Journal of Indian Association of Public Health Dentistry

REVIEW ARTICLE
Year
: 2016  |  Volume : 14  |  Issue : 2  |  Page : 231--236

Knowledge and awareness regarding oral health among anganwadi workers in India: A systematic review


Ramandeep Singh Gambhir1, Samir Anand2, Tarun Gupta3, Arshdeep Singh4, Harkiran Kahlon5, Amanpreet Kaur6,  
1 Department of Public Health Dentistry, Rayat and Bahra Dental College and Hospital, Mohali, Punjab, India
2 Department of Periodontics, Rayat and Bahra Dental College and Hospital, Mohali, Punjab, India
3 Department of Public Health Dentistry, MM University, Mullana, Ambala, Haryana, India
4 Department of Public Health Dentistry, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
5 Department of Oral and Maxillofacial Pathology, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
6 Department of Public Health Dentistry, Gian Sagar Dental College and Hospital, Rajpura, Punjab, India

Correspondence Address:
Ramandeep Singh Gambhir
Department of Public Health Dentistry, Rayat and Bahra Dental College and Hospital, Mohali - 140 104, Punjab
India

Abstract

Background: Anganwadi workers (AWWs) play a vital role in improving health of the community whom they serve especially in rural areas. They form a potential vehicle for disseminating even oral health-related message and knowledge. Aim: To conduct a systematic review of observational studies to assess AWWs' knowledge and awareness regarding oral health. Materials and Methods: Relevant cross-sectional observational studies were included in the systematic review to assess the level of knowledge and awareness regarding oral health among AWWs. Eight studies out of 32 were finally included in the present review after conducting both electronic and manual search of scientific databases like PubMed, MEDLINE, and EMBASE. No limitation in terms of publication date was considered. Potential biases were reported and appropriate data were extracted by the concerned investigators. Results: More than 90% of subjects had education till graduation level in some studies. Very few subjects were aware regarding the role of fluorides in other two studies (7.9% and 3.4%). Very few subjects (17.1% and 37.5%) felt the need for visiting a dentist during pregnancy in two studies. Majority of the subjects cited tooth decay/pain as the main reason to visit the dentist in three studies. There were only two studies in which > 90% of subjects were aware regarding the association of oral health and general health. Conclusion: The results of the present review had shown that knowledge and awareness of AWWs is not adequate. Therefore, there is an urgent need for further education on certain preventive and curative aspects of oral diseases and maintenance of oral health.



How to cite this article:
Gambhir RS, Anand S, Gupta T, Singh A, Kahlon H, Kaur A. Knowledge and awareness regarding oral health among anganwadi workers in India: A systematic review.J Indian Assoc Public Health Dent 2016;14:231-236


How to cite this URL:
Gambhir RS, Anand S, Gupta T, Singh A, Kahlon H, Kaur A. Knowledge and awareness regarding oral health among anganwadi workers in India: A systematic review. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2019 Jun 26 ];14:231-236
Available from: http://www.jiaphd.org/text.asp?2016/14/2/231/181900


Full Text



 Introduction



Oral problems are emerging as one of the main public health concerns in India. Oral problems are not only causing pain, agony, functional, and esthetic problems but also lead to loss of working man-hours. Hence, in the long run, they are bound to have a significant impact on our economy.[1] Oral health is also an essential and leading component of children's overall health, functional capacity, and social welfare.[2] In developing countries, there is a vast difference in oral health status between urban and rural populations, with enormous and widening disparities in access to quality care, predominantly in rural areas.[3]

Oral diseases are controllable only if services are oriented towards primary health care and prevention. Primary health care workers might play a crucial role in areas where there is deficiency of dental healthcare professionals in providing oral health services. An anganwadi worker (AWW) is a grass root-level worker who serves around 1000 population. Selected from the community, they are aware of the ways of the people, comfortable with the language, aware of their social and cultural backgrounds, hence making it easy to figure out the problem being faced by the people.[4] They have successfully demonstrated their useful role in community education under various national health programs.[5] Previous studies have also shown that these people are also responsible for inculcating healthy habits in children like correct brushing techniques and hand-washing through nonformal education methods.[6],[7] Monthly meeting of mothers at anganwadis provides a platform for disseminating health education to mothers regarding breast feeding, immunization, safe delivery practices, pre- and post-natal care, growth monitoring, supplementary nutrition, etc.[7]

AWWs clearly have a significant role to play in the nutrition, and oral health of children, and this thing needs to be further explored. Assessing the knowledge, attitude and practices of AWW is the first step towards planning an oral health education program in order to strength their skills so that they can efficiently function as oral health guides.[8] No systematic review has been conducted till now on AWW in India. Therefore, the present systematic review of the knowledge, awareness, and attitude of AWW was conducted so that their training curriculum can be modified if required.

 Materials and Methods



Eligibility criteria for the studies

The present systematic review included the studies conducted on oral health knowledge and awareness among AWW. Study selection was based on following inclusion criteria: (1) Studies on AWW; (2) published in English language; (3) studies evaluating the knowledge and awareness as outcome measures; and (4) observational cross-sectional studies. No limitation in terms of publication date was considered in the search strategy. The studies that were excluded from the present review were (1) reviews; (2) intervention and experimental studies and (3) unpublished material and abstracts.

Identification of appropriate studies

Search strategy utilized in the present systematic review is depicted in [Figure 1]. The present review was conducted according to the mentioned protocol and guidelines.[9] Relevant literature search was carried out through search of scientific databases like MEDLINE, EMBASE, PubMed using MESH terms – “village health workers,” “Oral health,” knowledge, etc., irrespective of the date of publication. Manual search was also conducted from Institutional and PGIMER library. Online search engines like “Google Scholar” were also assessed using various keywords - knowledge, awareness, self-care, attitude, AWWs, oral health, etc., Various combinations of key words were also made using “and,” “or” as Boolean operators. We identified 32 papers with these methods. Where possible, all terms were included as full text, with truncation used where possible to capture variation in the terminology. Finally eight articles were selected for inclusion in the review.{Figure 1}

Selection of studies

After retrieval of references yielded by the electronic and manual searches, duplicate studies were identified and excluded by three authors (RSG, SA and AK), who then screened the abstracts and titles to identify the publications fulfilling the inclusion criteria for the review. Reviews were not included though their reference lists were searched in turn for any studies not retrieved by the electronic search. For the remaining studies, full text articles were recovered that met the inclusion criteria. Selected studies were screened using STROBE checklist for observational cross-sectional studies.[10]

Quality assessment and control of bias assessment

The major aim of quality assessment was to determine the potential for selection bias (eligibility criteria, sampling strategy, sample size, generalizability, etc.). This is especially important in cross-sectional studies that aim to report knowledge and awareness levels. A total of nine domains were assessed. A score of one was given for fulfilling conditions in each domain, 0.5 for partial fulfillment and zero otherwise [Table 1]. The maximum possible score was 9 and a study scoring 6 or more was classified as high-quality study and low-quality study otherwise. The quality assessment of the studies was done on the basis of guidelines set forth by Preferred Reporting Items for Systematic Reviews and Meta-Analyses and STROBE checklist.[19] Two of the authors (TG and AS) independently used a predetermined data collection form to extract information on following nine domains: (1) Title of the study; (2) clear objectives; (3) study setting; (4) sample size adequacy; (5) study design; (6) eligibility criteria; (7) sampling strategy; (8) completeness of reporting information regarding oral health; and (9) discuss of generalizability. Any kind of disagreement regarding article screening and extraction was sorted out by other author (HK). Corresponding authors of selected studies were also contacted through E-mails for obtaining full text of included studies and missing or unclear data whenever deemed essential. When all criteria were met, the overall plausible risk of bias was estimated as low.{Table 1}

 Results



Description of selected studies

The original search identified 32 studies and only eight studies were potentially eligible for the present systematic review after performing necessary exclusions.[11],[12],[13],[14],[15],[16],[17],[18] The study population in all the studies comprised AWWs residing in urban and rural areas. A summary of various study characteristics is mentioned in [Table 2]. Six studies were conducted in Karnataka whereas one each was conducted in Madhya Pradesh and Uttar Pradesh. All the studies were cross-sectional in nature and used a self-structured questionnaire (close-ended) for gathering the relevant data on knowledge and awareness regarding oral health among AWWs.{Table 2}

Educational status of AWWs

[Figure 2] depicts the educational qualification of AWWs as mentioned in four out of eight studies.[14],[15],[17],[18] It can be noted from the figure that >90% of subjects were undergraduates in three of the studies.[14],[15],[17] However, findings of the fourth study revealed that >30% of the subjects were post graduates.[18] Only one study compared the knowledge of subjects regarding oral health with education level.[18] Mean knowledge scores were nonsignificant in relation to education level in this study.{Figure 2}

Fluoride prevents tooth decay

[Figure 3] depicts the knowledge of subjects regarding fluoride as an anti caries agent in different studies.[14],[15],[16],[17] It was shocking to note that almost all of the workers were unaware of the element fluoride and its role in preventing dental caries in study reports of Pankaj et al.[12] and very few subjects were aware regarding the role of fluorides in other two studies (7.9% and 3.4%).[16],[17] Moreover it was surprising to note that >80% of subjects believed that fluoride is added to drinking water to purify it in the study findings of Shilpa et al.[17] Only 64.8% of subjects were aware of the benefits of fluoride in spite of 90% saying that they considered tooth brushing to be a caries preventive measure in another study.[15]{Figure 3}

Aids and material used for cleaning teeth

[Table 3] depicts various aids and materials used by study subjects to clean teeth. Study findings of Sequeira et al.[11] revealed that about half of the subjects used materials other than tooth brush (curry leaves) to clean their teeth. Surprisingly, none of the studies reported association between cleansing aids used and oral health knowledge.{Table 3}

Association between oral health and general health

Six studies provided information on the participants' response on questions regarding relation of oral health to general health and well-being [Table 4].[11],[13],[14],[16],[17],[18] Study findings of Gangwar et al.[16] revealed that majority of subjects (88.5%) did not know the association between tobacco consumption and oral cancer. Moreover, 1.5% of subjects were of the opinion that nonremoval of deposits on the teeth can lead to cancer in study reports of Sequeira et al.[11]{Table 4}

 Discussion



The emphasis of the present systematic review was on the oral health knowledge and awareness among AWWs in India and no attempt was made to compare the oral health status of these workers. Various parameters were utilized in order to accumulate oral health information among AWWs which is evident from the results.

Strength and weakness of the review

This systematic review involved the search of multiple electronic databases, with no restrictions regarding year of publication. The reference lists of literature reviews were searched for other studies that could also be included. However, it was not possible to search technical reports, papers from research groups or committees and preprints and it is possible that some relevant data may have been left behind. This could have accounted for some publication bias. Moreover, there was under-reporting of some relevant information (descriptive data, questionnaire) related to knowledge, attitude, and awareness among AWWs in three studies.[11],[13] As a result of this, some important aspects pertaining to knowledge and awareness were not included and compared with other studies that were included in the review. Because of the marked variability in the questionnaire and outcomes of the included studies, it was not possible to combine the data and perform meta-analysis.

The quality of the studies ranged between three and eight points, which demonstrate methodological variability. All investigations were cross-sectional studies. This type of design offers a lower degree of scientific evidence compared with case–control and cohort studies. Moreover, cross-sectional descriptive studies, themselves have their own limitations in terms of methodological issues, generalizability, and internal validity. However, the use of scales for quality assessment has limitations that should be considered. The scales use a summary or domains that involve scores to different items and it is difficult to justify the scores assigned.

All the studies used a close-ended questionnaire to obtain information about various aspects of oral health and hygiene. Such type of questionnaire reduces recall bias and such questions are easy to analyze and may achieve quicker response from the subjects. Another limitation is that we excluded non-English studies. We found only one study in a Hindi language in which there was considerable under-reporting of results and was not complete. Therefore, it was excluded from the review. Thus, it is unlikely that this exclusion would affect the conclusions of this study.

Statement of principal findings

It is reported in three studies [14],[15],[17] that >90% of AWWs were undergraduates. This could be due to the reason that minimum qualification to be eligible for the post of AWW is matric or equivalent.[20] Moreover, AWWs are given similar type of training in aspects of health and disease after their selection irrespective of their educational qualification proving that mean knowledge scores were insignificant in relation to education level in one of the studies.[18]

Less than 10% of the subjects were aware regarding the role of fluorides as an anticaries agent in some studies.[12],[16],[17] This reflects the deficiency in oral health information among AWWs who are already in-service as care takers of children. Therefore, the AWWs need to be educated about the importance of fluoride.

More than 90% of subjects agreed to the fact that oral health has an important bearing on general health in few studies.[14],[17],[18] However, a vast number of subjects were unaware regarding the harmful effects of tobacco and oral cancer in two studies.[13],[16] This information shows that despite the best efforts of the Government of India to spread awareness on the harmful effects of tobacco in its various forms, there is ignorance among healthcare workers let alone the rural population.[21] Therefore there is a need for conduction of periodic oral health programs and topic of oral health should be included in their training curriculum.

There is a strong and intense need for improving the training quality provided to AWWs to enhance their knowledge which is evident from the results. When the AWWs are freshly recruited, they undergo an official 4-month training, in which the authorities can consider to include dental training in their curriculum. Furthermore, the dental colleges can adopt anganwadi centers in their vicinity and the dental interns can be utilized to train the AWWs. A concerted effort on the part of state, policy makers, health administrators, and public health professionals is required to impart the necessary knowledge and awareness among this important segment of population. Moreover, the present review found that majority of the studies were conducted among south Indian population. Therefore there is an urgent need of similar studies that could be conducted in other parts of the country to get reliable data.

 Conclusion and Suggestions for Further Research



An AWW has a pivotal role to play in the healthcare delivery system as she is in a position to deliver a package of services to mothers and children. The present review strongly felt the need of improving the quality of knowledge and awareness among AWWs about oral health as it was moderate in few dimensions and less than desirable in some aspects. Majority of them were not aware regarding the role of fluorides and association between tobacco consumption and oral cancer.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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