FACTORS THAT CONTRIBUTE TO THE THE INCIDENCE OF SELF MEDICATION AMONG PREGNANT WOMEN ATTENDING ANTENATAL CLINIC IN ABIA STATE TEACHING HOSPITAL

DEDICATION This work is dedicated to God almighty for his grace and mercies over us for giving us the wisdom, mercy and resources to put this research together. This is also dedicated to our beloved families for their financial and moral support. We also dedicate this work to ourselves as this marks the first of many great works to come from us. ACKNOWLEDGEMENT We thank everyone who has contributed to the success of this project work. We are immensely grateful to our project supervisor in the person of Dr. Mrs Iwuoha for her love, words of encouragement, tolerance and guidance as she worked relentlessly to ensure that this work was a success. We also acknowledge our amiable H.O.D Dr P.E.N Onyemachi, the entire staff of the department of community medicine for their immense hard work and passion geared towards ensuring that they impact knowledge into us. Special thanks to our family for their all round support and prayers. Above all, we return all glory to God, the author and finisher of everything. ABSTRACT Background Oral health has been one of the most overlooked aspect of personal hygeine both by young and old. Most people seem to remember their oral health in times of severe toothache and even so, only when it starts disrupting their normal routine. It is common practice to only visit the dentist in times of pain and never bothering to do a checkup except when the pain returns. Aims and Objectives The aim of this study was to evaluate the knowledge, attitude and practice of oral health among secondary school students in Aba. Materials and Methods: This was a cross-sectional study conducted among 638 secondary school students from 6 secondary schools(3 private schools and 3 public schools) across 3 local government areas in Aba, Abia state. They include Amazing Grace secondary school, Abayi boys and girls secondary school, Soundbase secondary school, Boys technical college/girls technical college, Ninlan secondary school, Osusu Amaukwa secondary school. Data collected were analysed using statistical package for social sciences(SPSS). Results From our study, 493(77.2%) admitted they that they had knowledge of oral health, about 45% heard of it in school, 28% heard it over the radio/television, 11.2% heard about it in health facilities and 5.7% heard about oral health at home. From our study, the oral health practices amongst the students differed widely as about 70.8% of them brushed their teeth twice daily while 10.2% brushed once daily, 19% brushed more than twice daily. Majority of the students changed their toothbrush once every 3 months. Attitude showed that 78.2% of the students think visiting the dentist is necessary,while 13.8% do not. About 53.4% have never visited a dentist, and about 46.6% has visited the dentist at some point. When asked, those who have never visited, 47% of them said it was because of fear of needles and drilling, 41% was due to fear of injection. There was a statistically significant relationship between the school type(0.000), age(0.009) and class(0.000) to the knowledge of oral health. Conclusion  A significant number of secondary school students have heard about oral health, they also know that oral health can affect the general health of an individual. They are also aware that the use of toothbrush can improve oral health. They know that sweets and soft drinks can affect oral health and that treatment of any oral disease is as important as the treatment of the disease of any organ in the body. ORAL HEALTH: KNOWLEDGE, ATTITUDE AND PRACTICE AMONG SECONDARY SCHOOL STUDENTS IN ABA, ABIA STATE CHAPTER ONE 1.1 BACKGROUND STUDY Oral health can be defined as the state being free from mouth and facial pain, oral and throat cancer, oral infections and sores periodontal (gum) diseases, tooth decay, tooth loss and other diseases and disorders that limit an individual’s capacity in biting, chewing, speaking, smiling and psychological(emotional) wellbeing as reflected by the mouth. Oral health cannot be separated from the overall health and is indispensable for health development 2 and senescence 3. Although the sequelae of oral diseases are often underestimated or ignored 1, yet oral complication reflects, amplifies and may even initiate other health problems 2 and can have an intense negative impact on the quality of life. The importance of oral health goals was first emphasized in 1981 by WHO as part of the program: “Health for All by the year 2000 5 . In 2003, WHO jointly with World Dental Federation (FDI) and International Association for Dental Research (IADR), formulated goals for oral health to be achieved by the year 20206. This shows that there has been interest in oral health globally for quite some time, although great improvement has been made in the oral health status of the populations, problems still exist 7. Good oral health behavior and attitude such as regular tooth brushing and flossing (cleaning the spaces between the teeth), fluoridation, healthy nutritional habit, regular visit to the dentist etc, plays a fundamental role for general wellbeing by preventing common oral diseases. Oral health can be affected by surfeit of diseases and conditions which may include dental caries, periodontal diseases, oral cancer, oral infections and trauma from injuries, noma, cleft lip and cleft palate 4 . Among these, dental caries and periodontal disease have historically been considered the most patient global oral health burden. Worldwide, 60-90% of school children and nearly 100% of adults have dental caries, often leading to pains and discomfort 4 . In 2005, dental caries was more prevalent in several Asian countries and Latin American countries. However, its incidence is expected to increase in developing countries of Africa particularly as the result of the growing consumption of sugar and inadequate exposure to fluorides 7 . Periodontal disease may result in tooth loss and is found in 15-20% of middle-aged (35-44 years) adults 5. In industrialized countries, studies show that tobacco use is a major risk factor for adult periodontal disease. Its prevalence is expected to increase with growing consumption of tobacco 8. The prevalence of oral cancer is particularly high among men. It is the 8th most common cancer worldwide 9 . Tobacco and alcohol use are the major predisposing factors. Almost half (40-50%) of people who are HIV positive have oral fungal infections, oral bacteria or viral infections. These frequently occur in early course of HIV infections. Noma is a gangrenous lesion that affects young children living in extreme poverty primarily in Africa and Asia. Lesions are severe gingival disease followed by necrosis of lips and chins. Many children affected by noma suffer from infections such as measles and HIV and 90% die without treatment 4 . Despite the obvious gravity of these oral diseases, many of them are preventable1. Manifestations only occur when certain negative conditions are met or overtly met. The common risk factors for oral disease include an unhealthy diet, tobacco use, harmful alcohol use and poor oral hygiene 4. It can be observed that these risk factors are same for the so called four leading chronic diseases namely cardiovascular diseases, cancer, chronic disease and diabetes 4. Evidently, it is known that periodontal disease and tooth loss are related to diabetes mellitus10, and the growing incidence of diabetes may further impact negatively on the oral hygiene of people in several developing countries. The burden of oral disease and other chronic disease can be decreased by addressing the common risk factors. Some preventive measures would include: decreasing sugar intake, maintaining a well-balanced nutrition to prevent tooth decay and premature tooth loss, proper oral hygiene, using protective sports equipment and vehicle equipment, safe physical environments 4 etc. Dental caries can be prevented by maintaining low levels fluorides in the oral cavity. Fluorides can be obtained from fluoridated drinking water, salt, milk, toothpaste 4 etc. 1.2 STATEMENT OF PROBLEM Oral health is an aspect of health that has been relegated to background with minimal attention in recent times. There is an increasing neglect on oral health practices among people due to changing lifestyle which includes diet rich in sugar, wide spread use of tobacco and even consumption of alcohol with emphasis on the younger population i.e. teenagers (secondary school students) as they represent the transition from childhood to adulthood and this is when most of these unhealthy habits or lifestyle are formed. This issue of oral health is only given attention when deleterious or unpleasant disease condition emerges. Oral disease has been identified as a “silent epidemic”. The cost of this silent epidemic is enormous and climbing from 1996 to 2016, the total cost of dental services increased from 66 billion to 101.26 billion in the united state. The same however cannot be said for certain developing countries of Africa where the knowledge of oral health and outcome of oral diseases are not yet fully understood. Accordingly, the world health organization oral health program give priority to research helping to correct the so called 10/90 gap which relates to the fact that only 10% of funding for global health is allocated to health problems that affect 90% of the world’s populations. Despite improvement made, problems still exist and the challenge of the future will be to translate existing knowledge and sound experience of disease preventions and health promotions into actions particularly in developing countries that have not fully benefitted from advances in the oral health science to the fullest extent possible 7 . Dental caries is associated with impaired growth in children and can affect their appearance, self-esteem and speech 1. Children with poor oral health have significantly higher absence and poorer academic performances than their peers independent of socioeconomic factors and race 1 . The current pattern caries reflects primarily on distinct risk of profile across countries (i.e. living conditions, life styles and environmental factors) and the outcome of implementation of preventive oral health system 7 . Secondary school students and adolescents in Nigeria face challenges regarding their oral health because of daily high consumption of sugary foods and drinks which predispose them to dental caries and periodontal disease 12 Evidence has showed that strong knowledge of oral health demonstrates better oral practices 13. And this converse is also true. Nutritional disorder (vitamin c deficiency) and diabetes have also been identified to be contributing factors to periodontal disease. Dental investigators have explained that plagues play an explicit role in the initiation and progression of dental disease. A plague is a mass of soft accumulated material covering areas of the mouth that are not cleaned. Lack of adequate hygiene practices has been identified as a possible predisposing factor for occurrence of dental caries. Dental caries is associated with impaired growth in children and can affect their appearance, self-esteem and speech. Children widely engage in unhealthy habit that can cause consumption of sugary snacks. All these cause acid formation and acid accumulation which destroys the enamel. Good oral health behavior and attitude plays a critical role for general wellbeing by preventing common oral diseases such as dental caries and periodontal diseases. Good oral health attitude include regular tooth brushing and flossing, preventive measures such as fluoridation and sealant, healthy nutritional habits and regular visits to the dentists. Dental caries constitutes one of the major oral health problems with its prevalence as high as 30-45% among young children and adolescents in Nigeria, between the ages of 12 and 15 years respectively 15 . Generally children are faced with health problems that can either predispose them to dental disease or complicate health care. Lack of awareness about the link between nutritional and dental disease has also caused a lot of dental health problems, scurvy, dental caries etc. 1.3 JUSTIFICATION This study will be relevant to public health because it will critically examine the knowledge; attitude or disposition and practice of oral health among secondary school childrenin order to enlighten educate and sensitize them on the need to adopt good oral health practices. It will evaluate those practices and lifestyle that are common among secondary school children that deter good oral health and help the government, parents and teachers to curb such negative practices. This study aims at determining the extent of knowledge of oral health and its practice in south eastern part of Nigeria using Aba in Abia state as the study area. The finding of the study would help in the area of inculcating oral health education into the existing school curriculum in Abia state, seeing as there is no current policy on the issue and for assessing the need for regular school visits by dental professionals. Furthermore, the study will seek to examine the effect of poor academic performances of secondary school students in Aba. It is therefore pertinent to inculcate proper oral hygiene habit early in school children in order to prevent dental health problems and promote healthy teeth growth. Also the curriculum used in most Nigerian schools does not adapt oral health education 15 . Therefore, the awareness level of the negative effect of poor oral health among Nigerian students is low. The negative impacts of poor oral health include health pain, functional impairments and reduced quality of life. A review of the literature of the oral health knowledge, attitudes on the topic, thus there was a literature gap that this research intended to fill. 1.4 OBJECTIVES 1.4.1 MAIN OBJECTIVE:To determine the oral health knowledge, attitudes and practice among secondary school students in Aba, Abia state. 1.4.2 RESEARCH QUESTIONS 1. What is the level of knowledge of oral hygiene among secondary school students in Aba, Abia State? 2. What is the oral health status of secondary school students in Aba, Abia State? 3. What is the attitude of secondary school students in Aba, Abia State towards their oral health? 4. What is the oral hygiene practice among secondary school students in Aba, Abia State? 1. 4.3 SPECIFIC OBJECTIVES 1. To determine the level of knowledge of oral hygiene among secondary school students in Aba, Abia State. 2. To assess oral health status of secondary school students in Aba, Abia State. 3. To determine the attitude of secondary school students in Aba, Abia State towards their oral health. 4. To determine oral hygiene practice among secondary school students inAba, Abia State. CHAPTER TWO 2.1 INTRODUCTION The majority of oral health conditions are: dental caries (tooth decay), periodontal diseases, oral cancers, oral manifestations of HIV, oro-dental trauma, cleft lip and palate, and noma (severe gangrenous disease starting in the mouth mostly affecting children). Most oral health conditions are largely preventable and can be treated in their early stages. The Global Burden of Disease Study 2017 estimated that oral diseases affect close to 3.5 billion people worldwide, with caries of permanent teeth being the most common condition. Globally, it is estimated that 2.3 billion people suffer from caries of permanent teeth and more than 530 million children suffer from caries of primary teeth.19 In most low- and middle-income countries, with increasing urbanization and changes in living conditions, the prevalence of oral diseases continues to increase. This is primarily due to inadequate exposure to fluoride (in the water supply and oral hygiene products such as toothpaste) and poor access to oral health care services in the community. Being among the lower socio-economic groups who often have unhealthy habits, poor knowledge and attitudes to oral health and uptake of dental services and therefore are more likely to suffer from the burden of oral disease35. Marketing of food and beverages high in sugar, as well as tobacco and alcohol, has led to a growing consumption of products that contribute to oral health conditions and other non-communicable diseases. Poor oral health can lead to serious complications, such as pneumonia36. 2.1.1 DENTAL PROBLEMS Dental caries (tooth decay) Dental caries result when plaque forms on the surface of a tooth and converts the free sugars (all sugars added to foods by the manufacturer, cook, or consumer, plus sugars naturally present in honey, syrups, and fruit juices) contained in foods and drinks into acids that destroy the tooth over time. Risk factors includes physical, biological, environmental and lifetyle related factors such as high number of cariogenic bacteria, inadequate salivary flow, insufficient fluoride exposure, poor oral hygeine, inappropriate methods of feeding and poverty37. Periodontal (gum) disease Periodontal disease affects the tissues that both surround and support the tooth. The disease is characterized by bleeding or swollen gums (gingivitis), pain and sometimes bad breath. In its more severe form, the gum can come away from the tooth and supporting bone, causing teeth to become loose and sometimes fall out. Severe periodontal diseases are estimated to affect nearly 10% of the global population. The main causes of periodontal disease are poor oral hygiene and tobacco use.Oral and periodontal diseases can determine severe functional, phonatory and aesthetic impairment and are the main cause of adult tooth loss38. Oral cancer Oral cancer includes cancers of the lip, other parts of the mouth and the oropharynx. The global incidence of cancers of the lip and oral cavity) is estimated at 4 cases per 100,000 people. However, there is wide variation across the globe: from no recorded cases to around 20 cases per 100,000 people.20 Oral cancer is more common in men and in older people, and varies strongly by socio-economic condition. In some Asian-Pacific countries, the incidence of oral cancer ranks among the three top cancers.21 Tobacco, alcohol and areca nut (betel quid) use are among the leading causes of oral cancer.22 In North America and Europe, human papillomavirus infections are responsible for a growing percentage of oral cancers among young people.23 Oral manifestations of HIV infection Oral manifestations occur in 30-80% of people with HIV,24 with considerable variations depending on the affordability of standard antiretroviral therapy (ART). Oral manifestations include fungal, bacterial or viral infections of which oral candidiasis is the most common and often the first symptom. Oral HIV lesions cause pain, discomfort, dry mouth, and difficulties swallowing. Early detection of HIV-related oral lesions can be used to diagnose HIV infection and monitor the disease’s progression. Early detection is also important for timely treatment. Oro-dental trauma Oro-dental trauma results from injury to the teeth, mouth and oral cavity. Around 20% of people suffer from trauma to teeth at some point in their life.25 Oro-dental trauma can be caused by oral factors such as lack of alignment of teeth and environmental factors (such as unsafe playgrounds, risk-taking behaviour and violence). Treatment is costly and lengthy and sometimes can even lead to tooth loss, resulting in complications for facial and psychological development and quality of life. Noma Noma is a severe gangrenous disease of the mouth and the face. It mostly affects children between the ages of 2 and 6 years suffering from malnutrition, affected by infectious disease, living in extreme poverty with poor oral hygiene and/or with weakened immune systems. Noma is mostly found in sub-Saharan Africa, although cases have also been reported in Latin America and Asia. Noma starts as a soft tissue lesion (a sore) of the gums, inside the mouth. The initial gum lesion then develops into an acute necrotizing gingivitis that progresses rapidly, destroying the soft tissues and further progressing to involve the hard tissues and skin of the face. In 1998, WHO estimated that there were 140 000 new cases of noma annually. Without treatment, noma is fatal in 90% of cases. Survivors suffer from severe facial disfigurement, have difficulty speaking and eating, face social stigma, and require complex surgery and rehabilitation. Where noma is detected at an early stage, its progression can be rapidly halted, through basic hygiene, antibiotics and improved nutrition. Cleft lip and palate Clefts of the lip or palate affect more than 1 in 1000 newborns worldwide. Genetic predisposition is a major cause. However, poor maternal nutrition, tobacco consumption, alcohol and obesity during pregnancy also play a role.26 In low-income settings, there is a high mortality rate in the neonatal period. If lip and palate clefts are properly treated by surgery, complete rehabilitation is possible. Oral health inequalities Oral diseases disproportionally affect the poor and socially-disadvantaged members of society. There is a very strong and consistent association between socioeconomic status (income, occupation and educational level) and the prevalence and severity of oral diseases.26 This association exists from early childhood to older age, and across populations in high-, middle- and low-income countries. 2.2: ORAL HEALTH KNOWLEDGE In a study at North Central Ethiopia, a total of 422 patients participated in the study; among whom 216 (51.2%) were female students26. The study revealed that 253 (60%) of the respondents had good knowledge with regard to oral hygiene. A Survey in Chandigarh, India, revealed that a total of 58% had knowledge that infrequent brushing led to dental caries, staining of teeth, dental plaque and bleeding from gums.27 Most of them knew sweets (92.7%) and soft drinks (67.8%) affected dental health. In regard to knowledge about toothbrush and the brushing technique, approximately 93.9% of the subjects were aware that it was important to choose the right toothbrush27. A total of 63.7% were not aware of the type of dentifrice being used and approximately half of the study population did not know the purpose of fluoride (49.9%) and were using full bristle length amount of the toothpaste.27 In Bayelsa State, Nigeria, Majority of students within the Bayelsa East Senatorial District 878 (91.0%) with a mean score of 16.35 ±1.95 and students within the Yenagoa metropolis 346 (88.3%) with a mean score of 15.87 + 1.70 had good knowledge of oral health28. In a study at Ibadan, Oyo State, Nigeria, consumption of sticky, sugary and chocolaty food items was perceived by a majority (81.8%) as unhealthy to dental health and 66.3% perceived consumption of fruits and vegetables as healthy to the teeth29. Vertical brushing technique was mentioned by 69.7% of respondents as the best method of brushing the teeth, and 89.6% stated that teeth should be brushed twice daily. Majority 57.0% of respondents open caps of soft drink bottles with their teeth and 74.3% used toothpicks to remove food trapped in between teeth.29 Majority (82.8%) perceived that dentist should be visited for check-up once in 6 months29. There was a statistically significant relationship between tooth brushing technique and type of school attended by the respondents (P< 0.05).29 Another study at Illorin West Local Government Area of Nigeria revealed that the knowledge of respondents as regards oral health was generally below average in many aspects. Far less than half of the respondents could not identify the types of oral disease and the prevention of oral diseases.30 More than half (67.4%) of the respondents could not also attempt the definition of oral health. Although it is also worthy to mention that almost all (94.7%) said that brushing of teeth is to prevent mouth disease and all the respondents could mention one cause of oral disease30. In Tanga, Tanzania a study was carried where a structured questionnaire assessed 785 students level of oral health knowledge and practices. About 694(88.4%) students had adequate level of knowledge on causes, prevention of periodontal diseases, 760(96.8%) on causes and prevention of periodontal diseases, 695(88.5%) on cigarette smoking as cause of oral cancer, and 770 (98.1%) students on importance of dental checkups39. In Abha, Saudi Arabia a study was carried out using close-ended questionnaire which was distributed to children of six randomly selected intermediate schools. Most (82.3%) of the school children were aware that good oral health is important for general health. The priority for oral health information was given to dentists(31.6%), whereas teachers were given the least priority40. About half (53.5%) of the schoolchildren reported that sweets are the cause of dental caries, and 47.1% of them related pain with dental caries. More than half (58.8%) took sweets between meals40. At Debre Tabo town, in North Central Ethiopia, a study in 2018 of 422 students among whom 216(51.2%) were female students. The study revealed that 253(60%) of the respondents had good knowledge with regard to oral hygiene, more than half 281(66.6%) of the students had positive attitude toward oral hygiene, but thier oral hygiene practices were still low that 260(61.6%) of the students had poor oral hygiene practice41. In Calabar, Nigeria, a study was carried out among in-school adolescents(10-19yrs) in secondary schools (JSS1-SS2), a total of 335 students participated in this study with 228(68.1%) reporting that they are aware oforal healthcare services45.  2.3 ORAL HEALTH STATUS Oral disease is a major health problem worldwide, and in India there is very little epidemiological research done in this field in recent times. This study was carried out to provide baseline information on the major oral health problems (dental caries, periodontal disease, malocclusion, and dental fluorosis) among school children in Andhra pradesh. A total of 604 children (331 government and 273 private) were examined in the study. The mean oral hygiene index simplified (OHIS) was higher among government school children (2.9) compared private school children (0.6).31 The mean gingival score and mean decayed missing filled teeth were also higher among government school children compared with private school children. A significantly higher number of children in the government schools had poor oral hygiene status, moderate to severe gingivitis and caries experience. Oral diseases such as gingival diseases and dental caries affect about 80% of the school students worldwide. Another study was carried out in Kangra, Himachal Pradesh, India. The study was taken up with the aim to evaluate the oral health status and treatment need in the School going children of NagrotaBagwan Block of Kangra District, Himachal Pradesh.The mean OHI-S was 2.7 ± 2.81and 2.8 ± 2.99 in 5-8 and 9-12 years age group, respectively. The gingival bleeding was observed in 76.8% and 75.9%, calculus in 10.2% and 18.3% in 5-8 and 9-12 years age group, respectively.32 The overall caries prevalence of subjects was 58.4% with high caries prevalence in females as compared to males and in 9-12 years age group as compared to 5-8 years age group.32 The mean dmft/DMFT was 2.05 ± 4.13 and 2.56 ± 4.20 in 5-8 years and 9-12 years age group, respectively Tooth loss, as a result untreated dental caries is higher among urban school children than their rural counterparts, this was discovered by a study carried out comparing secondary students in rural and urban areas in Lagos, Nigeria. There was a statistically significant difference between urban and rural students in caries experience in permanent teeth (mean DMFT = 0.26 in urban areas; 0.11 in rural areas). More of the parents of students in the urban schools are educated than those in rural schools.34 The decayed (D) and missing (M) components were higher in the rural area, indicating a high level of restorative treatment need among the students in rural area. The urban participants had better oral hygiene and the gingival index was higher among rural students. Dental clinic attendance was higher among the urban participants than the rural participants.33 2.4 ORAL HEALTH ATTITUDE In a study in Ethiopia, a total of 422 patients participated in the study; among whom 271 (66.6%) of the students had positive attitude toward oral hygiene26. Another survey in Ethopia showed that the majority (87.7%) of students answered that oral hygiene is important for good oral health and general well-being.27 About 291 (69%) of the students said that neither the parents nor the teachers showed concern about oral hygiene, the other 131(31%) participants said that their teachers and parents were concerned.27 Majority of the students 365 (86.5%) believed that it was important for the parents and teachers to be concerned, whereas 57 (13.5%) were on the contrary.27 More than half of 221 (52.4) students thought that visiting a dentist is important, and they would advise other students to perform at home oral hygiene practices.27 When given a chance, 54.7% of the students would go for a checkup, and they would also advise other students to do the same.27 A study in Ethiopia showed that 248 (58.8) of the participants had never visited a dentist. And 172 (40.7%) visited a dentist due to that they experienced any dental pain, 2 (0.5%) visited a dentist every year26. With regard to reasons for visiting a dentist, among those who had visited a dentist, majority 127 (73%) went for to toothache, 37 (21.26%), went for tooth extraction be, 8 (4.6) went for to have tooth cleaned, and 2 (1.15%) went for regular checkup. The reasons for not visiting a dentist, among those students who never visit the dentist 213 (85.89%) were due to that they never experienced any dental pain and 359 (14.11%) students said that it is expensive26. A study in ibadan, Oyo state, Nigeria revealed that majority(81.8%) deem consumption of sweet , sticky and chocolaty food items are unhealthy to dental health, while 66.3% percieved consumption of fruits and vegetables as healthy to the teeth42. Also 69.7% of respondents believe that the vertical brushing technique is the best method42. Another study in Ibadan, Oyo state carried out on 2097 students aged 12-18years recruited from 30 randomly selected secondary schools showed that the oral health attitude score ranged from 0% to 91.3%; mean oral health attitude score was 44.5%(+/-13.8%)44. 2.5 ORAL HEALTH PRACTICE A study was undertaken amongst 1027 secondary level students in Chandigarh, India revealed that only 40% subjects brushed twice daily27. Among these subjects 27.7% were brushing according to the dentist directed brushing method, whereas 71.3% of subjects were using non-directed brushing method.27 A combination of brushing strokes was used by 59.7% subjects during brushing and about 32.7% brushed for more than 2 minutes.27 About 17% reported use of dental floss and 20% used either mouthwash or tongue cleaner as adjuncts..The age of study population ranged between 13 to 15 years with a mean age of 14 years27. The survey revealed that approximately 54% of the population studied, brushed their teeth once daily, while 40% respondents brushed twice a day27. Soft bristle toothbrush was used by 53.8% and 32.8% replaced their brush every month. Tooth brush with dentrifice was the most frequent method of oral hygiene amongst study population. In all 1.7% of study sample reported using floss and 20% used either mouth-wash and tongue cleaner as extra aids for oral hygiene27. Only 12.9% visited dentist regularly after every 6-12 months.27 Among sample subjects 28.7% were brushing according to the dentist directed brushing method, where as 71.3% of subjects were using non-directed brushing method.27 A combination of brushing strokes was used by 59.7% subjects during brushing and about 32.7% brushed for more than 2 minutes.27 In a study in Saudi Arabia,392 participants were used, aged 15-22yrs, and approximately 87% of the students brushed their teeth twice daily, it was also revealed that girls practice better oral hygiene than boys in terms of daily brushing habit, brushing intervals, and toothbrush replacement43. In a study in Ethopia, their oral hygiene practices were so low. that 260 (61.6%) of the students had poor oral hygiene practice26. The higher percentage of students, 263 (62.3%) reported that they cleaned their tooth using different tools and dentifrices.26 Among the students who clean their tooth 234 (88.97%) brushed once daily, 10 (3.8%) brushed twice, 4 (1.52%) brushed three times per day, and other 15 (5.71%) student brushed their teeth occasionally. From those students who clean their teeth, 134 (50.96%) used chewing stick only to clean their teeth, 65 (24.7%) used a toothbrush and 55 (20.92) used both chewing stick and toothbrush and 9 (3.42) students use different material toothbrush their teeth.26 About 230 (87.43%) of the students brushed their teeth before meal, most students 14 (5.3%) brushed their teeth both before and after meals, and the rest 19 (7.22%) students brushed their teeth after meal.26 A study conducted in Ibadan, Oyo state, showed that majority (82.8%) perceived that dentist should be visited for check up once in 6 months, however, only 31.6% of respondents had visited dentists before42.89.6% of the respondents brushed twice daily while 11.4% brushed once daily42. In another study in Ibadan, Oyo state, Nigeria, 2097 students aged 12-18years were recruited from 30 randomly selected secondary schools. The oral health practice score ranged from 0% to 88.9% and the mean oral health practice score was 42.5%(+/- 13.8%)44. A study at Ilorin West Local Government Area of Nigeria revealed that the practices of respondents as regards oral health was generally below average in many aspects. Close to half (46.6%) of the children change their toothbrush only when it get frayed. Most of them brushed their teeth at least twice daily. Also, very few (9.3%) of them do not engage in consumption of confectioneries31. Majority (83%) had also never visited a dentist.31 A study was carried out in Bayelsa East and Yenegoa concerning oral hygiene practices of the students in both study areas, the majority of students were shown to have good oral hygiene practices including the use of toothbrush and toothpaste, cleaning their mouths twice a day as well as changing their toothbrushes every 1 – 3 months29. Most of the students had however never visited the dental clinic. In Calabar, Nigeria, a study was carried out among in-school adolescents(10-19yrs) in secondary schools (JSS1-SS2), a total of 335 students participated in this study with 136(40.6%) reporting that they have utilized oral healthcare services45. CHAPTER3 METHODOLOGY 3.1. Introduction This chapter explains the study area, population and design, and also sample and sampling technique, instruments, method of data collection and analysis. 3.2. Study Area Aba is located in Abia State, Nigeria. Abia State has 17 Local government areas and occupies a total land mass of 6,320km2(2,440sq mi) with a population of 4,112,320. Its population density is 650/km2 (1700/sq mi). There are 3 senatorial zones in Abia State namely Abia South, Abia North and Abia Central. Abia South has 7 Local government areas namely Aba North, Aba South, Ugwunagbo, Obingwa, Ukwa West, Ukwa East and Osisioma. Aba is the largest city in Abia State. It is located on 5.11 latitude and 7.37 longitude and is situated at elevation 64 meters above sea level. Aba has a population of about 1,114,388 making it the most populated city in Abia State. It is a major urban settlement and a commercial centre in a region that is surrounded by small villages and towns. Its residents are made up of civil servants, business people, farmers and students. The religion mainly practiced by these people is Christianity. 3.3. Study Design The design for this research is a cross sectional analytical study that was carried out among secondary school students in the 3 selected L.G.A. in Abia State. Information was collected on the knowledge, attitude, and practice among secondary school students. 3.4. Study Population This study was carried out among selected secondary schools in Aba, Abia State. The study population comprised of secondary school students in 3public and 3 private schools( names of the schools) 3.5. Sample Size Determination The sample size was determined using the formula; N = (Z2 P Q)/D2 Where, N = minimum sample size. Z = standard normal deviate (1.96) P = standard proportion of target population (20%) Q = 1- P D = degree of accuracy And, Z = 1.96 P = 20% = 0.20. Q = 1 – P = 0.8 D = 0.05 Therefore, N = [ (1.96)2 x 0.20 x 0.8] / (0.05)2 = (0.6144/0.0025) = 245.76 = 245 x 2 = 490 Hence, the sample size was adjusted to 490 using the design effect. 3.6. Sampling Technique Stratified random sampling method was used. 69 students were selected from each school using this technique. The sampling method was used to capture the picture of the whole school from each of the stratum. Students were randomly selected and given questionnaires to fill. 3.6.1. Inclusion Criteria Secondary school students in the 6 selected schools who were willing to participate. 3.6.2. Exclusion Criteria Students who were absent on the day of administering the questionnaire Students who were not willing to participate 3.7. Data Collection A self-administered closed and open-ended questionnaire will be used. For those questions where the respondent has more than one response. The questionnaire was in five sections. Section A: The socio-demographic characteristics of the respondents Section B: questions involving their level of knowledge of oral hygiene. Section C: involves questions about their oral health status. Section D: questions their attitude towards oral health. Section E: Their practice of oral hygiene. 3.8. Study Equipment • Questionnaires 3.9. Data Analysis The questionnaires were sorted and analysed using the Statistical Package for Social Sciences (SPSS, v. 20). 3.10. Data Presentation Data generated were summarized using tables and Frequency distribution of various variables. Descriptive analysis was done by calculating relevant means and standard deviation for quantitative variables (age,…) while qualitative variables (including gender, cadre, level of education) were analysed using proportions. Inferential statistics was used to test for relationship between the variables. A P-value of Two times 65 10.2% 452 70.8% 121 19.0% Frequency of dental flossing (cleaning between teeth) Never Once Twice > Two times 39 6.1% 112 17.6% 388 60.8% 99 15.5% Time spent on brushing. < 1 Minute 1 - 2 Minutes > 2 Minutes 61 9.6% 438 68.7% 139 21.8% Daily consumption of sugary food or drinks Once Twice Thrice > Three times 323 50.6% 204 32.0% 94 14.7% 17 2.7% Cigarette and tobacco smoking No Yes 625 98.0% 13 2.0% Regular change of toothbrush Once every 3 Months Once every 4 Months Once every 6 Months 568 89.0% 29 4.5% 41 6.4% The oral health practices among these students was studied and it was observed that 65 (10.2%) brushed their mouth once a daily, majority, 452 (70.8%) brushed their mouth twice a day, while 121 (19.0%) brushed their mouth more than twice a day. A vast majority of them, 546 (85.6%) used Toothbrush and paste, 41 (6.4%) used mouth wash, 19 (3.0%) used dental floss, 8 (1.3%) used chewing stick, and 24 (3.8%) used toothbrush and chewing stick. When asked how often they did lean in-between their teeth per day, 39(6.1%) never did, 112 (17.6%) said once. Majority 388 (60.8%) did twice, where as 99 (15.5%) more than twice. When asked about how much time they spend on brushing, 61 (9.6%) spent less than a minute when brushing, majority of them, 438 (68.7%) spent 1-2 minutes when brushing, and 139 (21.8%) brushed for more than 2 minutes. Majority of the students 568 (89.0%) said they changed their toothbrush once every 3 months, 29 (4.5%) once every 4 months, and 41 (6.4%) said once every 6 months. 13(2.0%) of the students admitted to smoking cigarettes/tobacco, while 628 (98.0%) of the students did not smoke cigarettes/tobacco. 4. ATTITUDE TOWARDS ORAL HEALTH TABLE 4 Variables Frequency (N=638) Percentage (%) Regular visits to the dentists are necessary No Yes Don't Know 88 13.8% 499 78.2% 51 8.0% Dental visits No Yes 341 53.4% 297 46.6% Duration of dental visits (n= 297) Once every 6 months Once every year Once in 2 years 185 62.3% 83 27.9% 29 9.8% FIGURE 3 From the figure above, 55% visited the dentist due to toothache, 35% visited due to dentist's advice and 13% due to parents advice. FIGURE 4 The figure above shows that 47% dislike visiting the dentist due to fear of needles and drills, 41% due to fear of injections, while 21% due to long waiting time. On attitude shows that 499 (78.2%) thinks visiting the dentist is necessary, while 88 (13.8%) of them thinks it is unnecessary. The other 51 (8.0%) said they did not know. 341 (53.4%) have never visited a dentist, whereas 297 (46.6%) have visited a dentist a some point in their life. Among those that admitted to have visited the dentist, 185 (62.3%) visits once every 6 months 83 (27.9%) once every year, and 29 (9.8%) once every 2 years. When asked about their reasons for visiting the dentist, 55% said it was because of toothache, 35% for dental advice, and 13% said it was due to advice from their parents. Those who never visited, 47% said it was because of fear of needles and drilling. 41% was due to fear of injection, and 21% long waiting time. TABLE 5 Knowledge of Oral Health by School-Type Variable Frequency (N=638) Statistics Private (n%) Public (n%) Total N (%) X P-value Awareness of oral health No Yes 0.627 0.429 64 (21.3) 81 (24) 145 (22.7) 236(78.7) 257 (76) 493 (77.3) Mode of information (n=493) School Radio/Tv/Social Media Health Facility Home Others 27.899 0.000013* 110 (46.6) 44 (18.6) 37 (15.7) 14 (5.9) 31 (13.1) 112 (43.6) 95 (37) 18 (7) 14 (5.4) 18 (7) 222 (45) 139 (28.2) 55 (11.2) 28 (5.7) 49 (9.9) Definition of oral health Activities that ensure cleanliness of the mouth as a whole. Incorrect Answers 13.905 0.0001* 226 (75.3) 208 (61.5) 434 (68) 74 (24.7) 130 (38.5) 204 (32) Effect of oral health on general health No Yes 8.801 0.003* 121 (40.3) 176 (52.1) 297 (46.6) 179 (59.7) 162 (47.9) 341 (53.4) Regular use of toothbrush & toothpaste only provide a healthy mouth No Yes 11.817 0.001* 145 (48.3) 118 (34.9) 263 (41.2) 155 (51.7) 220 (65.1) 375 (58.8) Treatment of any oral disease is as important as treatment of any organ in the body No Yes Don’t Know 8.245 0.016* 60 (20) 56 (16.6) 116 (18.2) 239 (79.7) 271 (80.2) 510 (79.9) 1 (0.3) 11 (3.3) 12 (1.9) Advance in age affects loss of teeth No Yes 1.989 0.158 101 (33.7) 132 (39.1) 233 (36.5) 199 (66.3) 206 (60.9) 405 (63.5) Sweets and soft drinks affect the oral health negatively No Yes 14.545 0.001* 29 (11.7) 23 (9.6) 52 (10.7) 52 (21.1) 38 (15.9) 90 (18.5) Don’t Know 9 (3) 29 (8.6) 38 (6) ** Significant (p