|Year : 2021 | Volume
| Issue : 1 | Page : 7-11
Awareness, attitudes, and practices related to oral potentially malignant disorders and oral cancer among indigenous medicine practitioners in the Western Province, Sri Lanka
Prasanna Jayasekara1, Priyanga A Gamage2, Pemith R Liyanage3, Nilanthi T Kossinna1
1 Institute of Oral Health, Ministry of Health, Colombo, Sri Lanka
2 Dental Services Unit, Ministry of Health, Colombo, Sri Lanka
3 Oral Pathology Unit, National Dental Hospital (Teaching), Colombo, Sri Lanka
|Date of Submission||25-Jul-2020|
|Date of Decision||21-Sep-2020|
|Date of Acceptance||13-Oct-2021|
|Date of Web Publication||25-Feb-2021|
Institute of Oral Health, Ministry of Health
Source of Support: None, Conflict of Interest: None
Introduction: Oral cancer is a major public health problem in Sri Lanka. Health-care professionals have an important responsibility in control of oral potentially malignant disorders (OPMDs) and oral cancer. Since a considerable number of patients in Sri Lanka seek treatment from indigenous medicine practitioners (IMPs) for common oral conditions, they can be utilized for oral cancer control program. Aims: The aim of this study was to assess awareness, attitudes, and practices related to OPMDs and oral cancers among IMPs of government Ayurveda health-care centers in the Western Province, Sri Lanka. Subjects and Methods: A descriptive cross-sectional study was conducted among 338 of IMPs working in government Ayurveda health-care centers in the Western Province, Sri Lanka, from July 2018 to October 2018. A self-administered questionnaire was used to assess the awareness, attitudes, and practices. Statistical Analysis Used: Chi-square test and Fisher's exact test were used to detect associations with 0.05 significance level. Results: The response rate was 89.6%. Most of IMPs (63.7%) possessed satisfactory awareness, while 64.4% of IMPs had positive attitudes regarding OPMDs and oral cancer. Majority (83.5%) believed that lime in betel quid contains carcinogens. Majority of them were willing to do opportunistic screening (90.7%) and they considered it as their responsibility (92.1%). Only 41.3% of the IMPs examine oral cavity routinely and 55.5% of them advice patients regarding risk factors of OPMDs and oral cancer. Conclusions: Majority of IMPs possessed satisfactory overall awareness and positive attitudes regarding OPMDs and oral cancer. However, practices of IMPs related to OPMDs and oral cancer need to improve.
Keywords: Indigenous medicine practitioners, oral cancer, oral potentially malignant disorders
|How to cite this article:|
Jayasekara P, Gamage PA, Liyanage PR, Kossinna NT. Awareness, attitudes, and practices related to oral potentially malignant disorders and oral cancer among indigenous medicine practitioners in the Western Province, Sri Lanka. J Dent Res Rev 2021;8:7-11
|How to cite this URL:|
Jayasekara P, Gamage PA, Liyanage PR, Kossinna NT. Awareness, attitudes, and practices related to oral potentially malignant disorders and oral cancer among indigenous medicine practitioners in the Western Province, Sri Lanka. J Dent Res Rev [serial online] 2021 [cited 2021 Apr 21];8:7-11. Available from: https://www.jdrr.org/text.asp?2021/8/1/7/310198
| Introduction|| |
Cancer of the lip and oral cavity ranks the 18th most common cancer globally in terms of incidence (2% of total new cancers). GLOBOCAN estimated 177,384 deaths due to cancers in the oral cavity and lip to occur worldwide in 2018 (1.9% of total cancer deaths in the world). The overall prevalence of oral potentially malignant disorders (OPMDs) worldwide was 4.47%, with male preponderance. Asian populations had the highest prevalence rates of 10.54%.
Oral cancer is the second most common cancer among Sri Lankan population and the leading cancer among males. In the year 2012, 2255 new oral cancer cases were detected with an age-standardized rate of 9.6 per 100,000 population. Oral cancer is of major concern in Southeast Asia, primarily because of the prevalent oral habits of betel quid chewing, smoking, and alcohol consumption.
Lesions in the oral cavity are relatively easy to detect. A cluster-randomized controlled trial done in India among a high-risk group of tobacco or alcohol users revealed a significant reduction in oral cancer mortality following three rounds of oral–visual screening. Currently, oral cancer screening is mainly performed by dental surgeons and dental specialists who are practicing in the government and private sectors. Guidelines are in place for screening and referral of patients with OPMDs and oral cancer. Screening within general medical practice and by other professional and nonprofessional health-care workers on an opportunistic basis has been recommended for early detection of OPMDs and oral cancer.
The indigenous system of medicine in Sri Lanka consists of Ayurveda system of medicine, Siddha system of medicine, the Unani system of medicine, and its own traditional system of medicine called “Desheeya Chikitsa.” The popularity of indigenous medicine is increasing in Sri Lanka. Studies conducted in Sri Lanka showed that a considerable number of patients seek treatment from traditional systems of medicine for common oral conditions and oral cancers. Since the indigenous medicine practitioners (IMPs) are professional health-care providers, their utility for early detection and prevention of oral cancer is worth to be considered. For this purpose, their level of awareness, attitudes, and practices (AAP) related to OPMDs and oral cancer needs to be assessed.
According to the available literature, very few studies have been done to assess the AAP related to oral cancer among IMPs in South Asian countries., However, due to small sample size, the results of these studies could not be extrapolated to a larger population. It is important to identify gaps in AAP related to OPMDs and oral cancers among IMPs using larger sample size.
The aim of this study was to assess AAP related to OPMDs and oral cancers among IMPs of government Ayurveda health-care centers in the Western Province, Sri Lanka.
| Subjects and Methods|| |
A descriptive cross-sectional study was conducted among 338 of IMPs working in government Ayurveda health-care centers in the Western Province, Sri Lanka, from July 2018 to October 2018. The sample size was calculated using the single proportion formula. With 50% prevalence and given 80% power with a type I error level of 0.05, the final sample size was obtained as 384. However, since there were only 338 IMPs available in the Western Province, the total study population was taken as the sample. Hence, sampling was not carried out to select the final sample. Practitioners of Ayurveda, Unani, and Siddha systems of medicine who were working in all the government Ayurveda health-care centers in the Western Province during the study period were included in the study. Practitioners who were not currently involved in clinical practice were excluded from the study.
A 32-item self-administered questionnaire designed by the principal investigator was used to assess the awareness, attitudes, and practices. It was drafted in the English language and the finalized questionnaire was translated into Sinhala language and Tamil language. The questions were designed to assess awareness on burden of oral cancer in Sri Lanka, risk factors, and presentation of OPMD and oral cancers. Attitudes of IMPs were assessed using questions on willingness to identifying and referring patients for further management, advising patients on prevention and value of having further training. Practices were assessed using questions on whether they screen the oral cavity of their patients routinely; they had ever come across suspicious lesions of OPMDs and oral cancer; they had treated patients with OPMDs and oral cancer; they refer patient suspected to have OPMD and oral cancer; and whether they give patients preventive instructions. Several measures were taken at the designing stage of the questionnaire, at the time of data collection, data entry, and analysis stage to ensure the validity and reliability of data. The questionnaire was validated for the judgmental validity in terms of face validity, content validity, and consensual validity by the relevant experts in the field.
Pretesting of the questionnaire was carried out among 10 IMPs from the Southern Province, Sri Lanka, to assure that all the questions are clear and understandable to the participants. The average time taken for answering the questionnaire was 30 min.
Data collected were entered through the Statistical Package for the Social Sciences, version 18. The responses were coded as numeric to facilitate the data entry. The results were analyzed using the Pearson Chi-square test and Fisher's exact test with the level of significance set as P < 0.05.
Approval of the study was obtained from the Ayurveda Commissioner of the Department of Ayurveda, Ayurveda Commissioner of the Western Province, and the heads of the Ayurveda health-care institutions. Ethical clearance for the study was obtained from the Ethical Review Committee, Postgraduate Institute of Medicine, University of Colombo (ERC/PGIM/2018/108).
| Results|| |
Of 338 IMPs, 303 responded to the questionnaire resulting 89.6% response rate. Sociodemographic data including age, sex distribution, working experience, and other characteristics are shown in [Table 1]. Majority of the IMPs were under 40 years of age (46.9%), females (71.9%), and were practicing Ayurveda (88.1%). Nearly half of them had work experience of 5–20 years.
|Table 1: Distribution of indigenous medicine practitioners according to the sociodemographic variables (n=303)|
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Most of the IMPs (63.7%) had a satisfactory level of overall awareness on OPMDs and oral cancer. The overall awareness was significantly associated with age (P = 0.006) and work experience (P < 0.001) of IMPs. Young IMPs having lesser work experience had higher overall knowledge on OPMDs and oral cancer (78.8%). More than 90% were aware that oral cancer is preventable and nonhealing ulcer could be a clinical feature of oral cancer [Table 2]. Only 56.8% were aware of the burden of oral cancer in Sri Lanka. With regard to ingredients having carcinogens, majority (83.5%) believed that lime in betel quid contains carcinogens. A large proportion (62.6%) of IMPs considered that all red and white lesions in oral mucosa as oral cancer.
|Table 2: Distribution of indigenous medicine practitioners who answered correctly to the questions on awareness|
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A higher percentage of the IMPs (64.4%) had positive attitudes toward prevention and control of OPMDs and oral cancer. As shown in [Table 3], the majority of them were willing to do opportunistic screening (90.7%) and they considered it as their responsibility (92.1%). They believed it is necessary to refer patients with suspicious lesions of OPMDs and oral cancer to a specialist and they are ready to receive more information on OPMDs and oral cancer. A considerable proportion of IMPs (37.9%) did not believe the effects of banning betel quid in the prevention of OPMDs and oral cancer.
|Table 3: Distribution of indigenous medicine practitioners who had positive attitudes for each attitude statement|
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Only 41.3% of the IMPs examine oral cavity routinely [Table 4]. Most of them (69.5%) had seen suspected lesions of OPMDs and oral cancer. Of the IMPs, 6.6% treated patient having OPMDs and oral cancer. Majority of IMPs (49.2%) selected oral and maxillofacial surgeons for referring patients with suspicious oral lesions. Nearly 55% of IMPs had mentioned that they advise about the risk factors of OPMDs and oral cancers during routine practice.
|Table 4: Distribution of indigenous medicine practitioners according to the practices|
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| Discussion|| |
Detection of OPMDs and early recognition of oral cancer and referral of such lesions not only improves the survival rate but also lowers the cost and morbidity associated with the treatment. Since a considerable number of patients in Sri Lanka seek treatment from traditional systems of medicine for common oral conditions, IMPs could be considered as a good source for prevention and control of oral cancer in Sri Lanka. Therefore, the IMPs should have better awareness, attitudes, and practices related to OPMDs and oral cancer.
The present study revealed better awareness of OPMDs and oral cancer among IMPs. However, different results are shown in studies done in other countries. Studies done in India where oral cancer is the third commonest cancer reported that the knowledge among Ayurvedic, Unani, and Homeopathy practitioners on OPMDs and oral cancer was poor., A Colombian study reported that a level of awareness on OPMDs and oral cancer was low even among dentists. However, there are many studies demonstrating better awareness among dental professionals compared to other health professionals.,
There were few areas in the knowledge of IMPs to be improved, especially knowledge on the ingredients in the betel quid containing carcinogens and the knowledge on OPMDs. A considerable number of IMPs did not know that areca nut contains carcinogens and majority believed lime used in the betel quid contains carcinogens. Even though 69.55% of the IMPs had mentioned that they had seen patients with suspicious lesion of OPMDs or oral cancer, majority of them did not have a clear picture of white and red lesions and oral cancers [Table 2]. Almost all of them were willing to refer patients with suspected lesion of OPMDs or oral cancer to a specialist. However, to refer patients, they should have a sound knowledge on risk factors and clinical features of OPMDs and oral cancer. As majority of the IMPs (80%) believed that they need more information and training regarding oral cancer, there should properly organized programs to improve their knowledge, attitudes, and practices. Similar studies found in the literature showed that most of the traditional practitioners have positive attitudes regarding gaining more knowledge on oral cancer.,
It was evident from the current study, most of the IMPs (87.8%) had identified the necessity to educate the patients to quit their habits. However, only 55.5% passed the information to their patients in their routine practice.
Fewer IMPs (41.3%) routinely carried out an oral mucosal examination of patients who attended their practice. However, majority of them (92.1%) believed that it is their responsibility to screen for OPMDs and oral cancer. Hence, oral examination should be made a mandatory part of patient examination.
In the present study, it was revealed that 64.4% of the study population had positive attitudes regarding prevention and control of OPMDs and oral cancer. Having good attitudes among most of the IMPs might be supportive of establishing good practices related to OPMDs and oral cancer. It was encouraging that 92.1% of participants believed that screening for OPMDs and oral cancer was their responsibility, while 90.7% were willing to do opportunistic screening for OPMDs and oral cancer. The results of this study confirmed that IMPs had understood their responsibility in the prevention of oral cancer in the country. This may convince that utilization of this group of practitioners in control of oral cancer in Sri Lanka will be effective. Hence, there is a strong need to strengthen the knowledge, awareness, and attitude concerning oral cancer among IMPs focusing more on prevention, early detection, and appropriate referrals without any delay. Greater emphasis should be given for the teaching on oral cancer during undergraduate level.
| Conclusions|| |
Majority of IMPs possessed satisfactory overall awareness and positive attitudes regarding OPMDs and oral cancer. The study identifies practices of IMPs related to OPMDs and oral cancer those need to be improved. The results support that the IMPs can be utilized effectively in prevention and early detection of OPMDs and oral cancer in Sri Lanka. A comprehensive awareness and training program for IMPs on OPMDs and oral cancer is focusing more on prevention, early detection, and appropriate referrals without any delay.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]