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PDF: 702
2161-0711-10-672Received Date: Dec 04, 2020
Accepted Date: Dec 10, 2020
Published date: Dec 21, 2020
Assessment of Knowledge, Attitude, Practice of Oral Hygiene and Prevalence of Dental Caries among School Children in Massawa Sub Zone, Eritrea: Cross Sectional Study
Nazrawi Mehari1*, Berhe Tesfai2, Andebrhan Tewelde3 and Efrem Kahsu4
1Dentist, Dental clinic head, Massawa hospital, Northern Red Sea zone, Ministry of Health, Massawa, Eritrea
2Medical doctor, Medical director, Massawa hospital, Northern Red Sea Zone, Ministry of Health, Massawa, Eritrea
3Epidemiologist, Health Research Division, policy and planning, Ministry of Health, Asmara, Eritrea
4Dentist, Dekemhare hospital, Zoba Debub, Ministry of Health, Dekemhare, Eritrea
*Correspondence author: Nazrawi Mehari, Dentist, Dental clinic head, Massawa hospital, Massawa, Northern Red Sea, ministry of Health, Eritrea; Tel: +291-7244677; E-mail:  HYPERLINK "mailto:nazrawi.mehari@yahoo.com" nazrawi.mehari@yahoo.com
Abstract 
Background: Dental caries is the most common chronic infectious disease of childhood caused by the interaction of bacteria and sugary foods on tooth enamel.  The objective of the study was to assess the Knowledge, attitude, oral hygiene practice and the burden of the disease among school children in Massawa sub zone, Eritrea.
Methods: A prospective, cross sectional study with an interviewer administered questionnaire was used as a data collection tool. A systematic random sampling method was used to select the schools and students from Massawa sub zone and dental checkups were done to all the students in the primary and secondary schools of Massawa subzone. CSPro and SPSS softwares were used for data entry and analysis purposes respectively. Results were presented in percent, tables, graphs and P-value.
Results: of the students, 96% had poor knowledge on oral health care, 91% of them believe that brushing teeth prevents caries and 83% practically brush their teeth. About 85% of the students reported that treatment of tooth ache is as important as other organ of the body and 34% of the participant believes that dental problems do not affect general health. Only 31% of the subjects brush their teeth twice a day and 52% of the students have never visited dental clinic. Moreover; 21% of the participants do not care even if they have decayed tooth but 67 % of the students reported visit a dentist when there is toothache. The Prevalence of dental carries on the students was found to be 32.8%.
Conclusion: The students have poor knowledge and positive attitude on oral health care and higher prevalence of dental carries was reported in the sub zone of Massawa; Eritrea. The level of education of the students showed significant association to their knowledge on oral health.  
Keywords
Knowledge; Prevalence; Toothache; Dental carries; Oral hygiene
Introduction 
Oral health implies being free of chronic oro-facial pain, oral and pharyngeal (throat) cancer, oral tissue lesions, birth defects such as cleft lip and palate, and other diseases and disorders that affect the oral, dental and craniofacial tissues, known as the craniofacial complex [1].
Oral diseases are public health problems worldwide [2]. Their impact on individuals and communities in terms of pain and suffering, functional impairment and reduced quality of life is considerable and are the fourth most expensive to treat in most industrialized countries [3]. Adolescents represent a challenging group in terms of oral health because they have vulnerable permanent teeth erupting by the time they are establishing their independence from parental influence [4]. Dental  caries  is  one  of  the  most  common  childhood  diseases  in  the  world. In many developed countries, dental caries has improved in older children in recent decade, but remains a significant problem in younger children [5].  Dental caries occurs during childhood and continues to be a major public health problem. The prevalence of dental caries was associated with oral hygiene practice, sugar consumption and implementation of the preventive oral health program [6]. Dental caries is a significant health problem among the people of all ages but the magnitude of the problem is greatest among young children [7]. To overcome the global burden of oral diseases community oriented preventive and oral health promotional programs have been emphasized and prioritized by World Health Organization to the general curative approach [8].
Children with inadequate oral health knowledge are twice as likely to have caries as children with adequate knowledge and on other studies showed that there is an association between increased knowledge and better oral health [9]. Most relevant target group to inform about preventive measures are parents, teachers and health care personnel as indirectly the information reaches at the hand of the children. Greater knowledge has been noted to be associated with better hygiene (i.e. lower plaque score) and also with a more positive attitude towards oral health. [10]. Although, the trend is not clear in developing countries, the burden of dental caries has been increasing among children due to the unlimited consumption of sugary substances, poor oral care practices and inadequate health service utilization. Studies revealed that the prevalence of dental caries was higher among urban children. Similarly, a study conducted in Ethiopia was reported 36.5% prevalence of dental caries among urban children in school [11]. Involvement to increase awareness for oral health promotion can prevent an irreversible damage on the teeth. In Eritrea there are very few published literature on the Knowledge, Attitude and Practice and prevalence of dental caries among school aged children. Dental carries were found to be a common public health problem among school going children in Eritrea. More than 50% of the students had dental caries. There is urgent need to institute national interventions to prevent the further increase in disease burden from dental diseases [12,13] 
Dental caries is consistently ranked as the first or second most commonly reported disease with the highest morbidity in Out Patient Departments in Eritrea. Dental caries was ranked as the highest morbid disease in the years 2013 and 2014 and second highest reported disease during the years 2011, 2012, 2015 and 2016 [13].
Gaps in dental health service utilization, dental health practices and suboptimal water fluoride levels contribute to poor dental health among school children in Eritrea [13]. Bearing in mind, this research will help to compare the knowledge attitude and oral hygiene practice with the prevalence of dental caries in those students.
Materials and Methods
A prospective cross sectional study was conducted during the academic year in June 2019 among the students of all Massawa sub zone. A stratified random sampling was used to select the required number of schools and students for the purpose of the Knowledge, attitude and practice study. First the schools were grouped to elementary, middle and high school and different schools were selected randomly from each category. Finally the students from each schools was also stratified by their level of education (grade) and from each of these strata respondents (students) was selected randomly by applying proportional to size (PPS) from the schools in Massawa sub zone and dental checkups were done to all the students in the schools. Students who were below ten years age were not invited to participate in the study as they were too young to understand and complete the questionnaire.
Sample size determination 
Sample size was determined using Daniel�s formula. Sample size was calculated from the source population using single population formula. The sample size determination was based on the level of precision required for the proportion of students who have favorable knowledge, attitude and practice towards dental hygiene. To the best of our knowledge, there is no documented information on proportion of students who have favorable knowledge, attitude and practice towards dental hygiene. Thus, we assumed the required precision level to be 50 percent. This is the "safest" choice for the population proportion since the sample size required is largest when P = 0.5.Taking this level of precision combined with the following assumptions, were used to calculate the minimum sample size.
Assumptions for sample size calculation:
p= proportional=0.5 or 50%
z= standard normal distribution (1.96) 
d= Margin of error (accepted error) =0.05 
n= Z �/2 P (1-P)/d2= (1.96)2(0.5) (1-0.5)/ (0.05)2=382 
Considering 5% non-respondents rate =383+10% = 384. A total of 384 students were selected 
Data collection and analysis
Massawa sub zone had a total of 8454 students on the academic year of 2018-2019 [source: ministry of Education, Massawa sub zone. All the students were checked up for dental caries and out of 8454 students 382 students were randomly selected with equal distribution that represent the three level of education (elementary, junior and  high school) and the schools all over Massawa sub zone to fill the questionnaire. The questionnaire was adopted from different similar studies and it was modified to suit the objective o the study and the students� capacity. The questions in the questionnaire were designed to suit their level and assess their basic knowledge, attitude and practices towards oral health and oral hygiene maintenance. There were 27 questions consisting of 9 questions to assess their knowledge, 8 to assess attitude and 10 to assess their oral hygiene practice. Subjects were divided into high and low knowledge groups. Students who scored six and above were categorized as having high knowledge and those with a score of below five were considered to be in poor knowledge group. Regarding the attitude and perception of oral health and the dental care providers, if a student answer indicated a positive impact on oral health, the subject was considered to be having a positive attitude. Positive attitude responses were given a score of 1 and negative responses were given a score of 2 and �I don�t know response� were given score 3. Those who responded five or more score were considered to be having a positive attitude and those scoring less than 5 score were considered having a negative attitude towards oral health. Data management and statistical analysis were performed using the statistical software SPSS version 17.0. 
Data was examined to explore the pattern and distribution of the characteristics of the students. Categorical variables were presented with frequency and percentages and continuous variables were presented as mean, standard deviation and range. Chi-squared test was employed to test association between categorical variables and t-test was applied to test continuous variables.
Ethical consideration
The study was approved by the Health research and ethical clearance committee of Ministry of health of Eritrea and the directorate of education in Massawa sub zone. A letter was sent to the selected schools directors explaining the purpose of the study and the procedures that would be followed during its conduct. The principal of each school was asked to inform the students.  Verbal consent to participate in the research was obtained from each student before enrolment in the study. The Verbal informed consent procedure for the students was approved by the Health Research Proposal Review and Ethical Clearance committee of the Ministry of Health.
Results
A total of 369 students have participated in the study with different age groups and genders demonstrated no significant differences in their responses, so the frequency tables present the subjects as a whole. 13 students were excluded from the study due to incomplete response in the questionnaire with a response rate of 96.6%. The number of male and female participants was almost equal, 50.4% female and 49.6% male.  And 68.8% of the participants were in age group of 10-14 years. Regarding the educational level, most of the participants were elementary and junior with High school participants consists only 19% [Table 1].
Knowledge category of students by background characteristics
Most of the students have poor knowledge in both age categories with only 3.1% and 5.2% in the age range of 10 to 14 and 15 to 19 years have good knowledge about dental carries respectively. Almost all (96.2%) of the students with similar gender distribution have poor knowledge on dental carries and as their level  of education increases, the level of knowledge increases with only 0.6% of elementary students and 12.9% of secondary students have good knowledge. The students knowledge was also associated with level of education of their family that those with illiterate family has very poor knowledge compared to these who reach secondary and tertiary level family [Table 2].
Attitude of students towards mouth and teeth cleanness by background characteristics
Most of the students have good attitude towards oral health care, interestingly 91% believes that brushing teeth prevents decaying, though 36%of the students are afraid of visiting dental clinic and 73% thought that regular visit to dentist is necessary. Majority of the students (66%) believed that dental problem can affect general health and 86% thought that treatment of tooth ache is as important as any other organ of the body [Table 3].
Practice of students on brushing their teeth, timing and frequency of brushing
Most of the students (93%) brush their teeth and the frequency of tooth brushing was low. About one third of the students had brushed their teeth once per day and a few percent brushes their teeth two times per week. Majority of the students (76%) brush their teeth in the morning while a very few brushes their teeth after lunch. About one tenth of the students brush their teeth for less than one minute but about one third of them brush their teeth from one to more than two minutes [Table 4]. Although most of the respondents (93%) brush their teeth but only 29% of these brush twice a day while 27% brushes when they remembered it [Figure 1].
Students care made towards their teeth and mouth cleanness
About half (52.4%) of the students aged 10 to 14 years were watched by their parents while brushing their teeth that; Elementary students were more watched (54.9%) by their parents compared to secondary students (31.4%). Only about one third of the students were advised by their parents to brush their teeth and most of the students brush their teeth after eating food. Above 50% of the students visit a dentist when they have a decayed teeth and around 10% was treated at home while a few students reported that they took medicine by their own when they have a decayed teeth. The majority of the students were treated at home when they have a tooth pain and only below 10% of students had regular visit to a dentist on 6 to 12 months [Figure 2].
Association knowledge and background characteristics
Of the students, 96.9% of them aged 10 to 14 years have poor knowledge score with similar gender distribution and 99.4% of the elementary students have poor knowledge compared to the secondary students (87.1%). Of the students, 99.4% with illiterate father had poor knowledge compared to tertiary level father's education (81.8%) [Table 5].
Prevalence of dental carries among students by sex and age
The overall prevalence of dental carries among the students were found to be 32.8%, which was much higher on males when compared to females, 59.4% and 40.6% respectively.  The prevalence was also higher on the younger students and as the age of the students� increases the prevalence of dental carries was decreased [Table 6].
Discussion
The majority of the study participants were between the ages of 10 to 14 years with elementary level of education. Amazingly (96.9%) of the students aged 10 to 14 years have poor knowledge score and 99.4% of the students with illiterate father had poor knowledge compared to tertiary level of father's education (81.8%). This could be a reason for the very poor knowledge of the students. Students with illiterate family had also very poor knowledge compared to these who reach secondary and tertiary level family, which also shows the significance of parental education on health awareness of the children. This result shows a direct relationship with the increase in dental caries rate among the participants with poor knowledge which is similar with the statement given by Du [14, 15], that Children with inadequate oral health knowledge are twice as likely to have caries as children with adequate knowledge and on other studies showed that there is an association between increased knowledge and better oral health.
As the age and level of education of the students increases, the knowledge of the students also increases, which shows the significance of the schools in general oral health awareness. Majority of the students (66%), most of them with secondary educational level thought that dental problem can affect general health, which is comparable to the study done in 2016 by Kumar et al. in which 64% agreed that oral health is important for overall health of the body. Above three �fourth of the students thought that regular visit to the dentist is necessary and smoking is a bad habit, which is an essential attitude of the students to improve their knowledge and practice in dental health. Some of the students still are afraid of going to the dentist and thought that Dentist care only about treatment and not prevention, which shows the importance of dental school health on preventive measures.
Only a few students have regular visit to a dentist (6.5%) and about half of the students have never visited a dentist which could be a reason for their poor knowledge and high prevalence of dental carries on the students, this is similar to other study conducted in Eritrea by Andegiorgish [13] that More than half of the respondents had never visited a dentist and visits for regular checkups were cited by only 6.6% of the respondents.  But this was lower when compared with Humagain M that 20% of regular attendees and visited dentist only when they got dental pain. Similarly shows 24.4% and Kumar reported 58% of students visit dentist only when there is a problem. similar study by Madhan showed the importance of visiting dentist once in every six months was known by 74% of subjects however 59% of them never been to dentist.
This study showed that the frequency of tooth brushing was low with only 30% students brush their teeth two times per day and most of the students (76%) brush their teeth in the morning. This was almost similar to Andegiorgish [13], that 28.1% of the study participants cleaned their teeth once a day and 19.1% twice daily, and Humagain that Only 35.1% of the students brushes their teeth at least twice daily while 64.9% reported regular brushing once daily. But it was lower to Kumar that 66% of students brush their teeth only once daily showed that 60% of the respondents practice brushing tooth twice daily.
About half of the students aged 10 to 14 years were watched by their parents while brushing their teeth and a few percent of students were not taking care by their parents on brushing their teeth. But Andegiorgish showed that, the majority of the students (85%) claimed that they cleaned their teeth unassisted while 9% reported they received assistance from their mother. The majority of the students brush their teeth after eating food and  above half of the students visit a dentist when there is a decayed teeth with some of them didn�t care and treated at home and a few took medicine by their own. 
The prevalence of dental caries among the study population is found to be 32.8% which is lower than studies carried out in other parts of Ethiopia (36.3-48.1%), Nigeria (35.5%), Nepal (52%) 59.4%, and India (77%). However, it was higher than a study conducted in Tanzania (17.6%). The difference in dental caries rate in these different studies could be due to difference in knowledge, attitude and practices on oral hygiene of the study population. This study showed that the prevalence of dental caries was higher on the young students (44.5%) with male predominance (59.4%) and was higher in these their family had no formal education. This high prevalence could be attributed by their poor knowledge and practice on oral hygiene.  This result was much lower when compared to previous studies conducted in Eritrea; the prevalence of dental caries was 78%, without significant difference between males (78%) and females (79%) [13]. Females had higher dental caries and was highly prevalent among children their aged d" 10 years (64.7%) [12].
Conclusion 
The study shows dental caries was a common public health problem in school children in the sub zone associated with poor knowledge on oral hygiene, low teeth brushing practice and dental visit habits. Therefore oral health-oriented education programs should be included in their curriculum that helps to improve their knowledge and behavior. The communities� knowledge and their awareness should be increased on the preventive methods of dental caries. Students should be advised by their family and teachers to have regular brushing and dietary habits advice with follow up to a dentist.   
The main limitation of the study was on diagnosis of the dental caries which leads as to define dental caries as presence of any cavitated or darkly stained tooth in permanent or primary dentition. Lack of standard and adequate basic examination instrument was also another burden to the study.
Acknowledgment
The authors acknowledge the Ministry of Health, Northern Red Sea Zone and the Ministry of Education Massawa subzone branch for their continued technical support. We also thank the data collectors and students who took part in this study.
Author�s contribution
Nazrawi Mehari, Berhe Tesfai, Andebrhan Tewelde and Efrem Kahsu have designed the proposal. All the authors have participated on drafting the final form of the proposal. Nazrawi Mehari and Berhe Tesfai have participated on data collection and supervision of the data collectors. Andebrhan Tewelde designed the data entry tool and analyzed the results using SPSS software. Nazrawi Mehari, Berhe Tesfai and Andebrhan Tewelde ,-6BI^o{������			���Ŷ��������tdTdDT4h�r�ht_5�CJOJQJaJh�r�hsE5�CJOJQJaJh�r�hVZH5�CJOJQJaJh�r�hye�5�CJOJQJaJh�r�h5CJOJQJaJh�'�CJOJQJaJhMN�CJOJQJaJh5h5CJOJQJaJh5CJOJQJaJh�r�hVZHCJOJQJaJhiQ0hiQ05�CJOJQJaJhiQ05�CJOJQJaJh{q�5�CJOJQJaJhiQ0h{q�5�CJOJQJaJIe�(	m	�	J
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