|Year : 2015 | Volume
| Issue : 4 | Page : 410-416
Factors affecting utilization of dental care among 6–12-year-old school children in Bangarpet taluk, Karnataka
C Priyadarshini, Manjunath P Puranik, SR Uma
Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India
|Date of Web Publication||7-Dec-2015|
Room No. 9, Department of Public Health Dentistry, Government Dental College and Research Institute, Fort, Victoria Hospital Campus, Bengaluru - 560 002, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Oral diseases qualify as major public health problems owing to their high prevalence and incidence worldwide. Access to oral healthcare refers to patient's ability to obtain or utilize oral healthcare. Aim: To assess the dentition status and treatment needs among 6–12-year-old school children and to assess the factors affecting utilization of dental care among parents. Materials and Methods: A cross-sectional survey was conducted among 420 school children (6–12 years) in Bangarpet taluk. Factors affecting utilization of dental care were assessed using a validated questionnaire and dentition status and treatment needs was recorded according to WHO 1997 proforma. Descriptive and inferential statistics were used. Results: The proportion of children with dmft was 62 (30%) and 54 (26%) in urban and rural children, respectively whereas the proportion of children with DMFT was 48 (23%) and 79 (38%) in urban and rural children, respectively. Among urban children 99 (47%) did not need any treatment when compared to 87 (41%) rural children. Around 32 (15.2%) needed one surface filling in urban children and 20 (9.52%) in rural children. About 30 (14.28%) urban and 40 (19.04) in rural children needed preventive care, respectively. Most of the parents were not aware of fluoride content in the toothpaste. Parents agreed that maintenance of oral health is their duty. There was a significant difference between urban and rural parents for the barriers "no time to visit" (P = 0.0002), "affects my work" (P = 0.048) and "scared of injection" (P = 0.0033). Dental visits were found to be low in both urban 37 (18%) and rural 56 (27%) children. Conclusion: The caries experience was similar among urban and rural children. Most of the children required restorative and preventive care. Fear of injection and lack of time to visit dentist were the major barriers to parents for utilization of dental care. Hence, integrated approach is suggested to strengthen preventive and early intervention of oral disease.
Keywords: Dental care, dental health services, oral health, school children, utilization
|How to cite this article:|
Priyadarshini C, Puranik MP, Uma S R. Factors affecting utilization of dental care among 6–12-year-old school children in Bangarpet taluk, Karnataka. J Indian Assoc Public Health Dent 2015;13:410-6
|How to cite this URL:|
Priyadarshini C, Puranik MP, Uma S R. Factors affecting utilization of dental care among 6–12-year-old school children in Bangarpet taluk, Karnataka. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2020 Jul 5];13:410-6. Available from: http://www.jiaphd.org/text.asp?2015/13/4/410/171176
| Introduction|| |
Health is a universal human need for all cultural groups and is central to human happiness and well-being. General health cannot be attained or maintained without oral health. Oral diseases are considered as major public health problems owing to their high prevalence and incidence in all regions of the world and the greatest burden of oral diseases is on disadvantaged and socially marginalized populations. The severe impact in terms of pain and suffering, impairment of function; and effect on quality of life is also tremendous.
The traditional concept of access to oral health care refers to a patient ability to obtain or make use of oral healthcare. Factors external to the patient such as adequacy of dental workforce and ability to pay for care are the primary determinants of access. There must be three essential elements for an increased access to dental care - the dental work force, the demand for dental care, and the economic environment.
On the other hand, the sources of the barriers that the patient experience in relation to accessing oral health care are said to arise from their life experiences and psychosocial factors. These factors may include age, gender, education, ethnicity, language, perception of need, and feeling of vulnerability. Others may include cost of treatment, health status of the individual, disability, transportation, residence/rurality, adequacy of dental workforce, and beliefs and charisma of dental healthcare personnel. A good understanding of the barriers that prevent people from seeking appropriate and timely oral health intervention is important that would bridge the gap between the need for care and the amount of care sought.
Subgroups of our population who have problem with accessing care are the poor and the working poor, poor inner city residents, rural area residents, mobility restricted people, culturally isolated groups, unemployed and uninsured and people with special needs. Children represent a dependent population. Especially those in rural with low socioeconomic status (SES) are pushed toward high unmet dental needs. The prevalence of caries is about 50–60% among children of 6–12 year age group. In urban regions and among high income groups, dental visits are more common and to some extent the burden of disease is reducing. Whereas in rural regions, due to lack of knowledge, perceived dental need, and many barriers, dental care is not being utilized.
Few studies have assessed factors related to utilization of dental care in children, in urban and rural regions in India.
To determine factors associated with utilization of dental care among school children aged 6–12 years of Bangarpet taluk.
- To assess the dentition status and treatment needs among school children
- To assess the knowledge, attitude, and practices; and barriers to parents of 6–12-year-old school children.
| Materials and Methods|| |
A cross-sectional study was conducted among school children aged 6–12 years in Bangarpet taluk for the duration of 2 months from May to June 2014. Ethical clearance was obtained from the Institutional Ethics Committee. Permission was obtained from the Block Education Officer and Head of the Institutions of respective schools. Informed consent was obtained from the parents/caregivers of the study participants.
A thorough literature search was done, and questions were selected from previous studies. A preliminary 20-item instrument was thus developed and screened for face validity. Three experts in Public Health Dentistry carried out the content validation. Further validation was performed using Aiken's V index (V > 0.7) to depict those items with a high degree of agreement among experts. This resulted in a 14-item questionnaire. Cross culture adaptation of the questionnaire was used by back translation.
Prior to the commencement of the main study, a pilot study was conducted among school children to assess the feasibility of the study and calculation of sample size. Based on the results of the pilot study, some modifications were made in the proforma.
The sample size was calculated using the formula: Z2 × p (q)/Δ2.
where Z = Z value for the confidence level chosen = 1.96 (for 95% confidence interval from standard normal distribution). P = 50% = 0.5 (prevalence of dental caries which was found to be 50%) q = 1 − P = 1 – 0.5 = 0.50 (50%). Δ = margin of error which is acceptable = 0.5% or 5%.
Therefore, a sample size of 384 was derived which was rounded off to 420.
School children aged 6–12 years were included and children who are suffering from any other systemic disease. For obtaining the required sample size, multistage sampling method was used. List of schools consisting of government, aided, and private was obtained from Block Education officer of Bangarpet taluk. From the list, one school representing government, aided, and private was selected randomly from the urban and rural region (total six schools). A sample size of 420 was divided equally for urban (210) and rural (210) region. In each region, an equal number of children was selected randomly from the age group 6–12 years representing both the genders from the government, private, and aided schools.
Data were collected using a structured proforma that consisted of two parts: The first part contained sociodemographic information such as age, sex, dental history, oral hygiene practices, and diet history of the child. SES of the parents was assessed using Kuppuswamy scale. In the second part, information regarding the perceived oral health status, knowledge, attitude and practices, barriers for a dentist, and utilization of dental health services among parents was collected using a validated 14-item questionnaire. Dentition status and treatment needs were assessed using the WHO proforma 1997.
The clinical oral examination was carried out by a single calibrated examiner under the artificial light. Children were examined in a chair, and recording was done by trained personnel. The sufficient numbers of autoclaved instruments were taken for the daily examination. Infection control measures were observed throughout the study.
Statistical analysis was done using (SPSS 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0 and R environment ver.2.11.1). Descriptive and inferential statistics were used for analysis. Chi-square test was used as a test of homogeneity for factors affecting utilization among urban and rural children. Student's t-test was used to test significant difference in mean caries experience. A P < 0.05 was considered as significant.
| Results|| |
Of 420 school children, 210 (50%) belonged to urban and 210 (50%) to rural region. The age of children ranged from 6 to 12 years with 60 children in each age group [Table 1]. An equal proportion of males and females formed the study sample: 210 (50%) males and 210 (50%) females with 105 (25%) from urban and rural regions each. The majority of the study participants belonged to lower middle class in urban (62%) and rural region (74%). Most of the urban children used toothbrush and toothpaste (63%) when compared to rural children (24%) and almost all of them in urban and in rural regions brushed only once a day.
The proportion of children with caries experience in primary teeth (dmft) was 30% in urban and 26% in rural children, whereas 23% in urban and 38% in rural children had caries experience in permanent teeth (DMFT). Mean caries experience (dmft) was 1.80 ± 1.10 in urban children when compared to 1.37 ± 0.55 in rural children (P < 0.01). Mean DMFT among urban children was 2.30 ± 1.90 whereas rural children had mean DMFT of 1.90 ± 0.10 (P < 0.01) [Table 2]. It was seen that 47% in urban and 41% in rural did not need any treatment; 15.2% in urban and 9.52% in the rural region needed one surface filling; 14.28% and 19.04 needed preventive measures; 3.3 and 6.66 required pulp care and 6.6% and 11.90 needed extraction among urban and rural region, respectively.
About 46% of the urban parents felt that their child's oral health is excellent compared to 27% rural parents. Similarly, 48% of urban parents were satisfied with their child's teeth when compared to 28% rural parents [Table 3].
About 14% in urban and 6% in rural region agreed regarding a visit to the dentist once in 6 months. Forty percent in urban and 53% in rural region agreed that it is not necessary to take care of milk teeth as it is going to fall off 1 day. Almost all the parents in urban and rural regions agreed that maintaining oral health of child is parents' duty [Table 4].
Television is the major source of health information in urban region (40%) when compared to teachers in rural region (47%) [Figure 1] and [Figure 2].
The majority of parents in urban (52%) and rural region (74%) did not know the role of fluorides in toothpaste. Most of the urban (89%) and rural parents (90%) told chocolates as cause for decay. By avoiding sweets, decay could be prevented was the answer by most of the urban (90%) and rural parents (84%). Of 210 urban parents, 71% agreed that systemic problems, not brushing properly, and food debris/calculus caused bleeding gums as compared to 56% in rural parents.
The response of urban parents was significant dissimilar when compared to rural parents for the perceived barriers "no time to visit" (P = 0.0002); "scared of injection" (P = 0.0033); "affects my work" (P = 0.0486) [Table 5].
|Table 5: Perceived barriers to utilization of child's dental care among parents|
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| Discussion|| |
Utilization of dental care depends on many factors of which few are internal and few external to the patient. Internal factors include perceived need for care, cultural preferences, language, and so forth. External factors include the adequacy of dental care and ability to pay. The problem of inadequate access to dental care for some segments of the population, especially in rural region cannot be solved without knowing the factors effecting the utilization of care.
Children constitute over one-third of India's population of 1.21 billion people, which means, India is home to 400 million children. WHO prescribed index age groups for children are 5 years, 12 years, and 15 years. However, the age group of 6–12 years was considered to represent a full span of primary school children. This age group accounts to about one-fifth of the total Indian population. There is a transition from deciduous to permanent dentition and experience many changes during this period. With the eruption of the first permanent teeth (from about 6 years on), the mouth contains a mixture of both primary and permanent teeth which puts children at increased risk of caries.
Bangarpet taluk in Kolar district has a good healthcare system with a general hospital and an urban primary health care (PHC). This taluk has 9 PHCs, and the general hospital has a working dental unit along with few private dental clinics in the urban region. There are few schools (government, aided, and private) and colleges. Further children have to depend on their parents to avail healthcare facilities. Most of the children in this region were studying in government school which is a proxy indicator of their low socioeconomic status.
The age of children ranged from 6 to 12 years with 60 children in each age group belonged to the urban and rural region from the government, aided, and private schools. Previous studies have considered various age groups ranging from 5 to 16 years.,,,,,,,, Most of the studies were conducted in urban regions ,,, when compared to rural ,, region. Some studies have compared between government and private schools. An equal number of males and females were present in both the regions and different types of schools. This is almost in line with other studies.,,,,
Individuals lower in SES have poorer health than individuals higher in SES. An understanding such as this would be critical for determining the timing of health interventions. The majority of them belonged to lower middle class in the urban and rural region which in line with Bengaluru  and Nepal study.
Most of the children in the urban area used toothpaste and toothbrush to clean the teeth when compared to one-fourth of the rural study participants. However, brushing once a day was reported by almost all the participants in this study. Whereas other studies have reported the use of fluoridated dentifrice, frequency of brushing gender wise, as well as ethnicity.,
Caries experience was similar to the primary and permanent dentition in urban and rural children (<40%). Whereas a study in Bengaluru reported nearly 3-folds caries experience in primary when compared to permanent dentition. Other studies in Bengaluru (57%  and Nepal (41–52%) have reported higher caries prevalence. Mean caries experience significantly differed in the urban and rural children for primary and permanent dentition. Whereas a study from Tamil Nadu reported decrease in mean dmft with increase in age.
The majority of the study participants in urban (47%) and rural region (41%) did not need any treatment. Urban children had higher restorative needs compared to rural children, whereas preventive care needs were higher in rural than urban children. Whereas in a study from Tamil Nadu reported higher restorative and preventive care.
Oral health perceptions provide additional information that will improve our understanding of some of the motivating factors influencing individuals' decisions to seek dental care. Perception about child's oral health and satisfaction was similar in urban area but differed in rural area. While in a Bengaluru study, lower proportion of study subjects considered their oral health as poor and were not satisfied with the appearance of their teeth.
Oral health knowledge is considered to be an essential prerequisite for health-related behavior. Majority in urban areas agreed regarding periodic dental visits when compared to rural area which was in line with Bengaluru study. About half in urban and rural areas felt the importance of milk teeth. Whereas a few considered keeping natural teeth was important in a study from Bengaluru.
Health communication, when delivered effectively in mass mediated contexts, has considerable potential to promote the health of individuals, communities, and population. These mass mediated messages are more likely to be successful in affecting health knowledge, attitudes, behavior, practice, and policy if they integrate health communication theory into their design and evaluation. Television is the major source of health information in urban region when compared to teachers in rural region which was similar to Bengaluru study.
Parents' habits and knowledge about oral health have been found to influence their children's oral health status. The majority of parents in urban, in rural region, were not aware of the presence of fluoride in the toothpaste nor its role which is in line with Nepal study.
Almost all of them in the urban and rural region knew the food items which can lead to tooth decay when compared to 48.9% in Bengaluru study. Prevention of tooth decay by avoiding sweets was reported in the present study when compared to brushing teeth in Bengaluru study. The majority of the parents knew that not brushing properly was the main reason for bleeding gums and felt brushing properly is the treatment for gum diseases which is line with the Bengaluru study. Nepal study reported that 23% as not brushing teeth for gingivitis.
Majority of them among urban and rural region had never taken their children to the dentist before. This is in line with Nepal study.
Barriers to dental healthcare exist, and these have been referred to as resistances that are said to exist within the dentist-patient relationship and are subject to changes in intensity. Essentially, they may act to prevent the patient from progressing from accessing care to accepting dental treatment. The first of these may be related specifically to the individual perception: "Lack of perceived need, anxiety and fear, financial considerations and lack of access." The second category is related to the dental profession: Inappropriate manpower resources, uneven geographical distribution, training inappropriate to changing needs and demands, and insufficient sensitivity to patient's attitudes and needs'. The third and the final category of the barrier are related to society: "Insufficient public support of attitudes conducive to health, inadequate oral health care facilities, inadequate oral health manpower."
Significant proportion of parents in urban and rural region expressed that dental treatment is painful, scared of injections, and scared of dental instruments, while other barriers existed among urban and rural children although the difference was not significant. In studies conducted in Bengaluru, fear of the dentist was the main cause of the irregular visit.,
- Community-based initiatives including school-based programs should emphasize developing trust with providers and encouraging and supporting caregiver-controlled care
- Various types of games, puzzles, and videos for children about oral health may be designed as a part of oral health promotion programs
- Create awareness about oral diseases among parents, children, and teachers by conducting camps and using local television channel and other mass media
- Dental treatment to the children in the school premises should be provided by using frontline workers in the healthcare system
- Along with mid-day meals, hand washing before meals and brushing or rinsing after meals should be inculcated under the supervision of the teacher
- Information regarding oral health should be included on a wider basis in the school curriculum in an attempt to prevent and control dental diseases.
The present study has a limitation of being a cross-sectional study. Qualitative studies are needed to furnish more information regarding factors affecting utilization of care. There was not much difference in the socioeconomic status of urban and rural parents. Hence, further studies should be conducted at district level representing various strata of the society.
| Conclusion|| |
- High caries experience and treatment needs among children in both urban and rural regions
- Overall, the study participants had moderate to poor knowledge, attitude, and practices
- Fear of dentist and dental instruments, nonavailability of dentist, and loss of time from work emerged as significant barriers among urban and rural parents in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]