A randomised controlled trial of a pilot intervention to encourage early presentation of oral cancer in high risk groups

Social cognitive theory to improve symptom appraisal and help-seeking among patients with autoimmune rheumatic diseases: A qualitative study

AIM

Social cognitive theory (SCT) has been successfully employed to improve symptom appraisal and help-seeking among patients with various conditions but is yet to be applied in the context of autoimmune rheumatic diseases (ARDs). This study aimed to explore the applicability of SCT in and possible approaches to improving symptom appraisal and help-seeking of patients with ARDs, one of the key barriers to earlier diagnosis.

METHODS

Semi-structured interviews were conducted with 33 ARD patients with a prolonged pre-diagnosis interval (>3 months). We coded the transcripts deductively using SCT as the overarching framework and inductively for approaches identified from the interviews.

RESULTS

All six main concepts of SCT (behavioral capacity, expectations, self-efficacy, observational learning, reinforcements, and reciprocal determinism) were observed in the three stages of symptom appraisal and help-seeking (detection, interpretation, and response) of patients with ARDs. While many participants reported that they were able and confident to detect their symptoms, they lacked the behavioral capacity and self-efficacy to interpret symptoms correctly, which resulted in delayed help-seeking and diagnosis. Possible approaches to address this suggested by participants (such as education of the general population) could improve behavioral capacity and self-efficacy in symptom interpretation and enhance expectations, observational learning, reinforcements, and reciprocal determinism in symptom response.

CONCLUSION

Lack of behavioral capacity and self-efficacy was observed in symptom interpretation of patients with ARDs, which resulted in delayed help-seeking. Approaches could target the behavioral capacity and self-efficacy for symptom interpretation to facilitate early help-seeking and, in turn, earlier diagnosis among individuals with possible ARDs.

Talking about cancer: Patient responses to raising awareness of oral cancer in primary dental care

OBJECTIVES

Dentists and other members of the dental team could raise awareness by talking about oral cancer during routine dental check-ups. A communication guide has been developed to facilitate this. However, it has been suggested that discussions about oral cancer may raise patients' anxiety and this has been documented by dentists as a barrier to having these conversations. The current research aimed to investigate implementation of the communication guide and its impact on the dental patient.

METHODS

A consecutive-case sample of adult dental patients attending primary dental care for a routine NHS check-up at one dental practice were invited to take part in the study via letter prior to their appointment. Consultations of participating patients (n = 77) were audio-recorded. Before and after their appointment, patients were asked to rate their current anxiety via the six-item version of Spielberger's State-Trait Anxiety Inventory. Audio recordings of each consultation were reviewed by two raters to determine the extent to which the dentist covered the topics recommended in the communication guide.

RESULTS

The dentist informed all patients that they were being checked for oral cancer, spoke about signs and symptoms, and discussed risk factors. However, they rarely recommended where help should be sought or addressed barriers to seeking help. Discussions took an average of 95 s. The extent to which oral cancer was discussed did not correlate with patients' post-appointment anxiety. Patients made positive or neutral responses to the discussions. The few questions that were asked were easily addressed.

CONCLUSIONS

As findings are based on one dentist working at one practice, generalization of these results should be cautious. The study indicated that using an evidence-based guide to talk about oral cancer did not appear to raise patients' anxiety in this practice population. This could help to increase awareness of oral cancer in the endeavour to facilitate early cancer diagnosis.

Approaches to improving symptom appraisal: a systematic literature review

OBJECTIVES

Poor symptom appraisal (detection, interpretation and response to symptoms) plays a major role in prolonged prediagnosis interval in various health conditions. Theories and models have been proposed to study the symptom appraisal process but how they could be employed to improve symptom appraisal remains unclear. We therefore aimed to review approaches to improving symptom appraisal in the literature and to develop a theoretical framework that could guide the development of approaches to improving symptom appraisal among individuals in the general population.

DESIGN

Systematic review.

DATA SOURCES

Medline, Web of Science, PsycINFO, Embase, CINAHL and Scopus were searched from inception to 30 March 2021.

ELIGIBILITY CRITERIA

We included original articles in English in which approaches to improve the detection, interpretation or response to symptoms for symptomatic individuals were described. We excluded articles in which approaches were developed to improve symptom appraisal among healthcare professionals.

DATA EXTRACTION AND SYNTHESIS

A predefined data extraction form was used to extract the development, characteristics and evaluation of approaches to improving symptom appraisal. This formed the basis for the narrative synthesis.

RESULTS

Of 19 046 publications identified from the literature search, 112 were selected for full-text review and 29 approaches comprising provision of knowledge of symptoms/signs and additional components (eg, symptom self-examination and comparison) for symptom appraisal were included in the synthesis. Less than half (41.4%) of these approaches were developed based on theories/models. Interestingly, despite the variety of theories/models adopted in developing these approaches, the components of these approaches were similar.

CONCLUSION

Symptom appraisal is an essential process in a patient's journey that can be targeted to facilitate early diagnosis but is largely unstudied. Building on the literature, we proposed a theoretical framework and approaches to improving symptom appraisal. This could facilitate early identification of a variety of health conditions in the general population.

TRIAL REGISTRATION NUMBER

CRD42021279500.

Effectiveness of Interventions to Improve Oral Cancer Knowledge: a Systematic Review

Oral cancer is prone to late-stage diagnosis, and subsequent low five-year survival rates. A small number of interventions or campaigns designed to enhance knowledge of risk factors and symptoms associated with oral cancer have been attempted in the UK, US, and some other countries. The purpose of this systematic review is to assess the effectiveness of interventions designed to improve oral cancer knowledge. We searched five databases to identify randomized controlled trials (RCTs) and non-randomized/quasi-experimental (NR/QE) studies targeting the general population or high-risk groups (tobacco users or alcohol consumers), aged ≥15 years, and reporting the outcomes of individual and/or community level interventions. Two co-authors independently identified relevant studies, extracted data, and assessed the risk of bias. Adhering to PRISMA guidelines, 27 (eight RCTs and 19 NR/QE studies) of the 551 studies identified from the five databases met the inclusion criteria. All RCTs and nine NR/QE studies used either printed materials, health education sessions, multimedia aids, or some combinations of these tools. The other ten NR/QE studies were community-based and used mass media campaigns to increase oral cancer awareness. Overall, the majority of studies significantly improved oral cancer knowledge; however, heterogeneity in study design and variation in measurement tools made it difficult to compare outcomes. Findings suggest that individual and/or community level interventions are generally effective in increasing knowledge of oral cancer risk factors, signs and symptoms, and/or its early diagnosis and prevention strategies among the general population or high-risk groups. However, the long-term benefits of these interventions are understudied.

Time-to-Treatment in Oral Cancer: Causes and Implications for Survival

The purpose of this review was to identify and describe the causes that influence the time-intervals in the pathway of diagnosis and treatment of oral cancer and to assess its impact on prognosis and survival. The review was structured according to the recommendations of the Aarhus statement, considering original data from individual studies and systematic reviews that reported outcomes related to the patient, diagnostic and pre-treatment intervals. The patient interval is the major contributor to the total time-interval. Unawareness of signs and/or symptoms, denial and lack of knowledge about oral cancer are the major contributors to the process of seeking medical attention. The diagnostic interval is influenced by tumor factors, delays in referral due to higher number of consultations and previous treatment with different medicines or dental procedures and by professional factors such as experience and lack of knowledge related to the disease and diagnostic procedures. Patients with advanced stage disease, primary treatment with radiotherapy, treatment at an academic facility and transitions in care are associated with prolonged pre-treatment intervals. An emerging body of evidence supports the impact of prolonged pre-treatment and treatment intervals with poorer survival from oral cancer.

Effectiveness of a health belief model intervention using a lay health advisor strategy on mouth self-examination and cancer screening in remote aboriginal communities: A randomized controlled trial

OBJECTIVE

Oral cancers caused by chewing betel nuts have a poor prognosis. Using a lay health advisor (LHA) can increase access to health care among underprivileged populations. This study evaluated a health belief model (HBM) intervention using LHAs for oral cancer screening (OCS) and mouth self-examination (MSE) in remote aboriginal communities.

METHODS

The participants were randomly assigned to intervention (IG; n = 171) and control groups (CG; n = 176). In the IG, participants received a three-chapter one-on-one teaching course from LHAs, whereas those in the CG received only a leaflet.

RESULTS

The IG participants were 2.04 times more likely to conduct a monthly MSE than those in the CG (95% confidence interval: 1.31-3.17) and showed significantly higher self-efficacy levels toward OSC and MSE (β = 0.53 and 0.44, effect size = 0.33 and 0.25, respectively) and a lower barrier level for OSC (β = -1.81, effect size = -0.24).

CONCLUSION

The LHA intervention had a significantly positive effect on MSE, strengthening self-efficacy and reducing barriers to OCS among aboriginal populations.

PRACTICE IMPLICATIONS

The effectiveness of the clinical treatment of underprivileged group can be improved through early diagnosis, which can be achieved using LHAs to reduce barriers to OSC.

Cognitive and emotional processes influencing patient presentation or non-presentation of oral Cancer symptoms to healthcare professionals

OBJECTIVE

Greater time that patients take to present symptoms to health care providers (HCPs) increases the likelihood of later stage cancer, which increases mortality and morbidity in symptomatic cancers. The common-sense model (CSM) is used to understand time to first consultation with a healthcare provider, but inconsistencies exisy between its current use and important empirical findings.

METHOD

To resolve inconsistencies, we conducted a qualitative examination to determine how the CSM could be revised to better account for these findings. We conducted in-depth interviews of a consecutive sample of 38 recently diagnosed patients who described events from first noticing symptoms to first consultation. Framework analysis was used to develop a theoretical model of processes leading to presentation or non-presentation.

RESULTS

Patients reported median presentation times of 3-4 weeks. Early presentation was facilitated by pre-symptomatic perceptions of vulnerability to serious illnesses and beliefs that early intervention could mitigate illness. These patients rarely tried to identify symptoms. They responded inductively, seeking help because symptoms were unusual. Where patients did not describe pre-symptom perceptions of vulnerability, many deductively tried to identify symptoms but misattributed them to minor conditions. Pre-symptomatic perceptions of vulnerability could also prolong presentation. When vulnerability was characterized by intense fears of cancer and cancer treatment, patients tended to avoid thinking about symptoms which extended presentation time.

CONCLUSION

Risk perception theories explain how participants' pre-symptomatic perceptions of vulnerability and potential treatment outcomes influence presentation time. Incorporating risk perception perspectives into the CSM can improve its ability explain responses to ambiguous symptoms.

Mass media and risk factors for cancer: the under-representation of age

BACKGROUND

Increasing age is a risk factor for developing cancer. Yet, older people commonly underestimate this risk, are less likely to be aware of the early symptoms, and are more likely to be diagnosed with advanced stage cancer. Mass media are a key influence on the public's understanding health issues, including cancer risk. This study investigates how news media have represented age and other risk factors in the most common cancers over time.

METHODS

Eight hundred articles about the four most common cancers (breast, prostate, lung and colorectal) published within eight UK national newspapers in 2003, 2004, 2013 and 2014 were identified using the Nexis database. Relevant manifest content of articles was coded quantitatively and subjected to descriptive statistical analysis in SPSS to identify patterns across the data.

RESULTS

Risk was presented in half of the articles but this was rarely discussed in any depth and around a quarter of all articles introduced more than one risk factor, irrespective of cancer site. Age was mentioned as a risk factor in approximately 12% of all articles and this varied by cancer site. Age was most frequently reported in relation to prostate cancer and least often in articles about lung cancer. Articles featuring personal narratives more frequently focused on younger people and this was more pronounced in non-celebrity stories; only 15% of non-celebrity narratives were about people over 60. Other common risks discussed were family history and genetics, smoking, diet, alcohol, and environmental factors. Family history and genetics together featured as the most common risk factors. Risk factor reporting varied by site and family history was most commonly associated with breast cancer, diet with bowel cancer and smoking with lung cancer.

CONCLUSION

Age and older adults were largely obscured in media representation of cancer and cancer experience. Indeed common risk factors in general were rarely discussed in any depth. Our findings will usefully inform the development of future cancer awareness campaigns and media guidelines. It is important that older adults appreciate their heightened risk, particularly in the context of help-seeking decisions.

Looking after the mouth - Evaluation of a pilot for a new approach to training care home carers in Kent, Surrey and Sussex

Objective This pilot study aimed to produce and evaluate training resources and training in oral health care, including oral hygiene, for carers in care homes in Surrey and Medway.Methods During two training days, for carers from these homes, short, interactive presentations were given on a range of topics relevant to oral health care and oral hygiene of older people, followed by practical training. Prior to any training all attendees completed a 39 question questionnaire to establish their baseline knowledge of oral health and hygiene. At the end of the training day they completed an evaluation form. Fourteen weeks later, they were visited at their place of work and completed the same questionnaire again. Differences in responses between baseline and after 14 weeks were statistically tested using the chi-squared test.Results Sixty-six carers attended the training sessions and 44 were followed up 14 weeks later. The results showed an improvement in carer knowledge at follow up. The majority of carers (36/44) spoke English as their first language. They had a mean age of 41 years, 37 were female and 7 male. They had worked as carers for a mean of 10.9 years (range 4 months-34 years). Over 90% stated that the training day fully met or exceeded their requirements and expectations.Conclusions The results indicated improvements in carer knowledge. However, the carers were atypical of carers in general, as they were self-selected and well-motivated. Nevertheless the content of the training day and the questionnaire should inform future work in this area.

Emerging infections - implications for dental care

Highlights the risk of transmission of emerging infections in dental settings.

If dental teams are aware of these issues they can reduce the risks to them and their patients.

Dentistry is often forgotten when new infections emerge; the appointment of dental emerging infection leads could ensure prompt advice is available.

Over the last 20 years the majority of emerging infections which have spread rapidly across the globe have been respiratory infections that are spread via droplets, a trend which is likely to continue. Aerosol spray generation in the dental surgery has the potential to spread such infections to staff or other patients. Although the diseases may differ, some common approaches can reduce the risk of transmission. Dental professionals should be aware of areas affected by emerging infections, the incubation period and the recent travel history of patients. Elective dental care for those returning from areas affected by emerging infections should be delayed until the incubation period for the infection is over.

Antimicrobial prescribing by dentists in Wales, UK: findings of the first cycle of a clinical audit

Objective To describe the findings of the first cycle of a clinical audit of antimicrobial use by general dental practitioners (GDPs).Setting General dental practices in Wales, UK.Subjects and methods Between April 2012 and March 2015, 279 GDPs completed the audit. Anonymous information about patients prescribed antimicrobials was recorded. Clinical information about the presentation and management of patients was compared to clinical guidelines published by the Scottish Dental Clinical Effectiveness Programme (SDCEP).Results During the data collection period, 5,782 antimicrobials were prescribed in clinical encounters with 5,460 patients. Of these 95.3% were antibiotic preparations, 2.7% were antifungal agents, and 0.6% were antivirals. Of all patients prescribed antibiotics, only 37.2% had signs of spreading infection or systemic involvement recorded, and 31.2% received no dental treatment. In total, 79.2% of antibiotic, 69.4% of antifungal, and 57.6% of antiviral preparations met audit standards for dose, frequency, and duration. GDPs identified that failure of previous local measures, patient unwillingness or inability to receive treatment, patient demand, time pressures, and patients' medical history may influence their prescribing behaviours.Conclusions The findings of the audit indicate a need for interventions to support GDPs so that they may make sustainable improvements to their antimicrobial prescribing practices.

Mouth examination performance by children's parents and by adolescents in Fanconi anemia

BACKGROUND

Fanconi anemia (FA) is a rare genetic syndrome characterized by increased risk of developing malignant neoplasms, particularly oral squamous cell carcinoma. This study aims to ascertain the extent to which adolescents and guardians/parents of children with FA are aware of their oral cancer risks and assess their ability to perform mouth examination (ME).

PROCEDURE

A cross-sectional study was conducted among patients with FA (between 6 and 16 years) and their parents. A total of 45 patients, 19 children and 26 adolescents, participated in the study. Among children less than 12 years of age, caregivers performed ME and adolescents between 12 and 16 years of age performed mouth self-examination (MSE). All parents were given a self-reporting questionnaire to collect sociodemographic data, information about health-related behaviors, and oral cancer awareness. Performance was evaluated using criteria for mucosal visualization and retracting ability. Subsequently, a dentist clinically examined all patient participants.

RESULTS

Performance evaluation indicated that the examination quality was unsatisfactory in both groups. Statistical significance was found between ability to perform ME by marital status (P < 0.036), where divorced parents had more difficulty performing ME than nondivorced parents.

CONCLUSION

Oral mucosa surveillance performed by parents and adolescents seems to be inaccurate. However, as an oral examination is a relatively inexpensive form of secondary prevention, it merits attention to teaching the technique to patients with FA and their caregivers.

Early oral cancer diagnosis: The Aarhus statement perspective. A systematic review and meta-analysis

BACKGROUND

Mortality is linked to diagnostic intervals in certain cancers. As symptom perception is conditioned by tumor site, a specific study on oral cancer is needed.

METHODS

This study's inclusion criteria were original data, symptomatic primary oral squamous cell carcinoma, and exposure of interest, diagnostic interval, or diagnostic delay. The outcome of interest was survival and disease stage. A meta-analysis was undertaken to investigate the relationship between intervals to diagnosis, TNM classification, and survival in oral cancer.

RESULTS

Regarding referral delay, the results present no heterogeneity and showed a risk increase in mortality of 2.48 (range = 1.39-4.42). The larger the diagnostic delay, the more advanced the stage at diagnosis. High quality studies reveal a higher risk increase than low quality studies (odds ratio [OR] = 2.44; 95% confidence interval [CI] = 1.36-4.36 vs OR = 1.53; 95% CI = 1.26-1.86).

CONCLUSION

A longer time interval from first symptom to referral for diagnosis is a risk factor for advanced stage and mortality of oral cancer. © 2015 Wiley Periodicals, Inc. Head Neck 38: E2182-E2189, 2016.

Mouth self-examination in a population at risk of oral cancer

BACKGOUND

Cancer of the oral cavity is a public health problem and many cases are not diagnosed until the disease has reached an advanced stage. The aim of this study was to initiate an educational programme in self-examination for patients at risk from oral cancer.

METHODS

This quasi-experimental study set out to initiate an educational programme in self-examination for patients at risk from oral cancer, assessing the outcomes after three months. In individual 15-minute face-to-face sessions, patients were given information and training in oral cancer risk factors and then verbal instructions as how to carry out oral self-examination. Three months later, patients were interviewed by telephone and asked if they had carried out self-examination independently at home. The programme was evaluated by means of a health belief model questionnaire on perceived susceptibility (3 items), severity (8 items), benefits (4 items), barriers (8 items) and efficacy (6 items).

RESULTS

Eighty-six patients (37 females [43.1%] and 49 males [56.9%]) with a mean age of 58.60±10.7 completed the oral self-examination programme. Logistic regression analysis indicated that patients who felt themselves subject to susceptibility (OR: 0.03 95% CI: 0.0-0.86; p<0.04), severity (OR 0.23 95% 0.08-0.68; p<0.008) and benefits (OR 0.11 95% 0.02-0.63; p<0.013) were more likely to perform self-examination.

CONCLUSIONS

Training programmes in oral self-examination are needed to decrease morbidity and mortality from oral cancer.

Patients' perceptions of oral cancer screening in dental practice: a cross-sectional study

Background

Oral cancer is increasing in incidence in the UK and indeed worldwide. Delay in diagnosis is common; up to half of patients are diagnosed with advanced lesions. Thus it is essential to develop methods to aid early detection. This study aimed to assess dental patients’ experiences and awareness of oral cancer and screening within general dental practice.

Methods

A cross-sectional questionnaire survey of 184 English-speaking adults, with no previous history of oral cancer was conducted. The questionnaire collected data on participant’s knowledge of oral cancer, experience of ‘screening’, attitudes and feelings towards having a screening, anticipated help-seeking behaviours, health-related behaviours (particularly risk factors) and sociodemographics.

Results

Twenty percent of respondents had never heard of oral cancer; 77% knew little or nothing about it and 72% did not know that their Dentist routinely screens for oral cancer. Overall, attitudes to screening were positive. Ninety two percent of respondents would like their Dentist to tell them if they were being screened for signs of oral cancer and 97% would like help from their Dentists to reduce their risk.

Conclusion

Patients seem generally unaware of oral cancer screening by their dentist but are happy to take part in screening, would like to be informed, and welcome the support of their Dentist to reduce their risk of developing oral cancer.

Evaluation of the different strategies to oral cancer knowledge: a randomized controlled study

OBJECTIVES

Oral cavity and pharyngeal cancer has been well recognized as a public health problem. Prognosis for oral cancer is substantially improved when diagnosed early. A study was made of the impact of different educational strategies upon knowledge of oral cancer, evaluating the intervention after 4 weeks.

METHODS

Ninety subjects over 40 years of age were consecutively included and randomized to three different groups (video, leaflet, verbal information). All subjects completed a 20-item pre-test on their knowledge of the risk factors, signs, and symptoms of oral cancer, and posteriorly received the video, leaflet, or verbal information, with evaluation of the results after 4 weeks.

RESULTS

In relation to the items correctly answered at baseline, all subjects showed an increase in knowledge score after 4 weeks: verbal information 4.77 ± 3.31, leaflets 4.53 ± 3.44, and video 3.67 ± 3.31 - no statistically significant differences being observed for any of the three strategies.

CONCLUSION

The oral cancer knowledge score increased following the educational intervention, which proved successful over the short term.