A Cross-sectional Assessment of Knowledge, Attitude, and Practices toward Oral Hygiene among Schoolchildren in Jimma, Ethiopia

DISCUSSION

Dental caries along with periodontal disease are perceived as major contributors to the global burden of oral health. Although it is more prevalent in the industrialized world, it also has affected the population in Asian and Latin American countries. Although Africa is less affected, it is anticipated that there will be a spur as the level of sugar consumption increases and the use of fluorides decreases.¹⁵,¹⁶

Though environmental factors have a major impact on oral health and diseases, it is noted in the recent epidemiological surveys that sociobehavioral factors also contribute apart from factors like poverty, dietary habits, and poor nutrition.⁶ Children, especially in the developing world, are at a disadvantage due to inadequate resources and access to oral care. However, it is possible to prevent poor oral health by modes of knowledge that are easy to comprehend and by utilizing inexpensive basic healthcare practices.

The present study was conducted in Jimma, Ethiopia, because according to us no such study has been performed in the past in this specific age-group in the country. The study was designed in a way to know the knowledge, attitude, and practices that may help us provide better insights into local understanding of practices. According to Ismail Abbas Darout, who performed a study on knowledge and behavior among Jimma University Health Sciences students in 2014, he concluded that although awareness was higher among selected samples, there were misconceptions.¹⁷

In our study, the students were able to participate and complete the questionnaires accurately which itself indicates their keenness to know about oral health issues. A similar study by Satish Vishwanathaiah assessed the knowledge, attitude, and behavior of schoolchildren in Davangere, India, and he too found that children were aware of oral health importance.

Good health practices essentially depend on self-care habits, utilization of dental services, oral health education, and professional preventive measures.¹⁸ In this study, knowledge toward oral hygiene was assessed as it decides good oral health practices and we noted that the majority of them (55.2%) thought that oral health has a role in general health although a significant number (40.5%) did not know about it.

With respect to the consequences of irregular toothbrushing, 21.6% of them opined that it caused bad breath which was 5% higher than the awareness about tooth decay (16.4%). The survey showed that 32.6% of them thought that not rinsing the mouth was the main reason to obtain dental problems but only 3.45% of them believed that not visiting a dentist regularly can be a problem. Even for the question about preventing dental problems, mouth rinsing after a meal (35.2%) was considered top priority and along with it avoiding sweets and sticky foods and brushing properly were considered important; however, a regular visit to a dentist was the last priority (6.5%) (Fig. 1). This indicates that further enhancement of knowledge with respect to benefits as well as consequences of proper brushing and obtaining professional healthcare services is indicated. It is possible that fear of and anxiety while going to a dentist can affect a majority of children and adolescents and this can be a considerable barrier.¹⁹ A study in Japan by Takaaki et al. opined that dental clinic was the common source of dental knowledge that resulted in better oral health behavior among university students.²⁰

Also, 66.4% of them knew that a clean mouth can prevent tooth decay, only 26.9% believed that brushing properly can prevent a dental problem which indicates inadequate knowledge about preventive measures. In our study, about 73% of them did not even know that a dentist could clean and polish teeth. However, 65.9% of them thought that bleeding from the gums, loosening of gums, loss of teeth, and bad smell can all be prevented by regular cleaning of the mouth. By imparting better knowledge about oral hygiene and improved health practices, it is possible to improve oral hygiene in children.⁶ Also, the central component of the WHO Health-Promoting School Model rests on the provision of knowledge and teaching/reinforcing healthy practices. Oral health education can be an effective method to improve knowledge, attitude, and practice to improve health as noted in a review by Nakre et al.²¹

The assessment of the attitude of schoolchildren revealed that a majority of 89.8% believed that maintaining a healthy mouth is an individual responsibility. It was noted that 92.2% of them had never visited a dentist before and if they had visited around 68.88% of them were for dental pain and none of them had visited for a filling. A combined value of 30% of them had visited for decay or extraction with the latter sharing the higher percentage. It was observed that 78.6% wanted to visit a dentist periodically to maintain oral health (Fig. 2). The lack of awareness regarding the role of a dentist and the importance of preventive measures combined with a deficiency of proper oral education can be observed. Also, it is recognized that parental behavior affects their children’s oral health. It is possible to make a difference in their children’s oral health by imparting the right knowledge and attitude to parents.²² In a study conducted in Greece, it was noted that barriers to applying oral hygiene methods included boredom, ignorance about its importance, and forgetfulness.²³ Therefore, the focus should be on ways to motivate the children about proper oral hygiene.

The practice toward oral hygiene showed that 72.41% depended on Mefakiya sticks for cleaning and only 14.13% used toothbrush and toothpaste. This finding was in unison with another study in Ethiopia by Ismail Abbas Darout who noted that Mefakiya stick usage was equal to toothbrushing practice among university students.¹⁷ A study by Malik et al. observed that chewing sticks at times provides improved mechanical and chemical cleaning as compared to a toothbrush.²⁴ Brushing teeth at least one time per day was observed between 90.34% and only 3.1% brushed twice daily (Fig. 3). This further advances our belief that parental guidance is an important aspect of improved oral hygiene behavior. While brushing, 64.3% of them used vertical strokes and 60.7% of them changed brush only when the bristles frayed up. Patil et al. have opined that a modified bass technique was the best method of brushing in children and there is a need to impart the right knowledge for students.²⁵ Also, the regular interval for changing a toothbrush is once in 3 months and the students were unaware of it.²⁶ Regarding the amount of paste applied, 96.34% of them applied it along the full-length of the brush but none of them pressed the paste between the bristles. It was impressive to note that 100% of them rinsed their mouth after meals but 88.4% of them did not clean their tongue and only 10.4% used a tongue cleaner. The above clearly indicates a need for a holistic, regular school oral health education program to provide information about right habits.

Oral health care in Africa is affected by an imbalance in the needs of the population and oral care personnel, higher cost of treatment, unreliable services, and general low priority to oral health care due to the pressing general health problems.¹² Various past approaches were based on models developed by developed nations. The problems are unique and therefore the solutions need to be specific. There is a general lack of policies and plans on oral health, poorly trained dentists, curative-based approach, and the lack of adequate materials and equipment.¹²,²⁷

The WHO Regional Office for Africa in its 48th session as early as 1998 had adopted that the future strategies should focus on districts and communities where special emphasis was given on children, pregnant women, and vulnerable groups where prevention of oral disease received higher priority. Al-Omari and Vishwanathaiah in separate studies have stressed decreasing the dependency on oral health professionals and improve the children to show improved responsibilities for their own health. We too concur with their observation.²⁶,²⁸ Oral health is an important aspect of health and maintenance is extremely important. Even in Jimma, similar to other studies in Africa, the studies concur with the fact that there is a lack of resources, the dearth of oral health providers, and inadequate educational programs on health. Also, we observe that the focus is intended more toward curative like filling or extraction, and the emphasis is not shown on preventive measures. These measures are relatively easier if proper educational material and reinforcement are provided. It is also pertinent that the involvement of parents to motivate their children to practice the behavior consistently is important. Healthcare providers in conjunction with school health programs have an obligation to improve the awareness about the importance of oral health. This also warrants further researches and studies to better understand the disparities that may further arise due to ethnicity, gender, or tribe in the region.