INTRODUCTION
Cancer is a major public health problem in world wide and major chronic life threatening disease. It is increasing as a leading killer across the globe especially in the developing world. 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.[Indian Journal of Medical and Pediatric Oncology 2007].Cancer causes 6 million deaths every year or 12% of deaths world wide. The most shocking part of statistics is that 6 persons die every day from cancer in India [Oral Cancer Foundation, 2005].
In particularly, oral cancer is one of the common cancer in India. Oral cancer ranks as the 7th most common form of cancer in world wide. Comparative to other cancers, oral cancer is the second most common cancer in men. [Clinical Oral Investigation, 2001].
Several districts in Gujarat state showed high incidence rates of tongue cancer among males and Wardha district in Maharashtra state had the highest incidence rate of 14.1/1,00,000 of mouth cancer among males (Development of an atlas of cancer in India). There are strong indications for an association of the habit of betel quid chewing, tobacco use, cigarette smoking with cancers of mouth, oropharyngeal cavity, lips, buccal mucosa, salivary glands and anterior two third of the tongue.
A variety of mucosal changes have been noted in habitual users of smoked and smokeless tobacco. 90% of oral cancer can be attributed to specific etiological agents, the most important being the habits of chewing and smoking tobacco in various forms (WHO-2005).Tobacco plays vital role in producing squamous cell carcinoma. Tobacco is currently the second major cause of death and single largest preventable cause of disease in the world. Tobacco consumption is decreasing in the developed world, but rapidly increasing in the developing world among the youth. 46.4 percentage of current tobacco users who are in middle school live in a household where someone else uses smokeless tobacco [2002-Ohio Youth Tobacco Survey, Ohio Dept of Health].
The prevalence survey of tobacco use in Karnataka and Uttar Pradesh in India carried out on study samples of 30, 000 persons aged over 10 yrs in each of the two states, found an overall prevalence of any kind of tobacco as 29.6% in Karnataka and 34.6% in Uttar Pradesh. People from lower socio-economic background are usually more likely to use tobacco.
Oral cancers develop by way of cancinogenesis, multiple factors are involved. Alcohol use is a second independent major risk factor for the development of oral cancer. Alcohol is a powerful “Promoter” capable of altering mucosal cells to make them much more susceptible to malignant transformation by tobacco carcinogens.
“There are about 7,00,000 new cases of cancers every year in india out of which tobacco related cancer are about 3,00,000.This can be completely prevented by simple changes in life style and regular screening and even have health benefits that reach beyond cancer”(TATA MEMORIAL HOSPITAL, 2001].
Carcinoma of the lip, predominantly on the lowerlip, occurs in approximately 3600 per year. Several studies have shown decreased intake of fruits and vegetables also develop the incidence of oral cancer. It is also associated with increased risk of oral cancer, occurs in 10% to 15%.
The risk of developing oral cancer is higher in people who use both tobacco and alcohol. Eliminating the use of tobacco in various forms through control programmes and public education can reduce the incidence of oral cancer. As a health professional, the nurse has a major responsibility in providing adequate information about oral cancer and its prevention.
NEED FOR THE STUDY:
India is one of the highest incidence of oral cancer in the world. Oral cancer ranks number one among men and number three among women in India. It is estimated that among the 400 million individuals aged 15 yrs and over 47% use tobacco in one form or the other. Annual incidence rate is estimated to be 64.46 per 1,00,000 (Source: National Cancer Institute Surveillance Research Programme, 2006).
Tobacco use, particularly cigarette smoking is the leading preventable cause of death in the United States is responsible for approximately 4, 40,000 deaths each year (Centres for Disease Control and Prevention, 2002). Long term snuff users may be 50 percent more at risk for cancer of the cheek and gums (American Cancer Society). 31,000 new cases of oral cancer diagnosed in the U.S. 2006 nearly two third are males estimated deaths from oral cancer in 2004 are at 4830 men and 2400 women (American cancer society cancer facts and figures 2004).The major threat faced by women and children in India is second hand smoke. India has 5 million child smokers with 55,000 children starting regular tobacco use every year (Journal of Health for the Millions, 2004).
“Smoking is the single most preventable cause of death in our society” Each year smoking kills more people than AIDS, drug abuse, suicides, fires, combined. In India the proportion of tobacco related cancers relative to all cancers range from 35% in Bangalore to 50% in Bhopal among males. About 2000 deaths a day in India is tobacco related. [TATA MEMORIAL HOSPITAL, 2001]. According to B.B.C, “4 in 10 of all cancer in India are oral cancer”.
In world wide 25% of oral cancers are attributable of tobacco usage (Smoking or Chewing), 7-14% to alcohol drinking, 10-15% to micronutrient deficiency (Oral cancer news, August 15th, 2008). Ill effect of tobacco uses leads to cancer of oral cavity, sino nasal cavity, oropharynx, lung, esophagus, stomach, pancreas and uterine cervix.
This above statistics data indicates that there are high incident rate of oral cancer in India. Lack of awareness, worldwide the problem is far greater with new cases annually exceeding. In future nation has to be saved from oral cancer, as a health care providers, nurses must come forward to speak against tobacco use through tobacco awareness and control programme.
Researcher personally viewed that there is a high prevalence of oral caner in Andhra Pradesh due to usage of tobacco use and betel chewing. So the researcher felt the need to do a study on prevention of oral cancer among risk group.
STATEMENT OF THE PROBLEM:
A study to evaluate the effectiveness of Planned Nursing Intervention to promote knowledge and to reduce the risk status for oral cancer among risk group in a selected area at Bangaluru.
OBJECTIVES:
- To prepare and validate the Planned Nursing Intervention to promote knowledge and to reduce the risk status for oral cancer among samples.
- To assess and compare the mean pre-test and mean post-test risk status for oral cancer among samples.
- To assess and compare the mean pre-test and mean post-test score on knowledge about prevention of oral cancer among samples.
- To associate the mean pre-test risk status for oral cancer among samples with their selected demographic variables [age, gender].
HYPOTHESES: (at 0.05 significance level)
H1: The mean post-test risk status for oral cancer among samples will be lesser than their mean pre-test.
H2: The mean post-test knowledge scores about prevention of oral cancer among samples will be higher than their mean pre-test knowledge score.
H3:There will be a significant association between the mean pre-test risk status for oral cancer among samples with their selected demographic variables [age, gender].
H3(a): There will be a significant association between the mean pre-test risk status for oral cancer among samples and their age.
H3(b) : There will be a significant association between the mean pre-test risk status for oral cancer among samples and their gender.
OPERATIONAL DEFINITION:
1. Risk Group:
Checklist was used to assess the risk status about the usage of risk substances ( tobacco, alcohol, smoking ) among individuals prone for oral cancer.
2. Effectiveness
Effectiveness is determined by following ways,
- Significant difference in mean pretest and post test risk status for oral cancer.
- Significant difference in mean pretest and post test knowledge scores on prevention of oral cancer.
i. Level of risk status:
In this study, it refers to certain criteria used to assess the samples to know the risk for developing oral cancer. The checklists contain 16 items and are in positive and negative statements. According to the self report response from the samples the scoring was done as 0, 1, 2 and for negative statements the score was reversed. The scores was interpreted as below 35% less risk , 36-70% moderate risk, 71-100% high risk .
ii. Knowledge:
In this study, knowledge refers to the information given to the samples through a structured interview schedule. It contains 24 items of multiple choice question and each correct answer carries 1 score. The scores will interpreted as below 50%-inadequate knowledge 51-75%-moderate knowledge, 76-100%-adequate knowledge.
3. Planned Nursing Intervention for Prevention of Oral Cancer:
It refers to a systematically organized teaching programme on prevention of oral cancer. It includes the information regarding meaning of oral cancer, risk factors, clinical manifestations, early detection and diagnostic evaluation and preventive measures. Practice measures included avoid use of tobacco, alcohol, smoking and avoid dietary carcinogenesis such as smoked foods, spicy foods, deep fried foods, and increase intake of fruits and vegetables, diversional therapy to reduce the risk status for oral cancer. A followed by demonstration was given regarding oral hygiene and regular self oral examination .The duration of Planned Nursing Intervention was one hour and a set of flash cards used as a teaching aids. Individual teaching was given in their home atmosphere.
4.Oral Cancer:
It refers to the cancer of the mouth, oropharyngeal cavity, lips, buccal mucosa, salivary glands and anterior two third of the tongue.
5. Demographic Variables:
These are the variables which include age, gender, education, family history of oral cancer, family income per month.
i. Age in years
Age refers to the length of life that has existed. In this study ,it is classified into 15-25yrs,26-35yrs,36-45yrs,above 45yrs are included.
ii. Gender:
Both female and male are included.
ASSUMPTIONS:
- Planned Nursing Intervention may be an effective method to increase the awareness related to risk factor regarding prevention of oral cancer among the samples.
- Increasing of knowledge related to prevention of oral cancer may help to avoid or reduce the intake of risk substances.
- Focus on risk samples will reduce the incidence of oral cancer,
ETHICAL CONSIDERATIONS:
Permission received from concerned authority for the settings.
Written consent was obtained from the samples after explaining the purpose of the study.
DELIMITATIONS:
- Risk status elicited by self report method only.
- Planned nursing intervention is given one time.
- Samples assessed for practice of oral self examination by self reporting.
REVIEW OF LITERATURE
Review of literature is a key step in research process. The literature review is to discover what has previously been done about the problem to be studied, what remains to be done, what methods have been employed in other research and how the result of other research in the area can be combined to develop knowledge.
It is essential steps, it can be done before and after selecting the problem. It can help to determine what is already known about the topic (A.P. Jainco, 2005).
The chapter deals with review of literature, the studies reviewed have been arranged under the following sections,
Section–I: Studies related to Risk Factor for Oral Cancer.
Section-II: Studies related to Prevalence of Tobacco use and Oral Cancer.
Section-III: Studies related to Knowledge Assessment on Oral Cancer.
Section-IV:Studies related to Clinical Manifestation and Early Diagnosis of Oral Cancer.
Section-V: Studies related to Preventive Measures about Oral Cancer.
Section–I: Studies related to Risk Factor for Oral Cancer:
Winn and Colleagues (1982) proved that long term use of snuff to develop oral cancer which consists of samples involving 255 women living in rural North Carolina. They found a four fold risk of oral cancer among nonsmokers who dipped snuff. Results showed that long term users there was a 50 fold increased risk for oral cancer of the gum and buccal mucosa. Even women who had used smokeless tobacco less than 25 years had a 14 fold greater risk for the cancer. Concluded that long term use of snuff appears to be a factor in the development of cancer of the oral cavity, particularly cancer of the cheek and gum.
Gangane. N, Chawla. S, Anshu, Gupta. SS, Sharma. SM (1995) study conducted that reassessment of risk factor for oral cancer smoking tobacco and alcohol consumption was most commonly associated with oral cancer. Totally 140 cases of histologically conformed oral cancer were evaluated for their demographic details, dietary habits and addiction to tobacco and alcohol using a pre-designed structured questionnaire at the Mahatma Gandhi Institute of Medical Sciences Sevagram in Central India. Oral cancer was predominant in the age group of 50 – 59 years. Individuals on a non-vegetarian diet appeared to be at greater risk of developing oral cancer, cases were habituated to consuming not beverages more frequently than controls. The results showed that Consumption of Gutka a granular form of chewable tobacco and arecanut, was significantly associated with oral cancer cases. Bidi smoking was most commonly associated with oral cancer. The study concluded that combination of regular smoking and oral tobacco use as well as a combination of regular alcohol intake and oral tobacco use were significantly associated with oral cancer cases.
Rosriah Btehain, Noriaki Ikeda, Prakash, Chandra Gupta, Saman Warnakulasuriya, et.al., (1996) study proved that oral mucosal lesions associated with betel liquid, arecanut and tobacco chewing habits. A variety of betel / arecanut/ tobacco habits have been reviewed and categorized because of their possible causal association with oral cancer and various oral cancer and various oral precancerous lesions and on account of their widespread occurrence in different parts of the world.
Balaram. P, Sridhar. H, Rajkumar. T, Vaccarella. S, Herrero. R, (1999) study proved that oral cancer in Southern India, the influence of smoking, drinking, paan-chewing and oral hygiene which carried out a case, control study in 3 areas in India, (Bangalore, Chennai and Trivandrum) including 591 incident cases of cancer of the oral cavity (282 women) and 582 hospital controls (290 women), frequency matched with cases by age and gender. Low educational attachment, occupation as a farmer or manual worker and various indicators of poor oral hygiene were associated with significantly increased risk. Results showed that Oral cancer risk of 2.5 (95%) was found in men for smoking > or = 20 Bidi/day. The Oral cancer risk for alcohol drinking was 2.2(95%). The Oral cancer risk for paan chewing was more elevated among women than men. Concluded that among men 35% of oral cancer is attributable to the combination of smoking and alcohol drinking and 49% of pan tobacco chewing. Among women, chewing and poor oral hygiene explained 95% of oral cancer.
Geoffrey. C, Kabat, James. R, Hebert and Ernst L. Wynder,[2003] study proved that risk factors for oral cancer in women. Interviewers were obtained from 125 women with oral cavity cancer and 107 female controls to assess the role of mouthwash use as risk factors for oral cancer in women. Cases reported taking more mouth wash at each use compared with controls. Again among mouthwash users, cases were significantly more likely than controls to give as a reason for using mouthwash “to disguise the smell of tobacco” and disguise the smell of alcohol” whereas similar proportion of cases and controls reported using mouthwash to “disguise the smell of onions, garlic, etc” and “to disguise breath odors due to mouth infection of dental problems”. Study concluded that oral cancer were strongly associated with smoking and drinking, respectively and appear to be proxies for these exposures.
Muwonge. R, Ramadas. K, Sankila. R, Thara. S, Thomas. G, Vinoda.J, Sankaranarayanan. R, (2004) study proved that role of tobacco smoking, chewing and alcohol drinking in the risk of oral cancer which evaluated from a randomized control trial conducted in Trivandrum, India. Data from 282 incident oral cancer cases and 1410 matched controls were analyzed using multivariate conditional logistic regression models. Tobacco chewing was the strongest risk factor associated with oral cancer. The results showed that effects of chewing pan with or without tobacco on oral cancer risk were elevated for both sexes. Bidi smoking increased the risk of oral cancer in men. Dose-response relations were observed for the frequency and duration of chewing and alcohol drinking as well as in duration of bidi smoking.
Girish Parmar, Pankaj Sangwan, Purvi Vashi, Pradip Kulkarni and Sunil Kumar, (2008) study concluded that the effects of chewing of quid containing arecanut and tobacco on periodontal tissue and oral hygiene status. A total of 365 subjects were enrolled clinical data on periodontal tissues, oral hygiene status as well as information on bleeding from gums, ulcers in the oral cavity or a burning sensation in the soft tissues were collected. The result indicated that a significantly higher number of quid chewers suffered bleeding from the gums, halitosis, difficulty in opening the mouth and swallowing solid food, a burning sensation in the soft tissues and ulcers in the oral cavity than non chewers. There was no significant difference between quid chewers and non-chewers with respect to oral hygiene measures adopted. Concluded that chewing quid comprising arecanut and tobacco has adverse effects on periodontal tissues, oral hygiene and incidence of oral lesions.