Dental caries and periodontal diseases are both preventable diseases and significant reduction in the disease pattern has been demonstrated worldwide by oral health education emphasizing importance of preventive strategies. As the disease starts in early childhood with the eruption of the milk tooth, preventive strategies would be most effective if it is started on or before the time of eruption of milk tooth at about 6 months of age. Many studies indicate that educational programs can effectively increase knowledge and improve attitudes related to infant oral health(5,6). Empowering community workers like junior public health nurses (JPHNs) of health services and anganwadi workers (AWW) of Integrated Child Development Services (ICDS), in oral health, and providing basic oral health awareness to the mothers through them is a feasible model for a country like India; where oral health is not a priority in the primary health care as yet. The service of a JPHN is available for every 5000 population while service of an anganwadi worker is available for every 1000 population. At the Anganwadis, monthly meeting of mothers are held and these serve as platforms for health education.

JPHNs and Anganwadi workers get rigorous training in various health aspects but dental health is not given due importance during their initial or in-service trainings. Nurses are expected to play active role in the promotion of health including oral health, particularly in the rural under-served communities. There is a paucity of oral health education in nursing curricula(7). Educating mothers on infant dental care will promote lifelong good oral hygiene habits and will bring down the prevalence of oral diseases considerably. Various types of oral health maintenance materials have been used and countless numbers of dental health information programs have been conducted in schools and other settings, but not primary health care settings catering to 0-6 year olds(8-12). The broad objective of the "Oral Health Care Project Kerala" is to incorporate preventive and promotive oral healthcare in to the broader concept of primary health care in the state. This report forms the results of the effectiveness of an education program conducted among community workers and mothers of under-6 year olds.

The study was conducted in a block panchayat in Thiruvananthapuram district of Kerala, after obtaining ethical clearance of the institutional ethical committee. Two separate interviewer-administered questionnaires, one for the community workers and the other for mothers of children (0-6 years) were prepared, pretested, piloted and necessary odifications made. The results of the baseline survey, conducted among community workers and mothers provided an understanding of areas where knowledge should be imparted on oral health. The same was used in developing training materials, which included audiovisual aids, modules, charts, posters and brochures in the regional language. After finalization of the training schedule, training classes on oral health were conducted for JPHNs and AWWs. Training was conducted as one-day program in four batches of around 50 participants per day. Dental surgeons conducted the classes with the help of audiovisual aids and the trainees were given modules and booklets on oral health so as to help them to conduct training in the community.

Subsequently, the trained JPHNS and AWWs together conducted oral health classes during mothers’ meetings at Anganwadis. Classes were conducted in 137 Anganwadis and 2708 mothers were trained during these meetings. The trained JPHNs and AWWs took classes using the modules prepared for this purpose. The effectiveness of the program was evaluated by a post-intervention knowledge survey among JPHNs and AWWs, and mothers who attended the training sessions, two months after the training. 115 workers and 232 mothers took part in the pre-intervention and post-intervention surveys. For statistical analysis, McNemar test using binomial distribution was used.

In order to assess the effectiveness of intervention, changes in knowledge level of the participants were analyzed in five important domains; oral hygiene habits, importance of milk teeth, causes of dental diseases, prevention of dental diseases and treatment of certain dental conditions. Results of the pre-and post-intervention among community level workers showed that statistically significant improvement in knowledge occurred among the participants in all areas (Table I). The level of oral health knowledge in pre survey was low among the participants, which stresses the need for in-service training. Considering the fact that the training of trainers was given as a one-day program, the effect created is rather significant.

TABLE I

Effectiveness of Intervention in JPHNs* and AWWs (N=115)

The workers conducted oral health classes at mothers meetings in the anganwadis. The pre and post comparison of knowledge level in mothers showed that the classes provided by the workers led to significant improvement in oral health knowledge of mothers (Table II). In the pre-intervention survey, only 3% of mothers knew that professional scaling was a treatment option for gum disease and this improved to only 10% in the post intervention period. This low improvement in knowledge gain can be observed in the knowledge change of community workers also (Table I). Being a one-day program, the training of trainers may not have covered these areas satisfactorily as reflected in the results. This highlights the need for incorporating more information about these aspects in the training program.

TABLE II

Effectiveness of Intervention in Mothers 

Dental diseases have a very high prevalence. Oral diseases have health consequences far beyond the oral cavity including health and developmental problems in children, adverse pregnancy outcomes and are even implicated in cardiovascular diseases. For optimal oral health, oral hygiene habits should be instilled at a very young age itself. Primary dental care is the way of achieving good oral health for the community. The most feasible and sustainable method to achieve this is through integration of oral healthcare in the existing primary healthcare activities, through training of community level workers to identify and promote oral healthcare practices. This intervention made statistically significant changes in knowledge level of the participants in the areas of oral health addressed.

This study results suggest that including oral health education in JPHNs and AWWs training program would enable them to provide oral healthcare instructions to mothers. The project which aimed to empower local communities through existing primary healthcare infrastructure and outreach mechanisms to provide a cost effective, replicable mechanism of providing primary preventive oral healthcare to the community proved to be a feasible model. However, for knowledge to be translated to positive practice and sustained behaviour change, concerted efforts and long term follow-up is necessary.

Dr K Sandeep, ECSRC; Dr K Nanda Kumar, and Dr Shobha Kuriakose, Government Dental College, Thiruvananthaupram; Dr Shankara Sharma, SCTIMST; Asokan N and Muraleedhran K Child Development Centre, Thiruvananthapuram.

Contributors: MKCN, and MR were involved in designing the study and preparation of the manuscript and MKCN will act as guarantor. SKE, LML, and BG were involved in the data collection. SKG helped in community mobilization.

Funding: European Commission Sector Investment Programme, Directorate of Health Services, Kerala.

Competing interests: None stated. The findings and conclusions of this study are those of the authors and do not necessarily represent the views of the funding agency.

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