As with most health outcomes, and particularly cancer, such community efforts ask persons who may otherwise be healthy to get informed and/or screened.   I learned about several barriers to participation in these efforts.  “I am well, why should I get screened?’ is one of the many attitudes that health workers have to address.  Another is stigma – “once they hear the word cancer, they don’t want to have anything to do with us, noted a social worker.  Women and men have to leave their homes and often times, paid work, to attend screening, a further disincentive.  Further, if their screening test is positive they have to travel to Chennai for further evaluation which is another link in the chain where people drop off.   If there is a factor that facilitates positive outcomes, it is the persistence of the team and the permanent presence of a preventive oncology team close to the community.

Finally, the role of gender in participation in these programs is noteworthy.  Women do most of the work at home and as I learned, in these rural areas, they also work out of the home.  Local industries such as tobacco rolling, prefer to employ women as they are deemed more conscientious, time efficient, and able to meet daily targets as compared to men.  Another role of gender is related to women’s role in the household.  Despite ability to bring in income, women note that they have to seek their husband’s permission to take part in cancer education programs. 

Despite these challenges, there are some service delivery related factors that seem critical to maximizing outreach to rural populations.  These include developing staff capacity to deliver services and care coordination to ensure follow-up and referral.  In Villupuram, the project has recruited and trained staff including nurses, doctors and social workers who reside locally and are likely to remain in the area.   This also helps coordinate services, planning and executing prevention education camps and fairs in the community and repeated visit to households for screening.  Staff also are able to meet regularly as teams and communicate results of follow-up attempts after initial screening and share lessons and challenges.  Further, as the project is physically located within the main government hospital in the district, this conveys a sense of permanence and sustainability to the community.

Poor access to cancer prevention services,  unavailability of cancer treatment, poor care coordination,   long distances to travel to see an oncologist are factors influencing cancer care in rural parts of the United States as well.  Understanding how to achieve equity in cancer care from experiences such as this one in Villupuram might inform cancer health disparities work in other