RAJIVGANDHIUNIVERSITY OF HEALTH SCIENCES,
BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1.Name of the candidate :LILLY. C.L
(Sr. Athma)
and address1st year M.sc. Nursing
St. John’sCollege of Nursing, S.J.N.A.H.S.
Bangalore - 560 034
2. Name of the Institution:St. John'sCollege of
Nursing
3. Course of the study:Master's Degree in
and subject Nursing.
Community Health Nursing.
4. Date of admission to the course:02-05-2007.
- TITLE OF THE TOPIC
“Knowledge of women regarding the oral cancer related to smokeless tobacco- use’’
6. BRIEF RESUME OF THE INTEDED WORK6.1: NEED FOR THE STUDY
Smokeless tobacco is an addiction for hundreds of millions of people worldwide and the use by young people is increasing in many countries. Many types of smokeless tobacco are marketed for oral or nasal use. All contain nicotine and nitrosamines. Epidemiological studies from the USA, India, Pakistan and Sweden provide sound evidence that smokeless tobacco causes oral cancer in human1.
The prevalence of chewing tobacco use, especially paan with tobacco, was as high as 27% in Goa and 35% in Kerala, in Bhavanagar, Gujarat, 14% of women applied bajjar to the gum, in Singhbum (Bihar) l6% of women apllied 'gudhaku to their gum and in Darbhanga 7% used tobacco with lime. In Pune district, Maharashtra, most of the women did not smoke but 49% of women were smokeless tobacco users3.
Tobacco use among women is prevalent in all regions of India and among all sections of society - overall 2.4% of women smoke and 12% chew-tobacco3.
Women' s tobacco use is higher in the less educated and poorer social strata. Yet, the, socioeconomic gradients for tobacco use are steeper for women than for men3.
The women who chewed paan -tobacco in a study in Bangalore had a 25-times higher risk of oral cancer relative to non-users, while men who chewed paan -tobacco had a 3.6- times related risk compared to non-chewers. Men who smoked had a 3.5 times significantly grater risk than non-users of tobacco. Smokeless tobacco users are also at an increased risk of oral cancer after 5-10 years. Most cancers occur within the oral cavity itself: the most common place for them to exist are the tongue (20%), with other areas including the gingival (gums) (18%), floor of mouth (12%), lip (11%) and salivary gland (8%).1
Each year in the UK about 3800 new cases are diagnosed and there are around 1700 deaths. The incidence of oral cancer increases with age and in UK majority of cases (85%) occur in people aged 50 or over.1
Statistics from Kidwai Memorial Institute of Oncology,Bangalore, showed that total tobacco related cancers for male was 53% and for female it was 24.0%, among these, for oral cancer in male -12.5% and in female-13.1%12.
On an average 4 people die every day from oral cancer in the UK. Clearly there is a need to raise public awareness of oral cancer and the numerous risk factors associated with it. Ignorance of the risk factors is more likely to result in the late diagnosis of cancer and can subsequently reduce the rates of successful recovery. The lack of understanding was highlighted in researches centered on the north-east of England which revealed general ignorance of oral cancer, even among those people who had been in recent contact with the disease. Patients must be made particularly aware that certain lifestyles will make them more prone to oral cancer1
Tobacco remains one of the most important preventable causes of addiction, sickness and mortality in the world. The development of potentially malignant oral lesions as well as various other undesirable conditions are the direct result of tobacco use, yet on the whole the knowledge of these implications amongst the general public is very low (4%)1.
Today in the slums of Bangalore, a good number of women are using smokeless tobacco and they are at high risk for oral cancer. Having a lower socio-economic background, they have only limited access to adequate information regarding the consequences of this habit. Therefore, the investigator felt that it would be beneficial to assess the knowledge of women regarding oral cancer related to smokeless tobacco chewing and to prepare an information booklet based on these findings. This would in turn, enhance their awareness and motivate them to prevent such a practice and improve their health. Hence it is found as “The need of the Hour” to conduct a study of this sort.
6.2REVIEW OF LITERATURE
“Longer life can be penalty as well as prize. It is not just enough to live longer but it is important how to live longer in good health.”4
INTRODUCTION
The term literature review refers to the activities involved in the identifying and searching for information on a topic and developing and understanding of the state of knowledge on that topic. Literature review can serve as a number of important functions in the research process. A systematic review aims to discover research ideas, what is unknown about the research topic, conceptual frame work into which a research problem will fit and information on the research approach.5The studies reviewed for the present study is organized under the following headings.
- Smokeless tobaccoconsumption
- Prevalence of smokeless tobacco use among women
- Oral cancer
- Knowledge level of women and public
Tobacco use definitions and criteria were based on standard WHO guidelines. Tobacco habit was broadly classified in to four categories non-user, smokeless, smoker and mixed.6
Forms of smokeless tobacco include moist and dry snuff, loose leaf, plug or pressed leaf, time cut and twist chewing tobacco. Usage of smokeless tobacco among the public is estimated as 24 million. Smokeless tobacco sales have increased more than 30% in the past ten years.About 30,000 cases of oral cancer are discovered each year, resulting in approximately 9000 death per year. 6
Human beings have been using tobacco since 600 A.D. It was introduced in Europe by Columbus who came to know about it from the Caribbeans during his historical journeys. It was introduced in India by the Portuguese. Earlier, tobacco was generally smoked using different types of pipes or as cigars or was consumed orally7 (smokeless tobacco).
The term smokeless tobacco' is used to describe tobacco that is consumed without heating or burning at the time of use. Smokeless tobacco can be used orally or nasally.8
The oral use of smokeless tobacco is widely prevalent in India; the different methods of consumption include chewing, sucking and applying tobacco preparations to the teeth and gums. Smokeless tobacco products are often made at home but are also manufactured. Recently, a variety of smokeless tobacco products have been produced industrially on a large scale, commercially marketed and are available in small plastic and aluminium foil packets.8
Pan masala is a commercial preparation containing area nut, slaked lime, catechu and condiments, with or without powdered tobacco. Paan masala contains almost all the ingredients that go into the making of a paan, but are dehydrated so that the final .product is not perishable. It comes in attractive sachets and tins, which can be stored and carried conveniently.8
Combinations of tobacco, areca nut and slaked lime are chewed in several regions of north India, where they are known by different names.8
2. Prevalence of smokeless tobacco among women
Gudhaku is a past made of tobacco and molasses. It is commonly used in Bihar, Orissa, Uttar Pradesh and Uttaranchal. Gudhaku is applied to the teeth and gums, predominantly by women. The prevalence in these statues ranged from 4% to 16%. In a survey in the Singhbhum district of Bihar, 1% of men and 16% of women used gudhaku.In rural and urban surveys in Maharashtra, smokeless tobacco use consisted' of the application of mishri (especially among women) and the chewing of tobacco, mainly in paan.8
Among women in Karnataka and Uttar Pradesh, the highest prevalence was reached in the age group of 70 years and above, at levels of 27.6% and 42.6%, respectively, suggesting that in areas with a high prevalence tobacco use, initiation may occur at an early age. Among women, very few (<1%) smoked and 41% were chewers.The prevalence of tobacco use among females was 10.3% and 13.8% in the two successive survey. 8
Presently more than 10 million people globally are diagnosed with cancer every year. It is estimated that by 2020, there will be 15 million new cases every year. Cancer causes 6 million deaths every year, or 12% of deaths worldwide. 8
When mothers used ST less than five times a day, the risk of having a low birth weight baby was 50% higher, whereas in mothers who used ST five or more times daily, the risk was over 100% higher than in non-users. The average decrease in birth weight increased with increasing ST use. 8A statistically significant reduction in birth length of 0.518 cm in tobacco chewers has been reported. Babies born to ST -user mothers were more often growth retarded. 8
Considering the prevalence of smokeless tobacco use among women in India to be 55% and of smoking among them to be 3%, about 5.9% deaths in women 35-69 years old can be attributed to tobacco use. This translates into 86,000 deaths among women per year, out of 1,453,000 deaths in women in India in the 30-69 years age group. 8
3. Oral Cancer
There have been a number of investigations into the implications of smokeless tobacco on South Asian populations in the UK,the majority of which show that betel chewing is prevalent in many areas.This is of concern because other studies concluded that there is sufficient evidence to show that using smokeless tobacco heightened the risk of developing oral cancer.The studies found that:
- Betel paan chewing with tobacco as an ingredient is carcinogenic.
- Chewing betel paan may increase the risk of leukoplakia and periodontal diseases.
- There is a high frequency of oral cancer in areas where betel! Paan chewing is prevalent.
- tobacco is low in many areas, so much so that it was recommended that a Government Health Warning should be attached to any betel sold within the UK. lt was found that many people, especially the young, were only concerned about betel paan chewing in terms of its appearance on their mouths13.
- •Problems also arose because of the use of tobacco by a significant proportion of people as an aid to oral hygiene, many of whom had never visited a dentist.1
In addition to cancer, potentially malignant lesions of the mucous membranes, pre-cancers or leukoplakia, occur 6-times more frequently in smokers than non- smokers. Studies have shown that between 3 to 28% of all leukoplakia will become malignant. Although not limited exclusively to smokers, the formation of leukoplakia has been linked to smoking and the use of smokoless tobacco. Between 40-60% of smokeless tobacco users have a lesion in the mouth where tobacco is stored which occurs within a few months of use. Cessation or reduction of tobacco intake may help the regression or disappearance of leukoplakia.1
4. Knowledge
The health impacts of tobacco on the mouth receive relatively little attention and are not widely acknowledged, certainly amongst the general public. Obviously, dentist have a crucial role to play both in alleviating the impact of tobacco on oral health and disseminating information about it. Special attention must be given to highlighting the risks of oral cancer. Mortality rates for oral cancer are so high because many curable lesions are ignored and not diagnosed until they have become malignant.1The lack of understanding was highlighted in research centre on the north east of England which revealed general ignorance of oral cancer, even among those people who has been in the recent contact with disease. Patients must be made particularly aware that certain lifestyles will make them more prone to oral cancer.1
An exploratory study in gutkha and smokeless tobacco conception revealed that, 84% were not aware of caraingenic content of smokeless tobacco. Majority of them started use of tobacco since young age, frequency is more then 10 to 12 times a day.12
Insure that public awareness of tobacco related oral diseases continues to improve and more people are regularly screened.1
Investigation of the knowledge, attitudes, and practices of women who use smokeless tobacco is also important, particularly in developing countries in India. For example some rural women are reputed to believe that chewing tobacco is health.10
6.3.STATMENT OF THE PROBLEM
"A STUDY TO ASSESS THE KNOWLEDEG LEVEL OF WOMEN REGARDING ORAL CANCER RELATED TO SMOKELESS TOBACO USE IN A SELECTED URBAN SLUM IN BANGALORE" WITH A VIEW TO DEVELOP AN INFORMATION BOOKLET.
6.4.OBJECTIVES OF THE STUDY
- To assess the knowledge of women regarding oral cancer related to
- To find out the association between knowledge score and related
- To develop an information booklet on effects of smokeless tobacco
6.5 OPERATIONAL DEFINITION
1.Knowledge : Knowledge refers to awareness of women regarding oral
cancer related to smokeless tobacco use, solicited through the response
given by women to specific question asked in a structured interview
schedule and scored.
2. Women: Women who are above 20 years of age and are residents of an urban slum at Bangalore.
3. Smokeless tobacco : In this study the term smokeless tobacco is used
to describe tobacco that is consumed without heating or burning at the
time of use.
4. Oral Cancer: refers to the disease caused by an uncontrolled division
of abnormal cells of lip, tongue, gingival, mouth floor, oropharynx.
- Information Booklet: A book let is printed with information
6.6ASSUMPTIONS
1. Use of smokeless tobacco leads to oral cancer.
2. Information booklet is an accepted strategy in improving knowledge.
6.7 DELIMITATIONS
1. The study is limited only to women between 20-70 years of age and residing in a particular urban slum at Bangalore.
6.8 PROJECTED OUTCOME
The study will reveal the existing knowledge of women regarding oral cancer related to smokeless tobacco use. This would enhance the health personnel to prepare an information booklet and improve the awareness of the women regarding the detrimental effect of smokeless tobacco use and thus prevent oral cancer.
7. MATERIALS
7.1 SOURCE OF DATA
7.1.1. RESEARCH DESIGN
Research Design that will be used for this study is an explorative descriptive design.
7.1.2 SETTING
The area, which is selected for the study is Jakkasandra, an Urban Slum at Bangalore. St. John’s medical CollegeHospital is a tertiary hospital apart from the Hospital services, it plays a major role in providing Public Services. It has various centers for rendering Public Health Services both in Rural and Urban areas. Jakkasandra is one such Urban slum area.
7.1.3 POPULATION
The study population consist of 378 women over 20 years of age, residing at Jakkasandra, Bangalore.
7.2 METHODS OF COLLECTION OF DATA
7.2.1.SAMPLING METHOD
Setting is selected purposively, sample will be selected by simple random sampling.
7.2.2 SAMPLE SIZE
The sample size will be 137 women over 20 years of age.
7.2.3 INCLUSION CRITERIA
1. Women over 20 years of age.
7.2.4.EXCLUSION CRITERIA
Women who are not willing to participate in the study
7.2.5. INSTRUMENTS INTENDED TO BE USED
Based on the objectives of the study the following instruments will be developed and used.
SECTION-I
A Structured interview schedule to elicit baseline data, name, age, occupation, education, income.
SECTION - II
1) A structured interview schedule to assess the knowledge of women regarding oral cancer related to smokeless tobacco use.7.2.6. DATA COLLECTION
Women who are willing to participate in the study will be identified based on the inclusion criteria. The identified women will be explained about the purpose of the study and their consent to participate in the study will be obtained. Investigator will interview each sample individually by administering the questionnaire.
7.2.9 DATA ANALYSIS PLAN
1.Data Analysis will be done using descriptive and inferential Statistics. To assess the knowledge descriptive statistics such as percentage, mean and SD will be used.
2.Association between knowledge and baseline variable “chi-square ” test is used.
7.3 Does the study require any investigation to be conducted as patients or humans and animals?
No.
7.4 Has Ethical clearance been obtained from your institution.
The investigator will obtain permission prior to conducting the study from the ethical committee of the College of Nursing.
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[Accessed on September 11, 2007]
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tobacco products C.Sushma e-mail:
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