Systematic Review on Oral Health Knowledge, Practice and
Attitude in Pakistan
Anum Karim1, Haniya Zehra Syed1,
Russell Kabir1*
1School of Allied Health,
Anglia Ruskin University, Chelmsford, Essex, UK
*Corresponding
author: russellkabir@aru.ac.uk
Submitted: 18.02.2024 Accepted: 24.05.2024 Published: 27.05.2024
.
Keywords: Oral
Health; Systematic review; Oral Health; Pakistan; Knowledge; Practice; Attitude
Introduction
As a crucial component of overall health, oral health
refers to a condition that protects the mouth from conditions including face
discomfort, ulcers, oral and throat cancer, birth deformities like cleft lip
and cleft palate, gum (periodontal) disease, tooth loss, decay, and other
conditions that impact the oral cavity.
Restricted Access to Care and lack of awareness are other factors which make
the oral health a great concern in Pakistan (Basharat and Shaikh, 2016).
Poor
dental health has a significant influence on day-to-day lifestyle due to the
accompanying difficulties, and it is a significant health and financial burden
in the long run (World Health Organization, 2003). Delayed interventions in
younger individuals may cause problems (Wu, et al., 2000). Early childhood oral
health awareness and hygienic practices are heavily impacted by carers. Mattos
and colleagues (Wu, et al., 2000), suggested that pediatric
dentists should urge the carers of the children to get advice and dental
treatment annually. In a study it was found that sixty-two percent of teaching
staff do not have the knowledge of dental decay (Dawani,
Afaq and Bilal, 2013). Pakistan places less emphasis on oral health. In
research conducted by Vakani F, Basaria
N, et al (Vakani, Basaria
and Katpar, 2011) in Karachi, it was shown that the
mean of DMFT was 1.27, indicating poor oral hygiene practices (Vakani, Basaria and Katpar, 2011), leaving a major gap in oral disease care,
with 90% of lesions never being treated. Oral hygiene found to be associated
with population socioeconomic status and literacy levels (Iqbal, et al., 2014).
The way one feels, knows, and practices oral hygiene is crucial to sustaining
good oral health. Regional KAP (knowledge, attitude, and practice) analyses
paint an incredibly bleak picture (Aslam, 2005).
The
most common dental problem in children was dental caries (Kwan, et al., 2005).
The discomfort from tooth decay made it difficult to do basic everyday tasks
including eating, sleeping, speaking, learning, playing, and going to school.
Various studies on the prevalence of caries in children across the world have
been carried out, and practically all of them have found significant prevalence
of caries (Farooqi, et al., 2015). Schools are a great setting for promoting
oral health since there are more than 1 billion students enrolled worldwide
(Kwan, et al., 2005). Childhood is the most formative time in a person's life
and is when beliefs, attitudes, and practice are formed that last a lifetime,
oral health message may be reinforced during this time.
Pakistan
is a developing nation with various oral health issues. Most dentists are
employed by the government, which also serves as the population's primary
source of access to low-cost oral healthcare (Basharat and Shaikh, 2016). Early
in childhood, oral health practices are developed. The development of healthy
habits in pupils can be greatly aided by the schoolteachers (Perry, Mullis and
Maile, 1985). The teachers themselves must be knowledgeable about oral health
and have a positive attitude towards it to develop healthy preventative dental
practices. There have been studies on the preventive knowledge and attitudes of
intermediate and high school teachers, but there have been few studies on the
incidence of dental caries and the prevention knowledge, attitudes, and
practices of schoolteachers in Pakistan's Northwest.
To
date, no systematic study has been carried out to summarize the findings that
can be used to better advice health measures by focusing on parts of Pakistan's
impoverished nation.
A
systematic assessment of oral health knowledge, practice, and attitudes in
Pakistan accomplishes numerous key goals.
·
The review's
findings can help in the design and execution of oral health education
programs.
·
Systematic
evaluations can aid in identifying discrepancies in oral health knowledge among
·
The review can
identify practices that are successful in improving oral health and preventing
oral illnesses by analyzing the available literature on oral health practices
in Pakistan. This data can help health care providers and policymakers
recommend evidence-based practices.
The
systematic review is aimed and proposed to examine current knowledge,
practices, and attitudes on oral health in Pakistan. The goal is to identify
trends, gaps, and viable interventions to promote oral health knowledge and
care across the country by synthesizing existing research.
Method
Sample (S):
Sample is different professionals
Phenomenon of interest (PI): phenomenon of interest
PI is oral health
Design (D): is questionnaire survey, interview, and
Focus groups
Evaluation (E): knowledge, practice and attitude
Research type(R): either qualitative, quantitative
or mix methods
Table 1 Literature
Search
To
identify distinct articles, thorough research of the available studies was
undertaken using the Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) standards for systematic reviews. To prevent missing key
research and to reduce bias, the literature search was conducted using several
databases.
Review
includes primary research conducted in Pakistan`s children and teenagers
between the ages of 12 and 18. The research ought to have investigated at least
one or more aspects of oral health-related knowledge, practices, behaviours,
attitudes, beliefs, or understandings. The design of study was not the
constraint so Studies that had both quantitative and qualitative elements, such
as mixed studies, were also acceptable. Elderly people and pregnant women were
not included in this review. Also, those studies, publications or journals are
not considered that have been published in language other than English.
The
search limits were applied and the publications that surfaced were initially
examined for research. In the next step, the further screening was done based
on title of the review. These were restricted to information gathered through
questionnaires, surveys, focus groups, and interviews. Fourteen (14)
publications were initially chosen for the fourth step after their full-text
articles had been scanned for participant data on oral health knowledge,
practice, and attitude in Pakistan.
Articles
about oral health that offered minimal or unfocused information were
eliminated. Eight research were chosen for the critical appraisal stage
following the application of the inclusion and exclusion criteria.
Figure 1 : Prisma 2020 Flow Diagram
Retrieval
of data
The
data was retrieved from all the included papers. The following information was
taken from each study: name of author, the year of publication, type of study
(qualitative or quantitative), study population, country of study, and
information about the participants, research methods, and results for the
Pakistan study. Meta synthesis was done in this review because the data
included from mix method studies so the meta-analysis
was not possible.
The
eight studies were evaluated critically to determine their methodological
merits, weaknesses, and findings' dependability. It was also checked to
determine if the studies were well-planned, carried out, and published as well
as if they addressed the problem raised by the systematic review. The Appraisal
Instrument for Cross-Sectional Studies (AXIS), which was developed specifically
for the evaluation of this type of design, was used to assess the studies
(Downes, et al., 2016). By removing publications with ethical problems, the
review's ethical and methodological quality was strengthened. This review also
contains an ethical evaluation.
The
inclusion of ethical assessment in this review aimed to enhance ethical
standards by filtering out articles that displayed clear ethical shortcomings
and steering clear of them. Six papers were included in the evaluation because
of the critical and ethical assessment. Two papers were removed from this
systematic review due to low internal validity, which impacts the dependability
of the results.
Results
The
systematic review includes six studies conducted primarily in different areas
of Pakistan. These include Sheikhupura, Mardan, Abbottabad, Azad jamu Kashmir, Mastang district Balochistan and
Northwest of Pakistan. Mostly the studies are conducted in low-middle income
population and the targeted population were schools or other educational
institutes. The sample size varies from 300 to 1000
and it includes children and teenagers. All the conducted primary studies were
cross sectional, where data was gathered using a self-administered
questionnaire, a face-to-face interview, or audio computer-assisted
self-interviews. The data retrieved from the research was self-reported by the
study`s participants and is presented in Table 2.
Table
2: Data Extraction
The
analysed review revealed a wide variety of oral health knowledge levels among
Pakistan`s community. While some people had a strong understanding of
fundamental oral hygiene, there were major gaps in knowledge about the
necessity of frequent dental check-ups, the use of fluoride, and the
relationship between oral health and overall health. One study depicts that the
97% of the sample size are aware of the brushing while only 13% students have
the knowledge that soft drinks are harmful for the teeth (Mehmood, Rasheed and
Ijaz, 2018).
Higher
education and income levels were associated with improved oral health
awareness, indicating socioeconomic differences. One of the studies conducted
in Sheikhupura shows that less than 50% students have knowledge about the oral
health while, parental education and family income were found statistically
significant factors in this report (Chand and Hadyait,
2014). The Mardan student’s statistical findings show that 60% of the students
have no knowledge about the oral health (Iqbal, et al., 2014). In another study
conducted in schools of Northwest of Pakistan, the overall prevalence of DMFT
was found 1.75 which is very less. Cultural norms also found significant, and
this is found in areas where traditional values are still practiced. For
example, the study conducted in Mastang showed that
the percentage of knowledge in male students is 30% more than the female
students which is probably because of their socializing factor (Baloch, Panezai and Murtaza, 2021).
Cultural
views, financial level, and access to healthcare all had an impact on attitudes
towards oral health. When compared to other health concerns, some people ranked
oral health as a low priority. Dental visits were generally regarded as a last
choice, particularly when enduring pain or discomfort. Stigmatization of dental
disorders and a lack of understanding about preventive treatments were cited as
barriers to obtaining early dental care (Barker and Horton, 2008). By inquiring
in one of the studies conducted in Kashmir about their ratio of visiting the
dentist it is found that only 51% of students visits the dentist at the time of
tooth ache while only 3% students’ regular visits the dentist (Mehmood, Rasheed
and Ijaz, 2018). The same percentage was observed in the students of Mastang, where almost 52% of sample size visits the doctor
only in case of pain and more than 50% brush once in a day (Baloch, Panezai and Murtaza, 2021).
This
percentage is better than the students of Northwest of Pakistan where 82% of
the sample size never visited the doctor while, their brushing habits are like
the study conducted in Mustang (Bhatti and Malik, 2019). The statistical data
of the students of Mardan shows that 75% never visited the doctor and 13 % of
students didn’t find it worthy to visit a dentist (Iqbal, et al., 2014). The
cultural norms and traditional values also impact a lot in visiting the
dentist. From the results it is found that the trend of visiting the dentist is
less where the old traditions are still followed.
Oral
hygiene practices vary greatly across demographic groupings. While a sizable
number of the population found to use brush on their teeth regularly, the
frequency and manner were frequently inconsistent with prescribed norms.
Misconceptions regarding how to use dental floss, mouthwash, and toothpaste
were common. Furthermore, restricted access to dental care services in some
areas prevented people from seeking treatment for oral health problems on time.
Tooth
brushing and its frequency have been documented in five researches (Baloch, Panezai and Murtaza, 2021; Mehmood, Rasheed and Ijaz, 2018;
Chand and Hadyait, 2014; Bhatti and Malik, 2019;
Noor, et al., 2022, three of which revealed tooth brushing as a common practice
among students (Baloch, Panezai and Murtaza, 2021;
Mehmood, Rasheed and Ijaz, 2018; Chand and Hadyait,
2014). However, the frequency with which teeth were brushed varied. In one
study, a larger proportion of female students reported not cleaning their teeth
(Iqbal, et al., 2014). Those who were in secondary school were more likely to
wash their teeth on a regular basis, but those in the primary section did not,
probably due to lack of knowledge and awareness (Noor, et al., 2022).
In
addition to brushing, flossing was mentioned in two studies (Baloch, Panezai and Murtaza, 2021; Mehmood, Rasheed and Ijaz, 2018.)
In one study, nearly 80% of the sample size reported flossing (Baloch, Panezai and Murtaza, 2021), while 20% reported never
flossing. Most studies show a decrease in dental visits. Given that most
studies found that seeing a dentist in the absence of symptoms was unusual,
parental education was identified as a factor of dental care.
Discussion
The
systematic review of primary research undertaken in Pakistan throws light on
the complex landscape of oral health knowledge, practice, and attitude among
various sectors of the population. The review situates the findings within the
larger literature, highlighting regional differences and suggesting major
policy and practice implications.
Oral
hygiene is one of the most important health factors in underdeveloped
countries, according to convincing evidence (Kandelman,
Petersen and Ueda, 2008). Repeated KAP studies are therefore strongly advised
to monitor trends; nevertheless, a reliable and culturally appropriate
questionnaire is one of the major prerequisites.
Disparities in Oral Health Knowledge
The
review's integration of studies completed throughout Pakistan sheds light on
the ongoing discrepancies in oral health knowledge between urban and rural
communities. Urban areas, in line with worldwide trends, have higher levels of
oral health awareness due to increased access to education and healthcare
facilities (Chand and Hadyait, 2014). Variations in
oral health knowledge among various areas of Pakistan parallel global
tendencies. The current review's findings from Baluchistan, Mardan, Abbotabad, Azad Kashmir, and the northwest are consistent
with larger research that shows that metropolitan areas have higher oral health
knowledge due to better access to educational resources and healthcare
facilities (Iqbal, et al., 2014; Mehmood, Rasheed and Ijaz, 2018; Noor, et al.,
2022). Rural areas, on the other hand, have lower levels of knowledge, owing to
difficulties in communicating oral health information to isolated and neglected
people (Baloch, Panezai and Murtaza, 2021).
However,
it is critical to emphasize that, while metropolitan regions may have higher
levels of knowledge, this does not imply universal understanding. Efforts to
eliminate rural-urban gaps should continue to be a top priority, with targeted
interventions ensuring equitable access to oral health education and
information (Rahman, et al., 2011).
Above
all, the cultural and traditional norms act as integral pillar for shaping up
the practices around oral health needs. Moreover, in one of the studies male
students were found more well-informed than female students, because in
Pakistan the girls are not allowed to socialize more frequently (Baloch, Panezai and Murtaza, 2021). In parallel teachers’ role
can’t be denied, in one study the teachers answered all questions correctly
(Bhatti and Malik, 2019). This depicts that a teacher`s guidance to its pupils
is very crucial about the importance of oral health and can yield better
results.
Cultural Factors and the Practice Gap
The
review reveals a significant gap between oral health knowledge and practice,
demonstrating a complex interaction of factors that impedes translation of
awareness into action. This phenomenon is not specific to Pakistan, but it is
felt globally, highlighting the complex task of creating behavioral
change.
Cultural
norms and socioeconomic restrictions play a key role in this disparity, as
evidenced by results from various primary studies conducted in Pakistan.
Lessons from various global contexts demonstrate that effective interventions
must go beyond simply disseminating knowledge. Instead, they should concentrate
on targeted approaches that overcome contextual barriers, use social influence,
and encourage individuals to adopt long-term oral health practices. The
cultural variables affecting this gap are especially notable in areas such as
Azad Kashmir and the northwest, where traditional practices and societal norms
may influence oral health behaviors (Mehmood, Rasheed
and Ijaz, 2018; Bhatti and Malik, 2019).
Although
most of the Pakistan`s population recognize the value of dental hygiene
practices such as brushing and flossing but adherence to these practices
varies. Individuals are more likely to follow prescribed oral hygiene habits in
metropolitan regions and among educated groups. Traditional practices, on the
other hand, may be more widespread in rural and less educated areas (Chand and Hadyait, 2014). Other studies (Honkala, et al., 2002;
Salwa, 2003) have revealed that girls clean their teeth more regularly and
spend more time brushing their teeth than boys. This might be owing to the
reason that girls consume sugary food more than boys. According to the studies,
girls prefer sweet foods, whereas boys prefer quick foods and snacks with
higher fat and salt content (Oogarah‐Pratap, 2007).
Other than 3 sweets, carbonated beverages were reported to be the most popular
among respondents, with the majority claiming to drink them and 49% doing so at
least once per day (Mehmood, Rasheed and Ijaz, 2018).
Many
people in Pakistan do not receive preventive dental care, such as regular
check-ups and cleanings. Dental checkups are frequently made in response to a
specific condition rather than as part of routine care. Traditional treatments
for dental problems are still used in some locations. This could be due to a
lack of contemporary dental care or cultural preferences. However, while some
traditional cures may provide temporary comfort, they may not address the
underlying cause of tooth problems (Baloch, Panezai
and Murtaza, 2021).
The
data found that checkup visits to dentists were rated as significant. They also
stated that dental appointments are only necessary when teeth pain occurs, and
that scary injections, pain, infection, long queue time, cost, and a lack of a
clinic nearby were the main reasons they were hesitant to attend dentists
(Noor, et al., 2022).
Early
oral education in children reduced dental anxiety and improved long-term dental
follow-up (Nicolas, et al., 2007). A study conducted in one of the primary schools
of California found that carers had a significant influence on their children's
dental health and early access to dental clinics. The results can be justified
by the fact that the teenagers when became independent then they do not want
anyone to intervene in their routine. Dentists play an important role in
raising and distributing knowledge about oral disease prevention. However,
because to the restricted number of dentists available to serve patients, the
quality time which can be spent by the dentists with each patient is a
constraint. As a result, dentists should not be solely responsible for
educating patients about oral health. Delays in seeking dental care could be
linked to a variety of circumstances, including a lack of financial resources
and access to dental services (Barker and Horton, 2008).
The
systematic review emphasizes the importance of schools as important platforms
for oral health education. Across areas, data consistently show that
school-based programs have a significant impact on improving oral health
knowledge and nurturing positive attitudes. This is consistent with global
policies that urge for the addition of oral health education in the syllabus.
Policymakers as well as the educators in Pakistan can learn from successful
efforts in other countries that use schools to promote health. Engaging
teachers and parents in raising awareness and enforcing oral health practices
can also increase the reach and effectiveness of school-based programs.
The
Strengths of this review include: Comprehensive
Synthesis: The systematic review presents a comprehensive synthesis of
primary research undertaken in several regions of Pakistan, including
Baluchistan, Mardan, Abbotabad, Azad Kashmir, and the
northwest. This depth of coverage increases the generalizability of the
findings and provides a more comprehensive view of the country's oral health
environment. Evidence-Based Insights: The review presents evidence-based
insights about oral health knowledge, practice, and attitude among various
sectors of the population by systematically analyzing
and synthesizing a varied range of primary research papers. This empirical
basis reinforces the review's conclusions and recommendations. Contextualization:
The review effectively contextualizes its findings within the larger body of
oral health literature. The review improves our understanding of how oral
health behaviors and attitudes in Pakistan fit into
the larger global picture by comparing the results from Pakistan with global
trends and similar studies in other countries. Regional variances: By
including studies from several regions of Pakistan, the review can highlight
regional nuances and variances in oral health knowledge, practice, and
attitude. This granularity allows for more targeted actions and policy
development that can address the individual needs of diverse places. Implications
for Policy and Practice: In addition to summarizing research findings, the
study draws practical implications for policy and practice. The research gives
actionable recommendations that might guide future endeavors
to promote oral health in Pakistan by recognizing the role of schools, the
influence of cultural norms, and the necessity for targeted interventions.
The limitations of this review includes:
Publication Bias: Because studies with favorable
or statistically significant results are more likely to be published, the
review's findings may be influenced by publication bias. This bias may have an
impact on the overall portrayal of the oral health landscape in Pakistan,
potentially leading to an overestimation of intervention effectiveness. Heterogeneity
of Studies: The original research studies included in the review may have
used varied techniques, sample sizes, and measurement instruments. This variety
may make direct comparison and synthesis of the results difficult, thereby
impacting the robustness of the review's conclusions. Access to Research:
The review's breadth may be limited due to difficulties in obtaining all
relevant original research studies. Language difficulties, limited access to
databases, and differences in research dissemination may result in the omission
of valuable studies, potentially impacting the comprehensiveness of the review.
Cultural Context: While the evaluation acknowledges the importance of
cultural norms on oral health knowledge and practices, it may not fully
represent the depth and complexity of these cultural elements. Cultural effects
may be interpreted differently, and a more in-depth qualitative investigation
may be required to completely comprehend their impact. Temporal Dynamics:
The review's findings may reflect the oral health landscape prior to the
inclusion of the original research studies. Given the ever-changing nature of
healthcare and socioeconomic issues, the review may not fully reflect recent
changes in oral health knowledge, practice, and attitude.
Conclusion
The
systematic evaluation of primary research undertaken in Pakistan emphasizes the
complexities of oral health knowledge, practice, and attitude. This discussion
emphasizes the necessity for comprehensive solutions that recognize
geographical variances, cultural effects, and socioeconomic inequities by
contextualizing the findings within the broader literature. The review's
findings can help policymakers, stakeholders, educators, healthcare
professionals, and researchers work together to create evidence-based
strategies that bridge gaps, raise awareness, and empower people to prioritize
and maintain optimal oral health throughout their lives.
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