Effectiveness of oral hygiene training and education programs among Anganwadi workers in improving mother and child oral hygiene. A cross-sectional study

Abstract

BACKGROUND:

An Anganwadi worker comes under the Integrated Child Development Scheme and is responsible for the health welfare of children and women belonging to the rural, urban, and tribal regions. The present study aimed to analyze the effectiveness of oral hygiene training and educational programs among Anganwadi workers for the improvement of mother as well as child oral hygiene.

MATERIALS AND METHODS:

This was a prospective, intervention-based, and cross-sectional study carried out on 100 preschool children. The age range of children was between 3 and 5 years, of which 65 were males and 35 were females. The participants were divided in two groups: 1) Group I: Interventional group (50 mother–child pairs) and 2) Group II: Control group (50 mother–child pairs). The oral hygiene trainingwas imparted to Anganwadi workers using oral health-related educational aids likeposters, pamphlets, booklets, or plaster models for the intervention group, while oral health education was provided to the controls. The assessment of baseline knowledge on oral health among mothers was done by prevalidated 17-itemed questionnaire. Maternal knowledge regarding oral health was assessed using questionnaires on third and sixth month intervals. Oral hygiene of the children was assessed using Oral Hygiene Index Simplified-Modified (OHIS-M) at baselineand 3^rd and 6^th months in preschool children by a single investigator under natural light. The collected data were entered in Microsoft excel worksheets and analyzed by SPSS software version 20.0.

RESULTS:

Before intervention (baseline), 30.1% mothers in the study group and 27.2% mothers in the control group answered questionnaire items correctly. However, no statistical significance (P = 0.23) was obtained. At 3^rd month assessment, the response in the intervention group increased till 48.2%, whereas in the control group, it was found to be 34.02% with no statistically significant difference (P = 0.35). At the 6^th month interval, the response had increased till 69.9% and 48.02% in intervention and control groups, respectively (P = 0.02). Oral hygiene status assessment using mean ± SD. OHIS-M scores in children was assessed at baselineand 3 and 6 months. Thus, a continuous decrease in mean ± SD. OHIS-M scores was found in both the study group and controls.

CONCLUSION:

Statistically significant improvement in knowledge of mothersand oral hygiene of children was noted after the they received training from Anganwadi workers regarding oral health care.

Introduction

The Integrated Child Development Scheme is India’s comprehensive as well as multiple dimensional programaimed toward deprived children living in poverty. This scheme started as an experiment in 33 blocks during 1975–76. At present, it is the largest outreach program in India focusedover early stages of childhood with an aim toward enhancement, survival, and development of children from susceptible as well as deprived segments of society. Under this scheme, an Anganwadiworker is generally covering 1000 individuals in rural as well as urban regions and 700 in tribal locations. Anganwadi workers work at designated AnganwadiCentres. These workers are part-time honorary employees.[1,2]

The management of oral and tooth-associated diseases form an integral part of primary health care and preventive services. Anganwadi workers are grass-root level workers in villages who hold responsibility for maintaining thehealth services and sanitation. The role of an Anganwadi worker is to providenutrition supplements, immunizationto children (<6 years) and to lactating or pregnant mothers, tetanus immunization for expectant mothers, imparting health education to women belonging to the age range of 18–45 years, and basic health checkup including antenatal care, postnatal care, neonatal care, and providing care of children below 6 years. Anganwadi workers possess knowledge concerning immunization, prophylactic measures against blindness, basic nutrition, health care, dietary supplementation, monitoring of body growth, and referral health services.[3,4]

Imparting the knowledgerelated to oral hygienepractices and the contributing factors for the dental caries like the role ofimmunity and habits (both dietary and nondietary) to Anganwadi workers will help inreducing the incidence of childhood caries.[5] The early risk identification and clinical signs in dental caries via screening in children is important. Hence, the role of grassroot level Anganwadi workers is important in the prevention of dental caries. These frontline grassroot level workers must be trained in oral hygiene measures so that they can educate expectant mothers along with children toward maintaining good oral health.[6,7]

Hence, this study was planned with an aim to assess the effectiveness of oral hygiene training and education programs among Anganwadi workers in improvement of mother and child oral hygiene.

Materials and Methods

Study design and setting

This prospective, interventional, cross-sectional study was carried out in a preschool in the year 2024 located in Jammu and Kashmir, India. The parents of children were explained about the study objectives, and written signed consent was obtained from them before commencing the study according to the Helsinki’s Declaration of Code of Ethics.

Study participants and sampling

A total of 100 preschool students aged between 3 and 5 years were randomly selected as study participants. The age range of selected students was between 3 and 5 years with 65 males and 35 female children.

The permission was also obtained from the Department of Womenand Child Development for involving Anganwadi workers for the study. The size of the sample was calculated by G*Power software, according to which the significance value was fixed at α = 0.05, effect size = 0.4, and power = 90%. The obtained sample size was found to be 47, which was then rounded off to “50”.

A total of 100 mother and child dyads were selected for the study. The study participants were then divided into two groups: 1) Group I: Interventional group comprised 50 mother and child pairs and 2) Group II: Control group containing 50 pairs. Anganwadi Centres were selected in a random manner.

Inclusion criteria

1. Children between 3 and 5 years of age.

2. Mothers who could understand local language or English.

Exclusion criteria

1. Those children on any medications.

2. If any hard or soft tissue pathologies that impeded oralexamination.

Training on oral hygiene was provided to Anganwadi workers using oral health-related educational aids such as posters, pamphlets, booklets, or plastermodels for the intervention group, and only oral health education was provided to control group subjects.

The Anganwadi workers used live demonstrations on models and used posters along with videographic representation to explain the proper brushing techniques for improving oral health in children.

Data collection tools and technique

Thetool for assessment of baseline knowledge on oral health among selected motherswas a prevalidated 17-itemed questionnaire. The mother’s knowledge regarding the oral health wasassessed using questionnaires on the sixth month interval. The status of oral hygieneof the children was assessed using Oral Hygiene Index Simplified-Modified (OHIS-M) at baselineand 3^rd and 6^th months in preschool children by a single trained investigator under natural sunlight. Index teeth as indicated by OHIS-Mwere assessed for plaque scoreusing a mouth mirror and periodontal probe, and the observations were recorded at predecided intervals.

The primary outcome of the study was improvement in oral health status following educational training by Anganwadi workers, while the secondary outcome was training of parents and caregivers toward maintaining oral health of children.

Ethical consideration

Institutional ethical clearance was obtained from the concerned research committee and reviewer board (IEC24-MME/12).

Statistical analysis

The collected data were entered in Microsoft excel worksheets and analyzed by SPSS software version 20 for descriptive statistics and determining significance. Descriptive statistics was done to calculate frequencyand mean ± standard deviation. Chi-square statistical test was done for calculating percentage differences. Student‘t’ test was employed for calculating the differences in variables. The statistically significant value was set at P value < 0.05.

Results

Demographic characteristics

A total of 100 mother–child pairs were assessed in this study. The mean ± SD age (in years) of mothers was found to be 31.28 ± 0.92, whereas the mean ± SD age (in years) of children was 4.08 ± 0.04 years, respectively. 65% children were males, and 35% were females.

59% mothers had education below high school, 11% had studied till high school, 12% had education till secondary school, 8% were graduates or diploma holders, and 10% studied up to postgraduation. 67.8% mother–child pairs belonged to lower-middle socioeconomic class, and 23.1% belonged to upper middle-class levels.

Knowledge level

Before intervention (i.e. baseline), 30.1% mothers in the study group and27.2% mothers in the control group answered questionnaire items correctly. However, this was found to have no statistical significance (P = 0.23). At 3^rd month assessment, the response in the intervention group had increased up to 48.2%, while in the control group, it was found to be 34.02% with no statistical significance (P = 0.35).

At the 6^th month interval, the response was found to be increased up to 69.9 and 48.02% mothers answered the questions correctly in the intervention and controlgroups, respectively, which was found to have statistical significance (P = 0.02).[Table 1, Figure X]

Table 1.

Comparison between the study group and control group for level of knowledge at baseline after third and sixthmonths following intervention

Groups		Baseline		3 months		6 months
Study group		30.1%		48.2%		69.9%
Control group		27.2%		34.02%		48.02%
P		0.23		0.35		0.02

Figure X.

Graph showing P values obtained after comparison between knowledge level at baselineand third and sixth months

Additionally, on collectively assessing the pretest and post-intervention test questionnaire items individually, statistically significant to extremely significant improvement in percentage responses was there in the mother’s knowledge regarding their child oral health and hygiene [Table 2 and Figure Y]. Figure 1 depicts the consort diagram representation.

Table 2.

Pretest and post-test questionnaire responses received from all mothers

Questionnaire items		Pretest percentage of correct responses		Post-test percentage of correct responses (after 6 months)		P
At what age does a new tooth erupt?		24.1%		65.2%		0.05
How many milk teeth are there in a child’s mouth?		12.9%		56.1%		0.05
Do you know that sugar containing foods can cause dental caries?		45.4%		89.3%		0.05
At what age oral care should start in a child under mother’s/caregiver’s supervision?		10.2%		72.9%		0.05
Can poor oral health of mother affect a child’s health?		09.1%		57.4%		0.05
Are you aware about the right toothpaste to be used in children?		12%		71.2%		0.04
When should be a child’s first dental visit?		13.8%		89.7%		0.05
Are you aware that routine dental checkups can prevent tooth decay in children?		23.1%		67.8%		0.05
When should be the first visit of a child to a dental clinic?		12%		93%		0.001

Figure Y.

Graph showing P values of overall response before and after intervention in studied mothers

Figure 1.

Consort diagram

Oral hygiene status assessment

The mean ± SD OHIS-M scores in children was assessed atbaselineand 3 and 6 months. At a baseline level, the mean ± SD scores were 1.89 ± 0.34 in the interventional study group and 1.73 ± 0.18 in the control group, which was found to have no statistical significance (P = 0.45). At 3 months, themean ± SD scores were found to be decreased to 0.67 ± 0.01 and 1.39 ± 0.83 inthe study and control groups, respectively, which was found to be statistically significant (P = 0.045). After 6^th month follow-up, the mean ± SD scores were further found to decrease to 0.03 ± 0.01 in the study group and 0.12 ± 0.03 in the control group. This was found to have statistical significance (P = 0.05).[Table 3, Figure Z] Thus, a continuous decrease in mean ± SD OHIS-M scores was found in both study and control groups [Figure 2].

Table 3.

Comparisons between OHI-S scores between study group and control group at baseline and 3^rd month and 6^th month follow-up

Groups		Baseline (mean±SD)		3 months (mean±SD)		6 months (mean±SD)
Study group		1.89±0.34		0.67±0.01		0.03±0.01
Control group		1.73±0.18		1.39±0.83		0.12±0.03
P		0.45		0.045		0.05

Figure Z.

Graph showing P values of OHI-S scores at baselineand third month and sixth month intervals

Figure 2.

Conceptual diagram showing theoretical framework

Discussion

Oral diseases constitute a public health issue that can affect health. Due to less availability and/or affordability dental treatmentin India, there is an increase in disease severity which results in an increase in treatment cost involved.

Providing education regardingoral health incorporates a person’s capacity for learning and managing their oral health. Inadequate or no knowledge of maintaining sound oral health has many challenges.[8]

There are common risk factors between oral and general health; hence, efforts for integrating and promoting both should be done as multiple objectives can be achieved if adequate efforts are started earlier in life. Interventions followed can significantly improve one’s knowledge regarding oral health and modifying risky behavior.

“Anganwadi”means“courtyard”, which is a childcare health center situated within a village or a slum population. It acts as the central point for deliveringhealth care-related services at the community level to children, adolescent females, pregnant ladies, and nursing/expectant mothers. An Anganwadi center is a meeting point whereinwomen and children and frontline Anganwadi workers come together for promoting health-associated awarenessand child development along with empowering women’s. An Anganwadi center works by providing health services under the Integrated Child Development Services. These services include preschool education, nutrition-related health education, referral health services, providing auxillary nurse midwives for immunization programs, and routine health checkup.[9] The Anganwadi workers receive regular training on communication skills and strategies for building of one’s capacity with health care education.[10]

Currently, in India, Accredited Social Health Activist (ASHA) workers, Auxilary Nurse Midwife (ANM), and Anganwadi workers (AWWs) are working as community healthcare workers or frontline healthcare workers. The main role and responsibilities of these frontline workers are to bring services to people’s doorsteps.[11]

An Anganwadi center caters to mother–child healthcare at grassroots. Anganwadi workers’ role is to promote as well as monitor development of children by providing services within a community for good quality care of small children and women.[12] Though these workers receive adequate training on overall health, they have limitedknowledge as well as awareness about oral health.[13]

Hence, empowerment of workers will help in encouraging primary oral care in community. Similar to our study findings where an increase in knowledge of mothers, that is, 69.9% (study group) and 48.02% (control) at 6 months of educational training, was observed, Satyarup et al.[14] in their study reported an improvement in knowledge level of mothers regarding maintaining oral hygiene and improvement in oral hygiene of children followingtraining of Anganwadiworkers.

Similarly, in astudy conducted by Keerthi et al.,[15] knowledge of mothers regardingoral health was found to have undergone a significant improvement after receiving training from Anganwadi workers. An increase in percentage, that is, 26.2% at baseline to 65.4% at 6 months of correct responses bymothers, was noted after receiving oral health educational training from Anganwadi workers. Also, the mean ± SD OHIS scores were found to have shown a significant decrease from 1.64 ± 0.23 at baseline to 3 months, that is, 0.97 ± 0.24 and at 6 months, that is, 0.17 ± 0.06. Similar findings were reported by Khanna et al.[16] These findings are in corroboration to our study findings where there is an improvement in mean ± SD. OHIS scores at 3-month and 6-month follow-up, which was found to be statistically significant, that is, P = 0.045 (3^rd month) and P = 0.05 (6^th month) in both the study group and controls.[17]

Nagamma etal.[18] in their study reported that the health interventions provided by the pamphlet and video were very effective in increasing cervical health literacy among Anganwadi teachers. These interventions were beneficial to the Anganwadi teachers to improve their knowledge and attitude about cervical cancer.

Hence, it can be summarized from the present study with support of other similar studies that educational training imparted by Anganwadi healthcare workers can help in improving mother’s knowledge regarding maintaining optimal oral health in children.[19,20,21]

However, the limitation of the study was its small sample and lesser representation which can be improved by increasing the area of study and larger size of population. The weakness of this study was its limited sample and restricted sample distribution. Different Anganwadicenters catering a wider population representing different clusters could represent the true impact of training on oral health maintenance. On the other hand, the strength of present study wasthe close follow-up by the investigators of the studied mother–child dyads. This is a novel study as it highlights the importance of Anganwadi workers in educating mothers about maintainingthe oral health as well asits importance.

Conclusion

Anganwadi workers play a crucial role in educating and promoting oral and general health care especially among women and children since its inception as Integrated Child Development Scheme by the Indian Government. The current study findingsprovide further evidence regarding the importance of these grassroot level health care workers in promoting and imparting knowledge to the general public, thus improving their overall health status including oral health. The present study can be further researched upon by including different zones representative of different clusters of the population. This would represent the impact of Anganwadi workers on child oral health care in a wider manner.

Abbreviations

SD: Standard Deviation

OHIS-M: Oral Health Index Score-Modified

SPSS: Statistical Program for Social Services

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.