J Canc Educ
DOI 10.1007/s13187-017-1239-y
Assessing the Feasibility and Effectiveness of an App in Improving
Knowledge on Oral Cancer—an Interventional Study
Prajna Pramod Nayak 1 & Sushma S. Nayak 2 & Deepicca Sathiyabalan 3 & NK Aditya 3 &
Priyanjana Das 3
# American Association for Cancer Education 2017
Abstract Although current oral health care initiatives have
proved to be quite successful, a great number of individuals
are unaware of how their choice of daily activities compromises
their oral health. That is why newer technologies like WhatsApp
can definitely serve as a platform to communicate dental advice,
thereby strengthening the bridge between health and technology.
The objective of the study was to assess the effectiveness of
WhatsApp as a tool for providing health education on tobacco
and oral cancer as compared to the conventional health educa-
tion via PowerPoint. The study was a cluster randomized
controlled trial, single-center study. The students of 18–24 years
of age with WhatsApp application active in their mobile phones
were included. Four classes with 182 students were randomly
divided into intervention and control groups. Control group
received health education on oral cancer using a PowerPoint
* Prajna Pramod Nayak
nayak.prajna@rediffmail.com
Sushma S. Nayak
dr_sushmanayak@yahoo.co.in
Deepicca Sathiyabalan
deepicca9@hotmail.com
NK Aditya
nkaditya@hotmail.com
Priyanjana Das
priyanjanadas1993@gmail.com
1
Department of Public Health Dentistry, Manipal College of Dental
Sciences, Manipal University, Manipal, India
2
Department of Public Health Dentistry, Index Dental College,
Indore, Madhya Pradesh, India
3
Manipal College of Dental Sciences, Manipal University,
Manipal, India
presentation weekly, for a total of 4 weeks. Intervention group
received health education through WhatsApp messaging thrice a
week for 4 weeks. Pre- and post-health education knowledge
scores were assessed using a questionnaire and compared using
unpaired and paired two-sample t tests. Statistically significant
increase in knowledge scores was seen in both groups, with
highly significant improvement in the intervention group
(p value = 0.00). Intergroup comparison showed no significant
difference in knowledge scores at baseline, but a significant
difference in post intervention knowledge scores (t = -15.05
p<0.001) WhatsApp can be a more effective tool for providing
dental education on tobacco and oral cancer as compared to
conventional audio-visual aids.
Keywords WhatsApp . PowerPoint . Tobacco-related
diseases
Introduction
Tobacco-related dental diseases are showing an increasing
trend. About 5.4 million people die every year due to
tobacco-related diseases. The number of people dying from
tobacco-related diseases every year is much higher than the
number of victims of tuberculosis, malaria, and HIV/AIDS
added as one. Smoking and spit tobacco contribute essentially
to the development of oral lesions [1].
Oral cancer is one of the tobacco-related diseases, whose
prevalence is increasing in recent years. India has the highest
rate of oral cancer worldwide [2]. It can be easily prevented by
providing awareness about tobacco hazards and also by moti-
vating the youth to avoid tobacco. Research has shown that
the awareness level regarding tobacco and oral cancer among
Indian population is very low [3]. Thus, the most feasible way
by which oral cancer can be controlled is by providing dental

health education to the general public and providing aware-
ness regarding the disease and its risk factors. This could be
followed by dental health programs which can motivate to-
bacco users to quit the habit [4, 5].
Many studies conducted to assess the effectiveness of den-
tal health education on knowledge, attitude, and practices
have reported an improvement in the same [6–8]. Various
tools have been tried and tested in the provision of dental
health education. Two among them showing extremely prom-
ising results as tools for providing health education in the
current dates are utilization of social media [9, 10] and
telehealth [11–13]. One of the smartphone applications,
WhatsApp, has a very high penetration and has thus devel-
oped into a powerful, real-time communication medium.
Literature review on WhatsApp as a health education tool
revealed very few studies [14–16]. Hence, the present study
was planned with an aim to assess the feasibility and effec-
tiveness of a smartphone application, WhatsApp, in improv-
ing the knowledge on oral cancer among college students.
Methodology
The present study was a cluster randomized controlled trial,
single-center study. Ethical clearance was obtained from the eth-
ical review board. Permission to conduct the study was obtained
from head of the institution after explaining purpose of the study.
Sample size was determined based on the data obtained
from the pilot study, keeping α, the probability of making type
1 error at 5%, power at 80%, and considering Cohen’s medi-
um effect size to be at 0.5, and the sample size was determined
to be 75 per group.
The present study was conducted among 182 students of the
first and second year Bachelor of Commerce (B.Com) and aged
17–22 years studying in a First Grade college in Barkur, a South
Indian town. We verified that there were no such campaigns/
oral cancer education programs previously conducted for them.
Both classes had two sections in it and each of them was ran-
domly allocated into study group (SG) and control group (CG),
thus making to two clusters in each group. Students were ex-
plained about the purpose of the study and they were informed
that their participation or non-participation in the study will not
have any influence on their academic matters.
One hundred eighty-two students, who were present on the
day of start of the study, were assessed for eligibility. Those
who gave informed consent and with WhatsApp active on
their smartphones were included in the study, making a total
sample size of 150.
SG received health education messages on tobacco and oral
cancer via WhatsApp and CG received health education mes-
sages on tobacco and oral cancer through PowerPoint presenta-
tion. Knowledge was assessed before and after the intervention
using a self-designed questionnaire. The questionnaire consisted
J Canc Educ
of two sections; the first section consisted of 55 items pertaining
to knowledge on tobacco use and oral cancer and the second
included five questions about the demographic characteristics
and smoking history of participants and their family members
and their willingness to quit. Comprehension and reliability of
the questionnaire were assessed. Reliability was found to be 0.8.
Preparation of PowerPoint Presentation
and WhatsApp Messages
List of topics to be included for the education on tobacco and
oral cancers was chosen based on the published material by
other workers [17, 18]. A group of four dental experts together
outlined five topics: (i) tobacco types and effects, (ii) risk
factors for oral cancers, (iii) epidemiology of oral cancer,
(iv) clinical signs of oral cancers and precancerous conditions,
and (v) primary prevention procedures including screening.
Based on this, PowerPoint presentation and WhatsApp mes-
sages were framed. Messages in the form of text, pictures, and
videos for both SG and CG were standardized.
WhatsApp messages were sent in a WhatsApp-based anony-
mous chat room and were moderated by two authors of the study.
Messages were sent everyday along with pictures and videos. SG
participants were informed prior that the messages will be sent at
a particular time every day, so as to ensure that everyone reads
messages. On every Saturday, all participants were asked to come
together online for group discussions on WhatsApp chat room to
clarify any doubts. Participants were allowed to share informa-
tion, pictures, and videos on tobacco effects and oral cancer
within the chat room. Participants were also instructed not to
forward these messages to anyone till the end of the study.
PowerPoint presentations were provided in the college class-
rooms twice every week, and at the end of the sessions, queries
were answered. This was done for a period of 1 month.
Statistical analyses were done using SPSS version 19.
Paired and unpaired t tests were used to assess the difference
in mean knowledge scores of the study and control group.
Results
Figure 1 shows the allocation of study participants into SG
and CG. A total of 76 students belonging to SG and 83 stu-
dents belonging to CG participated in the study. Five students
who did not complete the study in the CG as they were absent
in one or more days of PowerPoint instructions were not in-
cluded in the analysis making it to 78 subjects in CG. In SG,
four students were not in attendance for the post-intervention
questionnaire and, hence, excluded from analysis making it to
72 in the SG. Thus, the total dropout rate was 6%.
Table 1 gives the demographic details and tobacco usage
by participants and their family. Ninety-six of all the study
J Canc Educ

Fig. 1 CONSORT 2010 flow Assessed for eligibility (n=182)

diagram

Excluded (n=23)
Not meeting inclusion criteria (n=19)
Declined to participate (n=4)
Other reasons (n=0)

Randomized (n=159)

Allocation
Allocated to PowerPoint education group (n=83) Allocated to Whatsapp education group (n=76)
Received allocated intervention (n=78) Received allocated intervention (n=76)
Did not receive allocated intervention (n=5) Did not receive allocated intervention (n=0)

Follow-Up
Lost to follow-up (n=0) Lost to follow-up (n=4)

Discontinued intervention (n=0) Discontinued intervention (n=0)

Analysis
Analysed (n=78) Analysed (n=72)
Excluded from analysis (n=5) Excluded from analysis (n=4)

participants were females and 56 were males. The mean age of prevention (Table 2) shows that there was an increase in
subjects in the SG and CG was 20.2 ± 1.3 SD and 20.7 ± 1.5 post-intervention knowledge scores in both SG and CG.
SD, respectively. None of the female participants used tobacco Statistically significant increase was seen in all the core topics
in any form. Among male participants, 24.1% in the SG and except on the etiology of oral cancer in the SG whereas sig-
37% in the CG revealed that they were occasional or regular nificant increase in knowledge scores were found in only two
tobacco users. A very large, alarming proportion of parents/ core topics in the CG.
siblings were tobacco users in both the SG (36.1%) and CG Intragroup comparison revealed a significant improvement
(23.1%) as revealed by the participants. in knowledge scores in SG (t = −21.63; p < 0.000) and in CG
Comparison of mean knowledge scores of study partici- (t = −7.05; p < 0.05), with highly significant improvement in
pants in SG and CG based on the subtopics: tobacco effects, the SG. Intergroup comparison revealed no significant differ-
oral cancer etiology, signs, epidemiology, treatment, and ence in the knowledge scores at baseline but a significant
difference in knowledge scores post-intervention (t = −15.05
p < 0.001) (Table 3).
Table 1 Demographic data of the SG and CG When asked on their willingness to quit before the start of
study, three males among SG and six males among CG said
Characteristics SG (N = 72) CG (N = 78)
frequency frequency that they are willing to quit. Post-intervention results showed
(percentage) (percentage) statistically significant increase in the number of subjects will-
ing to quit in both SG (six males) (t = −3.873 p = 0.008) and
Gender Male 29 (37.5%) 27 (34.6%) CG (eight males) (t = −2.45 p = 0.037).
Female 45 (62.5%) 51 (65.4%)
Mean age ± SD 20.2 ± 1.3 20.7 ± 1.5
Tobacco users Male 7 (24.1%) 10 (37%) Discussion
Female 0 (0) 0 (0)
Tobacco users None 44 (61.1%) 55 (70.5%) The present study assessed the feasibility and effectiveness of
in family Parents and/or 26 (36.1%) 18 (23.1%) WhatsApp as a channel for providing oral cancer education.
siblings
Others 2 (2.7%) 5 (6.4%)
WhatsApp has a wide penetration even into remote areas with
over one billion users worldwide and over 200 million active
 J Canc Educ

Table 2 Mean knowledge scores

of subjects based on tobacco Focus area (scores range) SG CG
effects, oral cancer etiology,
signs, epidemiology, and Baseline Post-intervention Std. dev Baseline Post- Std. dev
treatment p value intervention p value

Effects of tobacco (0–10) 4.15 8.15 1.66 6.31 6.48 1.68

0.000a 0.495
Etiology of oral cancer 5.93 6.35 2.64 5.06 6.35 2.58
(0–10) 0.280 0.1
Signs of oral cancer 5.79 7.39 3.6 5.67 7.85 3.21
(0–11) 0.00a 0.00a
Epidemiology of oral 3.05 4.94 2.13 4.16 5.68 1.78
cancer (0–6) 0.00a 0.00a
Treatment & prevention 10.81 12.19 3.7 10.54 11.81 4.81
(0–18) 0.013 a
0.74
a
P value significant

users in India alone [19, 20]. Hence, it can be used as a plat-
form to communicate dental advice, thereby strengthening the
bridge between health and technology.
The other imperative to choose WhatsApp was that true
oral cancer awareness must result in a behavior oriented to-
ward prevention of oral cancer and not just an increase in
knowledge. We postulated that this aim can be achieved by
repeated reading, understanding, and discussing about the
risks of tobacco all of which are fulfilled by WhatsApp mes-
senger app. Oral cancer knowledge through campaigns based
on media like newspaper and TVor warning signs on cigarette
packs seem to be transitory and misunderstood more often. In
order to curtail this limitation, we intended to use WhatsApp
as a tool in oral cancer education.
As compared to the chalk and talk lectures, leaflets,
flipcharts, and other educational tools used for health educa-
tion, PowerPoint presentations are most preferred and one of
the most commonly used education medium in recent times
[21]. Hence, the comparison of effectiveness of WhatsApp
was done with that of PowerPoint presentations.
In the present study, college students were chosen as study
subjects, as this is the commonest age of initiation of tobacco
use. Moreover, the effect of health education in improving
knowledge of different other forms of cancer has revealed to
be beneficial for all age strata, but with younger subjects
benefitting the most.
When asked about the usage of tobacco in smoking or
chewable forms, none of the females agreed on using them
in both groups whereas nearly one third of the male subjects
revealed that they were using tobacco. National surveys have
shown that more than 25% of young adults are tobacco users
in India [22]. The reason for reduced prevalence of tobacco
use in our study could be the fear of disclosure. But when
asked on the tobacco habits among their family members
(parents/siblings/others), more than 30% of the study popula-
tion agreed so. This reflects the very high prevalence of to-
bacco use in India.
In the present study, highly significant improvement in
knowledge scores was seen in the study group as compared
to the control group suggesting WhatsApp to be an effective
educational tool. The improvement in knowledge could be
attributed to various advantages of WhatsApp over
PowerPoint like accessibility to the messages, pictures, and
videos at any time, opportunity for discussing with the other
subjects as well as the information provider. PowerPoint pre-
sentations have a disadvantage of covering small groups at a
time and are more didactic in nature. Furthermore, those who
are not in attendance during the educational presentation will

Table 3 Intragroup and

intergroup comparison of baseline Outcome variable SG CG Statistical analysis p
and post-intervention knowledge
scores (standard deviations N 72 78
between parentheses) and tobacco Baseline score 28.72 (5.9) 29.97 (6.3) t = 1.272 p = .205
use prevalence Post-intervention score 49.59 38.82 (6.8) t = 14.354 p < 0.000*
(5.4)
(Post-intervention-baseline)/baseline (%) 72.68 29.52 t = 6.658 p < 0.000*

*p value significant
J Canc Educ
not be able to view it again. Whereas WhatsApp messages
along with pictures and videos can be sent to large group of
people at the same time. What is more, unlike PowerPoint
presentations which require a health educator to deliver infor-
mation, prepared WhatsApp messages can be sent by the
group facilitator. Nevertheless, there is a need for a health
educator to be available at the time of online chat room
discussions.
In our study, group discussions on WhatsApp chat room
were held every week at a pre-decided time. This also allowed
inputs (more information about oral cancer) from subjects that
were displayed to other participants in the group thus facilitating
two-way learning. Students also had an opportunity of asking
any doubts in the chat room, making it feasible for even those
subjects who would not have stood up and clarified their doubts
in a classroom setting. Thus, it provides an opportunity for dis-
cussion among the subjects as well as the information provider.
In addition, it also provides for sharing interactive videos which
could contribute for better understanding of the subject.
Yet, there were many barriers that need to be overcome when
using WhatsApp for health education. Most important of all was
that of maintaining the anonymity of subjects in the group. In the
present study, anonymity was maintained by coding each name.
At the end of the study, the group was suspended. If the study
group is a heterogeneous one, question of maintaining each
individuals’ ambiguity arises. In which case, the messages can
be sent individually to each. Second impediment found in the
present study was readability of the messages by the subjects.
We could come over this obscurity by sending them the re-
minders to read through the messages regularly.
Conclusions
WhatsApp messenger app showed highly significant increase
in the knowledge and awareness on tobacco and oral cancer as
compared to the PowerPoint presentations. WhatsApp can thus
be effectively used as a channel for providing health education
on tobacco effects and oral cancer. Further studies could be
conducted on the long-term effectiveness of WhatsApp in the
knowledge, attitude, and behavioral changes.
References
1. World Health Organization. Tobacco. http://www.who.int/
mediacentre/factsheets/fs339/en/. Accessed on 1/2/17 at 11.00 am.
2. Rao SVK, Mejia G, Roberts-Thomson K, Logan R (2013)
Epidemiology of oral cancer in Asia in the past decade—an update
(2000-2012). Asia Pac J Cancer Prev 10(14):5567–5577
3. Agrawal M, Pandey S, Jain S, Maitin S (2012) Oral cancer aware-
ness of the general public in Gorakhpur city. India Asian Pac J
Cancer Prev 13(10):5195–5199
4. Goyal G (2016) Knowledge, attitude and practice of chewing
Gutka, areca nut, snuff and tobacco smoking among the young
population in the northern India population. Asian Pac J Cancer
Prev 17(11):4813–4818
5. Bhargava S (2016) Need of oral pre cancer awareness initiatives in
India. Open Dent J 10:417–419
6. Schluter P, Lee M, Hamilton G, Coe G, Messer-Perkins H, Smith B
(2015) Keep on brushing: a longitudinal study of motivational text
messaging in young adults aged 18–24 years receiving Work and
Income Support. J Public Health Dent 75(2):118–25
7. Hashemian TS, Kritz-Silverstein D, Baker R (2015) Text2Floss: the
feasibility and acceptability of a text messaging intervention to
improve oral health behavior and knowledge. J Public Health
Dent 75(1):34–41
8. Sharma R, Hebbal M, Ankola AV, Murugabupathy V (2011)
Mobile-phone text messaging (SMS) for providing oral health ed-
ucation to mothers of preschool children in Belgaum City. J
Telemed Telecare 17(8):432–436
9. Hefler M, Freeman B, Chapman S (2013) Tobacco control advoca-
cy in the age of social media: using Facebook. Twitter and change
Tob Control 22(3):210–214
10. Duke JC, Hansen H, Kim AE, Curry L, Allen J (2014) The use of
social media by state tobacco control programs to promote smoking
cessation: a cross-sectional study. J Med Internet Res 16(7):e169
11. Underwood B, Birdsall J, Kay E (2015) The use of mobile app to
motivate evidence based oral hygiene behavior. Br Dent J 219:E2
12. Zotti F, Dalessandri D, Salgarello S, Piancino M, Bonetti S,
Visconti L, Paganelli C (2015) Usefulness of an app in improving
oral hygiene compliance in adolescent orthodontic patients. The
Angle Orthodontist 86(1):101–107
13. Li X, Xu ZR, Tang N, Ye C, Zhu XL, Zhou T, Zhaol Z (2016) Effect
of intervention using a messaging app on compliance and duration
of treatment in orthodontic patients. Clin Oral Invest 20:1849
14. Raiman L, Antbring R, Mahmood A (2017) WhatsApp messenger
as a tool to supplement medical education for medical students on
clinical attachment. BMC Med Educ 17(1):7
15. Carrard VC, Martins MA, Molina-Bastos CG, Gonçalves MR
(2017) WhatsApp: a telemedicine platform for facilitating remote
oral medicine consultation and improving clinical examinations-
some considerations. Oral Surg Oral Med Oral Pathol Oral Radiol
123(3):408
16. Ganasegeran K, Renganathan P, Rashid A, Al-Dubai SA (2017)
The m-Health revolution: exploring perceived benefits of
WhatsApp use in clinical practice. Int J Med Inform 97:145–151
17. Askarian M, Kouchak F, Youssef M, Romito LM (2013)
Comparing tobacco use knowledge, attitudes and practices be-
tween engineering students at a public and Islamic Azad
University in Shiraz, Iran 2011. Int J Prev Med. 4(10).
18. Kanicka M, Poniatowski B, Szpak A, Owoc A (2013) Effect of an
anti-tobacco programme of health education on changes in health
behaviours among junior high school adolescents in Białystok.
Poland Ann Agric Environ Med 20(1):167–172
19. Downloaded from: https://www.statista.com/statistics/260819/
number-of-monthly-active-whatsapp-users/. Last visited the page
on: 21/4/17.
20. Downloaded from: http://www.business-standard.com/article/
technology/whatsapp-now-has-200-million-users-in-india-
117022400879_1.html. Last visited the page on: 21/4/17.
21. Savoy A, Proctor RW, Salvendy G (2009) Information retention
from PowerPoint™ and traditional lectures. Comput Educ 52(4):
858–867
22. Singh A, Ladusingh L (2014) Prevalence and determinants of to-
bacco use in india: evidence from recent global adult tobacco sur-
vey data. Gorlova OY, ed. PLoS One. 9(12):e114073. doi: 10.1371/
journal.pone.0114073.