Medical Journal of Zambia, Vol.

49 (2): 118 - 127 (2022)

ORIGINAL ARTICLE

Oral Health Knowledge, Attitude and Practices among

Adolescents in Choma District of Zambia
Bright Mukanga,KupuzoSakala, Tato H Nyirenda, Victor Daka, David Mulenga
1
The Copperbelt University, Michael Chilufya Sata School of Medicine, P.O Box 71769, Ndola, Zambia,

Results: The study had 173 males and 162 females

ABSTRACT
in the age range of 12-19 years. The majority
Introduction: Dental caries and periodontal (87.8%) had good knowledge, 69.4% had good
diseases are the most common oral diseases attitude and 87.5% had good practice on oral -
globally. Early control of oral health behaviours is hygiene. Practice was influenced by sex with
important because lifestyles acquired during females having good oral hygiene as compared to
adolescence are powerful predictors of adult health. their male counterparts. About 97.2% thought that
We conducted a study to determine knowledge, dental health education is essential in schools. 34%
attitude and practices on oral hygiene among indicated that they had visited the dentist when they
school-going adolescents in Choma district of experienced a toothache. However, parental advice
Zambia. to regularly visit the dentist was low (n=39).The
Methodology: A cross-sectional study was majority 49.9% (n=167) indicated that they had not
conducted among school-going adolescents in visited the dentist due to fear of the dental equipment
randomly selected schools in Choma District. A total set up.
of 335 participants were included in the study. Data Conclusion and recommendation: Despite the
were collected using a closed-end self-administered majority having good knowledge and attitude on
questionnaire. The sample size was distributed oral hygiene, there is a need to acquaint children
among the six schools in the ratio of their with milling and dental units found in most dental
population. The study included anyone from grades offices. This may instil confidence in children to
8-12. Data were analysed using IBM software for seek specialist dental treatment whenever they
SPSS. We employed the Chi-Square test to develop any dental disease. Further,parents need to
investigate the association between variables. A p- be incorporated as partners in promoting oral health
value less than 0.05 was considered statistically hygiene among school-going adolescents.
significant.
INTRODUCTION
Corresponding Author:
Dental caries and periodontal diseases are the most
Bright Mukanga: Lecturer, Department of Public
Health,Copperbelt University,Michael Chilufya Sata School of common oral diseases affecting humankind of all
Medicine,P.O Box 71769,Ndola, Zambia: Phone: Keyword: Attitude, Knowledge, Practice, Oral health,
+260971815362: Email: [email protected] Adolescents, Periodontal, Dental, Caries

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 Medical Journal of Zambia, Vol. 49 (2): 118 - 127 (2022)

1
age groups including adolescents. Risk factors for gingivitis. 9 Whilst, brushing with fluoridated
dental caries and periodontal diseases include poor toothpaste significantly prevents dentalcaries,
health hygiene and regular consumption of knowledge of oral hygiene is key to proper
2
sugars. Global trends show that dental and performance as it helps to empower an individual on
periodontal diseases are decreasing in the privileged improvement of personal oral health care.12
3,4
and increasing in the under-privileged populations. Similarly, attitude towards oral health predict
Treatment of oral health conditions is expensive and practice and therefore assessing attitude is key to
usually not part of universal health coverage in most planning interventions that enhance positive change
13
low-income countries. However, In most high- towards oral health hygiene.
income countries, dental treatment averages 5% of
total health expenditure and 20% of out-of-pocket Zambia being among the developing countries is not
health expenditure.2 Hence, most low and middle- an exception. Clinical observation during routine
income countries are unable to provide services to patients has revealed a number of adolescents with
prevent and treat oral health conditions.5Severe dental caries.14 Both dental caries and periodontal
periodontal disease which may result in tooth loss, is diseases are related to oral hygiene, hence
also very common, with almost 10% of the global understanding the level of knowledge, attitude and
population affected.
2 practice in the population is key in the prevention of
oral diseases. Whilst oral health preventive
Adolescents comprise nearly 20% of the global strategies are key in reducing dental caries and
population and more than half of them suffer from periodontal diseases among adolescents, most oral
some form of common oral disease.4Most oral health health services in Zambia are mainly centred on
conditions are largely preventable and can be treated curative and emergency procedures, such as tooth
in their early stages.2 Similarly, early control of the 14
extraction and restorative treatment. There is a
behaviours is important due to the fact that lifestyles paucity of studies on oral health knowledge, and
acquired during childhood and adolescence are attitudes in Zambia, with only a few studies showing
8
powerful predictors of adult health. Furthermore, a a general fair knowledge levels and attitudes
school setting is an advisable platform for educating regarding oral health oral hygiene.6,14 A recent study
9
and promoting oral health care , this is because conducted in Lusaka, Zambia, however, revealed
school-going children spend their entire day in the that over 80% of Zambians are still affected by oral
school and are exposed to various sugar-containing health problems, which include dental caries,
foods and beverages that are sold in tuckshops and periodontal disease and malocclusion.15 The impact
2
vending machines. of oral health is further compounded by the
prevailing high prevalence of HIV in Zambia.
Evidence exists, showing that strong knowledge on
10 Despite oral diseases being common in Zambia,
oral health demonstrates better oral care practice ,
there has been insufficient focus on preventative
and positive attitude on oral health is influenced by 16
10.11 measures. Whilst evidence suggests the need for
better knowledge. Therefore, assessing oral
early control of oral health behaviours in school
hygiene knowledge, attitude and practice during this 9
going children ,Few studies have assessed
age group is important for planning evidence-based
knowledge, attitude and practice among school-
preventive oral health interventions. Tooth brushing
going adolescents in Zambia. Therefore, this study
is a principal method of maintaining good oral
was aimed at assessing oral hygiene knowledge,
hygiene, other adjunctive methods include flossing
attitude, and practice among school-going
and the use of mouthwashes. Tooth brushing, if done
adolescents in Choma district of Zambia.
at an appropriate frequency of twice a day, is a
simple and effective way of reducing plaque and

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 Medical Journal of Zambia, Vol. 49 (2): 118 - 127 (2022)

METHODS of anonymity and confidentiality. Permission to

conduct a study was obtained from respective school
Research Design
authorities. Consent was obtained from parents of
A descriptive cross-sectional study was conducted adolescents who were below the age of 16 years.
in Choma District of Zambia between January 2018 Participants were free to withdraw from the study if
and October 2018. they so wished. The permission to enter and collect
data in various schools was obtained from the
Population and Sampling Provincial Education Offices in Southern Province.
The sampling frame comprised of school-going Data collection
adolescents between the ages of 12-19 years. The
study was done at six(6) secondary schools located Questionnaires were given to the pupils during their
in urban and peri-urban areas of Choma district of class hours and then collected within 15 min. The
Zambia., these include;ChomaSecondary School, questionnaire measured attitude, practice and
BatokaSecondary School,SikalongoSecondary knowledge on periodontal diseases, dental caries,
School, Swan Day Secondary School, ChomaDay oral hygiene, and oral hygiene practice. The
Secondary School and ChuunduDay Secondary questionnaire had four basic parts, that is,
School. School going adolescents aged 12-19 years demography which had an emphasis on age and sex,
who gave consent were allowed to participate in the knowledge on periodontal diseases and dental
study.The study employed a probability cluster caries, attitude on oral hygiene and oral hygiene
sampling technique in which schools were practice. Age was grouped in two groups from 12-15
randomly selected as clusters. Probability years and 16-19 years. The knowledge, attitude and
proportionate to size sampling was employed in practice parts were scored by awarding the right
each cluster to come up with a sample size of about response 1 and the wrong ones 0, thereafter the
335 participants. scores were summed up which gave a total of 7. The
scores 3 and below were considered poor while 4
Sample Size and above as good scores. Data were entered and
The formula adopted for sample sizecalculation analysed using Statistical Package for Social
wasZ2PQ/d2.This was at a level of confidence Sciences(SPSS) software version 20.0 (IBM
interval of 1.69(At 95% confidence interval) and Chicago, SPSS Inc.)and presented as frequency
with a marginal error of 5% and prevalence of 50%. distributions in tables and graphs. The Association
of variables was analysed using cross-tabulations,
Validity of the data collection tool and the Chi-square test. All tests were set at a 0.05
significance level.
A pilot study using a standard WHO validated
questionnaire on oral health was done on 30 pupils RESULTS
in order to assess the feasibility and to estimate the
sample size. This was necessary to identify flaws in Distribution by age group and sex of respondents
the questionnaire and also to enhance its content (n=335)
validity The response rate was 100% and out of the 335
Ethical Consideration participants, 335 pupils indicated their age and sex.
Table 1 summarises the age and sex of the
The study proposal was approved by the Tropical respondents and shows that males were slightly
Diseases Research Ethics Committee (TDRC Ethics more than the females. (Table 1)
Committee approval no: 00002911). Standard
procedures of informed consentwere used inclusive

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Bleeding gums is cause by: Eating sweet food 43 12

Table 1: Distribution by age group and sex of
respondents (n=335) Not brushing at all/
271 76
improper brushing
Sex Total Eating hard fruits/
26 7.3
food
Male Female
I don’t know 15 4.2
Age group 12-15 years 62(49.6%) 63(50.4%) 125(100%)
16-19 years 111(52.9%) 99(47.1%) 210(100%) Brushing and
* Bleeding gums can be prevented by: b 294 82
Total 173(51.6%) 162(48.4%) 335(100%) flossing
Use of medicines
52 15
from drug stores
Frequency distribution of participants according I don’t know 11 3.1
to knowledge on periodontal diseases and dental
caries questions (n=335) Knowledge on dental caries
The majority of the respondents (77.5%) knew that Frequent eating of
tooth brushing and flossing prevent plaque. Over c sweat food staff and
Tooth decay is caused by: 344 96
three quarters (76.3%) knew that not brushing at all not brushing with
or improper brushing causes bleeding gums and fluoride toothpaste
82.4 % (n=294) knew that brushing and flossing Eating fruits 6 2.2
prevents bleeding gums. The majority (96.1%) I don’t know 8 1.7
knew that frequent eating of sugary foods and
sweetened not brushing with fluoride toothpaste Cavity on tooth, pain,
Dental caries is associated with: d 249 70
causes tooth decay, more than half knew that cavity sometimes swelling
on tooth, pain and sometimes swelling as symptoms Bleeding gums 72 20
of dental caries. A majority (85.9%) knew that dental I don’t know 33 9.3
caries can be prevented by avoiding sweet and
brushing with fluoridated toothpaste and less than a Avoiding sweets and
quarter (18.1%) knew that filling of the decayed part e brushing with
was the best treatment of tooth decay. (Table 2) Dental caries can be prevented by: 304 86
fluoridated
toothpaste
Table 2: Frequency distribution of participants
Medicines from drug
according to knowledge on periodontal diseases 40 11
stores
and dental caries questions [n=335) It cannot be
10 2.8
prevented

Knowledge on periodontal diseases Tooth extraction

Questions Responses Frequency % What is the best treatment of decay: f 222 63
(removing tooth)
Brushing and
Plaque can be prevented by: a 269 78
flossing
Will disappear on its Frequency distribution of participants according
7 2 to attitude on oral health (n=335).
own
Medicines in stores 22 6.3
Less than half of the respondents (39.4%) strongly
I don’t Know 49 14 agreed that treatment of toothache is as important as
any other body organ and 7% disagreed. 35.2%

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 Medical Journal of Zambia, Vol. 49 (2): 118 - 127 (2022)

agreed to visit the dentist regularly and quite a Frequency distribution of participants according
handful 15.1% never visited a dentist, compared to to oral hygiene practice (n=360).
the 74.9% that said regular visits are necessary. The majority(85%) reported brushing at least two
Close to half (45.6%) of the respondents reported times and 0.6% (n=2) didn't brush, with 94.7% of the
visiting a dentist due to a toothache. respondents respondents using a toothbrush with fluoridated
(49.9%) didn't visit due to fear of the dentist's toothpaste. More than half, 69.9% reported brushing
instruments. The majority 98.1% and 97.2% agreed in the morning and before going to bed. On the
that tooth brushing has been done well and think approximated duration that they spent brushing their
dental health educational lessons are important at teeth, 44.4% said to brush for more than two
their schools. 49.9% didn't visit due to fear of the minutes. 86.1% reported brushing their tongue when
dentist's instruments. However, parental advice to brushing their teeth. The majority 91.3%(n=326),
adolescents to regularly visit a dentist was low11% respondents indicated that they rinse their mouth
(n=39) (Table 3) after a meal with 70.9% of them using just plain
Table 3: Frequency distribution of participants water. (Table 4)
according to attitude on oral health (n=335). Table 4: Oral hygiene practices among
respondents (n=335).
Questions Response Frequency %
Strongly agree 140 39 Questions Response Frequency %
Treatment of toothache
Agree 157 44 Non 2 0.6
is as important as any
Neutral 33 9.3 Occasionally 18 5
other organ of the body. How often do you brush your teeth?
a Disagree 20 5.6 Once per day 34 9.4
Strongly disagree 5 1.4 Twice or more per day 304 85

Regularly 126 35 Brush + toothpaste 341 95

How often do you visit Occasionally 56 16 Dental floss 3 0.8
the dentist? b When in pain 122 34 What do you use for cleaning your Mouthwash 5 1.4
Never 54 15 teeth? Toothpicks 10 2.8
Chewing stick
1 0.3
Yes 266 75 (mswaki)
Are regular visits to the
No 65 18
dentist necessary? c Morning 51 15
I don’t know 25 7
Noon (after lunch) 4 1.1
Toothache 162 46 Before going to bed 1 0.3
When do you brush your teeth a
Reason for visiting the Parent advise 39 11 Morning and before
246 70
dentist the last time. Friend advise 17 4.8 going to bed
Dentist advise 137 39 Other times 50 14

Fear of dentist’s instruments 167 50

Reasons for not visiting Assessing associations of knowledge to Age and
No clinic nearby 99 30
the dentist. d
I just don’t want 61 18 Sex of the pupils
Others reasons 8 2.4
Chi-square findings revealed that there was no
It’s good 353 98 significant association between the age of pupils and
What do you think about
Boring 2 0.6 level of oral hygiene knowledge. There was also no
tooth brushing
Time consuming 5 1.4
significant association between sex and knowledge
Do you think dental Yes 350 97 score. (Table 5)
health educational No 5 1.4
lessons are important at
your school? I don’t know 5 1.4

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Table 5: Knowledge characteristics by age group Table 7: Age/Sex*Practice Score Cross

and sex (N=335). tabulation (N=335).

Total Knowledge Score Total Statistics Total Practice Score Total Statistics
Poor knowledge Good Knowledge Poor Practice Good Practice
Age Age 12-15 11 (8.7%) 116 (91.3%) 127
12-15 yrs 9 (7.1%) 118 (92.9%) 127 (100.0%) X2 = 3.416 Grou yrs.
16-17 (100%)
213
group 29 (13.6%) 184 (86.4%) X2 = 1.881
yrs. (100%)
16-19 yrs 29 (13.6%) 184 (86.4%) 213 (100.0%) P = 0.065
340*
Total 38 (11.2%) 302 (88.8%) 340*(100%) Total 40 (11.8%) 300 (88.2%) P = 0.170
(100%)

Sex Male 27 (15.5%) 147 (84.5%) 174

Sex Male 17 (9.8%) 157 (90.2%) 174 (100.0%) X2 = 1.227 (100%)
169
Female 13 (7.7%) 156 (92.3%) X2 = 5.096
(100%)
Female 23 (13.6%) 146 (86.4%) 169 (100.0%) P = 0.268
Total 39.19 (11.7%) 295.8 (88.3%) 335(100%) P = 0.024
Total 40 (11.7%) 303 (88.3%) 343# (100%)
*#
only those were valid respondents of 335.

Attitude of participants by age group and DISCUSSION

sex(n=335)
The study aimed to assess knowledge, attitude and
There was a significant association between age and practice on oral hygiene among school-going
attitude. More than three-quarters of the younger adolescents in Choma District.The study revealed
age group (77.2%) had good attitude. However, sex that the majority (86.7%), of the respondents had
did not influence attitude. (Table 6) more knowledge on the causes and prevention of
periodontal diseases. Similar results were observed
Table 6: Attitude of participants by age group in a study done in Tanzania where 96.8% had
and sex (N=335) adequate knowledge of periodontal diseases.
1

Total Attitude Score Total Statistics Further, more than half (65.0%) had knowledge on
dental caries, however, this is low compared to the
Poor Attitude Good Attitude 1,2
findings reported elsewhere.
Age 12-15 29 (22.8%) 98 (77.2%) 127 (100.0%)
16-19 Only less than a quarter (19.2%) knew that the best
70 (32.9%) 143 (67.1%) 213 (100.0%) X2 = 3.877
yrs. treatment for dental caries was filling of the tooth
Total 99 (29.1%) 241 (70.9%) 340*(100%) P = 0.049 rather than extraction. This could be due to the fact
that there is not enough sensitisation regarding the
Sex Male 53 (30.5%) 121 (69.5%) 174 (100.0%) restorative treatment of dental caries, and most
Female 49 (29.0%) 120 (71.0%) 169 (100.0%) X2 = 0.088 dental clinics in Zambia readily offer extraction as a
14
Total 99.4 (29.7%) 235.5 (70.3%) 335(100%) P = 0.767 sole treatment option for dental caries. Though
*#
most studies have shown a strong link between
only those were valid respondents of 335 9
knowledge, age and sex , our study found that
knowledge was not influenced by age (p=0.065) and
Age/Sex*Practice Score Cross tabulation
sex (p=0.268). This could be due to differences in
(N=335)
social demographic factors such as education level,
Findings revealed that age did not affect oral income, and cultural values inherent in different
hygiene practice, though it was affected by sex with societies.
more females (92.3%) having good practice than
Regarding attitude, less than half of the participants,
males (84.5%). (Table 7)
(39.4%), strongly agreed that treatment of a

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 Medical Journal of Zambia, Vol. 49 (2): 118 - 127 (2022)

toothache is as important as any other part of the conducted in Iran, reported that out of 75%, 49.9%
body. This could be due to the fact that in most of school-going adolescents were scared of dental
18
societies, dental problems are not perceived as life- instruments. This is similar to the report in North
threatening diseases among most people unless they Jordan which had 49%, and another which revealed
develop into complications such as gum ulcers. that 53% of the adolescents did not visit the dentist
9,19
Also, conventional treatment of oral conditions is due to fear of dental equipment set up.
not highly regarded among most people, especially Nevertheless, attitude was found to be influenced by
those of low socioeconomic status, in most cases, age, 77.2% of those aged 12-15 years had good
they would only visit a dental clinic when symptoms attitude compared to 67.1% in the same age
become unbearable. The plausible explanation for group(16-19 years), p-value 0.049. A majority
the observed trend is that oral diseases are (85%)brushed their teeth at least twice a day,
behavioural related and positive change is findings similar to those reported elsewhere20, where
associated with the decrease in the prevalence of 95.7% of participants had brushed their teeth at least
6
periodontal diseases. Similarly,a study by Al- twice a day. Further, the majority (94.7%)were using
16
Omiriet al. , found that less than half (35.2%) of the a toothbrush and toothpaste to clean their teeth,
patients had visited a dentist regularly while 15.1% these findings are in consonance with those reported
never visited the dentist. Likewise, high numbers of elsewhere.7,14,16,18
respondents have been reported not to have visited
the dentist elsewhere.14 This could be due to As expected, 0.8% reported using dental floss, and
challenges in accessibility, as most health centres 2.8% usedtoothpicks,69% reported brushing in the
lack dental facilities in most low -middle-income morning and before bedtime, these are less
countries which result in a delay in seeking dental compared to those in Malaysia20where 80.4% were
services.2.9Other reasons cited for the delay in reported having brushed their teeth in the morning
seeking dental services include; lack of parental and before bedtime. About half (44.4%) compared
belief and practices, lack of economic resources and to 71% in North Jordan16reported having brushed
accessibility of dental services. Lack of parental their teeth for at least 2 minutes. Our findings are
encouragement regarding oral health hygiene has consistent with assertions from a previous study that
been documented as one of the reasons why some dental floss is not widely used in most societies in
4
adolescents delay their visits to the dentist. This is Africa because it is expensive to buy and is scarcely
14
because parents play a vital role in influencing a found. This makes it difficult for people of low
child' attitudes and practices regarding oral health socioeconomic status and in remote places to buy
9
behaviour. Similarly, in our study, parental advice and access them.
to school-going adolescents to regularly visit the Evidence also suggests that brushing habits are
dentist among school-going children was low influenced by sex. In our study, females,(92.3%)
(11%). Studies done elsewhere have revealed had better oral health practice than males (84.5%)
similar findings.16,17 p=0.024, similar findings have been documented
7
Though the majority (74.9%) agreed that regular elsewhere. This could be due to the fact that females
visits are necessary, about half (52.2%) of the adhere more to brushing their teeth regularly than
21
respondents visited the dentist because of their male counterparts. However, evidence as to
toothaches, these findings are similar to those why this is so is lacking. Further research is
7
reported in Malaysia. Fear of instruments used in therefore needed to establish why school-going
dental procedures was another reason why most female adolescents have better oral health practices
participants shunned away from dental clinics. than males. We found no statistically significant
Likewise, Kamran and colleagues, in a study association between knowledge and attitude on

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adolescents' oral health practices. Education is an Author's contribution

important tool in health promotion as it positively KS and BM conceived the study, and did data
9
influences knowledge, attitudes and practices. collection, BM, developed the conceptual
Despite all schools lacking oral health education, framework, provided insights in methodology,
our study found that the majority(350) 97.2% discussion and introduction, THN, BM, VD
indicated that oral health education in schools would performed the formal analysis. VD, KS, BM, DM
increase the knowledge levels and influence and THN reviewed and edited the final copy of the
attitudes and practices towards oral health hygiene. manuscript
This is in consonance with a study done by Farsi and
others who found that lack of oral health education Competing interests
in schools contribute to poor oral hygiene.22 This
The authors declare that there is no conflict of
calls for the need to include oral health education
interest regarding the publication of this paper.
into the school curriculum. In countries with well-
developed school oral health education programs Funding Statement
like New Zealand and Australia, there has been
evidence of a decline in dental caries among school The study was supported by a student grant by the
children in the past few decades.9,17 Higher Education Loans Board of the Government
of Zambia.
Study limitations and Strengths
ACKNOWLEDGEMENT
Data regarding demographic information on
adolescents' mothers and fathers such as education The authors would like to acknowledge the support
level and socioeconomic status which are strong rendered by the management and staff at all the
determinants of oral health literacy were lacking. participating secondary schools in Choma District,
Further, since we were dealing with adolescents, the as well the management and staff of the Copperbelt
influence of parents on adolescents' responses could University, School of Medicine.
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