J Community Health DOI 10.1007/s10900-014-9862-6

ORIGINAL PAPER

Oral Cancer Awareness Among Community-Dwelling Senior Citizens in Illinois Ewa Posorski • Linda Boyd • Lori J. Giblin Lisa Welch



 Springer Science+Business Media New York 2014

Abstract The study assessed participant awareness of oral cancer (OC), risk factors, signs and symptoms, and history of an OC screening exam and whether a relationship exists between these factors and the participant’s age, level of education, socioeconomic status (SES), ethnicity, and gender. It was a descriptive survey research with a nonrandomized sample. Participants were a convenience sample of seniors participating in a congregate dining program of the DuPage County Senior Citizens Council. Data was collected through a written, self-administered survey. Sixty-two surveys were completed, with an overall response rate of 66 %. A statistically significant relationship was found between the level of education and awareness of OC risk factors (r = 0.26; P = 0.04). An inverse relationship was found between the level of education and the level of OC awareness questions, ‘‘have you ever heard about OC?’’ (r = -0.37; P = 0.004), and ‘‘how much do you know about OC?’’ (r = 0.35; P = 0.008). A trend toward significance was noted for the level of education and awareness of OC signs and symptoms (r = 0.24; P = 0.06). The levels of OC awareness in the seniors were lower than the general population. Seniors in the lower SES strata and who have low education levels are of particular concern, and it is important to conduct further

E. Posorski (&) Harper College School of Dental Hygiene, 1200 W Algonquin Rd, Palatine, IL 60067, USA e-mail: [email protected] L. Boyd  L. J. Giblin Forsyth School of Dental Hygiene, MCPHS University, 179 Longwood Ave, Boston, MA 02115, USA L. Welch Dixie State University, 225 S 700 E, St George, UT 84770, USA

studies tailored towards populations with these combined factors. Additional research is needed to determine how to best communicate OC awareness and implement programs specifically for this high-risk group. Keywords Mouth neoplasm  Oral cancer  Health status disparities  Awareness  Determinants  Survival rate  Health surveys

Introduction While oral cancer (OC) accounts for only about 2–4 % of all cancer types in the US, it is considered to be a major public health issue due to the relatively low 5-year survival rate of 61 %, the lowest of all major cancer types [1]. Late diagnosis, usually in stages III and IV, has been implicated as the primary reason for the low survival rate for patients with OC [2, 3]. According to the National Institutes of Dental and Craniofacial Research (NIDCR) localized OC that has not spread to the surrounding tissues has an 83 % 5-year survival rate, whereas the rate drops significantly to only 32 % for more advanced tumors with regional invasion [1, 4]. The survival rate drops even more drastically in late stage OC with metastasis to distant organs, in which the 5-year survival rate is estimated to be around 9 % [5]. In addition to high mortality, advanced OC is a disfiguring and debilitating disease due to location and treatment options, often times resulting in a poor quality of life for survivors [6, 7]. With roughly one person dying of OC each hour and an estimated 7,900 total deaths in the United States in 2010, it is a major burden within the overall disease incidence in our population [1]. A number of OC biological, behavioral, environmental, and demographic determinants play a role in OC etiology

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and mortality rates. OC, similar to many other systemic diseases, is multifactorial [8–12]. Use of tobacco and alcohol products, as well as infection with the human papillomavirus (HPV), have been implicated as the primary risk factors for OC. Behavioral changes such as increased use of tobacco and alcohol products in females are associated with the narrowing of the male/female ratio of OC incidence. Thirty to forty years ago the ratio of men to women with OC was 6:1, now it is 2:1 [1]. In addition to the determinants associated with OC development, there are a number of other factors associated with high mortality rates. Individuals with low socioeconomic status (SES), elderly, and African-American males are disproportionally over-represented in the incidence rates of late-stage OC at diagnosis, resulting in high mortality for these individuals [8, 13, 14]. Low SES, defined by low education attainment and income levels, is a major OC determinant due to associated factors such as limited access to care, increased exposure to environmental carcinogens, poor nutrition, and higher tobacco and alcohol consumption [15, 16]. According to the Surveillance Epidemiology and End Result (SEER) data for the years 2005–2009, median age at diagnosis for OC was 62 years old and 70.7 % of those diagnosed were over 55 years old [1]. In 2011, 14.5 % of individuals over the age of 65 were poor or ‘‘near poor’’, and the rate of poverty increased with age [17]. Furthermore, socioeconomically disadvantaged individuals are faced with difficulty in getting regular care and often have minimal comprehension of their role in managing their health [18, 19]. Therefore, senior citizens present a unique target group for OC awareness and preventative intervention. While the socioeconomically disadvantaged individuals are at highest risk for OC, they are also typically the population with minimal access to preventative and screening care [8, 13, 14, 20]. Additionally, Medicare does not provide any dental benefits, including preventative and screening services [21]. An issue contributing to late diagnosis is lack of routine OC screening exams in either dental or medical settings, thus allowing the disease to develop and progress into more advanced stages before it is diagnosed [22–24]. Early diagnosis is critical for the success of the treatment and long-term outcome [2, 3]. However, despite the staggering statistics and the severity and devastation resulting from OC, historically OC awareness is low in the general population, including those at highrisk for the disease [20, 22, 25]. No recent literature was available indicating the level of OC awareness among senior citizens who are at higher risk. The primary purpose of this study was to analyze the level of awareness of OC, risk factors, signs and symptoms, and history of OC screening exam in a group of community dwelling seniors participating in a Community Dining

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Program, and if a relationship exists between participant demographics of age, level of education, SES, ethnicity, and gender utilizing a validated OC awareness survey instrument.

Methods The study was granted a Certification of Exemption under 45 CFR46.101(b) [2] by the University’s Institutional Review Board. This study was descriptive survey research with a non-randomized sample. Participants were comprised of a convenience sample of senior citizens who participated in the congregate dining program of the DuPage County Senior Citizens Council (DCSCC) which took place at five cities including: Wheaton, Glendale Heights, Bensenville, Lombard, and Downers Grove. The DCSCC is a 501(c) [3] not-for-profit; community-based, volunteerdriven agency dedicated to providing basic needs services to its senior residents. Their programs include Senior Nutrition, including the Home Delivered Meals and Community Dining, Health and Wellness Education, WellBeing Visits and Safety Checks, and Home Maintenance. The seniors participating in the above mentioned programs were ethnically diverse including immigrant populations of Asian, African, Latino, and eastern European descent, with a wide range of education and SES. The exclusion criteria included a history of employment in a dental setting and personal or close family history of OC. Inclusion criteria included: aged 55 or older, and/or eligibility to participate in the congregate meal program. A verbal invitation to participate in the written survey was given when individuals arrived at the congregate meal site. Interested individuals were presented with an informed consent form and the survey. Each participant was asked to put their name on a raffle ticket and entered into a drawing for a gift card. The written survey took approximately 10–15 min to complete. Participants had the option to withdraw at any point during the survey without penalty. Instrument The survey instrument utilized in this study was a slightly modified version of the Oropharyngeal Survey developed and validated by Dodd et al. [26]. The author’s permission for use was obtained prior to the study. The written survey consisted of 37 questions including the following sections: OC awareness (2 items), knowledge of risk factors (18 items), knowledge of symptoms (11 items), and history of an OC screening exam (6 items). The knowledge of risk factors, symptoms, and history of OC screening exam questions employed three-point answers in a ‘‘yes’’, ‘‘no’’, ‘‘not sure’’ format. The final portion of the survey included

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demographic questions related to: age, educational attainment, SES, gender, and ethnicity of participants. To maximize the printed survey’s legibility for senior citizens it was designed in font size and type following the recommendations of the National Institute on Aging (NIA) for printed materials for seniors [27]. Reliability and Validity The survey reliability and validity was established by Dodd et al. [26]. The reliability and validity of survey items were established trough test–retest methodology. Frequency distributions were calculated for each of the OC items. Pearson correlation coefficients were calculated for respondents’ scores from the first and second administrations of the survey. The composite coefficient alpha (a), (Cronbach’s alpha coefficient) for OC signs and symptoms was 0.84 [26]. Statistical Analysis The survey data was coded and transferred into an Excel spreadsheet after which it was analyzed with SPSS, version 19, (SPSS Inc., Chicago, IL, USA) software. Descriptive statistics, including frequency distributions, were used to present the demographic characteristics of participants. The questions in each sub-category: OC risk factors, OC signs and symptoms, and history of the OC screening exam, were combined into a total score for the respective category. The mean (l) and standard deviation (SD) were used to assess the level of OC awareness, awareness of OC risk factors, signs and symptoms, and history of OC screening exam sub-categories of the survey. The mean and SD were also used to present summary statistics for age, education, and the financial status questions. A t test was conducted to examine whether males have a different level of awareness about OC when compared to females. Spearman rank Correlation analysis was performed to determine if a relationship existed between age, level of education, SES, ethnicity, and gender and each subcategory: OC awareness, awareness of risk factors, awareness of symptoms, and history of an OC screening exam. An alpha significance level of .05 was set on all statistical tests.

Results A total of 93 individuals were approached at all sites to participate in the survey and the response rate (n = 62) was 66 %. Among the respondents, the mean age was 72.37 years old, with majority (71.9 %) of the individuals aged less than 80 years old. Additionally, 60.7 % were

female, 34.4 % male, and 3.3 % did not disclose their gender. A vast majority, 82 % were white, 8.2 % Hispanic, 1.6 % black, and 4.9 % Asian. Financially, 6.6 % of the respondents said they ‘‘can’t make ends meet’’, 55.7 % said ‘‘they manage to get by’’, 14.8 % said they ‘‘have enough money plus some extra’’, and 3.3 % said ‘‘money was not a problem.’’ Figure 1 shows the education attainment breakdown of the study group. A majority, 83.6 % of the individuals stated they have heard of OC, but 82 % of them said they knew ‘‘little’’ or ‘‘nothing’’ about OC. The level of awareness of the individual OC risk factors and signs and symptoms questions in this study group is presented in Table 1. Thirty-nine percent of the individuals indicated they have heard of an OC screening exam. When asked if they ever had an OC screening exam only 3.3 % said yes, but that number rose to 27.9 % after the exam procedure was described. However, only 8.2 % have had an OC screening exam within the past year, and nearly a quarter (24.6 %) of the individuals indicated the exam was performed in a dentist’s office. One in five individuals (19.7 %) said they were ‘‘definitely not concerned’’, 42.6 % said they were ‘‘a little concerned’’, and 23 % said they were ‘‘concerned’’ or ‘‘very concerned’’ about getting OC in the future. A t test demonstrated there were no significant gender differences for any of the outcome variables including: OC awareness, awareness of risk factors, awareness of symptoms, and history of an OC screening exam. Based on a correlation analysis, age and financial status were not significantly related to any of the outcomes variables. However, a statistically significant relationship was found between the level of education and awareness of risk factors of OC (r = 0.26; P = 0.04). An inverse relationship was found between the level of education and the level of OC awareness questions, of the ‘‘have you ever heard about OC’’ (r = -0.37; P = 0.004), and ‘‘how much do you know about OC?’’ (r = -0.35; P = 0.008), (Table 2). There was a trend toward significance between the level of education and the sign and symptoms total score (r = 0.24; P = 0.06).

Discussion While it has been previously established that OC awareness remains low in the general population, [22, 26, 28] the results of this study illustrate the level of OC awareness, specifically among senior citizens, a high-risk group. When asked ‘‘if have ever heard of OC’’, 83.6 % answered in the affirmative. This finding is consistent with the findings of a study conducted by Oh et al., in which 80.4 % of those surveyed have heard of OC [25]. In a study conducted by Dodd et al. [26] the response rate to the same question was

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J Community Health Fig. 1 Education level

somewhat higher at 95 %. However, 82 % of the individuals in current study stated they knew ‘‘little or nothing’’ about OC. This statistic was two times higher than the results reported by Tomar et al. [28] in which 40.3 % of their respondents said they knew ‘‘little or nothing’’ about OC. (Table 3). Regarding awareness of OC risk factors, 84 % of the seniors correctly identified smoking cigarettes, pipes, and cigars as OC risk factors, while 77 % identified smokeless tobacco. However, only 24.6 % knew that being over 60 years old was a risk factor. There was also a low level of awareness about alcohol consumption (32.8 %) and an infection with HPV (29.5 %) as contributing OC factors. Overall, awareness of OC risk factors was somewhat lower when compared to the findings of the study conducted by Dodd et al., where 96 % of the respondents knew smoking cigarettes, pipe and cigars were OC risk factors, and 88 % identified smokeless tobacco. In addition, proportionately more of the Dodd study respondents correctly identified the other three major risk factors; 34 %—being over 60 years old, 53 %—drinking alcohol nearly every day, and 34 %— having HPV [26]. Similarly, the level of knowledge of tobacco and alcohol use as OC risk factors was lower when compared to the percentages reported by Tomar et al. [28] in their study of Florida adults, where it was 95.4 and 44.1 %, respectively (Table 4). Knowledge of signs and symptoms is an important factor in early detection of OC. In general, the proportion of individuals in current study able to correctly identify OC signs and symptoms was significantly lower than the ones reported by the Dodd study. See Table 5 for a comparison of OC signs and symptoms results with those of the above mentioned study. In terms of an OC screening exam, 39.3 % of the individuals stated they have heard of it and 27.9 % stated they

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have had one in the past, but only 8.2 % have had an OC exam within the past year. In contrast, nearly three-quarters of the respondents to the Oh study had never heard of an OC screening exam, but 35 % reported having had one in their lifetime [25]. On the other hand, in the Tomar study only 21.5 % had heard of an OC screening exam, 30.1 % said they have had one in their lifetime, and 19.5 % reported having received one within the past year [28]. The Dodd study reported 46 % of the surveyed adults heaving heard of an OC screening exam and 23 % said they have had one [26] (Table 3). In the Healthy People 2020 (HP 2020) report, the US Department of Health and Human Services is carrying on a goal originally set for the year 2010 for at least 20 % of the US adult population to receive an OC screening exam. It was encouraging to find that the HP 2020 goal has been exceeded in the population under study. Interestingly, 24.6 % of the seniors reported having the OC screening exam performed in a dentist’s office and 6.6 % in a medical doctor’s office. In contrast, 72 % of the Oh study respondents reported having the OC screening exam performed by a dental professional, and 28 % by a medical professional [25]. This statistic might be reflective of the fact that senior citizens do not have dental coverage under Medicare and therefore many, especially those with low SES, do not see dental professionals as often as the general population and individuals with higher economic means [29]. This is an important point given the fact that in 2011, in the US, 14.5 % of individuals over the age 65 years or older were ‘‘poor’’ or ‘‘near poor’’, and the rate increased to 17.7 % for individuals who were aged 75 years or older [17]. In current study when asked the question: ‘‘If you were faced with an unexpected $500 medical bill that was not covered by insurance, how would you best describe your situation,’’ 37.7 % of seniors

J Community Health Table 1 Response rates to the OC risk factors and sign and symptoms questions Yes (%)

No (%)

Not sure (%)

Awareness of OC risk factors Smoking cigarettes, pipes, or cigars (?)

51 (84)

0 (0)

10 (16)

7 (12)

17 (28)

37 (61)

Being over 60 years of age (?)

15 (25)

22 (36)

24 (39)

Drinking alcohol nearly every day (?)

20 (33)

13 (21)

28 (46)

Spending too much time in the sun (?)

26 (43)

16 (26)

19 (31)

9 (15)

24 (39)

28 (46)

Eating spicy foods (-)

Drinking hot beverages (-) Having human papilloma virus (HPV) (?)

18 (30)

4 (7)

39 (64)

Not eating enough fruits and vegetables (?)

20 (33)

22 (36)

19 (31)

Use of spicy sauces (-)

13 (21)

19 (31)

28 (46)

Pollution in the air (-) Having the flu (-)

20 (33) 4 (7)

13 (21) 31 (51)

28 (46) 36 (43)

Having a relative who has had OC (?)

19 (31)

18 (30)

24 (39)

Regularly biting your lips or cheeks (-)

16 (26)

13 (21)

32 (53)

Ill-fitting dentures or partial dentures (-)

21 (34)

13 (21)

27 (44)

Smokeless tobacco (snuff, dip) (?)

47 (77)

3 (5)

11 (18)

Being overweight (-)

13 (21)

24 (39)

24 (39)

Having HIV (?)

23 (38)

6 (10)

31 (51)

3 (5)

40 (66)

17 (30) 26 (43)

Drinking water (-) Awareness of OC signs and symptoms Having trouble swallowing (?)

26 (43)

8 (13)

Sensitive teeth to hot and cold (-)

10 (16)

17 (30)

33 (54)

Sore throat that does not go away (?)

34 (57)

4 (7)

22 (37)

Cough that does not go away (?)

28 (46)

5 (8)

28 (46)

White patches in mouth that do not go away (?)

32 (53)

4 (7)

25 (41)

Bad breath (-)

22 (36)

10 (16)

29 (48)

A sore or ulcer in the mouth that does not go away (?) Numbness in your mouth (?)

45 (74) 25 (41)

4 (7) 6 (10)

12 (20) 30 (49)

Swelling in the throat or neck (?)

35 (57)

4 (7)

22 (36)

Pain in your mouth that does not go away (?)

38 (62)

1 (2)

22 (36)

Hoarse voice that does not go away (?)

33 (54)

5 (8)

23 (38)

(?) indicates true OC risk factor and sign and symptom, (-) indicates false risk factor and sign and symptom

surveyed said they were ‘‘able to pay, but with difficulty’’ and 29.5 % said they were ‘‘not able to pay the bill.’’ The low percentage of seniors receiving OC screening exams by medical professionals is of concern and indicates the potential benefit of OC awareness programs targeting the medical community. No gender differences were found for any of the outcome variables. Oh et al. and Tomar et al. reported no gender differences as well. However, there were unexpected findings after data analysis. Based on comparison studies, a positive relationship between age, level of education, SES, and ethnicity and the awareness of OC risk factors and signs and symptoms, as well as history of OC screening exam was expected. However, no relationship was found between age, SES, and ethnicity and level of OC

awareness, awareness of OC risk factors, sign and symptoms, and history of OC screening exam. The small sample size might have influenced those findings. It is unclear, however, as to why there was an inverse relationship between the level of education and OC awareness. This finding was the opposite of the findings reported by Oh et al. and Tomar et al. [25, 28] where the level of OC awareness increased proportionately to the level of education. Similarly, it was unforeseen that there was no relationship between the level of education and the participant’s history of OC screening exam. As expected a relationship was found between the level of education and the awareness of risk factors, and a trend toward significance was noted for the awareness of signs and symptoms as well.

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J Community Health Table 2 Correlation of demographics and survey sub-categories Age

Education

* Significant [.05. OC awareness questions: Q1: have you ever heard about OC?, and Q2: how much do you know about OC?

Financial status

OC awareness-1

OC awareness-2

Risk factor total

Sign & symptoms total

Oral screening exam total

-0.16196

0.01136

-0.09466

0.03444

0.06428

0.2245

0.9338

0.4758

0.7957

0.6286

58

56

59

59

59

-0.37070

-0.34572

0.25778

0.24400

-0.02019

0.0038*

0.0084*

0.0449*

0.0581

0.8772

59

57

61

61

61

-0.01718

-0.16340

-0.19290

0.07920

0.07181

0.8973

0.2246

0.1364

0.5440

0.5823

59

57

61

61

61

Table 3 Comparison OC awareness and history of OC screening exam questions Current Study (%)

Dodd et al. (%)

Oh et al. (%)

Tomar et al. (%)

Have you ever heard of OC? Yes

51 (84)

No

3 (8)

88 (95)

4,388 (80) 836 (20)

275 (15)

How much do you know about OC? A lot A little or nothing

3 (5) 50 (82)

709 (40)

Have you ever heard of an OC screening exam? Yes No

24 (39)

43 (46)

25 (41)

1,445 (26)

372 (21))

3,696 (74)

Have you ever had an OC screening exam? Yes

17 (28)

No

39 (65)

10 (23)

1,918 (35) 3,196 (65)

Was your OC screening exam in the past year? Yes 5 (8) n.d (72) No

532 (30)

346 (19)

29 (34)

Where was the OC screening exam done? Medical doctor’s office Dentist’s office

4 (7)

n.d (28)

15 (25)

n.d (72)

n.d no data

The study size proved to be a major limitation for this study. While the principal investigator and the DCSCC Program Director scheduled site visits on days traditionally showing high attendance rates, the actual number of participants on the scheduled days was limited at three out of the five sites. In addition, it would have been helpful for the seniors to be informed in advance of the research survey occurring on specific days; however, the program staff failed to do so. As a result, some of the seniors expressed discontent and distrust towards the principal investigator and the research being conducted. A large segment of those individuals who refused to participate in the study did so

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Table 4 Comparison of positive responses to OC signs and symptoms questions Possible sign and symptoms

Current study (%)

Dodd et al. (%)

Trouble swallowing (?) Hoarseness that does not go away (?)

26 (43) 33 (54)

63 (67) 77 (83)

Cough that does not go away (?)

28 (46)

58 (62)

White patches in mouth that do not go away (?)

32 (53)

76 (82)

A sore or ulcer in the mouth that does not go away (?)

45 (74)

83 (89)

Numbness in the mouth (?)

25 (41)

47 (51)

Swelling in the throat or neck (?)

35 (57)

70 (75)

Pain in the mouth that does not go away (?)

38 (62)

69 (74)

Sore throat that does not go away (?)

23 (56)

75 (81)

Tooth sensitivity to hot or cold (-)

10 (16)

51 (55)

Bad breath (-)

22 (36)

37 (40)

Instructions for signs and symptoms: Following is a list of things that might make some people think they have mouth or throat cancer. After each possible choice please tell us if …Response choices: Yes, you think it is a sign or symptom, or No, it is not a sign or symptom. If you are not sure of what to say, please say ‘‘not sure.’’ (?) indicates true sign and symptom, (-) indicates false sign and symptom

because they did not speak or read English. The DCSCC serves many minority groups, some with only a few members, and the language barrier proved to be a major limitation for the investigator. Since the participants were a convenience sample gathered from the population of senior citizens in the congregate dining program of DCSCC, the results of this study cannot be generalized beyond this population. Another limitation of the study is the instrument considered for this study, which is limited to the constructs considered in the OC Survey. Providing written material to senior citizens produces potential challenges related to comprehension, along with reduced physical ability to read the printed material. While the original authors of the

J Community Health Table 5 Comparison of positive responses to OC risk factors questions Possible OC risk factors

Current study (%)

Dodd et al. (%)

Smoking cigarettes, pipe, or cigars (?)

51 (84)

89 (96)

Being over 60 years of age (?)

15 (25)

32 (34)

Drinking alcohol nearly every day (?) Spending too much time in the sun (?)

20 (33) 26 (43)

49 (53) 37 (40)

Having human papilloma virus. (This is a sexually transmitted disease, also called HPV) (?)

18 (30)

32 (34)

Having a relative who has had mouth or throat cancer (?) Using smokeless tobacco PROMPT: This is also called ‘‘snuff’’ or ‘‘dip’’ (?)

19 (31)

59 (63)

47 (77)

82 (88)

Being overweight (-)

13 (21)

51 (55)

Wearing dentures or partial dentures that do not fit well (-)

21 (34)

48 (52) 54 (58)

Using spicy sauces (-)

13 (21)

Eating spicy foods (-)

7 (12)

64 (69)

Drinking hot beverages (-)

9 (15)

69 (74)

16 (26)

37 (40)

Lip or cheek biting (-)

Instructions for risk factor items: Following is a list of things that may or may not increase a person’s chance of getting mouth or throat cancer. After each possible cause, please tell us if you think…Response choices: Yes—it increases the chance of getting mouth or throat cancer. No—it does not increase a person’s chances of getting mouth or throat cancer. If you are not sure what to say, please say ‘‘not sure.’’ (?) indicates true risk factor, (-) indicates false risk factor

survey took numerous steps to ensure the survey questions were written in plain language appropriate for individuals with low literacy levels [26], it was apparent a small number of individuals struggled with question comprehension. At times these participants sought help with the survey questions from other participants, which may have influenced the answers they provided. In addition, some respondents did not provide answers to age and race or said ‘‘I don’t know’’, which may have reduced the validly of those survey responses. Three participants suffered from poor eyesight and the principal investigator read the questions to the participants and filled in the answers provided. All of the above mentioned issues pose threats to the internal validity of the study.

Conclusion The study’s focus on the high-risk senior citizen group demonstrates that overall they have lower levels of OC awareness then the general adult population. Although the rate of having received an OC screening exam at least once in the lifetime of the senior population in this study group was

higher than the goal set by the Healthy People 2020, there is need for continual OC awareness programs to increase the level of general OC awareness, as well as the awareness of risk factors and sigh and symptoms. As research indicates, past programs geared towards high-risk populations have produced mixed results [22, 24, 30]. This, along with the findings in this study, attests to the fact that further research must be conducted to determine how to best communicate OC awareness and implement programs strategically, specifically for high-risk groups. Seniors in the lower SES strata and who have low education levels are of particular concern, and it is especially important to conduct further studies tailored towards populations with these combined factors. Acknowledgments I would like to express my deepest gratitude to my thesis advisors for their tireless guidance and encouragement in the research process. In addition, I would like to thank all the individuals who helped with this research project and data analysis. Many thanks go to the DCSCC director and staff for allowing me to work with the seniors, and to the seniors who participated in this research. Finally, I am very grateful to my family members who supported me during this time.

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Oral cancer awareness among community-dwelling senior citizens in Illinois.

The study assessed participant awareness of oral cancer (OC), risk factors, signs and symptoms, and history of an OC screening exam and whether a rela...
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