Capacity building of primary care physicians of the tea garden hospitals in Dibrugarh, Assam: A demonstration project.

BACKGROUND: The three most commonly occurring cancers in India are those of the breast, uterine cervix, and lip or oral cavity, together accounting for approximately 34% of all cancers. All the three cancers are amenable to prevention, early detection, and treatment through which the morbidity and mortality due to these cancers can be reduced. This pilot study was conducted to assess the operational feasibility of the national cancer screening guidelines.
METHOD: This study was conducted in the Dibrugarh district of Assam in seven tea garden hospitals which serve as the primary health centers for the tea estate population in the Northeast region of India. The study intervention was a three-day training package designed to train primary care physicians in population-based screening for oral, breast, and cervical cancers. Knowledge evaluation and skill assessment were performed with a validated questionnaire and checklist, respectively.
RESULTS: Pre and posttraining knowledge assessment showed significant gain in the knowledge levels of the participants in all topics. The greatest knowledge increase was seen in breast cancer (96.3%), followed by cervical cancer (57.5%), oral cancer (35.5%) and general cancer-related information (16.7%). The skill assessment done for each participant individually at the end of the training indicated a need for retraining all participants in breast cancer screening.
CONCLUSION: The learnings from this study will be of great help in scaling up the capacity building programme for cancer screening when the nation-wide population-based cancer screening programme will be rolled out in the country. Copyright:

Introduction

Cancer accounts for 8.3% of all deaths and 5% of disability adjusted life years (DALYs) in India.[1] The three most commonly occurring cancers in India are those of the breast, uterine cervix, and lip or oral cavity, together accounting for approximately 34% of all cancers.[2] The northeastern part of the country has been found to be unfairly burdened with high incidence and mortality due to cancer. While the national average of reported cancer incidence is 80–110 cases per lakh population, this number varies between 150 and 200 cases per lakh in the northeast.[3] This may be attributable to the lack of awareness, poor socioeconomic conditions, and lack of prevention and treatment facilities.[456]

The Ministry of Health and Family Welfare (MoHFW) has published operational guidelines for population-based cancer screening of the three common cancers—oral, breast and cervical through the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular disease and Stroke.[7] All these three cancers are amenable to the prevention, early detection, and treatment through which morbidity and mortality due to these cancers can be reduced. To implement this programme, the existing health care providers (HCPs) at all levels of health care will be trained in the screening and early detection of the common cancers and training modules have been developed by the MOHFW. The training module for medical officers consists of a 3-day hands-on workshop but the same has not been evaluated in the field.

Considering the high burden of cancers in the Northeastern part of the country, a cancer screening demonstration project was initiated by the Indian Council of Medical Research in collaboration with the TATA Amalgamated Pvt. Limited in the tea gardens of Dibrugarh district of Assam to provide early insight into the implementation challenges in the field. Capacity building of HCPs for population-based cancer screening was done as a part of the demonstration project. This paper presents the objective assessment of the skills and knowledge gained by the HCPs using the Ministry's training module.

Materials and Methods

Study area

This study was conducted in the Dibrugarh district of Assam in seven tea garden hospitals of Dibrugarh which serve as the primary health centres for the tea estate population.

Study population

The nine primary care physicians posted at the seven tea garden hospitals with no prior training in cancer screening.

Study design

This is an interventional study with a pre and posttest design and skill assessment done at the end of a 3-day workshop.

Intervention

The study intervention was a 3-day training package designed to train primary care physicians in population-based screening for oral, breast, and cervical cancer. The package included theoretical sessions covering the sociodemographic aspects of cancer in the country, risk factors, and etiology of oral, breast, and cervical cancer, their signs and symptoms, screening tests, diagnostic tests, treatment, and referral linkages. Specialist teaching faculty including dental surgeons, breast surgeons, and gynecologists from premier medical institutes of the country namely ICMR-National Institute of Cancer Prevention and Research, All India Institute of Medical Sciences, Delhi, and Assam Medical College and Hospital, Dibrugarh were engaged in delivering the interactive sessions using powerpoint slides, demonstration videos of screening procedures, and evaluation of screen positive cases. Demonstration models and mannequins were made available to the study participants for the hands-on sessions along with demonstration in the outpatient clinics at the local medical college.

Ethics statement

This study was approved by the Institutional Ethics Committee at the ICMR-National Institute of Cancer Prevention and Research and ICMR-Regional Medical Research Center Dibrugarh. Date of Ethics committee approval: 16-03-2017.

Data collection/study questionnaire

A pretested questionnaire consisting of 30 multiple-choice questions with one right choice was administered for pre- and posttest evaluation [Annexure 1]. The questionnaire covered the different aspects of oral, breast, and cervical cancer including general information, risk factors and etiology, symptoms and signs of common cancers, screening tests, diagnostic tests, and treatment modalities.

Skill assessment was done for each participant individually on the third day by the trainers using a validated checklist to evaluate the step-wise procedure adopted by the participants for oral, breast, and cervical cancer screening [Annexure 2]. Stations were created for clinical breast examination, visual inspection by acetic acid, and oral visual examination at Assam Medical College and Hospital. Each station had one evaluator who observed and scored the participant as they performed the screening procedure on a patient. A written voluntary informed consent was obtained from the participants at the start of the training session.

Statistical analysis

Each item in the knowledge questionnaire and skill assessment checklist was given a score of “1” for a correct response/procedure practiced correctly and ‘0’ for an incorrect response/procedure or if it was not answered or not practiced.

In order to test the data obtained from the knowledge assessment questionnaires for normal distribution, Shapiro-Wilk Normality test was performed. The P value for both pretest (P = 0.95181) and posttest (P = 0.26902) were greater than 0.05; hence, the data is said to be normal. The results showed no significant departure from normality. After testing for normality, data were evaluated in terms of percentage for their scores. Subject experts determined the minimum pass marks for knowledge questionnaire and skills assessment as 70% and 80%, respectively.

Paired t-test was performed on the pre- and posttest results for knowledge assessment questionnaires to evaluate the impact of the training package intervention on participants’ knowledge about cancer and acquiring skills for cancer screening. A significant difference was found between the mean of pretest (M = 13.667, SD = 3.84, SE = 1.28, Range 8–20) and posttest (M = 21.111, SD = 4.25, SE = 1.41, Range 14-26) scores. Data was analyzed using the STATA 13 software.

Results

Of the nine physicians trained, two were female doctors and seven were males. The average number of years of service in their respective health centers was five years (range 1-12 years). Table 1 lists the average scores before and after training and the percentage of increase in scores for each topic. The greatest knowledge increase was seen in breast cancer (96.3%), followed by cervical cancer (57.5%), oral cancer (35.5%), and general cancer-related information (16.7%).

Table 1

Participant’s scores for pre and posttraining knowledge assessment

Knowledge parameter	Max score	Average Pretest score±SE (range)	Average Posttest score±SE (range)	% Increase in scores
General cancer information	4	2±0.29(1-3)	2.33±0.16 (2-3)	16.7
Cervical cancer	10	5.2±0.61 (3-10)	8.22±0.74 (3-10)	57.45
Oral cancer	9	3.4±0.4 (2-6)	4.67±0.33 (3-6)	35.48
Breast cancer	7	3.0±0.5 (0-5)	5.89 ±0.67 (2-9)	96.3
TOTAL	30	13.6±1.2 (9-20)	21.11±1.4 (14-26)

Results showed that out of total nine participants, with the passing score as 70%, no participant passed in the pretest assessment. The total individual pretest score of the participants ranged from 8 to 20 (max score 30). However, seven out of nine passed the knowledge assessment posttraining with the individual scores ranging from 14 to 26. The two participants who did not pass the posttraining assessment were retrained in all the topics. Paired t-test results showed significant difference in the knowledge level gained by the participants after the training t (8) = −4.84, P = 0.0013.

A total of six participants were presented with a skill assessment checklist after the hands-on session of screening procedures. Three participants could not attend the skill assessment as they had to attend an emergency meeting organized by the tea garden administration. All the six participants passed successfully (score >80%) in the cervical and oral screening procedures while none could clear the skill assessment for clinical breast examination [Table 2]. On scrutinizing the skill assessment forms of breast cancer screening, it was found that 2 parameters were not performed by the participants due to which they could not clear this assessment; (1) Place a pillow under the patient's left shoulder and place the arm over the head (2) Show the patient how to perform a breast self-examination. These were reiterated by the experts and a repeat assessment was performed in which all the participants performed the procedure as per the instructions.

Table 2

Results of Skill assessment in cancer screening procedures

TRAINING EVALUATION SKILL ASSESSMENT
Participants	Breast Cancer Screening (Total Score=17)			Cervical Cancer Screening (Total Score=30)			Oral Cancer Screening (Total Score=27)
	Observed Total Score	% Observed Total Score	Pass (≥80%)	Observed Total Score	% Observed Total Score	Pass (≥ 80%)	Observed Total Score	% Observed Total Score	Pass (≥80%)
1	11	64.7	NO	27	90.0	YES	27	100	YES
2	12	70.6	NO	29	96.7	YES	22	81.5	YES
3	12	70.6	NO	27	90.0	YES	27	100	YES
4	12	70.6	NO	28	93.3	YES	27	100	YES
5	13	76.5	NO	27	90.0	YES	27	100	YES
6	10	58.8	NO	28	93.3	YES	27	100	YES

Discussion

Training the health care providers is an essential component for the successful implementation of any national health programme. All the national programmes in India including the cancer screening programme are integrated under the National Health Mission utilizing the existing public health personnel for their implementation.[8] Training the HCPs can make them competent in implementing the cancer screening programme and adds advantage toward the larger mission of controlling the noncommunicable diseases in the nation. Currently, HCPs in the National Health Mission are trained in rolling out thematic programmes such as maternal and child health, control of infectious disease, and other national health programmes such as tuberculosis control, leprosy control, vaccination programmes, etc., Screening and management of noncommunicable diseases is one of the new components added to the existing services offered at the primary health care level. Hence, it becomes imperative to train HCPs at primary care level to carry out the screening of common cancers viz. oral, breast, and cervical cancer and refer the screen positives to higher centres for further evaluation and management.

In-person training is essential before the HCPs implement a population-based cancer screening programme because their knowledge about cancer and screening tests is minimal.[910] This is reflected by the participants’ low pretest scores in this study. The present study reiterates that the systematic training sessions which include theory and hands-on training are useful in increasing the knowledge and skill component of HCPs.

The limitation of our study is a small number of HCPs trained in the programme and all the participants could not take the skill assessment test. Such challenges will arise in the field and have to be considered during the actual roll out of the screening programme. Posttest assessments were done at the end of the 3-day training and there are chances of lower scores if the evaluation is done 4–6 weeks later.[11] On the other hand, it reflects the situation on the ground as HCPs may not be available together as a group if assessment is done at a longer interval. To avoid the attrition in knowledge and skill, the screening programme should be rolled out alongside the training programme. On-site technical support and supervision is also essential for the HCPs and, in this study, it was arranged through visits by experts, local medical college faculty, and online re-training through online cancer training programme.

This is a pilot study to assess the operational feasibility of the national cancer screening guidelines. Eventually, population-based cancer screening programme will be rolled out in all districts of the country and HCPs at all health care facilities will be involved in the programme. The learnings from this study will be of great help in scaling up of the capacity building programme for cancer screening.

Declaration of patient consent

The authors certify that they have obtained all the appropriate participant consent forms. In the form, the participants have given their consent for their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Checklist for Breast Examination
Step/Task	Cases
Getting Ready
Greet the woman respectfully and with kindness
Tell the woman you are going to examine her breasts
Ask the woman to undress from her waist up. Have her sit on the examining table with her arms at her sides
Wash hands thoroughly and dry them. If necessary, put on new examination or high-level disinfected surgical gloves on both hands
Skill/Activity Performed Satisfactorily
Breast Examination
Look at the breasts and note any differences in: shape
size
nipple or skin puckering
dimpling
Check for swelling, increased warmth or tenderness in either breast
Look at the nipples and note size, shape and direction in which they point. Check for rashes or sores and nipple discharge
Look at breasts while woman has her hands in two different positions, once over her head and second when she presses her hands on her hips
Have her lie down on the examination table
Look at the left breast and note any differences from the right breast
Place a pillow under the woman’s left shoulder and place her arm over her head
Palpate the entire breast using the spiral technique with the pads of the first three fingers. Note any lumps or tenderness
Squeeze the nipple gently and note any discharge
Repeat these steps for the right breast. If necessary, repeat this procedure with the woman sitting up with her arms at her sides
Have the woman sit up and raise her arm. Palpate the tail of the breast and check for enlarged lymph nodes or tenderness
Repeat this procedure for the right side
After completing the examination, have the woman cover herself. Explain any abnormal findings and what needs to be done. If the examination is normal, tell the woman everything is normal and healthy and when she should return for a repeat examination
Show the woman how to perform a breast self-examination
Skill/Activity Performed Satisfactorily
Total Score

Checklist for Via Counseling and Clinical Skills
Step/Task	Cases
Pre-Via Counseling
Greet woman respectfully and with kindness
If cancer screening counseling not done, counsel woman prior to performing pelvic (VIA test) examination
Determine that the woman has decided to have VIA done
Assess woman’s knowledge about cervical cancer and VIA test
Respond to woman’s needs and concerns about cervical cancer and the VIA test
Describe the procedure and what to expect
Getting Ready
Check that instruments, supplies and light source are available and ready for use
Check that the woman has emptied her bladder and washed her genital area
Have the woman undress from waist down. Help her get on to the examination table and drape her
Wash hands thoroughly with soap and water and air dry them.
Palpate the abdomen
Put one pair of new examination or high-level disinfected surgical gloves on both hands
Arrange instruments and supplies on high-level disinfected tray or container
Visual Inspection with Acetic Acid
Insert speculum and fix blades so that entire cervix can be seen clearly
Move light source so cervix can be seen clearly
Check the cervix for cervicitis, ectropion, tumors, Nabothian cysts or ulcers and clean cervix with cotton swab if necessary. Dispose off the swab
Identify the cervical os, Squammo-columnar junction (SCJ) and transformation zone
Apply 3-5% acetic acid to cervix with a swab on a stick and wait 1 minute. Dispose off the swab
Check if cervix bleeds easily. Check for any raised and thickened white plaques or acetowhite epithelium
Remove any remaining acetic acid from the cervix and vagina with a swab. Dispose off the swab
Remove speculum and place it in 0.5% chlorine solution for 10 minutes for decontamination
Perform the bimanual examination and rectovaginal examination if indicated
POST-VIA TASKS
Wipe light source with 0.5% chlorine solution or alcohol
Immerse all used instruments in 0.5% chlorine solution for 10 minutes for decontamination
Wash both hands with soap and water and air dry
Have the woman get dressed
Record the VIA test results and other findings in woman record
Discuss the results of VIA test and pelvic examination with the woman and answer any questions
If VIA test is negative, tell her when to return for repeat VIA testing
If VIA test is positive or cancer suspected, discuss recommended next steps
After counseling, provide treatment or refer to a higher appropriate facility for management
POST-VIA COUNSELING
Assure woman that she can return for advice or medical attention any time
Provide follow-up instructions
Total Score
Total Score%

Checklist for oral examination Counseling and Clinical Skills
Step/Task	Cases
Pre examination counselling
Greet the individual respectfully and with kindness
If cancer screening counseling not done, counsel him/her prior to performing oral examination
Determine that he/she has decided to have oral examination done
Describe the procedure and what to expect
Getting Ready
Check that the supplies and light source are available and ready for use
Wash hands thoroughly with soap and water and air dry them.
Put on examination gloves on both hands
Oral Visual Examination
Inspect the individual’s lips and the vermilion border
Evert the lips and carefully inspect the labial mucosa
Ask the individual to partially open the mouth
The buccal mucosa is examined by stretching it with a pair of tongue depressors or mouth mirrors
Opposite side buccal mucosa is examined in the similar manner
Ask the individual to protrude the tongue
The dorsal surface of the tongue is examined by holding the tongue gently by the fingers and a gauze sponge
The lateral borders of the tongue are examined by grasping the tip of the tongue with a gauze sponge
The ventral surface of the tongue and the floor of the mouth are visualized by having the person touch the tip of the tongue to the roof of the mouth
The gingivae are examined with the mouth partially opened and the lips retracted
The anterior part of the hard palate is better visualized using an intraoral mirror
The soft palate is examined by depressing the base of the tongue with a tongue depressor and asking the subject to say “aah”
The examination for cervical lymph nodes is carried out by standing behind the individual and slightly flexing and bending the neck to the side
POST-ORAL EXAMINATION TASKS
Immerse all used instruments in 0.5% chlorine solution for 10 minutes for decontamination
Dispose the gloves in leakproof container or plastic bag.
Wash both hands with soap and water and air dry
Record the oral examination test results and other findings in the record
If the individual is tobacco user, counsel about the ill effects of tobacco and provide tips to quit tobacco
Discuss the results of oral examination with the individual and answer any questions
Provide follow-up instructions
Total Score
Total Score%