns and messages have been proven to be more effective in inducing expected behavioral change, i.e. getting screened for cancer, when they are targeted and tailored towards it audience (Brian et al., 2018; Lee et al., 2018; Ukoli et al., 2013). In the following sections, audience specific differences found in the reviewed articles are discussed.

Knowledge about Cancer

While most studies that evaluated knowledge of cancer among participants mentioned a general knowledge of cancer, knowledge about specific cancers, such as cervical, or breast was not as common. Participants in cervical cancer studies were generally not aware of the Human Papilloma Virus (HPV), the vaccine can prevent contraction, and the fact that contracting HPV might result in cervical cancer. Cancer

screening was not well understood or practiced either. Cancer fatalism was also a common pattern in cancer knowledge, perceiving cancer as a “death sentence,” or that

“no good treatment exists” to prevent or treat cancer. Misinformation about the causes, symptoms, and treatment of cancer is also common. In one study, participants thought screening itself was a treatment for cancer. Good health behavior was also associated with preventing cancer. Culture and language specific barriers to knowledge exists as well; such as, there is no word for “breast cancer” in the native language, Bangla; cervical cancer is perceived as an “ulcer in the neck of the womb.” Female body is also perceived culturally inappropriate to talk about in the public. Hence, public announcements about screening that might contain words pertaining to female body parts might not be feasible. But, participants in surveys, interviews, and focus group discussions, in the articles reviewed in this scoping study, were open to discuss about cervical and breast cancer in private or semi-private settings. Studies evaluating the effectiveness of an intervention on increased knowledge mentioned positive trends among both men and women.

Perceived Barriers to Cancer Prevention

Most studies reviewed showed that increased knowledge did not translate into behavioral change. Despite the perceived severity of cancer, and the importance, or benefits (perceived response efficacy) of cancer screening, motivation to screen for cancer did not significantly increase in most cases. This finding supports the literature on health behavioral change which state that increased knowledge does not mean behavioral change. The most well-known example of it is the risk of oral and lung cancer due to smoking. Most smokers, despite being aware of the dangers of tobacco consumption, do not quit smoking. Their knowledge of the severity of lung cancer or oral

cancer does not affect behavioral change. There might be various barriers that prohibits behavioral change. In the scoping study, we found the following barriers:

Low perceived susceptibility to cancer.

Despite having the perceived severity of cancer, perceived susceptibility or an individual’s perceived belief of being at risk of having cancer is predominantly low among Bangladeshis. The articles reviewed in this study that detailed perceived susceptibility were about either breast or cervical cancer and predominantly based on female perceptions of susceptibility. For example, one study mentioned, only 11% of its participants perceived being at risk of breast cancer, and those who knew of mammogram, only 16% of them ever had it. Most women in that study mentioned they did not think breast exams were necessary. However, 59% of them reported of practicing breast self-exam.

Low perceived self-efficacy of cancer screening.

While participants in studies evaluating their understanding and perceptions of cancer screening methods agreed that screening was an effective way to prevent cancer and detect it in early stages, their circumstantial barriers made screening an un- affordable way to prevent cancer. Lack of healthcare facilities in the vicinity, especially in the rural areas, lack of guarantee that there will be a doctor at the facility once they got to the hospital, transportation problems, women’s social barriers such as shyness to talk about their problems to physicians, concerns about safety while going to the hospitals unescorted, lack of permission from husbands to go to get screened, lack of financial support, lack of female doctors in rural area, etc., expensive nature of getting screened- were predominant reasons that participants did not think they could get screened for cancer despite perceiving screening to be important.

Poor healthcare infrastructure.

The participants’ perceived lack of access to or existence of healthcare facilities was supported by the infrastructural reports reviewed in the study. Cancer screening in

Bangladesh is still predominantly opportunistic, rather than systematic or preventive. At the policy-making level and with the politicians, environmental disasters and deaths from infectious diseases take priority over cancer prevention. While, one of the studies found that government investment is one of the strongest predictors of improvement in cancer screening, policymakers’ perceived lower priority of cancer morbidity is a barrier to the development of the preventive infrastructure in Bangladesh. The formative literature indicates that demand for female doctors is high in both rural and urban areas for breast and cervical cancer screening. However, female physicians are rare in hospitals, especially in rural areas.

The International Atomic Energy Agency (IAEA, 2008) recommends that

Bangladesh needs 300 radiotherapy centers (two per one million of the population) for the treatment of all cancer patients. But, Bangladesh has only 14 functional radiotherapy centers, nine in public hospitals and five in private. The lack of access to healthcare adds to the reluctance of getting screened for cancer, since there is a fear of getting a positive result and then not being able to do anything about it. Poor healthcare infrastructure is further weakened by corruption, unavailability of specialized physicians, and brokers who get commissions from other physicians to draw patients from different doctors, which in turn reduces follow-ups. Lack of electronic health record system is another feature of the healthcare infrastructure that create barrier to cancer care in

Bangladesh.

Literacy.

All the studies that included literacy variable as an indicator of cancer screening found positive relation between them. In a study conducted in urban Bangladesh, women with more than 12 years of education were significantly more likely to get screened for breast cancer than women with fewer years of education. Women were also less likely to be even aware of breast cancer if they had only primary or no education. Another study found, women with greater than high school education were more likely to get pap smear test for cervical cancer.

Gender Differences

Review of the articles revealed gender differences in cancer beliefs, perceived barriers, and attitudes towards preventive methods. For example, for cervical cancer screening through speculum test, men in rural Bangladesh perceived women would be frightened but women did not mention being frightened themselves. While women were relatively more open to seeing a male doctor if conditions were painful, men only agreed for their female relatives to see a male doctor if it were a life and death situation and male doctors were the only option. For consequence of cancer, while women tend to think about the adverse effect on themselves such as being exiled from the family, men tend to focus on the physical consequences such as women not being able to do the household work they are supposed to do or not possible to have intercourse. In terms of lung and oral cancer, men tend to display more risky behavior than women. While women consume significantly less tobacco than men, women are more open to support receiving specific tobacco cessation training compared to men. In rural Bangladesh, other household issues such as child-rearing, health of a male member of the family, would often take priority over female health, which makes it difficult for women to get

screened for cancer, a barrier not commonly faced by men. For cervical cancer screening, an intervention evaluated that it increased awareness of cervical cancer and knowledge of pre-cancer cervix among rural women but had no effect on men.

Understanding the gender differences can help come up with message strategies that will influence and motivate men to take their wives for regular screening, especially in the rural areas because rural women are predominantly dependent on their male family members to travel to, and pay for screening.

Geographic Differences

An analysis of the World Health Survey showed that women residing in the rural areas have a reduced likelihood of getting screened for cervical or breast cancer. Within the rural area, lower SES women are even less likely still to get screened for breast or cervical cancer compared to rural women with higher SES. This relationship is true for urban women but with a stronger reduction in urban lower SES women. Healthcare seeking behavior also varies between urban and rural populations. While rural women are more likely to go to healthcare center if the travel time is more than hour while urban women display the opposite trend. They are less likely to go to the hospital if the travel time is greater than an hour. Rural men and women also prefer female community health workers providing service door-to-door. Going to private clinics instead of government healthcare centers is also related to increased screening. However, private clinics are more available in the urban areas while the rural areas are mostly dependent on government healthcare centers. Rural population is also more likely to look for traditional medicine, faith-healing, and homeopathic medicine. However, there is no comparative study with the urban population in this regard.

Theoretical Implications

Even though none of the studies mentioned any theory that they based their surveys or interventions on, the results of the systematic review seem to follow a couple of communication theories. Extended Parallel Process Model (EPPM; Witte, 1992) can help understand the lack of cancer screening practices in Bangladesh. EPPM postulates that, if perceived threat (perceived severity and susceptibility) of a disease is low, the solution provided by a message will not be evaluated at all. The scoping review shows an overall high perceived severity of cancer. Most studies that asked their participants if they thought cancer is a deadly disease, majority of the participiant answered positively.

However, a common trend of low perceived susceptibility of cancer among the

Bangladeshis is also observed. Participants in majority studies seem not to think they are individually susceptible to getting cancer. For example, in most of the breast cancer related studies, participants only thought they had susceptibility to contracting breast cancer if they had a family member who had breast cancer. Many participants did not think they could get breast cancer if they got old.

The misinformed causes of various cancers also seemed to reduce the perceived susceptibility of cancer. For example, poor menstrual hygiene was considered a reason for cervical cancer, punishment for sin was also a perceived cause of cancer. Thus, if an individual perceived, they have adequate menstrual hygiene or lived a religiously righteous life, s/he might perceive to have low susceptibility of cancer. Hence, despite having some sense of cancer severity, the reduced susceptibility might influence the screening behavior among the Bangladeshis.

Moreover, according to EPPM, if perceived threat of a disease is high, along with perceived efficacy (self-efficacy and response efficacy) of a solution provided by a message, the behavioral change will be maximum. However, even if perceived threat of cancer is high among Bangladeshis, perceived self-efficacy of cancer is evidently low, according to the findings of the scoping review.

Self-efficacy is an individual’s perception of his or her ability to perform a behavior, in this case, screening for cancer. The lack of access to healthcare, financial constraints, lack of trust in physicians, etc. result in a low perceived efficacy of screening. According to EPPM, if threat of a disease is high, but efficacy of the solution is low, people tend to avoid the behavioral change suggested by the message and the message itself. Witte (1992) terms this process as fear control, where an individual, instead of changing his or her behavior, follows a maladaptive path of avoiding the behavior.

Besides the EPPM, the Theory of Planned Behavior (TPB, Ajzen, 1991) also helps understand the barriers to increase screening in Bangladesh. In general, the study found that the Bangladeshis have a positive attitude towards cancer screening and preventive methods for cancer, such as, tobacco cessation or HPV vaccines.

However, despite the positive attitude about the likelihhod that prevention and early detection will help reduce the risk of cancer, the subjective norms and the perceived behavioral control about screening and cancer reduces the rate of screening and taking preventive measures.

For example, perceived behavioral control in the form of environmental barriers faced by the rural population, such as, poor transportation to reach screening facilities,

lack of cancer care facilities in close proximity and lack of money reduce their intention to screen or get preventive care for cancer. Among the urban populations, perceived behavioral controls such as lack of time due to family duties or not knowing the symptoms of certain cancers to intiate preventive measures, end up reducing the intention to seek cancer care. While smoking prohibition at work place was found to be the best predictor of smoking reduction at work place in the urban Bangladesh, lack of such prohibitive law for outdoor workers (i.e. construction workers, day laborers) aid to the lack of tobacco control. It can also be categorized as an environmental barrier that makes tobacco cessation as perceived difficult to attain.

Subjective norms faced by women, such as being abandoned by their husband if diagnosed positive for cancer, or being socially outcast for getting breast care act as barriers for them to get cancer care. Other subjective norms, such as, fatalistic beliefs about cancer (i.e. it has no cure and death is the only outcome), also reduce the intention of getting screened. Social norms, such as, lower priority given to women’s health in the family, influence the lack for cancer care seeking among Bangladeshi women.

Practical Implications

Out of the 985 search results in this scoping review, 722 were excluded in the abstract and title screening. The top criteria for exclusion was the articles being clinical research in nature. Moreover, 53 articles in the full-text screening phase were excluded because they did not include any information about the communication aspect of cancer prevention (i.e. sender, receiver, and message). It is evident that there is plenty of basic-science based knowledge about cancer as many studies are being conducted to understand the clinical aspects of cancer vulnerability among Bangladeshis. Compared

to that, little research is being conducted to translate that knowledge into practice, or to communicate with the general public. None of the articles reviewed in this study was even published in a communication based journal. This indicates a lack of research in preventive cancer communication in Bangladesh.

On June 14, 2019, the national budget for the 2019-20 fiscal year was announced in Bangladesh. While 4.9% of the total budget was dedicated to health sector, there was no budget allocation for any non-communicable disease prevention, including cancer screening (Palma, 2019). This can be directly attributed to the lack of policy on cancer prevention, which is a result of the gap between empirical research and action according to the KTA model. This study shows that there is a huge gap between the knowledge about cancer in Bangladesh, and the implementation of that knowledge into action. Only six studies among the 35, actually were about communication-based interventions to prevent cancer in Bangladesh. More research in communication is needed to utilize the knowledge base to develop effective campaigns to promote awareness about cancer, and screening.

This study also found that only four studies mentioned cultural appropriateness of the messages. While culturally appropriate interventions have been proven to be the most effective way to reach out to the target audience, and induce behavioral change

(Briant et al., 2018), none of the studies provided information about any systematic method for designing culturally appropriate interventions, neither did they provided any theoretical basis for evaluating the effect of culture in the outcome of an intervention.

However, tobacco cessation studies did report that messages had reduced impact on participants when the pictorial portrayals in the messages were race, age, and/or

gender discordant. The mHealth based studies about breast cancer screening mentioned the benefits of using CHWs in gaining the trust of the participants and having them participate in the study. Even though, the studies did not directly address the importance of cultural appropriateness in communication intervention design, their findings allude to it. Only one study discussed the linguistic and cultural barriers faced by the rural people when talking about breast cancer. The small numbers of studies reporting anything pertaining to culture also implies that there is a need for research in designing, implementing, evaluating culturally appropriate cancer-preventive communication interventions.

The studies also did not include many vulnerable populations, such as tribal people in the hill tracts, transgender people, intersex people, homosexuals, and sex workers, Only the tobacco related studies included slum dwellers in the city areas, and one study on HPV infection included garments workers and housemaids. More research is required to understand the vulnerability, effective methods of delivering preventive cancer messages, and raising awareness of cancer and screening among these populations. Moreover, there is a lack of research on communicating prevention among the under-age population. Only one study on the ethics of HPV vaccination included adolescent girls, but excluded adolescent boys. Few studies about breast and cervical cancer included under-age women, and studies on tobacco cessation included boys and girls over 15.

Limitations & Future Research

Like any other study, this one is not beyond limitations. First, this study is limited to the review of articles that are published in peer-reviewed journals. As academic publications often suffer from the filedrawer problem, not including unpublished articles

may have skewed the findings of the study. As a result, the study cannot provide information on what communication interventions have not worked in Bangladesh or whether there are sample populations that have high and satisfactory screening rates, as opposed to the general hypothesis that Bangladesh being an LMIC, suffers from low screening rate.

The study also excluded whitepapers, government and NGO reports on cancer control in Bangladesh. While this exclusion was necessary to be able to claim the findings of this study as completely evidence-based, such exclusion may have ingnored local, common knowledge. This may also have caused a bias towards studies satisfying

Western standards of research, and a bias against the Eastern research practices.

Future reseach should be conducted where unpublished and non-peer-reviewed literature is included.

While in any systematic review it is normative for at least two reviewers to screen titles, abstracts and then full-texts, in this study only 10% of the articles for title and abstract screening were evaluated by two researchers. Finding ample reliability, the rest of the screening was conducted by the author. Text screening was also conducted solely by the author. Normatively, in systematic reviews, data extraction and charting is also conducted by at least two researchers, dividing the workload equally between them. However, in this study, data extraction, and charting was done solely by the author as well. This might have invoked personal biases in the findings.

Future research is required to design, implement, and evaluate more communication-based intervention for cancer prevention in Bangladesh, preferably targeted towards specific population groups. Moreover, similar systematic reviews need

to be conducted to synthesize existing knowledge on cancer diagnosis, treatment and palliative care, in order to inform guidelines for cancer control.

Many available and past cancer-related campaigns and messages developed by private (e.g. private hospitals, NGOs) and public entities (Government, public schools) in Bangladesh have not been evaluated and hence, information about them is not available in peer-reviewed journal. Future research can include content, or textual analysis of newspapers, cancer-related websites and webpages, television advertisements, leaflets and posters. Multimethod studies using stakeholder interviews and surveys in the policy, treatment and research level can help inform policies.

Findings of this study can be used to develop interventions targeted towards particular populations, based on their needs. For example, culturally appropriate interventions for female-cancers in the rural areas, environmentally accessible tobacco cessation interventions in the slums in Dhaka, HPV vaccination and HPV awareness programs for adolescent boys, and tobacco control mechanisms in outdoor work places such as construction sites.

Findings also inform the populations that have not been researched in

Bangladesh. For example, tribal population in the hill tracts and in the Northern part of the country, sex workers, risk of breast cancer among garments workers and housmaids, risk of tobacco-induced cancer among adult females, and risk of cancer among the LGBTI members in the country. Future research need to be conducted to approach these populations to communicate about cancer prevention and detection, being conscious of the cultural sensitivity of the country. For example, homosexuality is

illegal in Bangladesh. Hence, finding members of this population group may cause severe risk to the safety of the participants.

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CHAPTER 6 CONCLUSION

The findings indicate key features to consider when creating a cancer prevention campaign. The emergent themes are not mutually exclusive. A rural-urban divide fuels the cancer burden as care and treatment are populated in urban centers, leaving rural residents marginalized. Associations with individual and neighborhood factors such as economic, transportation, and gender barriers appear to exist. These challenges operate and should not be overlooked despite minimal emphasis of the limited research.

Existing efforts are aimed to target behavioral change. The opportunity to educate the population about cancer has been underutilized. The findings demonstrate that a gap in accurate knowledge of cancer centers on misinformation. Using a multimethod approach may better account for the shortcomings. A media campaign using television and radio show promise in outreach especially in areas with stable electricity.

It may be that in rural areas, making microphone announcements enables delivery and also extends the reach to include women who may spend most of their time within the household. The participation of the healthcare sector must complement any cancer awareness campaign.

Direct communication to the patient from the health worker is critical for impact.

Two-way communication allows for dispelling myths, answering patient questions, and providing clinical advice. This type of training may be fruitful to include during medical school training to improve overall cancer outcomes. Community health workers can incorporate similar protocol in their coverage of rural populations.

Receiving correct information and having a space for expressing concerns appears to be inadequately addressed. Through home visitations, rural villages can

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overcome barriers to entry. Availability and accessibility challenges are pervasive in the country. Comprehensive care across the continuum is needed with an emphasis on health communication. Early detection and diagnoses can increase.

While cultural competency has been at the forefront of modern health practices, this preoccupation puts at risk the minimization of variables operating at the structural level. When approaches are developed by out-group members and groups, this must be considered so as to not impose biases and potentially misguide resource allocations.

Sensitivity must be informed by quality evidence retrieved from the target population and/or site.

Accordingly, our strategies indicate greater need to bridge communication gaps between the healthcare personnel and the public. Household factors are integrated within this larger framework. No large-scale systematic reviews exist on cancer communication in Bangladesh, and very few studies address the development of effective cancer prevention messages for this population. Future work must prioritize closing this gap as the threat of cancer continues to grow and affect the quality of life of many. Awareness campaigns coupled with access programs are essential to educate communities that the risk of dying from some cancers can be minimized significantly through screening and healthy lifestyles. Ongoing communication throughout the continuum of care can inspire change.

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APPENDIX A ARTICLE SEARCH STRATEGY

Research Question

What is known Core Databases Limits about the PsycINFO Publication Types: Scientific preventive cancer PubMed articles published in peer communication Academic Search Premier reviewed academic journals interventions in Dates: Until May 21, 2019 Language: English Bangladesh?

Primary Literature Searching: Databases Database: PsycINFO Concept: Concept: Concept: Communication Bangladesh Cancer Thesaurus Bangladesh Cancer Prevention Terms Intervention Treatment Program Campaign awareness PsycINFO SEARCH STRATEGY (“Bangladesh” AND “cancer” AND (“prevention” OR “intervention” OR “Treatment” OR “program” OR “campaign” OR “awareness”)) Conditions set in search option: Search modes: Find all my search terms, apply related words Language: English Publication type: Peer-reviewed journal Population group: Human Methodology: All Exclude Dissertation (Checked) No age-group selected Total Added: 17

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Database: PubMed

Concept: Concept: Cancer Concept: Bangladesh Communication

Thesaurus Bangladesh Cancer Prevention, Awareness, Terms Communication, Intervention, Program campaign Mesh bangladesh Neoplasms, cancer Awareness, Terms communication, methods

SEARCH STRATEGY (("bangladesh"[MeSH Terms] OR "bangladesh"[All Fields]) AND ("neoplasms"[MeSH Terms] OR "neoplasms"[All Fields] OR "cancer"[All Fields])) AND (("prevention and control"[Subheading] OR ("prevention"[All Fields] AND "control"[All Fields]) OR "prevention and control"[All Fields] OR "prevention"[All Fields]) OR ("awareness"[MeSH Terms] OR "awareness"[All Fields]) OR ("communication"[MeSH Terms] OR "communication"[All Fields]) OR ("methods"[MeSH Terms] OR "methods"[All Fields] OR "intervention"[All Fields]) OR program[All Fields] OR campaign[All Fields])

Total Added: 638 635 (in English)623 (Items with abstract)

Database: Academic Search Premier

Concept: Concept: Concept: Bangladesh Cancer Communication Thesaurus Bangladesh Cancer Prevention Terms Intervention Treatment Program Control Strategy

SEARCH STRATEGY ((Bangladesh) AND (Cancer) AND (Prevention OR Intervention OR Treatment OR Program OR Control OR Strategy))

Conditions set in search option: Search modes: Find all my search terms, apply related words Language: English Publication type: Peer-reviewed journal Document type: Article Total Added: 345

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APPENDIX B QUALTRICS SURVEY

Literature review cancer communication in Bangladesh

Start of Block: Default Question Block

Q1 Title of the Article

______

Q2 Publication year

______

Q3 Journal published in

______

Q4 Authors

______

Q5 Type of study...

______

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Q6 Cancer type

o Breast (1)

o Cervical (2)

o Colorectal/ Colon/ Rectal (3)

o Lung (4)

o Oral/Oral Cavity/Lip (5)

o Prostate (6)

o Stomach (7)

o Esophageal (8)

o Liver (9)

o Lukemia (10)

o Ovarian (11)

o General (12)

o Other (13) ______

Q7 Study population type

o Rural (1)

o Urban (2)

o Suburban (3)

o Mixed (4) ______

o Not specified (5)

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Q8 Study population size

______

Q9 Study population gender

o Male (1) ______

o Female (2) ______

o Both (3) ______

o Not Specified (4)

Q10 Age of the population

______

Q11 Study population SES

______

Q12 Aims of the study.

______

Q13 Methodology of the study

______

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Q14 Outcome measures

______

Q15 Important results

______

Q16 Conclusions drawn by the authors

______

Q17 Any additional information, not coded in the questionnaire but seemed important to the coder.

______

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LIST OF REFERENCES

Abdullah, A. S., Driezen, P., Quah, A. C., Nargis, N., & Fong, G. T. (2015). Predictors of smoking cessation behavior among Bangladeshi adults: findings from ITC Bangladesh survey. Tobacco induced diseases, 13(1), 23. doi:10.1186/s12971- 015-0050-y*

Ahmad, F., Kabir, S. F., Purno, N. H., Islam, S., & Ginsburg, O. (2017). A study with Bangladeshi women: Seeking care for breast health. Health Care for Women International, 38(4), 334-343. doi:10.1080/07399332.2016.1263305*

Ahmed, K., Asaduzzaman, S., Bashar, M.I., Hossain, G., & Bhuiyan, T. (2015). Association Assessment among Risk Factors and Breast Cancer in a Low Income Country: Bangladesh. Asian Pacific journal of cancer prevention : APJCP, 16 17, 7507-12 *

Ahsania mission cancer & general hospital (AMCGH). (2010). Retrieved from http://www.ahsaniamission.org.bd/amcgh/

Ajzen, I. (1991). The theory of planned behavior doi:https://doi.org/10.1016/0749- 5978(91)90020-T

American Cancer Society. (2012). Global cancer facts and figure, 3rd edition. (). Atlanta: American Cancer Scoeity. Retrieved from https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and- statistics/global-cancer-facts-and-figures/global-cancer-facts-and-figures-3rd- edition.pdf

Ansink, A., Tolhurst, R., Haque, R., Saha, S., Datta, S., & Broek, N. (2008). Cervical cancer in Bangladesh: Community perceptions of cervical cancer and cervical cancer screening. Transactions of the Royal Society of Tropical Medicine and Hygiene, 102(5), 499-505 

Arksey, H., & O'Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19-32. doi:10.1080/1364557032000119616

About Asian Pacific Journal of Cancer Prevention. Asian Pacific Journal of Cancer Prevention. Retrieved from http://13.228.5.104/journal/about

Banerjee, A., Bhawalkar, J. S., Jadhav, S. L., Rathod, H., & Khedkar, D. T. (2012). Access to health services among slum dwellers in an industrial township and surrounding rural areas: a rapid epidemiological assessment. Journal of family medicine and primary care, 1(1), 20–26. doi:10.4103/2249-4863.94444

Bangladesh cancer society. (2018). Retrieved From http://bangladeshcancersociety.org/newsite/about-us-2/

109

Bangladesh medical journal (2018). ResearchGate. Retrieved from https://www.researchgate.net/journal/0301-035X_Bangladesh_medical_journal

Basu, P., Nessa, A., Majid, M., Rahman, N., & Ahmed, T. (2010). Evaluation of the national cervical cancer screening programme of Bangladesh and the formulation of quality assurance guidelines. Journal of Family Planning & Reproductive Health, 36(3), 131-134. doi:10.1783/147118910791749218 

Bhuiyan, A., Sultana, F., Islam, J. Y., Chowdhury, M., & Nahar, Q. (2018). Knowledge and Acceptance of Human Papillomavirus Vaccine for Cervical Cancer Prevention Among Urban Professional Women in Bangladesh: A Mixed Method Study. BioResearch open access, 7(1), 63–72. doi:10.1089/biores.2018.0007*

Blankart, C. R. (2012). Does healthcare infrastructure have an impact on delay in diagnosis and survival? doi:https://doi.org/10.1016/j.healthpol.2012.01.006

Briant, K.J., Sanchez, J.I., Ibarra, G.S., Escareño, M., Gonzalez, N.E., Gonzalez, V.J., Marchello, N., Louie, S.W., & Thompson, B.C. (2018). Using a Culturally Tailored Intervention to Increase Colorectal Cancer Knowledge and Screening among Hispanics in a Rural Community. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 27 11, 1283-1288 .

Briñol, P., & Petty, R. (2006). Fundamental Processes Leading to Attitude Change: Implications for Cancer Prevention Communications, Journal of Communication, 56 (1), S81–S104, https://doi.org/10.1111/j.1460-2466.2006.00284.x

Call for massive awareness campaign to prevent breast cancer. (2007, 2007). The Daily Star Retrieved from https://www.thedailystar.net/news-detail-9802

Cancer (2018). WHO News. Retrieved from https://www.who.int/news-room/fact- sheets/detail/cancer

Cancer Control: Knowledge into Action. WHO Guide for Effective Programmes (2006). The World Health Organization. Retrieved from https://www.who.int/cancer/modules/Modules%20Flyer.pdf?ua=1

Cancer Control Continuum (2017). National Cancer Institute: Division of Cancer Control & Population Sciences. Retrieved from https://cancercontrol.cancer.gov/od/continuum.html

Carroll J, Epstein R, Fiscella K, Volpe E, Diaz K, Omar S, et al. Knowledge and beliefs about health promotion and preventive health care among Somali women in the United States. Health Care Women Int. 2007;28:360–80

110

CDC. (2017). Global disease detection program: Bangladesh. Retrieved from https://www.cdc.gov/globalhealth/healthprotection/gdd/bangladesh.html

Chowdhury, S. & Sultana, S. (2011). Awareness of breast cancer among the womn of reproductive age. Journal of Family and Reproductive Health, 5(4)*

Chowdhury, T. I., Love, R. R., Chowdhury, M. T. I., Artif, A. S., Ahsan, H., Mamun, A., Salim, R. (2015). Feasibility Study of Case-Finding for Breast Cancer by Community Health Workers in Rural Bangladesh. Asian Pacific Journal of Cancer Prevention, 16(17), 7853–7857. https://doi.org/10.7314/apjcp.2015.16.17.7853*

CIA. (2016). The world factbook: Bangladesh. Retrieved from https://www.cia.gov/llibrary/publications/the-world-factbook/geos/bg.html

Cohn, B., Merrill, M., Krigbaum, N., Yeh, G., Park, J., Zimmermann, L., & Cirillo, M. (2015). DDT Exposure in Utero and Breast Cancer, The Journal of Clinical Endocrinology & Metabolism, 100(8), 2865–2872, https://doi.org/10.1210/jc.2015- 1841

Corcoran, N. (2007). Theories and models in communicating health messages. In Communicating Health: Strategies for Health Promotion, pp 5-31. London, Sage Publication

DHHS (2008). National health care disparities report (AHRQ Publication No. 09-0002), Rockville, MD

Driezen, P., Abdullah, A. S., Nargis, N., Hussain, A. K., Fong, G. T., Thompson, M. E., Xu, S. (2016a). Awareness of Tobacco-Related Health Harms among Vulnerable Populations in Bangladesh: Findings from the International Tobacco Control (ITC) Bangladesh Survey. International journal of environmental research and public health, 13(9), 848. doi:10.3390/ijerph13090848*

Driezen, P., Abdullah, A. S., Quah, A., Nargis, N., & Fong, G. T. (2016b). Determinants of intentions to quit smoking among adult smokers in Bangladesh: findings from the International Tobacco Control (ITC) Bangladesh wave 2 survey. Global health research and policy, 1, 11. doi:10.1186/s41256-016-0012-9*

Florida Physician Workplace Profile (2017). Association of American Medical Colleges. https://www.aamc.org/download/152112/data/florida.pdf

Ginsburg, O. M., Chowdhury, M., Wu, W., Chowdhury, M. T., Pal, B. C., Hasan, R., … Salim, R. (2014). An mHealth model to increase clinic attendance for breast symptoms in rural Bangladesh: can bridging the digital divide help close the cancer divide?. The oncologist, 19(2), 177–185. doi:10.1634/theoncologist.2013- 0314*

111

Global Health Workforce Allaiance. Bangladesh. Retrieved from http://www.who.int/workforcealliance/countries/bgd/en/

Gough, D., & Thomas, J. (2017). Commonality and diversity in reviews. In Gough, D, Oliver, S., & Thomas, J. (Eds), An Introduction to Systematic Reviews (pp 48- 50). California, SAGE Publication

Graham, I., Logan, J., Harrison, M., Straus, S., Tetroe, J., Caswell, W., Robinson, N. (2006). The Journal of Continuing Education in the Health Professions, 26, 13- 24

Gupta, B., & Kumar, N. (2014). A Cross-Country Comparison of Knowledge, Attitudes and Practices about Tobacco Use: Findings from the Global Adult Tobacco Survey. Asian Pacific Journal of Cancer Prevention, 15 (12), 5035-5042. doi: http://dx.doi.org/10.7314/APJCP.2014.15.12.5035 *

Health Care for Women International (2017). Taylor & Francis Online. Retrieved from https://www.tandfonline.com/toc/uhcw20/current

Health Metrics Network (HMN) Secretariat. (2009). Health information system assessment: Bangladesh country report. Dhaka: Ministry of Health and Family Welfare, Bangladesh. Retrieved from https://www.k4health.org/sites/default/files/hmn_bgd_assess_final_2009_07 _en.pdf

HNAP (2018). World Health Organization Bangladesh. Retrieved from https://www.who.int/globalchange/resources/wash-toolkit/hnap-bangladesh.pdf

Hossain, S., Ferdous, S., & Karim-Kos, H. (2014). Breast cancer in South Asia: A Bangladeshi perspective. Cancer Epidemiology, 38(5), 465-470 

Hovland, C., & Weiss, W. (1951). The Influence of Source Credibility on Communication Effectiveness. Public Opinion Quarterly, 15(4), 635– 650, https://doi.org/10.1086/266350

HRW. (2016). Nepotism and neglect: The failing response to arsenic in the drinking water of Bangladesh's rural poor. Human Rights Watch. Retrieved from https://www.hrw.org/report/2016/04/06/nepotism-and-neglect/failing- response-arsenic-drinking-water-bangladeshs-rural

Hussain, A. (2013). Comprehensive update on cancer scenario of Bangladesh. South Asian Journal of Cancer, 2(4), 279-284. doi:10.4103/2278-330X.119901 

Hussain, S., & Sullivan, R. (2013). Cancer control in Bangladesh. Japanese Journal of Clinical Oncology, 43(12), 1159-1169. doi:0.1093/jjco/hyt140 

112

Hussain, S., & Zaman, M. (2008). National Cancer Control Strategy and Plan of Action 2009-15 IAEA. (2008). Setting up a radiotherapy programme: Clinical, medical physics, radiation protection and safety aspects. Vienna: International Atomic Energy Agency. Retrieved from https://www- pub.iaea.org/MTCD/Publications/PDF/pub1296_web.pdf

International Journal of Environmental Research and Public Health (2019). International Journal of Environmental Research and Public Health-Open Access Journal. Retrieved from https://www.mdpi.com/journal/ijerph

Islam, J. Y., Khatun, F., Alam, A., Sultana, F., Bhuiyan, A., Alam, N., … Nahar, Q. (2018). Knowledge of cervical cancer and HPV vaccine in Bangladeshi women: a population based, cross-sectional study. BMC women's health, 18(1), 15. doi:10.1186/s12905-018-0510-7*

Islam, R. M., Bell, R. J., Billah, B., Hossain, M. B., & Davis, S. R. (2015). Lack of Understanding of Cervical Cancer and Screening Is the Leading Barrier to Screening Uptake in Women at Midlife in Bangladesh: Population-Based Cross- Sectional Survey. The oncologist, 20(12), 1386–1392. doi:10.1634/theoncologist.2015-0235*

Islam, R., Bell, J., Billah, B., Hossain, M., & Davis, S. (2016). Awareness of breast cancer and barriers to breast screening uptake in Bangladesh: A population based survey. Maturitas, 84, 68-74 

Kopfman J., & Smith, S. (1996). Understanding the audience of a health communication campaign: A discriminant analysis of potential organ donors based on intent to donate. Journal of Applied Communication Researcg, 24, pp 33-49

Krieger, N., Chen, J. T., Waterman, P. D., Rehkopf, D. H., & Subramanian, S. V. (2003). Race/Ethnicity, gender, and monitoring socioeconomic gradients in health: A comparison of area-based socioeconomic Measures—The public health disparities geocoding project. Am J Public Health, 93(10), 1655-1671. doi:10.2105/AJPH.93.10.1655

Lee, H., Lee, M., Gao, Z., & Sadak, K. (2018). Development and evaluation of culturally and linguistically tailored mobile app to promote breast cancer screening. Journal of Clinical Medicine, 7 (181), doi: 10.3390/jcm7070181

Love, R. R., & Salim, R. (2015). Public health oncology in practice: The Amader Gram Rampal project in rural Bangladesh doi:https://doi.org/10.1016/j.jcpo.2015.05.003

Lown, B., & Banerjee, A. (2006). The developing world in The New England Journal of Medicine. Globalization and Health, 2, 3 - 3.

113

Mathew, A. (2018). Global survey of clinical oncology workforce. Journal of Global Oncology, 4, 1-12

Mays N Roberts E Popay J (2001) Synthesising research evidence In N. Fulop, P. Allen, A. Clarke, & N. Black (Eds.) Studying the organisation and delivery of health services: Research methodsLondon Routledge

Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh (2011). National Health Plan. Retrieved from http://www.mohfw.gov.bd/index.php?option=com_content&view=article&id=74&It emid=151&lang=en

Mohammad, T., Hossain, C., Allan, P., & Ray, C. (2010). Bangladeshi dental students’ knowledge, attitudes and behaviour regarding tobacco control and oral cancer. Journal of Cancer Education, 25(3), 391-395 

Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle, P., Stewart, L. & PRISMA-P Group (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews, 4(1), doi:10.1186/2046-4053-4-1

Mutti, S., Reid, J. L., Gupta, P. C., Pednekar, M. S., Dhumal, G., Nargis, N., … Hammond, D. (2016). Patterns of Use and Perceptions of Harm of Smokeless Tobacco in Navi Mumbai, India and Dhaka, Bangladesh. Indian journal of community medicine : official publication of Indian Association of Preventive & Social Medicine, 41(4), 280–287. doi:10.4103/0970-0218.193337*

Mutti-Packer, S., Reid, J. L., Thrasher, J. F., Romer, D., Fong, G. T., Gupta, P. C., . . . Hammond, D. (2017). The role of negative affect and message credibility in perceived effectiveness of smokeless tobacco health warning labels in Navi Mumbai, India and Dhaka, Bangladesh: A moderated-mediation analysis doi:https://doi.org/10.1016/j.addbeh.2017.04.002*

Mukti, R.F., Samaddar, P.D., Al Emran, A., Ahmed, F., Bin Imran, I, Malaker, A., & Yeasmin, S. (2014). Score based risk assessment of lung cancer and its evaluation for Bangladeshi people. Asian Pacific Journal of Cancer Prevention, 15(17), 7021-7027, doi: 10.7314/apjcp.2014.15.17.7021*

Mymensingh medical journal (2018). Scimago Journal & Country Rank. Retrieved from https://www.scimagojr.com/journalsearch.php?q=98609&tip=sid

National Institute of Population Research and Training (NIPORT), Associates for Community and Population Research (ACPR), and ICF International. (2016). Bangladesh health facility survey 2014. Dhaka, Bangladesh: NIPORT, ACPR, and ICF International. Retrieved from https://dhsprogram.com/pubs/pdf/SPA23/SPA23.pdf

114

Nahar, Q., Sultana, F., Alam, A., Islam, J. Y., Rahman, M., Khatun, F., Reichenbach, L. (2014). Genital human papillomavirus infection among women in Bangladesh: findings from a population-based survey. PloS one, 9(10), e107675. doi:10.1371/journal.pone.0107675*

Ndiaye, K., Krieger, J. R., Warren, J. R., Hecht, M. L., & Okuyemi, K. (2008). Health Disparities and Discrimination: Three Perspectives. Journal of health disparities research and practice, 2(3), 51–71. doi:10.1901/jaba.2008.2-51

Ndiaye, K., Krieger, J. L., Warren, J. and Hecht, M. L. (2011). “Communication and health disparities”. In Handbook of health communication, 2nd, Edited by: Thompson, T., Parrott, R.and Nussbaum, J. 469–481. New York, NY: Routledge.

Nepotism and Neglect: The Failing Response to Arsenic in the Drinking Water of Bangladesh’s Rural Poor (2016). Human Rights Watch. Retrieved from https://www.hrw.org/report/2016/04/06/nepotism-and-neglect/failing- response-arsenic-drinking-water-bangladeshs-rural

Nessa, A., Hussain, A., Rashid, H., Akhter, N., Roy, S., & Afroz, R. (2013). Role of print and audiovisual media in cervical cancer prevention in Bangladesh. Asia Pacific Journal of Cancer Prevention, 14(5), 3131-3137 

The Oncologist (2017). Wiley Online Library. Retrieved from https://onlinelibrary.wiley.com/journal/1549490x

Padela, A.I. & Curlin, F.A. J Relig Health (2013) 52: 1333. https://doi.org/10.1007/s10943-012-9620-y

Palma, P. (2019). Silent on rising healthcare cost. The Daily Star. Retrieved from https://www.thedailystar.net/bangladesh-national-budget-2019-20/silent-rising- cost-healthcare-1756828

Parrot, R. (2006). Emphasizing “communication” in health communication. Journal of Communication, 54(4), 751-787, doi: 10.1111/j.1460-2466-2004.tb02653

Peltzer, K., & Pengpid, S. (2015). Knowledge, attitude and practice of testicular selfexamination among male university students from Bangladesh, Madagascar, Singapore, South Africa and Turkey. Asian Pacific Journal of Cancer Prevention, 16(11), 4741-474, doi: 10.7314/apjcp.2015.16.11.4741*

Pengpid, S., & Peltzer, K. (2014). Knowledge, attitude, and practice of breast selfexamination among female university students from 24 low, middle income and emerging economy countries. Asian Pacific Journal of Cancer Prevention, 15(20), 8637-8640, doi: 10.7314/apjcp.2014.15.20.8637*

115

PLos ONE (2019). ResearchGate. Retrieved from https://www.researchgate.net/journal/1932-6203_PLoS_ONE

Policy to Action for Cancer Prevention. World Cancer Research Fund & American Institute for Cancer Research. Retrieved from https://www.wcrf.org/dietandcancer/recommendations/policy-public-health- implications

Rasu, S., Rianon, J., Shahidullah, M., Faisel, J., & Selwyn, J. (2010). Effect of educational level on knowledge and use of breast cancer screening practices in Bangladeshi women. Health Care Women International, 32(3), 177-189 

Refreshing Canada’s National Cancer Control Strategy (2018). Canadian Strategy for Cancer Control Retrieved from https://www.partnershipagainstcancer.ca/wp- content/uploads/2018/09/Discussion-Paper-Refresh-Cancer-Strategy-en.pdf

Reid, J. L., Mutti-Packer, S., Gupta, P. C., Li, Q., Yuan, J., Nargis, N., … Hammond, D. (2017). Influence of Health Warnings on Beliefs about the Health Effects of Cigarette Smoking, in the Context of an Experimental Study in Four Asian Countries. International journal of environmental research and public health, 14(8), 868. doi:10.3390/ijerph14080868*

Rosenstock, I. M. (1974). Historical Origins of the Health Belief Model. Health Education Monographs, 2(4), 328–335. https://doi.org/10.1177/109019817400200403

Salwa, M., & Abdullah Al-Munim, T. (2018). Ethical issues related to human papillomavirus vaccination programs: an example from Bangladesh. BMC medical ethics, 19(Supplement 1), 39. doi:10.1186/s12910-018-0287-0*

Sankaranarayanan, R., Bhatla, N., Gravitt, P. E., Basu, P., Esmy, P. O., Ashrafunnessa, K. S., Nene, B. M. (2008). Human papillomavirus infection and cervical cancer prevention in India, Bangladesh, Sri Lanka and Nepal. Vaccine, 26(Supplement 12), M43-M52. doi:https://doi.org/10.1016/j.vaccine.2008.05.005 

Simon, S. (2015). Study: Smoking causes almost half of deaths from 12 cancer types. American Cancer Society. Retrieved from https://www.cancer.org/latest- news/study-smoking-causes-almost-half-of-deaths-from-12-cancer-types.html

Singh, Z., & Chadha, P. (2016). Textile industry and occupational cancer. Journal of Occupational Medicine and Toxicology (London, England), 11, 39. http://doi.org/10.1186/s12995-016-0128-3

116

Sivaram, S., Majumdar, G., Perin, D., Nessa, A., Broeders, M., Lynge, E., … Mehrotra, R. (2018). Population-based cancer screening programmes in low-income and middle-income countries: regional consultation of the International Cancer Screening Network in India. The Lancet. Oncology, 19(2), e113–e122. doi:10.1016/S1470-2045(18)30003-2

Sloan FA, Gelband H Institute of Medicine (US) Committee on Cancer Control in Low- and Middle-income Countries. Cancer control opportunities in low- and middle- income countries. Washington, DC: National Academies Press; 2007.

Story, L., Love, R., Salim, R., Roberto, A., Krieger, J., & Ginsburg, O. (2012). Improving outcomes from breast cancer in a low-income country: Lessons from Bangladesh. International Journal of Breast Cancer, 2012 doi:10.1155/2012/423562 

Thomas, J., O’mara-Eves, A., Harden, A., & Newman, M (2017). Synthesis methods for combining and configuring textual or mixed methods data. In Gough, D, Oliver, S., & Thomas, J. (Eds), An Introduction to Systematic Reviews (pp 185-187). California, SAGE Publication

Thun, M. J., DeLancey, J. O., Center, M. M., Jemal, A., & Ward, E. M. (2010). The global burden of cancer: priorities for prevention. Carcinogenesis, 31(1), 100– 110. doi:10.1093/carcin/bgp263

The Tobacco Atlas: Bangladesh (2019). American Cancer Society. Retrieved from https://tobaccoatlas.org/country/bangladesh/

Tomi, A. (2012). Socio-economic and health access determinants of breast and cervical cancer screening in low-income countries: Analysis of the world health survey. Plos One, 7(11) doi:10.1371/journal.pone.0048834 

Uddin, A. F., Khan, Z. J., Islam, J., & Mahmud, A. (2013). Cancer care scenario in Bangladesh. South Asian journal of cancer, 2(2), 102–104. doi:10.4103/2278- 330X.110510

Uddin, R., & Huda, N. H. (2011). Arsenic poisoning in Bangladesh. Oman medical Journal, 26(3), 207. doi:10.5001/omj.2011.51

Ukoli, F. A. & Patel, K. & Hargreaves, M. & Beard, K. & Moton, P. J. & Bragg, R. & Beech, D. & Davis, R. (2013). A Tailored Prostate Cancer Education Intervention for Low-income African Americans: Impact on Knowledge and Screening. Journal of Health Care for the Poor and Underserved 24(1), 311-331. Johns Hopkins University Press. Retrieved May 13, 2019, from Project MUSE database.

117

Wakefield, M.A., Bayly, M., Durkin, S.J., Cotter, T.F., Mullin, S., & Warne, C. (2013). Smokers' responses to television advertisements about the serious harms of tobacco use: pre-testing results from 10 low- to middle-income countries. Tobacco control, 22 1, 24-31 *

What ministries of information and communications need to know (2016). World Health Organization. Retrieved from https://apps.who.int/iris/bitstream/handle/10665/250230/WHO-NMH-NMA-16.91- eng.pdf;jsessionid=B69686DCAD86B0BFD7F33347D5DFFEB5?sequence=1

Witte, K. (1992). Putting the fear back into fear appeals: The extended parallel process model. Communication Monographs, 59(4), 329-349. doi:10.1080/03637759209376276

The World Bank.Poverty & equity data portal: Bangladesh. Retrieved from http://povertydata.worldbank.org/poverty/country/BGD

Xu K, Soucat A & Kutzin J et al. Public Spending on Health: A Closer Look at Global Trends. Geneva: World Health Organization; 2018 WHO/HIS/HGF/HFWorkingPaper/18.3). Licence: CC BY-NC-SA 3.0 IGO.

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BIOGRAPHICAL SKETCH

Aantaki Raisa is a Bangladeshi international student at the University of Florida, who received her Master of Arts degree in Science and Health Communication in

August 2019, at the College of Journalism and Communications. She has also been accepted in the PhD program in the same field at UF. Aantaki Raisa earned her first MA degree in media arts and studies from Ohio University in 2015. She has a bachelor’s degree in electronics and telecommunications engineering from North South University in 2010. As an MA student at UF, she has worked as a research assistant to Dr. Janice

Krieger, and as a teaching assistant to Dr. Andrew Selepak. Her research interest is developing. Implementing and evaluating culturally appropriate interventions to improve health outcomes among marginalized populations.

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