Oral health knowledge, behavior, and care seeking among pregnant and recently-delivered women in rural Nepal: a qualitative study

Oral health knowledge, behavior, and care seeking among pregnant and recently-delivered women in... Background: Oral health behavior and attitudes of pregnant women in low-income countries are rarely examined, yet should be considered when designing preventative or therapeutic studies to reduce burden of oral diseases. We aimed to understand dental care-seeking behavior, as well as oral health knowledge and attitudes of oral health among pregnant women in rural Nepal. Methods: Semi-structured in-depth interviews (n = 16) and focus group discussions (3 groups, n = 23) were conducted among pregnant and recently-delivered women in Sarlahi, Nepal. Transcripts were translated from the local language to English then analyzed using a hybrid approach to thematic coding with Atlas.ti version 7. Results: Women felt confident describing the signs and symptoms of tooth decay and gum disease, but were not knowledgeable about where to receive care for tooth and/or gum pain and relied heavily on the knowledge of their community. Some women used a toothbrush and toothpaste at least once a day to clean their teeth, but many reported the traditional use of a branch of a local shrub or tree as their teeth cleaning instrument. Women suggested a willingness to consider using an oral rinse throughout pregnancy, perceiving that it might have a positive impact on infant health. Conclusions: Future studies should focus on providing adequate and sustainable resources for pregnant women in Nepal and other low income settings to engage in good oral health behaviors (possibly supported through community- based workers), to maintain dental hygiene, and to access qualified dentists as a means of improving their oral health. Trial registration: ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial). Keywords: Nepal, Periodontal disease, Oral health, Oral health behaviors, Dental care seeking behavior, Pregnancy Background addition to supply side approaches that call for substantive In low resource settings, oral health services are frequently human, infrastructural, and financial resources, demand inadequate to meet the needs of the population [1]. Poor side approaches require understanding of community accessibility, low quality, and human resources gaps – all norms, attitudes, practices, and knowledge toward oral key challenges to improving health systems in such set- health hygiene behavior, preventative care, and care-seeking tings – are more acutely felt for oral health systems. The practices. limited capacity and insufficient distribution of trained Nepal is one of many low- and middle-income countries oral health providers leads to utilization patterns almost where attention and resources applied to oral health have exclusively focused on pain management or emergency lagged behind other domains of public health. Most oral treatment responses, at the expense of prevention [1]. In health studies conducted in Nepal have tended to focus on burden of disease among school-aged children [2–7]or descriptive characteristics of dental professionals [8–10]. * Correspondence: lmullany@jhu.edu Department of International Health, Johns Hopkins Bloomberg School of Onestudy used amorebroadly focusedcross-sectional Public Health, 615 N. Wolfe Street W5009, Baltimore, MD 21205, USA population-representative survey to identify factors Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lubon et al. BMC Oral Health (2018) 18:97 Page 2 of 7 associated with improved practices. Researchers found that The pilot trial was being conducted in communities repre- odds of teeth cleaning/brushing were higher among partici- senting only one of the two broad ethnic groups in the pants living in the rural plains region (terai) bordering region. To address this, our selection of women for the FGD India, compared to those in the mid-hill regions, and higher phase of the research leveraged a population-representative among those with higher educational backgrounds [11]. database of reproductive aged women who were current (i.e. Additionally, while women were more likely than men to pregnant) or previous (i.e. recently-delivered) participants in report seeking dental care services, only 4.8% of these a large community-based randomized trial of topical women had seen a dentist in the past 6 months [11]. emollient therapies and neonatal health outcomes (clinical- Formative research studies from Nepal are necessary to trials.gov: NCT01177111). These women were purposively inform the design of context-appropriate interventions selected to broaden representation to both major ethnic and programmatic approaches. One study conducted in groups within the community: Madhesi women (n =2 Newalparasi, Nepal used the Theory of Planned Behavior FGDs, originally from the northern plains of India and [12] model to better understand oral hygiene and percep- southern Nepal) and Pahadi women (n = 1 FGD, origin- tions, and decisions related to care seeking. The study ating from Nepal’s hill regions). Women were excluded found that perceived self-efficacy in relation to oral if they had already participated in the IDIs or the pilot hygiene practices and expected social outcomes of having trialoforalrinses. healthy teeth were important predictors for oral health Prospective participants were approached by field staff behavior [13]. For example, researchers found that to assess interest in participation, and an individually once-daily tooth brushing was associated with the bathing signed consent was obtained prior to initiating inter- ritual, which has a symbolic meaning of creating purity views or discussion groups. All IDIs and FGDs followed [13]. There are few studies on the particular aspects of similar semi-structured interview guides with primarily oral hygiene behavior, perceptions, and attitudes among open-ended questions and recommended probes. The pregnant women. This group is of particular interest given IDI guide focused on oral hygiene behaviors and dental the often observed association in other settings between health care seeking, whereas the FGD guide additionally periodontal disease during pregnancy and perinatal included questions on the symptoms and causes of tooth outcomes [14–18]. Therefore, in Sarlahi District, Nepal, decay and gum disease and perceptions of dental health. we aimed to characterize these issues through in-depth Interviewers took hand-written notes during interviews; interviews (IDIs) and focus group discussions (FGDs) all interviews and group discussions were audio re- among pregnant and recently-delivered women. Specific- corded. Field researchers wrote expanded field notes ally, we aimed to understand dental care-seeking patterns, within 24 to 48 h of completing the interview or discus- practices of oral hygiene, attitudes, and knowledge rele- sion group. Audio recordings were transcribed verbatim vant to oral health of pregnant and recently-delivered from Maithili (the local language) into Nepali with the women. aid of expanded field notes. Completed Nepali tran- scripts were translated into English and reviewed for any apparent errors in translation. Methods Prior to initiating the field activities, the NNIPS qualita- Data collection tive research team, consisting of female staff members with This project was conducted by the Nepal Nutrition Inter- prior formal training and experience in conducting qualita- vention Project – Sarlahi (NNIPS), a multi-institution tive studies of a range of public health domains, received a research collaboration that has been conducting two-week refresher training conducted by the authors (AJL, community-based studies in rural Sarlahi district over the DJE). An additional training session using illustrative past 28 years. Between August and December 2016, we examples from the first two interviews was subsequently conducted 16 IDIs and 3 FGDs among pregnant and conducted to strengthen interviewer technique by one of recently-delivered women in this setting using purposive the authors (AJL). Interviews (avg. 43 min) took place in sampling to identify participants. the informants’ homes, while FGDs (avg. 74 mins) were For IDIs, we selected pregnant women enrolled in an conducted in field offices throughout the study area. ongoing randomized pilot trial of the acceptability of oral rinses (clinicaltrials.gov: NCT02788786). Four IDI Data analysis participants were selected from each of three oral rinse Demographic characteristics of IDI and FGD participants groups, and an additional four participants were selected were available as participants were enrolled in one or both from a group of women randomized to no rinse. The of the ongoing randomized control trials that collected rinse group individuals were selected to reflect diverse quantitative data. Transcripts were analyzed using a levels of adherence and reactions to taste, based on pre- hybrid approach combining deductive thematic analysis liminary data available from the trial. with inductive coding during analysis enabling themes to Lubon et al. BMC Oral Health (2018) 18:97 Page 3 of 7 emerge from the data [19]. An initial deductive coding Table 1 Demographic Characteristics of IDI and FGD Participants structure was created based on the anticipated themes and on the content of the IDI and FGD guides. The IDIs [n = 16] FGDs [n = 23] codebook was revised using inductive coding to reflect Age (years) emerging themes from initially coded IDIs and FGDs. The - Mean 20 21 list of codes was then narrowed down into categories to - Median 19 21 produce a final codebook used for coding of transcripts. - Range 16–29 15–33 After each field activity, the research team used reflective Previous live births Frequency N (%) memoing and debriefing sessions to analyze data quality, - 0 5 (31) 8 (35) scrutinize assumptions and approaches to the research, and develop the codebook. Data were compiled and coded - 1 5 (31) 7 (30) using Atlas.ti, version 7 using memos to track the process. - 2 3 (19) 7 (30) Data across IDIs and FGDs were analyzed to identify - 3 3 (19) –– themes related to dental hygiene methods, community -4 –– 1 (4) oral health knowledge, and dental care seeking behavior Gestational Age among pregnant women. This study closely approached - 0-3 months –– –– thematic saturation indicated by the aforementioned re- peating thematic categories and lack of new coding struc- - 4-6 months 10 (63) 10 (43) tures during these debriefing and memoing sessions [20]. - 7-9 months 6 (38) 4 (17) Women’s Education Results - No Schooling 7 (44) 12 (52) Characteristics of IDI and FGD participants - Years 1–9 8 (50) 9 (39) The average age of all IDI and FGD participants was - 10-SLC Pass 1 (6) 3 (13) 20 years (Table 1). Among the 16 IDI participants, all were Madhesi, were pregnant in either their second (n =10) or Ethnicity third (n = 6) trimester at the time of the interview, and - Madhesi 16 (100) 16 (70) had 0 to 3 prior children. Almost half (n =7) reported no - Pahadi –– 7 (30) formal education. The three FGDs included 23 partici- pants, fourteen of whom were pregnant, whereas the remaining nine women were in various stages of the work, but the other types of datuwan used included post-partum period. A majority of FGD participants had bamboo, mango, neem, snake’s tail or chaff flower and no formal education, and number of prior live births black honey shrub (sikat) for specific purposes. For ranged evenly from 0 to 2 (where one participant had 4). example, bamboo datuwan was reported by the partici- pants to help whiten teeth, whereas women stated that Oral hygiene the bitter taste of the black honey shrub helped to kill Madhesi participants (i.e. all IDI participants and those germs within the teeth. Mango datuwan was deemed from the Madhesi-comprised FGDs) reported that their “holy” as it can be used to clean teeth during fasting usual teeth cleaning practice was to use either a tooth- ceremonies since it is a twig of a fruit tree. This brush and toothpaste or datuwan, a teeth cleaning twig contrasts with the use of toothbrushes, which might that serves as both a toothbrush and toothpaste, once a have been in contact with meat and fish during prior day prior to their morning meal. In contrast, women in brushings, contact that would be perceived as breaking the Pahadi FGD stated that the norm in their communi- one’sfast. Other dentifrices mentioned included sand, ties was for women to brush their teeth twice a day if mud/dirt, wood ash, and charcoal. Among the Pahadi not more. community, women said that they used charcoal to IDI participants reported using either a toothbrush whiten their teeth, and the types of datuwan used dif- with Colgate (a toothpaste brand commonly found fered from the Madhesi community and included kamala throughout shops and markets in the area) or “Dabur tree (sindure), Bombay rosewood (sisoo), Jatropha curcas Lal Danta Manjan”, an ayurvedic toothpaste without (bagandi), and Sal tree (sakhuwa). fluoride, or using datuwan. IDI participants used the When asked regarding motivations for cleaning one’s word “medicine” to describe the toothpaste used for teeth twice per day, Madhesi and Pahadi community their tooth cleaning routine, which upon further probing members had similar reasons including reducing the risk was revealed to be ‘Colgate’ characterized by the red of caries, overall cleanliness, and preventing infections. color of the brand. Within the Madhesi community, By keeping the mouth clean, one also prevented the women used any available datuwan when doing farm development of other diseases: Lubon et al. BMC Oral Health (2018) 18:97 Page 4 of 7 It is possible to prevent some diseases by brushing your women added “swelling of the teeth”, specifically in the teeth. If you don’t brush your teeth, many different wisdom teeth area, and toothache as signs of gum disease, types of germs enter the mouth and spoil the teeth. Pahadi women described a throbbing pain due to pus col- It goes inside the stomach and [causes] diseases. lecting within the gums. Madhesi women suggested that It is because of the teeth that many diseases occur. gum disease could result from wounds inflicted by poking the gums with datuwan, swollen gums due to caries, not –6 months pregnant, Madhesi FGD participant. brush teething before eating, allowing impurities within the mouth to cause disease, or drinking sweet tea after Women predominately learned about and developed brushing. When similarly queried regarding cause of gum their teeth cleaning routines from their parents, but disease, Pahadi women described not knowing about others reported learning by watching people in their gums, and could not provide any specific causes. community, through radio and television advertisements, Women in the Madhesi community reported that chil- or indicated they were self-taught. In terms of maintain- dren, the elderly, tobacco users, and poor people were ing more frequent brushing (i.e. twice per day), IDI more likely to suffer from tooth decay or gum disease. participants identified the most pertinent barrier to be Some of these women felt strongly that poor people were accessibility to a toothbrush and toothpaste. Many indi- at a disadvantage because they lacked the resources to buy cated, however, a willingness to increase frequency if a toothbrush and thus were forced to use datuwan. When instructed by community-based workers, such as NNIPS prompted about the importance of oral health relative to staff. In both Madhesi and Pahadi communities, other other types of health issues, Madhesi women deemed that commonly mentioned barriers were lack of time due to tooth decay and gum disease were very serious health work obligations, laziness, sleepiness, forgetfulness, and problems because toothaches are extremely painful, can lack of awareness. In addition, Madhesi women said that cause other diseases to manifest, and if toothache is a some community members justified brushing only once continuous problem, one may need to have their teeth daily because a toothbrush could “ruin their gums”;it removed, thus losing their ability to eat. In contrast, was also suggested that the rough feel of a toothbrush women in the Pahadi focus group expressed doubt as to on teeth or swollen gums could lead to women prefer- the seriousness of tooth decay and gum disease, given the ring to use datuwan. ubiquitous nature of the issue within their community; these women did acknowledge that such opinions, how- Symptoms, causes, and severity of tooth decay and gum ever, differed among individual community members. disease Women generally felt confident describing the symptoms Dental healthcare seeking and causes of tooth decay, and toothache and swelling in When experiencing tooth and/or gum pain, participants gums were commonly listed as key symptoms of tooth frequently indicated that they would seek “English” or decay. Madhesi women additionally described a sensation “modern” medicine either from a local shop or from an of saksakauncha (“itching”) within the teeth that was ac- allopathic provider if brushing one’s teeth with toothpaste companied by tingling, “swelling in teeth”,lackofappetite, did not resolve the problem. Ibuprofen and paracetamol and feelings of nausea or vomiting. Pahadi women were mentioned as treatments to reduce or remove tooth additionally listed black patches on teeth, holes in teeth, pain. Several participants in both IDIs and FGDs indicated bad smell, and sensitivity when drinking water as signs of they would also consider going to a clinic or hospital. tooth decay. Not rinsing the mouth after eating sweets or Other participants described that to alleviate tooth pain getting food stuck between teeth were reported as poten- they would first get jhar fuk, a traditional approach where tial causes of tooth decay; some women in the Pahadi a healer performs a spell to chase “worms” (germs) out of focus group also reported that decay had a familial basis, the teeth. If this effort was unsuccessful, they would then where mothers could pass the condition to their children. seek allopathic medicine and/or medical treatment from Madhesi women suggested other possible causes included an allopathic doctor. Another common treatment option leftover food causing “a wound in the gums or tooth creat- for tooth pain was application of clove oil or “sancho,” a ing a ground for germs to infect other teeth”, not brushing blend of Himalayan essential oils, which is a multipurpose teeth before eating, eating eggplant or fish while having a herbal medicine used for the common cold, cough, body toothache, chewing tobacco, drinking alcohol, or misusing aches, and other illnesses. Pahadi women mentioned that a “toothpick to create a hole in a tooth”. people get fillings out of cement or silver when they have When discussing the symptoms and causes of gum tooth pain, and if the filling is of poor quality, people are disease, however, women were not as forthcoming as they forced to get their teeth extracted. were when talking about tooth decay. Swollen gums and Upon further probing as to where one could find a pain in the gums were listed as symptoms. While Madhesi dentist, most IDI participants could not say with certainty Lubon et al. BMC Oral Health (2018) 18:97 Page 5 of 7 where to go because they had never experienced pain that serious health problem because one does not eat, which would warrant such care-seeking. Women said they would can cause the child to become “lean and thin.” seek the counsel of their neighbors and community members on where to purchase medicine for tooth and/or Discussion gum pain, where to find a good doctor, and where to find Findings from this qualitative study highlight important a dentist. Among all IDI and FGD participants, no women implications regarding pregnant women and oral hygiene reported ever visiting a dentist; one FDG participant sum- within rural Nepal. First, while tooth brushing is commonly marized as follows: practiced, the normal practice was limited to once daily, and consistent use of toothbrushes and toothpaste was Some may have said [they didn’t need a dentist] lacking. Knowledge of symptoms and causes of tooth decay because of lack of money. Some might have ignored and gum disease were limited and varied substantially it [the pain]. Some might have taken care of it and across community members. This suggests that standard- might have become all right after using herbal ized, culturally-specific, and simple educational messaging medicine. Some might have extracted the tooth with need to be developed and delivered through appropriate the cavity and thrown it away after breaking it. behavioral change communication approaches. One such Some may not have been able to go because of other possibility includes trainingrural womeninoralhealth compulsions/ problems. Some guardians do not take promotion activities, an approach that has demonstrated them. They might have brought some tablets and said improved oral health knowledge among female community that this would make it all right. Some might have members in Nepal [21]. been told about herbal medicine and they must have Second, formal preventative maintenance remains a taken it and become all right. largely unknown concept in this sub-population, and dental care health seeking is almost entirely driven by a direct – 6 months pregnant, Madhesi FGD participant. response to tooth and/or gum pain. In the absence of pain, a majority of women stated it was unnecessary to seek a Even though participants expressed interest in seeing a dentist because teeth brushing would be sufficient to ad- dentist or doctor regarding tooth and/or gum pain, only dress bleeding gums or spots on their teeth in cases where a minority said that they would seek care in the absence the problem would not resolve itself. Delay in care-seeking of pain. Many stated that it did not make sense for them among this population is not unique to oral health and to treat a problem such as black spots on their teeth or pregnant women. For example, among the same commu- bleeding gums if there was no pain. Instead of seeking nity in Sarlahi district, delays in care-seeking for maternal medical attention, most women said they would either and newborn complications have been attributed to low brush their teeth with medicine (toothpaste) or take no perceived severity of the illness even when symptoms were action and wait for the problem to self-resolve. Madhesi recognized early [22]. In these cases, care was initially FGD participants described that when gums are very sought from informal health providers including traditional red, swollen, and/or bleeding without pain, people rinsed birth attendants, traditional healers, and village doctors their mouths with hot water, applied mud or clove oil, whereas barriers to seeking care from any health facility in- purchased oral medicine, and went to the hospital for cluded transportation, finances, and distance to the facility treatment of teeth. Pahadi women indicated that some [22]. These care-seeking findings for maternal and newborn people attempted to reduce bleeding through brushing complications suggest that it is norm for pregnant or with cooking oil and/or salt, or using datuwan made of recently delivered women in the Sarlahi district to delay J. curcas. care-seeking from formal providers and/or health facilities for many health problems including ones related to oral health. Moreover, care-seeking for maternal illness im- Pregnancy and oral hygiene proves significantly in low and middle income countries Many IDI participants, as well as FGD participants from when antenatal or postnatal counseling stresses illness both as both ethnic groups, did not report changes in recognition and referrals by community health workers teeth cleaning routines during pregnancy. All women [23]. By changing the way illness is perceived in these low agreed that keeping the mouth clean was essential in income settings and building a solid referral foundation preventing diseases, but there were mixed views on the using community health workers, the norm of delaying association between good oral hygiene during pregnancy care-seeking among pregnant and recently delivered and healthy birth outcomes. In one of the Madhesi women can be changed. FGDs (but not the other FGDs), women stated that poor Third, limited access to qualified providers tends to oral hygiene causes cavities that enter the abdomen and delay treatment seeking until pain is severe and/or home negatively affect the baby, and that toothaches are a or traditional remedies have failed. When more formal Lubon et al. BMC Oral Health (2018) 18:97 Page 6 of 7 care is sought, women often expressed going to a “hos- generalizable to broad population in this region, this pital for treatment of teeth,” of which there were two in specific population might be more amenable to behavior this area at the time of data collection. While one of change communication approach, given that NNIPS has these was staffed by a practitioner with a dental certifi- been working closely with these communities for 28 years. cate, neither practitioner was a fully trained or qualified Specifically their future readiness to engage in and follow dentist. During the study period, the nearest qualified instructions related to improved oral health behaviors dentists were in the neighboring districts of Janakpur such as improved frequency of brushing may be overesti- and Birgunj, located 80 km and 100 km to the east and mated relative to other populations. west, respectively. Public transportation to and from one of these providers would require a full day (or more if Conclusions the providers were not able to immediately see clients). We found that pregnant or recently-delivered women in Given these substantive distance barriers, women (and the Sarlahi community either brushed their teeth with a the broader community) would most benefit from the toothbrush and toothpaste once daily or used a teeth improvement of local facilities through formal dental cleaning twig, but were receptive to switching their training of local practitioners and from increasing the routine to brushing twice daily with toothpaste when number of qualified dentists in the area. instructed by a health worker. Women in this commu- A limitation of this study is that our interviewers found nity were unable to correctly identify the signs and it challenging to effectively probe women in this commu- causes of tooth decay and gum disease and lacked know- nity about oral health, in order to elicit richer responses. ledge on where to find qualified dentists within the study These challenges in engaging respondents in conversation area. Based on our findings, we suggest that future may not be surprising given that young women in this efforts involving oral health and pregnant women in community, especially among the Madhesi, are frequently low-income settings focus on providing tools and reticent to share their opinion or be assertive. Interviewers resources to maintain dental hygiene, promoting good frequently commented that IDI participants were reluc- oral health behaviors and knowledge (possibly through tant to speak about their oral health for fear of saying context-appropriate cadres of trained community-based something incorrect (social desirability bias) or because workers), and increasing access to qualified and fully they claimed that they had no knowledge on the subject. trained dentists to improve the overall oral health of This challenge may have resulted in interviewers resorting pregnant women. to more direct or leading questions. Interviewers were women of the community an in approximately similar age Abbreviations range as participants, but there other characteristics about FGD: Focus group discussion; IDI: In-depth interview; NNIPS: Nepali Nutrition Intervention Project Sarlahi the interviewers (for example, cultural deference towards “guests”; formal employment in non-agricultural or Funding “skilled” work can confer an extra level of respect, etc) This study was funded by the Bill & Melinda Gates Foundation through that might have inhibited more full sharing of information grants OPP1131701 and OPP1084399. or opinions.. Facilitators of FGDs indicated that the group setting allowed women to feel more comfortable not only Availability of data and materials All data files, metadata, and related manuscripts are available from the JHU expressing their opinion, but contrasting their viewpoints Data Archive (https://doi.org/10.7281/T1/ZPGBJW). with those of others in the group. In addition, as some IDI respondents had also participated in the ongoing oral Authors’ contributions rinse pilot trial, exposure to positive oral health behavior AJL helped design the sampling framework jointly with other authors, oversaw messages might have influenced their responses; it is implementation of data collection, ensured quality of the data, conducted the analysis, and wrote the manuscript. DJE helped conceptualize and design the possible that other IDI or FGD participants who had not study jointly with other authors, assisted with implementation in the field, participated in that trial might also have indirectly been aided with interpretation of the results, provided comments and edits to exposed to similar content. The impact, however of such the manuscript. SKK helped conceptualize and design the study jointly with other authors, oversaw field implementation and ensured quality, provided exposures is likely limited, as interviewers were instructed comments on the manuscript. SCL contributed to the study design and overall to parse out behavior changes related to involvement in implementation in the field, helped with interpretation of the results, and the oral health trial through effective probing during each provided comments on the manuscript. NKA helped design the study, provided input on the data collection approach and content, provided interview, and analysis of transcripts did not indicate comments on the manuscript. MAR conceptualized and designed the study substantively different knowledge or attitudes regarding, jointly with other authors, gave comments on the manuscript. JK contributed for example, oral hygiene practices between those who did to the study design, quality of data collected, and gave comments on the manuscript. LCM conceptualized and designed the study jointly with other or did not participate in the rinse trial In terms of authors, obtained funding the study, oversaw implementation approach, generalizability, while the knowledge, attitudes, and prac- obtained ethical approvals, and edited the manuscript. All authors read and tices related to oral hygiene and care-seeking are likely approved the final manuscript. Lubon et al. BMC Oral Health (2018) 18:97 Page 7 of 7 Ethics approval and consent to participate 15. Lopez NJ, Uribe S, Martinez B. Effect of periodontal treatment on preterm Ethical approval was obtained from the Institutional Review Board at the birth rate: a systematic review of meta-analyses. Periodontol 2000. 2015;67: Johns Hopkins Bloomberg School of Public Health (#6297) and from the 87–130. https://doi.org/10.1111/prd.12073. independent Ethical Review Board of the Nepal Health Research Council 16. Kim AJ, Lo AJ, Pullin DA, Thornton-Johnson DS, Karimbux NY. Scaling and root (#188/2015). Written consent was obtained from all participants in the study. planing treatment for periodontitis to reduce preterm birth and low birth weight: a systematic review and meta-analysis of randomized controlled trials. J Periodontol. 2012;83(12):1508–19. https://doi.org/10.1902/jop.2012.110636. Competing interests 17. George A, Shamim S, Johnson M, et al. Periodontal treatment during pregnancy The authors declare that they have no competing interests. and birth outcomes: a meta-analysis of randomised trials. Int J Evid Based Healthc. 2011;9(2):122–47. https://doi.org/10.1111/j.1744-1609.2011.00210.x. 18. Boutin A, Demers S, Roberge S, Roy-Morency A, Chandad F, Bujold E. Publisher’sNote Treatment of periodontal disease and prevention of preterm birth: Springer Nature remains neutral with regard to jurisdictional claims in systematic review and meta-analysis. 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J Clin Diagn Res. 2015; 9(9):ZE14–7. https://doi.org/10.7860/JCDR/2015/14143.6526. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Oral Health Springer Journals

Oral health knowledge, behavior, and care seeking among pregnant and recently-delivered women in rural Nepal: a qualitative study

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Dentistry; Dentistry; Oral and Maxillofacial Surgery
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Abstract

Background: Oral health behavior and attitudes of pregnant women in low-income countries are rarely examined, yet should be considered when designing preventative or therapeutic studies to reduce burden of oral diseases. We aimed to understand dental care-seeking behavior, as well as oral health knowledge and attitudes of oral health among pregnant women in rural Nepal. Methods: Semi-structured in-depth interviews (n = 16) and focus group discussions (3 groups, n = 23) were conducted among pregnant and recently-delivered women in Sarlahi, Nepal. Transcripts were translated from the local language to English then analyzed using a hybrid approach to thematic coding with Atlas.ti version 7. Results: Women felt confident describing the signs and symptoms of tooth decay and gum disease, but were not knowledgeable about where to receive care for tooth and/or gum pain and relied heavily on the knowledge of their community. Some women used a toothbrush and toothpaste at least once a day to clean their teeth, but many reported the traditional use of a branch of a local shrub or tree as their teeth cleaning instrument. Women suggested a willingness to consider using an oral rinse throughout pregnancy, perceiving that it might have a positive impact on infant health. Conclusions: Future studies should focus on providing adequate and sustainable resources for pregnant women in Nepal and other low income settings to engage in good oral health behaviors (possibly supported through community- based workers), to maintain dental hygiene, and to access qualified dentists as a means of improving their oral health. Trial registration: ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial). Keywords: Nepal, Periodontal disease, Oral health, Oral health behaviors, Dental care seeking behavior, Pregnancy Background addition to supply side approaches that call for substantive In low resource settings, oral health services are frequently human, infrastructural, and financial resources, demand inadequate to meet the needs of the population [1]. Poor side approaches require understanding of community accessibility, low quality, and human resources gaps – all norms, attitudes, practices, and knowledge toward oral key challenges to improving health systems in such set- health hygiene behavior, preventative care, and care-seeking tings – are more acutely felt for oral health systems. The practices. limited capacity and insufficient distribution of trained Nepal is one of many low- and middle-income countries oral health providers leads to utilization patterns almost where attention and resources applied to oral health have exclusively focused on pain management or emergency lagged behind other domains of public health. Most oral treatment responses, at the expense of prevention [1]. In health studies conducted in Nepal have tended to focus on burden of disease among school-aged children [2–7]or descriptive characteristics of dental professionals [8–10]. * Correspondence: lmullany@jhu.edu Department of International Health, Johns Hopkins Bloomberg School of Onestudy used amorebroadly focusedcross-sectional Public Health, 615 N. Wolfe Street W5009, Baltimore, MD 21205, USA population-representative survey to identify factors Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lubon et al. BMC Oral Health (2018) 18:97 Page 2 of 7 associated with improved practices. Researchers found that The pilot trial was being conducted in communities repre- odds of teeth cleaning/brushing were higher among partici- senting only one of the two broad ethnic groups in the pants living in the rural plains region (terai) bordering region. To address this, our selection of women for the FGD India, compared to those in the mid-hill regions, and higher phase of the research leveraged a population-representative among those with higher educational backgrounds [11]. database of reproductive aged women who were current (i.e. Additionally, while women were more likely than men to pregnant) or previous (i.e. recently-delivered) participants in report seeking dental care services, only 4.8% of these a large community-based randomized trial of topical women had seen a dentist in the past 6 months [11]. emollient therapies and neonatal health outcomes (clinical- Formative research studies from Nepal are necessary to trials.gov: NCT01177111). These women were purposively inform the design of context-appropriate interventions selected to broaden representation to both major ethnic and programmatic approaches. One study conducted in groups within the community: Madhesi women (n =2 Newalparasi, Nepal used the Theory of Planned Behavior FGDs, originally from the northern plains of India and [12] model to better understand oral hygiene and percep- southern Nepal) and Pahadi women (n = 1 FGD, origin- tions, and decisions related to care seeking. The study ating from Nepal’s hill regions). Women were excluded found that perceived self-efficacy in relation to oral if they had already participated in the IDIs or the pilot hygiene practices and expected social outcomes of having trialoforalrinses. healthy teeth were important predictors for oral health Prospective participants were approached by field staff behavior [13]. For example, researchers found that to assess interest in participation, and an individually once-daily tooth brushing was associated with the bathing signed consent was obtained prior to initiating inter- ritual, which has a symbolic meaning of creating purity views or discussion groups. All IDIs and FGDs followed [13]. There are few studies on the particular aspects of similar semi-structured interview guides with primarily oral hygiene behavior, perceptions, and attitudes among open-ended questions and recommended probes. The pregnant women. This group is of particular interest given IDI guide focused on oral hygiene behaviors and dental the often observed association in other settings between health care seeking, whereas the FGD guide additionally periodontal disease during pregnancy and perinatal included questions on the symptoms and causes of tooth outcomes [14–18]. Therefore, in Sarlahi District, Nepal, decay and gum disease and perceptions of dental health. we aimed to characterize these issues through in-depth Interviewers took hand-written notes during interviews; interviews (IDIs) and focus group discussions (FGDs) all interviews and group discussions were audio re- among pregnant and recently-delivered women. Specific- corded. Field researchers wrote expanded field notes ally, we aimed to understand dental care-seeking patterns, within 24 to 48 h of completing the interview or discus- practices of oral hygiene, attitudes, and knowledge rele- sion group. Audio recordings were transcribed verbatim vant to oral health of pregnant and recently-delivered from Maithili (the local language) into Nepali with the women. aid of expanded field notes. Completed Nepali tran- scripts were translated into English and reviewed for any apparent errors in translation. Methods Prior to initiating the field activities, the NNIPS qualita- Data collection tive research team, consisting of female staff members with This project was conducted by the Nepal Nutrition Inter- prior formal training and experience in conducting qualita- vention Project – Sarlahi (NNIPS), a multi-institution tive studies of a range of public health domains, received a research collaboration that has been conducting two-week refresher training conducted by the authors (AJL, community-based studies in rural Sarlahi district over the DJE). An additional training session using illustrative past 28 years. Between August and December 2016, we examples from the first two interviews was subsequently conducted 16 IDIs and 3 FGDs among pregnant and conducted to strengthen interviewer technique by one of recently-delivered women in this setting using purposive the authors (AJL). Interviews (avg. 43 min) took place in sampling to identify participants. the informants’ homes, while FGDs (avg. 74 mins) were For IDIs, we selected pregnant women enrolled in an conducted in field offices throughout the study area. ongoing randomized pilot trial of the acceptability of oral rinses (clinicaltrials.gov: NCT02788786). Four IDI Data analysis participants were selected from each of three oral rinse Demographic characteristics of IDI and FGD participants groups, and an additional four participants were selected were available as participants were enrolled in one or both from a group of women randomized to no rinse. The of the ongoing randomized control trials that collected rinse group individuals were selected to reflect diverse quantitative data. Transcripts were analyzed using a levels of adherence and reactions to taste, based on pre- hybrid approach combining deductive thematic analysis liminary data available from the trial. with inductive coding during analysis enabling themes to Lubon et al. BMC Oral Health (2018) 18:97 Page 3 of 7 emerge from the data [19]. An initial deductive coding Table 1 Demographic Characteristics of IDI and FGD Participants structure was created based on the anticipated themes and on the content of the IDI and FGD guides. The IDIs [n = 16] FGDs [n = 23] codebook was revised using inductive coding to reflect Age (years) emerging themes from initially coded IDIs and FGDs. The - Mean 20 21 list of codes was then narrowed down into categories to - Median 19 21 produce a final codebook used for coding of transcripts. - Range 16–29 15–33 After each field activity, the research team used reflective Previous live births Frequency N (%) memoing and debriefing sessions to analyze data quality, - 0 5 (31) 8 (35) scrutinize assumptions and approaches to the research, and develop the codebook. Data were compiled and coded - 1 5 (31) 7 (30) using Atlas.ti, version 7 using memos to track the process. - 2 3 (19) 7 (30) Data across IDIs and FGDs were analyzed to identify - 3 3 (19) –– themes related to dental hygiene methods, community -4 –– 1 (4) oral health knowledge, and dental care seeking behavior Gestational Age among pregnant women. This study closely approached - 0-3 months –– –– thematic saturation indicated by the aforementioned re- peating thematic categories and lack of new coding struc- - 4-6 months 10 (63) 10 (43) tures during these debriefing and memoing sessions [20]. - 7-9 months 6 (38) 4 (17) Women’s Education Results - No Schooling 7 (44) 12 (52) Characteristics of IDI and FGD participants - Years 1–9 8 (50) 9 (39) The average age of all IDI and FGD participants was - 10-SLC Pass 1 (6) 3 (13) 20 years (Table 1). Among the 16 IDI participants, all were Madhesi, were pregnant in either their second (n =10) or Ethnicity third (n = 6) trimester at the time of the interview, and - Madhesi 16 (100) 16 (70) had 0 to 3 prior children. Almost half (n =7) reported no - Pahadi –– 7 (30) formal education. The three FGDs included 23 partici- pants, fourteen of whom were pregnant, whereas the remaining nine women were in various stages of the work, but the other types of datuwan used included post-partum period. A majority of FGD participants had bamboo, mango, neem, snake’s tail or chaff flower and no formal education, and number of prior live births black honey shrub (sikat) for specific purposes. For ranged evenly from 0 to 2 (where one participant had 4). example, bamboo datuwan was reported by the partici- pants to help whiten teeth, whereas women stated that Oral hygiene the bitter taste of the black honey shrub helped to kill Madhesi participants (i.e. all IDI participants and those germs within the teeth. Mango datuwan was deemed from the Madhesi-comprised FGDs) reported that their “holy” as it can be used to clean teeth during fasting usual teeth cleaning practice was to use either a tooth- ceremonies since it is a twig of a fruit tree. This brush and toothpaste or datuwan, a teeth cleaning twig contrasts with the use of toothbrushes, which might that serves as both a toothbrush and toothpaste, once a have been in contact with meat and fish during prior day prior to their morning meal. In contrast, women in brushings, contact that would be perceived as breaking the Pahadi FGD stated that the norm in their communi- one’sfast. Other dentifrices mentioned included sand, ties was for women to brush their teeth twice a day if mud/dirt, wood ash, and charcoal. Among the Pahadi not more. community, women said that they used charcoal to IDI participants reported using either a toothbrush whiten their teeth, and the types of datuwan used dif- with Colgate (a toothpaste brand commonly found fered from the Madhesi community and included kamala throughout shops and markets in the area) or “Dabur tree (sindure), Bombay rosewood (sisoo), Jatropha curcas Lal Danta Manjan”, an ayurvedic toothpaste without (bagandi), and Sal tree (sakhuwa). fluoride, or using datuwan. IDI participants used the When asked regarding motivations for cleaning one’s word “medicine” to describe the toothpaste used for teeth twice per day, Madhesi and Pahadi community their tooth cleaning routine, which upon further probing members had similar reasons including reducing the risk was revealed to be ‘Colgate’ characterized by the red of caries, overall cleanliness, and preventing infections. color of the brand. Within the Madhesi community, By keeping the mouth clean, one also prevented the women used any available datuwan when doing farm development of other diseases: Lubon et al. BMC Oral Health (2018) 18:97 Page 4 of 7 It is possible to prevent some diseases by brushing your women added “swelling of the teeth”, specifically in the teeth. If you don’t brush your teeth, many different wisdom teeth area, and toothache as signs of gum disease, types of germs enter the mouth and spoil the teeth. Pahadi women described a throbbing pain due to pus col- It goes inside the stomach and [causes] diseases. lecting within the gums. Madhesi women suggested that It is because of the teeth that many diseases occur. gum disease could result from wounds inflicted by poking the gums with datuwan, swollen gums due to caries, not –6 months pregnant, Madhesi FGD participant. brush teething before eating, allowing impurities within the mouth to cause disease, or drinking sweet tea after Women predominately learned about and developed brushing. When similarly queried regarding cause of gum their teeth cleaning routines from their parents, but disease, Pahadi women described not knowing about others reported learning by watching people in their gums, and could not provide any specific causes. community, through radio and television advertisements, Women in the Madhesi community reported that chil- or indicated they were self-taught. In terms of maintain- dren, the elderly, tobacco users, and poor people were ing more frequent brushing (i.e. twice per day), IDI more likely to suffer from tooth decay or gum disease. participants identified the most pertinent barrier to be Some of these women felt strongly that poor people were accessibility to a toothbrush and toothpaste. Many indi- at a disadvantage because they lacked the resources to buy cated, however, a willingness to increase frequency if a toothbrush and thus were forced to use datuwan. When instructed by community-based workers, such as NNIPS prompted about the importance of oral health relative to staff. In both Madhesi and Pahadi communities, other other types of health issues, Madhesi women deemed that commonly mentioned barriers were lack of time due to tooth decay and gum disease were very serious health work obligations, laziness, sleepiness, forgetfulness, and problems because toothaches are extremely painful, can lack of awareness. In addition, Madhesi women said that cause other diseases to manifest, and if toothache is a some community members justified brushing only once continuous problem, one may need to have their teeth daily because a toothbrush could “ruin their gums”;it removed, thus losing their ability to eat. In contrast, was also suggested that the rough feel of a toothbrush women in the Pahadi focus group expressed doubt as to on teeth or swollen gums could lead to women prefer- the seriousness of tooth decay and gum disease, given the ring to use datuwan. ubiquitous nature of the issue within their community; these women did acknowledge that such opinions, how- Symptoms, causes, and severity of tooth decay and gum ever, differed among individual community members. disease Women generally felt confident describing the symptoms Dental healthcare seeking and causes of tooth decay, and toothache and swelling in When experiencing tooth and/or gum pain, participants gums were commonly listed as key symptoms of tooth frequently indicated that they would seek “English” or decay. Madhesi women additionally described a sensation “modern” medicine either from a local shop or from an of saksakauncha (“itching”) within the teeth that was ac- allopathic provider if brushing one’s teeth with toothpaste companied by tingling, “swelling in teeth”,lackofappetite, did not resolve the problem. Ibuprofen and paracetamol and feelings of nausea or vomiting. Pahadi women were mentioned as treatments to reduce or remove tooth additionally listed black patches on teeth, holes in teeth, pain. Several participants in both IDIs and FGDs indicated bad smell, and sensitivity when drinking water as signs of they would also consider going to a clinic or hospital. tooth decay. Not rinsing the mouth after eating sweets or Other participants described that to alleviate tooth pain getting food stuck between teeth were reported as poten- they would first get jhar fuk, a traditional approach where tial causes of tooth decay; some women in the Pahadi a healer performs a spell to chase “worms” (germs) out of focus group also reported that decay had a familial basis, the teeth. If this effort was unsuccessful, they would then where mothers could pass the condition to their children. seek allopathic medicine and/or medical treatment from Madhesi women suggested other possible causes included an allopathic doctor. Another common treatment option leftover food causing “a wound in the gums or tooth creat- for tooth pain was application of clove oil or “sancho,” a ing a ground for germs to infect other teeth”, not brushing blend of Himalayan essential oils, which is a multipurpose teeth before eating, eating eggplant or fish while having a herbal medicine used for the common cold, cough, body toothache, chewing tobacco, drinking alcohol, or misusing aches, and other illnesses. Pahadi women mentioned that a “toothpick to create a hole in a tooth”. people get fillings out of cement or silver when they have When discussing the symptoms and causes of gum tooth pain, and if the filling is of poor quality, people are disease, however, women were not as forthcoming as they forced to get their teeth extracted. were when talking about tooth decay. Swollen gums and Upon further probing as to where one could find a pain in the gums were listed as symptoms. While Madhesi dentist, most IDI participants could not say with certainty Lubon et al. BMC Oral Health (2018) 18:97 Page 5 of 7 where to go because they had never experienced pain that serious health problem because one does not eat, which would warrant such care-seeking. Women said they would can cause the child to become “lean and thin.” seek the counsel of their neighbors and community members on where to purchase medicine for tooth and/or Discussion gum pain, where to find a good doctor, and where to find Findings from this qualitative study highlight important a dentist. Among all IDI and FGD participants, no women implications regarding pregnant women and oral hygiene reported ever visiting a dentist; one FDG participant sum- within rural Nepal. First, while tooth brushing is commonly marized as follows: practiced, the normal practice was limited to once daily, and consistent use of toothbrushes and toothpaste was Some may have said [they didn’t need a dentist] lacking. Knowledge of symptoms and causes of tooth decay because of lack of money. Some might have ignored and gum disease were limited and varied substantially it [the pain]. Some might have taken care of it and across community members. This suggests that standard- might have become all right after using herbal ized, culturally-specific, and simple educational messaging medicine. Some might have extracted the tooth with need to be developed and delivered through appropriate the cavity and thrown it away after breaking it. behavioral change communication approaches. One such Some may not have been able to go because of other possibility includes trainingrural womeninoralhealth compulsions/ problems. Some guardians do not take promotion activities, an approach that has demonstrated them. They might have brought some tablets and said improved oral health knowledge among female community that this would make it all right. Some might have members in Nepal [21]. been told about herbal medicine and they must have Second, formal preventative maintenance remains a taken it and become all right. largely unknown concept in this sub-population, and dental care health seeking is almost entirely driven by a direct – 6 months pregnant, Madhesi FGD participant. response to tooth and/or gum pain. In the absence of pain, a majority of women stated it was unnecessary to seek a Even though participants expressed interest in seeing a dentist because teeth brushing would be sufficient to ad- dentist or doctor regarding tooth and/or gum pain, only dress bleeding gums or spots on their teeth in cases where a minority said that they would seek care in the absence the problem would not resolve itself. Delay in care-seeking of pain. Many stated that it did not make sense for them among this population is not unique to oral health and to treat a problem such as black spots on their teeth or pregnant women. For example, among the same commu- bleeding gums if there was no pain. Instead of seeking nity in Sarlahi district, delays in care-seeking for maternal medical attention, most women said they would either and newborn complications have been attributed to low brush their teeth with medicine (toothpaste) or take no perceived severity of the illness even when symptoms were action and wait for the problem to self-resolve. Madhesi recognized early [22]. In these cases, care was initially FGD participants described that when gums are very sought from informal health providers including traditional red, swollen, and/or bleeding without pain, people rinsed birth attendants, traditional healers, and village doctors their mouths with hot water, applied mud or clove oil, whereas barriers to seeking care from any health facility in- purchased oral medicine, and went to the hospital for cluded transportation, finances, and distance to the facility treatment of teeth. Pahadi women indicated that some [22]. These care-seeking findings for maternal and newborn people attempted to reduce bleeding through brushing complications suggest that it is norm for pregnant or with cooking oil and/or salt, or using datuwan made of recently delivered women in the Sarlahi district to delay J. curcas. care-seeking from formal providers and/or health facilities for many health problems including ones related to oral health. Moreover, care-seeking for maternal illness im- Pregnancy and oral hygiene proves significantly in low and middle income countries Many IDI participants, as well as FGD participants from when antenatal or postnatal counseling stresses illness both as both ethnic groups, did not report changes in recognition and referrals by community health workers teeth cleaning routines during pregnancy. All women [23]. By changing the way illness is perceived in these low agreed that keeping the mouth clean was essential in income settings and building a solid referral foundation preventing diseases, but there were mixed views on the using community health workers, the norm of delaying association between good oral hygiene during pregnancy care-seeking among pregnant and recently delivered and healthy birth outcomes. In one of the Madhesi women can be changed. FGDs (but not the other FGDs), women stated that poor Third, limited access to qualified providers tends to oral hygiene causes cavities that enter the abdomen and delay treatment seeking until pain is severe and/or home negatively affect the baby, and that toothaches are a or traditional remedies have failed. When more formal Lubon et al. BMC Oral Health (2018) 18:97 Page 6 of 7 care is sought, women often expressed going to a “hos- generalizable to broad population in this region, this pital for treatment of teeth,” of which there were two in specific population might be more amenable to behavior this area at the time of data collection. While one of change communication approach, given that NNIPS has these was staffed by a practitioner with a dental certifi- been working closely with these communities for 28 years. cate, neither practitioner was a fully trained or qualified Specifically their future readiness to engage in and follow dentist. During the study period, the nearest qualified instructions related to improved oral health behaviors dentists were in the neighboring districts of Janakpur such as improved frequency of brushing may be overesti- and Birgunj, located 80 km and 100 km to the east and mated relative to other populations. west, respectively. Public transportation to and from one of these providers would require a full day (or more if Conclusions the providers were not able to immediately see clients). We found that pregnant or recently-delivered women in Given these substantive distance barriers, women (and the Sarlahi community either brushed their teeth with a the broader community) would most benefit from the toothbrush and toothpaste once daily or used a teeth improvement of local facilities through formal dental cleaning twig, but were receptive to switching their training of local practitioners and from increasing the routine to brushing twice daily with toothpaste when number of qualified dentists in the area. instructed by a health worker. Women in this commu- A limitation of this study is that our interviewers found nity were unable to correctly identify the signs and it challenging to effectively probe women in this commu- causes of tooth decay and gum disease and lacked know- nity about oral health, in order to elicit richer responses. ledge on where to find qualified dentists within the study These challenges in engaging respondents in conversation area. Based on our findings, we suggest that future may not be surprising given that young women in this efforts involving oral health and pregnant women in community, especially among the Madhesi, are frequently low-income settings focus on providing tools and reticent to share their opinion or be assertive. Interviewers resources to maintain dental hygiene, promoting good frequently commented that IDI participants were reluc- oral health behaviors and knowledge (possibly through tant to speak about their oral health for fear of saying context-appropriate cadres of trained community-based something incorrect (social desirability bias) or because workers), and increasing access to qualified and fully they claimed that they had no knowledge on the subject. trained dentists to improve the overall oral health of This challenge may have resulted in interviewers resorting pregnant women. to more direct or leading questions. Interviewers were women of the community an in approximately similar age Abbreviations range as participants, but there other characteristics about FGD: Focus group discussion; IDI: In-depth interview; NNIPS: Nepali Nutrition Intervention Project Sarlahi the interviewers (for example, cultural deference towards “guests”; formal employment in non-agricultural or Funding “skilled” work can confer an extra level of respect, etc) This study was funded by the Bill & Melinda Gates Foundation through that might have inhibited more full sharing of information grants OPP1131701 and OPP1084399. or opinions.. Facilitators of FGDs indicated that the group setting allowed women to feel more comfortable not only Availability of data and materials All data files, metadata, and related manuscripts are available from the JHU expressing their opinion, but contrasting their viewpoints Data Archive (https://doi.org/10.7281/T1/ZPGBJW). with those of others in the group. In addition, as some IDI respondents had also participated in the ongoing oral Authors’ contributions rinse pilot trial, exposure to positive oral health behavior AJL helped design the sampling framework jointly with other authors, oversaw messages might have influenced their responses; it is implementation of data collection, ensured quality of the data, conducted the analysis, and wrote the manuscript. DJE helped conceptualize and design the possible that other IDI or FGD participants who had not study jointly with other authors, assisted with implementation in the field, participated in that trial might also have indirectly been aided with interpretation of the results, provided comments and edits to exposed to similar content. The impact, however of such the manuscript. SKK helped conceptualize and design the study jointly with other authors, oversaw field implementation and ensured quality, provided exposures is likely limited, as interviewers were instructed comments on the manuscript. SCL contributed to the study design and overall to parse out behavior changes related to involvement in implementation in the field, helped with interpretation of the results, and the oral health trial through effective probing during each provided comments on the manuscript. NKA helped design the study, provided input on the data collection approach and content, provided interview, and analysis of transcripts did not indicate comments on the manuscript. MAR conceptualized and designed the study substantively different knowledge or attitudes regarding, jointly with other authors, gave comments on the manuscript. JK contributed for example, oral hygiene practices between those who did to the study design, quality of data collected, and gave comments on the manuscript. LCM conceptualized and designed the study jointly with other or did not participate in the rinse trial In terms of authors, obtained funding the study, oversaw implementation approach, generalizability, while the knowledge, attitudes, and prac- obtained ethical approvals, and edited the manuscript. All authors read and tices related to oral hygiene and care-seeking are likely approved the final manuscript. Lubon et al. BMC Oral Health (2018) 18:97 Page 7 of 7 Ethics approval and consent to participate 15. Lopez NJ, Uribe S, Martinez B. Effect of periodontal treatment on preterm Ethical approval was obtained from the Institutional Review Board at the birth rate: a systematic review of meta-analyses. Periodontol 2000. 2015;67: Johns Hopkins Bloomberg School of Public Health (#6297) and from the 87–130. https://doi.org/10.1111/prd.12073. independent Ethical Review Board of the Nepal Health Research Council 16. Kim AJ, Lo AJ, Pullin DA, Thornton-Johnson DS, Karimbux NY. Scaling and root (#188/2015). Written consent was obtained from all participants in the study. planing treatment for periodontitis to reduce preterm birth and low birth weight: a systematic review and meta-analysis of randomized controlled trials. J Periodontol. 2012;83(12):1508–19. https://doi.org/10.1902/jop.2012.110636. Competing interests 17. George A, Shamim S, Johnson M, et al. Periodontal treatment during pregnancy The authors declare that they have no competing interests. and birth outcomes: a meta-analysis of randomised trials. Int J Evid Based Healthc. 2011;9(2):122–47. https://doi.org/10.1111/j.1744-1609.2011.00210.x. 18. Boutin A, Demers S, Roberge S, Roy-Morency A, Chandad F, Bujold E. Publisher’sNote Treatment of periodontal disease and prevention of preterm birth: Springer Nature remains neutral with regard to jurisdictional claims in systematic review and meta-analysis. 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Glob Health 2005;83(9):661–9. doi:/S0042-96862005000900011. Action. 2016;9:1–13. https://doi.org/10.3402/gha.v9.31408. 2. Prasai Dixit L, Shakya A, Shrestha M, Shrestha A. Dental caries prevalence, oral health knowledge and practice among indigenous Chepang school children of Nepal. BMC Oral Health. 2013;13:20. https://doi.org/10.1186/ 1472-6831-13-20. 3. Yee R, David J, Lama D. The periodontal health of Nepalese schoolchildren. Community Dent Health. 2009;26(4):250–6. https://doi.org/10.1922/CDH_ 2397Yee07. 4. Knevel RJ, Neupane S, Shressta B, de Mey L. Buddhi Bangara project on oral health promotion: a 3- to 5-year collaborative programme combining support, education and research in Nepal. Int J Dent Hyg. 2008;6(4):337–46. https://doi.org/10.1111/j.1601-5037.2008.00345.x. 5. Kanal S, Acharya J. Dental caries status and oral health practice among 12-15 year old children in Jorpati, Kathmandu. Nepal Med Coll J. 2014;16(1):84–7. 6. Thapa P, Aryal KK, Dhimal M, et al. 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BMC Oral HealthSpringer Journals

Published: Jun 1, 2018

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