Discussion
colorectal cancer, cancer survivor stories, whereas local CHWs, breast cancer
COLORECTAL CANCER, BREAST CANCER
This was the first randomized study in Malaysia to test the effectiveness of a bespoke multicomponent intervention to address the significant public health problem of low uptake of breast cancer screening. Overall, the results suggested that the intervention achieved positive outcomes in terms of improved CBE uptake and an increase in the number of women who reported intention to screen. CBE uptake was significantly higher in the IG (46%) compared to the CG (4%) despite the pandemic and the resulting restrictions in movement across sub-districts. The same option (but without the uptake intervention) of free CBE screening at the LPPKN clinic was offered to CG women immediately The components of the intervention or programme were informed by our earlier studies [All IG women who received a positive CBE attended mammogram screening (11/11). Similar positive results, overall, were reported for an education and navigation intervention in Jordan where women availed of free mammogram screening though the study intervention occurred prior to the pandemic and CHW interaction was face-to-face rather than over the phone [There were no significant differences between Malays and Chinese Malaysians in terms of CBE attendance (and there was an insufficient number of Indian Malaysians and members of the indigenous community in the study sample to make meaningful comparisons between these ethnic groups). However, the analysis indicated that women from low income households in the IG were more likely to attend the free screening service similar to findings from our recent colorectal cancer study where participants from the PeKa B40 category (i.e. citizens in the bottom 40% household income range of <RM 4,850) were more likely to use the free screening test [Overall, this multicomponent way of trying to increase uptake of CBE screening appeared to be acceptable to Malay and Chinese Malaysian women though it is difficult to discern the extent to which components exerted differential impacts. There was relatively low engagement with the mHealth component which comprised online information about the signs and symptoms of BC, the benefits of BC screening as well as cancer survivor stories, whereas local CHWs were described by participants in positive terms and, for example, as delivering easy-to-understand information about BC screening. Few studies have explored the role of CHWs in terms of navigating women to BC services compared to studies that have investigated the use of CHWs to promote BC education [The LPPKN clinic was also a significant intervention component as it demonstrated flexibility in its willingness and efforts to facilitate additional CBEs on a weekly basis (as well as engaging fully with the research team). In addition, the LPPKN clinic appeared to be an acceptable location for many women to receive their CBE (perhaps a preferred location compared to usual community clinics). A total of 58 LPPKN clinics throughout Malaysia [It is important to note that there are several study limitations. The difficulty related to obtaining clinic data about CBE uptake by the CG meant that the comparative analysis between the IG and CG was limited. We recruited about 50% of the target sample size and there was considerable attrition at the follow-up interview stage which is lower than a pre-pandemic face-to-face survey that our research team conducted as part of a previous study (68% attrition at follow-up) [Overall, and bearing in mind the above noted limitations, the results of this study suggest that the use of a multicomponent community education and navigation intervention or programme has considerable potential to elicit positive health protective intentions and improve clinical breast examination uptake in Segamat Malaysia even in the highly challenging circumstances of the COVID-19 pandemic. The results point to ways in which the intervention might be improved as well as the need for further research to test how well the intervention works in a non-pandemic context and how its generalisability might be addressed and extended.