The overarching findings of this study highlight several fundamental aspects related to the caregiver’s perceptions and practices at the children's care centers in Lahore. Food and shelter security at the children’s care centers is one of the major incentives for the poor and orphan children. The enrollment policy of the foster care centers was found comparatively flexible to that of the madrasa considering the significant age difference. Madrasa children appeared to be less supervised for their health issues than those of the foster care centers.
The role of caregivers was found important for developing a healthy environment for the children for living. A nurturing, controlled and conducing environment was observed at the centers with a stringent induction policy. Whereas, centers with no such policy found it difficult to maintain a healthy living environment. The consistency of behavioral habits also depends upon the practices of the caregivers [7]. The relationship with the primary caregiver is one of the fundamental principles of social determinants of health [17]. An imitating environment was also observed in one of the children’s care centers where the children followed the actions of their seniors and caregivers. The oral health environment was not found healthy in the children’s care centers with the uncontrolled and imitating environment.
The caregivers can adequately monitor children's oral health only if they have sufficient knowledge [18]. The oral health knowledge theme explains the understanding and perception of caregivers in this study. The knowledge perspective for cleaning the teeth was different. Inadequate, specific, non-specific, and religiously oriented oral health knowledge were observed at these children’s care centers. Inadequate oral health knowledge refers to the belief of the caregivers that it is not a health issue among children of this age group. This inadequate knowledge limits the caregivers not to put much emphasis on maintaining an appropriate oral health practice.
Oral health-specific knowledge was observed at the children’s care center where the caregivers showed their concern about good oral hygiene. Caregivers were found to have proficient knowledge and were concerned about oral health. Caregivers with religiously specific oral health knowledge recommended natural chewing sticks such as “Miskwak” which appeared as a popular and culturally embedded method at Madrasa.
The criteria of oral health varied at different children’s care centers depending upon the availability of resources. The centers with moderate to low facilities consider oral health only concerned with the mouth odor and their choices were inadequate. This perspective was not considered as a category in this study but was an interesting input to be mentioned for future research. However, the privileged class centers were concerned even with the brand of the toothpaste and had adequate knowledge about oral health.
The hygienic practice of the caregivers varied across children's care centers and the availability of resources. Limited-resourced foster care centers were dependent on the donors and availability of oral hygienic supplies. Their approach towards oral health was related to these factors and was not considered as a matter of concern due to limited resources. Oral hygienic practices appeared as need-based, availability of dentifrices, oral health-oriented, compromised, and religiously preferred practices at children’s care centers. At the foster care homes and low resources madrasas limited emphasis was observed on maintaining children’s oral hygiene by the caregivers.
Toothpaste with dentifrices and Miswak were common methods for cleaning the tooth at least once a day at boys Madrasas. Considering the low cost, simplicity and easy availability of Miswak makes this natural method to be widely used in many developing countries [19]. A strong affiliation exists between using Miswak with religious and cultural practices in Islamic countries [20]. The religious practice was found to use Miswak before every prayer which accounts for five times per day in madrasas for similar beliefs.
Besides these two methods, some children from the northern areas practiced their regional norms and were using babool chewing stick “Dantan”. The effectiveness of Datan against antimicrobial activities in the mouth has been reported in some studies [21]. However, some oral health hazards associated with the use of Dantan were mentioned by the participants. This finding was another interesting perspective to explore about oral hygiene and cultural settings in future research.
The health-seeking behavior varied immensely between the two children's care settings and also differ within the privileged level of the madrasas. Cultural remedies and self-medication by the recommendations from a dispenser or pharmacy assistant were the first treatment of choice at the low privileged centers. Previous studies conducted on managing children's oral health by dispensers and pharmacy assistants showed a low personal self-efficacy compared to other staff [22, 23].
Seeking medical care was based upon the personal preferences and convenience of the caregivers. Several oral health practices were in use by the caregivers such as self-medication, homeopathic medication, systematic practices, supplication-based practices, and non-healthcare professional practices. Previous studies have suggested integrated approaches on primary oral health by considering the local culture can be effective to improve oral health [24]. Restricted to merely local remedies can cause potential oral health hazards which need to be incorporated with proven scientific methods.
Girls Madrasa had a stronger belief in cultural remedies to treat oral health issues with limited exposure to proper oral care. Low oral health literacy in seeking medical treatment among caregivers and the community can be a potential barrier for the children to seek treatments [25]. It is also important to realize the caregivers about the potential oral health issues that can happen with children of this age group. Poor oral hygiene among these children can be a consequence of inadequate knowledge and the neglected behavior of the caregivers that can ultimately lead to oral health problems.
Interesting separate research can be conducted about any aspect of the health with those people, say, dandan saz means tooth makers but they are considered to be the dental experts without any formal qualifications and approved dental equipment.