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Barriers to adopting and implementing an oral health programme for managing early childhood caries through primary health care providers in Lima, Peru
© Pesaressi et al.; licensee BioMed Central Ltd. 2014
Received: 14 September 2013
Accepted: 26 February 2014
Published: 6 March 2014
To identify barriers to participation in a primary oral health care programme aimed at preventing early childhood caries, as perceived by nurses.
Of a total of 140 randomly selected nurses employed in 40 government health centres in Lima, 123 completed a pre-tested questionnaire. Background variables were districts’ ‘socio-economic status’ (SES) and ‘years of experience’. Factor analysis was performed. ANOVA was applied for testing the influence of the background variables on the barrier factors. Chi-square test was applied to test for differences between single item barriers and the background variables. The Likert-scale (1–4) was used.
There was no statistical significant effect of ‘SES’ or of ‘years of experience’ of nurses on any of the 7 barrier factors, nor on the 11 single item barrier factors. The highest mean score (3.81) was obtained for the barrier factor ‘importance of oral health’, followed by ‘perceived responsibility’ (3.44). The lowest mean score was (1.70) for ‘knowledge on caries prevention’.
Nurses consider oral health very important and are willing to participate actively in programmes aimed at reducing Early Childhood Caries, provided that they will be trained well and that the director and dentists of the health centre give their consent.
Worldwide, Early Childhood Caries (ECC) is a serious public health problem that affects, in particular, children from low-income and disadvantaged communities [1–3]. Untreated ECC can lead to serious adverse conditions affecting the psychological [4, 5], social  and physical  development of children. Current care is often based on behavioural management in conjunction with invasive restorative interventions that sometimes require sedation or general anaesthesia [5, 8]. This approach does not guarantee acceptable clinical outcomes, nor is it considered effective in preventing the occurrence of new caries lesions. Furthermore, treatment under general anaesthesia is expensive and risky.
ECC is preventable [9, 10]. It has been suggested that providing preventive oral care for children at risk of ECC within the first year of life is crucial [11, 12], as is providing oral health education . However, dental visits during early childhood are infrequent, owing to a number of factors that are country and culture dependent . In many countries infants and toddlers regularly visit health centres for vaccinations and well-child controls and advice, delivered by Primary Health Care Providers (PHCP) [15, 16]. PHCPs, in most cases, have not been trained in oral healthcare and they do not counsel young children or parents about the prevention of ECC [17, 18]. However, if trained, they could educate parents and/or caretakers about good oral health behaviour and about detecting early signs of ECC.
In Peru, ECC is a public health problem. Its prevalence among 0-11, 12-23, 24-35 and 36-47 months-old infants from deprived areas of Lima (capital of Peru) is 10.5%, 27.3%, 60% and 65.5%, respectively . This high prevalence needs a multi-disciplinary approach. Collaboration with PHCPs employed in the Peruvian Public Health Framework, such as nurses, would be advantageous. Nurses see mothers during pregnancy and after birth, at 3- or 5-month intervals, when their infants require immunization and well-child controls. Hence, adding good oral health education and maintenance activities to the duties of nurses would provide a huge potential for sustaining healthy dentition and reversing the current ECC situation. However, for such duties to become effective, possible barriers to adoption and implementation by nurses of the required oral healthcare activities need first to be addressed [20, 21].
The aim of the present study was to identify the barriers that nurses in Lima, Peru could experience in adopting and implementing a primary oral healthcare programme targeted at infants and their caretakers in order to prevent early childhood caries.
Development of a questionnaire
A validated questionnaire identifying barriers to the adoption and implementation of a preventive oral health programme for use in the Peruvian healthcare system was not available. Therefore, an appropriate questionnaire needed to be developed and validated. This process was begun by obtaining information from the literature [8, 14, 15, 18, 21]. This was summarized into statements by a team of experts from the Peruvian Association of Dentistry for Infants (ASPOB) and from the Department of Global Oral Health of the Radboud University Nijmegen, The Netherlands. Five nurses from three randomly selected health centres of the Ministry of Health (MINSA), were interviewed, in order to gain understanding about the health organization, delivery of care and constraints experienced in their daily routine, and subsequently develop a structured questionnaire. The results were used in designing an open-ended questionnaire. It was then presented to a focus group of twenty-five nurses, not previously interviewed, for discussion about the completeness and comprehensiveness of the statements. The outcomes were then discussed by the principle investigators and a support team (8 members from ASPOB). This discussion led to the construction of a closed-ended questionnaire covering the following issues: ‘Importance of oral health’, ‘perceived responsibility’, ‘intention to give advice’, ‘training’, ‘social norms’, ‘experience in seeing carious lesions’ and ‘knowledge on caries prevention’. The final questionnaire in English consisted of 34 statements, each accompanied by a 4-point Likert’s scale (1 = Totally disagree, 2 = Disagree, 3 = Agree and 4 = Totally agree).
Closed-ended questionnaire designing process
Sample size and randomization
In the 20 districts of Lima, MINSA operated in 554 health centres where 5,180 nurses were employed in 2012 . Only health centres that had: 1) a vaccination and “well-child visit” section and; 2) followed preventive public strategies (vaccination, health education, pregnancy controls, well-child visits) were suitable for inclusion in the study. Adhering to these criteria resulted in the potential eligibility of 1,036 nurses, employed in 181 health centres. Based on an initially required sample size of 10% of nurses, and a correction factor of 10% for nurses who would have left the services by the time they would have received the questionnaire, and for a non-response of 20%, a sample size of 138 nurses was calculated.
Randomization was done as follows. The 181 health centres together with the number of nurses employed, were listed by district. Using the software programme Easy Randomizer , health centres were selected until the estimated sample size was reached. This resulted in a total of 140 selected nurses, originating from 40 health centres.
Questionnaires: delivery and collection procedure
The questionnaires were delivered to and collected from each nurse, after they had provided their consent to participate in the study and they received visits from the main researcher [EP] at their workplaces over a period of one and a half months. During the first visit, the aim of the study and the lay-out of the questionnaire were explained. Contact information including their full names, health centres and telephone numbers was registered. One week later, the questionnaire was collected. A third visit was needed, as some nurses had not yet filled in the questionnaire or had lost it before the second visit.
Factor barriers extracted (italics), statements from which they were derived and their internal consistency (Cronbach’s α)
Importance of oral health
Oral health is important
Taking care of primary teeth is important
Primary teeth are necessary for the health of permanent teeth
Action for controlling tooth decay is necessary
Dentist should be assisted by other health professional in managing decayed teeth
I should assist the dentist in managing oral health
Intension to give advice
I would advise mothers about habits that are beneficial for their children
If sufficient time I would provide advice and inspect the oral cavity
I can contribute to improvement of children’s’ oral health
After training, I will examine parents of the children
If appropriate instruments are available, I will do mouth inspection
After training, I would include oral inspection in my routine work
I participate if the dentist in the health centre accepts it
I participate if the director of the health centre approves it
Dental treatment must be exclusively be performed by dentists
Experience in seeing carious lesions
It is common to see children with tooth decay
I see many children with decayed primary teeth
During routine work, I see many children with toothache
During routine work, I see many mothers with decayed teeth
Knowledge on caries prevention
Nursing bottle should be recommended from the 6th month of life
To sweeten the milk in the nursing bottle is good
To sleep with the nursing bottle is harmful
Breast feeding should not be given after the 6th month of life
Ethical clearance was obtained from the Dental School of the San Martin de Porres University (Lima-Peru) institutional review board (resolution N° 252-2013-D-FO-USMP). Written consent was obtained from the nurses before interviews and delivery of the questionnaires. The data was collected anonymously, as the personal information of the respondent nurses was detachable and codified.
Disposition of respondents
A total of 123 nurses, 120 females and 3 males, from 40 health centres completed the questionnaire, which gave a response rate of 87.9%. Eighty-five percent of nurses were employed in health centres located in low, and 15% in midium/high, socio-economic areas. Twenty-two percent of nurses had less than 5 years of work experience, 36% had between 5 and 10 years and 42% had more than 10 years of work experience.
Mean scores and standard deviations (SD) of the 7 barrier factors
Importance of oral health
Intension to give advice
Experience in seeing carious lesions
Knowledge on caries prevention
Mean and standard deviation (SD) of single-item barrier factors and test results (chi-square) by background variables
Single item barrier factor
Mean ± SD
Participation in a training course on diagnosing and preventing caries lesions
Willingness to examine children orally after training
Examining children’s mouth is one of my official tasks
Able to recognize severely decayed teeth now
Believes that breast milk may cause tooth decay
Considers eating sugary food several times a day is harmful
Thinks that children consume sugary food several time a day
Agrees that oral hygiene should start before teeth appear
Agrees that a child should visit the dentist when the first tooth appears
Considers cavities in primary teeth acceptable because they will be replaced
Knows that it is common for children to sleep with a bottle in the mouth
No measuring instrument for assessing barriers to adopting and implementing a primary oral health care programme aimed at infants and children was available in the literature. Therefore, such an assessment instrument had to be developed. That fact implies that the newly constructed questionnaire could not be validated. However, face and content validation was performed and the questionnaire was judged to be valid enough for use in the present study. This and the high response rate indicates a high probability that the results present a true reflection of the opinions of nurses regarding barriers to adopting and implementing a primary oral health care program aimed at infants and children. The fact that one of the factors, ‘importance of oral health’, had a low Cronbach’s α was due to the very low deviation in outcomes, as almost all nurses reported that oral health is important.
The two major barrier factors identified were ‘importance of oral health’ and ‘perceived responsibility’. The high mean scores imply that nurses consider oral health, and particularly infant oral health, very important. They perceived that they have a role to play in assisting the dentist in the health centre, in maintaining good oral health among infants and children. The next two influential factors, ‘intention to advise’ and ‘training’, also had high mean scores. Nurses were willing to give advice to parents visiting the health centre if they received proper training in preventive oral care, mouth inspection and carious lesion detection. They will perform these duties only if there is consent from the health centre director and the dentist. The mean scores of the barrier factor ‘social norms’ clearly indicate that. Therefore, prior to development of the training course, a meeting needs to be arranged with the resident dentist(s) and health centre director, for discussion of these issues and approval of the ultimate collaborative goal of the oral health programme. Considering the strategic position of nurses, in terms of regular close contact with mothers and their infants at the health centre, they may become an important link in good oral health maintenance of under-served populations.
The fact that many nurses have seen the problem of tooth decay in children and pregnant women (‘experience in seeing carious lesions’) will add to their understanding and motivation to assist the children and if needed, adults, in maintaining and obtaining good functioning dentition. ‘Knowledge on caries prevention’ was the barrier factor with the lowest mean score. That finding is a stepping stone towards organization of a training course on oral health for nurses. Such a training course would prepare the nurses for active participation in the oral health programme and, if the dentist and director of the health centre agree to its implementation, nurses would become an important sector of the workforce helping to keep teeth of infants carious lesion-free. However, the implementation of a training program needs to be carefully planned, to guarantee the long-term adoption of the new approach. O'Brien et al.  reported that six out of seven studies using didactic presentations did not improve the behaviour of primary care providers, whereas seven out of eight studies covering interactive workshops reported significant subsequent improvements in professional behaviour. The findings regarding the single-item barrier factors are in line with those of the constructed barrier factors.
Traditional barriers to introduction of new methods in health education and oral health strategies in the field include time constraints, inclusion of dental procedures , lack of knowledge , and confidence related to the proposed activities . Therefore, lack of knowledge and lack of self-confidence are crucial factors to be addressed before implementing oral health programmes delivered in conjunction with other health professionals . Whilst there are numerous studies on reducing ECC though task-based integration of oral health aspects into existing primary healthcare structures, to our knowledge, the literature does not contain studies regarding barriers perceived by nurses, which makes a comparison of the results found in the present study with those of others not possible.
Public health nurses in Lima consider oral health very important and they were very willing to participate actively in oral health programmes aimed at reducing Early Childhood Caries, provided that the directors and dentists of the health centres have given their consent and that they have been trained well in the tasks which they are supposed to perform.
We would like to show our appreciation to the members and the Directive Committee of the Peruvian Association of Dentistry for Infants (ASPOB) and give special acknowledgment to Carlos Nurko for his invaluable help in the translation process needed to validate the questionnaire. Our deepest gratitude to nurses, officers of the Ministry of Health and health centre staff for their support and active participation during the present study. This research was funded by the World Dental Federation (FDI) and supported by the Department of Global Oral Health of the UMC St. Radboud Nijmegen, The Netherlands and the Department of Paediatric Dentistry of the San Martin de Porres University, Dental School, Lima - Peru.
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