Reasons for non-compliance of patients to attend referral hospital after screening for oral pre-cancer lesions through camp approach in rural population of india

Sir, Oral cancer is a serious and growing problem and it is the sixth most common cancer in the world. In high-risk countries such as Srilanka, India, Pakistan, and Bangladesh, oral cancer is the most common cancer in men and may contribute up to 25% of all new cases.[1] The higher incidence of oral cancer and pre-cancers has been linked with the habit of betel quid and tobacco chewing in India and it is estimated that among the 400 million individuals aged 15 years and above, 47% use tobacco in one form or the other in our country.[2] Patient delay has been cited as the main reason for late attendance and it seems probable that in both the high risk and general population, neither the symptoms of oral cancer, nor the main risk factors are well-understood.[3] Public awareness about the risk factors and methods of early detection of oral cancer is quite low.[3] It has also been observed that chronic tobacco chewers and smokers, who are at a higher risk, do not take advantage of community oral cancer screening programs, if offered. Even if, they come for screening they avoid undergoing for further diagnosis and management. The purpose of this study was to determine the reasons behind the non-attendance and non-compliance of patients with oral pre-cancer and cancer lesions detected in camp screening program for further diagnosis and management at the hospital. This study was approved by an ethical committee of the institute. We organized oral cancer screening camps at UP State Government Transport Depot, Noida, Ghaziabad and nearby villages. High risk population comprising of drivers, conductors, farmers, and village population using the tobacco in any form were screened for oral pre-cancer and cancer lesions with Magnivisualizer® (magnifying device with white light illumination). Patients with positive lesions were referred to Guru Teg Bahadur (GTB) Hospital (20-40 km away from screening camp sites) for further management where facilities for biopsy and treatment were arranged free of cost. This hospital is a territory hospital having facilities for biopsy, surgery, and radiotherapy. Out of 150 patients diagnosed (with different positive for oral lesions, only 33 (22%) reached at GTB referral Hospital for further management. Remaining 117 (78%) patients refused to go for any management. Owing to social taboos only 3 females came forward for oral cavity examination and one reported to tertiary hospital. This is due to some social restrictions and for females health is not the first priority. Out of 150 patients, 34 homogenous leukoplakias, 13 non-homogenous leukoplakia, 3 nodular leukoplakia, 2 leukoplakia, 4 oral lichen planus, 88 oral submucus fibrosis 5 other lesions (Candida), and one suspicious for cancer were diagnosed in camp. Each patient has been told about better management facilities of a tertiary hospital, which is attached to a Medical College. A follow-up survey was conducted to determine the reasons behind the non-compliance of these 117 patients. Telephone numbers, mobile numbers and their contact numbers were already collected during the examination of patients. Patients have been told again and again about the free of cost facilities available in the hospital. These patients were contacted through telephone three to 4 times and were asked for reasons for their non-compliance. Table 1 shows the reasons behind the non-compliance observed in these patients after the first screening. Shortage of time was the main reason for non-compliance in 27% of patients. Further analysis showed that the long distance of referral hospital from their residence was found to be the main complaint in 20 (17.1%) followed by odd hour duties in 7 (5.9%), and long duty hours in 6 (5.1%) of cases. The next significant reason was denial of any treatment in 18 (15.4%), dependence upon their destiny or fate in 13 (11.1%), addiction for tobacco consumption and non-willingness to leave this habit in 8 (6.8%), fear of time consumption in crowded government hospital or rush in getting medical treatment in 8 (6.8%), fear of diagnosis in 8 (6.8%) of the cases, no support from family and friends in 4 (3.4%), fear of teasing from friends and society in 8 (6.8%) and hesitation to accept treatment in 9 (7.8%) cases were some of the reasons explained by the patients behind the non-compliance and acceptance of treatment. Even 12 (10.3%) of them gave their wrong contact numbers or the contact numbers of their friends during the first screening. Table 1 Reasons for non-compliance of patients to attend referral hospital after screening for oral cavity Screenings are organized for 3-5 days, which is too short to build the confidence among patients. Local influential people/village administrative bodies should be included in motivation drive and should be convinced to volunteer themselves to provide means/and facilitate for treatment of patients, who are a farmer and labor. Senior bosses should be also approached to act as a figure head providing leave medical aid for those patients, who are in the job. For distant areas, a mobile van having the facilities for taking a biopsy on the site may be a good option for improving the compliance among patients. Thus, cancer screening camps alone are not the solutions for any screening programs. A good awareness, involvement of local administrative bodies for follow-up and motivation program should be started before initiating any such program. The reasons behind non-compliance should be looked carefully and the problems should be worked out as far as possible for any successful screening program.