Annals of Tropical Medicine and Public Health

ORIGINAL ARTICLE
Year
: 2011  |  Volume : 4  |  Issue : 2  |  Page : 99--106

Dental health awareness, attitude, oral health-related habits, and behaviors in relation to socio-economic factors among the municipal employees of Mysore city


BR Chandra Shekar1, C.V.K Reddy2, BC Manjunath3, S Suma4,  
1 Department of Community Dentistry, People's Dental Academy, Bhanpur, Bhopal, Madhya Pradesh, India
2 Department of Community Dentistry, J S S Dental College and Hospital, S S Nagar, Mysore, Karnataka, India
3 Department of Community Dentistry, Jaipur Dental College, Dhand, Amer Tehsil, NH-8, Jaipur, Rajasthan, India
4 Department of Orthodontics, People's Dental Academy, Bhanpur, Bhopal, India

Correspondence Address:
B R Chandra Shekar
Department of Community Dentistry, People«SQ»s Dental Academy, Bhanpur, Bhopal - 462 037, Madhya Pradesh
India

Abstract

Objective: To assess the dental health awareness, attitude, oral health-related habits, and behaviors in relation to socioeconomic factors among the municipal employees of Mysore city. Study Design and Methodology: This study was cross-sectional in nature and involved completion of a predesigned structured questionnaire. The questionnaire included multiple option questions to collect information on awareness on dental diseases, visit to dentist, reasons for visit, reasons for not visiting dentist on routine basis, oral hygiene practices, and deleterious oral habits. Modified Kuppuswamy scale with readjustment of per capita income was used to classify individuals into different socioeconomic status (SES) categories. Data were entered onto a personal computer and analysis was done using SPSS version 14. Results: Awareness on dental diseases was 100% in upper SES and nil (0%) in the lower SES. Visit to dentist in the last 1 year was 100% in the upper SES and 32.3% in the lower SES. The prevalence of smoking, pan-chewing, and alcohol consumption was high in lower SES than in upper SES. Oral hygiene practices were better among the subjects in upper class than the lower ones. Conclusion: A direct relation was noted between the favorable dental health awareness, attitude, oral hygiene behavior, and SES.



How to cite this article:
Chandra Shekar B R, Reddy C, Manjunath B C, Suma S. Dental health awareness, attitude, oral health-related habits, and behaviors in relation to socio-economic factors among the municipal employees of Mysore city.Ann Trop Med Public Health 2011;4:99-106


How to cite this URL:
Chandra Shekar B R, Reddy C, Manjunath B C, Suma S. Dental health awareness, attitude, oral health-related habits, and behaviors in relation to socio-economic factors among the municipal employees of Mysore city. Ann Trop Med Public Health [serial online] 2011 [cited 2020 May 31 ];4:99-106
Available from: http://www.atmph.org/text.asp?2011/4/2/99/85761


Full Text

 Introduction



The attainment by all people of the world, a level of health that enables them to lead a socially and economically productive life, is the social target of World Health Organization. [1] Health is multifactorial and multidimensional influenced by factors such as genetics, lifestyle, environment, socio-economic status (SES), and many others. [2] All these factors have a direct or indirect bearing on the incidence, course, and outcome of a wide variety of communicable and noncommunicable diseases as well as many other health problems besetting the world today. Health cannot be isolated from its social context, and the last few decades have shown that social and economic factors have as much influence on health as the medical interventions. [2] Over the last century, health has improved significantly. This improvement, however, has not been experienced equally across the population, being considerably greater among the better off. [3] Oral health is always an inseparable part of general health. The last two decades have witnessed an improvement in oral health among the children and adolescents in many industrialized countries, especially with respect to dental caries. [4],[5],[6] Conversely, the oral diseases are on the rise in many developing and underdeveloped countries. [7],[8] The factors attributed to this dramatic change in the trend may be modification in the dietary habits, improved oral hygiene practices, effective use of fluorides, and establishment of school-based preventive programs. [9],[10] Along with this, a notable improvement in the level of oral health awareness, dental health knowledge, and attitudes among the children and parents in developed countries has been cited as an important contributing factor for improved oral health. [11],[12] Literature in the past has found the dental disease levels to be associated with cultural differences, [13] low-income families, [14] lower educational levels, [15] low levels of oral health knowledge, [16] inadequate oral hygiene, [17] fewer dental visits, [18] and a highly cariogenic diet. [19]

Oral hygiene behavior and seeking oral health care depend on a number of factors. Patients comply better with oral health care regimens when informed and positively reinforced. Lack of information is among the reasons for nonadherence to oral hygiene practices. Further, oral health attitudes and beliefs are significant for oral health behavior. [20] A higher likelihood of seeking preventive dental care is found to be associated with dental health knowledge. [21] The motives prompting people to seek preventive dental care include the beliefs that one is susceptible to dental disease, that dental problems are serious, and that dental treatment is beneficial. Those who believe that they are highly susceptible to dental disease make more preventive dental visits. [22] SES along with the attitude, awareness, habits, and behavior determine ultimately the level of health and oral health in an individual. Very few studies have been done in the past to investigate the relation between SES and dental health awareness, attitude, and dental health behavior among the adult population in India. [23],[24]

Municipal Corporation is a body consisting of employees of different socioeconomic categories from a high (commissioner, deputy commissioner, health professionals, engineers, administrative officers, etc.) to a low socioeconomic class (sanitary workers, gardeners, gang men, etc.) under one organization. The literature on the dental awareness, attitude, and dental health behavior among the municipal employees in India is also not available in the published dental literature. The assessment of these employees will provide an opportunity to assess the relationship between socioeconomic factors and dental awareness, attitude, and dental health behavior.

Hence, this study was taken up as an attempt to assess the relationship between socioeconomic factors and dental health awareness, attitude, oral health-related habits, and behaviors among the municipal employees of Mysore city. The city of Mysore is the second largest in the state of Karnataka, India, which is spread across an area of 128.42 km 2 . From ancient times, this district has played a significant role in the history of South India. The city is at 770 m above sea level and 140 km from Bangalore-The capital of Karnataka state. [25]

 Materials and Methods



The permission for this cross-sectional questionnaire study was obtained from the commissioner of Mysore City Corporation, who in turn, through a circular, notified all the employees about the intent of the study and date and place of their interview. The ethical clearance was obtained by the institutional ethics committee following the submission of questionnaire for their review. The study involved an interview to complete a predesigned and structured questionnaire that was prepared to collect all the relevant information regarding the socioeconomic and other characteristics of importance. The questionnaire collected information regarding the person's occupation, education, monthly income, the number of individuals in the family, and the education, occupation of the head of the family (if the head of the family was someone other than the employee), and total monthly income of the family from all sources. This information was used for determining the SES of the individual using Modified Kuppuswamy scale. [26]

Modified Kuppuswamy scale considers the education, occupation, and income of the head of the household. Each of these parameters was given weightages and then the total of these three indicators was taken to determine the SES of the individual [Table 1]. The readjustment of the per capita income in the scale was made after obtaining the expert opinion from the department of Economics and Co-operation, Manasa Gangothri, a reputed university, in Mysore, Karnataka, and the concerned statistician.{Table 1}

Procedure for readjustment

The basic pay scales of all the 20 classes of state government employees ever since the first pay scale revision (1970) to the latest pay scale revision (1998) was collected. [27] The change in the basic pay of each class of employees from 1985 pay scale (pay scale at the time when Modified Kuppuswamy scale was introduced) to 1998 pay scale (pay scale at the time of study) was noted. The basic pay of each class of employees in 1998 pay scale was divided by the basic pay of the respective class of employees in the 1985 pay scale. The average of this was taken. The average was then multiplied to the original per capita income in the Modified Kuppuswamy scale. The fractions were rounded off to the nearest whole number while readjusting the ranges in the per capita income of the Modified Kuppuswamy scale. The weightages of different items in the Revised Modified Kuppuswamy Scale for determining SES are denoted in [Table 1] and [Table 2].{Table 2}

The questionnaire also included multiple option questions to collect information regarding their awareness toward most common oral diseases such as dental caries, periodontitis, and oral cancer, awareness on the provision for reimbursement for dental care, dental visits, the reasons for the visits, the reasons for not visiting a dentist on a routine basis, smoking, pan-chewing, alcohol consumption, and oral hygiene practices. Three multiple option questions each on the causative factors and prevention for dental caries, periodontal diseases, and oral cancer were asked. Each correct answer was given a score of 1. If an individual has given at least five correct answers out of nine, he/she was considered to be aware about these common oral diseases. The questionnaire was filled by the investigator himself after obtaining consent from each of these study participants to avoid the misinterpretation of the questions and to ensure uniformity in data collection. The questionnaire was pretested with 30 selected study subjects on two different occasions separated by 10 days. The questionnaire was found suitable for application among the study population as there was high concurrence with the answers to the items on two occasions (Kappa test coefficient for all questions =0.96). The data were entered onto a personal computer, and statistical analysis was done using SPSS version 14. The statistical significance was fixed at 0.05. Chi-square test, cross-tabs, and contingency coefficient were used for analysis of the results.

 Results



Municipal Corporation of Mysore had 1198 employees. Among them 11 subjects were not available during the study period as they were on long leave. All the remaining 1187 subjects participated in the study and their data were considered for the final analysis. The mean age of the study population was 40.74 years with a standard deviation of 9.17 [Table 3] and the age range was 19-57 years. Some of the employees in the age range of 19-24 years were on contract basis and their job was not yet regularized by the corporation. But their data were considered for the study as they cooperated and they were working in the corporation at the time of study. Among the 1187 subjects, 817 (68.8%) were males and 370 (31.2%) were females [Table 4]. The awareness on the causative factors for most common oral diseases (dental caries, periodontal diseases, and oral cancer) was about 25.3% in the study population. All the subjects in the upper SES category were aware, and none of the subjects in lower SES category had awareness. The awareness was inversely related to SES [Table 5]. Although the study found the awareness on oral diseases to be slightly more among males (26.1%) compared with females (23.2%), the difference was not statistically significant. Municipal Corporation has a provision for reimbursing the cost of certain dental health services. The awareness on this was found only in 16.6% of the study population. The awareness on reimbursement for dental services was 100% among the subjects in the upper SES category, whereas none in the lower SES was aware about this. The difference was statistically significant [Table 6]. The awareness on the provision for reimbursement for dental care was marginally better among females (18.9%) than males (15.5%). But this difference too was not statistically significant; 43.9% of the study subjects had a dental visit within the last 1 year. All the subjects in the upper SES group had a dental visit, whereas only 32.1% of the subjects in the lower SES visited dentist. The visit to the dentist was directly related to SES [Table 7]. The visit to dentist in the last 1 year was more among males (44.7%) than females (42.2%) which was statistically not significant. Among the subjects having a dental visit in the last 1 year, 13.2% of the study subjects visited as a routine, whereas 58.3% visited to get their painful tooth/teeth extracted; 92.5% of the subjects in the upper SES visited dentist as a routine, whereas none in the lower SES made this routine dental visit. Among the subjects in the lower SES who visited dentist, 58.3% made a visit to get their painful tooth/teeth extracted, as a last ditch effort when all other measures failed [Table 8]. While assessing the reasons for not having dental visit among those who did not visit dentist in the last 1 year, 60.9% quoted high cost and 15.3% quoted lack of knowledge and motivation. Among the subjects in the upper classes who were not having frequent visits to dentist, lack of time (100%) was the primary reason, and among the subjects in the lower SES category, it was the high cost (71.4%) [Table 9]. The overall prevalence of smoking, pan-chewing, and alcohol consumption in the study population was 39.4%, 33.8%, and 14.6%, respectively. The prevalence of all these deleterious oral habits was inversely proportional to SES [Table 10]; 71.4% of the subjects in the study used a tooth brush and paste for cleaning their teeth. All the subjects in the upper SES were using brush and paste for cleaning their teeth, while majority of the subjects in the lower SES were using either finger with charcoal (46.4%) or finger with mud (50%) [Table 11]; 95.5% of the subjects in the upper SES cleaned their teeth twice in a day and all the subjects in the lower SES cleaned once a day [Table 12]. The oral hygiene practices were better among the subjects in the upper SES category than in the lower ones.{Table 2}{Table 3}{Table 4}{Table 5}{Table 6}{Table 7}{Table 8}{Table 9}{Table 10}{Table 11}{Table 12}

 Discussion



The awareness on the causative factors for dental diseases, [15] the attitude, [16] oral health-related habits, and behaviors [20],[21] plays a vital role in determining the oral health status of individuals along with SES. [4],[5],[6],[7],[14],[15] The scarce literature on dental health awareness, attitude, oral health-related habits, and behaviors among the adult population in relation to socioeconomic factors in India prompted us to take up this study on the municipal employees of Mysore city that had all the classes of employees under one roof.

The income categories in Modified Kuppuswamy scale were based on the 1988-1989 All India Consumer Price Index of 803 for industrial workers. Since then, the prices of all commodities have gone up, and in accordance with this, the salary of the government servants has also increased. There is no correction factor based on all India Consumer Price Index for readjusting the per capita income in Modified Kuppuswamy scale as we see for B G Prasad scale. [27],[28]

B G Prasad scale considers only per capita income and does not consider the education and occupation. Modified Kuppuswamy scale appears to be more comprehensive for SES classification compared with other scales applicable in India. Although this scale has the drawback of not having the correction factor for readjusting the per capita income, the scale was chosen in the study with readjustment of the per capita income to suit the present levels for SES classification as it was relatively comprehensive.

The awareness on the causative factors for most common oral diseases such as dental caries, periodontal diseases, oral cancer, the methods for their prevention and control, and awareness on the provision for reimbursement for dental care was better among the subjects in the upper class. The upper SES subjects tend to use the health and oral health services more frequently. The frequent dental visits facilitate the subjects in the upper class to gain more knowledge on the causes for oral diseases and their prevention, which is not the case among the lower class people. The favorable dental health attitude that develops because of dental visits drives the people in the upper class to seek information on oral diseases and apply the preventive procedures in their day-to-day life. The difference in the frequency of dental visits among the subjects in different SES categories may explain this difference in the degree of awareness. The results of our study were in agreement with the findings of studies by Newman et al.[29] and Sanders et al.[30] The dental visits were more frequent among the subjects in the upper class. Majority of the subjects in the upper class who visited dentist in the last 1 year did so for a routine dental check-up without any specific complaints, whereas a major bulk of the lower class people visited dentist to get remedy for an acute oral health problem. A look at the reasons for not having a dental visit reflected high cost and lack of attitude and motivation among the subjects in the lower class and lack of time among upper classes. The social pressure to retain the natural teeth and a pleasing appearance drive the upper class people into preventive action, whereas the high cost of sophisticated dental services may discourage the subjects in the lower class not to have a dental visit on a routine basis. They reserve the dental visit for an acute problem when all other possible methods to alleviate the existing problem have completely failed. [31] This in the long run may result in the development of a negative attitude toward dentist and dental procedures among the people in lower classes. This suggests a bidirectional adverse relationship between attitude, dental visits, and awareness on the causative factors for dental diseases. The results were in line with studies by Gundala and Chava. [32] The prevalence of various deleterious habits such as smoking, pan-chewing, and alcohol consumption were high among the subjects in the lower SES categories than in the upper ones. The lack of awareness on the ill effects of these habits among the subjects in the lower classes, scarce material resources, psychosocial stress due to an unfavorable social position, and poor material conditions explains this difference in the prevalence of deleterious habits between different socioeconomic classes as evidenced in the studies by Graham [33] and others. [34],[35],[36],[37] The oral hygiene aids used for cleaning the teeth and the frequency of tooth cleaning were better among the subjects in the upper classes than among those in the lower classes. The subjects in the upper class will have a better knowledge on the usefulness of oral hygiene aids and oral hygiene practices in the prevention of oral diseases which may be lacking among the lower classes. Besides, the lack of affordability to buy the oral hygiene aids may prompt the people in the lower classes to look out for cheaper alternates in the form of charcoal, mud, and so on along with finger that is detrimental to the oral health. The direct relationship between SES and oral hygiene practices has been documented in the studies by Davidson et al.[38] and Ronis et al.[39] The level of dental health knowledge, positive dental health attitude, and dental health behaviors are interlinked and positively associated with the level of education and income as demonstrated by studies in the past. [40],[41],[42],[43] All these studies have found the level of education to play a vital role, as, an educated individual gains the requisite knowledge from multiple sources. This in turn will drive these people to have a positive dental health attitude and behavior.

 Conclusion



Oral health care has been given a greater importance in many industrialized countries due to political and economic reforms. Comprehensive oral health educational programs were directed toward the professionals and the public, targeting the adults and the young in these countries. Health education attempts to change behaviors by altering an individual's knowledge, attitudes, and beliefs about health matters. However, educational oral health programs in India have been mainly conveyed to the public on a narrow scale by certain formal medical/dental institutes in the country. These efforts are limited and insufficient nationwide. There is a need for comprehensive national educational programs to improve the oral health practice, knowledge, and attitudes of the general population in the country as a whole. The data in this study indicate that a direct relation exist between the favorable dental health awareness, attitude, oral hygiene behavior, and SES. This suggests that the development and implementation of well-structured dental health education programs on periodic basis are needed to improve and maintain suitable oral health standards among municipal employees with special emphasis on the lower SES strata.

 Acknowledgements



I sincerely thank the Commissioner of Mysore city corporation, Professors in Economics and Co-operation department, Manasa Gangothri, Statistician, and the study participants for their kind support throughout the study.

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