|Year : 2014 | Volume
| Issue : 4 | Page : 237-242
Evaluation of short term impact of two training packages on oral health knowledge and skills of Anganwadi workers of a Northern City of India: Before and after comparison study
Sonika Raj1, Sonu Goel2, Naveen Krishan Goel3, Vijaylakshmi Sharma1, Sangeeta Ajay4
1 Centre for Public Health, Panjab University, Chandigarh, India
2 School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Community Medicine, Government Medical College, Chandigarh, India
4 National Rural Health Mission, Chandigarh, India
|Date of Web Publication||20-Nov-2014|
School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh
Introduction: Despite a serious public health problem, oral hygiene is largely ignored by community. Anganwadi workers (AWWs) can be trained on oral hygiene so that they disseminate information to a wider section of society. Objective: To compare the impact of two oral hygiene training packages on the knowledge and skills of AWW of Chandigarh. Materials and Methods: Before and after comparison study was conducted on AWWs of Chandigarh. The AWWs of Project-1 (n = 112) were provided with knowledge based training package and AWWs of Project-2 (n = 98) were provided with skill based training package. The difference between two packages was analyzed using Chi-square test and difference-in-difference analysis of group scores. Results: The pre-posttraining difference of a number of respondents scoring <22 in the knowledge domain was 43% (pretraining - 11% and posttraining - 54%) in Project-1, whereas, in Project-2 this increase was higher at 54% (pretraining - 6% and posttraining - 60%). The difference-in-difference results showed that there was statistically significant (P = 0.04) improvement in the knowledge scores of AWWs of two projects scoring <22 marks. The increase in skill scores between two projects was found to be statistically significant (P = 0.000). Conclusion: Increase in skills of AWWs imparted with skill based package was significantly better as compared to the knowledge based package, thus indicating its usefulness over a knowledge-based package. Skill-based oral hygiene package should be imparted to community workers.
Keywords: Anganwadi workers, health workers, oral health education, oral hygiene, oral hygiene education
|How to cite this article:|
Raj S, Goel S, Goel NK, Sharma V, Ajay S. Evaluation of short term impact of two training packages on oral health knowledge and skills of Anganwadi workers of a Northern City of India: Before and after comparison study. SRM J Res Dent Sci 2014;5:237-42
|How to cite this URL:|
Raj S, Goel S, Goel NK, Sharma V, Ajay S. Evaluation of short term impact of two training packages on oral health knowledge and skills of Anganwadi workers of a Northern City of India: Before and after comparison study. SRM J Res Dent Sci [serial online] 2014 [cited 2019 May 25];5:237-42. Available from: http://www.srmjrds.in/text.asp?2014/5/4/237/145124
| Introduction|| |
Oral health has been accorded low priority in curricula of basic level health professionals across the world.  Children affected with oral health diseases often suffer from associated health problems, ranging from local infections, reduced growth and altered behavior resulting in inferiority complex and reduced quality of life. ,, The behaviors learnt in early age are generally well imbibed within an individual and are difficult to change in the later stage of life. Compounding to the existing problem of the high incidence of caries among preschool children, there are very few dental professionals (dentist-to-population ratio in India is 1:10,271) as compared to general physicians in India. Over 95% of them are working in the private sector.  They cater primarily to curative/restorative needs rather than preventive needs of the population. 
An Anganwadi worker (AWW) is a grass root level worker who serves around 1000 population. They have successfully demonstrated their useful role in community education under various national health programs.  Few studies have shown that they are responsible for developing healthy habits in early childhood viz. correct brushing techniques and hand washing through nonformal education methods. , Empowering community workers like AWW in oral health, and providing basic oral health awareness to the mothers through them can be a feasible model for a developing country like India; where besides the scarcity of dentists, oral health is not considered a priority in the primary health care. Our research hypothesis was that the provision of skill based oral hygiene training package (OHTP) will be more helpful than knowledge based package in increasing knowledge and skills of AWW. Hence, the present study was conducted with the objective of comparing the impact of two OHTPs on the knowledge and skills of AWWs of Chandigarh.
| Materials and methods|| |
Chandigarh, located in North India, is one of the best planned cities of India and has a population of around 1 million (census 2011). The city has a total of 423 Anganwadis (administratively divided into three projects) catering to around 35,000 preschool children.  This before and after comparison study was conducted between September 2010 and March 2011 amongst AWWs of study area.
Two Anganwadi projects (out of three) were selected by lottery method. The AWWs of Project-1 (n = 112) were provided with OHTP-1, where they were imparted knowledge by means of a power point presentation, a self-designed poster, a story on oral hygiene and photo albums. The educational material focused on oral health care and hygiene practices; functions of teeth; dentitions and their significance; dietary habits and their effects on oral hygiene; importance of a tooth friendly diet; etiology and prevention of dental caries; injurious oral habits; influence of oral health on general health; importance of twice daily brushing; use of fluoride toothpaste; common dental/gum disorders; bottle feeding and its effect on caries; tongue cleaning; mouth rinsing; proper tooth-brushing technique and importance of a regular dental visit. The AWWs of Project-2 (n = 98) were provided with OHTP-2 in which, besides imparting knowledge by means of power point presentations (as in OHTP-1), they were provided an on-the-spot practical demonstration of tooth brushing and flossing methods using dentoform models and disclosure of dental plaque by the researcher. All the training material was translated in local language for better understanding of AWW. The training module, poster and story were developed by main researcher in collaboration with the professionals in the field of dental public health.
A pretest and posttest of knowledge (by questionnaire) and skills (by observational checklist) was also done before and after training on the same day. All the AWWs of Project-1 and -2 were assessed for knowledge, whereas, skill assessment was done in 10% (i.e., n = 14) randomly selected AWWs of Project-1 and -2 based on lottery method. For the assessment of skills, observational checklist comprising of various steps of brushing and flossing was used. For each right step of brushing and flossing, the respondents were graded accordingly. The reliability of study tools was checked by "test-retest" concept, that is, the tools were pretested in 10 Anganwadi Centers (AWCs) of the district of Haryana. The linguistic validity (questionnaire asked in similar language, i.e., local language) and content validity was also checked. The principal researcher (a qualified dentist) was initially trained in administering the tools and providing OHTPs to AWW at Oral Health Sciences Department of a tertiary care hospital. She administered the tools and provided trainings under supervision of a team from Department of Health and Family Welfare, Union Territory, Chandigarh. The results were analyzed by an investigator, not involved in data collection and monitoring.
All the AWW who were present on the day of training were eligible for the study. The consent of the Project Officer - Integrated Child Development Services (ICDS) (in-charge of AWCs), and Medical Officer, ICDS, Chandigarh was taken prior to the conduct of the study. Informed verbal consent was taken from the AWWs. The double data entry was done, and data was checked for normalcy by drawing a normal probability plot in IBM Statistical Package for Social Sciences SPSS-16. The Chi-square test for measuring the difference in proportions and difference-in-difference analysis for measuring the net difference in the outcome between the two intervention groups was done. The project was approved by Institute Ethical Committee.
| Results|| |
A total of 112 AWWs of Project-1 and 98 from Project-2 were enrolled in the study. There was a significant increase in their level of knowledge about various aspects of brushing after training in both groups. The knowledge of AWWs regarding correct amount of toothpaste required for brushing significantly increased from 20.5% (n = 23) to 93.8% (n = 105) in OHTP-1 and from 7.1% to 95.9% (n = 94) in OHTP-2. The knowledge about primary dentition was low among the respondents prior to the training. Only 31.3% in Project-1 and 33.7% of Project-2 knew that milk teeth should also be filled if they were carious. However, it increased significantly to 68.8% (n = 77) and 71.4% (n = 70) respectively posttraining. The knowledge regarding the right age of starting cleaning of gums also increased significantly after the training in both groups [Table 1].
|Table 1: Comparative effect of two training packages on knowledge about oral hygiene among AWWs|
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Around 50.9% (n = 57) of the AWWs in Project-1 were aware that secondary teeth start erupting in the oral cavity by the age of 6-7 years. None of the AWWs of Project-2 in pretest were aware of time of eruption of teeth. Only 17.9% (n = 20) and 14.3% (n = 14) AWW of Project-1 and -2 respectively had heard about the "floss" before the training. This number was significantly increased to 98.2% (n = 110) and 96.9% (n = 96) posttraining. The awareness regarding the frequency of visit to dentist and best time of the day to have sweetened products increased significantly in both the groups after the oral hygiene training [Table 1].
[Table 2] shows the comparison of knowledge scores between two projects. In Project-1, the difference between pretest (50%) and posttest (1.8%) knowledge score of respondents scoring <22, was about 48.2%; whereas, in Project-2, the difference between pretest (62.9%) and posttest (only 1%) knowledge score was about 61.9%. The difference-in-difference analysis results showed that there was statistically significant (P = 0.04) improvement in the knowledge scores of AWWs of two projects scoring <22 marks. However, the difference of overall knowledge score between AWWs of two projects was not statistically significant, indicating a statistically similar increase in knowledge after imparting packages.
|Table 2: Comparative effect of two training packages on knowledge score of AWWs|
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During skill assessment of OHTP-1 group, only two AWW (out of total 14) took the right amount of toothpaste, 8 (57%) brushed on both outer and inner surfaces of teeth, only 2 (14.3%) brushed the tongue, and 6 (42.9%) brushed on chewing surfaces. However, posttraining results in OHTP-1 group increased to 100% in most of the parameters after the training except in brushing of the tongue (42.9%) and brushing on chewing surfaces (57.1%). In OHTP-2 group, correct demonstration of skills in all parameters was found in almost 100% of AWW after the training. The level of skills of AWW regarding most of the steps of flossing was also significantly increased in OHTP-2 as compared to OHTP-1 [Table 3]. The increase in skill score between two projects (by difference-in-difference method) was found to be statistically significant after imparting skill based OHTP (OHTP-2) as compared to the knowledge based package (OHTP-1).
|Table 3: Comparative effect of two training packages on skills score of AWWs|
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| Discussion|| |
The present study was targeted at AWWs as they have been proven to be highly effective in imparting knowledge to the community for various national health programs.  Further, with inadequate human resources to run the minimal curative services for vast populations, we have to rely on effective utilization of existing human resource in health. Though oral health education plays a key role in the prevention of oro-dental problems and its related complications, very little focus is given to this component of primary prevention. 
Baseline knowledge and skill assessment of Anganwadi worker
Majority of AWWs (97%) in the present study believed that brushing should be done twice or more in a day, and only 29% were aware that child's first dental visit should be by 1-year of age. In the contrary, a study by Bahuguna et al., showed that only 30% knew that brushing should be done twice a day and one-third supported that child's first dental visit should be by 1-year of age.  This may also be due to the misconception that since children do not have full dentition up to 1-year of age, it is not necessary to visit the dentist. However, a study by Schroth et al. in Manitoba showed that the majority (74.7%) parents agreed that the first dental visit should be made by 1 st year of age.  Mere 32% of AWW's in our study were correctly aware that milk teeth need to be filled in case of decay. The studies have shown that only 24% of caregivers knew that fillings in baby teeth were necessary. , It was in contrast to a cross-sectional study conducted in Manitoba, where 91.2% caregivers agreed that the care of primary teeth was as important as secondary dentition.  The reason for such a belief in the present study may be due to fact that primary teeth get replaced by permanent teeth, so there is no need of their filling in case of decay.
Mani et al. in their study among caretakers showed most of them had good knowledge of the role of fluoride and tooth brushing in caries development while only 29% knew that the frequent bottle feeding could cause tooth decay.  Another study showed that 61.5% of parents agreed that bottle feeding affects child's teeth, and 75.5% agreed that fluoridated toothpaste helps in preventing tooth decay.  Similar results were found in the present study wherein 61.4% of AWWs believed that the fluoride is necessary for toothpaste and 80% knew that toothbrush and tooth paste is best method to clean the teeth. Only 18% of AWWs in the present study were aware that frequent bottle feeding causes tooth decay.
Impact of knowledge and skill-based oral hygiene package on knowledge and skills of Anganwadi worker
In the present study, there was an improvement (although not statistically significant) in level of oral health knowledge among AWWs of OHTP-2 (knowledge and skills) as compared to OHTP-1 (knowledge only). The results of the present study aiming at improved knowledge of various categories of health care staff after an oral health education program were in accordance with other studies conducted in different parts of the world. ,,, A study by Le et al. among nursing home staff members of Canada, showed that posttest knowledge statistically significantly increased from the pretest level after imparting oral health knowledge to them (P < 0.05).  Another postintervention survey among community workers of south India showed statistically significant improvement in various knowledge domains like oral hygiene habits, importance of milk teeth, causes of dental diseases, prevention of dental diseases, and treatment of certain dental conditions. 
Our study also demonstrated a statistically significant improvement in skills using skill based package as compared to the knowledge based package. The results are in concordance with other studies wherein, a greater change in the oral hygiene skills in group who received a lecture along with a demonstration of tooth brushing as compared to those who received a lecture.  Another study by Frazγo et al. in Brazil among community health workers has shown an increase in the level of skills by a skill based education package.  These findings show the importance of reinforcing the lecture with demonstration of skill (e.g., individual tooth brushing, flossing, plaque disclosure) over lecture method.
| Conclusions and recommendations|| |
There was a significant increase in knowledge and skills of AWW's about various aspects of oral health after imparting training packages. The impact of OHTP-1 was not statistically different from OHTP-2 in knowledge of AWW in most of the parameters of oral health. However, there was a significant increase in skills of AWW's imparted with OHTP-2 as compared to OHTP-1. Such orientation trainings to basic health workers in oral health have demonstrated its usefulness to bring about the desired change in the oral habits and dental morbidity of children. 
The sustenance of improvements observed in AWWs on oral health knowledge and skills could not be observed due to time constraints. Further, group randomization was preferred over individual randomization to avoid contamination bias.
What this study adds?
- There was a significant increase in knowledge and skills of AWW's about various aspects of oral health after imparting training packages.
- Impact of skill based training package was better as compared to the knowledge-based training package.
- Empowering community workers like AWW in oral health, and providing basic oral health awareness to the mothers through them can be a feasible model for a developing country like India, where oral health is not a priority in primary health care.
| Acknowledgments|| |
We are thankful to National Rural Health Mission, Chandigarh for providing financial support to the project. We also extend our thanks to AWWs for their active participation in the study.
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[Table 1], [Table 2], [Table 3]