Name: Clifford Paidamoyo Charera

Program: Bachelor of Dental Surgery.

Year of study: V

Research topic: Knowledge and risk perception of oral and oropharyngeal cancer

among patients attending the University of Zimbabwe Oral

Health Centre.

Title: Project proposal.

Supervisor: Dr R. Chikosi

1
TABLE OF CONTENTS

INTRODUCTION……………………………………….3

LITERATURE REVIEW………………………………...6

PROBLEM STATEMENT ………………………………19

OBJECTIVES……………………………………………21

JUSTIFICATION………………………………………...22

METHODOLOGY:

i. Study area.........................................23

ii. Study population...............................23

iii. Study design......................................23

iv. Sample size.......................................23

v. Sampling...........................................24

vi. Data collection..................................24

vii. Inclusion criteria...............................24

viii. Exclusion criteria..............................24

ix. Data analysis………………………24

x. Variables…………………………..24

ETHICAL CONSIDERATIONS………………………….25

BUDGET………………………………………………….33

WORK PLAN……………………………………………..34

REFERENCES……………………………………………32

2
Introduction

Cancer is not a single disease but several disorders with widely varying natural histories and
responses to treatment. Cancers of different types constitute the second leading cause of death
after cardiovascular diseases (American Cancer Society, 2018). A cancer is a type of tumor or
neoplasm. Neoplasm is a disorder of cell growth that results from dysregulated increase in
number of cells caused by a series of acquired mutations within the genome of a cell affecting a
single cell and its’ progeny ( Robbins and Cotran, 2015). A neoplasm can also be called a tumor
and the two terms are interchangeable. Neoplasms are comprised of two components, the
parenchyma and the stroma. The parenchyma is made up of the neoplastic cells and determines
the classification and biologic behavior of the neoplasm, whereas their growth and spread are
based on the stroma which is the connective tissue, blood vessels and cells of the innate and
adaptive immune system (Kumar et al, 2013).

There are three types of neoplasms namely; benign, malignant and mixed. Benign and malignant
tumors can be distinguished based on a number of histologic and microscopic features. Benign
tumors are generally slow growing, do not invade or infiltrate surrounding structures, well
differentiated histologically and do not metastasize. These can be removed by local surgical
excision as they have well defined borders (Kumar and Abbas, 2016). Malignant tumors
generally have a rapid growth rate, are locally invasive and infiltrate surrounding structures
causing damage leading to death, can be poorly differentiated or show anaplasia and metastasize
to distant bodily structures ( Cawson and Odell, 2008). A malignant tumor is a cancer. A mixed
tumor is made up of neoplastic cells with two different morphologic patterns derived from the
same germ cell layer, for example pleomorphic adenoma of the parotid gland. Teratomas e.g.
ovarian cysts, are different from mixed tumors as they arise from more than one germ cell layer
(Goljan, 2014).

Oral and oropharyngeal cancer are grouped together and are the tenth most common cancers by
incidence worldwide. They still pose a major public health challenge as their five year survival
rate is still disappointingly low at about 50% (Otoh et al., 2004). Their incidence and prevalence
varies geographically. They are twice as common in men as compared to women and more

3
common in developing than developed countries. Oral and oropharyngeal cancers can affect all
ages but usually present in those aged above 40 years (WHO, 2005). However, some studies
done in Africa by Chidzonga in Zimbabwe and Ajayi in Nigeria found less proportion of oral
cancer cases occurring in persons older than 40 years. In Zimbabwe, Chidzonga and in Nigeria,
Ajayi reported 70,8 % and 75% of oral carcinomas occurring above 40 years of age respectively
(Chidzonga, 2006; Ajayi et al., 2007). The exact causes of oral and oropharyngeal cancers is
unknown, however, a plethora of risk factors is known to predispose an individual to them.
These are tobacco use in its various forms, chronic alcohol consumption, malnutrition and in
oropharyngeal cases, infection with high risk subtypes of human papillomavirus HPV-16 and
HPV-18 have been implicated. Individuals in the low socio-economic groups have a higher
incidence of alcohol and tobacco consumption with a less likelihood to consume fruits and
vegetables and have poor access to proper healthcare services (Lowval et al., 2011). Gender, age,
extended exposure to ultraviolet light, betel nut chewing, several pre-neoplastic lesions of the
oral and oropharyngeal region, ingestion of smoked fish, poor oral hygiene and
immunosuppression are also known risk factors (Ravikiran and Pravkin, 2013).

Oral and oropharyngeal cancers can be classified according to their tissue of origin. They can be
of epithelial (squamous cell carcinoma and lymphoepithelial carcinoma), salivary gland,
odontogenic, bone and hematolymphoid origin (WHO, 2005). Majority of oral and
oropharyngeal cancers are squamous cell carcinomas. Diagnosis of oral and oropharyngeal
cancers starts by taking a good clinical history and thorough examination of the patient. A
conclusive diagnosis is made by a tissue biopsy of the suspected lesion. Other diagnostic
adjuncts such as MRI and CT scans, dental radiographs and fine needle aspiration can aid in
reaching a diagnosis (Pedlar and Frame, 2011). Management depends on the age, medical
condition of the patient, stage and histological type of the cancer. Staging according to the TNM
staging system is the major determinant of treatment options. These include surgery to locally
resect the tumor and affected lymph nodes, radiotherapy, chemotherapy or a combination of
either. Early diagnosis leads to a better prognosis (Cawson and Dell, 2008).

4
Literature Review

1.2.1 Introduction

Public awareness or knowledge concerning oral and oropharyngeal cancer and their risk factors
is crucial in the prevention and early detection of these malignancies (Formosa et al., 2015). Yet
there is no published data presently available on the awareness and perceived risk factors of oral
and oropharyngeal cancers amongst the adult population locally. Globally, oral and
oropharyngeal cancer, grouped together is the sixth most common cancer (Adeola et al., 2014).
According to Warnakulasuriya (2009, p.12) there is, “an estimated half a million cases around
the globe and the rising trends reported in some populations, particularly in the young, hence
urgent public health measures are needed to reduce the incidence and mortality of oral and
oropharyngeal cancer.”. Understanding the risk perceptions and beliefs that affect the health
seeking behavior of these populations particularly in our low resource setting is crucial in
preventing and reducing the morbidity and mortality associated with these malignancies. In Sub-
Saharan Africa, the incidence and mortality rates of cancer of the oropharynx and oral cavity
substantially varied depending on the regions, mix of carcinogenic substances per region and
quality of cancer registry data (Hille and Johnson, 2017). This data is displayed in Table 2.
According to the World Health Organization (2017, p.78) deaths due to oral cancer in Zimbabwe
reached 149 or 0.12% of total deaths. There is a huge educational need amongst the public and
health professionals so as to avoid risk factors and to be aware of the early signs and symptoms
(Dimba et al., 2010). Additionally, inadequate or absence of access to advanced head and neck
healthcare facilities in most low resourced Sub-Saharan African countries results in a high
incidence of advanced cases at first presentation that are difficult to treat (Speicher et al., 2015).

5
Table 2: Age Standardized Incidence Rates (ASIR) for lip and intraoral cancer in countries in

Sub Saharan Africa as of 2012.

1.2.2 Etiology and risk factors

Cigarette smoking and consumption of tobacco by various means is the most important risk
factor for intraoral cancer. The risk increases with cumulative doses over time that is measured in
pack years (Coulthard et al., 2013). This risk is increased when combined with high alcohol
intake and it is believed that carcinogens from tobacco accumulate on the floor of the mouth,
ventral surface and lateral borders of the tongue accounting for oral squamous cell carcinoma in
these sites (Feller et al., 2013). Alcohol acts as a solvent that dissolves the carcinogens into the

6
mucosal basal cells or as an irritant. It is also hypothesized that it may suppress DNA repair
mechanisms after exposure to nitrosamines contained in tobacco (Coulthard et al., 2013).

Infection with high risk variants of the human papilloma virus such HPV-16 and HPV-18 has
been implicated in the development of oropharyngeal carcinoma (Monsjou et al., 2013). This has
a relationship with changing sexual habits such as oral sex within the young population where an
increased incidence in oropharyngeal cancers has been noted despite absence of the traditional
risk factors – tobacco use and excessive alcohol intake indicating a possible etiological role of an
infection such as HPV (Lawal et al. 2012). HPV is transmitted through direct contact primarily
through vaginal, oral and anal sex. The risk of developing HPV positive oropharyngeal cancer is
increased by number of sexual partners, early sexual debut and history of having a same sex
partner (Glick et al., 2015).

Immunosuppression secondary to various systemic conditions is another risk factor (Chirenje et

al., 2006). Nutritional deficiencies in Vitamins A, vitamin C, vitamin E, iron, selenium, folate
and other trace elements have been shown through various studies to be linked with an increased
risk of oral and laryngeal cancers (Gridley et al., 1992). According to a study conducted in South
Western Nigeria not consuming fruits and vegetables on a regular basis was associated with an
increased risk of developing oral cancer with an odds ratio of 3.0 and 1.32 respectively (Lawal et
al., 2011). Vitamins A, C and E have an antioxidant effect that guards against free radical
damage to DNA preventing mutagenesis and they also boost the immune system (Lippmann et
al., 1994).

Another risk factor is the socioeconomic status of the patient. However according to (Hashibe et
al., 2003) association between oral cancer and the socioeconomic status of the patient has been
somewhat conflicting. Certain studies conducted in the early 90’s showed no association
between oral cancer, education and occupation yet another study conducted in the same period
postulated otherwise (Greenberg et al ., 1991 ; El Wood et al., 1984 ; Williams and Horms,
1977). Studies conducted in Nigeria in the past decade have consistently shown an association
between high prevalence of oral cancers and low socioeconomic strata in Nigerian society
(Lawal et al., 2011; Oji and Chukwunekwe 2007; Adeyemi et al., 2008). This has been
corroborated by studies conducted in India and the United States of America. In the USA, Kerr et
al., in 2004 reported that in addition to a higher prevalence of tobacco and alcohol consumption,

7
people of lower socioeconomic status were more likely to consume less fruits and vegetables.
This was similar to the findings of Hashibe in India (Greenberg et al., 1991). Also, according to
Poul, 2008, people of low socioeconomic status were less likely to have access to proper health
care services and health education that would empower them to make informed decisions that
would protect and improve their health. A Canadian study also found that people of low
socioeconomic backgrounds were less likely to visit their dentist regularly suggesting that
increased incidence of oral cancer may be related to their poor oral hygiene (Johnson et al.,
2010). Therefore, a low socioeconomic status may pose as a risk factor predisposing an
individual to oral and oropharyngeal cancer.

Gender is another risk factor. Oral and oropharyngeal cancers globally affect males twice as
often as females due to a relatively increased exposure of the males to the established risk factors
such as tobacco use and excessive alcohol consumption (Oral Cancer Foundation, 2017). Oral
and oropharyngeal cancers can affect all ages but usually presents in those aged above 40 years
(WHO, 2005). However, some studies done in Africa by Chidzonga in Zimbabwe and Ajayi in
Nigeria found less proportion of oral cancer cases occurring in persons older than 40 years.
According to these studies by Chidzonga in Zimbabwe and Ajayi in Nigeria, 70.8% and 75% of
oral carcinomas occur above 40 years of age respectively (Chidzonga, 2006; Ajayi et al., 2007).
This is not conclusive in itself as the life expectancies in Africa are lower as compared to
developed countries. It has been shown that the incidence of oral cancer rises with increasing age
due to increased exposure to risk factors, physiological degenerative processes and age related
mutagenic and epigenetic changes (Cawson and Odell, 2013).

1.2.3 Clinical presentation

Signs and symptoms of oral and oropharyngeal cancers include: a non-healing sore, persistent
pain, a lump, or a white or red patch/plaque on the gums, tongue, palate, tonsils or oropharyngeal
mucosal lining (National Cancer Institute, 2018). Cases of oral and oropharyngeal cancer vary in
their presentation and this is largely depended on the time of presentation. Unfortunately, in 85%
of the cases, patients present after development of symptoms which are associated with advanced
stages of disease. With advanced disease, individuals may present with dysphagia, odynophagia,
oral bleeding, otalgia, night sweats and weight loss (Glick et al., 2015). Squamous cell
carcinomas may present as a painless hard, fixed ulcer with a necrotic base or rolled up edges on

8
the lips, floor of the mouth, gingivae, lateral borders of the tongue, alveolar ridge, buccal mucosa
and less commonly on the palate (Coulthard et al., 2013). Within our setting oral squamous cell
carcinoma present on the following sites in order of decreasing frequency – mandibular gingivae,
tongue, floor of the mouth, maxillary gingivae, buccal mucosa, hard palate and the lips
(Chidzonga MM, 2006).

1.2.4 Perceptions and beliefs

Perceptions and beliefs regarding the cause of cancers can be a barrier to early presentation and
treatment of cancers (Chirenje et al., 2003). A study conducted on barriers to cervical cancer
screening in Malawi showed that cultural beliefs influenced perceptions of women on cervical
cancer screening (Fort, Makin, Siegler, Ault & Rochat 2011:129). In Africa, it is widely
understood that a major barrier to early detection and diagnosis of cancers is because patients
consult traditional healers first and often are treated by them until curative treatment cannot be
undertaken (Asuzu et al., 2019). This is similar to our setting as traditional, cultural and spiritual
beliefs can influence perception of cancer origin and how it is treated, ultimately affecting the
health seeking behaviors of patients.

Zimbabwe is comprised of an assortment of over 12 different ethnic groups (Central Statistical

Office of Zimbabwe, 2012). Each of these has its’ indigenous ways of ensuring the health of its
people. Therefore, an enduring component of the primary healthcare system in Zimbabwe is the
alternative healthcare system, composed of the traditional and faith-based healer systems which
is still popular (Chavunduka, 1978; Dhewa, 2008). The use of alternative healers was associated
with delayed presentation to health facilities (Tovey, P., Chatwin, J & Ahmed, S., 2005). Apart
from alternative practitioners, other factors such as ignorance, poverty, young age, superstition,
denial, fear of surgical procedures and unavailability of treatment facilities could also account for
the late presentation (Anyanwu, 2008; Ahmed et al., 2008). I could not find any single study on
the phenomological aspects of cancer in Zimbabwe at the time of study.

According to a study conducted in 2018 by Asuzu and colleagues (Asuzu et al., 2018) both
traditional and faith-based healers could not allude to the causes of cancer, instead referring to
bad spirits, spiritual curses, demonic attacks, stress and a bad diet. Their perception of the causes
of cancer was a mixture of spiritual and environmental/lifestyle factors but no real cause could

9
be established. In the same study, the authors found that patients believed that orthodox medicine
combined with faith-healing based prayers was more effective than alternative medicine alone.
In a separate study, majority of individuals believed that traditional healers could cure cancer
using herbs (Abubakar et al., 2007).

Levy in 1997 had the opportunity to interview Shona cancer patients at Parirenyatwa Central
Hospital in Zimbabwe. Her observations were that Shona people embrace traditional religious
beliefs including traditional healers. Furthermore, most Shona patients had little or no conception
of what cancer is, which was endorsed by the absence of a definition of cancer in Shona. It is
referred to as gomarara, nhuta, nyamakazi or mhuka words which imply a mole burrowing into
the ground or a parasitic entity in the human body (Levy, 1997). There is also a health-related
stigma associated with cancers within society which greatly influences health seeking behaviour.
According to Knapp et al (2014:5), there is a belief that cancer will lead inevitably to death
which in turn hinders cancer prevention practices and screening and stigmatization of those who
are diagnosed with cancer. This stigma is associated with late presentation, premature
termination of treatment, lack of disclosure to family and friends, poor quality of care as well as
psychological and social morbidity (Van Brakel, 2006; Chapple et al., 2004; Link and Phelan,
2006; Mazilano and Moyer, 2014). This discrimination due to various cultural and social beliefs
poses a barrier in the prevention and successful treatment of oral and oropharyngeal cancers.

1.2.5 Conclusion

In conclusion, to promote early cancer diagnosis and remove some of the barriers to effective
treatment, there is need to focus on both the orthodox and traditional medical systems to
optimize patients’ healthcare (Razali, 2009). This will empower and motivate both the patients
and alternative practitioners to seek appropriate treatment. The health belief model is used to
explain an individual’s behavior based on his/her beliefs or perception. According to this model,
an individuals’ perception, knowledge, beliefs, and awareness can influence the cancer
evaluation process and the treatment outcomes (Gautam et al., 2017). In Africa, low levels of
awareness is one of the multitude of factors hindering cancer prevention campaigns (Bosudolo
and Woodgate, 2015).This study attempts to understand the level of awareness/knowledge and
risk perceptions pertaining to oral and oropharyngeal cancers that influence health seeking
behaviors of adult patients attending the UZ- OHC.

10
1.2.6 References

1. Abubakar, M.S., Musab, A.M., Ahmed, A., Hussaini, I.M, (2007).The perception and
practice of traditional medicine in the treatment of cancers and inflammations by the
Hausa and Fulani tribes of northern Nigeria. J Ethnopharmacol. 2007; 111(3):625–9.
2. Ajayi, O.F., Adeyemo,W.L., Ladeinde, M.O., Ogunlewe, M.O., Effiom, O.A., Omitola,
O.G., Arotiba, G.T, (2007). Primary malignant neoplasms of orofacial origin: a
retrospective review of 256 cases in a Nigerian tertiary hospital. Int. J. Maxillofacial.
Surg. 36:403-408.
3. Anyanwu, S.N.C. (2008). Temporal trends in breast cancer presentation in the third
world. J Exp Clin Cancer Res; 27(1):17.
4. Cawson, R.A and Odell, E.W, 2008, Cawson’s Essentials of Oral Pathology and Oral
Medicine, 8th ed, Churchill Livingstone, Edinburgh.
5. Central Statistical Office of Zimbabwe, Harare, from <
http://www.zimstat.co.zw/statistical-databases/> accessed 21 May 2019.
6. Chapple, A., Ziebland, S., and McPherson, A. (2004). Stigma, shame, and blame
experienced by patients with lung cancer: Qualitative study, (Electronic version). BMJ,
328: 1470.
7. Chavunduka, G. 1978, Traditional Healers and the Shona Patient. Mambo Press; Gweru.
8. Chidzonga, M.M (2006). Oral malignant neoplasia: a survey of 428 cases in two
Zimbabwean hospitals. Oral Oncol. 42:177-183.
9. Chidzonga, M.M., Mahomva, L.(2006). Squamous cell carcinoma of the oral cavity,
maxillary antrum and lip in a Zimbabwean population: a descriptive epidemiological
study. Oral Oncol. 42(2): 184–189.
10. Chirenje, Z., Parkin, M., Sitas, F.(2006). Chapter 20: Cancers. Disease and mortality in
Sub-Saharan Africa, 2nd ed, Washington.
11. Coulthard, P., Horner, K., Thackey, D.E., and Sloan P, 2013, Master Dentistry Volume 1:
Oral and Maxillofacial Surgery, Radiology, Pathology and Oral Medicine, 3rd ed,
Churchill Livingstone, London.
12. Dimba, E., Chindia, M., Otoh, E.(2010). Global oral health inequities: the research
agenda - the case of oral malignancies in Africa. IADR Report, 2010.
13. Formosa, J., Jenner, R., Nguyen-Thi, M., Stephens, C., Wilson, C.F., & Ariyawardana, A.
(2015). Awareness and Knowledge of Oral Cancer and Potentially Malignant Oral
Disorders among Dental Patients in Far North Queensland, Australia. Asian Pacific
Journal of Cancer Prevention: APJCP, 16 10, 4429-34.
14. Gautam, R.G., Matthews, E., and Shah, D., 2017. Knowledge and beliefs about cancer in
an African American population. Journal of Health Disparities Research and Practice.
Vol 10: Iss. 1, Article 4.
15. Greenberg, R.S., Haber, M.J., Clark, W.S. (1991). The relationship of socioeconomic
status to oral and pharyngeal cancer. Epidemiology 2:94-200.
16. Johnson, S., McDonald, J.T., Corsten, M., Rourke, R., (2010). Socioeconomic status and
head and neck cancer incidence in Canada: a case-control study. Oral Oncology. 46:200-
203.

11
17. Knapp, S., Maziliano, A., and Moyer, A. (2014). Identity Threat and Stigma in Cancer
Patients. Health Psychology Open, 1-10: Sage Publications.
18. Lawal, A., Kolude, B., Adeyemi, B.F., Lawoyin, J., Akang, E., (2011). Social profile and
habits of oral cancer patients in Ibadan. Afr. J. Med. Med.Sci. 40:247-51.
19. Lawal, A.O., Kolude, B., Adeyemi, B.F., Lawoyin, J.O., Akang, E.E, (2012). Serum
antioxidant vitamins and the risk of oral cancer in patients seen at a tertiary institution in
Nigeria. Nigerian Journal of Clinical Practice. 15:30-3.
20. Levy, L. M .(1997). Communication with the Cancer Patient in Zimbabwe. Annals of the
New York Academy of Sciences, 809: 133–141.
21. Link, B.C., and Phelan, S.M .(2006). Stigma and its Public Health Implications. Lancet;
367:528-528.
22. Mangoma, J. F., Chirenje, M. Z., Chimbari, M.G., and Chandiwaa, S.K. (2006). An
Assessment of Rural Women’s Knowledge Constraints and Perceptions on Cervical
Cancer Screening: The Case of Two Districts in Zimbabwe. African Journal of
Reproductive Health, 10 (1) 91-103
23. Marimo, C., Hille, J.J. (2006). The burden of oral malignancies in Zimbabwe 1988 to
1997: a population based study. Central African Journal of Medicine; 52(5-6): 51–55.
24. Monsjou, H.S., Velthuysen, M.L.S., Brekel, M.W.M., Jordanova, E.S., Melief, C.J.M.,
Balm, A.J.M (2012). Human papillomavirus status in young patients with head and neck
squamous cell carcinoma. International Journal of Cancer, 130:1806–1812
25. Poul, E.P. (2008). Oral cancer prevention and control: The approach of the World Health
Organization. DOI:10.1016/ Journal of Oral Oncology.05.023
26. Razali, S.M.(2009). Integrating Malay traditional healers into primary health care
services in Malaysia: it is feasible? Int Med J; 16:13–27.
27. Speicher, D.J., Wanzala, P., D’Lima, M. (2015). Diagnostic challenges of oral and
cutaneous Kaposi’s sarcoma in resource-constrained settings. J Oral Pathol Med; 44(10):
842–849.
28. Tovey, P., Chatwin, J., Ahmad, S.(2005). Toward an understanding of decision making
on complementary and alternative medicine use in poorer countries: the case of cancer
care in Pakistan. Integrated Cancer Therapy; 4(3):236–41.
29. Van Brakel, W.H. (2006). Measuring Health Related Stigma: A Literature Review,
Psychol Health Med; 11 (3): 307-334.
30. Warnakulasuriya, S.(2009). Global Epidemiology of Oral and Oropharyngeal Cancer.
Oral Oncology; 45:309-316.
31. World Health Organisation WHO, (2005). Global Data on Incidence of Oral Cancer.
From < https://www.who.int/oral_health/publications/cancer_maps/en/> accessed 22
June 2019.

12
1.3 Problem Statement
There is a need to understand the level of awareness of the patients regarding cancer of the
mouth and throat amongst adult patients attending UZ OHC in Zimbabwe. This is due to the fact
that patients present late to the clinic when they have a growth that could be potentially a tumor
in their oropharyngeal region (Marimo and Hille, 2011). The information would help to refine
the current health promotion policies. Educating patients empowers them to take better care of
their health and present earlier for treatment. The goals of the research are to determine the
extent of knowledge of risk factors, signs and symptoms, and beliefs concerning oral and
oropharyngeal cancers amongst the adult patients presenting to the referral clinic. It will also
help to improve the public health of Zimbabwean communities and prevent unnecessary loss of
life and refine the current methods in use.

The data will inform health care professionals on additional oral cancer screenings and education
of patients during regular medical/dental visits to increase oral health literacy and ultimately
motivate individuals towards improved well-being.

1.4 Purpose of the study

The purpose of the study is to determine the level of knowledge and risk perceptions of oral and
oropharyngeal cancers amongst adult patients attending the UZ OHC. There is a paucity of data
in this area in Zimbabwe. The study results will help promote oral health awareness, preventive
measures and effective communication with patients regarding oral and oropharyngeal cancer.

13
1.5 Study aim and objectives

Broad objective:

To determine the level of knowledge and risk perceptions of oral and oropharyngeal cancer

amongst adult patients attending the UZ OHC.

Specific objectives:

 To determine the level of public awareness of oral and oropharyngeal cancer among adult
patients.
 To assess the level of knowledge of oral and oropharyngeal cancer risk factors among adult
patients.
 To determine the level of awareness of the presenting signs and symptoms of oral and
oropharyngeal cancer among adult patients.
 To understand the traditional, cultural and spiritual beliefs surrounding oral and
oropharyngeal cancer among adult patients.
 To propose a health education programme to raise awareness and education of oral and
oropharyngeal cancer among adult patients attending UZ OHC.
 To evaluate the attitudes towards prevention, treatment and early diagnosis.

14
2. Methodology

i) Study area

This study will be conducted in Zimbabwe, Harare at the University of Zimbabwe

Oral Health Centre facility. The University of Zimbabwe Oral Health Centre provides

dental services at Parirenyatwa Central Hospital, the biggest referral hospital in

Zimbabwe. Patients from all across Zimbabwe present to this center as referrals for

specialized oral health disease management and it is a teaching facility for

undergraduate and post graduate dental studies.

ii) Study population

The target population for the study is adult patients presenting to the University of

Zimbabwe Oral Health Centre.

iii) Study design

A descriptive cross-sectional survey study design.

iv) Sample size

A literature search revealed that other investigators in other countries have reported

awareness of oral cancer in the prevalences shown in Table 3 below.

Reference number Country Level of public Publication year of

awareness (%) study

32 Australia 79 2011

33 Germany 66 2012

34 USA ( Florida) 84.5 2005

15
 35 Turkey 39.3 2010

36 India (Gorakhpur) 91.2 2012

37 United Kingdom 95.6 2006

38 Malaysia 89.9 2006

39 Iran (Babol) 24 2009

40 Nigeria 72 2003

41 Sri Lanka 95 2005

Table 3: Public and dental patient’s awareness about oral cancer in different countries.
Note the reference number refers to the research article in the reference section at the end.

A study done in Malaysia (Saini, R et al., 2006) was chosen for the prevalence to be used based

on the following factors:

1) The similarity of the country’s healthcare system and socio-demographic profile to

Zimbabwe’s.

2) The study had participants drawn from a similar sampling frame i.e. adult patients

attending a teaching clinic.

The prevalence rate of awareness of oral cancer of the above named study was used in the

Dobson equation to estimate the sample size for this descriptive cross-sectional study.

In this study conducted in Malaysia, on the awareness of oral cancer in adult patients attending

School of Dental Sciences clinic, Universiti Sans Malaysia in 2006, the prevalence rate of

awareness of oral cancer was 89.9% (Saini, R et al., 2006).

Using the Dobson sample calculation formula:

16
 2
z × p × ( 1− p )
N=
c2

Where N is the sample size

Z is the Z-value=1.962

P is the prevalence=0.899

C is the confidence level =0.05

A sample size of 138 participants was deduced from the Dobson sample calculation.

v) Sampling

Probability sampling using a simple random sampling technique will be used. Adult

patients presenting to the University of Zimbabwe Oral Health Centre facility will

pick randomly from a container a card either green or red. I will interview those who

pick the green card. The participants will be interviewed as they wait to be attended.

vi) Data collection tool

A structured knowledge questionnaire designed by the researcher will be completed

by selected patients who meet the inclusion criteria. The questionnaires are to be in

simplified English and Shona language. Language to be selected according to the

patient’s preference.

The structured questionnaire will assess awareness, knowledge and beliefs relating

oral and oropharyngeal cancer.

Section A includes socio-demographic variables of the study participants which

include age, gender, religion, education, occupation, type of family, marital status

and monthly income of adults both male and female of age groups.

17
 Section B includes structured questionnaire which include 20 questions to assess the

awareness, knowledge and beliefs regarding oral and oropharyngeal cancer.

vii) Inclusion criteria

Consenting adults above the age of 18 attending the various clinical sessions at the

University of Zimbabwe Oral Health Centre.

viii) Exclusion criteria

Patients who do not consent and patients below the age of 18 will be excluded from

the study. Patients who were diagnosed of oral cancer or referred for a suspicious oral

mucosa lesion will also be excluded.

ix) Data Analysis

The data sought will be entered into EpiInfo, a statistical computer software. With the

aid of the software, frequencies and percentages will be calculated.

x) Variables

Independent variables

Socio-Demographic characteristics

a. Age.

b. Sex.

c. Occupation.

d. Educational level.

e. Marital status.

f. Average monthly income.

g. Race.

h. Religion.

18
 i. Area of residence.

Dependent variables

a) Awareness.

b) Level of knowledge of risk factors.

c) Level of knowledge of signs of oral and oropharyngeal cancer.

d) Beliefs about oral cancer.

Dummy Tables

Table 4: Socio-demographic characteristic of the adult patients interviewed

Characteristics Frequency Percent

Gender Male

Female

Marital Status Single

Married

Widowed

Level of education No formal education

attained

Primary Education

Secondary Education

College Education

University

19
 (Undergrad)

University (Postgrad)

Age 18-25

26-35

36-45

46-55

55-65

66-75

Socio Economic Employed

Group

Self Employed

Unemployed

Monthly Income <$250

$250-$500

>$500

Area of residence Rural

High Density

Low density

Religion Christian

Muslim

African Traditional
Religion

20
 Atheist

Tobacco Smoker
consumption
Non-smoker

Alcohol Drinker
consumption
Non-drinker

Table 5: Factors associated with oral and oropharyngeal cancer awareness

Variable Awareness P value

Yes No
Age
>40 years
<40 years
Gender
Male
Female
Education
Less than university
University
Tobacco use
Yes
No
Alcohol use
Yes
No

Where p value is the significance value at p <0.05.

Table 6: Factors associated with knowledge about risk factors for oral and oropharyngeal cancer

Variable Knowledge about risk factors P value

Good Average Poor

Age
>40 years
21
 <40 years
Gender
Male
Female
Education
Less than University
University
Tobacco use
Yes
No
Alcohol use
Yes
No

Table 7: Factors associated with knowledge about signs of oral and oropharyngeal cancer.

Variable Mean Score (SD) P value

Age
>40 years
<40 years
Gender
Male
Female
Education
Less than university
University
Tobacco use
Yes
No
Alcohol use
Yes
No

Ethical considerations
22
A complete copy of the research proposal will be submitted to the Joint Research Ethics

Committee (JREC) of the University of Zimbabwe (UZ) for authorization. Permission to give

patients the questionnaire will be sought from the University Of Zimbabwe Department Of

Dentistry. The reason for the study will be fully explained to the participants before giving out

the questionnaire and examination and their right not to precipitate without any clinical

consequences will be indicated to them.

Budget

Task Cost (RTGS$)

Printing 5000

JREC 1500

Other 2500

Total 9000

Work plan

23
Objective Date 2022

Submission of project proposal to supervisor 6 May

Submission of project proposal to JREC 13 May

Data collection 30 June

Data compilation and analysis 15 September

Submission of report to supervisor 31 September

Final draft 31 October

References
24
1. Abubakar, M.S., Musab, A.M., Ahmed, A., Hussaini, I.M, (2007).The perception and
practice of traditional medicine in the treatment of cancers and inflammations by the
Hausa and Fulani tribes of northern Nigeria. J Ethnopharmacol. 2007; 111(3):625–9.
2. Ajayi, O.F., Adeyemo, W.L., Ladeinde, M.O., Ogunlewe, M.O., Effiom, O.A., Omitola,
O.G., Arotiba, G.T, (2007). Primary malignant neoplasms of orofacial origin: a
retrospective review of 256 cases in a Nigerian tertiary hospital. Int. J. Maxillofacial.
Surg. 36:403-408.
3. Anyanwu, S.N.C. (2008). Temporal trends in breast cancer presentation in the third
world. J Exp Clin Cancer Res; 27(1):17.
4. Cawson, R.A and Odell, E.W, 2008, Cawson’s Essentials of Oral Pathology and Oral
Medicine, 8th ed, Churchill Livingstone, Edinburgh.
5. Central Statistical Office of Zimbabwe, Harare, From <
http://www.zimstat.co.zw/statistical-databases/> accessed 21 May 2019.
6. Chapple, A., Ziebland, S., and McPherson, A. (2004). Stigma, shame, and blame
experienced by patients with lung cancer: Qualitative study, (Electronic version). BMJ,
328: 1470.
7. Chavunduka, G. 1978, Traditional Healers and the Shona Patient. Mambo Press; Gweru.
8. Chidzonga, M.M (2006). Oral malignant neoplasia: a survey of 428 cases in two
Zimbabwean hospitals. Oral Oncol. 42:177-183.
9. Chidzonga, M.M., Mahomva, L.(2006). Squamous cell carcinoma of the oral cavity,
maxillary antrum and lip in a Zimbabwean population: a descriptive epidemiological
study. Oral Oncol. 42(2): 184–189.
10. Chirenje, Z., Parkin, M., Sitas, F.(2006). Chapter 20: Cancers. Disease and mortality in
Sub-Saharan Africa, 2nd ed, Washington.
11. Coulthard, P., Horner, K., Thackey, D.E., and Sloan P, 2013, Master Dentistry Volume 1:
Oral and Maxillofacial Surgery, Radiology, Pathology and Oral Medicine, 3rd ed,
Churchill Livingstone, London.
12. Dimba, E., Chindia, M., Otoh, E.(2010). Global oral health inequities: the research
agenda - the case of oral malignancies in Africa. IADR Report, 2010.
13. Formosa, J., Jenner, R., Nguyen-Thi, M., Stephens, C., Wilson, C.F., & Ariyawardana, A.
(2015). Awareness and Knowledge of Oral Cancer and Potentially Malignant Oral
Disorders among Dental Patients in Far North Queensland, Australia. Asian Pacific
Journal of Cancer Prevention: APJCP, 16 10, 4429-34.
14. Gautam, R.G., Matthews, E., and Shah, D., 2017. Knowledge and beliefs about cancer in
an African American population. Journal of Health Disparities Research and Practice.
Vol 10: Iss. 1, Article 4.
15. Greenberg, R.S., Haber, M.J., Clark, W.S. (1991). The relationship of socioeconomic
status to oral and pharyngeal cancer. Epidemiology 2:94-200.
16. Johnson, S., McDonald, J.T., Corsten, M., Rourke, R., (2010). Socioeconomic status and
head and neck cancer incidence in Canada: a case-control study. Oral Oncology. 46:200-
203.
17. Knapp, S., Maziliano, A., and Moyer, A. (2014). Identity Threat and Stigma in Cancer
Patients. Health Psychology Open, 1-10: Sage Publications.

25
18. Lawal, A., Kolude, B., Adeyemi, B.F., Lawoyin, J., Akang, E., (2011). Social profile and
habits of oral cancer patients in Ibadan. Afr. J. Med. Med.Sci. 40:247-51.
19. Lawal, A.O., Kolude, B., Adeyemi, B.F., Lawoyin, J.O., Akang, E.E, (2012). Serum
antioxidant vitamins and the risk of oral cancer in patients seen at a tertiary institution in
Nigeria. Nigerian Journal of Clinical Practice. 15:30-3.
20. Levy, L. M. (1997). Communication with the Cancer Patient in Zimbabwe. Annals of the
New York Academy of Sciences, 809: 133–141.
21. Link, B.C., and Phelan, S.M. (2006). Stigma and its Public Health Implications. Lancet;
367:528-528.
22. Mangoma, J. F., Chirenje, M. Z., Chimbari, M.G., and Chandiwa, S.K. (2006). An
Assessment of Rural Women’s Knowledge Constraints and Perceptions on Cervical
Cancer Screening: The Case of Two Districts in Zimbabwe. African Journal of
Reproductive Health, 10 (1) 91-103
23. Marimo, C., Hille, J.J. (2006). The burden of oral malignancies in Zimbabwe 1988 to
1997: a population based study. Central African Journal of Medicine; 52(5-6): 51–55.
24. Monsjou, H.S., Velthuysen, M.L.S., Brekel, M.W.M., Jordanova, E.S., Melief, C.J.M.,
Balm, A.J.M (2012). Human papillomavirus status in young patients with head and neck
squamous cell carcinoma. International Journal of Cancer, 130:1806–1812
25. Poul, E.P. (2008). Oral cancer prevention and control: The approach of the World Health
Organization. DOI:10.1016/ Journal of Oral Oncology.05.023
26. Razali, S.M.(2009). Integrating Malay traditional healers into primary health care
services in Malaysia: it is feasible? Int Med J; 16:13–27.
27. Speicher, D.J., Wanzala, P., D’Lima, M. (2015). Diagnostic challenges of oral and
cutaneous Kaposi’s sarcoma in resource-constrained settings. J Oral Pathol Med; 44(10):
842–849.
28. Tovey, P., Chatwin, J., Ahmad, S.(2005). Toward an understanding of decision making
on complementary and alternative medicine use in poorer countries: the case of cancer
care in Pakistan. Integrated Cancer Therapy; 4(3):236–41.
29. Van Brakel, W.H. (2006). Measuring Health Related Stigma: A Literature Review,
Psychol Health Med; 11 (3): 307-334.
30. Warnakulasuriya, S.(2009). Global Epidemiology of Oral and Oropharyngeal Cancer.
Oral Oncology;45:309-316.
31. World Health Organization WHO, (2005). Global Data on Incidence of Oral Cancer.
From < https://www.who.int/oral_health/publications/cancer_maps/en/> accessed 22
June 2019.
32. Park, J.H., Slack-Smith, L and Smith, A. (2011). Knowledge and perceptions concerning
oral and pharyngeal carcinoma among adult dental patients. Australian Dental Journal
56: 284-286.
33. Hertrampf, K., Wenz, H.J and Koller, M. (2012). Public awareness about prevention and
early detection of oral cancer: a population based study in Northern Germany. Journal of
Craniomaxillofac Surg 40: e82–e86.
34. Tomar, S.L., Logan, H.L. (2005). Florida adults’ oral cancer knowledge and examination
experiences. J Public Health Dent 65: 221–230.

26
35. Peker, I., Alkurt, M.T. (2010). Public awareness level of oral cancer in a group of dental
patients. J Contemp Dent Pract 11: 049–056.
36. Agrawal, M., Pandey, S., Jain, S. (2012). Oral cancer awareness of the general public in
Gorakhpur city, India. Asian Pac J Cancer Prev 13: 5195–5199
37. West, R., Alkhatib, M.N., McNeill, A. (2006). Awareness of mouth cancer in Great
Britain. Br Dent J 200: 167–169.
38. Saini, R., Ghani, Z.I., Rahman, N.A. (2006). The awareness of oral cancer in adult
patients attending School of Dental Sciences, Universiti Sains Malaysia: a preliminary
study. Singapore Dent J 28: 34–39.
39. Motallebnejad, M.M., Khanian, M., Alizadeh, R et al. (2009) Community survey of
knowledge about oral cancer in Babol: Effect of an education intervention. East Mediterr
Health J 15: 1489–1495.
40. Lawoyin, J.O., Aderinokun, G.A., Kolude, B et al.(2003). Oral cancer awareness and
prevalence of risk behaviours among dental patients in South-western Nigeria. Afr J Med
Med Sci 32: 203–207.
41. Ariyawardana, A., Vithanaarachchi, N. (2005). Awareness of oral cancer and precancer
among patients attending a hospital in Sri Lanka. Asian Pac J Cancer Prev 6: 58–61.

27