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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 20
| Issue : 1 | Page : 75-80 |
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Perceptions of health-care workers to educate community about oral cancer and its risk factors in Chikkaballapur District
KM Shwetha1, K Ranganath2, Pushpanjali Krishnappa1
1 Department of Public Health Dentistry, Faculty of Dental Sciences, M. S. Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India
2 Department of Oral and Maxillofacial Surgery, Faculty of Dental Sciences, M. S. Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India
| Date of Submission | 24-Sep-2021 |
| Date of Decision | 14-Nov-2021 |
| Date of Acceptance | 27-Dec-2021 |
| Date of Web Publication | 25-Feb-2022 |
Correspondence Address:
K M Shwetha
Department of Public Health Dentistry, Faculty of Dental Sciences, M. S. Ramaiah University of Applied Sciences, Gnanagangotri Campus, New BEL Road, Bengaluru - 560 054, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jiaphd.jiaphd_174_21
Background: Health-care workers form the strong linkage between the health-care system and the community they belong. The glaring maldistribution of dental workforce in rural areas with higher prevalence of oral cancer warrants the need for involving health-care workers for playing an active role in the prevention of oral cancer. Aim: The aim of this study is to study the perceptions and attitude of the health-care workers in creating the awareness on oral cancer and its associated risk factors to the community they serve. Settings and Design: Chikkaballapur District and Qualitative research. Subjects and Methods: Since the aim was to assess the perceptions and attitude, qualitative research method adopting ethnography strategy was conducted. The data were collected through focus group discussions (FGDs). The FGDs were carried out on the informed schedules with health workers to know their perceptions and attitude. The tools used were semistructured interview/discussion guides. Statistical Analysis Used: The codes were extracted by the deductive approach, and data analysis was done using the Spradley's method (1979) for Ethnography. This includes domain analysis, componential analysis, and identifying themes. Results: A total of 44 key informants and health workers were involved and more than 250 codes emerged after inductive coding. Eleven domains and three themes were identified reflecting the participants' compassion to serve people. Three themes emerged from the FGDs are: (i) Perception that oral cancer can be prevented, (ii) Recognition of the myths and practices associated with the disease and its treatment, and (iii) Motivation to educate people in their villages. Conclusions: Health workers perceived oral cancer was preventable and showed positive attitude to help their rural community by educating about OC and its risk factors.
Keywords: Ethnography, health education, health workers, oral cancer
How to cite this article:
Shwetha K M, Ranganath K, Krishnappa P. Perceptions of health-care workers to educate community about oral cancer and its risk factors in Chikkaballapur District. J Indian Assoc Public Health Dent 2022;20:75-80 |
| Introduction | |  |
Oral cancer is one of the fatal diseases which are most prevalent in the South-East Asian countries. It is the sixth common cancer in the world affecting lower socioeconomic groups causing burden to the families and also to the nation's economy. Males are more commonly affected than females. The most common causes include tobacco, arecanut, and alcohol consumption. This disease is preventable if risk factors are avoided.[1],[2],[3],[4],[5]
Indian health-care systems have been reaching out to most of the population of rural and urban areas. It is not so with oral health as the national oral health policy is still not reached the status of implementation, and also there exists inequality in the distribution of oral health care professionals. There is a lack of workforce in the rural areas where more than 70% of the population reside additionally the dentists' population is more in the urban areas.[6],[7],[8]
The oral health policy in the draft stage in our country leading to challenges for feasibility and sustainability of oral health programs.[6],[7] The oral health is given little priority by people in rural areas. Nonetheless, oral disease burden is expected to rise in future.[9] Primary health-care workers form a strong link between the people and health care in rural India. The Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwife, health workers, and Anganwadi workers work at the grassroots level. As they are selected from the community and work closely with the people, they are in continuous communication with the beneficiaries.[10],[11],[12]
World Health Assembly in 2007 passed a resolution in which there was a mention about including primary health workers in the prevention of oral cancer. WHO also suggested to take steps to ensure that the prevention of oral cancer is an integral part of national cancer-control programs. Also suggested to involve oral-health professionals or primary health care personnel with relevant training in oral health in detection, early diagnosis, and treatment of oral cancer.[3] Health education is the most important and powerful tool to address this issue as it is reported often in the literature that oral diseases are preventable if the risk factors which are responsible in causing diseases are avoided.[13],[14],[15],[16] Literature reports also show good evidence for effectiveness of the health education to have positive health behavior at later stages of life.[17],[18]
In India, the government has taken strict policy measures related to tobacco usage in recent years and also included oral cancer in National Program for Prevention and Control of Cancer, Diabetes CVD and Stroke,[19] the implementation will take its time. Meanwhile, the health care institutes and few nongovernmental organizations have taken initiatives to prevent oral cancer by providing health education, early diagnosis, and prompt treatment.[20]
In this situation of uncertainties regarding sustainability, planning an intervention through awareness programs on oral cancer can be initiated within the existing system using the health-care workers. The health-care workers form the part of community and are in close communication with the community than the professionals. ASHAs are mainly recruited for mother and child care. They are responsible for antenatal and postnatal care. Apart from this they are also supposed to educate community about the diseases and act as an activist for the betterment of their community.[10] Anganwadi workers are part of Integrated Child Development Service Scheme and rendering their services to mother and child, lactating mothers, adolescent girls in providing supplementary nutrition, following up with child care up to 6 years and health education.[11] This group is trained in educating community about health issues and government initiatives.[10],[11],[12]
However, ASHA workers and anganwadi workers have their set of duties to perform with their domestic responsibilities and are less satisfied with the remuneration provided.[10],[11] Information regarding their readiness to include oral health education, especially related to oral cancer was not available.
Hence, the research was conducted to explore perceptions and attitude of health workers in educating community about oral cancer and its risk factors along with the present responsibilities.
| Subjects and Methods | | |
Ethics committee clearance and permissions
The clearance was obtained from Institutional Ethics Committee (FDS/EC/2014-16/07). The necessary permissions to conduct the research were obtained from the District Health Officer of Chikkaballapur, the Deputy Director, Department of Women and Child welfare, Chikkaballapur District, Medical officers and Block Development officers.
Study design
The research was conducted using qualitative methods.
Research team and reflexivity
Personal characteristics and experience
Research team consisted of moderator (author 1 was the moderator for Focus Group discussions conducted, she is a female researcher, trained to conduct qualitative research methods by attending workshops and had experience in conducting qualitative research workshop and had the experience of guiding students), one research assistant and one note taker (research assistant and medico social worker were trained to record verbal and nonverbal communication and also communicate to participants about the media used for recording the discussion.).
Relationship with the participants
The participants were ASHA workers and Aganwadi workers. The research team was in constant touch with the gatekeepers [Table 1] for obtaining the permissions and understanding the work environment, key informants [Table 1] and few participants before the discussion. | Table 1: The information on gatekeepers and key informants in the context of the present research
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Participants were informed about the topic and reasons for doing the research and were provided with the information about the researcher's thesis work and importance of this discussion for the thesis and its implication on the public health.
Study design
Theoretical framework using nonclassical ethnography was conducted by the Author 1 in their natural settings through field visits and Focus Group Discussion (FGDs) to understand their perception on educating people and beliefs, values, and behaviors of people.[22]
Participant selection
The participants were recruited using the purposive sampling technique according to preselected criteria relevant our research question. We have selected the primary health workforce of Chikkaballapur district and personnel working at the grassroots level in the villages.
The participants included ASHAs and Anganwadi workers for FGDs. All the study participants were females. Participation was voluntary; hence, there were dropouts.
Study setting
The data were collected for the observation in the field areas of primary health-care workers of Chikkaballapur district. The environment was nonthreatening as the author and two members were present during the discussions which were conducted in one of their regular training hall. The places were Kaiwara, Chintamani, Chinnasandra, Talagwara, and Chikkaballapur taluk.
All the participants were from the villages of Kaiwara Hobli, Balagere, Kaiwara, Kuriyur, Chinnasandra, Gudlanarasimha halli, Nagadenahalli, Narayanahalli, Santhekallahalli, Peramachanahalli, Gowdanahalli, Aanuru, Doddakondrahalli, Vaddahalli, Kutthanuru, Kattraguppe, Burudugunte, and villages around Chikkaballapur.
Data collection
The data collection was conducted for 3 months, and before this, the observation and the process of discussion with all the gatekeepers and key informants started 2 months earlier (from February to June 2016).
The FGD guide was prepared that consisted of the introductory questions, specific questions with transition questions for three domains that is oral cancer and its implications on patients, signs, symptoms and its detection, preparedness of PHCWF for preventing it.[21] These were prepared based on the scientific literature[23],[24] and understanding the cultural issues in their area pertaining to oral cancer and its risk factors. The prepared FGD guide was validated with the professor in the department and two dentists in outreach centers. The questions were included to understand the probable barriers they may come across if they start educating in future.
Informed consent
Consent was obtained from the participants verbally before starting the FGD. Participants were informed about the process and audio recording of the discussion and were assured that the audio tape would be used for research purposes without disclosing the identity of participants. After transcribing it will be in the possession of author 1 for a short period of time.
A total of four FGDs were conducted for the 50–70 min each and were captured in a voice recorder after the participants consent. After the fourth discussion, the content analysis showed data saturation. First, the data were transcribed in Kannada and sent for participants for member checking, then was translated into English by the expert with good clarity of both the languages.
Data analysis
The data were analyzed on the translated document by Coding using the inductive method. The coding was done predominantly by the manual method by two coders. The data analysis of qualitative research was done simultaneously after each FGD. The data which was not elicited were included during the next FGD. The Spradley's technique was used for the analysis of the data, as given in [Table 2].[21] The analysis involved is domain analysis, componential analysis, and thematic analysis these are stand-alone process to categorize the data. | Table 2: Spradley's technique for the data analysis method of data analysis for ethnographic approach
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| Results | | |
There were around 36 participants for four FGD. All the study participants were female, and participation was voluntary; hence, there were no dropouts.
Domain analysis according to Spradley's method for ethnography was identified by inductive coding. Here is an example for coding from the transcript. One of the participant shared “we know it is caused by chewing tobacco but when we inform our village people they say that quid keeps their hunger away so that they can work longer, especially workers.” This reflects the participants are ignorant about the effects of tobacco on their health hence “ignorant” was the code given and other domains are presented in [Table 3]. | Table 3: The domain analysis according to Spradley's method for ethnography
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Componential analysis is presented in [Table 4], here the meaning of word was analyzed. For example, people often refer “Tobacco” as “Kaddipudi” in this region. The reference to word also helps us to know what the word refers to in this region. For example, silk worm rearing was an occupation along with agriculture, so if people mention “workers” it means masons and laborers working on silk rearing centers, agricultural fields, and construction sites [Figure 1].
The themes emerged from the FGDs are perception that oral cancer can be prevented, recognition of the myths and practices associated with the disease and its treatment and motivation to educate people in their villages. The three themes that emerged from the research work are presented in [Figure 2]. | Figure 2: Thematic analysis of the perceptions of the health workers about prevention of oral cancer and its risk factors
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| Discussion | | |
Qualitative research was the appropriate design to know about the perceptions of health workers as they shared their insights, observations from their interactions with people, and their beneficiaries.
As mentioned earlier, the health-care workers form a strong connection between health system and the community, particularly in rural areas. This association can be explored to create awareness about oral cancer in the community. In 2005, the WHO had suggested[25] to involve health workers to prevent and detect oral cancer at the early stages and disseminate the information through all the possible means of communication. However, earlier than this, the studies were conducted in Sri lanka and India to train health workers and detection of oral cancer and referral. The studies concluded that trained health workers were motivated to participate in the early diagnosis of oral cancer and were very helpful in identifying people with the signs of oral cancer and referring to higher centers.[26],[27]
The findings from the present research work also confirm that ASHAs and Anganwadi workers perceived that their role in health education is very important as the villagers are innocent about health-related issues and some were ignorant.
Three themes that emerged from the FGDs are on health workers are: (i) Perception that oral cancer can be prevented, (ii) recognition of the myths and practices associated with the disease and its treatment, and (iii) motivation to educate people in their villages.
Most of the FGD participants believed that the causative factors are related to smoking and alcohol, so the disease can be stopped if these factors are avoided. The participants observed that people in their villages are consuming tobacco in one or other forms. As they were aware that tobacco and alcohol are causes for oral cancer and informed people about the harmful effects of the habit. However, people were ignorant, and this ignorance was substantiated by them; “they have seen their parents and grandparents consuming tobacco without any effect on their health.” Some of the health workers have observed that even children were addicted to this habit by their elders in the family. One of the participants' during FGD with ASHAs said “Small kids too smoke cigarettes and chew tobacco while going to school, I saw even 8th standard and 9th standard students are smoking.” Similar observations are reported by Byakodi et al. in Maharashtra about the tobacco habit that was started at the young age.[28] It was also mentioned in the literature that health education given to the community about risk factors and disease repeatedly helps to create the awareness among the public. It further explains need for other methods such as group discussions, contact through telephones and visits to homes and reinforcing will help in overcoming the risk behaviours.[16]
Health workers also empathized about people's sufferings and their myths, as one of the participant narrated about the extent of addiction in their village as, “some of them are addicted so much that they keep the quid in the mouth for whole night so as to get good sleep. They are so careless about their own health.” Another participant shared one more observation from their village about the myths they have about oral cancer “there was this lady with oral cancer near our house, though she had sons, nobody used to care about her as they assumed it's a contagious disease so no one looks after her expect her daughter.” One more participant shared observations from her village: “They chew a lot of tobacco throughout the day and at night they even keep it in mouth to get good sleep. Some of the workers told us that they don't feel hungry if they keep tobacco during work hours.” Hence, people in the community have lots of myths and practices about oral cancer and tobacco consumption.
Health-care workers are motivated to work as their community people trust them more than anybody when it comes to health. One of them shared about the trust, “if they face any health problem, they won't go to the doctor, but will come to us first and then take the next step. This inspires us to work though we are paid less.” Sometimes, people come to them at odd times seeking help mostly because of labor pain. One of them shared her experience of attending the patient at 11 p.m. to PHC since the case was complicated it was referred to taluk hospital, the patient and attendant requested ASHA to accompany them to taluk hospital at Chintamani. Although it was late in the night by the time, she returned home, she was happy and satisfied that mother and child were safe. By these observations and discussions, we can notice that health workers are committed to their duties and they work because of the trust people have in them.
ASHAs and Agnawadis said that serving and helping people has become part of their life. Health workers told that they would “help people as much as possible,” and they also said “We feel happy when we share information and knowledge we have with them.”
It was also evident from our qualitative approach that health workers are motivated to educate their community. Hence, self-motivation with good intentions would bring about the sustained behavior and better outcome if they are provided with the right information. Otherwise, they sustain interest till the research is conducted. However, they also mentioned that the other motivating factor would be incentives or remuneration for the work as it helps in additional earnings but that will not stop their intention to share the information with the community. Saprii et al. also reported that they are valued for the duties they are performing in the community but the monetary benefits sometimes demotivate them.[10]
The limitation of our research work would be, the detailed interviews with the gatekeepers about their support for the health workers who are working in close proximity with the rural community regarding oral cancer awareness was not conducted. Future work can explore the perceptions of the administrators and immediate supervisors or reporting officers about their possible support to health workers in the prevention of oral diseases. This would be a moral help for health workers working in the rural areas and also be beneficial to the patients they refer.
| Conclusions | | |
Health workers perceive that oral cancer is preventable disease and there are myths about treatment. Hence, the health workers have intention to educate community because of the trust people have in them and improve their awareness about oral cancer prevention.
Acknowledgments
The authors would like to thank DHO, Chikkaballapur, District, Deputy Director, Department of Women and Child Welfare, Chikkaballapur, Prof. Sonali Jadav, Dean, MSRINR, Mr. Venkateshappa and Mr. Naveen MSW, Mr. Devaraj Health Assistant, Mrs. Roopa LHV, participated ASHA, Anganwadi and Health workers, Research Assistant team.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
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