Knowledge of cancrum oris among Nigerian university students: A cross-sectional study

INTRODUCTION

Cancrum oris (CO), also known as Noma Disease (ND), is an ancient but overlooked and poorly understood preventable disease affecting the most deprived populations globally. Cancrum oris is a speedily progressing infection of the oral cavity. It is associated with a reported 90% mortality rate within weeks after the early stage if left untreated.^[1] Cancrum oris is generally defined as the disease that starts with gingival ulceration and rapidly destroys part of the face within a few days. From its presence in Europe in the Middle Ages, Cancrum oris is now found almost exclusively in “developing” countries, especially in Sub-Saharan Africa, Asia, and Latin America. It is known for its high mortality rate, which the World Health Organization (WHO) estimates at 80 to 90% during the acute stage.^[2]

However, the WHO has estimated that 770,000 individuals living with cancrum oris, the global relative incidence of cancrum oris has been estimated at 140,000 new cases annually, with a mortality rate as high as 90%.^[3] It generally affects children and infants in low-income countries.^[4] In Northwest Nigeria in 2018, 3,300 out of every 100,000 children in the 0–15 year age group were estimated to have any stage of cancrum oris at the time of the survey. For the past 21 years, the Nigerian Ministry of Health has run a special program for the management of this disease at the Noma Children’s Hospital in Sokoto State, in the north-western part of the country.^[5] Only 15% of children survive the acute stage, and its disease burden was calculated to be a loss of one to ten.^[3] It affects hundreds of thousands of children annually, disfiguring them, leaving them with permanent disabilities, and sometimes taking their lives.^[6] Moreover, recent discoveries in the inquiry of cancrum oris microbiology have shown a polymicrobial interaction between intra-oral commensal microbes and extra-oral opportunistic microorganisms as the most likely causative agents of the disease. Although cancrum oris is almost exclusive to young children between 2 and 6 years, it has been shown to have an impact on individuals across all age groups, advancing through distinct clinical phases and stages, beginning at the reversible and seemingly inconsequential necrotizing gingivitis/edema phases, to the grotesque gangrenous stage connected with extensive soft and hard tissue necrosis, and an elevated mortality level of 90% in individuals not receiving treatment.^[7] Cancrum oris is a non-recurrent oro-facial necrotizing infection and is non-communicable, affecting mainly malnourished, debilitated children in remote rural areas and poverty-stricken communities in sub-Saharan African and Asian countries. It may also affect Human Immunodeficiency Virus (HIV) seropositive immunosuppressed individuals and occasionally HIV seronegative, impoverished, malnourished individuals of any age, anywhere globally. ^[8]

In addition, according to the WHO, cancrum oris comprises five sequential “phases/stages:” (1) necrotizing gingivitis, (2) edema, (3) gangrene; (4) scarring; and (5) sequelae. This WHO staging of cancrum oris is contentious, resulting in diagnostic confusion and misjudgment of the number of cancrum oris cases stated in epidemiological studies. We, therefore, suggest an easier, more practical, and scientifically valid two-stage classification comprising only (1) acute cancrum oris and (2) arrested cancrum oris.^[9] At the recently concluded Cancrum Oris Research Day, a renewed call for the WHO to identify and include cancrum oris as one of the diseases that have been ignored was accompanied by the identification that research into all elements of cancrum oris has experienced a decline over time or remained completely lacking specifically that addresses the fundamental scientific inquiries of the etiology, pathophysiology, and underlying processes of the disease.^[4]

In addition, two recent Nigerian studies assessed that disease prevalence ranged from seven cases per 1000 children aged between one and 16 years (2003) to 9–6.4/1000 children (2003). A study from 2019 estimated that the period incidence of Noma from 2010 to 2018 was 1.6/10, 0000 of the population at risk in Nigeria.^[10] Hence, the investigator felt that there was a need and desire to carry out a study to assess the knowledge regarding cancrum oris among Nigerian university students: a cross-sectional study. The purpose of this questionnaire-based cross-sectional study was to assess the knowledge of cancrum oris among Nigerian university students and to find a statistically significant association between their levels of knowledge and their selected sociodemographic variables.

MATERIALS AND METHODS

The research design used for the study was a questionnaire-based cross-sectional study design to assess the knowledge of cancrum oris among Nigerian university students and to find a statistically significant association between their level of knowledge and their selected socio-demographic variables. Ethical approval has been obtained from the Department of Nursing Science, College of Health Sciences, Federal University, Birnin Kebbi, Kebbi, Nigeria, Ref. No.: DNS/FUBK/005.

A stratified sampling technique was used to select 56 nursing students at the Federal University Birnin Kebbi, Nigeria. The sample size of this study was 56 respondents who were selected from the target population, which is nursing students at Federal University Birnin Kebbi, Nigeria. 400 and 500 nursing students at Federal University Birnin Kebbi, Nigeria; those who are willing to participate and those who are available during data collection were included in the study. 400 and 500 nursing students who are not studying at Federal University Birnin Kebbi, Nigeria; those who are not willing to participate in the study; and those who are not available during data collection are excluded from this study.

The researcher prepares a questionnaire to collect data from female biochemistry students. The tool used for the research was a self-structured knowledge questionnaire, which was prepared to assess the knowledge of cancrum oris. The tool was formulated based on the clinical experience of the investigator, an extensive library search, a review of literature, and the consultation of experts. The instrument for data collection was a self-structured questionnaire to suit the research objectives. The questionnaire consisted of sections A and B.

Section A consisted of demographic variables of students including six items such as age, gender, marital status, level of study, ethnicity, religion, area of residence, and sources of information regarding cancrum oris. Section B consisted of a self-structured knowledge questionnaire on cancrum oris. There were 20 knowledge questions; each question had multiple choices with four options (a, b, c, and d). Each correct option (answer) was given a score of one mark, while wrong answers and unanswered scored zero. The maximum score was 20. The level of knowledge score was interpreted as good, average, or poor. The data was collected from the respondents using a self-structured questionnaire; the analysis was done using descriptive and inferential statistics with the aid of IBMSPSS version 21.0; frequency and percentage distribution tables analyzed simple criteria. A Chi-square test was used to find out the association between their levels of knowledge of cancrum oris and their selected socio-demographic variable.

RESULTS

It is shown in Table 1 that, ≤ 45% is representing poor, ≥50<75% is representing average, and ≥75% is representing good level of knowledge of cancrum oris. Tables 1, 2, 3 & 4 reveal detailed statistics regarding the variables, frequency and percentage of the subjects in the study.

Associations between sociodemographic variables and the level of knowledge of cancrum oris is shown in Table 4. Regarding age, there is no significant association between age and level of knowledge (Chi-square = 7.17, P = 0.13). Gender is not significantly associated with the level of knowledge (Chi-square = 2.01, P = 0.37), while marital status has a significant association with the level of knowledge (Chi-square = 6.37, P = 0.04). Single individuals exhibit higher knowledge levels compared to married individuals. The level of study does not significantly affect the level of knowledge (Chi-square = 1.78, P = 0.41). Ethnicity as well is not significantly associated with knowledge level (Chi-square = 7.52, P = 0.48). Religion does not significantly impact the level of knowledge (Chi-square = 0.06, P = 0.97), and so does area of residence (Chi-square = 1.27, P = 0.53). Finally, the source of information of cancrum oris does not significantly affect knowledge level (Chi-square = 3.67, P = 0.72).

DISCUSSION

Justin conducted a study on an online cross-sectional study among dental and medical students in Nigeria. Data were collected using a knowledge questionnaire. The findings revealed that 300 respondents completed the study. About 51.3% (154) had less than satisfactory knowledge about Noma. Respondents also had satisfactory knowledge of nutrition and good oral hygiene in Noma prevention (79.7%, 239, 83.3%, 250, respectively).^[10] In another study conducted by Baratti-Mayer et al., on the sociodemographic characteristics of traditional healers and their knowledge of cancrum oris. A descriptive survey was conducted in three regions of Mali. The findings showed that the majority were illiterate (66.3%), which was associated with older age (P < 0.001). Although they treated all types of disease, only 10.5% had some knowledge of Noma, with regional differences (P < 0.001).^[11]

The key findings of this study revealed that the sociodemographic variables showed that the respondents are between 16 and 18 years, 19 and 21 years, 22 and 24 years, and ≥25 years, which accounted for 0 (0.0%), 3 (5.8%), 23 (44.2%), and 26 (50%), respectively. The majority 32 (61.5%) are females, whereas 18 (34.6) are males. A significant portion of 32 (61.5%) of the participants are married, while 18 (34.6%) are not. According to the level of study, 31 (59.6%) are from the 400 level, while 20 (38.5%) are from the 500. 26 (50.0%) of the respondents are Hausa, followed by 11 (21.2%) other minority tribes; 8 (15.4%) are Yoruba; 5 (9.6%) and 2 (3.8%) are Igbos. In terms of religion practice, 41 (78.8%) practice Islam, and 10 (19.2%) practice Christianity. Minority 7 (13.5%) of the respondents are residing in rural areas, while more than two-thirds 43 (82.7%) are from urban areas. Regarding sources of information, 23 (44.2%) had their sources from health workers, 13 (25.0%) from school, 6 (11.5%) from social media, family, and friends. The study results revealed that, out of 52 (100%) of the respondents, 6 (11.5%) had a “Poor” level of knowledge, while the majority, 31 (59.6%), exhibited an “Average” level of knowledge [Figure 1], and only 15 (28.8%) had a “Good” level of knowledge. Therefore, the null hypothesis (H_0:1) was rejected, while the alternate hypothesis (H_1:1) was accepted. This is not in alignment with a study conducted by Mujtaba et al., on Knowledge, Attitude, and Practices of Primary Health Care Workers toward ND in Sokoto. The results revealed that, out of 251 participants, 210 (83.7%) were aware of Noma. The total scores recorded in both the knowledge and attitude/practice domains were 75% and 78%, respectively.^[12]

Close

Figure 1:

Bar Chart showing frequency and percentages of the respondent’s level of knowledge of cancrum oris.

Export to PPT

The result shows that there was a statistically significant association between their level of knowledge of cancrum oris and their selected sociodemographic variables, such as marital status (single), Chi-square = 6.37, P = 0.04. Hence, the null hypothesis (H_0:2) was rejected, while the alternate hypothesis (H_1:2) was accepted. This is in alignment with a study conducted by Baratti-Mayer et al., on the sociodemographic characteristics of traditional healers and their knowledge of Noma. A descriptive survey was conducted in three regions of Mali. The findings showed that, among the 770 traditional healers invited to participate, The majority were illiterate (66.3%), which was associated with older age (P < 0.001). Although they treated all types of disease, only 10.5% had some knowledge of Noma, with regional differences (P < 0.001).^[11]

CONCLUSION

The results revealed that the majority of the respondents had average knowledge, whereas the minority had poor knowledge of cancrum oris. There was a statistically significant association between their level of knowledge of cancrum oris and their selected socio-demographic variables, such as marital status (single). Based on the study findings, the researcher recommends that a similar study be conducted on the knowledge of cancrum oris among nursing students in different settings and use a large sample size for the generalization of the findings.