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Year : 2018  |  Volume : 16  |  Issue : 3  |  Page : 208-212

Type of school as determinant of dental care-seeking behavior among adolescents in Mangalore Taluk: A cross-sectional study

1 Department of Public Health Dentistry, Yenepoya Dental College, Yenepoya University, Mangalore, Karnataka, India
2 Department of Public Health Dentistry, PMS College of Dental Science and Research, Thiruvananthapuram, Kerala, India
3 Department of Public Health Dentistry, Manubhai Patel Dental College and Hospital, Vadodara, Gujarat, India

Date of Submission17-Feb-2018
Date of Acceptance07-Jun-2018
Date of Web Publication6-Aug-2018

Correspondence Address:
Dr. Rekha P Shenoy
102, Mithila Apartments, Karangalpady, Mangalore - 575 003, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_51_18

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Background: The influence of location and type of school on dental care seeking behavior has not been adequately investigated. The objectives of this investigation were to determine whether the location and type of school enrolled in influenced dental care-seeking behavior among school-going adolescents. Materials and Methods: Public and private high schools in urban and rural areas of Mangalore taluk were selected through stratified cluster sampling. Sample size was determined to be 1340; after obtaining necessary permissions, data were collected on dental treatment obtained in the past, details of obtained treatment, facility where treatment was obtained, and its distance from place of residence from students who fulfilled the inclusion criteria. The Chi-squared test was used for analysis with the significance level set at P < 0.05. Results: Dental treatment history was reported by 35.6% respondents. More private schoolchildren had obtained dental care (P = 0.005). Restorative care was most frequent treatment modality obtained. Higher number of private school students received treatment at dental clinics, while public and rural schoolchildren seemed to prefer dental schools (P < 0.001). More private and rural schoolchildren traveled more than 5 km to obtain dental care (P < 0.05). Conclusions: Children enrolled in private and rural schools formed a large component of those who had obtained dental care, were more likely to obtain restorative treatment, and traveled considerable distances to obtain care.

Keywords: Access to care, adolescents, dental care, location, type of school

How to cite this article:
Shenoy RP, Abdul Salam T A, Agrawal R. Type of school as determinant of dental care-seeking behavior among adolescents in Mangalore Taluk: A cross-sectional study. J Indian Assoc Public Health Dent 2018;16:208-12

How to cite this URL:
Shenoy RP, Abdul Salam T A, Agrawal R. Type of school as determinant of dental care-seeking behavior among adolescents in Mangalore Taluk: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2018 [cited 2022 Jul 6];16:208-12. Available from: https://www.jiaphd.org/text.asp?2018/16/3/208/238588

  Introduction Top

Oral diseases have a profound impact on individuals and communities in terms of pain, suffering, functional impairment, and reduced quality of life.[1] Despite credible scientific advances and their preventable nature, they continue to be major public health problems.[1],[2] Children suffering from poor oral health are 12 times more likely to have restricted-activity days than those who do not.[1],[2],[3] The most prevalent oral diseases among adolescents in Mangalore taluk are gingival bleeding and calculus (80.6%), dental caries (33.3%), and malocclusion (22.3%).[4]

Spread over an area of 834 km2 with a population of approximately 882,856, Mangalore taluk has the highest population density in Dakshina Kannada district with females comprising 50.8% of the population.[5] Urban residents comprise 68.1% of the population and the literacy rate is pegged at 92.0% which is significantly higher than the state (75.6%) and national (74.0%) averages.[5],[6] It is also a reputed center for education and health care with five dental schools and a multitude of private dental clinics. The dental schools are privately-managed but offer subsidized/free treatment. A majority of the private clinics and two of the dental schools are located in urban areas.[7]

In India, Primary Health Centres (PHCs) are the core of the public health system. They are referral hubs to Community Health Centres (CHCs) and higher order public hospitals at the subdistrict and district levels. Mangalore taluk has a public health infrastructure comprising 21 PHCs and two CHCs. Dental treatment services are available only at the CHCs and the district hospital.[7],[8]

An individual's past dental history is often taken as an indication of his/her oral health awareness, attitude, and knowledge. An individual with regular dental attendance usually shows a healthy dentition and periodontium reflecting positive dental attitude. In contrast, a person with no history of dental visits or an irregular dental attendance usually suffers from poor oral health which may be compounded by a lack of awareness. Various authors have reported on dental attendance among schoolchildren in the age range of 9 to 19 years with prevalence ranging from 9.4% to 85.0%.[9],[10],[11],[12],[13],[14] To date, no studies on this parameter have been conducted either in India or in any other country around the world on a randomly selected sample of this size.

Public schools, funded and managed by the government, are the most heavily financed but the lowest achieving educational institutions within India. In contrast, private schools, managed and funded by voluntary organizations, philanthropic bodies, or individual owners, are generally perceived to be offering better quality education.[15],[16] Parental socioeconomic status often determines the school a child attends; and therefore, it can be considered a proxy indicator of socioeconomic status. It has been found that children of highly educated parents and from higher socioeconomic backgrounds attend private schools.[15],[16],[17]

It needed to be examined whether location and type of school were determinants of dental care-seeking behavior among school-going adolescents in a region with high literacy, increasing urbanization, and substantial health-care infrastructure. Therefore, the objective of this investigation was to determine whether the location of school and the type of school enrolled in influenced dental care-seeking behavior among school-going adolescents, and thereby highlight disparities, if present, in receipt of dental care and access to treatment facilities.

  Materials and Methods Top

A cross-sectional descriptive survey was carried out from October 2013 to February 2015 among school-going adolescents of Mangalore taluk. All schools in Mangalore taluk are grouped for administrative purposes under two Block Educational Offices (BEOs) – urban and rural. There are a total of 191 high schools of which 121 are rural-based, and 91 are private schools.

Sample size was calculated based on the existing oral condition with the least prevalence (malocclusion – 22.3%)[4] with the confidence level set at 95% and power of the test at 90%, and was determined to be 1340; 670 children each were to be evaluated from urban and rural high schools with numbers split equally between public and private schools, respectively. Schools were selected by stratified cluster sampling and permission to carry out the survey was obtained from the Institutional Ethics Committee (YUEC/89/11/8/12), BEOs and school authorities. Inclusion criteria were male and female children present in school on the day of the survey and assenting to participate. Since information was unavailable on the number of children in each high school, it was decided to select schools within the clusters by simple random sampling and examine all students who fulfilled the inclusion criteria till the required sample size was obtained. Informed assent/consent was obtained from all participants and consent was taken from their parents before data collection.

A pro forma was prepared for collecting data on demography (age, gender), educational qualifications of parents (from school records), location and type of school, whether the study participants had obtained dental treatment in the past, details of treatment obtained, facility where dental treatment was obtained, and distance of treatment facility from their place of residence. Oral examinations were carried out to verify whether dental treatment had been obtained by the respondents. The investigators decided to group various treatment procedures in the following manner: extractions; oral prophylaxis; restorations (restorations, endodontic therapy, and fixed prostheses); and preventive therapy (topical fluoride therapy, fissure sealants, and pain relief). Data collection was carried out during school hours by three investigators. Each participant was interviewed in the presence of the class teacher in sessions lasting for a maximum of 15 min. It was ensured that the academic and extracurricular activities of the participants were not affected.

Data obtained were entered into the Statistical Package for the Social Sciences version 21.0 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY, USA) and analyzed using the Chi-squared test. P < 0.05 was considered statistically significant.

  Results Top

An equal number of the study participants were evaluated from randomly selected five public and five private schools from urban and rural areas. They ranged in age from 11 to 18 years and the mean age was 13.91 ± 1.17 years. A majority (80.6% boys and 81.3% girls) were aged between 13 and 15 years. Among children from both categories of schools and location, males outnumbered females.

History of dental treatment was present among 477 of the 1340 participants (35.6%). When quantifying based on type of school, it was seen that a considerably higher number of private school enrollees (n = 263, 39.3%) had obtained dental treatment in comparison to public schoolchildren (n = 214, 31.9%) (χ2 = 7.82; P = 0.005); 33.1% urban (n = 222); and 38.1% rural (n = 255) respondents reported receiving dental treatment (χ2 = 3.55; P = 0.06). Dental attendance was found to be influenced by maternal educational status, being higher among children of highly educated mothers (P < 0.001). Participants who had obtained dental treatment were then evaluated for type of treatment obtained, facility where treatment was obtained, and distance of treatment facility from their place of residence.

Details of dental treatment obtained by the participants are displayed in [Table 1]. More children from private schools had obtained restorative care, while among those enrolled in public schools, a substantial number had undergone oral prophylaxis and tooth extractions (χ2 = 44.87; P = 0.001). An important finding in this context was that preventive treatment was reported by a higher percentage of private schoolchildren. Urban-rural comparison showed no significant differences in treatment obtained (χ2 = 8.45; P = 0.391).
Table 1: Distribution of the study participants based on the type of dental treatment obtained

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When the facilities where dental treatment was availed were tabulated [Table 2], the differences were pronounced, with a large number of students from private schools obtaining treatment at private dental clinics, while students from public schools showed a preference for dental schools (χ2 = 75.36; P < 0.001). Dental camps at schools (conducted by various dental schools with the objectives of screening for oral disease and treatment thereof) and community outreach programs also made noteworthy contributions to the treatment statistics in public schools. Similarly, highly significant differences were present between urban and rural children (χ2 = 23.87; P < 0.001) with a comparatively higher number of rural students having undergone treatment at dental schools while more urban children had obtained treatment at dental clinics.
Table 2: Distribution of the study participants based on the facility where dental treatment was obtained

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Distance of the dental care facility from the participants' homes is shown in [Table 3]. More than two-third respondents in both public and private schools, and from both urban and rural areas, reported treatment facilities within 5-km distance from their homes. Among the remaining, however, a sizeable number of respondents from private schools (χ2 = 60.39; P = 0.001) traveled distances >5 km to obtain dental care while a greater number of children studying in rural schools traveled more than 10 km. To obtain treatment (χ2 = 16.94; P = 0.002).
Table 3: Distribution of the study participants based on the distance of treatment facility from place of residence

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  Discussion Top

The National Commission on Macroeconomics and Health includes oral diseases among the 17 major health conditions that will account for a fairly sharp increase in India's disease burden in the future. Available data on current prevalence and future projections for oral conditions suggest a 25.0% increase over the next decade.[18] In India, as in most developing countries, lack of workforce, financial and material resources affect access to essential oral health services.[3],[19]

This is the first study reporting on the influence of location and type of school on access to dental care among adolescents. Such a study has not been reported in literature to date from any region. The age range of participants was similar to that reported by other investigators on study populations of a similar demography.[11],[12] The male predominance seen in this study, also observed among school-going populations in Nigeria[9] and Iran,[11] may be attributed to the skewed sex ratio in India (940 females/1000 males).[6]

Regular dental visits are necessary for early diagnosis, prevention, and treatment of dental diseases. Therefore, their importance in ensuring good oral health cannot be underplayed. Dental visits reported by school-going populations across the world showed a wide variation with high values reported in the Middle East,[10],[11] while lower statistics have been observed in Africa and the Indian subcontinent.[9],[12],[13],[14] In the present study, 35.6% children reported that they had obtained dental treatment in the past and sizeable percentages among them were enrolled in private schools. Comparison between public and private schools in earlier studies had revealed no significant differences.[9],[13] However, a study conducted in Nigeria found dental attendance to be higher among children from private schools.[9] Dental treatment history among children is often influenced by factors such as awareness, health priorities, parental preferences, distance of facility, and cost of care and is, therefore, beyond the control of adolescents such as the participants of this study. In this study, while dental attendance was found to be higher among children of highly educated mothers, the numbers reported seem to be disheartening in view of the literacy levels and available health-care facilities in this region. The higher dental attendance seen among children of more educated mothers may be attributed to their greater awareness of dental diseases and their sequelae, and therefore, emphasis on regular dental visits to seek early treatment. That dental attendance is higher among children in private schools may be a pointer to the heightened awareness, access to care, and affordability of treatment among families of private school enrollees. No literature exists on urban-rural comparison of dental treatment history among adolescents.

Restorations and extractions were the predominantly obtained treatment modalities by the participants of this study for complaints of pain and decayed and fractured teeth. Preventive care had been obtained to a greater degree by children from private and urban schools. This may be attributed to high literacy levels, oral health awareness among parents, and also their financial capacity as it involves treatment of disease which had not yet manifested. While no previous literature exists on differences in treatment modalities obtained between enrollees of public and private schools and urban-rural variations, pain in the dentofacial region was the most-quoted reason for seeking dental care, and restorations were the predominantly obtained treatment procedure.[11],[12],[13],[14]

In this survey, a significantly higher number of patients from private schools had availed dental care at private dental clinics. This may be attributed to greater economic freedom, as it was also found that more children studying in public schools had undergone treatment at dental schools where treatment was either free of cost or subsidized. Dental camps conducted in schools played a significant role in providing dental care to this disadvantaged population group; what is striking is their complete absence from private schools. A detailed search revealed an absence of scientific literature on this variable to facilitate a comparison with other populations. Urban-rural comparison was also not possible due to similar reasons.

Distant location of the dental clinic from the place of residence was the main factor discouraging adolescents from utilizing that service in Riyadh, Saudi Arabia.[10] When distance of dental care facilities from participants' homes was assessed, it was found that a larger number of adolescents from private and rural schools traveled significant distances to obtain care. While this may indicate limited access to facilities, it is also to be noted that a significantly greater number of private schoolchildren had received dental care, pointing to greater motivation and awareness. Limited access may also be the reason for lower number of public schoolchildren receiving restorative and preventive care, and the higher frequency of extractions among them. This lack of access lacuna was being filled to a degree by the school oral health programs through regular camps at public schools. These programs are focused to a marked degree on curative rather than preventive care. Furthermore, school dental programs seem to be conspicuous by their absence in private schools, a cause for concern due to the high levels of oral disease among children in this age group.[4] Again, previous studies on this parameter have not been reported from elsewhere.

Dental care, in India, is delivered primarily through private clinics, which may not be accessible to the medically indigent, or through dental schools which provide quality low-cost care to individuals and communities.[20] With public health establishments equipped to treat only a small part of the population, the health-care sector is ill-equipped to meet the need for oral care. Additional burdens are a lack of awareness and an urban bias, with three-fourth of dentists clustered in urban areas.[2],[7],[19],[21] With only 35.6% participants reporting a history of dental treatment, the findings of this study point to a lack of access to dental care in an area with superior health-care infrastructure in comparison to most other regions in India.

A limitation of this study was that it was self-reported, so there may be an over- or under-reporting of certain behaviors. Furthermore, data collection was limited to school-going adolescents. Therefore, the findings cannot be generalized to all children of this age range as those who cannot access schooling may be entirely cutoff from the dental health-care system.

  Conclusions Top

Children enrolled in private schools formed a large component of those who had obtained dental treatment, were more likely to obtain preventive and restorative care, reported greater access to private dental clinics and traveled considerable distances to obtain care. Similarly, enrollees of rural schools formed a large component of those who had obtained dental treatment, were more likely to obtain restorative care, reported greater access to dental schools and traveled considerable distances to obtain care. Oral health promotion activities, with a focus on improving knowledge, oral self-care practices, and promoting regular dental visits should be implemented in schools. Since frequency of dental visits is often determined by parents, they should be made aware of health infrastructure in the region with an emphasis on facilities where free treatment or treatment at concessional prices is offered. Based on the findings of this study, this seems a necessity, especially for children, enrolled in public schools. The dental care delivery system should be strengthened by improving available services and building new infrastructure in rural areas. Interventions for oral disease prevention should be prioritized with future investigations focused on children out of school.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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