Demographics
A total of 123 participants were included in the study with a mean age of 48.42 ±5.94 years, out of which 98% were females (Table1). Nearly 87% of the participants were above 40 years of age and 69.9% had completed higher secondary education. Nearly 95% of participants belonged to the middle socio-economic class and 70% of them have been working as a CHW for more than 10 years (Table 1). All the participants had undergone learning through health education programs during their service and 73.2% have attended oral health-specific education programs also. (Table 1) However, comparative analyses of different categories of CHWs revealed a significant difference in response to the questionnaire. (Table 2)
Table 1: Characteristics of the study participants
Characteristics
|
N(%)
|
Category of community health workers
|
Junior Public Health Nurses(JPHN)
|
15(12.2)
|
Junior Health Inspectors(JHI)
|
9(7.3)
|
ASHAworkers
|
32(26)
|
Anganwadi workers
|
67(54.5)
|
Gender
|
Male
|
2(1.6)
|
Female
|
121(98.4)
|
Age groups
|
20-40 Years
|
16(13)
|
>40 Years
|
107(87)
|
Education
|
Profession or Honours
|
13(10.6)
|
Graduate
|
16(13.0)
|
Intermediate or diploma
|
57(46.3)
|
High school certificate
|
37(30.1)
|
Socio-economic class
|
Upper Middle
|
51(41.5)
|
Lower Middle
|
65(52.8)
|
Upper Lower
|
7(5.7)
|
Working experience ( in years)
|
0-10 years
|
38(30.9)
|
11-20years
|
80(65.0)
|
>20 years
|
5(4.1)
|
Attendance of oral health education program
|
Attended
|
90(73.2)
|
Not attended
|
33(26.8)
|
Knowledge of oral health
More than 90% of the participants gave a positive response for daily oral hygiene practices to prevent dental diseases, the role of sugar consumption in dental decay, and the link of oral health to general health. The awareness about nursing bottle caries was the lowest among ASHA Workers in comparison to other CHWs (p=0.02). Most of the Junior Public Health Nurses (60%) were oblivious about the role of fluoridated toothpaste in the prevention of dental caries that showed a significant lack of awareness as compared to other groups (p=0.001). Of the total respondents, only 78% could correlate the use of tobacco with oral diseases. Moreover, only less than 40% of CHWs knew the appropriate time to commence oral healthcare in children. Around 71% of the participants reported previous educational programs as their source of knowledge on oral health.
Attitude towards preventive oral health care
All of the participants felt that oral hygiene is important in day to day life and most of them agreed that they could contribute actively in preventing oral diseases. A good majority of them (98%) reported willingness to attend oral health training programs, if given an opportunity. It was seen that about 40% of the participants believed that dental visits were the only effective means to prevent dental diseases. Most of the JHI (88.9%) and AWWs (53%) were negligent about the need for treatment of milk teeth (p =0.02). In addition, only 46.7% of the JPHN felt the requirement of ante-natal oral health care (p =0.007). Most of the participants agreed that parental education has a paramount role in preventing childhood caries and the families should be counselled on oral health-related behaviours. (Table 2)
Table 2: Responses for knowledge, attitude, and behavior according to category of community health worker
Questions
|
JPHNn(%)
|
JHIn(%)
|
ASHAn(%)
|
Anganwaadi workersn(%)
|
Total n(%)
|
p-value
|
KNOWLEDGE
|
Q1. Do you know about Early Childhood Caries (ECC)?
|
Yes
|
9(60.0)
|
8(88.9)
|
15(46.9)
|
34(50.7)
|
66(53.7)
|
0.02*
|
No
|
6(40.0)
|
1(11.1)
|
5(15.6)
|
18(26.9)
|
30(24.4)
|
I don’t know
|
0(0.0)
|
0(0.0)
|
12(37.5)
|
15(22.4)
|
27(22.0)
|
Q2. Does fluoridated tooth paste has a role in preventing dental decay?
|
Yes
|
6(40.0)
|
5(55.6)
|
24(75.0)
|
45(67.2)
|
80(65.0)
|
0.001*
|
No
|
9(60.0)
|
1(11.1)
|
1(3.1)
|
6(9.0)
|
17(13.8)
|
I don’t know
|
0(0.0)
|
3(33.3)
|
7(21.9)
|
16(23.9)
|
26(21.1)
|
ATTITUDE
|
Q3. Do you think that problems with milk teeth require treatment?
|
Yes
|
8(53.3)
|
1(11.1)
|
19(59.4)
|
31(47.0)
|
59(48.4)
|
0.02*
|
No
|
7(46.7)
|
8(88.9)
|
9(28.1)
|
33(50.0)
|
57(46.7)
|
I don’t know
|
0(0.0)
|
0(0.0)
|
4(12.5)
|
2(3.0)
|
6(4.9)
|
Q4. Do you think that pregnant women need special oral care?
|
Yes
|
7(46.7)
|
8(88.9)
|
26(81.3)
|
59(88.1)
|
100(81.3)
|
0.007*
|
No
|
5(33.3)
|
0(0.0)
|
5(15.6)
|
3(4.5)
|
13(10.6)
|
I don’t know
|
3(20.0)
|
1(11.1)
|
1(3.1)
|
5(7.5)
|
10(8.1)
|
Q5: Do you think that educating parents is important in preventing caries in children?
|
Yes
|
14(93.3)
|
9(100.0)
|
32(100.0)
|
67(100.0)
|
122(99.2)
|
0.001*
|
No
|
1(6.7)
|
0(0.0)
|
0(0.0)
|
0(0.0)
|
1(0.8%)
|
I don’t know
|
0(0.0)
|
0(0.0)
|
0(0.0)
|
0(0.0)
|
0(0.0)
|
BEHAVIOUR
|
Q6: What is your source of knowledge on oral health?
|
Previous oral health education programs
|
7(46.7)
|
8(88.9)
|
21(65.6)
|
52(77.6)
|
88(71.5)
|
0.004*
|
Self- learning (books, media etc)
|
6(40.0)
|
1(11.1)
|
3(9.4)
|
2(3.0)
|
12(9.8)
|
From co-workers
|
2(13.3)
|
0(0.0)
|
8(25.0)
|
11(16.4)
|
21(17.1)
|
No specific source
|
0(0.0)
|
0(0.0)
|
0(0.0)
|
2(3.0)
|
2(1.6)
|
Q7. Do you inform the community about dental problems associated with usage of bottle milk in children?
|
Always
|
2(13.3)
|
2(22.2)
|
16(50.0)
|
50(74.6)
|
70(56.9)
|
0.001*
|
Some times
|
9(60.0)
|
6(66.7)
|
10(31.3)
|
16(23.9)
|
41(33.3)
|
Chi square test, *Statistically significant( p<0.05)
|
Never
|
4(26.7)
|
1(11.1)
|
6(18.8)
|
1(1.5)
|
12(9.8)
|
|
Chi square test, *Statistically significant( p<0.05)
Behaviour pattern regarding oral health care
As a part of routine oral care, more than 80% of the participants reported brushing for more than a minute, twice a day, using fluoridated toothpaste and mouthwash while almost 60% of them changed their brush every three months. About 58% had never used dental floss to clean their teeth. More than 90% had visited a dentist at least once for dental problems in the past. During their door to door visits, only one-fourth of the participants recommended dental check-up as a part of antenatal care to mothers experiencing dental problems. A considerable variation was noticed in the responses when asked about the responsibility to educate the community about the problems associated with the use of bottle milk in children (p=0.001). While most of the AWWs and ASHAs were imparting knowledge regarding the harmful effects of using bottled milk on dentition, other workers were found reluctant in doing so. Among the various methods for the prevention of oral disease, about 50% of the participants made use of routine dental check-ups, 23% adopted caries prevention methods and 18.7% underwent professional cleaning of teeth.
The mean knowledge score (6.14±1.11) and the mean attitude score (7.63±1.03) of the participants were not significantly related to demographic characteristics (Table 3). CHWs who gained knowledge by attending previous oral health education programs showed a significantly better attitude score as compared to those who were not exposed to such programs (p=0.01). A significant difference in attitude score was obtained among the four groups of CHWs (p=0.009). (Table 3)
Table 3: Mean knowledge and attitude score of study participants
Parameters
|
Mean knowledge score ±SD
|
p value
|
Mean attitude score± SD
|
p value
|
Category of community health workers
|
Junior Public Health Nurses(JPHN)
|
5.87± 1.30
|
0.45
|
6.87± 1.18
|
0.009*
|
Junior Health Inspectors(JHI)
|
6.44 ±0.88
|
8.11± 1.05 τ
|
ASHAworkers
|
6.06 ±1.36
|
7.59 ±0.91
|
Anganwadi workers
|
6.31 ±1.07
|
7.76 ± 0.97 τ
|
Age groups
|
20-40 years
|
6.38 ±0.80
|
0.41
|
7.81 ± 0.91
|
0.41
|
>40 years
|
6.18 ±1.21
|
7.60 ±1.05
|
Level of education
|
Profession or Honours
|
6.31 ±1.18
|
0.32
|
7.69 ± 0.85
|
0.36
|
Graduates
|
6.25± 1.18
|
7.69± 1.19
|
Intermediate or diploma
|
6.23± 1.13
|
7.52 ± 1.06
|
High school certificate
|
6.31±1.10
|
7.90 ± 0.84
|
Socio-economic class
|
Upper Middle
|
6.29 ± 1.15
|
0.77
|
7.55± 1.01
|
0.59
|
Lower Middle
|
6.14± 1.15
|
7.72 ± 1.03
|
Upper Lower
|
6.14 ± 1.57
|
7.43± 1.27
|
Working experience(in years)
|
0-10 years
|
6.10± 1.08
|
0.47
|
7.76± 1.06
|
0.49
|
10-20 years
|
6.20± 1.20
|
7.57 ±1.03
|
>20 years
|
6.80± 1.09
|
8.00 ±1.00
|
Attendance of oral health education program
|
Attended
|
6.27± 1.13
|
0.34
|
7.78 ± 0.97
|
0.01*
|
Not attended
|
6.03 ± 1.26
|
7..24± 1.09
|
Sig. p<0.05 *Independent t test , *ANOVA, τ Tukey HSD test
The results of the bivariate analysis (Table 4) showed a significant association between subjects' oral health behaviour status, their attitude level (p=0.004), and the attendance status in oral health education programs (p=0.001). Further multivariate regression analysis explained that positive attitude had a significant influence on oral health behaviour status (p=0.006, adjusted OR=4.87). The results showed that CHWs who attended oral health education programs were likely to have a better oral health behaviour status when compared to those who had not attended (p=0.003, adjusted OR= 14.58).
Table 4: Factors associated with Oral health behaviour status of the study participants
Oral health behaviour
|
|
OR( 95% Conf. Interval)
|
P value
|
aOR(95%Conf.Interval)
|
p value
|
Age
|
20-40 years of age
|
1.00
|
|
1.00
|
|
>40 years
|
1.21(0.39-3.74)
|
0.73
|
1.04(0.24-4.50)
|
0.95
|
Level of education
|
Profession or Honours
|
2.26(0.92-5.53)
|
0.07
|
2.32(0.74-7.31)
|
0.14
|
Graduates
|
0.38(0.07-2.00)
|
0.25
|
0.15(.01-1.44)
|
0.10
|
Intermediate or diploma
|
1.68(0.44-6.39)
|
0.44
|
3.64(0.39-33.5)
|
0.25
|
High school certificate
|
1.00
|
|
|
0.14
|
Socio economic class
|
Upper middle
|
3.51(0.39-30.94)
|
0.25
|
1.77(0.14-21.35)
|
0.36
|
Lower middle
|
3.27(0.36-29.34)
|
0.28
|
3.58(0.23-55.76)
|
0.65
|
Upper lower
|
1.00
|
|
1.00
|
|
Working experience
|
0-10 years
|
1.00
|
|
1.00
|
|
11-20 years
|
1.55(0.67-3.57)
|
0.30
|
0.97(0.32-2.95)
|
0.96
|
>20 years
|
0.61(0.06-6.12)
|
0.67
|
0.31(0.02-4.34)
|
0.39
|
Attendance related to oral health education programs
|
Attended
|
8.00(2.27-28.13)
|
.001*
|
14.58(2.54-83.65)
|
.003*
|
Not attended
|
1.00
|
|
1.00
|
|
Attitude level
|
Positive
|
3.71(1.53-9.02)
|
0.004*
|
4.87(1.58-14.94)
|
.006*
|
Negative
|
1.00
|
|
1.00
|
|
Knowledge level
|
Good
|
1.44(0.68-3.07)
|
0.33
|
1.95(0.76-5.01)
|
0.16
|
Poor
|
1.00
|
|
1.00
|
|
aOR=adjusted odds ratio, OR=odds ratio, *P-values <0.05 are statistically significant
Odds ratios are exponentated coeffcients from multivariate logistic regression model, R2=0.377