ADVOCATING THE USE OF COMMUNITY HEALTH WORKERS IN

THE PREVENTION AND EARLY DETECTION OF ORAL CANCER: AN

ASSESSMENT OF THE KNOWLEDGE AND AWARENESS OF A GROUP
OF COMMUNITY HEALTH OFFICERS IN KANO, NIGERIA

JB ADEOYE 1, BO BAMGBOSE2, E A AKAJI3 AND RA ADEBOLA4

1
Department of Preventive Dentistry, Faculty of Dentistry, Bayero University, Kano, Nigeria
2
Department of Oral Diagnostic Sciences, Faculty of Dentistry, Bayero University, Kano, Nigeria
3
Department of Preventive Dentistry, Faculty of Dentistry, University of Nigeria, Enugu, Nigeria
4
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bayero University, Kano, Nigeria

Corresponding Author: Dr. Joshua Biodun Adeoye, Department of Preventive Dentistry, Faculty of
Dentistry, Bayero University, Kano, Faculty of Dentistry Building, Aminu Kano Teaching Hospital, No. 2,
Zaria Road., Kano. E-mail: [email protected] Phone: +2349099980889

ABSTRACT
Introduction: Oral cancer should be a public health priority. It is one of the commonest cancers worldwide,
and its incidence is rising. Early detection and prevention strategies are important, as treatment outcomes
are markedly affected by the stage at presentation. Community Health Workers number more than most
other health cadres in Nigeria, and are close to the populace. They also exist in varying forms in other
countries. The authors advocate their use in oral cancer prevention and early detection strategies worldwide,
and assess the level of awareness and knowledge of a group in Nigeria.
Methods: A cross-sectional study of a population of Community Health Officers (CHOs) in Nigeria was
conducted from September and December 2015 using a structured self-administered questionnaire.
Participants’ knowledge on specific attributes of oral cancer was assessed including knowledge of diagnostic
procedures, signs and symptoms, as well as risk actors. Their awareness about the condition was also
explored.
Results: One hundred and three (103) CHOs aged between 21 to 54 years (mean 30.03 ±7.24)
participated. Overall knowledge scores were adequate in only 28 (27.2%) of the subjects studied. Pointedly,
there was very low appreciation of the influence of dietary variables on the development of oral cancer,
and no continuing education courses on oral cancer available to this cadre of healthcare professionals.
Conclusion: Community Health Officers constitute a valuable manpower source of manpower in Nigeria
and worldwide, and should be utilised in efforts to prevent or detect oral cancer early. There is, however,
an obvious gap in knowledge and a need to aggressively address it in practicing and training CHOs by
utilising continuing education courses in Nigeria.

Keywords:
Oral Cancer, Community Health Workers, Early detection, Prevention, Continuing Education

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INTRODUCTION and oral cancer prevention 14-17. Making information

Oral cancer should be a public health available amongst these staff can help mitigate late
priority. It is common, as cancers of the oral cavity; presentation, especially in Nigeria, where nurses,
the pharynx; and the salivary glands were responsible midwives and even oral health auxiliaries number
for an estimated 694,000 new cases of cancers more than those primary responsible for oral cancer
worldwide in 2015 alone 1, 2. Its incidence increases management (dentists) 20, 21. They are also closer to
yearly 1, 2, and it has severe consequences if left the populace, and are found with more regularly in
untreated3 - including causing more than 145,000 rural or sub-urban areas where greater than 60% of
deaths annually worldwide 4. In Nigeria, oral cancer the populace reside 11, 21. They also have the pre-
constitutes between 2.7% and 3% of all cancers, 1, requisite skill and education to perform oral cancer
5-7
although rates are most likely higher due to under- examinations or share oral cancer knowledge, and
reporting 1, 8. Its indolent course; a poor (almost are probably more likely to be approached for health
non-existent) cancer registry; a low dentist-to- advice in Nigeria, where dentists, and even
population ratio; inadequate hospital services and physicians, are few 21, 22.
records, and too few studies on the subject - with Community health workers are country-
most lacking the size and scope to represent the specific ancillary staff 23, recruited to provide care
general populace - all contribute to under-reporting and health education in Primary Healthcare settings
4, 8
. in Nigeria23. As a result, they are closer to rural
Oral cancer is largely preventable, and when dwellers than most other health cadres. They also
arrested early, possesses minimal sequelae 8, 9. At provide a malleable and ready source of workers
least two thirds of cases appear to be due to lifestyle that can be harnessed to target the health needs of
factors, such as tobacco and alcohol use, that are any particular community21 , as they were
modifiable by effective primary prevention commissioned to mitigate the neglect of primary
programmes 8-10 Visual access to the oral mucosa is healthcare due to shortage of health professionals
also so easy that early detection is theoretically 23
. They number more than most other health
simple. Despite this, the proportion of oral cancer professionals, numbering as many as five per doctor,
cases diagnosed at an early and localised stage is and thirty-five per dentist in Nigeria21. Therefore,
less than 50% in studies worldwide,and probably rural dwellers have a higher chance of accessing a
much less in Nigeria 1,11,12. Instead, patients present community health worker than a primary physician
late, with attendant negative impact on treatment or an oral and maxillofacial surgeon in Nigeria. Thus,
outcomes; and significant functional impairment in they can play important roles in the early identification
speech, mastication, swallowing, dental health, and and prompt referral of oral cancer cases in rural
even the ability to interact socially 5, 8, 13-17. environs.
The costs of late presentation in functional, The authors are unaware of any efforts to
aesthetic and psychological terms can lead to a use this cadre of health staff to tackle prevention or
significant reduction of patient’s quality of life, as well early detection of oral cancer nationwide since their
as to high social costs (roughly estimated to be as cadre was instituted in 197824. There is also a
high as 4 billion US dollars worldwide annually) with growing body of literature investigating oral cancer
average patient expense of as high as 15,000 USD issues among health care professionals, including
in some countries 4, 18, 19. Worldwide, it is now Primary Care Physicians 25, 26, Nurse practitioners
accepted that prevention and early detection can help 27
,and Dentists 28-31. None have investigated
prevent the incidence of these costs on patients, their Community Health Workers, probably because oral
relatives, and a country’s economy. cancer is not thought of as their responsibility. This
Previous studies highlight the important roles study therefore, sought to assess their awareness
of auxiliary healthcare professionals in early detection and knowledge of the subject matter to determine

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how this gap can be bridged. These findings can previously been Community Health Extension
serve as baseline for their mobilisation for oral cancer Workers (CHEWs) or Allied Health Staff for periods
screening or prevention efforts in Nigeria and more than five years and had experience with the
worldwide. The study also further the use of a Nigerian Primary Healthcare system. The hospital
knowledge assessment tool, piloted in earlier, similar Ethics committee gave ethical approval and all
studies by the authors11,22. participants gave verbal consent in accordance with
principles outlined in the Declaration of Helsinki.
The sample size was determined using
METHODS statistical methods. Study subjects were recruited,
Study Population informed via the data instrument of the purpose of
The study was a cross-sectional analysis of the study, and informed that results would be
a population of Community Health Workers at a published. There was no identifying information
training at the Kumbotso outpost of the Aminu Kano elicited by the instrument. It obtained information
Teaching Hospital (AKTH), Kano, Nigeria between on socio-demographic characteristics of the subjects

Figure 1: SS – Signs and Symptoms of Oral Cancer; RF – Risk Factors for Oral Cancer; DP – Diagnostic
Procedures for Oral Cancer

September and December, 2015. Kumbotso, a rural and oral cancer awareness. It also obtained
locale about 20 Kilometers from Kano metropolis, information about knowledge of signs and
houses a comprehensive Primary Healthcare Center symptoms, risk factors and diagnostic procedures
(PHC), run as an outpost of the community health of oral cancer using questions adapted from previous
department of the teaching hospital. CHOs undergo oral cancer studies, and piloted in similar studies by
field training in this facility. All participants had
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the authors 11, 22, 27, 28. The knowledge scores of each Current Knowledge of Signs and Symptoms
individual section were organized into scales. (SS)
‘Knowledge about signs and symptoms’ Respondents were asked to identify correct signs
(SS) and “Knowledge about diagnostic procedures” or symptoms of oral cancer using ‘yes’ and ‘no’
(DP) scales had a total obtainable score of 8. Those responses. Table 2 summarizes our findings.
with “adequate” knowledge had more than 50% Most participants identified the signs and
correct responses. “Knowledge about risk factors” symptoms incorrectly in six of the eight questions.
scale had a total obtainable score of 14, and was The two questions with the best responses were “A
classified into ‘Low’ (0-6), ‘Medium’ (7-10) and sore in the mouth that does not heal” – 54.4% and
‘High’ (11-14). An “overall knowledge of oral “A lump or thickening in the cheek that can be felt
cancer’ measure combined these three scales as with the tongue” – 56.3%.
shown in Figure 1: If a respondent had adequate On the Knowledge of SS scale, 84 (81.6%)
knowledge on the SS and DP scales, and high scores had inadequate knowledge (Knowledge of 50% or
on the RF scale, he/she had overall adequate less). The average score was 3.8, standard deviation
knowledge of oral cancer. If a respondent had 0.8, with range of 2 to 6 (Total score 8). Modal
adequate knowledge on the SS and DP scales, and score received on the scale was 2, by 32
moderate scores on the RF scale, he/she had overall respondents.
adequate knowledge of oral cancer. And so on.
Statistical analyses were performed Current Knowledge of Risk Factors (RF)
usingMicrosoft Excel for Mac and SPSS for Mac Valid risk factors are supported by evidence
(version 18.0 SPSS Inc., Chicago, IL). Univariate to increase the predisposition of an individual to oral
analyses for demographic variables and knowledge cancer. Non-valid risk factors may have been
of oral cancer were processed as simple proposed as risk factors, but are not backed by
percentages and frequencies. A two-sided evidence. Table 2 shows non-valid risk factors
significance of 5% was applied. grouped below valid risk factors and written in italics.
“Alcohol use” was the most correctly identified valid
risk factor [100% of respondents] and “Low
RESULTS consumption of fruits and vegetables” [16
Characteristics of the Study Group respondents (15.5%)] was the least commonly
One hundred and three (103) Community Health identified. As many as 93 subjects (90.3%) knew
Officers with previous primary health experience in that “consumption of spicy foods” did not increase
the Northern region of the country were studied. the risk of developing oral cancer, while only 3
Ages ranged between 21 to 54 years (Mean: 30.03 subjects (2.9%) correctly identified viral infections
± 7.24 years). Most (96.1%) had served as CHEWs as non-valid risk factors.
for 5 years or more, and 57 of the 99 CHEWs 42 respondents (40.8%) had moderate
(55.3% of all respondents) had previously practiced knowledge on the ‘Knowledge of RF scale’. 59
in Primary health care centers. Table 1 reflects these (57.3%) had poor knowledge scores, and only 2
and other details. 78.6% of all respondents had heard respondents had high knowledge scores. The
of oral cancer, and a similar proportion (74.8%) had average was 5, standard deviation 1.0, with a range
personally encountered oral cancer patients in of 1 to 10 (Total score 14). The modal score
practice. None had ever had a continuing education received was also 5 with 42 subjects receiving this
course on oral cancer while practicing as CHEWs score.
or Nurses however (Table 1).

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Table 1: Demographic characteristics of the participants

Variable Number % Mean ± SD
Gender
Male 44 42.7
Female 59 57.3
Age (in years) Range: 21- 54 30.03 ± 7.24
20 – 29 45 43.6
30 – 39 46 44.7
> 40 12 11.7
Previous Profession
CHEWs 99 96.1
Nurses 4 3.9
Others 0 0.0
CHEW Practice Type
PHC 57 55.3
Secondary 41 39.8
Tertiary inst. 1 1.0

Nurses Practice Type

PHC 0 0.0
Secondary 3 2.9
Tertiary inst. 1 1.0
Years in Public Health Practice 13.41 ± 5.33
Range: 0 - 35 yrs
0 – 4 years 4 3.9
5 – 10 years 38 36.9
10 - 20 years 49 47.6
> 20 years 12 11.6
Location of Previous Practice
North-Eastern Nigeria 5 55.3
North-Western Nigeria 45 43.7
North-Central Nigeria 1 1.0
Other Nigerian regions 0 0.0
Ever heard of Oral Cancer (OC)?
Yes 81 78.6
No 20 19.4
Ever Encountered an OC Patient?
Yes 77 74.8
No 26 15.2
Any Continuing Education Courses in OC?
Yes 0 0
No 103 100

Current Knowledge of Diagnostic Procedures On the ‘Knowledge of DP scale’, 59

(DP) (57.3%) of the respondents had adequate
The eight diagnostic procedures outlined in Table 2 knowledge (Knowledge of more than 50%). The
were asked in a ‘Yes’ and ‘No’ format, and average was 3.6, standard deviation 1.6, with a
constitutes the third part of the knowledge tool.
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Table 2: Respondents with correct answers on knowledge about oral cancer

Correctly indicated
N %
Signs and Symptoms
A sore in the mouth that bleeds easily and does not heal 56 54.4
A white or red patch on the gums, tongue or lining of the mouth 45 43.6
A lump or thickening in the cheek that can be felt with the tongue 58 56.3
Numbness of the tongue or other area of the mouth 26 25.2
Soreness or a feeling that something is caught in the throat 27 26.2
Difficulty chewing or swallowing 47 45.6

Risk factors (Non-valid in italics)

Tobacco Use 101 98.1
Use of alcohol 103 100.0
Older age 22 21.4
Prior oral lesions 41 39.8
Exposure to sunlight 19 18.4
Low consumption of fruits and vegetables 16 15.5
Occupational hazard 57 55.3

Spicy foods 93 90.3

Family history of cancer 11 10.7
Viral infection 3 2.9
Poor oral hygiene 61 59.2
Hot beverages and foods 43 41.7
Obesity 29 28.2
Poorly fitting dentures 36 35.0

Diagnostic procedures
Patient sticks out tongue; posterior dorsum of tongue examined; pull 92 89.3
tongue out; examine both sides; inspect underneath of tongue
Patient is asymptomatic in early oral cancer (OC) 9 8.7
Squamous cell most common type of OC 40 38.8
Ventral lateral border of tongue most likely site for OC 29 28.2
A white or red patch on the gums, tongue or lining of the mouth 44 42.7
When palpated a hard, painless, mobile or fixed lymph node is characteristic 84 81.6
Tongue & floor of the mouth most common site of OC 18 17.5
OC lesions most often diagnosed in advanced stages 88 85.4

range of 0 to 6 (Total score 8). The modal score respondents possessed “adequate” knowledge
received was 4 with 31 respondents receiving this scores.
score. The results, respondent opinions about oral
cancer, and the relationships between other factors
Overall Knowledge Scores and other Variables and these overall knowledge scores are as shown in
Overall Knowledge about Oral Cancer as Tables 3–5.
estimated revealed that only 28 (27.2%) of the

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Table 3: Respondents desire for continuing

education courses Table 4: Overall knowledge scores
Characteristic Frequency Percentage
(n= 103) (%) Characteristic Frequency Percentage
Do you feel you have (n= 103) (%)
sufficient knowledge
Adequate 28 27.2
Yes 27 26.2
No 76 73.8 Inadequate 75 72.8
More information
Yes 103 100.0
No 0 0
Which format
Information pack 10 9.7
Lectures 77 74.7
Seminars 15 14.6
Others 1 1

Table 5: Overall knowledge scores vs. respondent characteristics and opinions

Characteristic Total Adequate Inadequate Significance

Age group (years)
20 – 29 45 9 36 Not significant
30 – 39 46 17 29 c2 = 1.489; P > 0.05
40 or more 12 2 10 (0.2224)

Years in Public Health

Practice
0 – 10 years 42 8 34 Significant
10 – 20 years 49 18 31 c2 = 19.43; P < 0.0001
Greater than 20 years 12 2 10

Do you think you have

sufficient knowledge about
oral cancer?
Yes 27 21 7 Significant
No 76 7 69 c2 = 41.732; P < 0.0001

including prevention and treatment of communicable

diseases, antenatal care, child health services and
DISCUSSION health promotion. JCHEWs train for 2 years on the
Community health workers are grouped into same skills as CHEWs, however, their admission
Community Health Officers (CHOs), Community requirements and scope of training are lower and
Health Extension Workers (CHEWs) and Junior more limited, and so, they only assist CHEWs in
Community Health Extension Workers (JCHEWs) their duties 23. Both these categories are to be found
23
. CHEWs train for 3 years to provide basic public at various health posts in local government wards
health services in PHC clinics and communities, around the country.

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USE OF CHO IN THE PREVENTION AND EARLY DETECTION OF ORAL CANCER JB Adeoye, et al

CHOs are the senior-most community Even though oral cancer is one of the most
officers, and are stationed at local government debilitating and disfiguring of all cancers, it has known
districts and headquarters to provide health and risk factors, an asymptomatic phase with identifiable
medical care32. They have a foundational role in the clinical features, an available and efficient screening
public health system in Nigeria and enforce applicable modality, and effective non-deforming treatment for
laws and administrative rules enacted by the early lesions25, 35. The most effective mitigation against
community32. They do more than CHEWs in scope the morbidity and mortality of oral cancer is
and depth, and usually run or man comprehensive therefore, the prevention of new cases by changing
PHC centers where there is a higher volume of behaviour or lifestyles known to be associated with
patients and variety of diseases. They also supervise oral cancer. If it has already occurred however, early
the actions of CHEWs and JCHEWs and provide detection is a powerful tool. It improves the ease
more specialized primary health care23. CHEWs that and outcome of intervention and Quality of life
have practiced for the appropriate number of years thereafter, and is achieved easily by visual and tactile
or more enroll for a 2-year training to become examination of the oral cavity and the head and neck
CHOs, as can retired allied health personnel 8-10, 12-14, 19
. This comprehensive oral cancer
interested in Primary Health Care23. In this study, examination is recommended every 3 years for those
most participants had previous experience as 20–39 years of age, and annually for individuals 40
CHEWs in PHCs in rural areas (Table 1), and were years and over, to reduce the morbidity and mortality
finishing the training to become CHOs. rate 17, 36, 37. These examinations can be carried out
The authors opted to study CHOs or those by just about anybody trained in healthcare provision
months away from that level, as they would be 11, 26, 38
and not just clinicians or specialist dentists.
responsible for most decision-making in rural areas, Community Health workers can play this role.
and the amount of knowledge and awareness about The oral health manpower profile of Nigeria
oral cancer available would impact their behaviou definitely supports their use. In a comprehensive
rs towards the condition in the field. Having trained manpower assessment in 2005, there were 17,800
and worked as CHEWs, and then trained to be medical doctors in Nigeria, of whom 2,500 were
CHOs, it was expected that subjects would dentists 21. In comparison, there existed 86,600
demonstrate high levels of knowledge or awareness. community-level staff 21, and majority were in
This was not so (Table 5). This trend corroborated primary care facilities situated in rural areas, equating
a suggestion in earlier studies, that knowledge about five community officers for every doctor, and thirty-
oral cancer reduced as the years of practice of the five for every dentist. The distribution of health
professional in question increased28. It would be manpower in Nigeria is such that compared to a
interesting to study those just finishing training to be rural resident, urban residents have access to three
JCHEWs and CHEWs to see if that trend is times as many doctors, nurses and midwives put
corroborated. together. Rural dwellers have greater access to
Many countries have employed Community community level staff however, as they are primarily
healthcare workers to great effect 33, 34. In Nigeria, located in rural areas 21 . While no similar
other medical specialties such as Obstetrics & comprehensive manpower assessments have been
Gynecology and Ophthalmology have employed the repeated recently, but not much in articulate
availability and versatility of these officers to varying development has occurred in healthcare provision
success also, and international organisations have country-wide. Instead, the number of health staff
utilised their reach in vaccination and other projects available has reduced with the increase in medical
23
. Such can be replicated in Dentistry to tackle tourism.
priority oral diseases, including oral cancer. Some form of training is necessary for oral
cancer screening examinations to be effectively and

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USE OF CHO IN THE PREVENTION AND EARLY DETECTION OF ORAL CANCER JB Adeoye, et al

efficiently performed, as early detection depends on found a link between Iron deficiency anemia
the recognition of patients at risk based on socio- (Plummer- Vinson syndrome) and pharyngeal cancer
demographic and lifestyle factors and identification in women39. People whose diets are deficient in fruits
of particular signs and symptoms. It also needs a and vegetables have been found to be at a higher
high index of suspicion when cancerous or risk of developing oral cancer and,in a study in South-
precancerous lesions are encountered. This index is west Nigeria, it was discovered that infrequent
best raised by directed and targeted information or consumption of fruits and vegetables was associated
experiences. A cursory review of the CHO with an increased risk of developing oral cancer (OR
curriculum by the authors revealed that information 3.0 and 1.32)1, 38.Other studies from India and Brazil
about Oral cancer was absent, indicating the need prove that regular consumption of fruits and
for directed training. The absence of the subject vegetables are protective against oral cancer40. It is
matter in the curriculum makes the rather poor therefore, an important finding in this study that most
knowledge demonstrated by the participants of the subjects were oblivious of the protective ability
unsurprising (Tables 2 and 4). of the most potentially modifiable of risk factors [only
This training should take the form of 16 participants (15.5%) correctly identified ‘Low
continuing education courses during their practice. consumption of fruits and vegetables’ as a risk
Currently, however, no continuing education courses factor] in a rather agrarian country like Nigeria where
exist for this cadre in Nigeria, especially as regards fruits and vegetables are quite available and
oral cancer (Table 1). The authors therefore propose affordable.
the formal use of this cadre for prevention and early Most other similar studies did not highlight
detection of oral cancer, with continuing education knowledge of signs and symptoms of oral cancer in
courses provided that are focused on prevention and their study protocol 15, 28, 41. We however, consider
early detection of oral cancer. The authors intend to this knowledge important as the signs and symptoms
take up this task. of a disease influences health-seeking behaviour in
Earlier mention has been made of the society42. Knowledge about possible signs and
distinction between valid and non-valid risk factors, symptoms can bring oral cancer into the differentials
and multiple textbooks and literature contribute to of any oral disease. Therefore, the authors included
confusion about the subject 4, 11, 28. It is important a ‘Knowledge of signs and symptoms’ scale in the
that the correct information be made available to knowledge tool used, combined with the other scales
the populace, and the healthcare workers serving as described. In the study, Knowledge about this
them. In the North of the country where most of the attribute was quite poor.
study subjects practiced (Table 1), and even most When given the opportunity to rank their
parts of Nigeria, a lot of patients visit traditional perceived knowledge of oral cancer, 85.5%
healers when they have health problems, citing the indicated they had insufficient knowledge on oral
scarcity of orthodox healthcare professionals11. cancer and desired further instructions on the subject.
Wrong information from health professionals can It is interesting that 21 of the 27 who felt they had
help exacerbate detrimental culturally- and sufficient knowledge about oral cancer actually had
traditionally-held beliefs. Worryingly, the CHOs were adequate overall knowledge about the subject. This
in the final phases of their training, and had had no indicates an ability to self evaluate correctly
didactic exposure supplying the right information. demonstrated by both those with and without overall
In inquiring about risk factors, dietary adequate knowledge. This ability is rare, and is at
variables were included to investigate knowledge of variance with reports in other studies involving
current trends on the subject. One of the earliest professional subgroups, including dentists 25, 28, 30.
suggestions that nutrition may play a role in etiology Despite this ability however, there is an
of oral cancer comes from studies in Sweden that obvious gap in knowledge highlighted by the
individual and overall knowledge scales used, and
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USE OF CHO IN THE PREVENTION AND EARLY DETECTION OF ORAL CANCER JB Adeoye, et al

patient_education/oralcavity/. (Last
similar to the generally low to moderate knowledge
accessed 9th February 2017).
encountered in studies of most other allied health
4. Torre LA, Bray F, Siegel RL, et al. Global
staff studied 16, 27, 38. There is therefore, a need to
Cancer Statistics, 2012. CA Cancer J. Clin.
aggressively expose practicing and intending
2015; 65:87–108.
community health officers to knowledge that will
5. Adekeye EO, Asamoa E, Cohen B. Intra-
improve their understanding of oral cancer.
oral carcinoma in Nigeria: a review of 137
cases. Annals of Royal College of Surgery
of England 1985; 76: 180-182.
CONCLUSION
6. Otoh EC, Johnson NW, Mandong BM, et
Community health workers constitute a valuable
al. Pattern of oral cancers in the North
source of manpower all over the world and in
central zone of Nigeria. African Journal of
Nigeria, and should be utilized in efforts to prevent
Oral Health 2004; 1:47-53.
oral cancer in populations at risk, or in early detection
7. Oji C, Chukwuneke F. Oral cancer in
of the disease. In Nigeria, there is an obvious gap in
Enugu, Nigeria, 1998-2003. British Journal
knowledge and awareness of oral cancer amongst
of Oral. Maxillofacial Surgery. 2007; 45:
CHOs who are the senior-most community health
298-301.
workers in the country. There is therefore, a need to
8. Ezzati M, Lopez AD, Rodgers A, et al.
aggressively address this gap in practicing and
Comparative quantification of health risks:
training CHOs.
Global and regional burden of disease
attributable to selected major risk factors.
Comflict of Interests
Vol.1. Geneva: WHO; 2004.
The authors report no conflict of interests in the
9. Room R, Babor T, Rehm J. Alcohol and
execution and publication of this study.
Public Health. Lancet 2005; 365: 519–530.
10. Vora AR, Yeoman CM, Hayter JP. Alcohol,
Tobacco and Paan use and understanding
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