Knowledge, attitude and practices of mothers toward their children s oral health: A questionnaire survey among subpopulation in Mumbai (India)

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1 E-ISSN DOI: / Original Research Knowledge, attitude and practices of mothers toward their children s oral health: A questionnaire survey among subpopulation in Mumbai (India) Romi Jain, Kunal C Oswal, Rajeev Chitguppi Department of Public health Dentistry, Terna Dental College, Nerul, Navimumbai, Maharashtra, India Access this article online Website: Quick response code Abstract Aim: Oral health related knowledge, attitude, and practices shown by preschool children determine their oral health status in the future. This in turn depends on the knowledge, attitude, and practices inculcated into them by their parents. Objective: The objective was to assess the knowledge, attitude, and practices of mothers toward their children s oral health. Materials and Methods: A cross sectional questionnaire survey was conducted among 422 mothers of preschool children who visited dental colleges in Mumbai, India. Data were collected through an interview, using a structured proforma. Results: Majority (60.4%) had poor knowledge, 53.8% exhibited poor attitude and 58.8% were following fair practices towards a children s oral health. Knowledge regarding the role of fluorides, causes and prevention of dental caries, gum disease, malocclusion were found to be inadequate. Conclusion: This study showed that mothers had poor knowledge and attitude towards a children s oral heath due to which majority were following poor oral health practices. Key words: Knowledge, oral health, practices, preschool children Introduction Preschool children form an innocent and compassionate segment of the society and their oral health care is given due priority as it determines the oral health status of the future generations. [1] Children under the age of 5 years generally spend most of their time with parents and guardians, especially mothers, even when they attend preschools or nurseries. These early years involve primary socialization during which the earliest childhood routines and habits are acquired. [2] These include dietary habits and healthy behaviors established as norms in the home. These are dependent on the knowledge and behavior of parents and elder siblings. [3] Young children s oral health maintenance and outcomes are influenced by their parent s knowledge and beliefs, which affect oral hygiene and healthy eating habits. Parent s knowledge and positive attitude toward good dental care are very important in the preventive cycle. It has been found that the more positive is the parents attitudes toward dentistry, the better will be the dental health of their children. [4] Mothers, who are the primary role model for them, their health beliefs and attitude towards oral health care, act as a significant predictor of children s oral health. [5] Hence an attempt has been made in this study to assess the knowledge, attitude, and practices of mothers toward their children s oral health and also to compare the knowledge, attitude, and practices with regards age, educational level, and socioeconomic status. Materials and Methods A cross sectional questionnaire study was conducted for 4 months among mothers of 3-5 year old preschool children who visited Dental Colleges in Mumbai from August 2012 to November Ethical clearance was obtained from Institutional Review Board and an informed consent was obtained from the study participants. The study was carried out in four randomly selected Dental Colleges in Mumbai (Terna Dental College, Nair Hospital Dental College, Guardian College of Dental Sciences and Research Center, YMT Dental College and Research Center) and 105 study subjects from each college were included in the study. The structured questionnaire proforma was designed in English and then translated in Hindi by two dentists who were fluent in both English and Hindi. The Hindi version was then back translated into English by another two people fluent in both Hindi and English. The back translated version was Correspondence to: Dr. Romi Jain, C-503, Intop Heights, Sector 19, Airoli, Navi Mumbai , Maharashtra, India. jain.romi215@yahoo.com 40

2 compared with the English version to verify that the questions were properly translated. Questionnaire was pretested and validated among 30 mothers and these subjects were not included in the final analysis. Based on the response rate with error fixed at 5%, sample size was calculated to be 422. Sample size was calculated based on Z 2 pq/e 2. Z = 1.96 for 95% of the confidence interval p = proportion of the population who had knowledge about oral health was 20% (0.2) q = 1 p = 0.8 e = margin of error was at 4% =0.04. All mothers having children aged between 3 and 5 years and who gave consent were included in the study. All participants were interviewed by a single investigator. A structured proforma was designed to collect the data, which consisted of two parts. The first part consisted of general information such as the name, age, gender of the child, parent s education, occupation and total family income. The second part was the questionnaire, which consisted of 29 questions related to knowledge, attitude and practices toward children s oral health. Out of which 10 questions were related to knowledge, six were related to attitude and nine were related to practices and four were general questions. The responses for the attitude questions were rated as: (1) Agree, (2) uncertain and (3) disagree. To assess the responses for the questionnaire, a scoring system was developed; scores were based on the number of correct/favorable answers given by mothers. [6,7] (Knowledge good: >7, fair: 4 6, poor: <3, Attitude good: >5, fair: 3 4, poor: <2, Practices good: >7, fair: 4-6, poor: <3). Data analysis The data were analyzed using SPSS version 17 Inc., Chicago, IL, USA). The P value was considered as significant when<0.05 (confidence interval of 95%). Descriptive statistics was carried out to calculate responses for each question. Further analysis was performed by using one way ANOVA and Pearson s correlation coefficient. Results In this study, a total of 420 mothers completed the questionnaire. Their mean age was 31.2 ± 1.2 years. The results of this study are presented in tables. Table 1 presents the distribution of study participants according to their responses to the questions related to knowledge, attitude, and practices. Table 1: Distribution of study participants according to their responses to knowledge, attitude and practice questions Number Percentage Knowledge How many milk teeth are there in a child s mouth I don t know Does the tooth paste contain fluoride? Yes No I don t know What is the role of the fluoride in the tooth paste? Prevents tooth decay Prevents gum problems Gives freshness I don t know What is the most common dental disease in the child? Tooth decay Bleeding gums Discolored tooth I don t know Which of the following food items can lead to tooth decay? Chocolates Bakery products Soft drinks All of the above I don t know Which of the following do you think prevents the tooth decay? Restricting sweets Tooth brushing Regular dental visits Fluoridated tooth paste All the above I don t know Causes for gum disease? Improper brushing Tartar All of the above I don t know Which of the following do you think prevents the gum disease? Regular brushing and mouth wash Professional cleaning All of the above I don t know Which of the following can lead to irregular teeth? Contd... 41

3 Table 1: Contd... Thumb sucking/tongue thrusting/mouth breathing Number Percentage Runs in the family All of the above I don t know Can irregularly placed teeth be aligned in the correct position? Yes No I don t know Attitude It is necessary to take the child for regular dental visits Agree Uncertain Disagree Cleaning of the child s teeth should be done by mothers Agree Uncertain Disagree It is necessary to clean the child s teeth after every meal Agree Uncertain Disagree Milk teeth do not require good care as it is going to fall anyway Agree Uncertain Disagree Good oral health is related to the good general health Agree Uncertain Disagree Healthy milk teeth are essential for children to chew the food properly Agree Uncertain Disagree Practice When was the child s first dental visit? 6 months after birth After the eruption of first milk tooth year after birth Not yet visited When do you take your child to visit the dentist? Only during problems Every 6 months Every 1 year Contd... Table 1: Contd... Number Percentage Not particular When did you commence the cleaning of your child s teeth? Soon after first milk tooth eruption After 4-6 milk teeth eruption After all milk teeth eruption After first birthday of the child Don t remember Which of the following aids are used to clean your child s teeth? Finger Tooth brush Twig Any other How many times do you brush your child s teeth? Once in a day Twice in a day After every meal Not particular When do you change your child s tooth brush? Once in 15 days Once in a month Every 2-3 months Once the bristles fray out Not particular What material do you use to clean your child s teeth? Tooth paste Tooth powder Any others Does your child rinse the mouth after eating/drinking? Yes No Sometimes I don t know At what time do you give the sugary food items to your child? With meals In between meals Before going to bed Not particular Overall knowledge, attitude, and practice Based on the scoring criteria as described earlier, it was found that >60% mothers exhibited poor knowledge, 53.8% showed poor attitude, and 36.7% showed poor practices. Whereas around 30% exhibited fair knowledge, 32.7% fair attitude and around 58% showed fair practices. In this study very few participants were in the good category. Merely 9.5%, 13.5%, 42

4 and 4.5% mothers were in the good category for knowledge, attitude, and practices respectively. General information (four questions were asked in this section) Regarding the source of information, around 45% mothers said that they get information about oral health through newspapers and TV. Whereas 19.2% mothers reported dentists, 12.8% reported pediatricians and 20.1% reported all of the above mentioned sources. In this study, we also asked our participants to rate their oral health as good, fair and poor. Around 51% mothers rated their oral health as fair, 41.5% rated good, and 7.6% rated as poor oral health. To know the awareness of mothers regarding their children s oral health, we asked them about the number of decayed teeth and alignment of teeth in their children s mouth. Around 51% mothers reported <3 decayed teeth, 24.2% reported 3-6 decayed teeth, 4.5% reported >6 decayed teeth and 20.1% were not aware about it. About the teeth alignment, 58.1% reported well aligned teeth, 13% reported malaligned teeth, whereas 28.9% said that they have never checked it. Association between age, educational qualification and socioeconomic status with knowledge, attitude and practice scores Mothers in the age group of years showed significantly higher mean attitude scores (4.30 ± 1.3) compared with other age groups (P = 0.000) [Table 2]. Mothers with high educational qualification (graduates and postgraduates) scored significantly higher mean knowledge (5.13 ± 2.6), attitude (4.62 ± 1.2) and practice (4.35 ± 1.4) scores compared with lower educational qualification (P = 0.000) [Table 3]. Similarly mothers belonging to higher socioeconomic status showed better knowledge (3.85 ± 2.4), attitude (4.28 ± 1.3) and practices (4.18 ± 1.5) than those of lower socioeconomic status [Table 4]. We also found significant positive correlation between knowledge and attitude as well as attitude and practice scores [Table 5]. Table 2: Mean knowledge, attitude, and practice scores according to age <30 years years >45 years F value (P value) Knowledge 3.25± ± ± (0.177) Attitude 4.2± ± ± (0.006) Practices 4.07± ± ± (0.839) NS ANOVA test used for comparison Discussion Oral health of children is associated with oral health knowledge of their parents/guardians as oral health related habits are established during infancy and maintained throughout early childhood. [8] In this study, knowledge regarding role of fluoride was poor. This was similar to the study done by Moulana et al., [7] Suresh et al. [9] whereas studies done by Gussy et al., [10] Franzman et al., [11] Kamolmatyakul and Saiong [4] reported good knowledge about fluoride. Majority of the mothers could identify tooth decay as the most common dental disease among children. This was in line with the other studies. [4,9,12,13] The results of this study were similar to the results of studies conducted by Moulana et al., [7] Wyne et al., [12] Kamolmatyakul and Saiong [4] and Chan et al. [13] where majority of the mothers were aware that sugary item likes chocolates can lead to dental caries. However, there was low awareness about the different forms of sugary items, which are harmful to the teeth. This throws the light on inadequate knowledge about the relationship between the different forms of sugar consumption and dental caries. Furthermore, knowledge about the caries preventive methods, cause and prevention of gum disease and malocclusion was low which was in line with the study done Suresh et al. [9] All these finding are suggestive of poor knowledge about oral health and indicates the need for effective oral health education program. Majority of the mothers were in opinion that, it is necessary to take the child for regular dental visits, which was similar to the results of Moulana et al. [7] and Chan et al. [13] It is suggested that the earlier a child visits to dentist, the greater would be his likelihood of being caries free. [14] Respondents had partial knowledge on the importance of deciduous teeth. Many of them said that baby s teeth do not require good care as they will fall off. This was in accordance with the study done by Suresh et al. [9] In this study, majority of mothers commenced tooth brushing for their child only after eruption of all primary teeth. Contrary to our result, 95% of the parents in rural Australia believed that they should start brushing when the first tooth erupts, as reported in a study done by Gussy et al. [10] Around 75% mothers agreed that child s teeth should be cleaned by them which shows positive attitude. A randomized Table 3: Mean knowledge, attitude, and practice scores according to education level Illiterate Primary Secondary Graduate Postgraduate F value (P value) Knowledge 2.20± ± ± ± ± (0.000) Attitude 3.80± ± ± ± ± (0.006) Practices 3.40± ± ± ± ± (0.008) ANOVA test used for comparison 43

5 Table 4: Mean knowledge, attitude, and practice scores according to socioeconomic status Upper middle Lower middle Upper lower F value (P value) Knowledge 3.85± ± ± (0.001) Attitude 4.28± ± ± (0.005) Practices 4.18± ± ± (0.009) ANOVA test used for comparison Table 5: Correlation between knowledge, attitude, and practices Knowledge Attitude Practices Knowledge 0.553** P= P=0.250 Attitude 0.553** P= ** P=0.002 Practices P=0.250 **Correlation is significant 0.667** P=0.000 controlled trial in UK showed that visits to a dental health educator by the mothers of preschool children increased the parental knowledge and improved attitudes toward their children s oral health. [15] In this study even though majority of mothers agreed that regular dental visit is required, very few reported to follow this. This was in line with the other studies. [8,16,17] Reasons for lack of visit could be apprehension, high costs, accessibility or lack of motivation. These barriers need to be evaluated by further research. More than 80% children used tooth brush and tooth paste for cleaning their teeth. This was comparable to the other studies. [7,13,18] Majority of the respondent do not know the importance of time of intake of sugars. Similar results were extracted from the reports obtained by Moulana et al. [7] and Chan et al. [13] In contrast, Blinkhorn et al. [15] has reported that 78% of mothers restricted the intake of sugary food items to meal times only. Newspapers and TV were reported to be the major source of information regarding oral health. This shows how extensively mass media influence people in their daily lives. Strategies should be made to utilize mass media more effectively for oral health education. Wyne et al., had reported that 34.2% of the Saudi population get the oral health information from dentist, followed by media. [12] Whereas in the present study very few (10 15%) subjects got the information from dentist. This indicates the urgent need to motivate dentist and other health professionals (like pediatrician) to incorporate oral health education in their routine clinical procedure for all the patients. Mothers with higher education have a better knowledge regarding the oral hygiene practice and importance of deciduous teeth. This is similar to a Polish study which reports that mothers with lower level of education also have low levels of oral health knowledge. [19] It has been suggested that the parents with a general, improved level of education may be able to assess appropriate source of information and understand that information more completely. [20] A significant association was observed in this study between knowledge, attitude and practice scores and socioeconomic status. Studies by Suresh et al. [9] and Williams et al. [20] have also shown that parents with lower education had poor dental knowledge and attitude level. It is possible that parents with higher education level are more likely to have positive health attitudes and render greater attention to the health of the child. Overall mothers showed poor oral health knowledge, attitude and practices. Keeping in mind the changing attitude in society, it is important to plan appropriate oral health programs targeting different groups through the strategies designed for specific requirements. More emphasis should be placed on improving the level of knowledge, which would be reflected in their oral health behavior. Conclusion This study showed that mothers had poor knowledge and attitude towards oral health, which reflected in their poor oral health practices towards their children. The results of this study cannot be extrapolated as the sample size was small and the study included only those mothers who were visiting dental colleges. Hence, studies exploring the same issue need to be conducted on larger samples covering different populations so as to evaluate, which strategies will be effective and efficient in bringing about a behavior change in mother/parents. Furthermore, oral health behavior of both the parents affects their children s oral health behavior. As this study has interviewed only mothers, it is essential to conduct further epidemiological research involving both the parents. References 1. Director of oral health. Guidelines on Oral Health Care for Pre-School Children. Oral Health Division Ministry of Health Malaysia August Rajesh G, Prasad KV, Mohanty VR, Javali SB. Effect of various methods of oral health education on oral health knowledge and oral health status of high school children in Gadag town A randomized control trial. J Indian Assoc Public Health Dent 2008;11: Berkowitz RJ. Mutans streptococci: Acquisition and transmission. Pediatr Dent 2006;28: Kamolmatyakul S, Saiong S. 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