Evaluation of oral health care seeking behavior in rural population of central India.

OBJECTIVES: To study the perception regarding common oral diseases and health seeking behaviour related to those diseases among rural population of central India.
METHODS: A cross sectional study was conducted in the rural areas of Wardha, Maharashtra on a population between the age group of 18 and above. Data was recorded by a self administered, structured questionnaire in this study. Questionnaire was based on oral health literacy and health seeking behaviour of participants.
RESULTS: Study included 700 participants, 343 males and 347 females. Dental problem was reported by 68% of participants. Toothache was the most common dental problem reported. Government hospitals were chosen by 19% of participants as treatment centre. Fear 24.3% was found to be the major reason for not visiting the dentist.
CONCLUSION: Healthcare seeking behaviour among rural population towards oral diseases was poor. So efforts must be made to bring a change in this scenario. Copyright: © Journal of Family Medicine and Primary Care.

Introduction

The oral cavity is described as an integral part of the overall health of human being.[1] It is rightly said by Seymour that “Good general health cannot be achieved without good oral health.”[23]

Oral disease is a complex phenomenon and association with various elements leads to its increased occurrence.[4] The etiology of oral diseases is multifactorial. Various risk factors are also associated with increased risk of oral diseases; adverse habits such as smoking, tobacco, areca nut chewing, etc., prevail as the most important risk factor for the occurrence of oral diseases including cancer. In the world, India is one of the largest producers and consumer of tobacco.[5] Hence, the risk of dental problems and oral cancers is high in these residents. Primary prevention reduces the prevalence of dental problems and oral cancer and act as a preventable cause.

Patient associated factors such as age, gender, and family background appear to be particularly significant components in the advancement of oral diseases while in rural population risk seems to increase due to their geographical location, food habits, and oral hygiene practices. The most important determinant of oral disease is Socio Economic Status (SES).[6] Oral hygiene behaviors differ greatly among regions, countries, and even within countries. Different oral hygiene behaviors result in different oral health outcomes across the nation. For example, use of tobacco and areca nut for recreational and therapeutic purposes is widely prevalent in rural regions of central India resulting in high incidence of abrasions, dental caries, periodontal diseases, and oral lesions.[7]

Health Seeking Behavior (HSB) is described as the action to be taken by an individual to preserve or regain good health.[8] HSB is an outcome of the complex interaction between patient illness and household characteristics.[9] HSB is greatly affected by the availability and accessibility of health care services.[10] In both developing and developed communities, poor attentiveness regarding oral health has been particularly seen among unprivileged group.[11] Poor-feeding conditions, food habits, and lower levels of literacy and health awareness among the population are inadequate which lead to poor utilization of healthcare facilities could be some of the reasons for it.[12] The most affected population having oral diseases (dental caries) are children; hence, educating the parents is of utmost importance.[13]

The reasons for people avoid visiting the clinicians and neglect the symptoms of oral diseases are economic instability, fear of cancer, or lack of faith in medical services. This is known as “patient delay” or “diagnostic delay.”[11] The early detection and prevention is an important key in stopping the progression of oral diseases and improving the quality of life of patient. To amend health behavior and improve their quality of life while reducing social inequalities regarding health, it seems crucial to consider both patients’ portrayals regarding health as well as the social and emotional elements of their decision and behavior.[9]

Health service deficits (HSDs) are evolving concepts that assess healthcare access and utilization. Conceptually, healthcare access and utilization are distinct yet inter-related since access is necessary for utilization. Access to health services entails the timely use of personal health services to achieve the best health outcomes. Access involves being able to make use of necessary healthcare, at a physical location, from a healthcare provider that the patient is able to communicate and trust (personal relationship). Healthcare utilization, in contrast, entails the actual use of healthcare services.[14]

Inaccessibility to dental care is one of the major challenges; poor utilization of services is another dreadful challenge attenuating the scope for improvement of the oral health status of rural India.[15] Especially, when it comes to the rural population, many challenges exist pertaining to the betterment of oral health care. In a country where thousands of dentists are graduating per year, it is astounding to know that only a handful of them serve the rural population, while the majority of dentists prefer to serve in an urban area. Shortage of dental professionals can lead to reduced availability to oral health services and poorer oral health status for rural dwellers in comparison to urban populations.[16]

Approach to health-seeking behavior is usually determined by knowledge and attitude of the people.[17] To provide need-based health care services to the people, a thorough understanding of the health-seeking behavior is crucial. By understanding patients health-seeking behavior, their attitude toward oral health can be judged which would help to reduce the amount of damage caused by neglecting dental problems. Hence, the aim is to study the perception of people belonging to rural areas about common oral diseases and their health-seeking behavior related to those diseases. Proper understanding of health-seeking behavior could reduce the delay in diagnosis and improve the treatment compliance and the strategies for health promotions.

Subjects and Methods

A cross-sectional study was carried from December 2018 to April 2019 after receiving approval from the Institutional Ethical Committee [DMIMS (DU)/IEC/2018-19/7575], 28th September 2018. The study was conducted in the rural areas of Maharashtra on age group 18 years and above. The study Performa comprised of informed consent, demographic information, and questionnaire.

The questionnaire was self-administered and closed-ended. Expert committee was established and items were generated by referring to the questionnaire used in the study by Bommireddy et al.[15] The questionnaire was translated and back translated and the final questionnaire was prepared in the regional language, Marathi. To check the understanding, feasibility, reliability, and validity of the structured questionnaire, a pilot study was conducted on 30 participants. The Cronbach's alpha and split-half reliability values were found to be 0.83 and 0.78, respectively. The results and participants of the pilot study were not included in the main study.

The questionnaire consisted of three parts. The first part consisted of demographic details. The second part was based on oral health literacy; it included questions like knowledge, attitude, and habits of oral health, deleterious habits, and frequency of dental care visits. Third part had nine questions which were based on health-seeking behavior of participants like any visit to a dentist, frequency, and reason for visits. The responses of seven questions were scored as one and two, while scores for the remaining two questions were given one, two, and three, respectively. One is the minimal score. The maximum total score was 20 and the minimum was 9. Further, patients were divided into two groups based on total score.[18] Negative health-seeking behavior was scored from 9–14 and positive from 15–20.

The main study data was done on 700 participants. Data was recorded with an allotted time of 5 min for each patient by a single investigator. After the data collection, data was entered into the MS Excel (MS Office version 2007 developed by Microsoft, Redmond, WA). The analysis was done using Chi-square test by SPSS version 21(SPSS statistics IBM CORPORATION). The difference was statistically significant (P < 0.05).

Results

Table 1 shows that use of smokeless tobacco was reported by 46% of males and 43.3% of females, while the habit of betel nut chewing was seen more in females (23.1%) as compared to males (20.2%). Toothbrush (48.7%) was the most commonly reported cleaning aid and toothpaste (40.4%) was the commonly used cleaning material.

Table 1

Descriptive statistics on habits and oral hygiene of study participants based on gender

Variable		n	%	Male n (%)	Female n (%)	Chi-square	P
Adverse habits	Smokeless tobacco	386	55.2	162 (46)	150 (43.3)	0.866	0.352
	Smoke tobacco	35	5.0	54 (15.3)	55 (15.9)
	Betel nut	151	21.6	71 (20.2)	80 (23.1)
	Others	73	10.4	29 (8.2)	44 (12.7)
How do you clean your teeth?	Brush	341	48.7	182 (51.7)	159 (45.8)	4.465	0.215
	Fingers	318	45.4	148 (42)	170 (49.0)
	Neem stick	38	5.4	22 (6.2)	16 (4.6)
	Others	3	0.4	1 (0.3)	2 (0.6)
What material do you use to clean your teeth?	Toothpaste	283	40.4	145 (41.2)	138 (39.8)	2.419	0.490
	Snuff	135	19.3	60 (17.0)	75 (21.6)
	Powder	276	39.4	145 (41.1)	131 (37.8)
	Others	6	0.9	3 (0.9)	3 (0.9)
What method do you follow for cleaning the teeth?	1. Horizontal	221	31.6	109 (31.0)	112 (32.3)	0.576	0.902
	2.vertical	181	25.9	96 (27.2)	85 (24.5)
	3. Both	298	42.5	148 (42)	150 (43.2)
How often do you change your tooth brush?	1. 3 months	82	11.7	45 (12.8)	37 (10.7)	1.694	0.638
	2. 6 months	94	13.4	50 (14.2)	44 (12.7)
	3. 1 year	143	20.4	67 (19.0)	76 (21.9)

Total 68% of people reported with a dental problem, out of these, 73.1% were males and 65.4 were females. Toothache was the most common dental problem reported by 33.2% of males as compared to 34.3% females followed by the mobility of teeth, which was a second most common dental problem. Over 53.1% of study participants visited dentists for their dental problem; 41.5% of males and 43.8% of females visited a dental clinic for pain [Table 2A].

Table 2A: Differences in responses of oral health problems based on gender among study participants

Variable		n	%	Male n (%)	Female n (%)	Chi-square	P
Dental problem	Yes	476	68.0	257 (73.1)	227 (65.4)	4.372	0.037*
What kind of dental problem?	Toothache	236	33.7	117 (33.2)	119 (34.3)	10.598	0.102
	Bleeding gums	58	8.3	38 (10.8)	20 (5.8)
	Mobile teeth	136	19.4	65 (18.5)	71 (20.5)
	Caries	36	5.1	22 (6.2)	14 (4)
	Ulcers	15	2.1	9 (2.6)	6 (1.7)
	Others	14	2.0	9 (2.6)	5 (1.4)
Span of dental problem	Less than one month	135	19.3	69 (19.6)	66 (19.0)	2.721	0.257
	More than one month	359	51.3	189 (53.7)	169 (48.7)
Have you ever visited dentist?	Yes	372	53.1	184 (52.3)	188 (54.2)	0.255	0.614
For what dental/problem did you visit dental clinic?	Pain	298	42.6	146 (41.5)	152 (43.8)	0.938	0.816
	Bleeding gums	19	2.7	11 (3.1)	8 (2.3)
	Sensitivity	54	7.7	26 (7.4)	28 (8.1)
	Esthetics	0	0	0	0
How often do you visit a dental clinic in a year?	Once	276	39.4	141 (40.1)	135 (38.9)	1.971	0.578
	Twice	18	2.6	9 (2.6)	9 (2.6)
	Not at all	77	11.0	33 (9.4)	44 (12.7)

*The value of significance P<0.05

In Table 2B, we can see that out of the total study population, 47.4% of people had dental clinics nearby. Out of 353 males 65 (18.5%) and 68 (19.6%) females out of 347 visited government hospital for receiving dental care due to less expenditure of treatment. This shows that less expenditure plays a key role in choosing oral health-care facilities. It was found that fear is the major reason among 26.1% of males and 22.5% of females for not receiving dental treatment.

Table 2B: Differences in responses about receiving oral health care based on gender among study participants

Variable		n	%	Male n (%)	Female n (%)	Chi-square	P
Who has advised you to visit dental clinic?	Neighbors	172	24.6	87 (24.7)	85 (24.5)	1.184	0.881
	Relatives	141	20.1	68 (19.3)	73 (21.0)
	Colleagues	45	6.4	23 (6.5)	22 (6.3)
	No one	13	1.9	5 (1.4)	8 (2.3)
Do you have any dentist nearby your place?	Yes	332	47.4	166 (47.2)	166 (47.8)	0.032*	0.857
Have you ever received any dental treatment?	Yes	291	41.6	141 (40.1)	150 (43.2)	1.599	0.450
Where did you go for dental treatment	Government hospital	133	19.0	65 (18.5)	68 (19.6)	0.766	0.858
	Private dental clinic	51	7.3	25 (7.1)	26 (7.5)
	Medical store	107	15.3	51 (14.5)	56 (16.1)
	Not undergone any treatment.	409	58.4	211 (59.9)	197 (56.8)
Reasons for preferring particular center	Others advice	69	9.9	31 (8.8)	38 (11.0)	3.901	0.564
	Accessibility	72	10.3	37 (10.5)	35 (10.1)
	Less expenditure	121	17.3	55 (15.6)	66 (19.0)
	Quality treatment	21	3.0	13 (3.7)	8 (2.3%)
Reasons for not receiving any dental treatment	Fear	170	24.3	92 (26.1)	78 (22.5)	3.669	0.598
	No time	76	10.9	35 (9.9)	41 (11.8)
	Expensive	87	12.4	38 (10.8)	49 (14.1)
	Lack of knowledge	46	6.6	24 (6.8)	22 (6.3)
	Do not think important	61	8.7	34 (10)	27 (7.8)

*The value of significance P<0.05

365 (52.1%) of respondents used home remedies for curing their dental problem. 77.8% of males felt that there is a need to improve their oral health. 40.6% of the total study population felt that dental facilities should be improved around them. Majority of them (19.6%) suggested that the cost of treatment should be reduced while free treatment (9.7%) was also one of the common suggestions [Table 2C].

Table 2C: Differences in responses about health care seeking behavior on gender among study participants

Variable		n	%	Male n (%)	Female n (%)	Chi-square	P
Have you tried home remedies for dental problem?	Yes	365	52.1	178 (50.9)	187 (53.9)	0.911	0.340
What kind of home remedies?	Clove oil	137	19.6	69 (19.6)	68 (19.6)	1.802	0.615
	Balm	214	30.6	101 (28.6)	113 (32.6)
Opinion on your state of teeth	Above average	97	13.9	51 (14.5)	46 (13.3)	1.615	0.656
	Average	415	59.3	203 (57.6)	212 (61.1)
	Below average	176	25.1	94 (26.7)	82 (23.6)
Opinion on your state of gums	Above average	97	13.9	52 (14.8)	45 (13.0)	5.607	0.132
	Average	352	50.3	163 (46.3)	189 (54.5)
	Below average	241	34.4	134 (38)	107 (30.8)
Do you think there is a need to improve your oral health?	Yes	526	75.1	274 (77.8)	252 (72.6)	2.276	0.131
Suggestions to improve dental facilities around you	Less cost	137	19.6	71 (20.2)	66 (19.0)	2.371	0.668
	Free treatment	68	9.7	31 (8.8)	37 (10.7)
	Dentist nearby	49	7.0	29 (8.2)	20 (5.8)
	Dental camp nearby	31	4.4	15 (4.3)	16 (4.6)

Association of Health seeking behavior toward common oral diseases and demographic variables is presented in Table 3 which depicts that maximum negative and positive behavior was shown in the age group 21–40 years. In addition, the majority of males and females have negative health-seeking behavior toward oral diseases.

Table 3

Association of health-seeking behavior toward common oral diseases and demographic variables

Sample characteristics	Variables	Health seeking behavior		Chi-square	Df	P
		Negative n (%)	Positive n (%)
Age in years	20 and below	15 (0.78)	4 (0.21)	22.440	27	0.715
	21-40	295 (0.73)	105 (0.26)
	41-60	185 (0.73)	68 (0.26)
	61 and above	21 (0.75)	7 (0.25)
Gender	Male	264 (0.75)	88 (0.25)	6.059	9	0.734
	Female	252 (0.72)	96 (0.27)

Discussion

Oral health importance in the maintenance of general health has been long acknowledged by the WHO. There have been a lot of efforts toward raising awareness on oral health among the public by various local, national, and international bodies/organizations.[15] Despite these efforts, oral health continues to be neglected by the people, especially in rural areas as observed in our study. The present study reported that significantly males had more dental complaints than females.

In this study, toothache was the most common reason (33%) for seeking oral care which was also reported by Bommireddy et al.[15] It could be comprehended from these observations that oral healthcare services were elective unless there was pain in the view of a majority of the rural population. However, in another study, missing tooth was the major complaint for seeking dental care.[2] The fact that they conducted a study on geriatric population might be the reason for this variation.

Furthermore, it was reported by the participants that low expenditure (12.4%) was one of the main reasons why they had chosen the facility at which they had sought care. Contrary results were seen two other studies who reported accessibility as the reason for choosing the particular center for seeking dental treatment.[1519] It could be concluded that people choose government hospitals over private dental setups because of less treatment cost.

In the present study, 12.4% of the people stated that expenses of treatment were the reason for not utilizing oral health services and the results of Gupta et al.[20] coincide with the results of the present study. The possible cause for this could be difficulty in accessing oral health facilities due to poor transport system, residing in a rural area, or poor health.

National health authorities should actively take part to develop policies for oral health sectors. It is recommended that dental camps in the rural sector, mobile dental clinics, and oral health education and promotion should be conducted to spread awareness among the people. The cost of dental treatments should be revised and made affordable for the rural population. The health centers should have a complete oral health setup so that people do not have to travel long distances to get oral health care.[20]

Conclusion

Healthcare seeking behavior among rural population toward oral diseases was poor. As the primary intervention is the key to effective prevention, appropriate steps should be taken to prevent it. Poor attitudes of people on the importance and awareness of oral health are quite evident, and efforts must be made to bring a change in this scenario. Hence, there still is need for awareness among the population. People should be told about the importance of primary prevention. The services should be provided on the basis of felt needs of the rural population so that utilization of dental services can be increased, thereby improving the oral health status of the underprivileged population. Despite national goals for achieving health equity, persistent disparities in dental utilization remain for underprivileged population of central India. Hence, dental camps, oral health education, and awareness camp should be conducted and dental services should be made readily accessible to rural population.

List of Abbreviations

HSB = Health seeking behavior, SES = Socioeconomical status, HSD = Health service deficit

Financial support and sponsorship

Nil.

Conflict of interest

There is no conflict of interest.