Factors associated with dental visit and barriers to the utilization of dental services among tribal pregnant women in Khurda district, Bhubaneswar: A cross-sectional study.

BACKGROUND: There is a lack of knowledge related to the utilization of dental services by tribal pregnant women who constitute over 35% of the Indian population. The aim of the present study was to identify barriers to the utilization of the dental services and also the factors that concern the tribal mothers' visit to the dental office.
MATERIALS AND METHODS: A total of 300 tribal mothers visiting a tertiary care unit participated in this cross-sectional, observational study. A pilot study with twenty participants was conducted before the commencement of the study. Data were collected using a modified questionnaire consisting of demographic data and questions relating to oral health knowledge, attitude, and practices, as well as barriers to the utilization of dental services and factors that concern dental visits during pregnancy. Data analysis was done using SPSS software package 21.0. Nonparametric statistical tests were done to analyze oral health knowledge and attitude of the participants. Various factors were identified using univariate and multivariate models using simple logistic regression analysis and multiple logistic regression analysis.
RESULTS: Among the two different tribes considered in the present study, the Saora tribe seemed to be more conscious toward oral health, and 29.7% of participants visited the dentist during pregnancy. The age and experience of the participants along with the educational level, employment status, and knowledge about oral health-related pregnancy outcomes influenced their dental visits. The most reported barrier included the lack of awareness and knowledge of the availability of the dental services. Accessibility and distance to the dental clinic were not found to be negative confounding factors among the participants for the utilization of the services.
CONCLUSION: This study concludes that previous experience and consciousness of the mother to utilize the dental services played a vital role in the utilization of dental services among tribal pregnant women. However, the findings of the present study clearly indicate the need for further research to understand barriers to the utilization of dental services among underprivileged tribal groups of population. Copyright:

INTRODUCTION

The major half of the population remains devoid of the knowledge about the probable association of oral and systemic health[1] as well as the accessibility to the dental services. It is observed that most of them either belong to tribal communities or reside in rural areas where accessibility to the dental services remains a challenge till date. The dental fraternity has started focusing on the potential association between periodontitis and systemic conditions along with a bright note on pregnancy outcomes of periodontitis.[2] Studying the pattern of oral health among tribal pregnant women is growing interest because of the lack of literature. Pregnancy is a conglomeration of complex physiological and physical alterations that can have a marked influence on oral health. It is characterized by increase in the permeability of oral vasculatures and decrease in the host immune competency due to an increase in the levels of sex hormones, progesterone and estrogen.[3] This leads to increase in the tendency and severity of oral inflammation in reaction to bacterial, physical, and chemical irritations.[4] It has been well documented that, during pregnancy, there are a number of changes in the oral cavity, especially in the periodontium, including preterm delivery, low birth weight, and preeclampsia. In addition to this systemic influence, local production of inflammatory mediators in periodontal tissues as a result of gingival and periodontal diseases can reach and affect the fetal–placental unit directly or can enhance the production of cytokines and acute-phase proteins, which in turn affect the fetal–placental unit.[56]

Emphasis on the preventive oral care measures during pregnancy along with a mandatory visit of the females of childbearing age to the dentist has been recommended by the joint European Federation of Periodontology and American Academy of Periodontology Workshop on Periodontitis and Systemic Diseases, considering the local and systemic influence of oral and periodontal diseases on systemic health.[7]

Nonetheless, limited utilization of dental services has been reported among pregnant women by several studies, even when there are obvious signs of oral disease.[89] There are several reasons that have already been noted; some include the barriers to attempting oral health-care services among pregnant women, of which all are related with mother's knowledge, attitude, misconception regarding the effects of dental treatment on the developing fetus, and low perception for dental problems and treatment.

Due to various confounding factors, the utilization of dental services among tribal pregnant women has not been well documented. Hence, this study was taken up with the aim of exploring factors that affect dental care-seeking behaviors and barriers to achieving optimal oral health among tribal pregnant women in Khurda district, Bhubaneswar, Odisha, India. The study also determined the factors associated with the utilization of oral health-care services and dental visits and ascertain the barriers in the utilization of oral health-care services among pregnant tribal women.

MATERIALS AND METHODS

A cross-sectional, observational study was taken up. Ethical approval was obtained from the university's ethical committee and SC and ST Research Institute and Training Centre (Letter no. 1179), Government of Odisha, for conducting the study on the tribal women. There was an appointed local coordinator who was trained and calibrated on 25 women before conducting the study. The study was conducted between June 2017 and August 2017. The sample size derivation was done after conducting a pilot study on twenty women along with a confidence interval (CI) of 95% and precision value of 5%. The sample size was derived to be 300 by using the following formula: n = Z2 P (1 − P)/d2 where n is the total sample size, Z is the statistic corresponding to the level of confidence, P is expected prevalence percentage derived from the pilot study, and d is precision (corresponding to effect size). The study population consisted of tribal pregnant women along with those having children of 0–2 years of age, attending various public health centers, situated in Khurda district, with the purpose of routine medical checkup or vaccination of their infants or toddlers. A total of 300 women, who gave a written consent for the study after detailed explanation of the study procedure, were included in this study. Women with a history of cognitive disturbances and hormonal therapy in the past 1 year were not included in the study. Women on any medications which have deleterious effect on oral and periodontal status were excluded from the study. Data were collected through a modified questionnaire (translated in the study population's regional language with the help of a regional coordinator) which was pretested prior to the study to ensure its clarity and comprehensiveness. Changes were made after collection of the feedback regarding the difficulty levels from the participants. The questionnaire addressed the following:[36] the sociodemographic details which included their age, ethnic group, highest education level, household income, and employment status.

Reports on the oral health status during pregnancy included perceived oral health status as well as any self-reported oral health problem. The third part of the questionnaire was on the knowledge, attitude, and practice regarding oral health. There were some questions on the access to the oral health-care services, namely awareness about free dental services in government clinics, distance to the nearest clinic, perceived accessibility, visit to dentist during pregnancy, reasons for visit to the dentist, duration of pregnancy during the first visit, and type of practice visited. Some other questions mentioned about the difficulties faced by the pregnant women in the utilization of dental services were misperceptions or misconceptions regarding dental visit, dental fears, problems with accessibility, time constraint, and dissatisfaction with the quality of oral health-care services at government dental clinics.

The obtained results were analyzed using IBM SPSS Statistics for Windows, version 21 (IBM Corp., Armonk, N.Y., USA). Results were evaluated statistically using univariate and multivariate models using simple logistic regression analysis and multiple logistic regression analysis. P < 0.05 was considered statistically significant.

RESULTS

A total of 300 antenatal mothers willingly participated in the study. The age group of the participants ranged from 18 to 37 years. Mothers belonging to the age group of 18–30 years seemed to have not visited the dental office during pregnancy (76.9%), whereas 46.2% of the mothers belonging to the age group of above 30 years seemed to visit the dental office during pregnancy. Among the two different tribal groups included in the study, the Saora tribes had a better response in visiting the dentist during gestation (29.7%). Those mothers who have a university degree (45.0%) seemed to have better response as compared to others with primary (15.9%) or secondary (24.2%) levels of education. Employed mothers (36.7%) seemed to be more concerned about oral health during pregnancy.

The comparative profiles of the mothers who visited the dental office during pregnancy and who did not are mentioned in Table 1a. It also states the oral health behavior and belief among the tribal pregnant women. Significant results were obtained for the knowledge of the mothers about the probable association of oral health and pregnancy and their oral hygiene practices.

Table 1a

Comparative profiles of the mothers about oral health awareness and belief to visit the dentist during pregnancy

Factors	Options	Visit (%)		χ2	P
		Yes	No
Oral health status	Very poor	4.3	95.7	11.768	0.008
	Poor	15.6	84.4
	Fair	26.2	73.8
	Good	31.1	68.9
Self-reported oral health problem	None	25.6	74.4	3.63	0.304
	One problem	18.9	81.1
	Two or more problems	29.4	70.6
Oral health education received during pregnancy	Yes	18.9	81.1	7.253	0.008
	No	32.7	67.3
Possible connection between oral health and pregnancy	Yes	48.1	51.9	34.15	<0.0001
	No	15.4	84.6
Main source of learning	Magazine	100.0	0.0	18.43	0.001**
	Medicinal doctor	56.4	43.6
	Mentioned in prenatal care	21.4	78.6
	Dentist have told	50.0	50.0
Unhygienic mother’s mouth affecting child’s birth process	Agree	58.8	41.2	58.57	<0.0001
	Not sure	13.9	86.1
	Disagree	0.0	100.0
Importance of brushing	Not important at all	25.0	75.0	46.67	<0.0001
	Not important	12.5	87.5
	Important	38.5	61.5
	Very important	2.1	97.9
Importance of visiting a dentist	Not important	0.0	100.0	39.204	<0.0001
	Important	34.8	65.2
	Very important	2.6	97.4

**Statistically highly significant, P<0.05 is considered statistically significant. P – Probability constant; χ2 – Chi square

Table 1b shows the comparative profiles of the mothers based on the oral hygiene practices. Significant results were obtained with the frequency of brushing, the fluoride content of the toothpaste, and the frequency of visiting a dentist for a checkup.

Table 1b

Comparative profiles of the mothers based on the oral hygiene practices to visit the dentist during pregnancy

Factors	Options	Visit (%)		χ2	P
		Yes	No
Frequency of brushing	Less than once/day	39.3	60.7	10.709	0.005*
	Once/day	16.4	83.6
	More than once/day	30.0	70.0
Presence of own toothbrush	Yes	24.6	75.4	2.263	0.303
	No	0.0	100.0
Use of toothpaste	Yes	23.0	77.0	3.66	0.089
	No	46.2	53.8
Fluoride content of toothpaste	Yes	32.1	67.9	31.96	<0.0001
	No	42.9	57.1
	Don’t know	1.2	98.8
Frequency of visiting a dentist for a checkup	6 months	52.4	47.6	39.53	<0.0001
	1 year	23.3	76.7
	Almost never	15.5	84.5

*Statistically significant, P<0.05 is considered statistically significant. P – Probability constant; χ2 – Chi square

The results of simple logistic regression analysis of factors associated with the mothers’ visit to dentist are tabularized in Table 2. No significant association was found between dental visit and the mothers’ self-reported oral health problems, awareness of free dental services in government clinics, perception regarding unhygienic mother's mouth affecting child's birth process, and perceived accessibility to dental services. However, significant association was found between the mothers’ visit to dental clinic and mother's age (odds ratio [OR]) of 3.429 (95% CI: 1.38–8.5), ethnicity of 4.46 (95% CI: 1.95–10.21), educational level of 4.336 (95% CI: 1.59–11.81), household income of 6.97 (95% CI: 2.22–21.29), employment status of 6.5 (95% CI: 3.25–12.49), oral health status of 9.94 (95% CI: 1.3–68.27), oral health education received before the current pregnancy of 2.08 (95% CI: 1.21–3.57), and awareness of the probable effects of pregnancy on oral health 5.1 (95% CI: 2.87-9.04) and oral health with OR of 0.19 (95% CI: 0.037–0.943).

Table 2

Factors associated with dental visit during pregnancy among mothers by simple logistic regression

Factor	Crude OR	95% CI	LR Chi-square (df)	P
Age (years)
Below 18	1		7.420	0.024
18-30	1.2000	0.66-2.181	0.358	0.550
>30	3.429	1.384-8.495	7.085	0.008
Ethnicity
Savar tribals	1	-	12.549	<0.0001
Soara tribals	4.462	1.951-10.207
Highest education level
Primary	1		14.563	0.002
Secondary	1.691	0.901-3.177	2.672	0.102
Postsecondary	4.053	1.705-9.634	10.034	0.002
University	4.336	1.592-11.813	8.232	0.004
Household income (Rs. )
<10,000	1		13.095	0.001
10,000-30,000	6.910	2.387-20.004	12.705	<0.0001
>30,000	6.967	2.222-21.285	11.082	0.001
Employment
No	1		28.021	<0.0001
Yes	6.496	3.249-12.488
Oral health status
Very poor	1		9.996	0.019
Poor	4.062	0.499-33.051	1.717	0.190
Fair	7.792	0.794-52.034	3.746	0.053
Good	9.935	1.296-68.269	4.882	0.027
Self-reported oral health problem
None	1		2.053	0.358
One	0.678	0.362-1.269	1.476	0.224
Two or more	1.213	0.39-2.731	0.217	0.641
Oral health education received
No	1	-	7.108	0.008
Yes	2.081	1.214-3.567
Aware of connection between oral health and pregnancy
No	1	-	31.040	<0.0001
Yes	5.098	2.871-9.041
Aware of free dental services in government clinics
No	1	-	0.552	0.458
Yes	0.815	0.474-1.399
Unhygienic mother’s mouth affecting child’s birth process
Disagree	1		0.734	0.859
Not sure	2.345	0.234-10.638	0.389	0.792
Agree	5.748	0.895-10.734	0.726	0.372
Distance to the nearest dental clinic (km)
<5	1	-	23.5	<0.0001
≥5	0.190	0.037-0.943
Accessibility to dental clinic
Long distance	1	-	4.558	0.102
No self-transport	1.674	0.768-3.648	1.681	0.195
Difficult to get public transport	0.434	0.086-2.192	1.021	0.312

P<0.05 is considered statistically significant. LR – Logistic regression; OR – Odds ratio; CI – Confidence interval; P – Probability value

The results of multiple logistic regression analysis are shown in Table 3, and it can be interpreted as mother's age, employment status, oral health status, perception regarding association between pregnancy and oral health, and distance to the nearest dental clinic remain as significant factors associated with mother's visit to dental clinic. Those mothers who were below 18 years of age, were employed, had poor oral health status, perceived an association between pregnancy and oral health, and whose house is within 5 km distance from the dental clinic were found to be more likely to visit a dentist during pregnancy.

Table 3

Factors associated with dental visit during pregnancy among mothers by multiple logistic regression

	Adjusted OR	95% CI		LR Chi-square (df)	P
		Lower	Upper
Age (years)
Below 18	1	-	-	9.429	0.019
18-30	0.238	0.091	0.622	8.562	0.03
>30	0.645	0.176	2.364	0.437	0.509
Employment
No	1	-	-	6.368	0.012
Yes	4.805	1.420	16.261
Oral health status
Very poor	1	-	-	13.216	0.004
Poor	327.043	9.565	111,82.409	10.323	0.001
Fair	106.507	3.141	3611.646	6.742	0.009
Good	61.833	1.596	2395.162	4.887	0.027
Awareness about connection between oral health and pregnancy
No	1	-	-	13.361	<0.0001
Yes	35.282	5.221	238.432
Distance to the nearest dental clinic (km)
<5	1	-	-	7.881	0.005
≥5	0.241	0.089	0.651

P<0.05 is considered statistically significant. LR – Logistic regression; OR – Odds ratio; CI – Confidence interval; P – Probability value

Table 4 depicts that there was a significant correlation in the dissatisfaction with the quality of services and the dental visits. There was no significant relation between the misperceptions of dental visits or any dental fears, or the accessibility to the dental clinic or other time constraints during pregnancy. Thus, from this study, it can be perceived that previous experience plays a significant role in the subsequent visits of a particular individual.

Table 4

Tribe-wise variations in the barriers to the utilization of dental visit by the mothers during pregnancy

	Ethnic group (%)		χ2	P
	Savar	Soara
Misperceptions regarding dental visits
Not having dental problem	36.6	63.4	18.603	<0.0001
Oral health less important	17.1	82.9
Negative effect of treatment on fetus	0.0	100.0
Any dental fears
Fear to dentist	7.0	93.0	38.671	<0.0001
Fear to dental instrument	38.1	61.9
Fear to dental treatment	18.1	81.9
Fear to dental pain	42.7	57.3
Accessibility to dental clinic
Long distance	0.0	100.0	18.954	<0.0001
No self-transport	25.5	74.5
Difficult to get public transport	65.0	35.0
Time constraints during pregnancy
Busy at work	29.8	70.2	6.202	0.045
Busy with household chores	31.3	68.7
Others	16.0	84.0
Dissatisfaction with the quality of services
Late appointment	24.1	75.9	0.185	0.912
Long waiting time	27.5	72.5
No immediate treatment given	25.7	74.3

P<0.05 is considered statistically significant. P – Probability constant; χ2 – Chi square

DISCUSSION

These days, antenatal care is being advocated prominently with an effort to improve pregnancy outcomes by the promotion of preventive health care. Although the association of oral health and antenatal care is not well established, keeping in mind the extended range of problems associated with the pregnant women, maintaining a good oral hygiene becomes an integral part of antenatal care. A complete approach to an antenatal care should include a better oral health care as a mandatory component along with other integrated services received by pregnant women. A recent study shows a negative association of periodontal health and pregnancy, which encourages the utilization of dental services more vividly during gestation.[10] Practitioners should be encouraged to carry out dental examinations along with basic antenatal checkups which include monitoring of blood pressure, weight gain assessment, and other obstetric examinations. It is disappointing to know that the World Health Association has not included oral health care as one of the basic components in the new antenatal care model. Most of the dentists believe that there is a strong need for the antenatal mothers to visit the dental orifice during pregnancy because a number of dental problems are directly linked to the fetal growth and well-being.[11]

In the present study, it was observed that there was not much association between the socioeconomic statuses, mother's age, and ethnic group. In a study conducted by Saddki et al.,[3] similar finding was found, but it also included literacy rate and the general awareness of the individuals about accessing the free dental treatment provided at government hospitals.[3] Dinas et al.[12] stated that a majority of pregnant women during pregnancy do not attend dental services.[12] The awareness of the population about the access to dental services provided by dental personnel depends on the literacy rate and the consciousness of the population. The literacy rate of the population here again depends on their socioeconomic and unemployment statuses.[81314] This affects the decreased utilization of the dental services during pregnancy. It has been observed that the women participating in this study were constrained by time due to their busy work schedule. A similar inference was derived on Malaysian population by Saddki et al.,[3] where the authors reported lower prevalence of dental visits in mothers with tertiary education. Fewer studies have been conducted related to tribal women and their antenatal care associated with dental services in India as well as worldwide. In this study, it has been found that the knowledge about the availability of dental care during gestation is scarce. The inaccessibility to low-cost services provided by the government dental clinics led to the fact that the dental care was never amalgamated with the routine antenatal checkup. Hallah et al.[15] has reported that self - reported dental problems were a reason why gestational mothers visited the dentist. This was in contrast to our study findings.

This study reported that those women who have already encountered dental problems during their first pregnancy term period are more likely to visit a dental office in comparison to others who were having their first issue. Most of the mothers did not give importance to a better oral hygiene and proclaimed that they already had a good oral hygiene. The need and importance of the oral treatment was not appreciated by most of them and instead preferred treating them post delivery. The barriers to utilization included the less conscious mothers due to improper patient education. Studies conducted by Rogers,[16] Honkala and Al-Ansari,[14] and Mangskau and Arrindell[17] showed similar results. Medical professionals should take up active efforts to instill consciousness among antenatal mothers to avoid postpartum complications. They should be evaluated well by the physicians and that oral examination should be made mandatory in the examination schedule.[18] Several studies have been done on establishing an oral health policy for the expecting mothers.[1920] Moreover, pregnancy is one period where women can be educated regarding these issues.[212223]

The findings of this study reported that lack of knowledge regarding the free dental care provided at government hospitals is one of the major causes of limitations in the use of dental services among the pregnant tribal women in India. In this study, only 36.7% of the population received oral health education before pregnancy. Distance was not always a negative factor in availing oral health care provided at nearby health centers. Analyzing the data collected in the in the present study, it was observed that the women had misperceptions regarding dental visits along with fear of dentists and anxiety regarding dental pain. It is an established fact that the fear of dental pain holds a prominent effect on the use of dental services.[2425] In the in the present study, it was reported by a certain number of mothers that the fear of dental pain along with increased waiting time holds them back from attending dental treatments. It was also observed that the mothers complained about the long waiting time along with the cost of the desired treatments. This was a negative restraint in the service utilization. There are studies that have found a similar finding.[2627] In this study, 50% of the women in their gestational period received oral health education before pregnancy. It was seen that 58.3% of the participating individuals presented with good oral hygiene during their first visit. This is in conjunct with the study by Al Habashneh et al.[8]

Unfortunately, only a few studies have been conducted on antenatal care and the awareness of the tribal population about the barriers of utilization of services. This promotes the researchers to highlight this part of the population and acknowledge further researches in this regard. Identifying the predictors or the barriers to the utilization of oral and periodontal care among tribal pregnant women would help in the improvement in the utilization of the existing oral and periodontal health-care services and would also help in the early detection and screening of various systemic problems. This would be a boon to the individual and the society as a whole.

CONCLUSION

To prevent pregnancy complications associated with oral/periodontal disease, low use of dental services by pregnant tribal women has to be investigated, and barriers toward seeking dental care during pregnancy have to be overcome. This cross-sectional study comprehensively evaluates the factors affecting the utilization of dental services during pregnancy and is helpful in understanding the barriers which prevent the use of dental services by pregnant women. The findings of this study call for investigations on mass scales subjecting the underprivileged tribal groups of population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.