Correlation of Knowledge, Attitude, and Practice with their Oral Health Status among Young Adults of Nursing Care: A Cross-Sectional Survey.

Background: Nursing profession execute an imperative role in health promotion, disease, and injury prevention, providing care and assist in cure of patients with diverse age groups, and backgrounds both in individual and community settings. The study aimed to determine and compare the oral health knowledge, attitude, and practice (KAP) with oral health status among nursing students in Salem. Materials and
Methods: A cross-sectional study was conducted on nursing students of Vinayaka Mission's Annapoorna College of Nursing, Salem, Tamil Nadu, India. The study included self-administered questionnaire covering demographic details and oral health KAP questions (18-items) followed by oral examination using the World Health Organization survey (2013). Data analysis was performed using SPSS 22.
Results: Two hundred and sixty-one students were included in the survey (63 males and 198 females). Females reported better mean ± standard deviation (SD) in knowledge (24.08 ± 4.3), attitude (5.43 ± 1.3), and practice (10.82 ± 1.5, P = 0.000) than males. Moreover third-year students had higher mean ± SD scores in knowledge (24.42 ± 4.3) and practice (10.89 ± 1.7) while higher mean ± SD attitude scores (5.61 ± 1.2) was reported among second years. Relationship between attitude-practice indicated a positive significant correlation (r = 0.145, P = 0.05). Conclusions: There are an adequate knowledge, negative attitude, and inadequate practice toward oral health among nursing students. The study introspects the gap between knowledge and actions. As attitude influence on a person's behavior, discriminate knowledge in the right direction to best bring out the outcomes. Copyright:

INTRODUCTION

Oral health attributes to be a fundamental component of general health as deprived oral health can lead to substantial impact on health-related quality of life. Nearly 3.9 billion people were affected by oral diseases globally.[1] Totally, oral conditions resulted for 15 million disability life years, exhibiting a mean health loss of 224 years per 100,000 population.[2] In this regard, India possesses increased encumbrance of oral diseases in contrast to other Southern Asian countries.[3] Thus, oral problems are widespread and chronic in nature constituting departure from the state of positive health which in turn further encroaches on the financial matters of the public.

The nursing profession being a vital component of the health care team plays an imperious role in health promotion, disease and injury prevention, providing care, and often in constant contact to assist in cure of patients with diverse age groups and backgrounds in community settings.

Literature review revealed that research on oral health among nursing students carried out in several diverse countries report generally reliable findings.[45] Despite the fact that several studies[67] have assessed the knowledge, attitude, and practices (KAP) among nursing students not many studies[8] have stated their relation with oral health status. As the cognitive and affective domains can be the best interpreter for change in the behavior of the individual, this study aimed at assessing the oral health KAP of nursing students and to correlate KAP with their oral health status.

MATERIALS AND METHODS

This cross-sectional study was performed for 6 months (September 2018 to February 2019) among undergraduate (B.Sc.) nursing students of Vinayaka Mission's Annapoorna College of Nursing, Salem, Tamil Nadu, India.

At the outset of data collection, the principal investigator explicated the purpose of the study to the targeted cohort of nursing students. The minimum sample estimated using Epi Info application software calculating the margin of error 5%, confidence interval 95%, and response distribution of 50%, nearly 177 students were required of an aggregate of 324 students to contribute adequate statistical power.

The recruitment of the study participants is shown in Figure 1. The data collection included two stages. At stage 1, the students (n = 281) filled questionnaire comprised demographic information (age, gender, and year of study), as well as data on oral health KAP (18 questions) under the surveillance of the chief investigator.

Figure 1

Flow chart of the participants' recruitment for the study

Questionnaire was in the English language, and the retest reliability method was followed to check the test consistency during the pilot study done among 30 students (Cohen's kappa statistics 0.90). Cronbach's alpha which measures the internal consistency for the questionnaire was 0.90.

Stage 2 included a noninvasive clinical Type III oral examination by one pretrained and precalibrated examiner. Dental caries and periodontal status were assessed using the World Health Organization (WHO) oral health assessment form 2013.[9]

Data analysis was done using the Statistical Package for the Social sciences 22 (SPSS Inc., Chicago, IL, USA) to carry out the Chi-square, Mann–Whitney, Kruskal–Wallis, Spearman's correlation, and linear regression analysis. P ≤ 0.05 was considered statistically significant.

The institutional ethics committee approved this study (Reference: VMSDC/IEC/Approval No: 146). Anonymity and confidentiality of the respondents were maintained. Written informed consent was obtained from all the participants.

RESULTS

Of 261 students, majority were female (75.9%, n = 198) and the remaining were male (24.1%, n = 63) with mean age 22 ± 2.58 years. Most of the study population belonged to the age group of 18–20 years (51%, n = 133), ensuring the proportionate number of participants among all years of study.

The assessment of knowledge responses between gender showed the number of permanent teeth and goal of brushing was statistically significant (P ≤ 0.05). On comparing among year of study, a significant difference was noted for the number of teeth (P = 0.001), gingivitis (P = 0.000), and tooth loss is a natural phenomenon as growing old (P = 0.02) [Table 1]. Most of the students had adequate knowledge (n = 205, 78.5%), negative attitude (n = 219, 83.9%), and inadequate practice (n = 176, 67.4%) for oral health.

Table 1

Assessment of study participants response to questionnaire based on gender and year of study

Question	P
	Gender	Year of study
1. Total number of permanent teeth in adult’s mouth	0.04*	0.001*
2. How do you notice tooth decay?	0.25	0.21
3. What causes tooth decay?	0.84	0.06
4. What is dental plaque?	0.48	0.43
5. What is gingivitis?	0.92	0.000*
6. What is the goal when we brush our teeth?	0.05*	0.06
7. What are the dental problem that is caused due to LBW?	0.34	0.14
8. Which trimester is safe for undergoing dental treatments?	0.73	0.06
9. Does oral health has impact on general health	0.53	0.14
10. Do you think, tooth loss is a natural phenomenon as growing old	0.14	0.02*
11. Is it important to replace missing teeth for better oral health	0.51	0.19
12. I know the proper method of tooth brushing?	0.44	0.32
13. How many times do you brush your teeth daily?	0.50	0.33
14. What kind of toothbrush to be used?	0.20	0.22
15. In addition to tooth brush and tooth paste, any these oral hygiene methods used?	0.12	0.01*
16. How often do you change your tooth brush?	0.42	0.20
17. Routine dental check-ups	0.72	0.10
18. What was the reason for not visiting dentist?	0.99	0.07

*P≤0.05. LBW: Low birth weight

Table 2 illustrates that the females reported better mean ± standard deviation (SD) in knowledge (24.08 ± 4.3), attitude (5.43 ± 1.3), and practice (10.82 ± 1.5, P = 0.000) when compared to their male counterparts. Moreover, third-year students had higher mean ± SD scores in knowledge (24.42 ± 4.3) and practice (10.89 ± 1.7) while higher mean ± SD attitude scores (5.61 ± 1.2) was among second years.

Table 2

Comparison of demographic characteristic with mean knowledge, attitude, and practice scores

Variable	Knowledge (mean±SD)	P	Attitude (mean±SD)	P	Practice (mean±SD)	P
Age groups (years)
18-20	24.05±4.2	0.915	5.63±1.1	0.000*	10.85±1.6	0.292
21-23	24.10±4.1		5.09±1.1		10.62±1.5
24-26	24.00±4.0		4.00±0.9		9.00±0.9
Gender
Male	24.06±3.3	0.717	5.14±1.2	0.071	10.46±1.6	0.000*
Female	24.08±4.3		5.43±1.3		10.82±1.5
Year of study
Second year	24.02±4.2	0.620	5.61±1.2	0.620	10.56±1.5	0.379
Third year	24.42±4.3		5.56±1.3		10.89±1.7
Fourth year	23.76±3.8		4.89±1.1		10.74±1.4

*P≤0.05. SD: Standard deviation

KAP score revealed significant linear correlation with attitude-practice only [r = 0.145, P < 0.05, Table 3]. In the study, the association of periodontal status to DMFT was highly significant (r = 0.161, P = 0.009), suggesting that young adult students with poor periodontal status have more prevalence of decayed teeth.

Table 3

Spearman’s correlation between knowledge, attitude, and practice scores

Variables	Knowledge	Attitude	Practice
Knowledge	1.000	0.069	0.040
Attitude	0.069	1.000	0.145*
Practice	0.040	0.145*	1.000

*P≤0.05 statistically significant

As shown in Table 4, the multivariable linear regression analysis included KAP as the dependent variable, having a higher mean DMFT (Beta = −0.176, P = 0.033) and Community Periodontal Index score (Beta = 0.337, P = 0.046) were associated with a higher negative attitude toward oral health.

Table 4

Multivariate Linear regression analysis of decayed missing filled teeth and community periodontal index scores with oral health knowledge, attitude, and practices

Variable	Unstandardized coefficients	Standardized coefficients	P
Regression analysis of DMFT scores
Knowledge score	0.021	0.053	0.394
Attitude score	-0.176	-0.135	0.033*
Practice score	0.026	0.025	0.686
Regression analysis of CPI scores
Knowledge score	0.020	0.025	0.684
Attitude score	0.337	0.126	0.046*
Practice score	-0.145	-0.069	0.268

*P≤0.05. DMFT: Decayed missing filled teeth, CPI: Community periodontal index, KAP: Knowledge, attitude, and practices

DISCUSSION

The present study provides a framework on KAP of oral health among young adults of nursing care in Salem city, South India. The WHO workforce statistics state that approximately 90% of the nursing personnel are female. This has been identified in the present study (75.9%) and was in accordance with the study by Rwakatema et al.[8] among Tanzanian community.

According to the study by Mulla and Omar,[10] on Saudi medical students, 89.9% of the participants felt that dental caries is caused by increase intake of sugar, which was comparatively high to our findings (71.3%). The present study revealed that the majority of the participants (78.5%) reported having adequate knowledge. This result was in keeping with a study conducted by Bhattarai et al.,[11] on Nepal nursing students. A larger percentage of the students exhibited a negative attitude reliable with the results by Baseer et al.[12]

Our study findings revealed more than half of the participants had not visited a dentist which does not concur with the findings on paramedical staff (8%) by Amith et al.[13] It was noted that the majority of the students (56.7%) were twice-a-day brushers, which was in contrast to the results by Yao et al.,[14] on University students, China (65%). Females had a greater significant mean score than males and exposed only significant differences in practice, showing more affirmative application toward oral health. These findings concur with Rajiah and Ving, study[15] among Malaysian pharmacy students.

In the current study, attitude and practice were significantly correlated with each other. A definite connection between cognizance and application is yet uncertain. From this, it can be interpreted that the attitude of the individual executes an important role between knowledge and practice. This was notably in corroborated with the study by Jain et al.,[16] among nursing students, Bengaluru.

Our study has some limitations.First, it was a cross-sectional design, thus prevent to clarify the causation of differences. Second, all participants were nursing students from one private institution; hence, the results have to generalized with caution to the community. Diverse studies are suggested employing larger sample at different institutions in India.

CONCLUSIONS

This study introspect the gap between knowledge and actions. As attitude influence on a person's behavior, funneling the knowledge in the right direction to best bring out the outcomes. Need of incorporation of oral health course modules to increase the proficiency of nursing to accomplish Sustainable Development Goals to metamorphose our world.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.