THE EFFECTIVENESS OF ORAL HEALTH EDUCATION CONDUCTED AT A RURAL COMMUNITY MARKET SETTING

Abstract

Background

The workplace is one of the avenues for educating the public about their oral health in developing countries; particularly in rural communities where the workplace plays a major role in communal living. It is therefore necessary to find out if the market is appropriate for achieving the set aim of improving oral health awareness among the populace in rural communities.

Aim and Objectives

The aim of this study was to determine the effectiveness of oral health education conducted in a market in a rural community by comparing the oral health practices of market women involved in the oral health education programme to those not involved in the programme.

Design:

A prospective study.

Setting:

A rural community in South-western Nigeria.

Materials and Methods:

A prospective interventional study was conducted among market women in Igboora, a rural community in South-western Nigeria. The intervention was oral health education differentiating between the intervention group and the control group. Structured interviewer administered questionnaires were used to obtain information from the participants on their oral hygiene measures, fluoride use, dental attendance and the demographics of the participants. Data collected was analyzed using SPSS and p-value set at <0.05.

Results:

Two hundred market women participated in the study with a mean age of 45.2 ± 17 years. The interventional group was made up of 106 market women while the control group was made up of 94 market women. There were no significant differences in the sociodemographic characteristics of women in both the intervention and control groups. Women in the intervention group engaged in more frequent cleaning of their teeth and tongue than those in the control group (p < 0.001). Market women who had participated in the oral health education subsequently visited the dentist more often than those in the control group (p = 0.010).

Conclusion:

The study showed that oral health education conducted at a market was effective in improving some oral health practices of participants. It is recommended that oral health practices be extended to major markets in our communities.

Introduction

The World Health Organization has described oral diseases as a global health problem in both industrialized and developing countries1. In developing countries, this could be attributable to factors such as poor socio-environmental factors and, more importantly, low level of oral health awareness as a result of inadequate oral health education2. Oral health education as defined by Kay3 is any learning activity aimed at improving the individual’s knowledge, attitude and skills in relation to oral health. It provides information required for modifying attitude and changing the individual’s behaviour. Furthermore, it involves improving the oral health awareness of individuals and communities.

The effect of interventions, such as oral health education in populations, has been reported to be beneficial, leading to improvement in oral health awareness4,5,6. This, among other reasons, makes oral health education an important aspect of the activities conducted by primary oral health care centres. The primary oral health care centre in Igboora, a rural community in South-western Nigeria is not left out of this important activity; with the intention of increasing oral health awareness among the populace and ultimately leading to a desirable change in oral health behaviour. The Community Dentistry Unit of the University College Hospital, Ibadan since establishment has, as part of its mandate on oral health promotion, conducted regular oral health education programmes for the public. This is given, mainly, at different places of work to different sub-populations as most people can only be met at their places of work during the week. In rural areas of resource poor countries, most of the adults are engaged in one form of commercial or farming activity during the week, in order to make ends meet.

Even though this core activity of the unit has been ongoing since 2008, it is unknown if this programme is effective in promoting good oral health practices among the populace since they were conducted at places of work when participants at such programmes were busy. Although studies have reported the effectiveness of oral health education conducted in school environments4,5,6, not many have evaluated the benefits of such interventions in market environments, an essential workplace in rural communities. The aim of this study, therefore, was to determine the effectiveness of oral health education conducted among rural market women in Igboora, South-western Nigeria. It was necessary to compare the oral health care practices of women who participated in the oral health education to those of women those who did not. The findings could be instrumental towards improving the quality of oral health education activities carried out in similar settings in developing countries.

Patients & Methods

Study site

This prospective interventional study was conducted among market women in Igboora, Southwest Nigeria. Igboora, the headquarters of Ibarapa Central Local Government Area, is a rural community situated about 80km south of Ibadan, the metropolitan capital city of Oyo State, Nigeria. It has about 60,000 inhabitants7 who are mainly farmers, traders and artisans. In this community are two major markets – Oja-Oba and Towobowo – and some other smaller markets. The Oja-Oba market serves as a receiving centre for traders from different areas of the South-western region of Nigeria and was thus chosen as the study site.

Structure of a typical large rural market

The market system in rural Nigeria is made up of buyers and sellers who are busy engaged in trading. The Oja-Oba market typifies a major market in a rural community. These types of markets are big and are characterized by trading in cheap but quality goods and services; traders from smaller markets buy from here and thereafter sell at stalls in the smaller markets. These big markets are thus very busy, especially, when they operate on fixed market days compared to smaller markets that operate daily. Fixed market days operation indicates that the market system offers no form of services until the scheduled market day.

Oral health educational intervention

The system of trading in the selected market is such that traders converge for trading every five days. This is the time that the market is visited for oral health education by the dental team. The dental team, which is usually made up of two dentists and a community health assistant, visits the market at least once a month and this has been conducted consistently over a period of two years (January 2011 to December 2013). The intervention for this study was oral health education reinforced four weeks before collection of data for this study at the Oja-Oba market square. The oral health talk reinforced previous messages, which were on oral hygiene (focusing on tooth brushing, cleaning aids and tongue cleaning) as well as on fluoride use, dental attendance and diet. The exercise also involved the demonstration of the cleaning procedure using a locally fabricated wooden mouth model (modified Nasher mouth model). Four weeks later, the market was revisited and the evaluation phase of the study conducted. All the market women present at their duty posts were approached during the study in a form of total sampling. Ethical approval was obtained from the Institution’s Ethical Review Committee and the study was conducted in strict compliance with the Helsinki Declaration principles on studies involving human subjects.

Questionnaire

A 13-item semi-structured questionnaire, translated into the local Yoruba language, was used to collect information in two sections as follows: section A assessed the respondents’ biodata and section B was made up of items on oral hygiene measures such as frequency of tooth brushing, the choice of tooth cleaning materials, utilization of dental services and a question on if they had ever listened to oral health talk in the market. The questionnaires were administered by trained dentists, who had not been participating in the oral health activities conducted in the market, and who were blinded as to those who were in the control and the intervention group. Pre-test was done by administering the questionnaire to market women in Idikan community of Ibadan to ascertain the comprehensibility and validate the questionnaire. The data collectors were also not informed of the presence of an intervention or control group. The information passed across to them during the process of training was to collect data from market women using the questionnaire. Furthermore, the market women were also not aware of the presence of an intervention group or a control group, making it a double-blinded procedure. Randomization of study participants was not done in this study. At the end of data collection, questions were entertained from the market women and answers provided to those questions.

Data management and analysis

The data collected were analyzed using SPSS version 21 to determine frequencies, percentages and proportions of relevant variables. To reduce the number of empty cells during cross-tabulation, the level of education was re-coded into two; those with secondary school level of education or less in a category and those with tertiary education in the other group. Chi-square was used to test for association between categorical variables in the intervention and control groups while the student t test was used to compare continuous variables with the p value for statistical significance set at < 0.05.

Results

Sociodemographic characteristics of the study participants

A total of 200 market women participated in the study; 106 (53.0%) had attended previous oral health education sessions i.e. in the intervention group while 94 (47.0%) had not and were in the control group. The age range of the respondents was 16 to 81 years, with a mean age of 45.2 (± 17.0) years. The majority, 137 (68.5%), were in the age range 16 to 55 years. All but one of the respondents were Yorubas and 158 (79.0%) were full time traders. A total of 91 (45.5%) women had no formal education, 38 (19.0%) had primary school education, 48 (24.0%) secondary school education and 22 (11.0%) had tertiary education. There were no significant differences between the sociodemographic characteristics of those in the intervention group or the control group, p > 0.05 as shown in Table 1.

Table 1. Sociodemographic characteristics of the study participants.

Variable	Intervention group N (%)	Control group N (%)	p value
Age group (Years)
16- 35	39 (36.8)	35 (37.2)	0.772
36-55	36 (34.0)	27 (28.7)
56-75	30 (28.3)	30 (31.9)
≥76	1 (0.9)	2 (2.1)
Ethnic group
Yoruba	105 (99.1)	94 (100.0)	0.345
Hausa	1 (0.9)	0 (0)
Level of education
None	48 (45.3)	43 (45.7)	0.824
Primary/secondary	45 (42.5)	42 (44.7)
Tertiary	13 (12.3)	9 (9.6)
Total	106 (100.0)	94 (100.0)

Oral hygiene measures of the study participants

Table 2 shows that a higher proportion (70.8%) of participants in the intervention group than those in the control group (59.6%) used toothbrushes to clean their teeth, p = 0.097. Forty percent of the respondents in the control group used chewing sticks and other agents such as charcoal and ash to clean their teeth. With regards to the frequency of teeth cleaning, a significantly higher proportion of those in the intervention group (91.5%) cleaned their teeth regularly, at least once a day, compared with those in the control group (75.5%), p = 0.009. A higher proportion of respondents in the intervention group cleaned their teeth before breakfast and before going to sleep compared to respondents with similar tooth cleaning habits in the control group (45.3% vs. 28.7%, p < 0.001).

Table 2 . Oral hygiene practices of participants in the intervention and control groups .

Variable	Intervention group N (%)	Control group N (%)	p value
Tooth cleaning aids
Toothbrush	75 (70.8)	56 (59.6)	0.097
Chewing sticks / charcoal/ ashes	31 (29.2)	38 (40.4)
Frequency of tooth cleaning
None/ irregularly	9 (8.5)	23 (24.5)	0.009*
Once	39 (36.8)	28 (29.8)
Twice or more	58 (54.7)	43 (45.7)
Time of tooth cleaning
Morning before breakfast only	56 (52.8)	48 (51.1)	0.000*
After breakfast only	2 (1.9)	19 (20.2)
Before breakfast and going to sleep	48 (45.3)	27 (28.7)
Tooth cleaning technique
Horizontal strokes	67 (63.2)	63 (67.0)	0.656
Miniscrub or vertical strokes	39 (36.8)	31 (33.0)
Cleaning of the tongue
Never	4 (3.8)	25 (26.6)	0.000*
Sometimes	22 (20.8)	15 (16.0)
Everyday	80 (75.5)	54 (57.4)
Use of fluoride
Yes	7 (6.6)	4 (4.3)	0.341
No	99 (93.4)	90 (95.7)
Total	106 (100.0)	94 (100.0)
*Statistically significant

A total of 102 (96.2%) out of the 106 respondents in the intervention group cleaned their tongue, at least sometimes, during tooth cleaning/brushing compared to 69 (73.4%) of the 94 in the control group, p < 0.001. The majority (65.0%) of the study participants cleaned their teeth using horizontal strokes; there was no significant difference between respondents in the two groups based on their technique of tooth brushing.

Fluoride use among the study participants

There was poor awareness of fluoride being used as a component of toothpaste by the respondents; with no difference between the intervention and control groups (Table 2).

Dental attendance of the study participants

A total of 21 (19.8%) women in the intervention group had visited a dentist in the past compared to 4 (4.3%) in the control group, p = 0.010. The major reason for not consulting regularly with a dentist as stated by 78 (91.8%) women in the intervention group was that there was no problem with them, while the main reason given by women in the control group for not seeing a dentist regularly was that they did not know the location of a dental clinic (Table 3). The other reasons given for not consulting a dentist regularly included “financial constraint”, “not feeling like consulting a dentist” and “fear of pain”.

Table 3 . Reasons for not consulting a dentist.

Variable	Intervention group N (%)	Control group N (%)
No problem with me	78 (91.8)	27 (30.0)
Do not know the location of a dental clinic	0 (0)	59 (65.6)
Others	7 (8.2)	4 (4.4)

Discussion

The main finding of this study was better oral hygiene practices by market women who had participated in oral health education programmes compared to their colleagues who had not. The significance of this finding is that oral health education conducted consistently at markets and other places of work will generate positive behavioural changes necessary for effective community oral health9,10.

The typical large rural market setting, such as Oja-Oba market used for this study, is a peculiar but distinct location to study the effectiveness of oral health education at places of work because of its extremely busy, mobile and versatile traders. Furthermore, the avenue of getting the traders together in one location is difficult compared to other places of work where the audience can be easily organized, thus describing a situation whereby oral health education has to be given in piecemeal fashion with patience.

This study has shown an improvement in the care of the teeth by market women who had participated in oral health education over those of their peers. The recommended frequency of cleaning of the teeth from the oral health education programme was twice daily, which was more often practiced by participants in the intervention group. Likewise, women in this group were more likely to clean their teeth before going to sleep as well as clean their tongue. This agrees with findings from previous studies where good oral hygiene practices and improvement in oral cleanliness as well as in the gingival health of the studied group was noted after a period of oral health education4,6,8. Kowash et al.9, similarly, reported the effectiveness of regular oral health education conducted among mothers in improving the oral hygiene of their children as well as prevention of the occurrence of dental caries. The need for a continuous oral health education programme for people in order to achieve the desired behaviour change has thus been re-emphasized10.

The oral health education programme discouraged the faulty horizontal brushing of teeth and taught the miniscrub technique or the vertical strokes method. However, no significant difference was found in the type of brushing technique utilized in the two groups although women in the control group engaged in the faulty horizontal technique of tooth cleaning. This is a reflection of the brushing technique practiced in this community as was reported in a previous study and in a peri-urban community11,12. The intervention group had imbibed the recommended brushing technique and with time it was hoped that it would be entrenched into their oral hygiene habits.

The importance of fluoride use in the health of teeth was one of the key messages in the oral health education programme at the market used for this study, however, no significant difference was found between the two groups with regards to the use of fluoride. This is at variance with reports by Tai et al.6 where participants in the intervention group utilized fluoride containing tooth paste more often than those in the control group. In Nigeria the fact that the available toothpastes are known to contain fluoride such that the participants who brush their teeth have no choice but to use the available toothpaste may be responsible for the non-discriminatory nature of that particular question in the present study.

The relevance of utilization of dental services was emphasized during the education programme for the market women. This study also revealed that the overall utilization of dental services by the study participants was low as similarly reported by other authors12,13,14. The participants in the intervention group in the present study had a better dental care seeking behaviour than those in the control group, and were less likely to mention that they did not know where a dental centre was located as a reason for not visiting the dentist. Knowledge about the location and availability of a dental centre by the intervention group came from the oral health education programme conducted for this group thus sporting the increased level of awareness that comes with education. The major reason provided by the participants in the intervention group for not consulting the dentist was that they had no problems with their teeth. This is the most reported reason in the literature for not visiting the dentist13,15,16. This may be because many oral diseases are quiescent and give major symptoms only at advanced stages. On the other hand, the role of cultural beliefs and norms as important factors in the adoption of lifestyle and behaviour change in humans cannot be over emphasized. However, the fact that oral health education provides the required knowledge that can bring about good behaviour change in a positive direction among the intervention group is encouraging.

A limitation of this study was the absence of randomization of the participants; the documented benefits of oral health education made obtaining ethical approval for randomization of participants, in which the design would have stated that one group would not be offered oral health education, would have been challenging because it would have violated the principles of beneficence.

Conclusions

The study showed that oral health education conducted at a market was effective in improving some oral health practices of participants. It is recommended that oral health practices be extended to major markets in our communities.