Quasi Experimental Non Randomized Study on Effectiveness of Instructional Strategy on Knowledge, Practice and Quality of Life of Head and Neck Cancer Patients Receiving Radiotherapy in Selected Cancer Research Institute, Uttarakhand

The cancer is a disease of cell in which the normal mechanism of the control of growth and proliferation has been altered. Annually, nearly 3 million people die of cancer in India. The Indian Council of Medical Research said in 2016 the total number of new cancer cases is expected to be around 1.45 million and the figure is likely to reach nearly 1.73 million new cases in 2020. Over 0.736 million people are expected to succumb to the disease in 2016 while the figure is estimated to shoot up to 0.88 million by 2020. Data also revealed that only 12.5 percent of patients come for treatment in early stages of the disease. Purpose: The Purpose was to educate the patients with Head and Neck Cancer undergoing radiation therapy about management of side effects to improve their quality of life. Method: A Quantitative research approach with Quasi-experimental pre-test post-test design. The study was conducted in selected Cancer Research Institute, Dehradun, Uttarakhand. Consecutive sampling technique was used for data collection from 60 Head and neck cancer patients by using Structured Knowledge interview schedule, structured self-reported practice checklist and EORTCH & N35 QLQ. Result: The mean post-test knowledge score in experimental group was 18.70 ± 3.06 which was significantly higher than the control group 11.50 ± 5.00. The mean post-test practice score in experimental group was 16.40 ± 1.86 which was significantly higher than the control group 10.00 ± 3.01. There was significant improvement in the Quality of Life of the patients in experimental group in different phases of radiation therapy. In multiple item scalesPain (0.014 on 8th day and <0.001 on 16th day), swallowing (<0.001 on 16th day), sense problems (0.019 on 8th day and 0.020 on 16th day), speech problem (0.058 on 8th day and 0.041 on 16th day), social contact (0.005). In single item scale teeth (0.019 on 8th day), opening mouth (<0.001 on 16th day), dry mouth (<0.001 on 16th day), sticky saliva (0.040 on 8th day and <0.001 on 16th day), felt ill (0.017 on 16th day). Moderately positive correlation was found between post-test knowledge & practice score. Conclusion: The instructional strategy was effective in increasing knowledge, practice of Head and Neck cancer patients and also improving their Quality of life. used to kill cancer cells. Radiation therapy where waves of energy are sent to kill cancer cells in and around the tumor. High-energy radiation is delivered to cancer cells or a tumor. Radiation therapy works in two ways • Radiation can stop or slow the growth of the cancer. • Radiation can shrink tumors, reduce some symptoms, and relieve pain [1] J o u r n a l o f N uc lea r M edicine & Riatio n T h e r a p y ISSN: 2155-9619 Journal of Nuclear Medicine & Radiation Therapy Citation: Nigam K, Prakash K (2016) Quasi Experimental Non Randomized Study on Effectiveness of Instructional Strategy on Knowledge, Practice and Quality of Life of Head and Neck Cancer Patients Receiving Radiotherapy in Selected Cancer Research Institute, Uttarakhand. J Nucl Med Radiat Ther 7: 313. doi: 10.4172/2155-9619.1000313


Introduction
Cancer is one of the leading causes of adult deaths worldwide. In India International Agency for Research on cancer estimated that average life expectancy of Indian population will increase to 70 Years by 2021 to 2025. In India more than 75% cases reported cases of oral cancers are associated with smoke and tobacco consumption. According to the National Cancer Institute, head and neck cancer accounts for nearly 3 percent to 5 percent of all cancer in the United States. These types of cancer are more common in men and in people older than age 50. Around 47, 560 men and women in this country develop head and neck cancer every year [1].
Cancers that are known collectively as head and neck cancers usually begin in the squamous cells that line the moist, mucosal surfaces inside the head and neck. Cancers of the head and neck are further categorized by the area of the head or neck in which they begin. Oral cavity, Pharynx, (nasopharynx, oropharynx) Larynx, Paranasal, sinuses and nasal cavity, Salivary glands [2]. The three main types of treatment for managing head and neck cancer are radiation therapy, surgery and chemotherapy [3]. Surgery where a part or all of the tumor or cancer cells are removed. Chemotherapy where certain drugs are used to kill cancer cells. Radiation therapy where waves of energy are sent to kill cancer cells in and around the tumor. High-energy radiation is delivered to cancer cells or a tumor.

Radiation therapy works in two ways
• Radiation can stop or slow the growth of the cancer.
• Radiation can shrink tumors, reduce some symptoms, and relieve pain [1]  Nurses in radiation therapy departments apply evidence-based practice when pro viding patient and family education and managing side effects [4,5]. Dry mouth (xerostomia) is a common and significant consequence of head and neck radiotherapy. Because of the loss of saliva, patients with xerostomia are more susceptible to periodontal disease, rampant caries, and oral fungal and bacterial infections [6].
Mucositis, characterized by inflammation and ulceration of the oral mucosa, is the most significant acute side effect reported by patients and is a potential source of life-threatening infection. Almost all patients undergoing head and neck radiation therapy experience confluent mucositis by approximately the third week of treatment [7,8] (Figure 1).
Modern equipment and sophisticated treatment planning techniques produce a "skin-sparing" effect, with the therapeutic dose delivered to the target organ, minimizing the dose to the skin. Still, approximately 95% of patients receiving radiation therapy may experience some degree of skin reaction, ranging from mild erythema to more serious and uncomfortable moist desquamation [9]. Severe moist desquamation results in pain and discomfort, and may require a break in treatment, pos sibly compromising the effectiveness of treatment [10]. Treatment-related factors, such as type of energy (e.g., photon versus electron), daily dose, size of the treatment field, and use of bolus material (the purpose of which is to increase the dose to the skin surface) affect the degree of skin reaction. Individual patient characteristics also play a role in the development of skin reactions [11] ( Figure 2). QOL is defined by the World Health Organization's Quality of Life Group (WHOQOL, 1993) as follows: "Quality of life is an individual's perception of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectations, standards and concern. It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, level of independency, social relationship and their relationship to salient features of their environment" [12].

Objective
• To determine the effectiveness of instructional strategy on the knowledge of head and neck cancer patients receiving radiation therapy.
• To determine the effectiveness of instructional strategy on the practice of head and neck cancer patients receiving radiation therapy.
• To determine the effectiveness of instructional strategy in term of quality of life of cancer patients before and after intervention.
• To find correlation between post-test knowledge score and posttest practice score.

Hypothesis
All the hypotheses will be tested at p<0.05 significance level. H 1 -The mean post-test knowledge score of head and neck cancer patients in experimental group will be significantly higher than the mean post-test knowledge score of patients in control group.
H 2 -The mean post-test practice score of head and neck cancer patients in experimental group will be significantly higher than the mean post-test practice score of patients in control group.
H 3 -There will be significant improvement in quality of life of head and neck cancer patients in experimental group than those in control group. H 4 -There will be significant correlation between post-test knowledge score and post-test practice score.

Research design
Quasi-experimental design with experiment and control group pre-test post-test design.

Setting of the study
Selected Cancer Research Institute in Dehradun, India.

Sample and sample size
Head and Neck Cancer Patients undergoing radiation therapy. Sixty Head and Neck Cancer Patients were taken in study thirty in experimental and thirty in control group.

Sampling technique
Total Enumeration sampling technique.

Inclusion criteria
The study included the patients of head and neck cancers who were: • Undergoing radiation therapy at CRI, HIHT.
• Patient who could follow instructions in Hindi/ English language.
• Willing to participate in study.
• Undergone surgery prior to radiation therapy.
In stages of cancer in this majority (61.7%) were diagnosed in 2 nd stage and (8.3%) were having 4 th stage head and neck cancer (Figures 3  and 4, Tables 1 and 2).
The mean pre-test knowledge of experimental group was 10.50 ± 4.747 which has increased to post-test knowledge score 18.70 ± 3.064. Whereas the mean pre-test knowledge of control group was 12.23 ± 4.86 and post-test was 11.50 ± 5.002. The calculated 't' value was 6.723 which is more than the table value of 2.0 (df=59 at p=0.05 level) ( Table 3).
The mean pre-test practice score of experimental group was 12.50 ± 3.560 which has increased to 16.40 ± 1.868. Whereas the mean pretest practice score of control group was 10.33 ± 3.198 and post-test was 10.00 ± 3.017. The calculated 't' value was 9.878 which is more than the table value of 2.0 (df=59 at p=0.05 level) (

Exclusion criteria
The study excluded the patients of head and neck cancers who were: 1. Getting Chemotherapy along with radiation.

Intervention
The intervention selected was instructional module carried out for the minimal duration of one hour per day, for a period of one week. Pretest was conducted on the first day of the intervention. Following that, eight and sixteenth day of the intervention the Quality of Life increased progressively in control group and decreased in experimental group were performed in the formative manner. The sessions came to an end with the evaluative phase of taking a Posttest. Regarding trouble with social contact among experimental group there was no gradual changes and in control group there was no gradual change in control group. The difference between both the groups was significant on 16 th day (Z=2.808, p=0.005).
Therefore it could be inferred that instructional strategy was effective in improving the quality of life of patients in experimental group as compared to control group (Table 5).
It shows comparison of symptoms and side effect of radiation therapy. Regarding teeth among experimental group there was gradual increased in 1 st day to 8 th day and decreased from 8 st day to 16 th day to 16 th day with mean 20.00 ± 29.81, 25.55 ± 25.79, 23.33 ± 29.23 and within the group p value was 0.530 as compared to control group there was gradual increase 20.00 ± 22.48, 11.11 ± 15.98, 15.55 ± 22.71 and within the group the p value was 0.230. The difference between both the groups was significant on 8th day (Z=2.337, p=0.019).
Regarding opening mouth among the experimental group there was slight reduction in opening mouth difficulty from 1st day to 8th day to 16th day with mean 41.11 ± 32.38, 38.88 ± 29.14, 33.33 ± 21.44 and within the group the p value was 0.786 as compared to control group there was increased in the opening mouth problem 37.77 ± 31.23, 46.66 ± 29.81, 56.66 ± 26.47 within the group p value was 0.038. The difference between both the groups was significant on 16th day (Z=3.915, p ≤ 0.001).
Regarding dry mouth among experimental group there was slight increase in the mean from 1 st day to 8 th day and gradual decreased from 8 th to 16 th day with mean 46.66 ± 36.72, 51.11 ± 28.67, 41.11 ± 24.26 and within the group p value was 0.268 as compared to control group there was increase 36.66 ± 29.49, 57.77 ± 19.44, 93.33 ± 22.14 within the group p value was <0.001. The difference between both the groups was significant on 16 th day (Z=5.865, p ≤ 0.001).
Regarding sticky saliva among experimental group there was slight increase in the mean from 1 st day to 8 th day and gradual decreased from 8 th to 16 th day with mean 43.33 ± 39.29, 46.6 ± 34.57, 35.55 ± 24.65 and within the group p value was 0.357 as compared to control group there was increase 41.11 ± 32.38, 63.33 ± 25.29, 60.00 ± 25.37 and within the group p value was 0.003. The difference between both the groups was significant on 8 th (Z=2.056, p=0.040) and 16 th day (Z=4.030, p ≤ 0.001).
Regarding felt ill among experimental group there was slight decreased in the mean from 1 st day to 8 th day and gradual increased from 8 th to 16 th day with mean 33.33 ± 35.01, 23.33 ± 24.99, 33.33 ± 19.57 and within the group p value was 0.154 as compared to control group there was no gradual changes 30.00 ± 29.49, 23.33 ± 27.88, 22.22 ± 22.02 and within the group p value was 0.480. The difference between both the groups was significant on 16 th day (Z=2.376, p=0.017). Therefore it could be inferred that instructional strategy was effective in improving the quality of life of patients in experimental group as compared to control group (Figures 4 and 5    The above figure shows that there was moderately positive correlation between post-test knowledge and practice score of Karl Pearson r=0.438, p ≤ 0.001 at 5% level of significance. P ≤ 0.001 statistically significant it shows when knowledge increases than the practice also increases.   in improving the Quality of life of Head and Neck Cancer patients. These results are in tune with an earlier study, which found that teaching practice produced marked improvement in a Quality of life of Head and Neck Cancer patients.

Discussion
Stephen et al. [12] conducted a study to determine advances in modern radiotherapy (RT), many patients with head and neck cancer (HNC) can be effectively cured, and their health-related quality of life (HR-QoL) has become an important issue. A cross-sectional investigation was conducted to assess the HR-QoL of 640 HNC patients with cancer free survival of more than 2 years. Among them 371 patients were treated by two-dimensional RT (2DRT), 127 by three-dimensional conformal RT (3DCRT), and 142 by intensity-modulated RT (IMRT). A general linear model multivariate analysis of variance was used to analyze the prognosticators of HR-QoL. By multivariate analysis, significant difference (p<0.05) of HR-QoL outcome by different RT techniques was observed at 2 of the 15 scales in QLQ-C30 and 10 of the 13 scales in H&N35.

Conclusion
Based on finding of the study, it is concluded that the instructional module on management of side effects of radiation therapy was significantly effective in improving quality of life of head and neck cancer patients undergoing radiation therapy.

Recommendations
• A similar study can be conducted on cancer patients undergoing radiation therapy with large sample size.
• A survey can conducted among cancer patients to identify problems experienced by patients while undergoing different treatment modalities for cancer.
• Study can be done to identify the factors affecting the side effect of radiation therapy.
• A prospective community based study can be conducted on the incidence and prevalence of cancer.
• Similar study can be conducted on another type of cancer patient.