The Concern of UHEW toward Oral Health Promotion within Primary Health Care approaches in the assigned Communities, Addis Ababa, Ethiopia, 2017
Fasil Kenea Duguma1*, Belachew Kahasye1, Ali Adem1, Adnan Ibrahim1, Ayalew Mengesha1, Yemisirach Tesema1, Sara Dula1, Lulseged Salvator2, Nugusu Kelemwork3, Mitike Molla4, Addisalem Bogale5, Belay Leulseged6, Tufa Kolola7 and Atikure Defar8
1Department of Public Health, Defense Health Science College, Addis Ababa, Ethiopia
2,3Department of Dentistry, Atlas College of Dental Medicine, Addis Ababa, Ethiopia
4Health Science college, Addis Ababa University, Addis Ababa, Ethiopia
5,6Millennium Medical College, St Paulo’s Hospital, Addis Ababa, Ethiopia
7Health Science College, Ambo university, Ambo, Ethiopia
8Ethiopian Public Health Institute, Addis Ababa, Ethiopia
Submission: September 11, 2019; Published: September 27, 2019
*Corresponding author: Fasil Kenea Duguma, Department of Public Health, Defense Health Science College, Addis Ababa, Ethiopia
How to cite this article: Fasil Kenea Duguma, Lulseged Salvator, Nugusu Kelemwork, Mitike Molla, et al. The Concern of UHEW toward Oral Health Promotion within Primary Health Care approaches in the assigned Communities, Addis Ababa, Ethiopia, 2017. Adv Dent & Oral Health. 2019; 11(3): 555811. DOI:10.19080/ADOH.2019.11.555811
Abstract
Introduction: WHO defined Oral health a state of being free from any pain originated from mouth and face, oral and throat cancer, oral infection and sores, periodontal disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing. Ethiopia ratio of dentists: population is 1:1,268,000. WHO recommend that, it needs to shift the oral health management away from the old paradigm of dentistry treatment and surgery-based approach? Emphasize prevention and health promotion in impoverished regions
Methodology: Institutional based descriptive cross-sectional study. The sample size was calculated by using single population formula. The sampling method was simple random sampling from the sampling frame of health extension workers. The collected data entered, coded, cleaned and analyzed by SPSS. Ethical issue was secured from concerned institution, officials and study participants.
Result: On this study majority (84.1%) of the participants were provided regular house to house visit in their catchment areas and 76.2% were given general health education. Of this health education activities 84.5% was specific to oral health topics. About 137 (90.7%) had tooth cleaning practice. Of this about 86 (57%) clean their tooth twice a day while the rest (65 (43%)) was once a day. To the complain of the community dental problems the HEW were maneged 62.9% in giving oral hygiene advises, 30.5% refered to health center and 6.6% advised to extract.
Conclusion and Recommendation: The finding indicate as there is a gap on the knowledge, attitude and practice of oral health among the health extension workers. The concerned body should give a refreshment training specific to oral health and oral health should be thought to the community in corporate with personal hygiene and lifestyle course during regular community visits.
Keywords: Oral health; Health extension; Health promotion; Ethiopia; Primary health care; Dental health
Abbreviations: ECC: Early Childhood Caries; UHEW: Urban Health Extension Worker; KAP: Knowledge, Attitude, Practice; MOH: Ministry of Health; OHE: Oral Health Education; SNNP: South Nations Nationality Peoples; SPSS: Statistical Package for Social Sciences; UNAIDS: United Nations program on HIV/AIDS; WHO: World Health Organization
Introduction
Oral health is acknowledged as an important part of general health. It is defined by the World Health Organization (WHO), as “a state of being free from any pain originated from mouth and face, oral and throat cancer, oral infection and sores, periodontal disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing’’ [1]. In fact, oral health is a component of human right, an important aspect of general health and essential for holistic wellbeing [2]. The importance of oral health goals was first emphasized in 1981 by WHO as part of the programme known as Alma Ata declaration; “Health for All by the year 2000” [3,4]. A healthy mouth enables people to eat and digest foods without discomfort, prevent caries and tooth loss, avoid bad breath thereby build self-confidence [5]. The oral cavity plays a central role for intake of basic nutrition and protection against microbial infections. Living without teeth severely affects quality of life and can lead to unhealthy diets, malnutrition, and social isolation [6]. The major devastating issue was Polymicrobial gangrenous infection of the oral cavity. Fuso bacterium necro phorum and Prevotella intermedia are thought to be key players in the process and interact with one or more other bacterial organisms (such as Borreliavincentii, Porphyromonas gingivalis, Tannerella for synthesis, Treponema denticola, Staphylococcus aureus, and none hemolytic Streptococcus spp) [7].
Globally dental caries affects 40-60% of children. Oral health is the 4th most expensive disease to treat worldwide. Periodontal disease is a major cause of tooth loss in adults worldwide. Oral cancer is the 8th most common cancer worldwide. Inequalities of access to oral health care exist Croatia ratio of dentists: population is 1:560. Ethiopia ratio of dentists: population is 1:1,268,000 [8]. Oral health problem was the disease of poverty: In the US, 80% of all dental disease in children occurs in low-income Medicaid eligible children. Worldwide, dentists migrate and practice in wealthy, urban areas. More than one billion people live on $1 per day or less, making dental care unaffordable. In populations of poverty, dental IQ and oral health prevention is extremely low and needs to be improved [8]. Rapidly increasing levels of oral disease have been observed in several low- and middle-income countries comparably with changes in living conditions and the increasing exercise of unhealthy lifestyles [8]. Oral health is preventable none communicable disease most of the cause was linked with lifestyle, oral hygiene, fluoride water, lack of access to safe water, lack of awareness and poor perception, lack of access to the service so this all issue was solved like other public health problems by community based primary health care approach that was undertaken the last 20 years by health extension workers so the main aim of this study is to assess the existing oral health knowledge, attitude and practice of health extension worker and the status health promotion level of the oral health in assigned sub-city.
Study conduct on the Wondogenet southern Ethiopia described 14.3% of health extension workers that provided oral health education had good oral health knowledge but 10.7% of the knowledgeable didn’t provide oral health education to the community. Half of those not knowledgeable respondents didn’t provide oral health education to the community whereas 7.1% of them provided. Among the respondents 14.3% of the respondents that provided oral health education had good oral health attitude, but 28.6% of them didn’t provide oral health education to the community. About 50% of the respondents didn’t had good attitude to oral health and not provided oral health education to the community whereas 7.1% of them provided. Among the respondents 14.3% of the respondents that provided health education had adequate oral health practice but 10.7% of them didn’t provide oral health education to the community. 64.3% had inadequate oral health practices which were not provided oral health education to the community whereas 7.1% of them provided. The community-based approach is the mechanism through which households and communities strengthen their role in health and health related development by increasing their knowledge, skills and participation indirectly by creating the demand for the services it may create easy the approach of the service at large community level [9].
Oral health problems are becoming increasingly prevalent in many of the low-income developing countries. They create a double burden on top of the infectious diseases by which these countries continue to be suffered. [10] In Africa the burden of oral health related problem was occur in 39 out of 46 countries. The incidence was 20:100,000. Mostly it was affecting children 2-6 years old and about 70-90% mortality rate [8]. The prevalence of dental caries was reported to range from 47.4% to 74% in two separate studies done in Addis Ababa [11].
Rapidly increasing levels of oral disease have been observed in several low- and middle-income countries comparably with changes in living conditions and the increasing exercise of unhealthy lifestyles [11]. The main risk factor was associated with: Malnutrition or dehydration, Poor oral hygiene, Poor sanitation, Unsafe drinking water, Proximity to unkempt livestock, Recent illness, Malignancy, an immunodeficiency disorder, including AIDS More than 20 million cases in Africa. 50-60% of HIV+ patients will have: Oral fungal, bacterial and viral infection, Oral Hairy Leukoplakia. HIV gingivitis and periodontitis, Kaposi Sarcoma, Non-Hodgkin Lymphoma and Xerostomia. Insufficient number of dental schools and graduating dentists. Ratio of Dentist: Population in Ethiopia1:1,268, 000.Majority of dentists graduating in African country will immigrate to new continent [8].
WHO Examine the common determinants of dental disease on economic, environmental, social and behavioral level and final it would recommend that as it needs to develop oral health systems to distribute resources equitably in addition it may need to develop oral health policies and need to halt or decrease burden of disease and disability in disadvantaged, developing countries [12]. WHO explain boldly as Oral health worse in areas that do not have clean drinking water, so it needs to address fluoridation, it Need to address tobacco and alcohol use and it need to address poor dietary habits and sugar consumption? It needs to Shift the oral health management away from the old paradigm in dentistry that is treatment and surgery based. Emphasize prevention and health promotion in impoverished regions [8]. To manage strongly the oral health problem WHO recommend target issues that need compressive approaches that is: Diet/nutrition and oral health, Fluorides in preventing dental caries, Tobacco use and impact on oral health, HIV/AIDS and oral health, High burden of disease in children, Ageing population [11]. Global Oral Health reports boldly discussed and recommend five items to improve oral health: Meet the increasing need and demand for oral healthcare, Expand the role of oral healthcare professionals, shape a responsive educational model, Mitigate the impacts of socio-economic dynamics, Foster fundamental and translational research and technology [11].
Study conduct on the Wondogenet southern Ethiopia described that as those HEW who were knowledgeable on oral health, were 6.605 times more likely to practice oral health education to the community compared to those who were not knowledgeable (AOR: 6.605, 95% CI: 1.438-30.338). Those HEW who had adequate practice of oral health by own self were 4.507 times more likely to practice oral health education to the community compared to those who had inadequate practice (AOR: 4.507, 95% CI: 1.213- 16.749). Results from this study revealed all of the respondents were health extension workers and all of them provided health education to the community during their house to house visit. But a small proportion of the respondents practiced oral health education to the community. This could be a result of either oral health knowledge, practice and their level of education. Generally Oral disease is epidemic around the world. Leads to high rates of morbidity and mortality. Resources needed to improve oral health but often shifted to other pressing medical problems with higher mortality rates. Improvements in oral health systems, access to care and dental education are crucial [8].
So, if it need to reduce this oral health related problem and to extend the service like other public health prioritized issue the community health approach that was given by health extension worker has a lot of impact, so this study mainly wants to deal the role and the level of their contribution in accessing, availing, creating a demand for the service and providing health promotion to the large community. Data on awareness, attitude, practice and level of health promotion of urban health extension worker about oral health would assist public health administrators in planning effective health information communication and education strategy to improve the health extension worker knowledge on a way that provide and maintain oral health care for their large community, as awareness level of the health extension is directly associated with their level of health promotion practices to assigned community. it is impossible to effectively assess the impact of policies, programmes or any interventions in the health sector, hence it is recommended that regular conduct of oral health promotion surveys is mandatory for assessment of apparent trends in oral health promotion status particularly the role player health extension workers [7,10].
To reduce risk factors and the burden of oral disease, and to improve oral health systems and the effectiveness of community oral health implementations, Oral Health Programme anywhere in the world; should have to focus on stimulating oral health research. Building and strengthening research capacity in public health are highly recommended by WHO for effective control of disease and the socioeconomic development of any given country [11]. World Oral Health Report recommends that every countries should establish a complete oral health information system for monitoring and continued evaluation of national oral health programmes; the data generated by this study will supplement the existing efforts at local level, and as such information is instrumental for planning or adjustment of interventions by health authorities [7]. Therefore, this study will be conducted to generate information regarding knowledge; attitude and practice, the role and level of health promotion status the health extension program in lafto sub city Ababa, Ethiopia. The findings of this study will inform the policy makers and the other stakeholders to come up with better mechanisms on improving the community strategy. This will propel the country to move faster towards achieving high quality health care as desired by the community and achieve the goals.
Methodology
Study Area
The study was conducted in Nifas silk Lafto sub city health office (in all health center to access the urban health extension workers), Addis Ababa Ethiopia.
Study Period
The study was conducted from August 2017 to September 2017.
Study Design
The study design was institutional based cross-sectional quantitative method. The quantitative variables were assessed by using self-administrative close ended question. The aim of this was it may help to get broad insight about the health extension awareness and practice level, trend and approach used to promote the oral health while in the community health services conceptually.
Population
Target Population
i. The target populations were all HEWs who were found in Nifas silk Lafto sub city.
ii. The total number of the health extension worker in the study site is 198.
Study Population
a) The Study populations was all HEWs found in specific health centers found in Nifas silk Lafto sub city.
b) The total number of the health extension worker in the study site was 198.
The size of study population: For the study 181 Urban Health Extension workers were selected.
Sample Size Determination: The sample size for the study was calculated by using single population proportion formula, 95% confidence interval and 5% degree of precision. Prevalence is estimated to be 86.3% (oral health knowledge of health extension workers in Koraro millennium village cluster in Ethiopia [13]. Sample size (n) was estimated based on single population proportion formula. n = 181.
Sampling method and producers: Probability Simple Random Sampling (lottery)Method was conducted from the sampling frame of the health extension workers to select 181 participants [14-20].
Study Variables
Dependent Variables: The role of health extension worker on oral health of assigned community while in the community health interventions.
Independent Variables
i. Age.
ii. Demographic variable.
iii. Oral health related refreshment training.
iv. Knowledge.
v. Perception.
vi. Attitude.
vii. Trainee curriculum.
viii. Trend of on job training of oral health.
ix. The value of primary health care approach to oral health service.
x. The presence of oral health on the work plan of community health promotion.
xi. Influencing factors to promote oral health.
xii. The enabling and motivating factors to expand the oral health promotion.
Data Collection
Instrument and Process: A standardized questionnaire was adopted from different published and unpublished research; after moderate modification is being made in accordance with my research objectives. The questionnaire was in the English version and translated into Amharic language and then re-translated back to English to check the consistency. Finally, the Amharic version was utilized as interview guide and distributed to study participants during data collection time. Prior to the actual data collection, the questionnaires were pre-tested; to assess the consistency and clarity of questions among target groups, by distributing to 5% of sample size, which were 9 individuals from other sub city health extension workers. The feedback from the pretest was incorporated to the actual tool before data collection is effectuated. During data collection, the data collector was provided appropriate introductory information to the study participants for emotional support and to avoid misconception if any, and to secure verbal consent from each participant [21-30].
Data quality control: The data was collected by using pretested, structured, self-administered close ended questioner, throughout data collection period, the necessary assistance was offered to the participants, while filling the self-administered questioner, and the filled questioner was checked on the spot for completeness, consistence and clarity issue.
Data Analysis: Data was entered, coded, cleaned and checked for completeness and consistency and analyzed by using Statistical package for social studies (SPSS) version 21.
Inclusion and Exclusion Criteria of the Participants
Inclusion Criteria
i. All HEWs who were present at the time of the study.
ii. All HEWs that work at least for 6month and above.
Exclusion Criteria
a) All HEWs who were not present at the time of the study.
b) All HEWs that work for at less than 6 months.
Ethical Clearance: The research proposal was submitted to the research and publication department of Atlas College, ethical review committee for further ethical approval. The health office of study area and health centers were informed about the study through official letter sent from the collage. Participants filling out a questionnaire survey and being interviewed were informed about the objectives of the study; the time needed to complete the questioner, which was about 15 to 10 minutes. The risk and benefit, Anonymity, confidentiality, privacy, justice issue was informed orally and secured practically in the consent part to make the respondent confident and responsible for their response’s confidentiality was ensured by excluding participant’s name and address from the questioner. They were informed that the data was used for statistical purposes only [30-43].
Result
Socio-Demographic Background of Participants
Majority (25.8 %) of the health extension workers had an experience of above five years and 5.3 % had less than six months. 70.2% of the HEW were found within the age of 20-30 years and the rest 29.8 % were above 30 years old. 58.3% had married while 39.7% single, 1.3% divorced and 0.7% live separated. Among the study population 3.3 % had no child while the rest had one child (32.5%), two (15.9%), three (6 %) and four (6 %). The dominant religion in the study population was orthodox (59.6 %) followed by protestant (29.1 %), Muslim (10 %) and catholic (1.3 %). Among the study population 77.5 % had college diploma in nursing and 17.2 % had degree in nursing while 5.2 % had certificate and other related professions. It was found that majority of the study population had taken oral health education in the collage (78.15 %) and as refreshment training (58.3 %) (Table 1).
Knowledge of Oral Health
To assess the knowledge of the study population about oral health fifteen basic questions were presented and the result was found in detail in the following table. Only 23 (15.2 %) had the knowledge that someone need to brush his / her teeth three times a day whereas the majority (72 (47.7 %)) replied that someone should brush his / her teeth twice a day and 52 (34 %)) once a day. Among the study population Only 1 (0.7 %) had spent 2 minutes and more for brushing their teeth, many of them (87 (57.6 %)) spent one minute for brushing their teeth. When we evaluate their knowledge about the importance of toothpaste, majority 134 (88.7%) knew that brushing with toothpaste is very important and 4 (2.6 %) did not knew the importance of toothpaste. 76 (50.3 %) of the study population knew that the goal of teeth brush is to remove germs (bacteria) and foods from all tooth surface but 12 (7.9 %) did not know the goal of teeth brush. Out of the study population, 12 (7.9 %) did not know the effect of fluoride in toothpaste. The majority 80 (50.3 %) had a knowledge that fluoride prevents dental carries, 28 (18.5 %) knew that fluoride make the teeth whiter, 31 (20.5 %) it makes mouth fresh. Only 13 (8.6 %) knew the correct way of teeth brushing is 45 degrees oblique while the rest replied as follow 40 (26.5 %) horizontal, 73 (48.3%) vertical & 25 (16.6 %) circular motion. About 94 (62.3 %) had a knowledge that gingivitis is the inflammation of the gums that involve swelling and bleeding. Only 20 (13.2 %) had a knowledge that most commonly periodontal (gum) disease could be linked with low birth weight babies, diabetes and heart disease and stroke. Majority 91 (62.3 %) had a knowledge that only diabetes has a link with periodontal (gum) disease. Among the study population 80 (53 %) had a knowledge of the effect of smoking on periodontal disease and cause cancer of the mouth. It was found that HEW had a gap in the knowledge about oral health (Table 2).
Practice of Oral Health Care
To assess the practice of oral health care eighteen basic questions were presented to the participants and the detail result were found in the following table. The result shows that the study population had a good practice of oral health care. Among the study population, 137 (90.7 %) had tooth cleaning practice whereas 14 (9.3 %) did not have. When we see the frequency of their teeth cleaning, 86 (57 %) had the habit of cleaning their teeth twice a day while the rest (65 (43 %)) clean their teeth once a day. The time they cleaned their teeth was found as, 112 (74.2 %) clean their teeth before or after breakfast, 16 (10.6 %) after launch & 23 (15.2 %) before going to bed at night. Among the study population 81.5 % clean the teeth of their child and their own whereas 28 (18.5 %) do not. when we see the time, they brush their teeth 52 (34.4 %) in the morning only, 69 (45.7 %) in the morning and before going to bed, 24 (15.9 %) in morning, before going to bed, and after meal and 6 (4 %) brush their teeth occasionally. It was found that 98 (65 %) of the study population used toothbrush, 20 (13.2 %) wooden toothpick, 10 (6.6 %) plastic toothpick 1 (0.7 %) thread (dental floss, 6 (4 %) charcoal and 1 (0.7 % 0 other materials for tooth cleaning. Majority (106 (70.2 %)) of the study population used fluoridated tooth paste whereas 45 (29.8 %) do not use fluoridated toothpaste. The study also showed that majority (82 (54.3 %)) do not visit the dentist to for checkup, only 69 (45.7 %) had the habit of visiting dentist for checkup (Table 3).
Attitude Towards Oral Health
To evaluate the attitude of the study population towards oral health twenty-seven closed ended questions were presented and the result was found in the following table. As the below table shows that the study population had a positive attitude toward oral health, but it was also found that there is a gap. Among the study population majority 60 (39.7 %) agree and 25 (16.6 %) strongly disagree that “only the dentist can prevent cavities “and 32 (21.2 %) disagree & 21 (13.9 %) strongly disagree to this idea. 80 (53.0 %) agree that everyone should have regular visit to the dentist for dental health care. 73 (48.3 %) of the study population agree that regular use of toothpaste is important to youth and adults. 78 (51.7 %) agree and 34 (22.5 %) strongly agree that they know how to brush their teeth, 16 (10.6 %) were neutral, 12 (7.9 %) disagree and 11 (7.3 %) strongly disagree for this question. For the question “there is no advantage to use anti carries tooth paste for milk teeth, because they are replaceable “, 58 (38.4 %) disagree & 19 (12.6 %) strongly disagree (Table 4).
Community Health Related Trend of Urban Health Extension
To assess the activity of the HEW in the community related to oral health education eleven multiple choice questions were presented and the result was found in the below table. Most of the community complain was Acute febrile illness and there was also complain of dental problems in the community. Tooth pain 67.5%, bad oral odor 14.6 %, and gum bleeding 15.9 % and other type of pain 2 %. Majority of the study population (84.1 %) provide regular house to house visit to the catchment area and 76.2 % provide general health education. Among the study population 84.5 % provides health education specifically to oral health. To the complain of the community to dental problems 62.9 % of the HEW advise oral hygiene, 30.5 % refer to health center and 6.6 % advise to extract (Table 5).
Discussion
Oral health is the 4th most expensive disease to treat worldwide. Periodontal disease is the major cause of tooth loss in adults worldwide [7]. On this study most of the community complain was acute febrile illness and there was also complain of dental problems in the community. A study conducted in Saudi Arabia on the title of “Dental and oral problem patterns and treatment seeking behavior of geriatric population “indicate the most common oral problem was missing tooth (80.9%) followed by gum problem (74.2). On this study the major oral problems were tooth pain (67.5%), bad oral odor (14.6 %) and gum bleeding (15.9 %) and other type of pain (2 %). Study conducted on Wendogenent, southern Ethiopia among health extension worker described 14.3% of the respondent that provide oral health education had good oral health knowledge but 10.7% of knowledgeable respondent did not provide oral health education to the community. On this study majority (84.1 %) of the study population (Health Extension Workers) provide regular house to house visit to the catchment area and 76.2 % provide general health education. Among the study population 84.5 % provides health education specifically to oral health. Furthermore, Study done at Wondogenet revealed that as those HEW who were knowledgeable on oral health were 6.605 times more likely to practice oral health education to the community compared to those who were not knowledgeable (AOR: 6.605, 95% CI: 1.438-30.338). Those HEW who had adequate practice of oral health by own self were 4.507 times more likely to practice oral health education to the community compared to those who had inadequate practice (AOR: 4.507, 95% CI: 1.213-16.749).
Study conducted on Wondogenet shows that among the respondent only 14.3 % of the respondent that provide health education had adequate oral health practice and 64.3 % had in adequate oral health practice. On this study among the study population, 137 (90.7 %) had tooth cleaning practice whereas 14 (9.3 %) did not have. When we see the frequency of their teeth cleaning, 86 (57 %) had the habit of cleaning their teeth twice a day while the rest (65 (43 %)) clean their teeth once a day. A study conducted by the north Vallejo, California School based oral health project indicated that many (44 %) reported students have regular visit to the dentist (about once per year), one-half (51 %) reported having only visited a dentist one to three time ever. Of the respondents who had ever visited the dentist, approximately three quarters (71 %) reported a” checkup “as a primary reason. Whereas this study showed that majority (82 (54.3 %)) do not visit the dentist for checkup, only 69 (45.7 %) had the habit of visiting dentist for checkup.
Limitation of the Study
The study assessed the knowledge, attitude and practice of the health extension workers towards oral health. The major limitation of this study was the absence health extension workers 30 (16.6 %) on their job during the study period due to varies reason.
Conclusion
The result of the study showed that there is a gap in the knowledge, attitude and practice of oral health among the health extension workers. The concerned body should give a refreshment training specific to oral health and oral health should be thought to the community in corporate with personal hygiene and lifestyle course during regular community visit by the health extension workers.
Recommendation
Based on the finding of the study the following is recommended;
a) Refreshment training to the health extension workers about oral health should be given.
b) Oral health education should be in corporate in the curriculum during health extension training.
c) The health extension workers should teach the community to increase the society`s knowledge of risk factors for dental disease
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- Hosam Alrqiq, Sharon Carter, Columbia University College of Dental Medicine; Emily Byington, Columbia University College of Dental Medicine; Joanna Pudil, New York Presbyterian Hospital; Author Burton Edelstein, Columbia University in 2016. Dental and oral problem patterns and treatment seeking behavior of geriatric population.
- Bader K AlZarea (2015) College of Dentistry, Aljouf University, Saudi Arabia.
- PayalKahar (Fort Lewis College); Idethia Harvey, (MPH, DrPH, Department of Health and Kinesiology, Texas A&M University); Christine Tisone (Department of Health and Kinesiology, Texas A&M University) in 2015 in central rural India on the ‘Assessment of oral health knowledge, attitude, utilization and barriers toward professional dental care among adults.
- Stephanie Lin, Janet, Bozzone, Caroline Inaba, Luz House, New York Medical College; Penny Liberatos, Denise Tahara, New York Medical College in 2015. Analysis of poverty, education, community water fluoridation and other demographic findings as risk factors for caries and periodontal disease in New York state.
- Anita Glicken, Bre Holt, Qualis Health; Melinda Clark, American Academy of Family Physicians published in 2016. Building a culture of shared responsibility for oral health: creating tools to advance oral health integration in primary care education and practice.
- Caswell A. Evans, University of Illinois at Chicago, College of Dentistry; Author Khatija Noorullah, University of Illinois, Chicago, College of Dentistry; Author Darien Weatherspoon, DDS, MPH, University of Illinois at Chicago, College of Dentistry published in 2016. Community-based service-learning: lessons learned after 10 years.
- Zewdu Getachew, Fasil Kenea D (2016) The Status of Health Extension Workers on the Role of Oral Health Education Practice to the Community and Its Predicting Factors at Wondogenet Woreda, SNNP Region of Ethiopia 2016.