title: Behavioural risk factors associated with oral cancer: assessment and prevention in primary care dental practices in Scotland
Creators: name: Mathur, Sweta
Publisher: name: University of Glasgow
Year: 2019
Subjects: subject: Oral cancer, risk assessment, prevention, primary care.

description: The incidence of oral cancer continues to rise in the UK and in Scotland, with a steady increase in oral cavity cancer rates and a rapid increase in oropharyngeal cancer rates in the last decade. These rates are projected to increase further over the next decade, so there is a pressing need to optimise oral cancer prevention strategies. Tobacco and alcohol use are recognised as the major modifiable risk factors for developing oral cancer (both oral cavity and oropharyngeal). In addition, there is a significant increased risk for oral cancer among lower socioeconomic groups, males, and older age groups. Recently there has been recognition of the role of human papillomavirus in the aetiology of oropharyngeal cancers. The major behavioural risk factors (tobacco and alcohol) implicated in oral cancer risk are also associated with a wide range of diseases affecting oral and general health and are thus termed ‘common risk factors’, increasing the public health benefit should they be tackled. Given the pivotal role in oral cancer and wider disease prevention of reducing tobacco and alcohol use, there is a clear need to optimise the role of primary care dental professionals in delivering behavioural interventions. However, there are uncertainties about the best evidence for particular strategies and approaches to assess risk factors, advise and/or refer in the dental practice setting, with a particular lack of clarity in terms of the specific form and content of such interventions (for example: duration, tailoring to need, who delivers). In addition, the barriers and facilitators to implementation in primary care dental practice - from both the dental professional and patient perspectives - is relatively under-explored. This thesis describes studies undertaken to address these gaps in the knowledge and evidence-base. First a systematic overview was undertaken of systematic reviews and published (international) clinical guidelines. This aimed to identify the evidence on the best practice for the assessment of the major behavioural risk factors associated with oral cancer and for delivering effective behaviour change preventive interventions (in relation to, for example: advice, counselling, signposting/referral to preventive services) by dental professionals in primary care dental practice setting. This evidence was then explored via a study in primary care dental practices in Scotland utilising qualitative in-depth interviews with dental professionals, to identify barriers and facilitators to implementation, and to gather suggestions to inform the development of interventions to support dental professionals in delivering prevention. Finally, a small qualitative survey of patients attending primary care dental practice was conducted to explore barriers, facilitators, and acceptability of risk factor assessment and preventive interventions from the patients’ perspective. The overview shows a lack of direct evidence from the dental practice setting (one high-quality systematic review relating to tobacco prevention and none relating to alcohol). However, relatively strong evidence and recommendations from other primary care (medical/pharmacy) settings were identified and synthesised, which could potentially be adapted and adopted by dental professionals. Overall the findings show that robust risk factor assessment is an important first step in any prevention intervention. There is a clear indication of the effectiveness of a “brief”, in-person, motivational intervention for sustained tobacco abstinence and reduced alcohol consumption. The lack of detail particularly in relation to duration made it difficult to make a conclusion regarding precise specification of the duration of element of the “brief” interventions. For tobacco users, though longer (10-20 minutes) and intensive (more than 20 minutes, with follow-up visits) interventions have shown to be effective in increasing quit rates compared to no intervention, very brief (less than 5 minutes) interventions in a single session also showed comparable effectiveness to the longer brief or intensive interventions. While, for alcohol users, 10-15 minutes multi-contact interventions were most effective, compared to no intervention or very brief intervention or intensive intervention; brief interventions of 5 minutes duration were also reported to be equally effective. Thus, very brief or brief advice of up to 5 minutes, should be trialled for tobacco and alcohol respectively in a dental practice setting, tailored to patient motivational status. Exploring use of the dental team is supported, as effectiveness was generally independent of primary care provider (i.e. general practice physician or nurse). The qualitative studies on feasibility showed time and resources to be the major barriers from the dental professional perspective. Dental professionals also reported social barriers for a) using cancer as a term to frame preventive consultations and b) in delivering alcohol advice which may not be welcome by patients. Professionals were willing to receive training to overcome confidence issues in approaching behavioural aspects of both main risk factors. Patients however generally supported explicit conversations on oral cancer, and were amenable to alcohol as well as smoking advice, provided their stage-of-change (motivational readiness) was incorporated. The use of formal risk assessment tools to frame discussions was broadly supported by patients and professionals alike. Recommendations are made for testing a model of preventive consultation that draws from this best available evidence and addresses barriers for professionals and patients alike to help shape practice and support this important area of public health going forward.