Comparison of Oral Health Knowledge, Practice and Behaviour among Rural and Urban Population Attending Dental Institution in Bangalore, India: A Cross Sectional Study.

INTRODUCTION

Oral health is an important determinant of general health, which enables an individual to live without active disease or discomfort¹. Despite this, oral health issues in rural and remote areas of the world do not always receive the attention it deserves. Dental caries and periodontal disease are most common oral diseases affecting 50-60%² and 95-100%³ adult populations in India respectively. Nearly 19% of the population aged between 65-74 years is edentulous ⁴. India is the second highest populated country with more than 1030 million population⁵ , out of which approximately 72% live in 6 rural areas and remaining 28% in urban areas⁶ . The dentist to population ratio is 1:10000 in urban areas, whereas 1:150,000 in rural areas⁷ . There are several challenges being faced in delivery of oral health care to the rural population, such as lack of man power and poor accessibility which is compounded by poverty and illiteracy. The policies implemented so far, which concentrate only on growth of economy not on equity and equality, have widened the gap between 'urban and rural' and 'haves and have-nots'. Moreover in India, particularly in Bangalore, there is a great paucity of data pertaining to oral health of rural population which is essential for planning oral health services for the population. Thus in the light of above situation, among rural population it is essential to assess the oral health knowledge, practice and behaviour and hence this study was conducted.

MATERIALS AND METHODS

Sample: A cross-sectional study was conducted between October 2009 to February 2010, for a period of 5 months among the patients attending outpatient department of Rajarajeswari Dental College and Hospital Bangalore, India. This dental hospital acted as a catchment and because of its geographical location it has constant flow of patients from both rural and urban areas of Bangalore. For this crosssectional study design the following considerations were employed for sample size calculation: Based on survey of literature on knowledge on oral health status in community (42%), the sample size was fixed at 1050 (patients aged 18 years and above were included in the study) for 99% confidence interval, 10% margin of error and 20% correction factor for non-response using simple random sampling technique using table of random numbers. Informed consent was obtained in English and Local language Kannada from each patient.

Questionnaire: A self constructed close ended questionnaire was given to all subjects. The data collection tools were pre-tested on 50 patients attending outpatient department of the Rajarajeswari Dental College and Hospital Bangalore, India, to ensure readability and proper administration of the data collection forms. A reliability coefficient was calculated (kappa value:- 0.821, Spilt –half method) and for parental data (=0.7956). Modifications were then made according to the responses before the final questionnaire was administered. Out of 20, 13 items questionnaire was selected for the final study. The first section of the questionnaire included information related to the patient's name, age, gender, family, education and residence. The second section of questionnaire was further categorised to evaluate the knowledge, practice and behaviour related to oral health. Forward and backward translation of the questionnaire has been done in the presence of expert panel members. For patient who was uneducated, an interviewer transferred the answers onto the questionnaire. Later the data was subjected for statistical analysis.

Analysis: Out of 1050 patients, 1000 agreed to participate (95.2% response rate). Those who refused to participate did not differ significantly. Descriptive statistical analysis has been carried out in the present study. Results on continuous measurements are presented on Mean SD (Min-Max) and results on categorical measurements are presented in Number (%). Data entry and data processing was carried out using SPSS V15.0 software. Confidence interval of 95% was applied.

Ethical consideration: This proposed study was reviewed by the Institutional ethical committee and clearance was obtained.

RESULTS

Out of 1000 participants, 72% were males and 28% were females. The age group ranged from 21-30 years was 49.1% (47.2% rural, 50.9% urban). Among the participants, rural residents were 52.3 % and 47.7% from urban area. Seventy five percentages of the participants were having joint family (75.5% rural, 72.6% urban) and 25% (24.5% rural, 27.4% urban) were of nuclear family. The Participants were literate 83.8% (74.8% rural, 91.9% urban) of the participants were literate and 16.2% (25.2% rural, 8.1% urban) of them were illiterate (Table 1).

Brushing

Only 11.6%; 95% CI (9.76-13.73) (10.6% of rural, 12.8% urban, p<0.001) participants were brushing twice daily. The participants unaware about the type of brush used by them, were 30.2%; 95% CI (27.43-33.12) (32.5% rural, 27.6% urban, p<0.001). Toothpaste with toothbrush was used by 68.2%; 95% CI (65.25-71.01) (85.3% rural, 82.4% urban, p<0.001) of them and 25.6%; 95% CI (22.90-28.29) (36.1% rural, 13.8% urban, p<0.001) were using salt with toothbrush. In response to other methods to clean the teeth, 74.6%; 95% CI (71.81-77.20) (79.9% rural, 68.8% urban, p<0.001) were using Neemstick. (Table 3)

Flossing

Only 7%; 95% CI (5.49-8.64) (0.4% rural, 14.3% urban, p<0.001) of the participants were doing flossing. Out of them only 5.3%; 95% CI (4.07-6.87) (0.4% rural, 10.7% urban, p<0.001) were doing once a day (Table 3).

Visiting the dentist

The participants who had visited the dentist were 80.1%; 95% CI (77.51-82.46) (70.2% rural, 91% urban, p<0.001). Out of them 82.8%; 95% CI (63.41-69.26) (83.4% rural, 82.5% urban) had visited dentist due to pain. (Table 3).

Oral health awareness information

As the effective sources to educate the public about oral health, 46.2%; 95% CI (43.13-49.30) (44% rural, 48.6% urban) of the respondents preferred television, 27.2% (16.3% rural, 39.2% urban, p<0.001) dentist, 13.2%; 95% CI (11.24- 15.44) (24.1% rural, 1.2% urban, p<0.001) radio and 1.9% (3.1% rural, 0.6% urban, p=0.005) friends and family. (Table 3)

The opinions of the respondents on how to avoid tooth decay, gum diseases and oral cancer, were not promising. Approximately 30% of the respondents were unaware about the ideal ways to avoid it. (Table 2)

Distribution of patient according to dental care (brushing, flossing, dental check up, residence – Urban / Rural)

Brushing as an only oral health preventive measures was used by 16.8% of urban and 21.4% of rural participants (p=0.063). Only 11.5% of the urban participants were using all the three oral health preventive measure (brushing, flossing, dental check up) where as 1.3% of the rural participants (p<0.001) were doing the same (Table 4).

Distribution of patient according to dental care (brushing, flossing, dental check up, family- Joint/ Nuclear)

The participants who had gone for dental check up and used brushing only as preventive oral health measure, were 71.9%; 95% CI (64.41-74.84) from joint family and 80%; 95% CI (74.50-84.49) from nuclear family (p=0.011). All the three oral health preventive measures (brushing, flossing, dental check up) were used by 6.9% participants of joint family and 4% of nuclear family (p=0.096). (Table 5)

DISCUSSION

The present study was undertaken in order to provide socioepidemiological data on oral health knowledge, practice and behaviour with regard to urban and rural populations and the results would thereby aid in planning and evaluation of oral health programmes. India has adopted the primary health care approach and the data are particularly useful for organisation of essential oral health care, disease prevention and development of health promotion activities at community level. Preventive oral health education is in transition stage in India. Population based oral health promotional programmes yet to be implemented and followed. Hence in this study attempts were made to describe the preventive oral health knowledge, practice and behaviour of the rural and urban population.

This study showed that brushing of teeth by almost the entire population is the most commonly practiced method, yet only a small percentage used floss, and the dentist isvisited primarily for pain relief. A small percentage of subjects brushed their teeth twice a day, and even a smaller percentage performed all three means of prevention to maintain good oral health. Most of them were unaware about the ways to prevent tooth decay, gum diseases and oral cancer. The television and the dentist were the two common sources of information for educating the public. Results show that persons staying in joint family have better preventive oral health behaviour and practice than nuclear family. It was found that rural population is taking minimal preventive oral health measures as compared to urban population.

Hundred percent of both urban and rural population use toothbrush as a cleaning aid in our study in comparison to a study done by Varenne B et al.⁸ in Burkina Faso, Africa, shows 81% urban and 33% rural population use the same. In the present study, only 82.4% urban and 55.3% rural population use the toothpaste, whereas 90% of urban and rural population of China in study done by Lin HC et al.⁹ , use toothpaste. Use of salt as oral self care aid was found among 36.1% of rural population in the present study whereas Arcury TA et al.¹⁰ reported in south central North Carolina that 51% of rural population use same as oral self care aid.

Our study shows that 12.8% urban and 10.6% rural population brush twice daily whereas a study done by Bondarik E, Leous P¹¹ had reported in Belarus that 59.7% urban and 54.8% rural study population were doing the same. It clearly indicates lack of awareness about importance of brushing twice daily among the study population.

In our study it was found that 68.8% urban and 79.9% rural respondents use chewing stick whereas a study done by Masalu JR et al.¹² in Tanzania showed the use of chewing stick among 15.7% urban and 49.6% rural population, which may be due to better accessibility and cost effective method of chewing stick. In the present study 14.3% of urban and 0.4% of rural population use dental floss as other oral hygiene aid whereas Petersen PE¹³ had done a study among 25-44 yearsold Danes population which shows that 21.8% of urban and 14% of rural population uses dental floss as other oral hygiene aid. The low percentage of participants using floss emphasizes the need for educating and motivating the public to use this efficient method for oral health care.

It was reported in our study that 82.5% urban and 83.4% rural population had visited dentist only when experienced toothache whereas Petersen PE et al.¹⁴ found in China that among 35-44 years old , 19% urban and 31% rural population had visited dentist due to the same reason. This is another gap in public education regarding the crucial role of regular dental checkups in prevention and early detection of oral diseases.

Oral health messages had been received by 48.6% urban and 44% rural population from television and 1.2% urban and 24.1% rural population from radio in the present study while Lin HC et al.⁹ in China had reported that percentages of subjects who had received oral health messages from television or radio were 61% and 43% among the urban and rural middle-aged, respectively and the corresponding figures for the urban and rural elderly were 32% and 17% respectively. It shows the need of utilization of mass media to educate and spread the knowledge of proper dental care and the prevention of oral diseases.

Our study shows 11.3% urban and 53% rural population were unaware about the preventive methods to avoid oral cancer while, Pakfetrat A et al.¹⁵ had reported the level of knowledge regarding ways to avoid oral cancer among Iranian population which shows 88% of urban citizens and 100% of rural residents had less knowledge about this.

The present study reported that 16.2% population (8% urban and 25.2% rural) was illiterate and having less preventive oral health knowledge and behaviour whereas a study done by Bhasin V¹⁶ among Bhils, a tribal rural community of Rajasthan, India, where approximately 90% of the population is illiterate, shows very less preventive oral health knowledge and behaviour among them. It was found that the person of joint family has better preventive oral health knowledge and behaviour than person of nuclear family, which is probably due to effect of family members on improvement of person's oral health knowledge and better practice and behaviour.

Challenges to access to dental care to rural population include socioeconomic nature of rural populations (poverty, low educational attainment, , lack of transportation), absence of a coordinated screening and referral network, lack of dentists, absence of dental insurance, reluctance by dentists to participate in managed care programs. This study result recommends that dental health education programmes based on the felt needs of rural population should be carried out. Periodic oral health screening and awareness camps with appropriate referral system should be done. Oral health knowledge through common mass media such as television and radio should be imparted. Improving oral health is contingent on the availability of professionals, especially in underserved areas. Given the decreasing trend in the number of dental care professionals, other health care professionals must be included in the dental team. Another mechanism that may prove effective in improving oral health is dental insurance reforms. Expansion of dental insurance coverage and improvement of access to this service could have a beneficial effect in eliminating the disparity seen in rural areas, provided expansion includes addressing the lack of dental providers.

Various preventive methods like fluoridation or alternative methods to deliver fluoride (toothpastes, mouth rinses, and professionally applied gels) may also improve the oral health status of rural areas.

LIMITATIONS

The results of this study must be considered with the following limitations. This cross-sectional study was conducted among the patients attending only one dental institution in Bangalore, India; hence the results of this study cannot be generalized.

There are possibilities of selection bias and social desirability bias (questionnaire answered in interviewer's presence) in this study. Selection of patients using rigorous criteria would have reduced the selection bias and indirect questioning may reduce social desirability bias. Assessment regarding knowledge of risk factors for oral diseases (like number of sugar exposures) has not been done. The effects of other social determinants like family income, occupation on oral health were not considered in the present study. These limitations may be the important objectives for the further researches to explore the oral health of rural and urban population.

CONCLUSION

This study shows presence of less oral health knowledge and minimal preventive oral health measures taken by the rural population as compared to urban population. This may be due to higher socio-economic status, availability of resources, higher literacy rate and better accessibility of dental services in urban areas as compared to rural area. Hence there is a need to educate, create awareness among rural population regarding proper oral care through relevant public health awareness methods and prevention of oral diseases through the dentists, outreach programmes, various preventive process like use of fluoride. Social determinants of health which act as important barrier to rural oral health should be broken to make a healthy individual and a healthy society.