UTILIZATION OF ORAL HEALTH SERVICES
AMONG ADULTS IN A MIDDLE INCOME
ESTATE IN NAIROBI.
GICHERE SYLVIA NYAMBURA
BDS III
V28/1950/2010
A COMMUNITY DENTISTRY RESEARCH PROJECT SUBMITTED IN PARTIAL
FULFILMENT OF THE AWARD OF BACHELOR OF DENTAL SURGERY (BDS)
DEGREE AT THE UNIVERSITY OF NAIROBI.
OCTOBER 2013
(i)
DECLARATION
I, Gichere Sylvia Nyambura, do declare that this is my original work and that it has not been
submitted by any other persons for research purposes, degree or otherwise in any other
university or institution.
Signature: ...................................................................................
Date: ...........................................................................................
(ii)
SUPERVISORS' APPROVAL
This research project was submitted for the partial fulfillment of the degree of Bachelor of
Dental Surgery with our approval as supervisors:
Dr. Regina Mutave BDS (Nbi), MRes (St. Andrews), PGD-RM (Nbi)
Chairman, Dept. Periodontology/ Community and Preventive Dentistry,
Senior Lecturer,
Community and Preventive Dentistry.
Signature:................................................................
Date:.......................................................................
Dr. B.N. Mua BDS, MPH, Pg Dip. STI (Nbi), MBA (St. Paul’s)
Lecturer,
Community and Preventive Dentistry.
Signature:.....................................................................
Date:.............................................................................
(iii)
DEDICATION
This project is dedicated to my parents Mr. Samuel Gichere and Mrs. Virginia Gichere for
their continued prayers and support and to my brother, Simon Gichere for his constant
encouragement.
(iv)
ACKNOWLEDGEMENTS
My sincere gratitude goes out to my supervisors, Dr. Regina Mutave and Dr. B.N. Mua for
their patience, guidance and useful critique of this research work.
I would also like to thank Mr. Ben Mwaniki, the chairman, Prudential estate welfare
association for his assistance during data collection.
Finally, I wish to thank all the members of Prudential estate, Buruburu for their cooperation
and support.
(v)
TABLE OF CONTENTS
Page
Title page
Declaration..............................................................................................................................(i)
Supervisors approval..............................................................................................................(ii)
Dedication.............................................................................................................................(iii)
Acknowledgements..............................................................................................................(iv)
Table of contents...................................................................................................................(v)
List of tables and figures......................................................................................................(vii)
List of abbreviations……………………………………………………………………....(viii)
Summary...............................................................................................................................(ix)
Chapter 1: Introduction & Literature review
1.1 Introduction......................................................................................................................1
1.2 Literature Review.............................................................................................................3
Chapter 2: Problem statement, research justification, objectives & variables
2.1 Problem statement............................................................................................................6
2.2 Research justification.......................................................................................................6
2.3 Objectives.........................................................................................................................6
2.4 Variables...........................................................................................................................7
Chapter 3: Research Methodology
3.1. Study Area......................................................................................................................8
3.2 Study Population.............................................................................................................8
3.3 Study Design...................................................................................................................8
(vi)
3.4 Sampling..........................................................................................................................9
3.5 Data collection instruments and techniques...................................................................10
3.6 Data Analysis.................................................................................................................10
3.7 Ethical considerations....................................................................................................10
3.8 Benefits of the study......................................................................................................10
Chapter 4: Results
4.1 Results............................................................................................................................11
Chapter 5: Discussion, Conclusion & Recommendation
5.1 Discussion………….......................................................................................................22
5.2 Conclusion……………..……………………………………………………………....24
5.3 Recommendation...........................................................................................................24
References...........................................................................................................................25
Appendix I...........................................................................................................................27
Appendix II.........................................................................................................................28
Appendix III……………………………………………………………………………...30
(vii)
LIST OF TABLES AND FIGURES
Page
TABLES
Table 1: Relationship between marital status and past dental visit...............................13
Table 2: Reasons for not being able to get dental care.................................................16
FIGURES
Figure 1: Distribution of gender...................................................................................11
Figure 2: Distribution of respondents by age and gender............................................11
Figure 3: Past visit to a dental office...........................................................................12
Figure 4: Distribution of past dental visit by gender...................................................12
Figure 5: Distribution of past dental visit by age group..............................................13
Figure 6: Duration since last dental visit.....................................................................14
Figure 7: Reason for last dental visit...........................................................................14
Figure 8: Method of payment during last dental visit.................................................15
Figure 9: Need for dental care in the past year but couldn't access it.........................15
Figure 10: Particular concerns regarding teeth...........................................................16
Figure 11: Frequency of cleaning teeth......................................................................17
Figure 12: Interdental cleaning...................................................................................17
Figure 13: Smoking/tobacco use................................................................................18
Figure 14: Inability to eat due to teeth and mouth problems ....................................18
Figure 15: Frequency of toothache/painful gums/sore spots.....................................19
Figure 16: Embarrassment due to teeth/denture problems........................................19
Figure17: Avoided smiling/laughing/conversation due to appearance of teeth........20
Figure 18: Overall rating of health of teeth/gums.....................................................20
Figure 19: Modified dental anxiety scale (MDAS) mean.........................................21
(viii)
LIST OF ABBREVIATIONS
BDS – Bachelor of dental surgery
Nbi – Nairobi
MRes – Masters in research
PGD-RM – Postgraduate diploma in rural management
MPH- Masters in public health
Pg Dip.STI – Postgraduate diploma in sexually transmitted infections
MBA – Masters in business administration
SPSS – Statistical package for social sciences
WHO- World Health Organization
MDAS- Modified dental anxiety scale
(ix)
SUMMARY
Background
Good oral health is achieved by one’s personal oral hygiene. However, the role of an oral
health practitioner cannot be undermined in achieving it. This study was aimed at
investigating the need to seek oral health care or lack thereof and the reasons behind each.
Objective
To determine utilization of oral health services by adults in a middle income estate in
Nairobi.
Study Design
This was a descriptive cross sectional study.
Study Area
This research was carried out in a middle income estate (Prudential estate) within Buruburu
in Nairobi County, Kenya.
Methodology
Data was gathered using self administered questionnaires. The data was analyzed using
Statistical package for social sciences (SPSS) version 16 for Windows and Microsoft Excel.
Results
Out of 121 respondents, 66 (54.5%) were female and 55 (45.5%) were male. Their ages
ranged from 18 years to 70 years. The majority were in the age group 20 - 29 years. 91 of
them (75.21%) had visited a dentist before. 30 (24.79%) of them had never visited a dentist
before. For those who had previously visited a dentist, 47.25% were male and 52.75% were
female. More married people visited a dentist than any other group. Out of those who had
visited a dentist previously, majority (26.37%) had last been there more than five years ago.
Regarding the reason for their last dental visit, 33.88% went in because something was
wrong/bothering or hurting them. 30.58% went in by themselves for check-up, examination
and/or cleaning. 7.44% went in for treatment of a condition tht the dentist had dicovered
during an earlier appointment. 2.48% were called in by the dentist for a check-
up/examination/cleaning. When asked about the method of payment during their last dental
(x)
visit, 44.63% used cash (out of pocket expense). 20.66% used insurance cover provided for
by their employer/ government. 9.92% used personal insurance cover. A majority of people
(75.21%) had not experienced any dental problem of which they were unable to access dental
care. 23.97% had experienced a dental problem and were unable to access oral health
services. Out of those who were unable to access dental care (23.97%), most cited the reason
as not thinking there was anything seriously wrong and expected the problem to go away,
being unable to afford the cost, were afraid of dentists and were unable to take time off from
work. 59.50% of the respondents were concerned with maintaining healthy teeth and mouth.
28.93% were concerned with maintaining healthy teeth/mouth and also cosmetic appearance
of teeth. Majority of the respondents (71.07%) brush their teeth twice a day. 15.07% claimed
to brush more than once a day while 13.22% brushed once a day. 61.16% of them cleaned
interdentally occasionally. 19.83% never did so. 9.92% cleaned once a day. 6.61% cleaned
twice a day. 0.83% cleaned twice a week. 90.91% of them were non-smokers/ did not use
tobacco in any form. 9.09% used tobacco in some form/ were smokers. Most of the
respondents had never experienced difficulties with eating food due to mouth and teeth
problems. 35.54% reported they have never experienced toothache, painful gums or sore
spots. 33.84% reported hardly ever. 27.27% occasionally experienced toothache. 3.31% often
experienced toothache. Most of the respondents (36.36%) viewed the overall rating of the
health of their teeth/gums as good, 29.75% as very good, 18.18% as excellent, 14.88% as fair
and 0.83% as poor. 31 respondents out of the 121 had high dental anxiety (≥19). 90 of them
had moderate to low dental anxiety (≤18).
Conclusion
Majority of the population had previously utilized oral health services. The main reason was
that something was bothering or hurting them. Most had dental services available to them
whenever they needed them. Those who could not access oral health services stated the main
reason was that they did not think anything was serious and expected the problem to go away.
Attitude towards oral health care services was positive. Most respondents recorded moderate
to low dental anxiety. Moreover, the second most popular reason for visiting a dental office
was also out of free will for a check up or cleaning.
(xi)
Recommendations
There is need to educate the population on the benefits of regularly visiting a dentist, not just
when a problem arises. Preventive treatment should be emphasized. In addition, the dental
profession should be demystified to remove the perception that dental treatment is always
painful in order to reduce patients' anxiety.
(1)
CHAPTER 1: INTRODUCTION AND LITERATURE REVIEW
1.1 INTRODUCTION
Oral health is essential to general health and quality of life. It is a state of being free from
mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum)
disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s
capacity in biting, chewing, smiling, speaking, and psychosocial well being1. It describes a
standard which enables an individual to eat, speak and socialize without disease, discomfort
or embarrassment, and which contributes to their general well being.
Utilization of oral health services involves visiting a dental practitioner regularly. The
National Institute for Clinical Excellence (NICE- United Kingdom) states that the
recommended interval between dental check-ups should be determined specifically for each
patient, and tailored to meet his or her needs, on the basis of an assessment of disease levels
and risk of or from dental disease. It recommends that for adults, the interval should be
between 3 and 24 months2. Problems are treated more easily at an early stage. People at high
risk of dental diseases need more regular check-ups. These may include smokers, diabetics,
people with current gum disease, people with a weak immune response to bacterial disease
and people who tend to get rampant caries or build up of plaque.
The aetiology of periodontal diseases is dental plaque. Brushing of teeth, however significant
a role it plays in eliminating plaque, needs to be reinforced by a dental practitioner from time
to time. A dentist will explain on the best method of tooth brushing, the appropriate
dentifrices to use and give prophylactic treatment. He/ she will also diagnose oral diseases at
an early stage which makes management easier.
Oral health is one of the most neglected areas of global health, yet 90% of people have had
dental problems or toothache caused by caries and severe periodontitis affects up to 15% of
the worldwide population3.
A study done in Europe indicated that dental attendance varies with the socio-economic
status of the population. A far lower percentage of the population appear to visit a dentist in
socially and economically less well developed European Union member states, where there is
little or no publically funded dentistry, than those which provide publicly subsidized oral
health care4.
(2)
In America, a study done in 2010 showed that nearly half of those with medical cover had not
visited a dentist in the past year, and 22% reported they had not seen a dentist in the last 5
years5.
In Kenya, Oral Health Services Division falls under the Curative and Rehabilitative
department of the Ministry of Health. Oral health services comprise a promotive and
preventive section, and corrective and rehabilitative section. The Chief Dental Officer heads
the Oral Health Division, assisted by two auxiliary oral health persons, a community oral
health officer and a chief dental technologist. Oral Health services are offered by the public
and private sectors, which comprise of hospitals, health centres, dispensaries, nursing and
maternity homes, and health clinics.
The majority of dental personnel in Kenya are dentists. Others include dental technologists,
community oral health officers and dental hygienists. The ratio of dentists to the population is
approximately 1:60,000 when both the public and private sector are combined. 20% of the
dentists are in the rural area while 80% are in the urban centres6.
(3)
1.2 LITERATURE REVIEW
Oral diseases such as dental caries, periodontal diseases, malocclusion, and oral cancer are a
major proportion of Kenya's oral health problems6. This can be attributed to the fact that the
government has allocated very little funds towards provision of oral health services. Oral
health accounts for only 0.0016% of the Ministry of Health budget. The government
provides very minimal oral health services at public health facilities. There are also no
organized insurance schemes for subsidizing the high cost of oral health care. Majority of
those visiting a dentist paid out of pocket expenses.
Many of the elderly persons living in an estate in Nairobi suffer from dental problems,
especially periodontitis7. Dental problems are an issue of concern among the elderly. Poor
nutrition and lack of policies that dictate the provision of oral health services among the
elderly are the main reason behind this.
In a study done among adults living in Nairobi8, failure to brush teeth and lack of utilization
of toothpastes are significantly associated with the development of oral leukoplakia, while the
choice of brushing tools between conventional toothbrush and chewing stick is not. In
addition, failure to brush teeth appeared to potentiate the effect of smoking tobacco in the
development of oral leukoplakia. Oral health education, instruction and motivation from an
oral health practitioner were found to be necessary for the improvement of oral hygiene
habits and practices; and therefore oral hygiene status, oral leukoplakia preventive and
control programmes.
Most Americans seek care from a dentist regularly. However, some individuals face
challenges accessing dental care. Access challenges include difficulty getting to a dental
office, lack of prioritizing dental care among other health crises, financial barriers and
difficulty in navigating government assistance programmes. Basic awareness of oral health
issues for many Americans may be quite limited because of cultural or language barriers or
problems with literacy5.
There are profound oral health disparities across European Union (EU) countries, related to
socio-economic status, age, gender and general health status4. The structure for the delivery
of oral health care services varies significantly among member states and this impacts on
dental attendance. A far lower percentage of the population appears to attend the dentist in
(4)
socially and less well developed EU member states. Vulnerable and low income groups
attend services less frequently than the general population, and mostly for primary care or
emergency treatment when in pain rather than for preventive treatment. The association
between education and attendance at the dentist varies significantly between member states.
Europeans who are in full time education the longest appear to be more likely to visit a
dentist for check up, rather than only attending when in pain.
In Ouagadougou, the capital city of Burkina Faso, multivariate analyses revealed that several
socio-economic and socio-cultural factors such as religious affiliation, material living
conditions and participation in a social network were significantly associated with the use of
oral health care services by adults who had experienced oral health problems during the
previous year9. After a study, the proportion of people found to have had obtained oral health
care was alarmingly low. Self medication appeared to be an important alternative source of
care for adult city dwellers (both traditional and modern self medication). Out-of-pocket
expenses for oral health services may lead to widespread self medication among the
populations of developing countries.
There is an association between dental care service utilization and two domains of social
relationships (social integration and social support) among older adults. Social interaction,
social participation, neighbourhood cohesion and marital status are related to an increased
likelihood of visiting a dentist. Older persons exhibiting loneliness and having received
financial aid from network members demonstrate a decreased likelihood of visiting a dentist.
The increased likelihood of visiting a dentist when a child lives nearby only occurs after
introducing health covariates10
.
There are various inequalities affecting dental attendance. Besides socio-economic
disparities, higher educational attainment results in an increased probability of regular dental
attendance throughout subsequent life years in all nations11
.This is because awareness of oral
health is increased when one attains a higher educational level. Better job opportunities and
improvement in the socio-economic status as a result of education also contribute to
increased dental visits.
(5)
A survey done in the United Kingdom12
demonstrated a relationship between dental anxiety
and dental attendance. Adults with extreme dental anxiety were more likely to attend only
when they had trouble with their teeth than for a regular check-up.
Intensive population-directed strategies for oral health education should be considered in
order to further improve the oral hygiene practices of the entire population. Both community
and personal enabling factors must be present for use of oral health services to take place.
First, health personnel and facilities must be available where people live and work. Then,
people must have the means and know-how to get to those services and make use of them.
Income, health insurance, a regular source of care, and travel and waiting times are some of
the measures that are important23
.
(6)
CHAPTER 2: PROBLEM STATEMENT, JUSTIFICATION AND OBJECTIVES
2.1 PROBLEM STATEMENT
Oral health instructions and motivation from a dentist are frequently the first step in treatment
planning by a dentist. Preserving good oral health starts early in life by developing healthy
lifestyles, practising appropriate self-care, and regularly using oral health services when
available21
. The role of a dentist can therefore not be undermined in prevention of oral
diseases and the population should be encouraged to visit a dentist regularly.
According to a study done in China22
, dental caries experience was affected by urbanization,
gender, frequency and time spent on the method of brushing. Knowledge of causes of and
prevention of dental diseases was low with somewhat negative attitudes on prevention
observed.
Systematic community based oral health promotion should be strengthened and preventive
oriented oral health care systems are needed, including promotion of further self care
practices.
2.2 RESEARCH JUSTIFICATION
This research project provided an understanding of the thought process, knowledge and views
of the population towards oral health services in the urban population in Kenya.
Consequently, it will help in improving their oral health and at a higher level, enhance the
Oral Health Policy in Kenya as put out by the Ministry of Health in 2003.
2.3 OBJECTIVES
General Objective
To determine oral health knowledge, attitudes, practices and oral health seeking behaviour
among adults living in a middle income estate in Nairobi.
(7)
Specific Objectives
1 To investigate the oral health seeking behaviour of adults in a middle income estate in
Nairobi.
2 To determine attitudes towards oral health care services among adults in a middle
income estate in Nairobi.
3 To determine oral health practices among adults in a middle income estate in Nairobi.
2.4 VARIABLES
Socio-demographic variables
i. Age
ii. Gender
iii. Level of education
Dependent variables
● Number of visits to a dentist in a year
● Reason for visiting a dentist
Independent variables
i. Knowledge of oral hygiene practices
ii. Location of nearest oral health facility
iii. Perceived cost of dental treatment
iv. Attitude towards dental services
(8)
CHAPTER 3
RESEARCH METHODOLOGY
3.1 Study Area
Nairobi is the capital city of Kenya. It is also the largest city in Kenya. Together with its
surrounding area, it forms the County of Nairobi. The city is located at 1°17′S 36°49′E and
occupies 696 square kilometres (270 sq mi).
Nairobi is located in south-central Kenya, 140 kilometres (87 miles) south of the equator.
3,138,369 inhabitants live within the 696 km2
in the administrative area of Nairobi.
Most lower-middle and upper middle income neighbourhoods are located in the north-central
areas such as Highridge, Parklands, Ngara, Pangani, and areas to the southwest and southeast
of the metropolitan area near the Jomo Kenyatta International Airport. The most notable ones
include Avenue Park, Fedha, Pipeline, Donholm, Greenfields, Nyayo, Taasia, Baraka,
Nairobi West, Madaraka, Siwaka, South B, South C, Mugoya, Riverbank, Hazina, Buru
Buru, Uhuru, Harambee Civil Servants', Akiba, Kimathi, Pioneer, and Koma Rock to the
center-east and Kasarani to northeast area among others.
This research was carried out in a middle income estate (Prudential estate) within Buruburu.
3.2 STUDY POPULATION
Residents of Prudential estate who are over 18 years of age.
Inclusion criteria
● Individuals 18 years and above
● An adult residing in Prudential estate during the study period
● An adult who gives consent
Exclusion criteria
i. Individuals who are under 18 years
(9)
3.3 STUDY DESIGN
This was a descriptive cross sectional study.
3.4 SAMPLING
3.4.1 Sample size determination
Z2P(1-P)
N= ______________
C2
N= 1.962
x 0.61(1-0.61)
________________
0.052
N=366 adults
Where Z= z value, C= 1- Confidence level, P= Proportion of population estimated to have
utilized oral health services in literature12
.
This sample size was moderated for a population of less than 10,000 as follows;
n=desirable sample size when n<10,000
= n
1 + n/N
Where N=estimated population size (100 patients seen in a day)
n= 366
1+366/180
n= 121 adults
(10)
3.4.2 Sampling method
Convenient sampling method was used. Questionnaires were administered to individuals by
the interviewer during a door to door campaign.
3.5 DATA COLLECTION INSTRUMENTS AND TECHNIQUES
The interviewer administered semi structured questionnaires to collect data. Any clarification
sought by the respondents concerning the study was answered directly by the investigator.
3.6 DATA ANALYSIS
SPSS 16.0 software and Microsoft Excel was used for data analysis and computation of
various statistics. These statistics included frequencies, measures of dispersion (percentiles
and standard deviation) and tests of significance. The data was presented in form of graphs
and pie charts.
3.7 ETHICAL CONSIDERATIONS
● Approval was sought from the Kenyatta National Hospital Ethics and Research
Committee.
● Permission was obtained from relevant government authorities in the area.
● Informed consent was obtained from individuals who participated in the study.
● Information gathered was treated with confidentiality.
● Data collected will benefit the community.
3.8 BENEFITS OF THE STUDY
1. Results from this study will form a basis for development and/or modification of oral
health promotions locally.
2. Results from this study will provide a means of enhancing the Oral Health Policy in
Kenya as put out by the Ministry of Health in 2003.
3. The study will be part of the requirements for the fulfillment of the award of Bachelor of
Dental Surgery degree from the University of Nairobi.
(11)
CHAPTER 4: RESULTS
4.1 RESULTS
A total of one hundred and twenty one questionnaires were administered to adults living in
Prudential estate, Buruburu, Nairobi in the month of September. Among them 66 (54.5%)
were female and 55 (45.5%) were male. Their ages ranged from 18 years to 70 years. The
majority were in the age group 20 - 29 years.
Figure 1: Distribution of gender
Figure 2: Distribution of respondents by age and gender
(12)
Oral health care use
Out of the 121 respondents, 91 (75.21%) had visited a dentist before. 30 (24.79%) of them
had never visited a dentist before.
Figure 3: Past visit to a dental office
For those who had previously visited a dentist, 47.25% were male and 52.75% were female.
Figure 4: Distribution of past dental visit by gender
(13)
Figure 5: Distribution of past dental visit by age group
More married people visited a dentist than any other group.
Table 1: Relationship between marital status and past dental visit.
Gender * Past dental visit * Marital status Crosstabulation
Count
Past dental visit
Marital status Yes No Total
Married Gender Male 29 5 34
Female 23 5 28
Total 52 10 62
Single Gender Male 11 7 18
Female 19 13 32
Total 30 20 50
Separated Gender Male 3 3
Female 3 3
Total 6 6
Divorced Gender Female 3 3
Total 3 3
Out of those who had visited a dentist previously, majority (26.37%) had last been there more
than five years ago. 18.68% had been there more than 6 months but less than a year ago.
17.58% had seen a dentist less than 6 months ago. 16.48% had visited a dental office more
than a year ago but not more than 2 years. 10.99% more than two years but not more than 3
years. 6.59% more tan 3 years but not more than 5 years and 3.30% couldn't remember when
they had last visited a dentist.
(14)
Figure 6: Duration since last dental visit
Regarding the reason for their last dental visit, 33.88% went in because something was
wrong/bothering or hurting them. 30.58% went in by themselves for check-up, examination
and/or cleaning. 7.44% went in for treatment of a condition tht the dentist had dicovered
during an earlier appointment. 2.48% were called in by the dentist for a check-
up/examination/cleaning.
Figure 7: Reason for last dental visit
(15)
When asked about the method of payment during their last dental visit, 44.63% used cash
(out of pocket expense). 20.66% used insurance cover provided for by their employer/
government. 9.92% used personal insurance cover.
Figure 8: Method of payment during last dental visit
Need for oral health care and oral health practices
A majority of people (75.21%) had not experienced any dental problem of which they were
unable to access dental care. 23.97% had experienced a dental problem and were unable to
access oral health services.
Figure 9: Need for dental care in the past year but couldn't access it
(16)
Out of those who were unable to access dental care (23.97%), most cited the reason as not
thinking there was anything seriously wrong and expected the problem to go away, being
unable to afford the cost, were afraid of dentists and were unable to take time off from work.
Table 2: Reasons for not being able to get dental care
Figure 10: Particular concerns regarding teeth
59.50% of the respondents were concerned with maintaining healthy teeth and mouth.
28.93% were concerned with maintaining healthy teeth/mouth and also cosmetic appearance
of teeth.
Reason for not getting dental care Frequency Percentage
Couldn't afford the cost 4 13.79%
Didn't want to spend the money 2 6.90%
Insurance didn't cover the recommended procedures 2 6.90%
Dental office is too far away 2 6.90%
Dental office is not open at convenient times 1 3.45%
Afraid/do not like dentists 4 13.79%
Unable to take time off from work 4 13.79%
Too busy 1 3.45%
Didn't think anything serious was wrong/expected problem to go away 10 34.48%
Answer missing 1 3.45%
Couldn't afford the cost, dental office is not open at convenient times and unable to
take time off from work 1 3.45%
(17)
Figure 11: Frequency of cleaning teeth
Majority of the respondents (71.07%) brush their teeth twice a day. 15.07% claimed to brush
more than once a day while 13.22% brushed once a day.
Figure 12: Interdental cleaning
61.16% of the respondents clean interdentally occasionally. 19.83% never do so. 9.92% clean
once a day. 6.61% clean twice a day. 0.83% clean twice a week.
(18)
Figure 13: Smoking/tobacco use
Majority of the population (90.91%) were non-smokers/ did not use tobacco in any form.
9.09% used tobacco in some form/ were smokers.
Figure 14: Inability to eat due to teeth and mouth problems
Most of the respondents had never experienced difficulties with eating food due to mouth and
teeth problems.
(19)
Figure 15: Frequency of toothache/painful gums/sore spots
35.54% reported they have never experienced toothache, painful gums or sore spots. 33.84%
reported hardly ever. 27.27% occasionally experienced toothache. 3.31% often experienced
toothache.
Figure 16: Embarrassment due to teeth/denture problems
Most had never been embarrassed before due to teeth or denture problems.
(20)
Figure17: Avoided smiling/laughing/conversation due to appearance of teeth
Majority of the respondents had never avoided smiling, laughing or conversations because of
the appearance of their teeth.
Figure 18: Overall rating of health of teeth/gums
Most of the respondents (36.36%) viewed the overall rating of the health of their teeth/gums
as good, 29.75% as very good, 18.18% as excellent, 14.88% as fair and 0.83% as poor.
(21)
Modified dental anxiety scale
The modified dental anxiety scale (MDAS) was scored as follows:
Not anxious = 1
Slightly anxious = 2
Fairly anxious = 3
Very anxious = 4
Extremely anxious = 5
Total score is a sum of all five items, range 5 to 25: Cut off is 19 or above which indicates a
highly dentally anxious patient, possibly dentally phobic.
31 respondents out of the 121 had high dental anxiety (≥19). 90 of them had moderate to low
dental anxiety (≤18).
Figure 19: Modified dental anxiety scale (MDAS) mean
(22)
CHAPTER 5: DISCUSSION, CONCLUSION AND RECOMMENDATION
5.1 DISCUSSION
A total of 121 respondents participated in the study and all responded to the questionnaire
administered. Among them 66 (54.5%) were female and 55 (45.5%) were male.
Out of the 121 respondents, 91 (75.21%) had visited a dentist before. 30 (24.79%) of them
had never visited a dentist before. For those who had previously visited a dentist, 47.25%
were male and 52.75% were female. This is similar to a study by Auerbach et al15
which
explains that women are the major consumers of health care services. The age group 20-29
years had the highest frequency of having visited a dentist before. This may reflect a major
concern with facial appearance and facial attractiveness. Older individuals seldom sought
dental treatment. This may be partly due to the belief that dental problems are part of the
ageing process rather than a sign of ill health and appearance of the teeth becomes less
important with increasing age. Slack-Smith L. et al16
found a strong influence of age that
indicated a need to target dental services among older Australians. More married respondents
visited a dentist than others. Manski RJ.17
reported that married respondents were more likely
to visit a dentist than were single respondents, and widowed/divorced/separated respondents
were overall less likely to visit a dentist.
The study found out that the main reason for visiting a dentist was something bothering or
hurting them, as reported by 33.88% of the population. This was similar to the results from
the study of Bedos C. et al18
which concluded that patients made a decision to visit a dentist
due to great pain which was not responsive to self medication. 30.58% went in by themselves
for check-up, examination or cleaning. This indicated a high level of self awareness on oral
health.
44.63% of the respondents who had visited a dentist before paid for the services rendered by
cash (out of pocket expenditure). 20.66% used insurance cover provided for by the
government or employer. 9.92% used personal insurance cover. Patel R.4 in a study of
European Union member states found that oral health services are mainly provided for by
private practitioners, and patients usually pay the total cost. This may create access problems
for low income groups. In some countries such as Denmark, the government provides
subsidies for adults seeking dental treatment from private dental practitioners. In member
(23)
states such as France and Germany, prevention and treatment are covered within the basic
package of public health insurance, but a share of the cost is borne by patients.
When asked whether there was a point in the past year that they needed dental treatment but
couldn't get it, 23.97% responded affirmatively. Among those who said yes, majority said the
main reason they weren't able to seek treatment was that they didn't think anything serious
was wrong and expected the problem to go away. A study by Hanson L.19
indicated that his
study population had an attitude of waiting for a problem to occur before seeking dental care,
so tooth extraction was the only available treatment option.
Regarding their oral hygiene habits, there was a positive correlation between frequency of
cleaning teeth and previous visit to a dentist (p=0.003). Majority of those who had visited a
dentist in the past brushed their teeth twice a day (79.12%). 10.99% of those with previous
dental history brushed more than twice a day. only 9.89% brushed once a day. For those who
had never visited a dentist before, 46.67% brushed twice a day, 30% brushed more than twice
a day and 23.33% brushed once a day. 61.16% of the total population cleaned interdentally
only sometimes.19.83% never cleaned interdentally, 9.92% cleaned once a day and 6.61%
cleaned twice a day.
Relationship between past dental visit and dental problems experience was statistically
significant (p=0.004). 43.80% of the population never experienced dental problems. 28.10%
hardly ever experienced them. 23.97% occasionally experienced dental problems. 3.31%
fairly often and 0.83% experienced problems very often. Majority of the population were not
embarrassed about their teeth or dentures and did not avoid smiling, laughing or
conversations due to embarrassment. 36.36% rated the health of their teeth and gums as good,
29.75% as very good, 18.18% as excellent, 14.88% as fair and 0.83% as poor.
With regards to attitude towards oral health care service, majority scored moderate to low
dental anxiety using the mean dental anxiety scale. 31 respondents out of the 121 (25.62%)
had high dental anxiety (≥19). 90 (74.38%) of them had moderate to low dental anxiety
(≤18). Humphris et al20
estimated proportion of participants with high dental anxiety (cut-off
score 19) was 11.6%. Anxiety was related to experience of invasive treatment procedures.
(24)
5.2 CONCLUSION
Majority of the population had previously utilized oral health services. The main reason was
that something was bothering or hurting them. Most had dental services available to them
whenever they needed them. Those who could not access oral health services stated the main
reason was that they did not think anything was serious and expected the problem to go away.
Attitude towards oral health care services was positive. Most respondents recorded moderate
to low dental anxiety. Moreover, the second most popular reason for visiting a dental office
was also out of free will for a check up or cleaning.
All the respondents brushed their teeth and the highest frequency was twice a day. Most
occasionally cleaned interdentally. Only 9.09% consumed tobacco in whichever form.
Majority rated the overall health of their teeth and gums as good.
5.3 RECOMMENDATIONS
1. There is need to educate the population on the benefits of regularly visiting a dentist,
not just when a problem arises. Preventive treatment should be emphasized.
2. The dental profession should be demystified to remove the perception that dental
treatment is always painful in order to reduce patients' anxiety.
(25)
REFERENCES
1. World Health Organization. 2012. (Accessed on 22nd
June 2013) Available from:
http://www.who.int/mediacentre/factsheets/fs318/en/
2. National Institute for Clinical Excellence, Dental Recall: NICE Guideline (2004), 7-
10.
3. Beaglehole R, The Oral Health Atlas (2012). Accessed from
http://issuu.com/myriadeditions/docs/flipbook_oral_health on 22nd June 2013.
4. Patel R., The State of Oral Health in Europe 2012, Better Oral Health European
Platform, 1-68.
5. Kaiser Commission Key facts: Oral Health in the US, 2012. Accessed from
http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8324.pdf on 22nd June
2013.
6. Kaimenyi, J.T., Oral Health in Kenya, International Dental Journal (2004) 54, 378-
382
7. Ngatia, E.M.; Gathece, L.W. ; Macigo, F.G.; Mulli, T.K.; Mutara, L.N.; Wagaiyu
E.G. Nutritional and oral health status of an elderly population in Nairobi. East
Africa Medical Journal 2008. Vol 85(8) 378 -385.
8. Mutara L.N., Ngatia E.M., Macigo F.G., Gathece L.W., Wagaiyu E.G., and Mulli
T.K. Oral Health Seeking Behaviour among the elderly (45-80 years) in Kenya.
Journal of Oral Health Sciences June/July 2004. Vol. 5 No 2, 265-268.
9. Benoît Varenne et al, Illness-related behaviour and utilization of oral health services
among city-dwellers in Burkina Faso: evidence from a household survey, BMC
Health Services Research, 2006 December 27; 6:164.
(26)
10. Jeffrey A. Burr, Social Relationships and Dental Care Service Utilization Among
Older Adults, Journal of Aging and Health, March 2013 vol 25 no.2 191-220.
11. Listl S, Inequalities in dental attendance throughout the life course, Journal of Dental
Research, July 2012 vol. 91 (7) S91-S97.
12. Hill B.K et al, Adult Dental Health Survey 2009: relationships between dental
attendance patterns, oral health behaviour and the current barriers to dental care,
British Dental Journal (2013) 214, 25-32.
13. Humphris GM, Morison T and Lindsay SJE. 'The Modified Dental Anxiety Scale:
Validation and United Kingdom Norms' Community Dental Health (1995), 12, 143-
150.
14. Pancharaoen K., 2005, 'Oral health service utilization among government employees
under social security scheme in Maehongson province, Thailand', MPH Thesis,
Mahidol University, Bangkok, Thailand.
15. Cockham WC. Medical sociology. 7th ed. Englewood Cliffs (NJ): Prentice Hall;
1998.
16. Slack-Smith et al. The relationship between demographic and health-related factors
on dental service attendance by older Australians. British Dental Journal. 2004;
197(4): 193-199.
17. Manski RJ, Magder LS Demographic and socioeconomic predictors of dental care
utilization. Journal of the American Dental Association. 1998 Feb: 129
18. Bedos C, et al. The dental care pathway of welfare recipients in Quebec. Social
Science and Medicine. 2003; 57(11): 2089-2099.
19. Hanson WL. et al. Periodontal conditions and service utilization behaviour in a low
income adult population. Oral Health Preventive Dentistry 2003; 2: 99-109.
(27)
20. Humphris G.M. et al, The modified dental anxiety scale: UK general public
population norms in 2008 with further psychometrics of age. BMC Oral Health 2009,
9:20.
21. Petersen K., The 7th WHO Global Conference on Health Promotion - towards
integration of oral health (Nairobi, Kenya 2009), Community Dental Health (2010)
(Supplement 1) 27, 129-136.
22. Zhu L., Oral health knowledge, attitudes and behaviour of adults in China,
International Dental Journal (2005) 55, 231-241.
23. Andersen M., Revisiting the Behavioral Model and Access to Medical Care: Does it
Matter?, Journal of Health and Social Behaviour, March 1995 vol. 36 no.1 1-10.
(28)
APPENDIX I
CONSENT FORM
THE PURPOSE OF THE STUDY
I am a 3rd year undergraduate student at the University Of Nairobi School Of Dental
Sciences. I am currently conducting a study whose aim is to determine the utilization of
oral health services among adults in a middle income estate in Nairobi. Your participation
in this study will help form a basis for development and/or modification of oral health
promotion policies locally.
VOLUNTARY PARTICIPATION
I understand that I have entered the study voluntarily and that no guarantee can be made
to the ultimate outcome of the program. I also understand that I can terminate my
participation in the study at will without any consequences. I understand that my
participation in the study does not entail financial benefit.
ANTICIPATED RISK
No risk is anticipated in participating in the study.
CONFIDENTIALITY
The information given to the researcher will be kept in strict confidentiality. No
information by which your identity can be revealed will be released or published.
I, the undersigned having been informed about the study/ having read all the above, and
having asked questions and received answers concerning issues I did not understand from
the researcher, do willfully give consent to participate in the study.
......................................................... .............................
Participant's signature Date
......................................................... ..............................
Researcher's signature Date
(29)
APPENDIX II
UTILIZATION OF ORAL HEALTH SERVICES AMONG
ADULTS IN A MIDDLE INCOME ESTATE IN NAIROBI.
QUESTIONNAIRE
This is a community dentistry research project being carried out as a partial fulfilment
for the award of a Bachelor of Dental Surgery degree at the University of Nairobi.
Participation is voluntary and any information filled will be treated with utmost
confidentiality and will only be used for study purposes.
You are kindly requested to answer all the questions.
Circle the appropriate response or fill in the necessary information wherever
necessary.
BIODATA
i.) Age:
ii.) Gender
(a) Male
(b) Female
iii.)Marital status
(a) Married
(b) Single
(c) Separated
(d) Divorced
iv.) Highest level of education attained
(a) None
(b) Primary
(c) Secondary
(d) Tertiary
(30)
PART A: ORAL HEALTH CARE USE
1.) Have you ever visited a dentist in the past?
(a) Yes
(b) No
If yes, go on to number 2. If no, skip to number 5.
2.) About how long has it been since your last dental visit?
(a) 6 months or less.
(b) More than 6 months but less than 1 year
(c) More than 1 year but not more than 2 years ago
(d) More than 2 years but not more than 3 years ago
(e) More than 3 years, but not more than 5 years ago
(f) More than 5 years ago
(g) I don't know
3.) What was the main reason you last visited the dentist?
(a) Went in on my own for check-up/examination/cleaning
(b) Was called by the dentist for check-up/examination/cleaning
(c) Something was wrong/bothering or hurting me
(d) Went for treatment of a condition that the dentist discovered at an earlier
check-up or examination
(e) I don't know
(f) Other (Specify) :...........................................................................................
4.) What method of payment did you use during your last dental visit?
(a) Out of pocket expense
(b) Personal insurance cover
(c) Insurance cover provided for by employer/government
(d) Other (Specify):............................................................................................
(31)
5.) During the past 12 months, was there a time when you needed dental care but
could not get it at that time?
(a) Yes
(b) No
If yes go on to number 6, if no, skip to number 7.
6.) What were the reasons that you could not get the dental care you needed?
(a) Could not afford the cost
(b) Did not want to spend the money
(c) Insurance did not cover recommended procedures
(d) Dental office is too far away
(e) Dental office is not open at convenient times
(f) Another dentist recommended not doing it
(g) Afraid/ do not like dentists
(h) Unable to take time off from work
(i) Too busy
(j) I did not think anything serious was wrong/ Expected dental problems to go
away
(k) Other (Specify):..............................................................................................
PART C: NEED FOR ORAL HEALTH CARE
7.) What are your particular concerns regarding your teeth?
(a) Relief of pain only
(b) Maintain healthy teeth/ mouth
(c) Appearance of teeth/ cosmetic treatment
(32)
8.) How often do you clean your teeth?
(a) Never
(b) Sometimes
(c) Once a day
(d) Twice a day
(e) More than twice a day
9.) Do you floss your teeth or use any other form of interdental cleaning?
(a) Never
(b) Sometimes
(c) Once a day
(d) Twice a day
(e) Other (Specify):...........................................................................................
10.) Do you smoke or use tobacco in any form?
(a) Yes
(b) No
11.) How often have you experienced difficulties with eating food due to mouth and
teeth problems?
(a) Never
(b) Hardly ever
(c) Occasionally
(d) Fairly often
(e) Very often
12.) How often have you experienced toothache/painful gums/sore spots?
(a) Never
(b) Hardly ever
(c) Occasionally
(d) Fairly often
(e) Very often
(33)
13.) How often have you felt embarrassed because of teeth (or denture) problems?
(a) Never
(b) Hardly ever
(c) Occasionally
(d) Fairly often
(e) Very often
14.) Have you avoided smiling/laughing/conversations because of the appearance of
your teeth (or dentures)?
(a) Never
(b) Hardly ever
(c) Occasionally
(d) Fairly often
(e) Very often
15.) Overall, how would you rate the health of your teeth and gums?
(a) Excellent
(b) Very good
(c) Good
(d) Fair
(e) Poor
(f) I don't know
(34)
PART D: ATTITUDE TOWARDS ATTENDANCE OF A DENTAL
APPOINTMENT (Modified Dental Anxiety Scale)
16.) If you went to your Dentist for treatment tomorrow, how would you feel?
(a) Not anxious
(b) Slightly anxious
(c) Fairly anxious
(d) Very anxious
(e) Extremely anxious
17.) If you were sitting in the waiting room (waiting for treatment), how would you feel?
(a) Not anxious
(b) Slightly anxious
(c) Fairly anxious
(d) Very anxious
(e) Extremely anxious
18.) If you were about to have a tooth drilled, how would you feel?
(a) Not anxious
(b) Slightly anxious
(c) Fairly anxious
(d) Very anxious
(e) Extremely anxious
(35)
19.) If you were about to have your teeth scaled and polished (cleaned), how would you feel?
(a) Not anxious
(b) Slightly anxious
(c) Fairly anxious
(d) Very anxious
(e) Extremely anxious
20.) If you were about to have a local anaesthetic injection in your gum, above an upper back
tooth, how would you feel?
(a) Not anxious
(b) Slightly anxious
(c) Fairly anxious
(d) Very anxious
(e) Extremely anxious
Thank you for accepting to participate in this scientific study.
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