Study design and settings
A quasi-experimental interventional study was conducted among Community Health Officers (CHOs) posted in Ayushman Arogya Mandir in the Jodhpur district of Rajasthan, India. The fifty CHOs posted at Ayushman Arogya Mandir in six different blocks (Balesar, Baori, Bilara, Bhopalgarh, Luni, and Mandore) of the Jodhpur district were nominated randomly for the study by the Chief Medical Health Officer (CMHO) of Jodhpur. In India, CMHOs supervise and coordinate medical activities at the district level. CHOs were selected using a convenience sampling method.
Study participants
Out of 50 nominated CHOs, 46 CHOs attended the training and participated in the study. Trained CHOs conducted opportunistic oral cancer screening at their respective Ayushman Arogya Mandirs. As this was an opportunistic screening conducted at Ayushman Arogya Mandirs, individuals were screened during their routine visits to the health centres. Community mobilization and routine outreach activities were used to raise awareness and encourage participation. The informal verbal communication regarding Oral cancer screening service was made by Accredited Social Health Activists (ASHAs) and CHOs during their routine house-to-house visits. Individuals who visited the Ayushman Arogya Mandir for any reason and met the inclusion criteria, such as being above 30 years or between 18 and 30 years with tobacco and/or alcohol consumption habits, were invited to participate and enrolled after providing written informed consent. CHOs conducted Oral cancer screening at their respective Ayushman Arogya Mandir for eight months (May 2023- December 2023). Forty-six trained CHOs screened a total of 209 participants at their respective Ayushman Arogya Mandir.
Training intervention
CHOs received a comprehensive training program on oral cancer screening conducted by a team of ENT and pathologists. One day of training and a workshop on Oral cancer screening by Oral Visual Examination (OVE) was given to CHOs at ICMR-NIIRNCD, Jodhpur. The training included theoretical and practical components, covering identifying OPMDs, oral visual examination techniques, informed consent procedures, and the use of mobile phones for clinical photography. The program included a hands-on practice session. The practical sessions focused on performing oral visual examinations (OVE), capturing high-quality intraoral cavity photographs using mobile phones, and using standard data collection formats. An oral cancer screening tool kit (tongue depressor, disposable mask and gloves, flashlight, hand sanitizers, wooden spatula, and red medical waste bag) was given to all CHOs. For conducting oral visual examination, CHOs were instructed to ask participants to rinse their mouths with water and remove any dentures, if present. CHOs were trained to conduct a thorough bilateral examination of the oral cavity and capture photographs of the oral mucosa with their mobile phones. CHOs were trained to take clear, well-lit images, minimizing reflections and obstructions. Any suspected OPMDs were documented, and the photographs of all screened participants were then forwarded to ENT specialists for remote validation.
An online group was created to provide technical support and resolve CHO queries. The monitoring visit was done at the respective Ayushman Arogya Mandir every three months to resolve their queries and replenish the oral cancer screening kit. The knowledge assessment test was conducted at three time points: before the training (pre-training), immediately after the training (post-training), and during a follow-up assessment after two months of training.
Data collection
Following the training, CHOs were assigned to conduct Oral cancer screening at their respective Ayushman Arogya Mandir for eight months (May 2023- December 2023). Forty-six trained CHOs screened a total of 209 participants. CHOs did OVE on the screened participants and documented the OPMD type, if any, which was later validated by an ENT specialist. The second-level validation of suspected OPMDs was conducted remotely by an ENT specialist. Oral cavity photographs taken by CHOs during the screening were reviewed by an ENT specialist, enabling expert evaluation without requiring participants to attend an in-person follow-up visit. The photographs of all the screened 209 participants were validated by ENT remotely.
Data variables
CHOs’ sociodemographic characteristics, such as age, residence, marital status, place of posting, highest educational qualification, previous work experience, work experience as CHO, and previous knowledge of oral cancer screening, were collected at the time of training. These variables were used to find the association with the Oral cancer screening performance.
Statistical analysis
SPSS Version 28.0 was used for data analysis. One-way repeated measures ANOVA was done to compare pre-training, post-training, and follow-up knowledge scores. The independent samples t-test was employed to assess differences in the mean number of screened participants by CHO based on their sociodemographic variables. P-values < 0.001 and P-values < 0.05 were considered to be statistically significant. Sensitivity, Specificity, Positive prediction value, Negative prediction value, Positive likelihood ratio, Negative likelihood ratio, and overall diagnostic accuracy with 95% CI were determined.
Ethical considerations
The study was approved by the Institutional Ethics Committee of the Indian Council of Medical Research-National Institute for Implementation Research on Non-Communicable Diseases (ICMR-NIIRNCD), Jodhpur, Rajasthan, India. The approval number is IEC-NIIRNCD/2022/FR/002. The present study methods were performed following the relevant guidelines and regulations. Written informed consent was taken from the study participants. No incentives were given to CHOs to conduct the oral cancer screening. There was no provision of incentive for the screened participants. Following Wilson and Junger screening guidelines25, the OPMD-suspected participants were referred to the tertiary health care centers where further clinical evaluation, including biopsy and treatment, could be undertaken.
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