|Ahead of print
Tobacco and cancer awareness program among school children in rural areas of Ratnagiri district of Maharashtra state in India
Atul Budukh1, Snehal Shah2, Suyash Kulkarni2, Sharmila Pimple2, Suvarna Patil3, Devendra Chaukar2, CS Pramesh2
1 Centre for Cancer Epidemiology, Tata Memorial Centre (ACTREC), Kharghar, Navi Mumbai; Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra State, India
2 Tata Memorial Centre, Parel; Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra State, India
3 BKL Walawalkar Hospital, Dervan, Ratnagiri District, Maharashtra State, India
|Date of Submission||15-Jul-2019|
|Date of Decision||16-Jul-2019|
|Date of Acceptance||06-Jun-2020|
|Date of Web Publication||10-Dec-2020|
Centre for Cancer Epidemiology, Tata Memorial Centre (ACTREC), Kharghar, Navi Mumbai; Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra State
Source of Support: None, Conflict of Interest: None
Background: Promoting awareness of tobacco and cancer in the community needs multipronged efforts. We performed a study to evaluate whether we could raise awareness about the harmful effects of tobacco, oral and esophageal cancer among school students by providing them health education. Moreover, we also compared the awareness level in students of age group 12 to ≤14 years with the age group >14 to 18 years.
Methods: We conducted an awareness program in the schools of Ratnagiri district of Maharashtra state. Students aged 12–18 years participated in this study. We provided health education to school students using a standard presentation; the presentation was rich in illustrations depicting the harmful effects of tobacco as well as oral and esophageal cancer's signs, symptoms, diagnosis, treatment, and preventive measures. After the health talk, a questionnaire was circulated. The questions were focused on tobacco, signs, and symptoms of the diseases along with early detection, prevention, and treatment of cancer.
Results: A total of 1354 students participated in the program. Totally, 567 (41.9%) students were from 6th to 8th grade (Group A, age group 12 to ≤14) and 787 (58.1%) students were from 9th to 12th standards (Group B, age group >14 to 18). Overall scores were high, ranging from 69% to 98%. Group A scored in the range of 69% to 95%, and Group B scored in the range 72%–98% The difference between the two groups was found to be statistically significant (P-value ≤0.05).
Conclusion: A standardized health education program helped to raise awareness about the harmful effects of tobacco and cancer amongst school children. Further studies are needed to evaluate whether educating school children has an impact on community understanding of the disease.
Keywords: Awareness, cancer awareness program health promotion, schools, students, tobacco prevention
Key Message Healthy lifestyle and raising awareness of cancer and its risk factors among school childrens is an important component of cancer control.
|How to cite this URL:|
Budukh A, Shah S, Kulkarni S, Pimple S, Patil S, Chaukar D, Pramesh C S. Tobacco and cancer awareness program among school children in rural areas of Ratnagiri district of Maharashtra state in India. Indian J Cancer [Epub ahead of print] [cited 2021 Oct 23]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=302942
| » Introduction|| |
Awareness of the harmful effects of tobacco and cancer varies in the community, especially in rural areas. Several ongoing initiatives using print media and audio-visual media to create awareness of these aspects show different outcomes. Tobacco is one of the major risk factors for both oral and esophagus cancers. As per GLOBOCAN 2018, there are 119,992 and 52,396 incidence cases as well as 72,616 and 46505 mortality cases, respectively, lip-oral cavity and esophageal cancers in Indian population for both sexes. Most of the Indian cancer registries have reported that oral cavity and esophagus cancer are leading cancers in males. The oral cavity cancer incidence rates reported by the Indian population-based cancer registries range from 2 to 22.3 per 100,000 population and for esophagus cancer, it is 2.7 to 51.2 per 100,000 population., Tobacco users are at high-risk of developing various non-communicable diseases (NCDs) including cancer. In India, 22.4% of males and 7.3% of females NCD deaths are due to tobacco use. As per the Global Tobacco Adult Survey (GATS 2) 2016-17, 266.8 million of all adults currently use tobacco (smoked or smokeless). Moreover, the GATS survey also indicates 55.4% of current smokers are planning or thinking of quitting smoking and 49.6% of current smokeless tobacco users are planning or thinking of quitting smokeless tobacco use. There is a need to create awareness about tobacco hazards in the population.
The cancer education program that raises the awareness for risk factors and promotes a healthy lifestyle among the general population is the fundamental initiation of primary prevention. We have conducted several health education programs in the schools of Ratnagiri district during 2013–2017, to raise awareness of tobacco and its harmful effects as well as oral and esophageal cancers. These school-based cancer awareness programs included a comprehensive health education followed by a questionnaire-based test to evaluate the impact of health education in raising awareness of the disease among the participants. Moreover, the study also compared the awareness level among students of age group 12 to ≤14 years with the age group >14 to 18 years.
| » Methods|| |
The awareness programs amongst school children were conducted as a part of a larger study evaluating the role of oral and esophageal cancer screening using visual examination by trained health workers, and double-contrast barium swallow, respectively. This cluster-randomized community-based screening trial started in the year 2010 involving two rounds of screening of high-risk population (tobacco and/or alcohol consumers) in rural Maharashtra (Ratnagiri district). The trial was approved by the Institutional Ethics Committee and is currently in its final phases of screening. While interacting with the community leaders and the health authorities, the project staff obtained permission to conduct an education program among school students to enhance understanding of tobacco hazards, signs and symptoms of oral and esophageal cancer, and also their preventive measures. The team leader and social worker of the screening project arranged a meeting with the school principal, teachers, and administrator along with the community leaders to receive support for conducting the cancer awareness program in the school. School children of 6th to 12th grades (age group 12 to 18 years) who agreed to participate in the awareness session were given health education on oral and esophageal cancer by an experienced personnels including medical officers and social workers. School children of 6th to 8th grades were considered as Group A (age group 12 to ≤14) and children from the 9th to 12th grades were considered as Group B (age group >14 to18). Before providing health education, the health educator asked a few questions to the students related to the harmful effects of tobacco on health as well as regarding the signs and symptoms of oral and esophageal cancer to assess their knowledge. Because of time constraints, we could not objectively measure the awareness level among the students before the program. A questionnaire was circulated to the entire class in every health education program (as per [Table 1]). The prevalent knowledge regarding these subjects was found to be low. Very few students in a class knew about harmful effects of tobacco and healthy lifestyle including balanced dietary habits and physical exercises. Similarly, we observed that the students had information regarding the nearby cancer centers including the Bhaktshreshtha Kamalakarpant Laxman Walawalkar (BKLW) hospital, Dervan village, Ratnagiri district and Tata Memorial Hospital (TMH), Mumbai. We found that before providing health education the overall awareness level among students was very low.
After assessing the general knowledge, we provided health education with topics covering hazards of tobacco usage and its ill effects on health and about oral and esophageal cancers through a standardized PowerPoint presentation using a screen and a projector. The presentation was rich in illustrations making the session interesting, informative, and interactive. An interactive health education session was also conducted which was chaired by either the school principal or a senior teacher of the school. The students were encouraged to ask questions related to the disease and its available treatments.
Following the health talk, questionnaires were circulated among the children. The questionnaire was divided into three parts. The first and second parts included 15 objective type questions: one point for each correct answer. On the other hand, the third part had descriptive questions with a total of 15 points. The objective questions were related to preventive measures and the descriptive questions were related to control of tobacco and alcohol and information about the cancer center in the area. [Table 1] shows the types of questions asked in the cancer quiz program.
The total allocated time to answer the cancer quiz questionnaire was 60 minutes. After 60 minutes, the medical officer or the project staff examined the answers given by the children. Based on the results, prizes along with certificates were distributed to the top five students. Generally, not every school has the class from 6th to 12th standards; some schools have facility upto 12th classes while some have facility upto 10th standards. The students were divided into groups based on their age to undertstand the level of awareness by age group. The understanding of the student may be different due to differences in the age group.
The data collected were a knowledge score of the student in a different dimension. These scores were added and divided by the sample size to get the mean knowledge score in a particular group to test the significance of preference in the knowledge score of two groups. Student's t-test was applied. Analysis was done using Stata Software Version 15.0 (StataCorp LLC, College Station, Texas, USA). The t-test was considered to be statistically significant if P value was ≤0.05.
| » Results|| |
During 2013–2017, we conducted 13 school education programs to raise the oral and esophageal cancer awareness among the school children in the rural areas of Ratnagiri district. In total, 1354 students participated (676 boys and 678 girls). A total of 567 (41.9%) students were from Group A and 787 (58.1%) students were from Group B. [Table 2] shows the grade and gender distribution of the school children. The total number and proportion of students who answered correctly to the objective and descriptive questions are shown in [Table 3].
|Table 2: Distribution of students who participated in the cancer awareness program, according to their group and genders|
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|Table 3: Distribution of the marks obtained in part 1 and 2 sessions by group wise|
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Results of questionnaire part 1 indicated a good understanding of the mechanism of the cellular growth. The students accurately understood general concepts of cancer and the symptoms of oral and esophageal cancer. Because of the awareness program, the students gained information about the required measures that need to be taken if they identified a person showing symptoms. The results reflected the positive outcome for the same. The comparison between the two groups was significant (P-value <0.05) in providing the answer of question number 2 to 6. The students also understood that apart from cancer, tobacco was a risk factor for heart and lung diseases. In terms of knowledge on cancer prevention by early detection, the results were satisfactory. The comparison between the two groups was found to be statistically significant (P-value <0.01).
Results of the part 2 of the questionnaire showed improved knowledge of the students of both the Group A and B regarding unhealthy tobacco use and role of physical exercise and leafy vegetables for better health. Of the total 567 students of Group A, 76.2% students recognized tobacco as a harmful substance (question 11) and 68.6% students accepted leafy vegetables for better health (question 12). Similarly, positive results were found for the Group B. Of the total 787 students, 85.6% and 83.7% students correctly answered questions 11 and 12, respectively. The difference between the two groups for the same was found to be statistically significant (P-value <0.01). Moreover, more than 90% of the students of Group A and B recognized beneficiary health effects of physical activities (question 13).
Furthermore, conducted health education programmes increased the level of awareness of passive smoking hazards. Findings indicated that students from both the Group A and B have developed an excellent understanding regarding effects of smoking inside the house by one family member on the other family members. About 89.4% of Group A students and 95% of Group B students showed improved knowledge of second-hand smoking (question 14). In addition, results also demonstrated that 71.1% Group A students and 83.9% of Group B students recognized cancer as a preventable disease if detected early (question 15). The comparison between two groups was found statistically significant (P-value <0.01) for both the questions 14 and 15.
Part 3 of the questionnaire required detailed answers and was assigned 15 points. Through these questions, the study examined the ability of the students in cancer prevention. The students were asked to share their views or suggestions in controlling the tobacco and alcohol habits of their family members as well as restricting the tobacco use in their villages. The students answered these questions satisfactorily. Many students suggested that village leaders should prohibit tobacco and alcohol trade in villages. Moreover, students also mentioned that they would explain the harmful effects of tobacco and alcohol use to their family members and would give continuous counseling to them. Some of the students stated that they would request their family members to participate in the cancer screening program while some mentioned to take their family members to the nearest primary health center/or general practitioner to control the tobacco habits. Many students mentioned the name of BKLW and TMH as a nearby cancer center. Further, few students mentioned that they would take away their parents' tobacco pouch and would complaint to the senior member of the family about their tobacco habit. Apart from these, a few students mentioned that alcohol habit of a key person has affected the entire family socially and financially.
For part 3 questions [Table 4], 66% of Group A students received less than or equal to 40% marks as compared to 36.6% from Group B. The Group B students show better understanding in describing their views on cancer control activities; 63% of students received more than 40% marks. The difference between the two groups was found to be statistically significant (P-value <0.001). The students have also written good slogan on cancer prevention in the local language Marathi. The students' knowledge about the cancer treatment center in the nearby area was at moderate level.
|Table 4: Distribution of the marks obtained in part 3 session by group wise|
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| » Discussion|| |
This study was conducted to evaluate the levels of awareness of oral and esophageal cancer and its preventive measures in school children after a structured educational session. An excellent response was received from the schools and teachers for conducting the cancer awareness program. The program turned out to be very effective in raising awareness of oral and esophageal cancer among school children. As a result of this program, the students acquired awareness of the warning signals of oral cancer as well as of esophageal cancer. The students also learned about harmful effects of tobacco on health. Moreover, due to the awareness program, the students understood the impact of physical activities and good nutritional dietary habits on health and wellbeing. It was noticed in our study that the level of understanding of the diseases was much better in the group B as compared to group A. The understanding of the students regarding the treatment of cancer and its early detection was at a moderate level (Questions 8 and 15). With regards to the part 3 of the questionnaire, the students responded reasonably well on actions required to break the tobacco and alcohol habits in their family members. As an organizer, we have understood that in cancer awareness program, it is essential to focus more on the aspects of early detection and treatment of the disease along with the efforts required to be put forth by an individual to control tobacco and alcohol habits of his/her family members and/or close relatives. A study conducted in India has reported that knowledge about diagnostics and treatment is at moderate level. The awareness program was organized in a well-planned manner. The prizes and certificates motivated the students who also showed much appreciation for the organiser of the cancer awareness program.
It was necessary to educate the students about what steps should be taken when one identifies a person who shows symptoms of oral or esophageal cancer. Students were also educated on motivating people with symptoms of oral and esophageal cancer to consult the medical officer at the nearby primary health center or cancer centre for a checkup. It has been reported that there is lack of public information and awareness in recognizing the cancer signs. This delays timely access to care, resulting in late stage cancer diagnosis and premature cancer mortality. Health education is very important factor in cancer control activities. No cancer control efforts could be mounted without education at all levels, both the public and the professionals. As per the Hospital Based Cancer Registries report of India, most patients with cancer reached the hospital at an advanced stage. Several reasons have been put forth to explain why patients present in advanced stages. One of the reasons is that the patients and their close relatives do not have knowledge about the warning signals of cancer and also about the risks involved in not treating the disease at an early stage; on the other side, even if they are aware, they do not know whom they should consult and/or what steps should be taken. Late detection of cancer increases treatment morbidity and reduces survival rate. We observed that students' knowledge about the treatment center was at moderate level. In awareness programs, we need to spend more time on providing information on cancer treatment centers in the nearby area.
Raising cancer awareness level by health education has played a very important role in cancer prevention activities. It was reported that due to effective health education and easy access to diagnosis and treatment, the cervical cancer cases had been detected at an early stage in Barshi and Madha areas of Solapur district of Maharashtra state.,
In rural areas of Ratnagiri district, most of the population is busy with their agricultural activities or in their daily-wages jobs for their livelihood. India is a large country with more than 600,000 villages in it. Most villagers are busy in the daytime with agricultural-related work, and it is a challenge to organize cancer awareness program during their working hours. Rather, it is easier to educate school children who would then pass on the cancer awareness message. Cancer awareness program in schools should be made mandatory for effective cancer control and prevention. It is much easier to reach the community and the population at large via organizing cancer control activities in schools. In this program, students had written catchy slogans on cancer prevention in the local language, which are likely to pass effective cancer prevention messages in the community. It has been reported that intensive school education on tobacco hazards would be an economical efficient investment for the nation.
It has been reported that the mean age of initiation of tobacco habit was 19 years and more than one third (36%) of daily tobacco users aged 20–34 had already started using tobacco on daily basis before attaining the age of 18. It is necessary to educate children about the harmful effects of tobacco before they fall into the habit. Hence, the school-based awareness programs are useful in raising the awareness of the harmful effects of tobacco. According to Global Tobacco Adult Survey 2 India 2016–2017, there were 266.8 million tobacco users. As per this report, 28.6% of adults in India use tobacco in some form or another. Tobacco is not only a risk factor for cancer, but also a risk factor for common non-communicable diseases, such as cardiovascular diseases, stroke, diabetes, and chronic respiratory diseases. Awareness programs regarding cancer and especially educating students about the harmful effects of tobacco in schools are essential. A study indicates that schools are capable to promote cancer prevention as schools have necessary tools to provide a positive impact on students' health and also to create awareness among students who in turn could help the society. The studies have reported that health education in schools is a necessary tool to provide a positive impact on the students' health.,
The World Health Organization (WHO) Global School Health Initiative has established health-promoting school programmes in all six regions of WHO. High-income countries showed that health-promoting school programmes played a vital role in improving children's health by reducing risk factors, such as tobacco use, increasing the intake of fruits and vegetables, and increasing physical activities in children. The risk of using tobacco, either in smoking or smokeless form, is more in less-educated people. The number of smokers in urban India will increase from 101.8 million reported in the year 2015 to 106.2 million in the year 2025; therefore, health education on the hazards of tobacco will play an important role in the prevention of tobacco use.
Our study has limitation that we have not measured the awareness level of the student before health education session. We have asked the questions to the student in the class before health education programme and we have noticed awareness level is poor. Before interpretation of the result one should take into account the limitation of the study. The studies reported that awareness level in the general population of India is very poor. There is a significant deficiency in the awareness of oral cancer and its risk factors among the public., To assess the effect of experience and exposure comparison between the two groups was done, considering the second group B (age group >14 to 18) as more exposed. The study has shown a highly significant difference between the two groups; however, part of the difference may be due to differences in the age group. The health education program organizer should consider the age group of the student and more intensive health education is recommended for the younger age group. We recommend to study with baseline measurement of the awareness level. Different strategies by age group should be adopted in the school awareness program.
To conduct a cancer control programme effectively, this study recommends that the public health department should organise cancer education programs in schools with the help of cancer hospitals/medical colleges/cancer registry team which will play a vital role in the control and prevention of cancer, particularly, in the rural areas of India. Further studies are needed to evaluate whether educating school children has an impact on community, to evaluate students' knowledge of the disease as well as for organizing the awareness program again in the same school after some time to refresh the knowledge to the students.
We gratefully acknowledge the financial support provided by the Department of Atomic Energy, Government of India for screening project. We acknowledge the support and guidance provided by Dr R A Badwe – Director, Tata Memorial Centre, Mumbai. We thank the administration of the Tata Memorial Hospital, school teachers, and district health authorities for their help as well to the students who participated in this program. We thank Dr Rajesh Dikshit – Director and Dr. Pankaj Chaturvedi - Deputy Director, Centre for Cancer Epidemiology in providing administrative and technical support to the screening project. We are thankful for the dedicated work done by Miss Seema Pange, Project assistant, Mr. Arpit Singh, Research Fellow and all the staff members of the screening project.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al.
Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer. 2018. Available from: https://gco.iarc.fr/today
, [Last accessed on 2020 May 03].
Institute for Health Metrics and Evaluation (IHME). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington, 2018. Available from: http://vizhub.healthdata.org/gbd-compare
. [Last accessed on 2019 Jan 31].
StataCorp. Stata Statistical Software: Release 15. LLC, College Station, Texas, USA. 2017.
Gupta S, Jain M, Roy P, Maiti D. Effect of a health education program on cancer awareness among college students: Responding to the challenges of cancer control in India. Int J Med Sci Public Heal 2014;3:146-9.
Prager GW, Braga S, Bystricky B, Qvortrup C, Criscitiello C, Esin E, et al.
Global cancer control: Responding to the growing burden, rising costs and inequalities in access. ESMO Open 2018;3:e000285.
Desai PB. Cancer control efforts in the Indian subcontinent. Jpn J Clin Oncol 2002;32(Suppl 1):S13-6.
Warnakulasuriya KAAS, Harris CK, Scarrott DM, Watt R, Gelbier S, Peters TJ, et al.
An alarming lack of public awareness towards oral cancer. Br Dent J 1999;187:319-22.
Jayant K, Rao RS, Nene BM, Dale PS. Improved stage at diagnosis of cervical cancer with increased cancer awareness in a rural Indian population. Int J Cancer 1995;63:161-3.
Tengs TO, Osgood ND, Chen LL. The cost-effectiveness of intensive national school-based anti-tobacco education: Results from the Tobacco Policy Model. Prev Med (Baltim) 2001;33:558-70.
Barros A, Moreira L, Santos H, Ribeiro N, Carvalho L, Santos-Silva F. “Cancer - Educate to Prevent” - High-school teachers, the new promoters of cancer prevention education campaigns. PLoS One 2014;9:e96672.
Mayer AB, Smith BJ, McDermott RJ. Health education: Always approved but still not always on schools' radar. Am J Heal Educ 2011;42:349-59.
Prasad JB, Dhar M. Tobacco use in India and its states: Burden of smoking and smokeless forms of tobacco (2015-25) and its predictors. J Cancer Policy 2017;14:21-6.
Elango KJ, Anandkrishnan N, Suresh A, Iyer SK, Ramaiyer SK, Kuriakose MA. Mouth self-examination to improve oral cancer awareness and early detection in a high-risk population. Oral Oncol 2011;47:620-4.
Agrawal M, Pandey S, Jain S, Maitin S. Oral cancer awareness of the general public in Gorakhpur city, India. Asian Pac J Cancer Prev 2012;13:5195-9.
[Table 1], [Table 2], [Table 3], [Table 4]