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Year : 2022  |  Volume : 20  |  Issue : 3  |  Page : 281-286

Factors associated with women's autonomy regarding dental health care utilization in Bengaluru - A cross sectional study

Department of Public Health Dentistry, Government Dental College and Research Institute Victoria Hospital, Bengaluru, Karnataka, India

Date of Submission26-Mar-2022
Date of Decision21-Apr-2022
Date of Acceptance20-Jun-2022
Date of Web Publication12-Sep-2022

Correspondence Address:
B K Aparna
Department of Public Health Dentistry, Government Dental College and Research Institute Victoria Hospital, Kalasipalayam, Near City Market, Bengaluru - 560 002, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_60_22

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Background: Preventive dental care benefits people of all ages and genders' oral health. Among many conceptual implications, autonomy suggests the power to alter one's fate and environment, among other things. Little is known about women's autonomy and factors influencing dental health-care utilization in India. This study was designed to assess knowledge, attitude, and oral hygiene practices and its association with women's autonomy and dental care utilization. Materials and Methods: A cross-sectional study was conducted among 400 women aged 18 years or older in Bengaluru Urban District. Questionnaires were employed to assess women's autonomy, knowledge, attitude, oral hygiene practices, and dental care service utilization. Descriptive statistics and bivariate and regression analyses were carried out. The P < 0.05 was considered statistically significant. Results: More than half of the women (61.3%) had a high level of autonomy. Women with a high level of autonomy had more knowledge, a more positive attitude, and better dental hygiene habits. Autonomy, knowledge, and attitude were all significant independent predictors of women's use of dental care services. Conclusions: Women's autonomy was found to influence knowledge, attitude, and oral hygiene practices which in turn are associated with dental health-care service utilization.

Keywords: Autonomy, health-care delivery, health knowledge-attitudes-practice, oral hygiene, women

How to cite this article:
Aparna B K, Yashoda R, Puranik MP. Factors associated with women's autonomy regarding dental health care utilization in Bengaluru - A cross sectional study. J Indian Assoc Public Health Dent 2022;20:281-6

How to cite this URL:
Aparna B K, Yashoda R, Puranik MP. Factors associated with women's autonomy regarding dental health care utilization in Bengaluru - A cross sectional study. J Indian Assoc Public Health Dent [serial online] 2022 [cited 2023 Dec 6];20:281-6. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2022/20/3/281/355893

  Introduction Top

Oral health encompasses the status of the teeth, the gums, oral soft tissues, chewing muscles, palate, tongue, lips, and salivary glands. Oral illnesses are a global public health issue, but they are characterized by socioeconomic inequality, with the burden falling disproportionately on the poor and disadvantaged.[1] Women are the impoverished, underemployed, and socially and economically disadvantaged worldwide, from health to economy, security to social protection.[2]

According to the World Health Organization's global review of oral health, dental caries, periodontal disease, oral cancer, oral symptoms of HIV/AIDS, dental trauma, and craniofacial abnormalities all have a significant influence on women's health and well-being worldwide.[3] Inadequate usage of dental health-care services may be a key factor to poor oral health in women. The female disadvantage in less-developed countries with regard to health and well-being has been documented abundantly. Few studies have looked at the link between women's status and health-care utilization.[4]

Women's status is determined by extrinsic hierarchies as well as the degree of regard bestowed on her as a result of her gender. It is the result of socially organized gender standards, personal characteristics, and accomplishments. Others' perceptions of women standing in the social environment largely affect her status, which displays her ability to make decisions and act on them.[5]

Women's treatment-seeking behavior is influenced by the power imbalance between men and women. The power dynamic that prevents women from leading healthy and satisfying lives exists on a personal, societal, and extremely public level.[6]

Although connected to women's status, the idea of women's autonomy is more strongly tied with women's power and agency.[5] Women's autonomy is defined in three dimensions; control over finance, decision making power, and extent of freedom of movement.[4] Women's autonomy has been employed by several researchers to capture behaviors such as decision-making and mobility that may or may not be under the women's control.[7] It may be viewed as women's control over their own lives, possessions, and access to knowledge and information, as well as having an equal voice with their spouses or partners on issues that impact them and their families.[6]

Women have a lesser social position and autonomy than males in areas of South Asia and elsewhere.[8] There is a scarcity of data on the link between women's status and the usage of health services, especially oral health care. Individual oral health knowledge, attitudes, and practices (KAP) are, nonetheless, a factor in improved oral health.

In light of these findings, it is critical to analyze women's oral hygiene, knowledge, attitudes, and behaviors, as well as their use of dental health-care services, in terms of their autonomy. KAP surveys have become a valuable tool for measuring diverse health-seeking behaviors. The ease of design, simplicity of interpretation, clear presentation of data, projection of small sample results to larger populations, and speed of implementation are all advantages of KAP surveys.[9] As a result, this study focused on women's autonomy in terms of their ability to make autonomous decisions, their physical mobility, and their financial authority in the home.

The objective of the study was to analyze women's autonomy as well as their oral hygiene knowledge, attitudes, behaviors, and their use of dental health-care services.

  Materials and Methods Top

Study design, participants, and ethical clearance

This community-centered cross-sectional study was granted ethical approval from the institutional ethics committee and review board (GDCRI/IEC-ACM (2)/10/2020-21). A representative sample of women aged 18 years or older living in Bengaluru Urban District, Karnataka, and those who were willing to participate were chosen by employing a stratified cluster sampling method according to the age and socioeconomic status (SES) during September–October 2021. Women who were intellectually disabled and those who were not able to read and write were excluded from the study. After describing the study's purpose and nature, written informed consent was obtained from participants.

Sample size calculation

According to the 2011 census, Bengaluru Urban District has five taluks with urban and rural populations of 90.94% and 9.06%, respectively. Among the five taluks, four taluks (Bengaluru North, Bengaluru South, Bengaluru East, and Yelahanka) constituted the urban sample and one taluk (Anekal) was a rural sample.[10]

The sample size was calculated as 400 using prevalence or proportion (considered 50% from previous literature), Zα/2 = 1.96 at 95% confidence interval, E = margin of error (considered 10%. To maintain the urban and rural population proportion, 364 were selected from the urban area and 36 were selected from rural areas.

Data collection

Structured, prevalidated, and interviewer-guided questionnaires adopted from similar research were used to gather data.[6]

Sociodemographic characteristics

The first section was general information of the women including sociodemographic profiles such as age, education, occupation of the women, head of family, income, SES,[11] marital status, and dental visiting behavior were collected.

Women's autonomy questionnaire

The second section was a 15-item questionnaire to assess three indicator variables; decision-making power, freedom of movement, and financial control adapted to measure women's autonomy.[6] The total of equally weighted binary (1 = responses contributed for a higher degree of autonomy against 0 = otherwise) and two input variables (2 = for women who could decide independently and 1 = for joint decision) were used to build a composite measure for each construct. Based on these values, the total score is found to be 25. Therefore, scores above 12.5 (>50%) and below 12.5 are considered having high and low autonomy, respectively.

Decision-making power was assessed using an 8-item questionnaire about the role of women in decision-making in health care. Respondent alone, respondent and husband/partner jointly, respondent and someone else, husband/partner alone, and someone else were the options for each item. For each question, a woman was given a score of 2 if she made the choice alone and 1 if she was taking decision along with someone (husband/ partner or someone else), with the sum of the scores being an overall indicator of a woman's decision making capacity. For decision-making power, the total score was 16. As a result, scores of 8 and more are deemed high decision-making power, whereas scores of <8 are considered low decision-making capacity.

Three items related to the woman's capacity to leave the house for health treatment, family visits, or any other reason without the consent of another adult were included as markers of freedom of movement. These items had binary replies (yes or no), and those who answered “yes” received a 1, whereas those who answered “no” received a 0. Scores of one and a half and above are regarded as strong freedom of movement, while scores of less than one and a half are considered low freedom of movement.

Four components comprised the indications for financial control: two with binary responses (yes or no with scores 1 or 0) and two with two input variables for independent decision and joint decision (score 2 or 1). The total score for financial control was 6. Scores of three and more were deemed to have good financial control, whereas scores of less than three were judged to have low financial control.

Knowledge, attitudes, and practices questionnaire

The third section was an 18-item questionnaire to assess the knowledge, attitude, oral hygiene practices, and dental health-care utilization in women. Knowledge was assessed using seven questions scored as 0 and 1 for true or false responses. Knowledge was considered “low” for a score of 1–4 and “high” for 5–7. Five questions with binary responses of important/unimportant or pleasant/unpleasant were used to measure attitude. Scores 1–5 were classified as “unfavorable,” whereas scores 6–10 were classified as “favorable.” Four questions were used to measure self-care oral hygiene behaviors, as well as a history of dental treatments.

The questionnaire was in English. Cross-cultural validation of the questionnaire was performed using the back-translation (English to Kannada and Kannada to English) method with help of linguistic experts. It was assessed for readability and comprehension. Upon recruitment, each participant was asked to fill the questionnaire and checked for the completeness of the same once they completed. The participants were requested further to complete the questionnaire if missing values were encountered.

Statistical analysis

The SPSS version 25.0 was used to analyze the descriptive data (IBM SPSS Statistics for Windows, Armonk NY, USA: IBM Corp). The Chi-square test was used to evaluate bivariate frequency distributions statistically. The association of dental care utilization with autonomy, knowledge, and attitude was analyzed using binary logistic regression analysis.

  Results Top

In the current study, 400 participants completed the questionnaires. The mean age of the participants was 34.4 ± 11.9 years. Among women, more than 75% had education of high school or more. Almost 25% were unskilled employees and 15% were unemployed. Majority of them were married and were belonging to the upper-middle class. Majority of them (64.8%) had health concession cards, 7.5% visited the dentist at least once in a year and 70% rated their oral health as good [Table 1].
Table 1: The sociodemographic characteristics and dental visiting behavior among women (n=400)

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Overall, 61.3% of the women had high autonomy and 38.8% had low autonomy measured according to decision-making power, freedom of movement, and financial control. Among women, 60.3% had high decision-making power, 55.3% had high freedom of movement, and 55.5% had high financial control [Table 2].
Table 2: Distribution of women according to autonomy based on decision-making power, freedom of movement, and financial control

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The majority of women exhibited high autonomy across all age categories, and the difference was not statistically significant. Most of the urban dwellers (65.7%) and 34.3% of the rural dwellers had high autonomy. All single and divorced women among the participants had high autonomy. Most of the women having higher education had high autonomy. All of the women from the upper class and most of them from upper-middle and upper-lower socioeconomic classes had high autonomy. Majority of the women with high autonomy perceived their oral health as good compared to very less number of women with low autonomy. A statistically significant difference was found with respect to the area of residence, marital status, education, SES class, and self-rated oral health among women [Table 3].
Table 3: Sociodemographic characteristics of women stratified according to autonomy

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Majority of the women having high autonomy (53.75%) had high knowledge. Women with high autonomy perceived that preventing future problems with teeth, mouth, or dentures, getting teeth cleaned, and getting oral problems fixed are important compared to women with low autonomy (P < 0.001). Majority of the women with high autonomy responded that being afraid about the dental visit is important and women with low autonomy responded important and unimportant almost equally (P < 0.001). All women with high autonomy expected their dental visit would be pleasant compared to very less number of women with low autonomy (P < 0.001). There was a statistically significant difference between women with high and low autonomy with respect to frequency of brushing, use of mouth rinse/mouthwash, and cleaning between the teeth [Table 4].
Table 4: Association of knowledge, attitude, and oral hygiene practices among women according to autonomy

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The majority of women with high autonomy and a small percentage of women with poor autonomy had visited a dentist in the previous 2 years, with the majority of them doing so due to discomfort, and the difference was statistically significant [Table 5].
Table 5: Utilization of dental services by women according to autonomy

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According to logistic regression analysis, women with high autonomy were 2.48 times more likely to use oral health services, whereas women with high knowledge were 1.01 times more likely. Women with a positive attitude were 2.65 times more likely than those with a negative attitude to use oral health services [Table 6].
Table 6: Logistic regression of women's utilization of dental health services as the dependent variable

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  Discussion Top

To achieve gender equality, techniques and policies must frequently be accessible to compensate for women's historical and societal obstacles that prohibit them from being treated equally. Fairness necessitates equity and equity, in turn, necessitates equality. Gender inequality if exists always affects women, leading to their less role in decision-making and limited access to financial or other social resources including health care.[12]

Most research has looked on the supply and accessibility of health services to find answers to women's low levels of health-care usage in developing countries. Only a very few have assessed women's autonomy or other inherent or controlled behavioral factors that can affect health-seeking behaviors.[4],[5],[6] Studies have reported that measured autonomy of women in maternal health-care utilization,[4],[5],[13],[14] maternal and child health care,[6] and reproductive behavior.[2] Regarding dental health care, none of the studies have assessed the role of women's autonomy in accessing care, which may be a proximate determinant of oral health.

In the present study, 61% of women had high autonomy in terms of decision-making power, financial control, and freedom of movement and it was associated with education, occupation, SES, and place of residence. The proportion of women with high autonomy was more compared to a study done in Ethiopia (41%). In our study, more than half of them (61%) had high decision-making power at the household level which was similar to a previous study done in rural India.[5] More than half of them (55.5%) had a high financial control and regular access to money which was a higher proportion compared to the study reported in Ethiopia (38.1%).[6] More than half of them in our study (55.3%) had high freedom of movement indicating they could leave home without any other adult's permission. On contrary, a large majority of women needed permission to go to the market or to visit relatives or friends in a study reported in India.[5] However, a similar result was found in an Ethiopian study.[6]

Almost 56% had made a dental visit within the past 2 years. Majority of them had high autonomy with high knowledge and favorable attitude toward oral hygiene and dental visiting behaviors. Women with high autonomy utilized dental services significantly better compared to those with low autonomy in the current study. It was found that autonomy, knowledge, and attitude regarding oral hygiene and dental service utilization were significant predictors of dental health service utilization in women. Having high autonomy, high knowledge, and favorable attitude toward oral hygiene and dental visiting behavior were contributing to more utilization of dental services.

This is likely to be the first study to measure women's autonomy in terms of their oral hygiene KAP, as well as the possible relationship between these indicator factors and dental treatment consumption. This may be regarded as one of our study's strengths.

Even though the cross-sectional study design did not allow us to find the causality, the study results are suggestive of a possible association between the variables. The group we obtained in our study can be considered heterogeneous population due to the stratified sampling method chosen which could aid in generalization of the findings in similar populations.

Although the questionnaire we used for autonomy was for health-care service use, it might also be used for dental health-care use. The confidentially of the participants was ensured to eliminate social desirability bias concerning prior dental care service consumption due to the use of a self-administered questionnaire.

To determine the cause-and-effect relationships, further longitudinal studies with a bigger sample size are recommended. Specific measures to assess autonomy regarding dental health-care utilization can be incorporated in future studies for further validation.

  Conclusions Top

Women's autonomy can affect health-care-seeking behaviors including dental health-care-seeking behaviors influenced by factors such as knowledge, attitude, and oral hygiene practices. Dental health behavior is shaped by many environmental subsystems, including family, community, attitudes, education, occupation, and the physical and social environments in which people live, so effective interventions for behavioral change to increase the utilization of dental health-care services must influence multiple factors.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hosseinpoor AR, Itani L, Petersen PE. Socio-economic inequality in oral healthcare coverage: Results from the World Health Survey. J Dent Res 2012;91:275-81.  Back to cited text no. 1
Khan N, Ram U. Can women's perceptions of their own autonomy enable them to generate changes in their reproductive behavior ? Evidences from gender perspectives. Sociology 2008;1-43.  Back to cited text no. 2
Callister LC. Global oral health in women and children. MCN Am J Matern Child Nurs 2008;33:60.  Back to cited text no. 3
Bloom SS, Wypij D, Das Gupta M. Dimensions of women's autonomy and the influence on maternal health care utilization in a north Indian city. Demography 2001;38:67-78.  Back to cited text no. 4
Mistry R, Galal O, Lu M. “Women's autonomy and pregnancy care in rural India: A contextual analysis”. Soc Sci Med 2009;69:926-33.  Back to cited text no. 5
Nigatu D, Gebremariam A, Abera M, Setegn T, Deribe K. Factors associated with women's autonomy regarding maternal and child health care utilization in Bale Zone: A community based cross-sectional study. BMC Womens Health 2014;14:79.  Back to cited text no. 6
Shroff MR, Griffiths PL, Suchindran C, Nagalla B, Vazir S, Bentley ME. Does maternal autonomy influence feeding practices and infant growth in rural India? Soc Sci Med 2011;73:447-55.  Back to cited text no. 7
Saleem S, Bobak M. Women's autonomy, education and contraception use in Pakistan: A national study. Reprod Health 2005;2:8.  Back to cited text no. 8
Avula H, Mishra A, Arora N, Avula J. KAP assessment of oral health and adverse pregnancy outcomes among pregnant women in Hyderabad, India. Oral Health Prev Dent 2013;11:261-70.  Back to cited text no. 9
Census of India 2011. Karnataka. Direct Census Handbook Bangalore. Directorate of Census Operations, Karnataka; 2011. Available from: https://censusindia.gov.in/2011census/dchb/2918_PART_A_DCHB_BANGALORE.pdf. [Last accessed on 2021 Jan 30].  Back to cited text no. 10
Saleem SM, Jan SS. Modified Kuppuswamy socioeconomic scale updated for the year 2021. Indian J Forensic Community Med 2021;8:1-3.  Back to cited text no. 11
Sundar I. Gender equality and women empowerment. Int J Humanit Soc Sci 2017;7:7-21.  Back to cited text no. 12
Woldemicael G. Do women with higher autonomy seek more maternal health care? Evidence from Eritrea and Ethiopia. Health Care Women Int 2010;31:599-620.  Back to cited text no. 13
Mullany BC, Hindin MJ, Becker S. Can women's autonomy impede male involvement in pregnancy health in Katmandu, Nepal? Soc Sci Med 2005;61:1993-2006.  Back to cited text no. 14


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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