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research-article2015
PED0010.1177/1757975914567512Original ArticleR. Sankeshwari et al.
Original Article Awareness regarding oral cancer and oral precancerous lesions among rural population of Belgaum district, India Roopali Sankeshwari1, Anil Ankola1, Mamata Hebbal1, Sidramesh Muttagi2 and Nilam Rawal1
Abstract: Belgaum district of Karnataka state is well known for high production and consumption of tobacco in Southern India. This study aimed to investigate the rural population’s awareness of oral cancer, precancerous lesions and their risk factors. Data were collected via face to face interviews using a pretested and validated questionnaire. The questionnaire comprised two parts: part one had questions concerning socio-demographic data and part two consisted of 25 questions pertaining to people’s attitudes to and awareness of risk factors for oral cancer and precancerous lesions. One researcher interviewed participants and recorded the responses verbatim. Of the participants, 17% identified all the symptoms of oral cancer and 27.8% identified all the symptoms of oral precancerous lesions. Approximately 90% of the participants had never noticed statutory warnings on tobacco and alcohol products. Awareness was especially poor in people of lower socio-economic status. This study highlights a need for education concerning the risk factors for oral cancer, its clinical manifestations and the impact of adverse habits on long term health. Health education campaigns emphasizing oral cancer need to be integrated with broader public health messages. Keywords: oral cancer, awareness, oral precancer, rural population, oral health, risk factors, public health, tobacco, cancer screening and prevention
Introduction Oral and pharyngeal cancer is the sixth most common cancer in the world (1). Recent data on worldwide incidence of oral cancer suggest that South-East Asian countries are at high risk of oral cancer. Being the commonest cancer in men and third commonest cancer in women, this disease contributes up to 25% of all new cases of cancer in India (2,3). The age standardized incidence of oral cancer is 12.6 per 100,000 of the Indian population. Cancer in developing countries may be due to combined effects of an ageing population and supplemented by the associated risk factors in this group (4). Although several risk factors have been
suggested for oral cancer, habitual use of tobacco in various forms and consumption of alcohol have remained the most significant. Tobacco use can be considered as the world’s most avoidable cause of cancer. Long term tobacco consumption in various forms is associated with oral precancerous lesions, oral cancer or both. Over one third of tobacco consumed regionally in South India is smokeless. Smokeless tobacco users cohort studies of India pointed at an age adjusted relative risk for premature mortality of 1.2–1.96 (men) and 1.3 (women) (5). The stage of the disease in which a patient presents to the clinician may be an important prognostic factor. The majority of Indian patients with oral
1. KLEVK Institute of Dental Sciences – Public Health Dentistry, Belgaum, Karnataka, India. 2. KLEVK Institute of Dental Sciences – Oral & Maxillofacial Surgery, Belgaum, Karnataka, India. Correspondence to: Roopali Sankeshwari, KLEVK Institute of Dental Sciences – Public Health Dentistry, JNMC Campus Nehru Nagar, Belgaum, Karnataka 590010, India. Email: [email protected] (This manuscript was submitted on 30 December 2013. Following blind peer review, it was accepted for publication on 5 October 2014) Global Health Promotion 1757-9759; Vol 0(0): 1 –9; 567512 Copyright © The Author(s) 2015, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914567512 http://ghp.sagepub.com Downloaded from ped.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 20, 2015
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cancer present in advanced stages resulting in guarded prognosis along with need for surgical intervention, which is associated with high morbidity and added expenditure. A recent study shows that early detection and prevention of the disease are of primordial importance if the incidence of oral cancer is to be reduced or prognosis is to be improved (6). Within Karnataka state there are many challenges regarding tobacco products which range from the relative ease and unrestricted access to tobacco products to the rising numbers of 13–15-year-olds using tobacco products, and these tobacco products are a risk factor for the development of oral cancer (7). Of greater alarm is the rising proportion of the population with oral and pharyngeal cancer (8). Some researchers suggest that as a whole there has been a reduction in tobacco smoking and bidi use in India, but argue that this is offset by the rise in pan and betel nut use among people of lower socio-economic status, especially women (9). It has been argued that delay in presentation with oral cancer is a risk-taking behaviour (10). Rogers et al. suggest that patient delay in presenting accounts for late diagnosis, which has a negative effect on quality of life and survival (11). It would appear that creating awareness of oral cancer and its risk factors is an essential prerequisite for facilitating reduced tobacco consumption habits and early presentation for diagnosis (12). In order to facilitate a comprehensive reduction in the use of tobacco and its products, India ratified the WHO Framework Convention on Tobacco Control, which recommends several demand reduction measures and some supply reduction measures, and its components are integrated in the National Strategy for Tobacco Control. Cessation of tobacco use is best promoted through a strategy which combines such policy interventions as raising taxes on tobacco products, advertising bans, health warnings on tobacco products, mass health education, behavioural counselling and clinic-based settings, in addition to pharmacological aids when indicated (13). Belgaum district of Karnataka state in South India is one of the highest producers and consumers of tobacco in the country (14,15). In this study we intend to evaluate the awareness of the rural population of Belgaum district about oral cancer and oral precancerous lesions, and explore whether gender plays a role in the level of awareness towards oral cancer and precancerous lesions.
Materials and methods This was a cross sectional descriptive study depicting a population with a high prevalence of tobacco usage and oral cancer. Ethical clearance was obtained from the Institutional Ethical Review Board of KLEVK Institute of Dental Sciences, Belgaum.
Pilot study A pilot study was conducted among 10 participants belonging to rural areas of Belgaum district with the objective to determine the feasibility of the study. It was conducted in two stages: 1. In the first stage, a questionnaire was prepared in English and then translated to Kannada and Marathi (vernacular languages) and was given to 10 participants to check for its comprehension. The translated questionnaires were retranslated back to English to assess if they conveyed the same meaning. Questions were modified wherever required. 2. After one month the questionnaire was again given to the same 10 participants to check for its reliability. Test retest score of 0.80 was obtained confirming good reliability of the questionnaire. The questionnaire was assessed for validity. Mean Content Validity Ratio of 0.87 was obtained. When Face validity was evaluated 92% of the participants found the questionnaire to be easy.
Details of the questionnaire A pretested and validated questionnaire which was framed by the investigator was used for the survey. The interviewer administered a questionnaire consisting of two parts. The first part dealt with details of socio-demographic variables such as age, gender, occupation, and education, and the second part was structured with 25 closed and open-ended questions related to the extent of awareness regarding risk factors of oral cancer, precancerous lesions, source through which people had acquired this information, their attitude towards oral cancer and its prevention.
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Sample selection A multi-stage sampling method was used. In the first stage, five villages within the radius of 10 km from Belgaum city were randomly selected out of 100 villages. In the second stage, each village was divided into four zones: north, east, south and west. A house-to-house survey was conducted and continued until a sample of approximately 20 participants was selected in each zone. The same procedure was repeated for each zone of every village, until a final sample size of 400 was obtained. Participants who were aged between 20 to 50 years and gave verbal consent after the study was explained to them (because many could not read or write) were included for the study.
Implementation of the survey Approval from Village Panchyat Office (head of the village) was obtained. Time and dates of the study were finalized. A trained investigator interviewed study participants in their homes. On reaching the house, all the family members who met the inclusion criteria were gathered and the purpose of the study was explained to them in their own language. One person was randomly chosen if there were multiple volunteers in the same house by using the lottery method. Informed consent was then obtained. Participants were instructed not to converse or obtain assistance from others. Details of socio-demographic profile and respondent’s answers to the structured questions on oral cancer and oral precancerous lesions were recorded by the investigator.
Socio-economic status (SES) Information regarding education, occupation and family income collected from the questionnaire and participants were stratified accordingly from Class I to Class V, using modified family income group of the Kuppuswamy socio-economic status scale (16).
Method of statistical analysis Data were entered in Microsoft Excel and analysed using SPSS (Version 17, Chicago, IL). Qualitative data were presented as frequency and percentages. Categorical data were analysed using the chi squared test for linear trend. A p value of 50 8 (2%) Religion Hindu 391 (97.8%) Muslim 8 (2%) Christian 1 (0.2%) Education Illiterate 35 (8.75%) Literate 365 (91.25%) Socio-economic status Upper class 3 (0.8%) Upper middle 152 (38%) Lower middle 114 (28.5%) Upper lower 126 (31.5%) Lower 5 (1.3%) Have habits Yes 102 (25.5%) No 298 (74.5%)
n and % aware of p value oral cancer
n and % aware of p value oral precancerous lesions
253 (63.25%) 121 (30.25%)
0.389
237 (59.25%) 108 (27%)
0.369
134 (33.25%) 154 (38.5%) 78 (19.5%) 8 (2%)
0.464
119 (29.75%) 147 (36.75%) 71 (17.75%) 8 (2%)
0.05
365 (91.25%) 8 (2%) 1 (0.2%)
0.726
337 (84.25%) 7 (1.75%) 1 (0.25%)
0.918
31 (7.75%) 343 (85.75%)
0.268
24 (6%) 321 (80.25%)
0.004
3 (0.8%) 146 (36.5%) 111 (27.75%) 110 (27.5%) 4 (1%)
0.007
3 (0.75%) 139 (34.75%) 106 (26.5%) 93 (23.25%) 4 (1%)
0.000
92 (23%) 282 (70.5%)
0.160
79 (19.75%) 266 (66.5%)
0.004
374 (93.5%)
345 (86.25%)
Table 2. Awareness of the participants to the symptoms, risk factors and attitude towards oral cancer. Questionnaire
Knowledge of oral cancer
Heard the word Knowledge of symptoms Consequence Can be treated Can be prevented Early detection leads to improved chances of survival
374 (93.5%) Red patch – 141 (35%) White patch – 31 (7.75%) Non healing ulcer – 96 (24%) Any growth – 18 (4.5%) Swelling/lump – 4 (.25%) Loss of sensation – 7 (1.25%) All of above – 68 (17%) None of above – 18 (4.5%) It could lead to death/deformity – 366 (91.4%) 345 (86.25%) 375 (89.25% ) 362 (90.5%)
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Table 3. Awareness of the participants to the symptoms, risk factors and attitude towards oral precancerous lesions. Questionnaire
Knowledge of oral precancerous lesions
Heard the word Knowledge of symptoms Consequence Can be treated Can be prevented Early detection leads to improved chances of survival
345 (86.3%) Burning mouth sensation – 57 (14.2%) Restricted mouth opening – 32 (8%) Red patch – 150 (37.5%) White patch – 24 (6%) All of the above – 111 (27.8%) None of the above – 26 (6.5%) It could lead to oral cancer 85% 332 (82.8%) 352 (88%) 360 (90.3%)
Table 4. Distribution of subjects according to awareness of risk factors of oral cancer. Awareness of risk factors Smoking Alcohol Gutkha Betel quid chewing Poor oral hygiene Micro nutrient deficiency
Number of subjects (percentage) 91 (22.75%) 21 (5.25%) 101 (25.25%) 12 (3%) –
noticed statutory warnings on tobacco and alcohol products. Only 11.2% (45/400) said they had been to a dentist for a check-up. Gender-wise, the difference in the level of awareness among the rural population of Belgaum district was analysed using the chi squared test. There was a significant difference between male and female participants regarding the knowledge of symptoms of precancerous lesions (p = 0.003). Also, there was a significant difference in the belief that oral precancerous lesions are preventable disorders (p = 0.02).
Discussion Recent studies (17–20) have shown that chewing or smoking of tobacco or its products and consumption of alcohol have been considered as significant risk factors in the development of precancerous lesions and oral cancer. This survey
Table 5. Distribution of subjects according to their source of information for OC and oral precancerous lesions. Source of information
Number of subjects (percentage)
Health personnel Newspaper TV/radio Family member Friends Any other
219 (54.75%) 59 (14.75%) 46 (11.5%) 27 (6.75%) 35 (8.75%) 14 (3.5%)
was planned so as to assess the awareness and knowledge of the rural population towards oral cancer and oral precancerous lesions. Although prognosis of the disease depends upon various factors, such as stage of the disease, site involved, presence/absence of risk factors, lifestyle of an individual, access to health care facilities, financial status, and so on, a recent meta-analysis on oral cancer confirms that diagnostic delay contributes up to 30% worsening of stage at presentation of the oral cancer (21). Self-reporting of precancerous lesions and oral cancer is possible only when people are made aware of such lesions. According to many recent reports, prevalence of oral cancer is increasing in 25–50-year-olds (22). Thus the participants chosen for the present study belonged to the age group of 25–45±5 years. IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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Awareness While 93.5% of the study participants had heard of oral cancer, 86.5% had heard of oral precancerous lesions. Awareness of the participants of the present study is much higher compared to a similar study conducted in Sri Lanka (23). Most participants were not aware of the symptoms of oral cancer. Only 17% of the participants could make out all seven symptoms given in the questionnaire as those of oral cancer and 27.8% recognized all the given symptoms as those of oral precancerous lesions. Similar reports have been published by other authors (15,24). This finding may be attributed to the low educational level of the study population. Of the participants, 89% thought that oral cancer and oral precancerous lesions were dangerous diseases but could be treated. They were also aware that early detection of these could lead to improved chances of survival. These findings provide an insight that the study population was sensitized to oral cancer and oral precancerous lesions but lacked knowledge on certain aspects as to identification of the symptoms. Awareness regarding oral cancer and precancerous lesions was statistically low for lower socio-economic status. As per a meta-analysis (25) lower socio-economic status could be one of the risk factors for oral cancer. Lower occupation/social class may reflect exposure to harmful physical environments and agents which could increase the risk of oral cancer. While formulating health education programmes for this population, inclusion of messages like self-detection of suspicious lesions, pictorial presentation of various symptoms of oral cancer and oral precancerous lesions may improve the overall impact of the programme. This may also help in persuading people to seek health care facilities at the earliest.
Risk factors Overall there was poor awareness regarding risk factors and the impact of adverse habits on long term health. Unlike other studies, none of the participants in the present study recognized poor oral hygiene and micro nutrient deficiency as risk factors for oral cancer (23–26). Tobacco chewing, smoking and alcohol consumption appear to be the main reasons for the increasing incidence rates. Low socio-economic status and a diet low in
nutritional value, lacking vegetables and fruits, contribute towards the risk. In addition, viral infections such as human papilloma virus and poor oral hygiene are important risk factors (27). There is a need to inform and educate the public in matters related to recognized risk factors. Although health hazards of smoking and chewing gutkha (preparation of crushed areca nut, tobacco, catechu, paraffin, slaked lime and sweet or savoury flavourings) were recognized by 27.2% of the participants in our study, the association between alcohol consumption or betel quid chewing and oral cancer were known to only a few. This can be attributed to the health education campaigns initiated by the mass media which are responsible for the increased awareness regarding ill effects of tobacco in both smoking and smokeless form. However, these campaigns lack information regarding the role of alcohol and areca nut in the initiation and progression of oral cancer and oral precancerous lesions and hence fail to create awareness about these factors (28). Only 3% believed that betel quid chewing may be a risk factor for oral cancer. Most participants were not aware of the carcinogenic potential of areca nut. Recent studies have shown that areca alkaloids promote a wide variety of diseases from type 2 diabetes, central obesity to liver cancer (29– 32). Thus the use of areca nut in any form should be discouraged, either with lime or without lime. None of the participants in the present study were aware that diet had any role to play in the prevention of cancer. Rogers et al. suggest that poor oral hygiene and diet were risk factors and this was also suggested by 12% and 19% of participants, respectively, in that study (33). We can suggest that diversity in response may be attributed to various factors such as literacy rate, socio-economic development, lack of public health insurance and thus limited access to health care facilities. The protective role of Vitamin A and Vitamin E, which are present in green leafy vegetables and fresh fruits, should be incorporated into health promotion programmes.
Role of mass media The majority of participants (55.5%) had received information regarding oral cancer from health care personnel, followed by newspapers and television.
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As discussed earlier, mass media are playing a major role in disseminating information to the public at large. However, only tobacco in various forms has been depicted as a carcinogen. On-screen smoking by actors was disliked by many. This is a piece of positive feedback obtained from participants.
Warning on tobacco products Only 9.5% of the participants had noticed warnings on tobacco and alcohol products. This may be due to the lower literacy level coupled with the fact that warnings on tobacco products are so small that they are negligible. The results of a cross sectional survey conducted in five states of India revealed that the pictorial warnings displayed on the tobacco products were inadequate in conveying the adverse outcomes of tobacco on health and hence failed to discourage the users from consuming tobacco products, especially people with lower literacy rates (34).
Use of dental health care facility In the present study only 13% of the participants had attended a dental practitioner. The villages had the benefit of a mobile dental clinic provided by KLEVK Institute of Dental Sciences Belgaum. In spite of the fact that dental health care facilities were being delivered to their doorstep, people were reluctant to use them. Fear, ignorance and cost may be some of the barriers which prevented people from accessing services. Changing the attitude of individuals cannot be achieved by health education alone, but a thorough understanding of various barriers and the alternative strategies to overcome these barriers could be beneficial in achieving mass behavioural change. Among all the behaviour change models, Prochaska and Velicer’s ‘Transthoretical model of health behaviour change’ could be considered. This model assesses an individual’s readiness to act on a new healthier behaviour and provides strategies, or processes of change to guide the individual through various stages from behaviour change to action and maintenance (35). A comparison of males and females revealed that females had lesser knowledge than males regarding symptoms of oral precancerous lesions and to the fact that these could be prevented. Since the study was done in a rural setting, we can suggest that females
had comparatively limited access to information and education.
Limitations The questionnaire was devised by clinicians, so it was from their perspective rather than that of participants. The questionnaire was also translated into regional languages. Both these facts might have introduced some bias in the study, the extent of which remains undetermined. Variations in the wordings and response formats can alter the results. In all the questions asked, respondents only had to pick the response and this may have led to over estimation of awareness regarding oral cancer and oral precancerous lesions. Future studies can be planned with a qualitative study design to overcome most of these limitations.
Conclusion The result of this study, in addition to showing poor awareness of OC and precancerous lesions, also showed that gender and socio-economic status were important factors influencing the association between all three. This study provides benchmark findings against which changes in attitude and awareness towards oral cancer can be measured. Awareness of oral cancer and oral precancerous lesions was particularly poor in the rural population of Belgaum district in several aspects such as early signs, symptoms and risk factors.
Recommendations Health education campaigns particularly emphasizing oral cancer must be integrated with wider health messages. Oral cancer awareness programmes, along with oral cancer screening for high risk groups should be considered. Use of the salutogenic model of health promotion (36) along with a regulatory approach may help in raising awareness regarding oral cancer and decreasing its morbidity and mortality. Acknowledgments The authors sincerely thank Indian Council of Medical Research and all the study participants.The authors would also like to thank Dr.Vinuta Hampiholi for careful proof reading of the manuscript. IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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Conflict of interest None declared.
Funding This study was sponsored by Indian Council of Medical Research (ICMR) under STS 2011 Reference Id 201101577.
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research-article2015
PED0010.1177/1757975914567512Original ArticleR. Sankeshwari et al.
Original Article Awareness regarding oral cancer and oral precancerous lesions among rural population of Belgaum district, India Roopali Sankeshwari1, Anil Ankola1, Mamata Hebbal1, Sidramesh Muttagi2 and Nilam Rawal1
Abstract: Belgaum district of Karnataka state is well known for high production and consumption of tobacco in Southern India. This study aimed to investigate the rural population’s awareness of oral cancer, precancerous lesions and their risk factors. Data were collected via face to face interviews using a pretested and validated questionnaire. The questionnaire comprised two parts: part one had questions concerning socio-demographic data and part two consisted of 25 questions pertaining to people’s attitudes to and awareness of risk factors for oral cancer and precancerous lesions. One researcher interviewed participants and recorded the responses verbatim. Of the participants, 17% identified all the symptoms of oral cancer and 27.8% identified all the symptoms of oral precancerous lesions. Approximately 90% of the participants had never noticed statutory warnings on tobacco and alcohol products. Awareness was especially poor in people of lower socio-economic status. This study highlights a need for education concerning the risk factors for oral cancer, its clinical manifestations and the impact of adverse habits on long term health. Health education campaigns emphasizing oral cancer need to be integrated with broader public health messages. Keywords: oral cancer, awareness, oral precancer, rural population, oral health, risk factors, public health, tobacco, cancer screening and prevention
Introduction Oral and pharyngeal cancer is the sixth most common cancer in the world (1). Recent data on worldwide incidence of oral cancer suggest that South-East Asian countries are at high risk of oral cancer. Being the commonest cancer in men and third commonest cancer in women, this disease contributes up to 25% of all new cases of cancer in India (2,3). The age standardized incidence of oral cancer is 12.6 per 100,000 of the Indian population. Cancer in developing countries may be due to combined effects of an ageing population and supplemented by the associated risk factors in this group (4). Although several risk factors have been
suggested for oral cancer, habitual use of tobacco in various forms and consumption of alcohol have remained the most significant. Tobacco use can be considered as the world’s most avoidable cause of cancer. Long term tobacco consumption in various forms is associated with oral precancerous lesions, oral cancer or both. Over one third of tobacco consumed regionally in South India is smokeless. Smokeless tobacco users cohort studies of India pointed at an age adjusted relative risk for premature mortality of 1.2–1.96 (men) and 1.3 (women) (5). The stage of the disease in which a patient presents to the clinician may be an important prognostic factor. The majority of Indian patients with oral
1. KLEVK Institute of Dental Sciences – Public Health Dentistry, Belgaum, Karnataka, India. 2. KLEVK Institute of Dental Sciences – Oral & Maxillofacial Surgery, Belgaum, Karnataka, India. Correspondence to: Roopali Sankeshwari, KLEVK Institute of Dental Sciences – Public Health Dentistry, JNMC Campus Nehru Nagar, Belgaum, Karnataka 590010, India. Email: [email protected] (This manuscript was submitted on 30 December 2013. Following blind peer review, it was accepted for publication on 5 October 2014) Global Health Promotion 1757-9759; Vol 0(0): 1 –9; 567512 Copyright © The Author(s) 2015, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914567512 http://ghp.sagepub.com Downloaded from ped.sagepub.com at WASHINGTON UNIV SCHL OF MED on November 20, 2015
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cancer present in advanced stages resulting in guarded prognosis along with need for surgical intervention, which is associated with high morbidity and added expenditure. A recent study shows that early detection and prevention of the disease are of primordial importance if the incidence of oral cancer is to be reduced or prognosis is to be improved (6). Within Karnataka state there are many challenges regarding tobacco products which range from the relative ease and unrestricted access to tobacco products to the rising numbers of 13–15-year-olds using tobacco products, and these tobacco products are a risk factor for the development of oral cancer (7). Of greater alarm is the rising proportion of the population with oral and pharyngeal cancer (8). Some researchers suggest that as a whole there has been a reduction in tobacco smoking and bidi use in India, but argue that this is offset by the rise in pan and betel nut use among people of lower socio-economic status, especially women (9). It has been argued that delay in presentation with oral cancer is a risk-taking behaviour (10). Rogers et al. suggest that patient delay in presenting accounts for late diagnosis, which has a negative effect on quality of life and survival (11). It would appear that creating awareness of oral cancer and its risk factors is an essential prerequisite for facilitating reduced tobacco consumption habits and early presentation for diagnosis (12). In order to facilitate a comprehensive reduction in the use of tobacco and its products, India ratified the WHO Framework Convention on Tobacco Control, which recommends several demand reduction measures and some supply reduction measures, and its components are integrated in the National Strategy for Tobacco Control. Cessation of tobacco use is best promoted through a strategy which combines such policy interventions as raising taxes on tobacco products, advertising bans, health warnings on tobacco products, mass health education, behavioural counselling and clinic-based settings, in addition to pharmacological aids when indicated (13). Belgaum district of Karnataka state in South India is one of the highest producers and consumers of tobacco in the country (14,15). In this study we intend to evaluate the awareness of the rural population of Belgaum district about oral cancer and oral precancerous lesions, and explore whether gender plays a role in the level of awareness towards oral cancer and precancerous lesions.
Materials and methods This was a cross sectional descriptive study depicting a population with a high prevalence of tobacco usage and oral cancer. Ethical clearance was obtained from the Institutional Ethical Review Board of KLEVK Institute of Dental Sciences, Belgaum.
Pilot study A pilot study was conducted among 10 participants belonging to rural areas of Belgaum district with the objective to determine the feasibility of the study. It was conducted in two stages: 1. In the first stage, a questionnaire was prepared in English and then translated to Kannada and Marathi (vernacular languages) and was given to 10 participants to check for its comprehension. The translated questionnaires were retranslated back to English to assess if they conveyed the same meaning. Questions were modified wherever required. 2. After one month the questionnaire was again given to the same 10 participants to check for its reliability. Test retest score of 0.80 was obtained confirming good reliability of the questionnaire. The questionnaire was assessed for validity. Mean Content Validity Ratio of 0.87 was obtained. When Face validity was evaluated 92% of the participants found the questionnaire to be easy.
Details of the questionnaire A pretested and validated questionnaire which was framed by the investigator was used for the survey. The interviewer administered a questionnaire consisting of two parts. The first part dealt with details of socio-demographic variables such as age, gender, occupation, and education, and the second part was structured with 25 closed and open-ended questions related to the extent of awareness regarding risk factors of oral cancer, precancerous lesions, source through which people had acquired this information, their attitude towards oral cancer and its prevention.
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Sample selection A multi-stage sampling method was used. In the first stage, five villages within the radius of 10 km from Belgaum city were randomly selected out of 100 villages. In the second stage, each village was divided into four zones: north, east, south and west. A house-to-house survey was conducted and continued until a sample of approximately 20 participants was selected in each zone. The same procedure was repeated for each zone of every village, until a final sample size of 400 was obtained. Participants who were aged between 20 to 50 years and gave verbal consent after the study was explained to them (because many could not read or write) were included for the study.
Implementation of the survey Approval from Village Panchyat Office (head of the village) was obtained. Time and dates of the study were finalized. A trained investigator interviewed study participants in their homes. On reaching the house, all the family members who met the inclusion criteria were gathered and the purpose of the study was explained to them in their own language. One person was randomly chosen if there were multiple volunteers in the same house by using the lottery method. Informed consent was then obtained. Participants were instructed not to converse or obtain assistance from others. Details of socio-demographic profile and respondent’s answers to the structured questions on oral cancer and oral precancerous lesions were recorded by the investigator.
Socio-economic status (SES) Information regarding education, occupation and family income collected from the questionnaire and participants were stratified accordingly from Class I to Class V, using modified family income group of the Kuppuswamy socio-economic status scale (16).
Method of statistical analysis Data were entered in Microsoft Excel and analysed using SPSS (Version 17, Chicago, IL). Qualitative data were presented as frequency and percentages. Categorical data were analysed using the chi squared test for linear trend. A p value of 50 8 (2%) Religion Hindu 391 (97.8%) Muslim 8 (2%) Christian 1 (0.2%) Education Illiterate 35 (8.75%) Literate 365 (91.25%) Socio-economic status Upper class 3 (0.8%) Upper middle 152 (38%) Lower middle 114 (28.5%) Upper lower 126 (31.5%) Lower 5 (1.3%) Have habits Yes 102 (25.5%) No 298 (74.5%)
n and % aware of p value oral cancer
n and % aware of p value oral precancerous lesions
253 (63.25%) 121 (30.25%)
0.389
237 (59.25%) 108 (27%)
0.369
134 (33.25%) 154 (38.5%) 78 (19.5%) 8 (2%)
0.464
119 (29.75%) 147 (36.75%) 71 (17.75%) 8 (2%)
0.05
365 (91.25%) 8 (2%) 1 (0.2%)
0.726
337 (84.25%) 7 (1.75%) 1 (0.25%)
0.918
31 (7.75%) 343 (85.75%)
0.268
24 (6%) 321 (80.25%)
0.004
3 (0.8%) 146 (36.5%) 111 (27.75%) 110 (27.5%) 4 (1%)
0.007
3 (0.75%) 139 (34.75%) 106 (26.5%) 93 (23.25%) 4 (1%)
0.000
92 (23%) 282 (70.5%)
0.160
79 (19.75%) 266 (66.5%)
0.004
374 (93.5%)
345 (86.25%)
Table 2. Awareness of the participants to the symptoms, risk factors and attitude towards oral cancer. Questionnaire
Knowledge of oral cancer
Heard the word Knowledge of symptoms Consequence Can be treated Can be prevented Early detection leads to improved chances of survival
374 (93.5%) Red patch – 141 (35%) White patch – 31 (7.75%) Non healing ulcer – 96 (24%) Any growth – 18 (4.5%) Swelling/lump – 4 (.25%) Loss of sensation – 7 (1.25%) All of above – 68 (17%) None of above – 18 (4.5%) It could lead to death/deformity – 366 (91.4%) 345 (86.25%) 375 (89.25% ) 362 (90.5%)
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Table 3. Awareness of the participants to the symptoms, risk factors and attitude towards oral precancerous lesions. Questionnaire
Knowledge of oral precancerous lesions
Heard the word Knowledge of symptoms Consequence Can be treated Can be prevented Early detection leads to improved chances of survival
345 (86.3%) Burning mouth sensation – 57 (14.2%) Restricted mouth opening – 32 (8%) Red patch – 150 (37.5%) White patch – 24 (6%) All of the above – 111 (27.8%) None of the above – 26 (6.5%) It could lead to oral cancer 85% 332 (82.8%) 352 (88%) 360 (90.3%)
Table 4. Distribution of subjects according to awareness of risk factors of oral cancer. Awareness of risk factors Smoking Alcohol Gutkha Betel quid chewing Poor oral hygiene Micro nutrient deficiency
Number of subjects (percentage) 91 (22.75%) 21 (5.25%) 101 (25.25%) 12 (3%) –
noticed statutory warnings on tobacco and alcohol products. Only 11.2% (45/400) said they had been to a dentist for a check-up. Gender-wise, the difference in the level of awareness among the rural population of Belgaum district was analysed using the chi squared test. There was a significant difference between male and female participants regarding the knowledge of symptoms of precancerous lesions (p = 0.003). Also, there was a significant difference in the belief that oral precancerous lesions are preventable disorders (p = 0.02).
Discussion Recent studies (17–20) have shown that chewing or smoking of tobacco or its products and consumption of alcohol have been considered as significant risk factors in the development of precancerous lesions and oral cancer. This survey
Table 5. Distribution of subjects according to their source of information for OC and oral precancerous lesions. Source of information
Number of subjects (percentage)
Health personnel Newspaper TV/radio Family member Friends Any other
219 (54.75%) 59 (14.75%) 46 (11.5%) 27 (6.75%) 35 (8.75%) 14 (3.5%)
was planned so as to assess the awareness and knowledge of the rural population towards oral cancer and oral precancerous lesions. Although prognosis of the disease depends upon various factors, such as stage of the disease, site involved, presence/absence of risk factors, lifestyle of an individual, access to health care facilities, financial status, and so on, a recent meta-analysis on oral cancer confirms that diagnostic delay contributes up to 30% worsening of stage at presentation of the oral cancer (21). Self-reporting of precancerous lesions and oral cancer is possible only when people are made aware of such lesions. According to many recent reports, prevalence of oral cancer is increasing in 25–50-year-olds (22). Thus the participants chosen for the present study belonged to the age group of 25–45±5 years. IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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Awareness While 93.5% of the study participants had heard of oral cancer, 86.5% had heard of oral precancerous lesions. Awareness of the participants of the present study is much higher compared to a similar study conducted in Sri Lanka (23). Most participants were not aware of the symptoms of oral cancer. Only 17% of the participants could make out all seven symptoms given in the questionnaire as those of oral cancer and 27.8% recognized all the given symptoms as those of oral precancerous lesions. Similar reports have been published by other authors (15,24). This finding may be attributed to the low educational level of the study population. Of the participants, 89% thought that oral cancer and oral precancerous lesions were dangerous diseases but could be treated. They were also aware that early detection of these could lead to improved chances of survival. These findings provide an insight that the study population was sensitized to oral cancer and oral precancerous lesions but lacked knowledge on certain aspects as to identification of the symptoms. Awareness regarding oral cancer and precancerous lesions was statistically low for lower socio-economic status. As per a meta-analysis (25) lower socio-economic status could be one of the risk factors for oral cancer. Lower occupation/social class may reflect exposure to harmful physical environments and agents which could increase the risk of oral cancer. While formulating health education programmes for this population, inclusion of messages like self-detection of suspicious lesions, pictorial presentation of various symptoms of oral cancer and oral precancerous lesions may improve the overall impact of the programme. This may also help in persuading people to seek health care facilities at the earliest.
Risk factors Overall there was poor awareness regarding risk factors and the impact of adverse habits on long term health. Unlike other studies, none of the participants in the present study recognized poor oral hygiene and micro nutrient deficiency as risk factors for oral cancer (23–26). Tobacco chewing, smoking and alcohol consumption appear to be the main reasons for the increasing incidence rates. Low socio-economic status and a diet low in
nutritional value, lacking vegetables and fruits, contribute towards the risk. In addition, viral infections such as human papilloma virus and poor oral hygiene are important risk factors (27). There is a need to inform and educate the public in matters related to recognized risk factors. Although health hazards of smoking and chewing gutkha (preparation of crushed areca nut, tobacco, catechu, paraffin, slaked lime and sweet or savoury flavourings) were recognized by 27.2% of the participants in our study, the association between alcohol consumption or betel quid chewing and oral cancer were known to only a few. This can be attributed to the health education campaigns initiated by the mass media which are responsible for the increased awareness regarding ill effects of tobacco in both smoking and smokeless form. However, these campaigns lack information regarding the role of alcohol and areca nut in the initiation and progression of oral cancer and oral precancerous lesions and hence fail to create awareness about these factors (28). Only 3% believed that betel quid chewing may be a risk factor for oral cancer. Most participants were not aware of the carcinogenic potential of areca nut. Recent studies have shown that areca alkaloids promote a wide variety of diseases from type 2 diabetes, central obesity to liver cancer (29– 32). Thus the use of areca nut in any form should be discouraged, either with lime or without lime. None of the participants in the present study were aware that diet had any role to play in the prevention of cancer. Rogers et al. suggest that poor oral hygiene and diet were risk factors and this was also suggested by 12% and 19% of participants, respectively, in that study (33). We can suggest that diversity in response may be attributed to various factors such as literacy rate, socio-economic development, lack of public health insurance and thus limited access to health care facilities. The protective role of Vitamin A and Vitamin E, which are present in green leafy vegetables and fresh fruits, should be incorporated into health promotion programmes.
Role of mass media The majority of participants (55.5%) had received information regarding oral cancer from health care personnel, followed by newspapers and television.
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As discussed earlier, mass media are playing a major role in disseminating information to the public at large. However, only tobacco in various forms has been depicted as a carcinogen. On-screen smoking by actors was disliked by many. This is a piece of positive feedback obtained from participants.
Warning on tobacco products Only 9.5% of the participants had noticed warnings on tobacco and alcohol products. This may be due to the lower literacy level coupled with the fact that warnings on tobacco products are so small that they are negligible. The results of a cross sectional survey conducted in five states of India revealed that the pictorial warnings displayed on the tobacco products were inadequate in conveying the adverse outcomes of tobacco on health and hence failed to discourage the users from consuming tobacco products, especially people with lower literacy rates (34).
Use of dental health care facility In the present study only 13% of the participants had attended a dental practitioner. The villages had the benefit of a mobile dental clinic provided by KLEVK Institute of Dental Sciences Belgaum. In spite of the fact that dental health care facilities were being delivered to their doorstep, people were reluctant to use them. Fear, ignorance and cost may be some of the barriers which prevented people from accessing services. Changing the attitude of individuals cannot be achieved by health education alone, but a thorough understanding of various barriers and the alternative strategies to overcome these barriers could be beneficial in achieving mass behavioural change. Among all the behaviour change models, Prochaska and Velicer’s ‘Transthoretical model of health behaviour change’ could be considered. This model assesses an individual’s readiness to act on a new healthier behaviour and provides strategies, or processes of change to guide the individual through various stages from behaviour change to action and maintenance (35). A comparison of males and females revealed that females had lesser knowledge than males regarding symptoms of oral precancerous lesions and to the fact that these could be prevented. Since the study was done in a rural setting, we can suggest that females
had comparatively limited access to information and education.
Limitations The questionnaire was devised by clinicians, so it was from their perspective rather than that of participants. The questionnaire was also translated into regional languages. Both these facts might have introduced some bias in the study, the extent of which remains undetermined. Variations in the wordings and response formats can alter the results. In all the questions asked, respondents only had to pick the response and this may have led to over estimation of awareness regarding oral cancer and oral precancerous lesions. Future studies can be planned with a qualitative study design to overcome most of these limitations.
Conclusion The result of this study, in addition to showing poor awareness of OC and precancerous lesions, also showed that gender and socio-economic status were important factors influencing the association between all three. This study provides benchmark findings against which changes in attitude and awareness towards oral cancer can be measured. Awareness of oral cancer and oral precancerous lesions was particularly poor in the rural population of Belgaum district in several aspects such as early signs, symptoms and risk factors.
Recommendations Health education campaigns particularly emphasizing oral cancer must be integrated with wider health messages. Oral cancer awareness programmes, along with oral cancer screening for high risk groups should be considered. Use of the salutogenic model of health promotion (36) along with a regulatory approach may help in raising awareness regarding oral cancer and decreasing its morbidity and mortality. Acknowledgments The authors sincerely thank Indian Council of Medical Research and all the study participants.The authors would also like to thank Dr.Vinuta Hampiholi for careful proof reading of the manuscript. IUHPE – Global Health Promotion Vol. 0, No. 0 201X
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Conflict of interest None declared.
Funding This study was sponsored by Indian Council of Medical Research (ICMR) under STS 2011 Reference Id 201101577.
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