Oral health knowledge, attitude and oral hygiene practices among adults in Rwanda

¹School of Dentistry, University of Rwanda, Kigali, Rwanda, ²Department of Community Dentistry, School of Oral Health Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa, ³Department of Orthodontics, School of Dentistry, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa

^&Corresponding author
Emmanuel Nzabonimana, School of Dentistry, University of Rwanda, Kigali, Rwanda

Introduction    

Oral diseases (OD), commonly tooth decay and periodontal disease, are a major public health problem with 3.58 billion people reported to have tooth decay, according to the Global Burden of Disease Report conducted in 2015 [1]. Periodontal diseases are prevalent in developed and developing countries and effect about 20-50% of the global population [2]. Some studies have found a strong association between poor oral hygiene and common dental diseases such as dental caries and periodontal diseases [3,4]. Globally, the burden of oral disease is high among older people and has a negative effect on their quality of life [5]. Poor oral hygiene causes tooth loss, which leads to disability and compromised patients' oral health [6]. In Africa, OD is a significant public health problem [7]. The prevalence of dental caries has increased in many African countries and may further increase due to increased sugar consumption and inadequate exposure to fluorides [7]. The prevalence of gingival inflammation is high in all age groups in several African countries [8]. In a study from Sudan, about 64.5% of participants considered poor tooth brushing habits to cause gingivitis and less than 20% of adolescents visit dentists regularly for a dental check-up [9]. In Tanzania, a study found that 44.8% of the participants had fair to poor oral hygiene status [10]. A study in Uganda found that 56% of participants had not visited oral health services in the last two years, and those who did was due to pain [11].

In Rwanda, OD is among the leading cause of morbidity at the health center level, with poor oral hygiene, tooth decay, and periodontal disease, have been reported [12-14]. The Rwanda National Oral Health Survey in 2018 found that the oral health status of the population was poor, with 70% of individuals not utilizing oral health services. Adults aged 20 years and above from Rwanda have been reported to present with oral debris, and dental calculus [14]. Studies have associated low health literacy with greater use of emergency care and poor preventive health-seeking behavior for oral health services [15,16]. A correlation between limited oral health knowledge and poor oral health behavior has been reported [17], however, there is a scarcity of information on oral health awareness levels in Rwanda. Therefore, this study evaluated knowledge, attitude, and oral hygiene practices among adults in Rwanda. It is part of a large doctoral study entitled "Oral Health in Nyarugenge District of Rwanda: The Role of Mobile Application in Oral Health Education."

Methods     

Study design and setting: a descriptive cross-sectional study was conducted among participants attending public health facilities in Nyarugenge District, Rwanda. Rwanda stands as of one of the 56 countries in the African continent. Rwanda is divided into four provinces, plus Kigali City, the capital city. The four provinces have 27 Districts, while Kigali City has three districts (Gasabo, Kicukiro, and Nyarugenge) based on Government data [18,19]. The study was conducted in July 2022 in Nyarugenge District, Kigali City, Rwanda.

Study population: adult patients aged 18 years and above attending health services in Nyarugenge District were recruited for the study. Participant who voluntarily agreed and signed informed consent to participate were included in the study. Patients who were hospitalised and mentally challenged were excluded from the study. The seven urban health facilities services in Nyarugenge District were randomly sampled to obtain three health centres. The participants were selected conveniently from the three health centres. The sample size was calculated based on the estimated oral health knowledge prevalence of 50%, with 95% confidence level and 5% level of precision to be 420 participants.

Data collection: data were collected by principal investigator (EN) and four research assistants who have dental background with adequate experience in collecting quantitative data. The participants were recruited conveniently and those who consent were interviewed in Kinyarwanda local language using a structured questionnaire which was adapted from previous reported studies [21-23]. The questionnaire elicited the demographic characteristics, oral health knowledge, oral health attitude, and oral hygiene practices of the participants.

Definition

Outcome variable: oral health knowledge, oral health attitude, and oral hygiene practices.

Exposure variable: demographic characteristics (age, gender, marital status, owning smartphone and level of education).

Statistical analysis: the Stata software version 16 was used for analysis (StataCorp, College Station, Tx). Descriptive statistics frequency and percentage distribution were used to analyze demographic characteristics, oral health knowledge, oral health attitude, and oral hygiene practice. Bivariate and logistic regression was done to assess factors associated with oral health knowledge, oral health attitude, and oral hygiene practices. The oral health knowledge questions were analyzed by assigning the most correct answer a score of "1", and wrong answers and don't know a score of "0". The nine statements on knowledge were summed up to a total score of 9, equivalent to 100%. A score of less than 60% was classified as 'poor oral health knowledge' and a score of 60% and above indicated 'good oral health knowledge'. The oral health attitude questions were analyzed by allocating the positive attitude a score of "1" and the negative attitude a score of "0" while neutral responses were not allocated any score and not used in computing the total attitude score. The attitude responses were summed up to a total score of 7 indicating 100% good attitude. The attitude score of less than 60% indicated a poor oral health attitude, and the score of 60% and above showed a good oral health attitude. In addition, the responses of attitudes "strongly disagree" and "disagree" were combined to "disagree" and "strongly agree" and "agree" were combined and became "agree", and neutral responses were reported as it is in the frequency tables. Oral hygiene practice questions were analyzed by allocating the most correct answer a score of "1", and the wrong answer a score of "0". The response score was summed up to a total score of 8, indicating 100% good oral hygiene practices. A score of less than 60% were categorized as 'poor oral hygiene practices' and scores of 60% and above indicated 'good oral hygiene practices'.

Ethics consideration: the Human Research Ethics Committee (HREC) (Medical) of the University of the Witwatersrand, Johannesburg provided ethics approval (M220213) to conduct the research. Permission was also obtained from the relevant healthcare authorities, Rwanda IRB ethical committee (No234/CMHS IRB/2022), and the National Health Research Committee (No NHRC/2022/PROT/26). Informed consent was signed by all participants.

Funding: “Emmanuel Nzabonimana was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University of the Witwatersrand and funded by the Carnegie Corporation of New York (Grant No. G-19-57145), Sida (Grant No:54100113), Uppsala Monitoring Center, Norwegian Agency for Development Cooperation (Norad), and by the Wellcome Trust [reference no. 107768/Z/15/Z] and the UK Foreign, Commonwealth & Development Office, with support from the Developing Excellence in Leadership, Training and Science in Africa (DELTAS Africa) programme. The statements made and views expressed are solely the responsibility of the Fellow.”

Results     

Demographic characteristics of the participants: a total of 426 respondents participated in the study, with majority in the 18-27 years old age category (39.44%; n=168). The median age was 30, interquartile range (IQR) at 25 - 39. The majority of the participants, (61.5%; n=262) were female (Table 1).

Oral health knowledge, attitude and practice: poor oral health knowledge was found in 42.02% (n=179) of the participants. Oral health practices, 67.37% (n=287) and oral health attitude 12.44% (n=53) were also poor.

Frequency distribution of oral health knowledge among the respondents: most of the respondent knew the importance of tooth cleaning, even though some had poor oral knowledge of the cause of gingival disease. The majority of the respondents 82.16% (n=350) new the importance of cleaning between teeth in order to prevent gum inflammation. Most of the participants knew the importance of regular dental check 74.88% (n=319), while 25.12% (n=107) of the respondents did not know. Regarding tooth brushing 39.19% (n=397) of the respondents knew that tooth brushing should be done in the morning and at night daily (Table 2).

Frequency distribution on oral health attitude among the respondents: according to the respondents' attitude towards oral health, 56.19% (n=227) do not believe that teeth can be cleaned effectively without using toothpaste, while 43.81% (n=177) agree with this statement. Believe on dentists should be visited regularly, even without having an oral problem 23.66% (n=97) disagree, 76.34% (n=313) agree. Regarding oral health attitude on performing oral self-care regularly to identify any abnormality in my mouth, such as a hard deposit on my teeth, 3.33% (n=14) disagree and 96.67% (n=406) agree (Table 2).

Oral health practices among the respondents: most respondents, 64.1% (n=273) brushed their teeth twice a day, while 35.9% brushed them once daily. The soft bristle toothbrush was used by 35.9% (n=153) respondents, while 21.1% (n=90) used a hard bristle toothbrush, and 3.1% (n=13) respondents visited dental services every six months. Most of the respondent 92.7% (n=395) had never used dental floss to clean their teeth, and only 0.9% (n=4) of the respondents use it twice daily, 2.11% (n=9) use it once a day, 3.52% (n=15) use dental floss sometimes and 0.7% (n=3) use floss once a week (Table 3).

Frequency distribution of the reason for visiting dental services: the majority of the respondents 79.58% (n=230) among 289 who visited dental services in the past, had visited dental services due to pain, while 4.15% (n=12) respondents visited dental services for teeth cleaning, 5.54% (n=16) respondents visited for oral check-ups and advise, 2.77% (n=8) visited for gum problems and 7.96% (n=23) participants sought dental services due to gum problems.

The association between oral health knowledge, oral health attitude, oral health practices, and demographic characteristics: oral health knowledge was found to be significantly associated with oral health practices (P-value= 0.017), oral health attitude (P-value=0.000) and level of education (P-value=0.006). Owning a smartphone was found to be significantly associated with oral health knowledge (P-value=0.011), oral health attitude (P-value=0.049) and oral health practice (P-value=0.011) (Table 4).

Logistic regression for KAP and demographic characteristics of the respondents: the variables found being significant in the univariate analysis concerning oral health knowledge were marital status, smartphone ownership, and level of education. Oral health practices showed significant associations with smartphone ownership and level of education in the univariate analysis. In the multivariate analysis, individuals with a high school education were more likely to possess better oral health knowledge aOR=1.79, 95% CI 1.14; 2.82 and p-value 0.011 (Table 5).

Discussion     

Our study is among the first to report data on oral health knowledge, attitudes, and oral hygiene practices of adult participants in Nyarugenge, Rwanda. The study revealed that among Nyarugenge adults, more than 40% exhibited knowledge deficits. The oral health attitudes and oral hygiene practices were also found to be poor. The findings showed that 39. 4% of the participants were young adults between 18 and 37 years old. A similar age group has been reported in India and Nigeria where the participants evaluated dental needs [24,25]. The current results showed that most of the participants were women. Previous studies have reported a similar gender predominance, citing that women were more proactive in seeking dental care [26]. Similar gender differences were reported in Saudi Arabia and India where it was found that women acted more positively than men on oral health [27,28].

Our results showed that almost half of the participants had poor oral health knowledge. Our sample knowledge (58.0%) was lower compared to 62.2% reported in Nigeria, but it was similar to that reported in Spain with oral health knowledge of 58.5% [29,30]. Although in our study participants knew that they must brush their teeth to prevent tooth decay (84.27%) and that to prevent gum inflammation, it is also necessary to clean between teeth (82.16%), most of them did not feel that a regular dental visit was necessary. Our study participants' knowledge of dental and gum care was lower than in the results reported in Cyprus at 97.3% and 96% respectively [31] and Romanians at 95.3 and 88.3% [32]. The knowledge of the participants in our study was strongly associated with the ownership of a smartphone (P=0.011), secondary education (P = 0.006), good oral hygiene practices (P=0.017), and good oral health attitudes (P=0.000). A study conducted in Iran found an association between oral health knowledge and financial status, which can be reflected in our study as the ownership of a smartphone [33]. In addition, a similar association was reported between oral health knowledge and a higher level of education among adult populations in Spain [30]. More educated people are more likely to use reading, social media, news, and the internet to learn more. Bastani et al. found that smartphone-delivered oral health information enhanced knowledge [34]. The association between oral health knowledge and attitude was consistent with what was found in China [35] but contrasting results were found in the South Indian population [36]. These differences might be due to different geographic location, sociodemographics of the participants, and access to oral health care. The knowledge of study participants also reflected on their attitude, where 69.25% demonstrated a good attitude. This overall attitude was better compared to the South Indian, Saudi Arabian, and Nigerian populations where the attitude levels were 33.3%, 48.3%, and 44.5% respectively [36,37]. The differences could be attributed to the different settings where the studies were conducted. In our study, only 76.34% of the participants agreed that dentists should be visited regularly, even without having an oral problem. The participants agreed that waiting until they have a toothache before visiting the dentist can lead to tooth extraction. Our findings are almost similar to the study with Libyan's parents, who agreed that regular dental check-ups are important for the prevention of dental problems at 79.5% [38]. However, the attitude of Romanian dental patients was better compared to our study participants because 88.3% of them agreed that regular dental check-ups can prevent dental problems [32]. Our study findings showed that the participants attitudes were associated with oral health knowledge (P=0.002). A similar association between attitude and oral health knowledge was also found among Iranian patients [18] and Brazilian patients [39]. According to Rodrigues et al. a patient's attitude is a key construct for causing them to adopt a certain behavior and maintain that behavior [39]. The participants' attitudes in our study were also associated with ownership of a smartphone (P=0.049). The relationship between the ownership of the smartphone and the level of attitude could be that smartphone users tend to obtain more information online, which may improve their attitude.

The knowledge and oral health attitudes levels of our study participants did not translate to improve their oral hygiene practices. Only a third of our study participants displayed good oral hygiene practices, in contrast to the Libyan study, where 78.7% of parents displayed good oral hygiene practices [38]. Similarly, good practice findings have been reported in the literature [32,33,35] except in Brazil where low oral health literacy was associated with poor oral hygiene practices [33,40]. Approximately 64.08% of our study participants brushed their teeth twice a day, compared to the Chinese dental patients who reported that 77.4% brushed their teeth twice a day [41]. Furthermore, 51.64% of our study participants responded that they should visit dentists only when they experience pain, as compared to 55% of the Saudi Arabian participants [42]. The results of our study found poorer oral hygiene practices in contrast to the Indian study where 82.0% of the participants went for routine dental check-up and 25.8% expressed that the reason for their last dental visit was only consultation and advice [27,38]. Dental flossing was not popular among our study participants because 92.7% reported never using a dental floss. Similarly, dental flossing was low in Romania at 27.9% [32]. Oral hygiene practices in our study were found to be only associated with oral health knowledge. The result of our study differed from what was found in Brazil, where level of education was associated with oral health practices [40].

One of our study's limitations is the use of a cross-sectional design, which cannot establish causality. However, we addressed this limitation by conducting a regression analysis that adjusted for confounding factors likely to influence the outcomes. Additionally, our study's sample bias arose from recruiting participants solely from government facilities, limiting the generalizability of results to those using private facilities. Moreover, because the data was collected from one district with a limited sample size, this study cannot be generalized to the entire country.

Conclusion     

Almost half of the adults in Nyarugenge district had poor oral health knowledge, one-third of them had poor oral hygiene practices despite showing good oral health attitudes. The discordance requires that oral health education and oral health attitudes be improved. The association between smartphone ownership and oral health knowledge was identified among the participants. This suggests an opportunity to utilize smartphones as educational tools for oral health alongside traditional methods to enhance knowledge and promote better oral hygiene attitudes and practices.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Conception and study design: Emmanuel Nzabonimana, Phumzile Hlongwa, and Yolanda Malele-Kolisa. Data collection: Emmanuel Nzabonimana. Data analysis and interpretation: Emmanuel Nzabonimana, Phumzile Hlongwa, and Yolanda Malele-Kolisa. Manuscript drafting: Emmanuel Nzabonimana. Manuscript revision: Emmanuel Nzabonimana, Phumzile Hlongwa, and Yolanda Malele-Kolisa. Guarantor of the study: Emmanuel Nzabonimana. All authors approved final version of the manuscript.

Acknowledgments     

We appreciate the Biostatistician team from both University of Rwanda and Wits University for their contribution and guidance.

Tables     

Table 1: demographic characteristics of the participants

Table 2: frequency distribution of oral health knowledge and oral health attitude

Table 3: oral health practice

Table 4: association between KAP and demographic characteristics

Table 5: logistic regression for oral health knowledge, oral health attitude, oral health practice and demographic characteristics

References