A qualitative study on cultural sensitivity during survey fieldwork for early childhood caries in Ile-Ife, Nigeria: bridging the gap between culture and science

Abstract

Objective

The qualitative study described culture-related issues that may bridge the ethical conduct of fieldwork for a cross-sectional study of the oral health of preschool children in the Ife Central Local Government Area of Nigeria, conducted between December 2024 and January 2025.

Results

There were 1,411 mother‒child pairs recruited by 20 research assistants and nine dentists trained on ethical considerations and cultural sensitivity before data collection began. A group discussion (debriefing session) was held with 18 consenting research assistants and nine dentists of the fieldwork. The transcripts from the discussions were inductively analysed, and key themes were identified. Both research assistants and dentists observed cultural norms infringing on the privacy of study participants, and dentists had to overcome mistrust and consent challenges (concerns with touching the child’s head during height measurement and with dentists conducting oral examinations). This study highlights the need to map the cultural nuances of study sites before conducting a population-level survey to help develop culturally sensitive study protocols.

Introduction

Field research in diverse communities requires the integration of ethical standards with cultural sensitivity. Researchers must navigate social structures, language barriers, and belief systems to build trust [1, 2]. Culture, a key component of social structure [3], shapes research design, influencing question formulation, methodology, data collection, and interpretation [4, 5]. Both researchers’ and participants’ cultural backgrounds impact study outcomes, necessitating awareness to ensure ethical and contextually relevant findings [6]. Culturally sensitive research adapts informed consent to local contexts and clarifies the study purpose, risks, and rights, often with community leader or interpreter support [7]. In addition to providing consent, participatory methods help balance power dynamics [8], whereas culturally competent translators ensure communication integrity [9]. Despite these efforts, cultural norms can challenge ethical research. Language barriers hinder informed consent [10], and unique cultural contexts may complicate ethical conduct.

Among Yorùbá, a deeply traditional ethnic group in southwestern Nigeria [11, 12], communal decision-making and indigenous knowledge systems influence research perceptions and ethics [13]. This underscores the need for culturally sensitive approaches to maintain ethical integrity, prevent misinterpretation, and maintain community trust [14]. Ethical research must respect community values and belief systems, where integrity extends beyond formal consent to ensure cultural alignment. In Yorùbá, for example, health beliefs incorporate spiritual and ancestral influences, and ignoring this context may lead to the rejection of research outcomes [15]. Culturally sensitive approaches help to maintain integrity, prevent misinterpretation, and support meaningful collaborations for impactful solutions.

By bridging the gap between culture and science, researchers can generate contextually relevant knowledge and contribute to ethical and impactful research practices in diverse cultural settings. The primary objective of the present study is to identify Yorùbá cultural nuances that could create ethical challenges, enabling us to adapt research methods to align with cultural contexts while prioritizing ethical principles. This study aims to provide practical strategies for conducting ethical and culturally respectful oral health research involving infants, toddlers, and preschool children among Yorùbá in southwest Nigeria, which benefits both researchers and communities.

Main text

Ethics approval for the study was obtained from the Institute of Public Health Ethics Committee, Obafemi Awolowo University, Ile-Ife, Nigeria (IPH/OAU/12/2742). Written informed consent was obtained from caregivers who participated in the study. The caregivers for the child provided written informed consent for the child’s participation in the study.

Data collection was conducted for a cross-sectional study aimed at determining the prevalence of early childhood caries and associated risk factors for children 0–5 years old who were living in the Ife Central Local Government Area in Osun State, Nigeria. The local government is the ancestral home of the Yorùbá people, with Ile-Ife regarded as the cradle of the Yorùbá civilization [16]. The region boasts a rich heritage reflected in its traditional beliefs, arts, and social structures [17]. Despite modernization, Yorùbá traditions remain deeply embedded in social and religious life, making Ife Central a key location for studying the intersection of culture, tradition, and ethical research practices.

Data collection took place between December 2024 and January 2025. To address the potential bias that the cultural background of researchers can introduce into the study, training was conducted for the field staff. The 20 research assistants underwent training: a two-day, two-hour online session and a five-hour in-person session. The training covered the research protocol, study questionnaire, ethical considerations, effective communication, and cultural sensitivity in data collection. In addition, research assistants conducted a pilot study to identify and address challenges in questionnaire administration. During fieldwork, research assistants randomly identified households and recruited 1,411 mother‒child pairs. A child is recruited per household. When there is more than one eligible child in the household, one is selected at random for inclusion in the study. The research assistants administered questionnaires to collect data on participants’ biodata, mothers’ or caregivers’ oral health knowledge and attitudes, and children’s oral health behaviours.

Nine dentists received specialized training from a Consultant Paedodontist on conducting physical and oral examinations for children, including measuring height and weight and detecting dental caries via the ICDAS criteria [18]. To ensure consistency, the dentists underwent standardization through inter-rater and intra-rater reliability assessments.

Research assistants and dentists were divided into groups to recruit study participants. Working in groups was important because of security, to support consensus decision-making in the field, and to improve the team’s representation as a research group. The team was coordinated by two coordinators—one for the Dentists and the other for the research assistants. The research assistants were paid $4.85 per day for collecting data from 15 participants, whereas the dentists were paid $6.06 per day of work. Payments were made to the research assistants after their debriefing session and to the dentists after their debriefing session. The study participants received no payment and no gift items.

A group discussion (debriefing session) was conducted with 18 of the 20 research assistants who consented to participate in the debrief, and with the nine dentists, two weeks after completing the fieldwork. These sessions provided an opportunity for participants to share their experiences. Guided by an interview framework, they reflected on various aspects, including training and preparation, challenges faced during fieldwork, interactions with participants, and experiences with the data collection process. The discussions also covered collaboration and team dynamics, such as communication, support, and supervision, alongside perspectives on the cultural significance of oral health among the Yoruba. The participants further explored the research’s contribution to improving oral health behaviours and service utilization, offering personal reflections on enhancing future fieldwork processes and strengthening cultural sensitivity in research.

AI-generated transcripts of the audio-recorded debriefing discussions were inductively analysed via ChatGPT 3.5 and Deepseek. The focus of the inductive analysis was to identify culture- and ethics-related themes and subthemes in the discussion. Relevant quotes were also retrieved from the transcripts. The output from the AI-generated analysis was validated by two authors—the MOF and OA—who cross-checked the identified themes and subthemes for accuracy and relevance. This validation process ensured that the AI-generated insights aligned with the contextual realities of the discussions. Any discrepancies or ambiguities in theme identification were resolved through iterative discussions among the research team, incorporating their cultural and ethical expertise to refine the final analysis.

The results of the analysis indicated that the research assistants and the dentists encountered cultural challenges, and the nature of their interactions with participants shaped their experiences differently. Three themes were identified, namely: privacy concerns common to both research assistants and dentists, language barrier encountered by the research assistants, and mistrust and consent challenges encountered by the dentists.

Theme 1: privacy concerns for both research assistants and dentists

Male members of the family often intruded during interviews, and in some instances, relatives actively prevented mothers from participating despite their willingness to engage in the study. Privacy concerns were also a major issue, as some communities had strict restrictions regarding access to certain areas or discussions involving women and children.

“There are some areas that it was supposed to be new areas… Some gates were always locked, we could not knock on the gates because they didn’t want people to disturb their privacy.” Research Assistant RO.

“We had to be careful in some areas where people were very sensitive about their privacy… we had to respect their space.” Research Assistant AOD.

“Some places are very sensitive… there’s a particular place where the people truly believe in spirits, so much that we had to be careful… we were like, what’s going on up there? We must be careful.” Research Assistant OE.

“We had to be culturally sensitive, especially in areas where people were not used to outsiders coming in to ask questions.” Research Assistant AOD.

“I recall three cases where men interfered with the interview sessions with the mothers—one was a brother-in-law who came to sit in on the interview, and the other two were neighbours. They seem to feel that they had a right to interfere with the process as men did. When the team tried to secure privacy, the women were asked if they would be allowed to sit in on the interview. Like, it was their rightful place to be there. The second and third cases are men who interfered in the interview as neighbours, as if they were set to protect the women from strangers”. Dentist FOM.

Theme 2: language barriers encountered by research assistants

Research assistants faced significant language barriers that hindered effective communication, particularly in households where the primary language was different from that of the research team.

“There was a particular day we went to an area where they spoke more of Hausa… we had to look for translators, for some of us who could not get translators at the moment, we had to leave. Therefore, it was more or less like the Hausa community was not put into consideration for the project.” Research Assistant EC.

Theme 3: mistrust and consent challenges encountered by dentists

Dentists, on the other hand, struggled with mistrust and consent challenges. Some caregivers expressed concerns about the study procedures, particularly regarding the touching of a child’s head during height measurement and the oral examination conducted by dentists. Superstitions and misconceptions about medical professionals further complicated the consent process, requiring additional efforts to reassure participants about the safety and purpose of the study.

“This mistrust stemmed from cultural beliefs, such as the fear that dentists might ‘put something in the children’s mouths or that the examination could harm them. Some mothers refused to let their children be examined due to superstitions. Dentist OB.

“In some areas, mothers were the primary caregivers, and fathers were often absent, which created challenges in obtaining consent for children’s participation”. Dentist OT.

“Some participants believed in traditional remedies or were skeptical of modern medical practices. This cultural belief system sometimes conflicts with the dentists’ recommendations, requiring them (the dentist) to navigate these beliefs carefully while providing evidence-based advice (following the oral examinations). Dentist AO.

“This is my third population-level ECC survey in this local government over the last 1 year. I was surprised to encounter cultural issues that affected our data collection process. There was a child whom I was to measure the height of. The anxiety on the face of the mother when I touched her head to be able to measure her height caused me to ask the mother why she was concerned. She told me it was wrong to touch the head of her child. That was the last time I touched the head of any other child, giving me reason to be cautious with height measurement. The second was that mothers were reluctant to have me hold their children and open the children’s mouths. Therefore, I ask mothers to hold their children and open their mouths, and I just look into the mouth”. Dentist FOM.

Despite these challenges, both groups emphasized professionalism and teamwork, although their experiences differed. Research assistants reported hierarchical tensions with senior researchers, whereas dentists focused on fostering collaboration and training research assistants in cultural competence. The participants suggested that addressing these challenges requires enhanced training in cultural sensitivity, ethical engagement strategies, and tailored communication approaches to ensure that research is both effective and respectful of local norms.

“We sensitize them that it was not only when you are sick that you go to the hospital… You need to check on your contact care so that you will not have issues.” Research Assistant RO.

“There is a strong ethical responsibility to provide immediate benefits for the communities, such as free dental check-ups and education on oral hygiene. It is important to give back to the community and ensure that participants derive some tangible benefit from the study”. Dentist OF.

“I referred to participants with serious dental issues. This raises ethical questions about the researchers’ responsibility to ensure that participants receive follow-up care, especially in this community with limited access to healthcare”. Dentist DOR.

The study highlights how cultural norms shape fieldwork. A prior study on research protocol adherence revealed that non-compliance with privacy guidelines often results from participants not perceiving privacy as necessary [19]. This study adds nuance by showing why maintaining privacy in semi-urban Yorùbá communities is challenging. In patriarchal societies such as Ile-Ife [20], gender dynamics and traditional structures influence social interactions, complicating confidential participation, especially for women.

Prior studies had highlighted how language can constitute a barrier to ethical study conduct, especially with obtaining informed consent and conducting interviews [21, 22]. In the current study, the language barrier led to the undue exclusion of populations within the study location, increasing the risk of poor representativeness of the population in the study findings. This has implications for policy development and programming. Lessons learnt highlight the need for mapping of the community to population level surveys to be able to adequately plan for effective communication and take care of possible language barriers.

Cultural gender norms also affect consent, with mothers requiring paternal approval to enrol children [23] and even to participate themselves [24, 25], making spousal assent widely recognized in patriarchal settings [26]. This study reveals further cultural complexities that impact ethical fieldwork in the Yorùbá community [20]. Male intrusion during female interviews, often seen as interference, may reflect cultural guardianship. Women’s acceptance of this oversight [19] underscores the tension between privacy, autonomy, and ethical research. To navigate these dynamics, researchers should engage male household heads early, involve trusted female intermediaries, and ensure cultural competency within research teams.

Despite the challenges in the field, both research assistants and dentists remained committed to professionalism, emphasizing the ethical responsibility of ensuring that participants derived tangible benefits from the study. These findings underscore the need for enhanced training in cultural sensitivity, ethical engagement strategies, and tailored communication approaches to ensure that research is both effective and respectful of local norms.

Limitations

Because the study was conducted in one of 774 local government areas in Nigeria and among mother–child pairs, the findings may not apply to other regions and populations with different cultural norms. Data collection was based on self-reports from research assistants and dentists, who are prone to recall and social desirability biases, potentially underreporting negative experiences.

The study underscores the critical importance of cultural sensitivity in fieldwork, which can be addressed through enhanced training, ethical engagement, and tailored communication. Researchers can foster a better understanding of the nexus between culture and the ethical conduct of research to inform appropriate adaptations of research ethics guidelines that contribute to ethical and impactful research practices.

Author contributions

M.O.F conceived the study, curated and analysed the data, and developed the first draft of the document. OA was involved with data curation SZM and MRK supervised the project. OA, SZM and MRK read the draft manuscript and made intellectual contribution prior to the final draft. All authors approved the final manuscript for submission.

Funding

This research was supported by grants from TETFUND, Nigeria: DVC/RID/CE/UNIV/ILE-IFE/IBR/2023/VOL.1/020.

Data availability

The analysed for the study are summarised in the publication. The qualitative data can be obtained from the corresponding author.

Declarations

Ethics approval and consent to participate

Ethical approval for the study was obtained from the Institute of Public Health, Obafemi Awolowo University institutional review board (IPH/OAU/12/2742). Written consent was obtained from the caregivers for study participation. The caregivers for the child provided written informed consent for the child’s participation in the study. The study adhered to the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

Morẹ́nikẹ́ Oluwátóyìn Foláyan is a Senior Editorial Board member with the BMC Oral Health. All other authors declare no conflict of interest.