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Table of Contents   
ORIGINAL RESEARCH  
Year : 2022  |  Volume : 33  |  Issue : 3  |  Page : 241-246
Advanced virtual mentoring of dentists in oral cancer screening and tobacco cessation - An interventional study


1 Honorary Scientist, School of Preventive Oncology, Patna, Bihar, India
2 Independent Public Health Researcher, Duisburg, Germany
3 Department of Public Health, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson – Arizona, United States
4 Division of Clinical Oncology, Indian Council of Medical Research - National Institute of Cancer Prevention & Research (ICMR-NICPR), Noida, Uttar Pradesh, India
5 Center for Ethics, Fogarty International Centre, Yenepoya University, Mangalore, Karnataka, India

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Date of Submission27-Feb-2021
Date of Decision06-Sep-2022
Date of Acceptance12-Sep-2022
Date of Web Publication17-Jan-2023
 

   Abstract 


Context: Oral cancer is the third common cancer in India. Its mortality can be reduced through early detection and tobacco cessation ideally by dentists owing to their forte of work. Aim: This study was conducted to discuss effectiveness of an advanced tele-mentoring programme in oral cancer screening and tobacco cessation for dentists across India. Settings and Design: Online, interventional study. Methods and Material: The 14-week long training programme with 52 participants/spokes from across India had weekly hour-long online sessions comprising of an expert-led didactic and case discussions by spokes. Online evaluation (pre- and post-training, post-session), weekly and post-one-year feedback were conducted. Successful spokes attended a hands-on workshop subsequently. Statistical Analysis Used: One and independent sample t-tests determined the significance of the evaluation scores of the participants. Findings on attitudes and practice-related questions are presented as simple percentages. Results: A notable increase in the overall and per-session mean knowledge score, and confidence in oral cancer screening was observed. Many participants started these services at their clinics, thereby reducing further referrals, and were also motivated to spread community awareness about the same. Conclusion: This tele-mentoring programme, based on the novel Extension for Community Healthcare Outcomes model, is the first oral cancer screening training programme for dentists. This model—comprising of expert didacts, case discussions, and significant spoke-expert interaction—is a promising best-practices tool for reducing the disparity in knowledge and skills regarding oral cancer prevention among dentists across different locations. This would enable these most appropriate healthcare providers to contribute toward the overall goal of oral cancer prevention.

Keywords: Dental health education, oral cancer, prevention, tele-mentoring, tobacco cessation

How to cite this article:
Nethan ST, John A, Ravi P, Dhanasekaran K, Babu R, Hariprasad R. Advanced virtual mentoring of dentists in oral cancer screening and tobacco cessation - An interventional study. Indian J Dent Res 2022;33:241-6

How to cite this URL:
Nethan ST, John A, Ravi P, Dhanasekaran K, Babu R, Hariprasad R. Advanced virtual mentoring of dentists in oral cancer screening and tobacco cessation - An interventional study. Indian J Dent Res [serial online] 2022 [cited 2023 Feb 3];33:241-6. Available from: https://www.ijdr.in/text.asp?2022/33/3/241/367890



   Introduction Top


Oral cancer is the third most common cancer overall and the most common among males in India, with reported age-standardised rates (ASR) of 9.8 and 14.8 per 100,000 individuals, respectively.[1] Tobacco is the primary yet preventable risk factor for oral cancer,[2] with 266.8 million adult habituates in India.[3]

Almost half the cases of oral cancer worldwide are diagnosed in their advanced stages, with a five-year survival rate persisting at 50%.[4] But this can be increased through early diagnosis,[4] ideally by dentists who are familiar with the structures of the oral cavity[5] and have proven more competent at diagnosing oral cancer than general medical practitioners (odds ratios [95% confidence interval (CI)]: 2.68 [1.6, 4.4]).[6] They can also provide tobacco cessation simultaneously.[7] However, most dentists focus primarily on the hard tissues and procedural sites rather than soft tissues, owing to the relative ease and familiarity of examining the former.[6]

Project Extension for Community Healthcare Outcomes (ECHO)—a tele-mentoring model based on “moving knowledge, not people”—was initially developed in 2003 to assist primary healthcare providers (HCPs) in rural New Mexico to manage hepatitis C virus–infected patients[8] but has gradually expanded globally and includes numerous other medical conditions.[9],[10]

In lieu of the national cancer screening programme for oral, breast, and cervical cancer launched in 2016, the National Institute of Cancer Prevention and Research (NICPR), Noida (India) adopted Project ECHO for training HCPs in the same.[11] Findings of the module on oral cancer screening (and tobacco cessation) of the first basic training programme[12] and of nine cohorts of medical officers trained across India in screening of the abovementioned cancers[13] have been published, which reported significant changes in their knowledge[12],[13] and skills scores.[13] Cofta-Woerpel et al.[14] (United States or US) and Sagi et al.[15] (India) also published the positive outcomes of their respective ECHO tobacco cessation training programmes. ECHO model-based cancer prevention programmes were also launched by the Indiana University Fairbanks School of Public Health (US) and the Indiana Cancer Consortium (US)[16] and the Robert Mangaliso Sobukwe Hospital in Kimberley (South Africa).[17]

The success of NICPR's basic training programme (open to all clinicians) led to a huge demand for an advanced level and dentist-centric programme in oral cancer prevention, given the high burden of smokeless tobacco use and incidence of oral cancer in India. The current study discusses the findings of NICPR's first online Advanced Cancer Screening Training Programme for Dentists (ACSTP-O) in the abovementioned areas.


   Subjects and Methods Top


A 14-week curriculum covering important aspects of oral cancer screening as per the national guidelines in the Operational Framework and the Tobacco Cessation Clinic was designed in a primary healthcare set up [Supplementary Table 1]. Announcements regarding the programme were made on our official websites and previous programme participants were intimated by email. A nominal registration fee of ₹1000 was charged. The study was approved by the NICPR Institutional Ethics Committee (reference number: NICPR/IEC/2020/011, dated 14th Aug 2020). As only interested individuals self-enrolled to the course, an additional formal informed consent was not required from them.



Fifty-two participants from 15 states enrolled in this programme (demographic details in [Supplementary Table 2]). Each online session started with an expert-led didactic followed by a question-and-answer session. Experts from various premier institutes of India presented didactics every week, sharing their knowledge and enriching the participants with their field experiences. Thereafter, participants presented cases, ensuring better understanding of the didactic in clinical settings. The expert commented on the best practices for case management, thus facilitating case-based learning. Relevant reading materials were shared with the participants after the sessions. After every session, a pertinent online quiz was e-mailed to the participants (passing score = 60%). An e-certificate of completion was awarded to any candidate who attended at least 70% sessions and presented a case. Pre- and post-training evaluation surveys were conducted to assess the knowledge, attitude and practice of the participants regarding oral cancer screening and tobacco cessation.



Participants successfully completing the online course (n = 8/52) attended a one-day, free-of-cost, in-person workshop at NICPR that involved a quick revision of all the topics covered during the online training followed by hands-on training in oral visual examination (OVE) and tobacco cessation. Pre- and post-training evaluation, including clinical skill assessment (passing score = 80%), were conducted followed by a collection of anonymous feedback from the participants. In the end, the attendees were provided another certification.

One year after the online course, a short follow-up questionnaire was e-mailed to all of the participants to obtain information on their utilization of the knowledge and skills gained through this course in their clinical practice. The questionnaire consisted of open-ended and five-point Likert scale-based questions. The value of Cronbach's alpha was determined as 0.90.

To adequately evaluate the outcomes of the online training, we used Moore's seven-level evaluation framework for continued medical education [Supplementary Table 3].



Statistics

Information collected from the online training programme was entered into a Microsoft Excel sheet and analysed using the Statistical Package for the Social Sciences (SPSS) version 21 software. The one sample t-test determined if a statistically significant difference existed between the test score 60 and the average post-session scores of the participants for each session. The independent sample t-test determined the significance between the mean score of pre-training and post-training scores. P values of <0.05 and <0.001 were considered significant and highly significant, respectively. Findings from questions on attitudes and practices in the post-online training survey (one to ten) are presented as simple percentages. Responses to the open-ended questions of the post-online training and follow-up questionnaires (sent a year later) were analysed manually using the thematic framework.

The workshop's pre- and post-training questionnaires were not analysed due to very low participation.


   Results Top


Level One: Programme attendance ranged between 35 to 47 (70% to 94%) with an average attendance of 40.7 (81.4%). Forty participants (80%) presented cases. Thirty-nine (78%) eligible participants received the course completion certificate.

Level Two: Most of the participants provided positive feedback in the post-online training evaluation survey:

”I would take this opportunity to thank all the team members for their valuable time, patience and support throughout the course sessions. This is one of the most successful training courses I have ever taken. Unequivocally, I would recommend this course to my friends and colleagues. I look forward to putting skill and techniques that I have learned from this course into my dental practice” (Female, Delhi).

”The ACSTP-O course has been a source of intellectual enrichment and practical professional development for me. Thank you to each and every member of this organization including the technical and communication staff for the timely updates” (Female, Karnataka).

However, some participants found the timing of the online course inconvenient:

”Kindly make timing of lecture convenient to everyone” (Male, Punjab).

”The timing of course clashes with duty hours. It can be in the evening” (Male, Uttar Pradesh).

More than 95% of the participants said that they would recommend this course to their peers and colleagues [Table 1].
Table 1: Change in attitudes and practices of the participants between pre and post training

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At the end of one year, only nine participants provided feedback on the course: the session on nicotine and areca nut addiction and measurement scales proved most useful in their current practice, while that on setting up of tobacco cessation services was least useful.

Level Three: Although 52 participants enrolled for the programme, the number of participants ranged from 23 to 50 for the sessions and the post-session quizzes. Except for session 8, all the other sessions showed a significant increase in knowledge. The total score of all the 14 sessions also showed a significance association [Table 2].
Table 2: Evaluation of post-test scores of each session

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Forty-three participants took the pre-training survey while only 30 participants took the post-training survey. Hence, the 13 non-participants of the latter were excluded from analysis. A significant overall increase in knowledge was seen after training, that is, from a mean knowledge score of 3.1 before training to 5.9 after training [Table 3]. The ranges for pre- and post-training evaluations were 0–6 and 2–10, respectively.
Table 3: Change in knowledge level after the ECHO training

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The eight participants who attended the hands-on workshop scored 80% or above in the clinical skills assessment.

Level Four: At the beginning of the course, about 9% of participants reported no confidence in performing oral cancer screening which reduced to 0% of such participants after the course. The percentage of confident participants also increased from 67% to 89% at the end of the course [Table 1].

Level Five: During the course, the percentage of participants performing oral cancer screening in their clinics rose from 51.2% to 60.7%, along with an increase in the number of attendees [Table 1].

At the post-one-year follow-up, all the participants reported improved oral cancer screening and tobacco cessation skills owing to the course, with the majority performing them daily.

”On a regular basis (use the skills). I am a professor who teaches oral pathology to under and post graduates. Oral cancer is a major topic and also comes up in routine pathology cases submitted for examination” (Male, Uttar Pradesh).

”On an average ten to fifteen cases per month are being screened through various outreach programmes. Tobacco cessation counselling is also done now in a planned and proper way” (Female, Maharashtra).

Level Six: About 75% of participants were able to treat OPMDs and counsel patients better by the end of the course. The referrals also decreased from 30% to 18% [Table 1].

Level Seven: All the participants believed they could create a positive change in the community by increasing awareness about oral cancer, increasing oral cancer screening, and thus, decreasing the burden of oral cancer and tobacco use in the community [Table 1].


   Discussion Top


The ACSTP-O was the first tele-mentoring certificate programme started by the NICPR ECHO Superhub in India to further the knowledge and skills of dentists in oral cancer prevention, in part to fulfil the objectives of the national cancer screening guidelines for oral cancer.[11]

The effectiveness of this training programme is evident from the significant increase in the overall mean knowledge score after the programme, and at the weekly sessions (except in one). A favourable outcome was also reported from NIPCR's aforementioned basic training programme's module on oral cancer prevention (mean knowledge score: pre-evaluation = 6.7, post-evaluation = 7.4).[12]

Majority of the participants reported increased confidence levels in oral cancer screening after the training programme, with many starting the same at their respective clinics. Even the few participants who previously reported a complete lack of confidence in the above before the training felt confident to perform oral cancer screening after the programme. Participants also reported an increase in the number of clinic attendees since they started providing this service. Even after a year, some of the participants routinely practiced the skills acquired during the training. This change may be attributed to not only the well-developed didactics but also the demo videos shown by the experts; for example: clinical OVE (recommended method for oral cancer screening), and self-OVE. Additionally, participants were allowed to clarify their doubts with the experts, reiterate topics upon request, and were provided relevant resource materials for further reading.

As a result of the above, another favourable outcome of the training programme was the decrease in further referral of suspected OPMDs or oral cancer cases to another healthcare facility for confirmation of diagnosis. As already elaborated, a dentist is in the most favourable position to perform opportunistic screening for oral cancer in all patients seen, along with advising on behavioural risk factors on an individual basis. Owing to such advantages, the operational framework guidelines on the management of common cancers by the Indian government have also indicated dental professionals working at various levels of the Indian healthcare system, that is, the primary health centres (PHC), community health centres (CHC), district hospitals (DH), or private clinics as the primary point of referral by the auxiliary nurse midwife or mid-level providers at the health and wellness centres (sub-centres), and staff nurses at the PHCs, performing preliminary oral cavity screening. These dentists are responsible for further evaluation of the referred cases and for confirming the presence or absence of any OPMDs or oral cancerous lesions by performing the required clinical investigations (OVE with or without biopsy, exfoliative cytology, etc.), along with appropriate medical management and tobacco cessation; dysplastic and frank cancer cases are to be then referred to higher centres (tertiary care centres) for further management.[11]

The literature shows a low level of public awareness regarding the early signs and symptoms of oral cancer and its risk factors in many countries, thus deeming further action in this regard. This was particularly noted among those from low socioeconomic status, education and health literacy levels.[18] A qualitative study conducted among young oral cancer patients also reported that in spite of being aware of the term oral cancer, the patients neither considered their initial symptoms to be associated with the disease nor that their symptoms were serious enough to seek medical help; they instead self-managed the same.[19] In addition to population-based programmes, mass media campaigns, and one-on-one interventions, promotion of oral cancer awareness also involves community-based initiatives. Instead of screening only those attending their clinics, all the participants in our study were also motivated to extend their services and spread awareness regarding the importance of screening and early diagnosis of oral cancer on a larger scale in their communities. However, the general consensus from various such programmes conducted worldwide is that local programmes, utilising information, education and communication (IEC) materials such as posters and leaflets usually result in short-term increased awareness (mostly among the low-risk group), with limited behaviour change, if any.[20] In view of this, working along with community-based health advocates (community groups, services or agencies, including primary health care workers) who use a more active approach may prove to be more effective in raising oral cancer awareness and increasing presentation at screening, as has also been shown in the literature. However, further research is also required to understand the reasons for inadequate patient attendance at health facilities even following recognition of their symptoms.

The main limitations of this programme include a mild attrition rate which varied through the course and very few spokes providing course feedback when approached one year later, resulting in incomplete information from all spokes regarding the practical adaptation of the knowledge and skills acquired in the programme at their healthcare settings. A negligible number of spokes attending the hands-on workshop after the online training could be perceived as a limitation; however, the large majority of spokes reporting increased confidence in oral cancer screening after the online training itself—to the extent of them starting such services at their clinics—rather reinstates the positive outcome of the programme.


   Conclusion Top


The ECHO model is a promising best-practices tool in reducing the disparity in knowledge and skills regarding oral cancer prevention among dentists across different locations. As Project ECHO moves knowledge, not people, in the current scenario since the COVID pandemic, the need for effective alternatives to in-person professional training such as tele-mentoring programmes has never been more evident, which can also be easily continued and prove beneficial in the future. Additionally, removing barriers to receiving knowledge through technology and thereby empowering more and more HCPs in cancer screening will speed progress towards the overall cancer prevention goal.

Acknowledgments

The authors thank Ms Pratibha Jaiswal for her contribution to data collection and data entry, and Mr Vipin Kumar for his assistance in data analysis. The authors are also thankful to the participants for their cooperation and response to the evaluation surveys.

Financial support and sponsorship

Tata Trusts [Grant number: NICPR/2018/235].

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Correspondence Address:
Dr. Roopa Hariprasad
Division of Clinical Oncology, ICMR-NICPR, I-7 Sector 39, Noida 201 301, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.ijdr_8_21

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