FormalPara Key Points

  • TRIBES and STITCH are heuristics that guide a sustainable approach to cervical cancer testing in rural India.

  • The TRIBES concept involves training Accredited Tribal Social Health Activists who conduct the intervention in their local communities, working from Tribal Mini Health Centers.

  • The STITCH strategy is a way of approaching cancer screening in rural India.

  • TRIBES and STITCH provide a framework to help address barriers such as poverty, low health literacy, cultural and religious differences, and challenges created by difficult-to-access, remote locations.

In India, the most common cancer types are breast, lung, mouth, cervix uteri, and tongue [1]. Knowledge of cancer and cancer prevention is limited in many rural communities, particularly among Scheduled Castes (SCs) and Scheduled Tribes (STs) (these terms are recognized in the Constitution of India). SCs and STs are the most socioeconomically disadvantaged groups in India, making up approximately 16.6% and 8.6% of the population, respectively [2]. People belonging to SCs are subject to untouchability, suppression, oppression, discrimination, and exploitation. ST populations typically live in isolated, remote, hilly, or forested areas and are often separated from the wider Indian population. Both the SC and ST populations largely rely on traditional medicines and local healers [3].

In this case study, we describe an approach to developing a sustainable cancer control program among SC and ST populations, defined through two heuristics: a concept called TRIBES and a strategy called STITCH.

What We Did

The demographics of our study population were 20% Tribal community, 50% SC, and 30% other castes. In this population, we implemented a randomized controlled trial with healthy women aged 30 to 59 years to develop and test an approach to cervical screening using visual inspection with 4% acetic acid [4]. Of the 114 study clusters in India’s Dindigul district, 57 were randomized to one round of visual inspection by trained nurses, and 57 to a control group. Screen-positive women received colposcopy, directed biopsies, and, where appropriate, cryotherapy by nurses during the screening visit. Over five years, the study demonstrated a 25% reduction in the cervical cancer incidence rate and a 35% reduction in the mortality rate.

We developed the TRIBES concept and STITCH strategy for the study described above. We believe that, for both the Tribal and SC populations, TRIBES and STITCH played an important role in our project’s success. We argue that they offer a valuable heuristic for future cancer control projects among Indigenous and Tribal populations.

The TRIBES Concept

The TRIBES concept provides a heuristic for planning a cancer control program. A central part of our approach is recruiting and training Accredited Tribal Social Health Activists, who conduct the intervention in their local communities.

T—Translational training and technology

Organizations involved in cancer screening programs should select volunteers from relevant ST and SC communities and offer them certified training in primary healthcare with special emphasis on cancer screening techniques and pre-cancer management. This must be supported by an effective referral system. In our cervical cancer study, we selected women as volunteers.

R—Research

Research projects should include community-based interventions, with all tools evaluated for their acceptability, availability, and cost-effectiveness. Randomized controlled trials are needed to test recommendations about cancer control.

I—Indigenous

Indigenous and Tribal peoples should be involved in cancer screening in their communities. This empowers communities and creates local employment. In our work, we developed the role of Accredited Tribal Social Health Activists (ATSHA), individuals who are nominated from and supported by their local communities. These health activists must complete a health center–based structured training program. Known and trusted in their local communities, they become powerful healthcare providers.

As part of this approach, we recommend opening Tribal Mini Health Centers, each built to serve a population of approximately 1000 people. These mini centers should be equipped with basic medical equipment and provide a base from which the Accredited Tribal Social Health Activists can work. These mini-centers require funding, which might be garnered from local sources, health insurance, government, or non-government organizations. Tools and tests for cervical cancer screening can be made locally.

B—Behavior change

Behavior changes among local populations should be encouraged through intensive, focused, tailor-made health education models and activities, implemented and conducted by local health activists and with a focus on local activities.

E—Empowerment

Accredited Tribal Social Health Activists can be empowered by the provision of simple and effective screening tools, including Pap smear kits, acetic acid, Lugols iodine, speculums, simple portable colposcopes, and cryotherapy equipment.

S—Social status and recognition

Relevant government and non-government agencies should give appropriate recognition and status to Accredited Tribal Social Health Activists as they are part of the local health workforce.

The STITCH Strategy

Our proposed STITCH strategy provides a useful way to approach cancer screening in rural India. We believe that implementing the STITCH strategy can help to close the cancer care gap experienced by SC and ST populations.

S—Screening

Screening should be available, applicable, acceptable, and affordable, and should give assurance of efficacy and sustainability in healthcare delivery.

T—Treatment

Treatment of precancers should be standard procedure, with outcomes monitored through follow-up biopsies until a status of “cured” is achieved.

I—Immunization

Immunization should be more effectively implemented in rural communities. For example, the HPV vaccine should be promoted through the health communication process of “information, motivation, and action.”

T—Translational research

Researchers should engage in the translation of research results in which strategies, technologies, and resources flow from high-resource to low-resource settings, offering greater benefits for Indigenous and Tribal populations.

C—Continuum of care

Cancer care organizations should offer a continuum of care from screening, through treatment, and beyond. These organizations need to be trustworthy, transparent, dependable, and reliable if they are to win the confidence and mandate of local communities. Health programs should not close down or stop abruptly and without warning.

H—Health policy

Health policy should be framed to prioritize primary, secondary, and tertiary prevention measures for the entire population, regardless of location.

Challenges and Opportunities

TRIBES and STITCH offer ways to think about cancer control programs for Indigenous and Tribal peoples. In rural India, these heuristics have proved helpful in developing and designing a cervical cancer control program.

Our approach has provided several opportunities, including funding and support from government and non-government organizations. The approach has also provided opportunities for health education and technical training within local communities and led to the development of a local income-generating scheme.

The TRIBES and STITCH approach provides a framework that has helped us to address barriers such as poverty, low health literacy, cultural differences, religious differences, and challenges created by difficult-to-access, remote locations.

Conclusion

TRIBES and STITCH provide heuristics that describe our approach to cervical cancer testing, with demonstrated success in rural India. We believe this approach has broad application for cancer control among Indigenous and Tribal communities in other rural locations and contexts.