A single-blinded assessment of the effect of communication on psychological burden among oral cancer and oral potentially malignant disorder patients

Abstract

Objective

Lack of communication begets distress in patients and often hampers patient care. This study aims to assess the effect of communication on psychological distress among patients with Oral Cancer (OC) and Oral Potentially Malignant Disorder (OPMD).

Methods

This is a prospective single-arm study wherein the psychological burden in terms of depression, anxiety, and stress was evaluated in 120 patients through Beck's anxiety inventory, Beck's depression inventory, and perceived stress scale respectively when they were diagnosed with OPMD or OC. All patients were then communicated and informed about their disease through an audiovisual mode and their queries were resolved. Their psychological status was re-evaluated 15 min after this communication.

Results

Wilcoxon signed ranks test revealed a statistically significant decline in the scores of each domain for both OC and OPMD post communication. When OC and OPMD were compared, a statistically significant difference was observed for only depression and anxiety domains.

Conclusion

Audiovisual communication by healthcare professionals reduces the psychological burden of patients and is immensely useful in providing tailored information to the patients and their families. It is recommended to initiate such communication set ups at the waiting area of all outpatient departments as a good practice, where detailed tailored information can be provided to the patients.

Practice implications

The intervention used in this study was not time-consuming and expensive, and can be used by the clinicians or health professional in their clinical practice to improve upon their treatment outcome. However, it should not be considered as a substitute to treatment.

Graphical abstract

1. Introduction

The Institute of Medicine associated with the National Academy of Sciences, India has proposed six integral objectives for superior virtues of the 21st century's health care system. Among the virtues, patient-centered communication (PCC) is considered to be the most crucial; especially amongst cancer patients. It is defined as “the communication establishing a relationship amongst health providers, patients, and caregivers, providing education and support, to make decisions regarding treatment”. PCC is important as it leads to better and enhanced patient outcomes. Organizations are encouraged to ameliorate and implement PCC. Also, the National Cancer Institute, India has developed a monograph, which focuses on the need for PCC and means to reduce the suffering of cancer patients¹

Among several cancer types, oral cancer (OC) is the fifth most common type of cancer and is preceded by oral potentially malignant disorders (OPMD).² There has been an upsurge in the incidence rate of OC with no improvement in its survival rate or morbidity. When OC or OPMD are diagnosed, patient becomes stressed, depressed, anxious and their quality of life becomes compromised.^3,4 Such unrelieved anxiety and depression severely impact patients’ treatment modality.⁵ Patients need to handle this complicated information regarding their disease, treatment, and prognosis through support from the health care providers. Besides, patients have limited knowledge of health literacy, which is defined as the capacity of an individual to receive, understand, and process basic information of health and related services. Studies have reflected that lower health literacy rate, misconceptions, vulnerability, lack of knowledge and information about the benefits associated with early detection of cancer, and methods of reducing the risk, effectuates more distress in the patients.⁶

Providing effective information about the disease helps patients in deciding the treatment modalities, thereby assisting them to follow and optimize survival, and improving their psychological state. Thus, communication not only helps in quick decision making but also helps in improving the bio-psychosocial model of health including patients’ biological, social, psychological, and behavioral aspects. It has been ascertained that patient-centered effective communication could provide better patient outcomes in cancer treatment. Besides, studies have reported that lack of communication leads to a state of distress that often hampers patient care and treatment.^7,8 Due to the lack of knowledge about the effect of communication on the psychological status among cancer patients, this study was planned to assess the effect of communication on psychological distress in OC and OPMD patients.

2. Materials and methods

This study was conducted in a reputed tertiary health care centre of northern India. The patients were enrolled from out-patient clinics of Oral & Maxillofacial Surgery and Oncology departments. The patients fulfilling the inclusion criteria were enrolled in the study after obtaining informed consent. SPIKE protocol was followed by the clinicians, who informed the patients about their disease. The protocol was approved by the institutional ethics committee (Ref. Code: 89^thECMIIBPh.D./P7). The inclusion criteria included clinically diagnosed and histopathologic confirmed OC and OPMD patients, above 18 years of age, not suffering from an established psychiatric or psychological ailment (reasserted by using the GHQ-12) and undergoing and/or needing treatment.⁹

127 participants met the inclusion criteria and were enrolled in this study; however, 7 participants withdrew from the study for unknown reasons. Thus, a total of 120 participants were finally included in the study. Beck's anxiety inventory, Beck's depression inventory, and perceived Stress Scale were administered both before and 15 min after the intervention¹⁰ (Belzer, 1999) (3 min ‘audio-visual communication) by a psychological expert (KK) to evaluate their psychological burden. A pre-recorded audio-visual mode of communication was used to provide relevant information (about OC and OPMD) to the patients and their queries were resolved through this interaction of 5 min. The questionnaires were administered just after the audio-video mode and before solving the queries. So that the effect of the intervention which was due to the audio-visual information was apparent and the responses to questions or the extended timeframe of the consultation had no influence on the intervention.

2.1. Data recorded

General Health Questionnaire (GHQ-12)- is a short version of General Health Questionnaire (GHQ). It measures current mental health and is being used in different cultures and settings. It was developed by Goldberg in 1970. There are 12 questions/items (which the respondent experienced a particular symptom recently) which are rated on a four point comprising of four responses (less than usual, no more than usual, rather more than usual, or much more than usual).¹¹

Demographic data- The patient's background information was obtained according to the Kuppuswamy's socioeconomic status scale, which included age, sex, religion, education, occupation, and marital status. Information about alcohol/tobacco habits was also obtained.¹²Beck's Anxiety Inventory (Questionnaire) –The patient's anxiety was measured by Beck Anxiety Inventory (BAI) questionnaire composed of 21 items with a 0–3 scoring system; where 0 represents “Not at All” and 3 represents “Severely- It bothered me a lot”.¹³

Beck's Depression Inventory (Questionnaire)–The patient's depression was measured by Beck Depression Inventory (BDI) questionnaire composed of 21 items with a 0–3 scoring system in which 0 represents “Not at All” and 3 represents “Severely- It bothered me a lot”.¹⁴

Perceived Stress Scale- The level of patient's stress was measured by the Perceived Stress Scale (PSS) questionnaire composed of 10 items with a 0–4 scoring system in which 0 represents “Never” and 4 represents “Very Often”.¹⁵

2.2. Blinding

The psychological expert who evaluated the psychological burden was blinded for intervention.

2.3. Intervention

Audiovisuals were used as a mode of communication and were treated as an intervention in the study. Because of their long-lasting impression, audiovisual aids are predominantly used tools in the area of health and education. Audiovisuals are standardized tools and a better way to understand the information as they can be repetitively used according to the needs of the viewer.¹⁶ In our study, audiovisual aid comprised of information related to OC and OPMD, including the causes, symptoms, treatment modalities and instructions to be followed after the treatment. Patient's queries were responded, which generally included the time of recovery (if any), recurrence, life expectancy, cost of treatment, number of visits, and departments to approach.

2.4. Statistical analysis

The socio-demographic details and questionnaire data were first entered in Microsoft Office Excel. The analysis was done by using SPSS version 20, where p < 0.05 was considered to be significant. Descriptive statistics were used to analyze the background characteristics. Since the data was not normally distributed as tested by Shapiro–Wilk test (p < 0.05), therefore, the non-parametric alternative of the paired t-test, Wilcoxon signed ranks test was used as a non-parametric alternative of paired t-test. It was used to assess the effect of communication in changing the patient's psychological state.

3. Results

120 patients, with the mean age of 39.85 years (for OPMD) and 50.47 years (for OC) were investigated. The study included 83.3% males and 16.7% females including both OPMD and OC. According to the total scores of education, occupation, and income, 76.7% and 75% belonged to upper lower socioeconomic strata among OPMD and OC patients respectively. Maximum patients enrolled in the study were married and belonged to the rural areas in both the study groups (Table 1).

Table 1.

Demographic details of the patients.

Variables	OPMD (n = 60) n (%)	OC (n = 60) n (%)
Age, Mean (S.D.)	39.85(10.19)	50.47(8.68)
Gender, n(%)
Male	50(83.30)	50(83.3)
Female	10(16.70)	10(16.7)
Religion, n(%)
Hindu	35(58.30)	34(56.7)
Muslim	21(35.00)	23(38.3)
Sikh	03(05.00)	03(05.0)
Christian	01(01.70)	–
Marital Status, n(%)
Single	–	02(3.3)
Unmarried	05(08.30)	06(10.0)
Married	53(88.30)	51(85.0)
Widow	02(03.30)	01(1.7)
Domiciliary Status, n(%)
Rural	52(86.70)	49(81.7)
Urban	08(13.30)	11(18.3)
SES, n(%)
Upper	–	–
Upper Middle	–	–
Lower Middle	03(05.00)	04(6.7)
Upper Lower	46(76.70)	45(75.0)
Lower	11(18.30)	11(18.3)

The psychological status was evaluated in terms of depression, anxiety, and stress. It was observed that the scores for each domain declined after intervention in both the groups (Table 2). Wilcoxon Signed Ranks test revealed a statistically significant decline in the scores of each domain. When OPMD and OC were compared it was observed that there was a significant difference between OPMD and OC for depression and anxiety domains (Table 3).

Table 2.

DAS (Depression, Anxiety and Stress) scores before and after intervention.

Depression, Anxiety and Stress variables	Median (IQR) for Pre Intervention	OPMD Post Intervention	P value	Median (IQR) Pre Intervention	for OC Post Intervention	P value
Depression (Beck's depression inventory)	28.00 (23.50–29.00)	20.00 (17.00–23.75)	<0.001	37.00 (34.00–38.75)	<0.001	<0.001
Anxiety (Beck's anxiety inventory)	32.00 (26.00–33.00)	23.00 (19.00–24.00)	<0.001	41.00 (35.00–46.75)	<0.001	<0.001
Stress (Perceived stress scale)	21.00 (18.25–22.00)	14.00 (12.25–16.00)	<0.001	21.00 (19.00–23.75)	<0.001	<0.001

Table 3.

–Comparison between OC and OPMD scores.

Depression, Anxiety and Stress variables	Pre Intervention	P Value	Post Intervention	P Value
Depression
OPMD	35.81	<0.001	35.82	<0.001
OC	85.19		85.18
Anxiety
OPMD	37.48	<0.001	35.84	<0.001
OC	83.52		85.16
Stress
OPMD	57.92	0.413	62.63	0.499
OC	63.08		58.38

Values are reported in terms of mean rank.

4. Discussion and conclusions

4.1. Discussion

The diagnosis of cancer leads to significant turmoil in the patient's psychology and leads to several questions about the disease and its prognosis in the patient's mind.³ Even when OPMD is diagnosed, it was observed that it also generated turmoil no matter what the condition and lesion of the disorder.⁴ Although all OPMDs have a different malignant transformation rate and treatment strategies, still for a patient it was considered as a precancerous stage, which has a potential of transforming into cancer. Mostly, the health care providers involved in the treatment are not able to answer all their queries perhaps due to time limitations. It has also been observed that due to change in the duties of health providers there is a lack of communication and trust between patients, caregivers, families, and health providers.¹⁷ The patient is found under unrest with less information about the treatment outcome and modalities. Studies have reflected the need for implementing the strategies, to provide information and resolve the queries related to the disease progression and cure.¹⁸

In our study, the effect of communication was observed among OC and OPMD patients. Audiovisuals were used as a mode of communication and the psychological burden in terms of depression, anxiety, and stress were observed during pre and post-communication. The analysis showed remarkable improvement in the psychological burden after receiving information through communication. We not only educated our patients but also resolved their queries. This provided the patient a sense of control and reassurance regarding the consequences of the disease and led to a reduction in their psychological burden. Additionally, the targeted and relevant information provided lowered their level of anxiety. This observation was in accreditation with other studies that reported that adequate information helps in lowering the psychological burden in terms of depression, anxiety, and stress.^5,18,19

Our analysis is in corroboration with the study by Rai et al., which emphasized the importance of communication, observed a decrease in anxiety and stress levels after communication, and reported that it was important to inform the patients about the progress of the treatment as well as its pros and cons. This information not only reduced their anxiety but also created a trust relationship with their healthcare provider.²⁰

Patient satisfaction is an important factor to evaluate their psychological status. In a study, it was also indicated that patients’ satisfaction was associated with communication, treatment, and financial problems.²¹ Corroborated by recent studies between patients-clinicians was integral for the overall development of the patient. building relationships, making decisions, information exchange, self-management of the family, uncertainty management, responding to emotions, supporting hope, and providing validation or manifesting beliefs among patients and caregivers. Authors believe these communication functions might prove beneficial for clinicians, patients, and caregivers.²²

Moreover, another study has also emphasized that communication failure on account of misconceptions or delusions regarding the prognosis of the disease, unmet prognostic information, resulted in communication failures between patient caregivers and the clinicians leading to feelings of distrust and dejection.²³ Access to information therefore was considered to be of immense value both for the patient and for the healthcare providers. This study was in accordance with our study where we not only provided information but also satisfied patients’ queries and helped them in decision making.²⁴ Studies have suggested that patients yearned for clinical support in decision making and reported decreased anxiety after receiving information from the clinicians. They were in agreement with our study as they also observed that after intervention patient showed knowledge enhancement, learned-new things which they can share with others, and a reduction in the level of anxiety.^5,25

To the best of our knowledge, this is the first study that has focused on this untouched aspect as we provided intervention through communication and provided appropriate information. Appropriate information that was shared included the causes, symptoms, treatment modalities and instructions to be followed after the treatment, and resolution of patient's queries about the time of recovery, recurrence, life expectancy, cost of treatment, number of visits, and departments to approach. By including the high risk (OC) and moderate risk (OPMD) patients and comparing their psychological state using communication as a medium of intervention using the local language of communication (Hindi), our study thus improved trust building between the patients and the clinicians.

However, the study has few limitations. Firstly, the study utilized only one mode of communication (audio-visual) in the intervention; more modes of communication like pamphlets or booklets is planned to be used in the next phase of the study. Secondly, only one tertiary health care system was selected, and therefore, the results may not be generalizable to other groups of the population. Thirdly, a large majority of the participants in this study belonged to lower socioeconomic strata, therefore, any relationship between the socioeconomic status and stress, anxiety and depression in OC and OPMD patients could not be evaluated. Therefore, further studies are recommended with different populations and locations to provide the same or different perspectives.

4.2. Conclusions

Audio-visual communication is immensely useful in providing relevant tailored information to the patients and helps to reduce their psychological burden and thereby allow the healthcare professionals to deliver effective patient outcomes. Sympathetic resolution of patients’ doubts and queries related to cancer, by the healthcare providers, encourages patients to exhibit positive behavior and attitude, leading to enhanced treatment outcomes. It is recommended to initiate such communication set ups at the waiting area of all outpatient departments as a good practice, where detailed tailored information can be provided to the patients.

4.3. Practice implications

The intervention used in this study was not time-consuming and expensive and can be used by the clinicians or health professional in their clinical practice to improve upon their treatment outcome. However, it should not be considered as a substitute to treatment.

Funding sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.