Oral Health-Related Knowledge, Attitudes, and Practices of Diabetic Patients in Tanzania
Diabetes mellitus (DM), a metabolic endocrine disorder characterized by hyperglycaemia, is one of the most rapidly growing chronic conditions in the world. , Its burden has been increasing substantially in low- and middle-income countries (LMICs). , , Chronic hyperglycaemia can cause damage to various organs of the body such as the heart, kidney, nerves, and pancreas, including the oral cavity. Oral complications and manifestations of diabetes include periodontal diseases (gingivitis and periodontitis), xerostomia, candidiasis, opportunistic infections, delayed healing of the oral wound, and altered taste. , A synergetic relationship between periodontal disease and DM has been reported, whereby poor glycaemic control in diabetic patients increases the severity of periodontal diseases and likewise, periodontal disease can negatively affect glycaemic control, aggravating the diabetic status of an individual. , Thus, maintaining good oral hygiene and periodontal health contributes to good glycaemic control in diabetics. In order to assess the willingness of patients with DM to adopt good oral hygiene practices, it is important to evaluate their knowledge and attitudes towards oral health. This is so because good knowledge leads to better practice of oral health and has a positive influence on attitude towards oral health. Studies from different countries have reported varying results regarding the general oral health-related knowledge, attitude, and practices (KAP) of patients with DM. A scoping literature review of oral health-related KAP of patients with DM in South Asia revealed that the people with DM had some level of awareness about oral health and limited care practices to maintain good oral health. A study from Egypt reported that the level of awareness and dental health knowledge in patients with DM was deficient. Likewise, in Bangladesh, Arefin et al. noted the level of knowledge of patients with DM on oral health was good but the level of practice on oral health was poor. Similarly, a study by Yuen et al. from the USA showed that only 47% of the patients with DM answered the oral health knowledge questions related to diabetes correctly. Though in Tanzania the number of patients diagnosed with DM is increasing, a knowledge gap exists regarding their oral-health-related KAP. Thus, it is obligatory to assess the KAP of patients with DM regarding oral health to establish baseline information and therefore plans for oral health awareness programs among patients diagnosed with DM. The present study was carried out to assess oral health-related KAP of patients with DM attending public diabetic clinics in Dar es Salaam, Tanzania.   Study design, setting, and population This multicentric cross-sectional study was carried out between November 2020 and May 2021. It involved adult patients diagnosed with type 1 or type 2 DM attending treatment in public referral hospitals in Dar es Salaam. The selected diabetic clinics were those in Muhimbili National Hospital, Mwananyamala Referral Hospital, Temeke Regional Hospital, and Amana Referral Hospital. All patients with DM aged 18 and above who visited the selected diabetic clinics were eligible to participate in this study. Patients with DM with intellectual disabilities and those who were unwell on the day of data collection, hence could not answer the questions were excluded from the study. The sample size was estimated by using the population adjustment formula for single-proportion estimation. A sample of 384 participants was calculated based on a 95% confidence level, a 5% margin of error, a power of 0.8, and an expected proportion of 50%. Simple random sampling was used to obtain participants from a list of patients who attended the diabetic clinics on the day of data collection. For the total sample size calculated, 40% of the patients were from the MNH diabetes clinic, and the rest 60% were equally obtained from the 3 referral hospitals. Questionnaire and data collection Due to the lack of a Swahili study tool for use in this research setting, An English questionnaire (SI-1) was developed and subsequently translated into Swahili (SI-2). To check for consistency of the Swahili questionnaire with the original version, an independent translator (language expert) was used to back-translate it into English again. The questionnaire used was composed of questions inquiring about the sociodemographic characteristics of the participants (age, sex, marital status, level of education, and occupation), the general question regarding patients’ history with diabetes, 13 questions on oral health knowledge in relation to DM, 4 attitude questions towards oral health, and 5 oral health practice related questions. The KAP questions were measured in the yes/no/I don't know fashion. Each correct response was allocated 1 point. The Swahili version of the questionnaire was distributed to the patients on the day of data collection to the participants while they awaited in the waiting area of the diabetic clinic. The investigator was always around to aid participants who needed clarifications and also to ensure participants did not discuss the answers among themselves. For a few patients without formal education, the investigator interviewed them and recorded their responses to the questionnaire. There was no follow-up visit of the patients who had taken part in this study Statistical analysis Data coding and analysis were done using the Statistical Package for Social Sciences software (SPSS) for Windows (version 26: IBM Corp). Means, standard error of the mean, and proportions were used for descriptive analysis. The reliability of the questionnaire was assessed by distributing the Swahili questionnaire to 30 subjects, and after an interval of 7 days, the same group of individuals filled in the English questionnaire. Cohen's Kappa statistics were performed with a substantial agreement in responses ( К = 0.78 [95% CI, 0.510-0.921], P < .001). The participants’ age was categorized as young adults (<40 years), middle-aged (40-59 years), and elderly (≥60 years). The level of education was dichotomized into a low level (no formal and primary education) and a high level (secondary and tertiary education). The duration since diagnosis of DM was made was dichotomized into <5 and ≥5 years. The cut-off point between good and poor KAP domains was decided based on the sample mean points for each domain. The cut-off point for good knowledge was >7 points. A good attitude was considered if the participant answered all 4 questions correctly. The cut-off point for good practice was >3 points. Univariate analysis was carried out to assess factors associated with good KAP related to oral health among diabetic patients. The probability level of α < 0.05 was selected for statistical significance. The strength of the association between good oral health-related KAP and the predictor variables was assessed by multivariate logistic regression.   This multicentric cross-sectional study was carried out between November 2020 and May 2021. It involved adult patients diagnosed with type 1 or type 2 DM attending treatment in public referral hospitals in Dar es Salaam. The selected diabetic clinics were those in Muhimbili National Hospital, Mwananyamala Referral Hospital, Temeke Regional Hospital, and Amana Referral Hospital. All patients with DM aged 18 and above who visited the selected diabetic clinics were eligible to participate in this study. Patients with DM with intellectual disabilities and those who were unwell on the day of data collection, hence could not answer the questions were excluded from the study. The sample size was estimated by using the population adjustment formula for single-proportion estimation. A sample of 384 participants was calculated based on a 95% confidence level, a 5% margin of error, a power of 0.8, and an expected proportion of 50%. Simple random sampling was used to obtain participants from a list of patients who attended the diabetic clinics on the day of data collection. For the total sample size calculated, 40% of the patients were from the MNH diabetes clinic, and the rest 60% were equally obtained from the 3 referral hospitals.   Due to the lack of a Swahili study tool for use in this research setting, An English questionnaire (SI-1) was developed and subsequently translated into Swahili (SI-2). To check for consistency of the Swahili questionnaire with the original version, an independent translator (language expert) was used to back-translate it into English again. The questionnaire used was composed of questions inquiring about the sociodemographic characteristics of the participants (age, sex, marital status, level of education, and occupation), the general question regarding patients’ history with diabetes, 13 questions on oral health knowledge in relation to DM, 4 attitude questions towards oral health, and 5 oral health practice related questions. The KAP questions were measured in the yes/no/I don't know fashion. Each correct response was allocated 1 point. The Swahili version of the questionnaire was distributed to the patients on the day of data collection to the participants while they awaited in the waiting area of the diabetic clinic. The investigator was always around to aid participants who needed clarifications and also to ensure participants did not discuss the answers among themselves. For a few patients without formal education, the investigator interviewed them and recorded their responses to the questionnaire. There was no follow-up visit of the patients who had taken part in this study   Data coding and analysis were done using the Statistical Package for Social Sciences software (SPSS) for Windows (version 26: IBM Corp). Means, standard error of the mean, and proportions were used for descriptive analysis. The reliability of the questionnaire was assessed by distributing the Swahili questionnaire to 30 subjects, and after an interval of 7 days, the same group of individuals filled in the English questionnaire. Cohen's Kappa statistics were performed with a substantial agreement in responses ( К = 0.78 [95% CI, 0.510-0.921], P < .001). The participants’ age was categorized as young adults (<40 years), middle-aged (40-59 years), and elderly (≥60 years). The level of education was dichotomized into a low level (no formal and primary education) and a high level (secondary and tertiary education). The duration since diagnosis of DM was made was dichotomized into <5 and ≥5 years. The cut-off point between good and poor KAP domains was decided based on the sample mean points for each domain. The cut-off point for good knowledge was >7 points. A good attitude was considered if the participant answered all 4 questions correctly. The cut-off point for good practice was >3 points. Univariate analysis was carried out to assess factors associated with good KAP related to oral health among diabetic patients. The probability level of α < 0.05 was selected for statistical significance. The strength of the association between good oral health-related KAP and the predictor variables was assessed by multivariate logistic regression.   Characteristics of the study population Of the 384 participants, females were 224 (58.3%) with male-to-female ratio of 1:1.4. Their ages ranged between 18 and 88 years. The mean age was 55 years (SEM = 0.57). A majority ( N = 201; 52.3%) were middle-aged adults. Most ( N = 210; 54.7%) participants had a primary level of education. The duration since the participant was diagnosed with DM ranged from 0 to 30 years, with a mean duration of 6.3 years (SEM = 0.27). Most ( N = 202; 52.6%) participants were diagnosed more than 4 years. The duration since the participant started using antidiabetic medications was between 0 and 30 years and the mean drug use duration was 6.11 years (SEM = 0.27). Almost all ( N = 381; 99.2%) participants reported using their medications regularly. Only 19 (4.9%) reported that their physicians had ever referred them to a dental professional for oral health check-ups . Knowledge regarding oral health Of the possible score of 13 points (range 0-13 points), the mean oral health-related knowledge score was 7.27 points (SEM = 0.14). A majority ( N = 337; 87.8%) of participants knew that wound healing is generally delayed in diabetics. Only a few ( N = 120; 31.3%) participants knew that oral health influences the progression of DM . Attitude towards oral health The mean oral health-related attitude score of the participants was 3.69 points (SEM = 0.04) out of 4 points (range 0-4 points). Most ( N = 375; 97.7%) participants thought it is important for patients with DM to maintain proper and good oral hygiene. Some ( N = 52; 13.5%) participants did not think it was important for patients with DM to have regular dental check-ups . Oral health practices For oral health-related practice, the mean score was 2.93 points (SEM = 0.05) of a total possible score of 5 points (range 1-5 points). The most common oral health-related practices among the participants were brushing of teeth ( N = 384; 100%) and consulting a dental professional whenever they have oral health-related problems ( N = 338; 88%). The least oral health-related practice was the use of mouthwash . Factors associated with knowledge, attitudes, and practices related to oral health Good levels of KAP related to oral health among participants diagnosed with DM were 51.0%, 82.3%, and 20.6%, respectively. Oral health knowledge had a statistically significant association with the level of education and previous referral to the dentist ( P < .05). Where the level of education and knowledge regarding oral health were significantly associated with the attitude of participants ( P = .038). The practice was associated significantly with level of education, previous referral to the dentist, oral health knowledge, and attitude towards oral health ( P < .05) . Results of multiple regression analysis showed that the odds of good oral health knowledge among participants were almost 2 folds higher in participants with high education levels and 7 folds higher in those who had been referred to a dentist by a physician. Compared to participants with low education levels, the chances of a good attitude towards oral health were 1.6 folds higher among participants with high education levels. Participants with good oral health knowledge were 5.5 times more likely to have a good attitude compared to their counterparts. The participants with high education levels were almost 3 times more likely to have good practice compared to those with low levels, and the odds of good oral health practice were 2 folds higher among those with good knowledge of oral health .   Of the 384 participants, females were 224 (58.3%) with male-to-female ratio of 1:1.4. Their ages ranged between 18 and 88 years. The mean age was 55 years (SEM = 0.57). A majority ( N = 201; 52.3%) were middle-aged adults. Most ( N = 210; 54.7%) participants had a primary level of education. The duration since the participant was diagnosed with DM ranged from 0 to 30 years, with a mean duration of 6.3 years (SEM = 0.27). Most ( N = 202; 52.6%) participants were diagnosed more than 4 years. The duration since the participant started using antidiabetic medications was between 0 and 30 years and the mean drug use duration was 6.11 years (SEM = 0.27). Almost all ( N = 381; 99.2%) participants reported using their medications regularly. Only 19 (4.9%) reported that their physicians had ever referred them to a dental professional for oral health check-ups .   Of the possible score of 13 points (range 0-13 points), the mean oral health-related knowledge score was 7.27 points (SEM = 0.14). A majority ( N = 337; 87.8%) of participants knew that wound healing is generally delayed in diabetics. Only a few ( N = 120; 31.3%) participants knew that oral health influences the progression of DM .   The mean oral health-related attitude score of the participants was 3.69 points (SEM = 0.04) out of 4 points (range 0-4 points). Most ( N = 375; 97.7%) participants thought it is important for patients with DM to maintain proper and good oral hygiene. Some ( N = 52; 13.5%) participants did not think it was important for patients with DM to have regular dental check-ups .   For oral health-related practice, the mean score was 2.93 points (SEM = 0.05) of a total possible score of 5 points (range 1-5 points). The most common oral health-related practices among the participants were brushing of teeth ( N = 384; 100%) and consulting a dental professional whenever they have oral health-related problems ( N = 338; 88%). The least oral health-related practice was the use of mouthwash .   Good levels of KAP related to oral health among participants diagnosed with DM were 51.0%, 82.3%, and 20.6%, respectively. Oral health knowledge had a statistically significant association with the level of education and previous referral to the dentist ( P < .05). Where the level of education and knowledge regarding oral health were significantly associated with the attitude of participants ( P = .038). The practice was associated significantly with level of education, previous referral to the dentist, oral health knowledge, and attitude towards oral health ( P < .05) . Results of multiple regression analysis showed that the odds of good oral health knowledge among participants were almost 2 folds higher in participants with high education levels and 7 folds higher in those who had been referred to a dentist by a physician. Compared to participants with low education levels, the chances of a good attitude towards oral health were 1.6 folds higher among participants with high education levels. Participants with good oral health knowledge were 5.5 times more likely to have a good attitude compared to their counterparts. The participants with high education levels were almost 3 times more likely to have good practice compared to those with low levels, and the odds of good oral health practice were 2 folds higher among those with good knowledge of oral health .   With rapid urbanization in LMICs changes in lifestyle behaviours, including harmful changes in the diet of the population have led to an increase in noncommunicable diseases like DM. Currently, it is estimated that almost 80% of people living with diabetes are LMICs. Like other LMICs, Tanzania is facing a growing burden of diabetic patients as well. This increase raises concern for oral health professionals considering the synergetic relationship between oral health, especially periodontal diseases, and DM. It is well known that maintaining good oral hygiene and periodontal health contributes positively towards controlling DM, and good practice is influenced by better knowledge of the subject matter. Results from elsewhere suggest that the oral health-related knowledge of diabetic patients is deficient and thus low oral health practice. , Thus, this study aimed at assessing oral health-related KAP of patients with DM in Tanzania. In the current study, there were slightly more female patients attending diabetic clinics compared to their counterparts. Our findings were concurrent with the findings of a previous study from Tanzania and Egypt. The findings of a higher number of females reflect improvements in gender equity in access to health care in Tanzania. The mean age of patients with DM enrolled in this study was similar to those from elsewhere, , , but higher than previous findings from Tanzania. , Nearly 60% of the participants in this study were aged less than 60 years. These findings are of public health concern since diabetes not only affects functional capacities of an individual but the quality of life as well. Moreover, recent findings point out that more than one-third of diabetes-related deaths occur in people under the age of 60 years. Among the most worrying findings of this study was that only less than 5% of the patients with DM who participated in this study had ever been referred to a dental professional by their attending physician. The tendency of low referral rates of patients with DM to the dentist has been also noted in a study from Australia. This low referral rate in the current setting of the study may indicate that the physician attending the diabetic patients may have very limited knowledge of the significant association between DM and oral health. Similarly, it may also mean there are no solid guidelines that necessitate patients with DM to be regularly reviewed by dental professionals. Low knowledge among physicians is anticipated because it is a fact that the more knowledgeable doctors are, the more likely they are to make dental referrals. Based on these results, there is a need to carry out a study to assess the oral health-related knowledge and attitude of physicians who care for diabetic patients in Tanzania. The proportion of patients with DM who knew that diabetes affects oral health was higher than reports from Egypt and Bangladesh but lower than the findings from Kuwait. Yet still, only a few participants in this study knew that poor oral health can exacerbate diabetes. This signifies that a majority of people with diabetes are still unaware of the bidirectional link between diabetes and oral health, which is similar to reports from elsewhere. , The findings of this study pointed out that only 51% of the study participants had a good level of oral health-related knowledge. This was nearly similar to the findings from Egypt and USA but lower than the findings from Kuwait and Iran. The difference in results of these various studies can be attributed to differences in methodology and the study population. The questionnaire used in this study was solely based on oral health, unlike in other studies, where knowledge questions incorporated some other systems of the body. Based on the findings of this study, it may be just to generalize that almost half of the population of patients with DM in Tanzania lacks sufficient oral health-related knowledge. Thus, deliberated efforts must be put into sensitizing the community regarding the synergetic relationship between diabetes and oral health. The odds of having good knowledge regarding oral health among patients with DM were almost 2 folds higher in participants with high education. This may be brought about by the fact that the educated tend to have better access to information and thus better knowledge. It was also noted that good oral health-related knowledge was 7 folds higher among those who had been referred to a dental professional in the past. Such findings indicate that during dental visits, patients are equipped with necessary oral health knowledge, thus, further supporting the importance of patients with DM attending dental clinics for checkups. A good oral health-related attitude was noted in more than three-quarters of the participants of the current study which was similar to the attitude of the diabetic population elsewhere. , The attitude did differ significantly by oral health-related knowledge, with the chances of having a good attitude towards oral health being 5.5 folds higher among participants with good oral health knowledge. This finding signifies that a positive attitude towards oral health is influenced by a good knowledge of the subject matter. Therefore, it is worth providing oral health education to patients with DM to improve their attitude thereby helping them take better care of themselves. Despite the majority of participants showing a positive attitude towards oral health, their oral health-related practices were low, similar to findings from South Asia. The findings of the present study do indicate that good practice towards oral health is not dependent on one's attitude but rather multiple contributing factors including oral health-related practice. It was noted that the odds of good oral health practice were 2 folds higher among those with good oral health-related knowledge. Though all of the participants reported daily toothbrushing, the findings indicated that other aspects of good oral health practice are not satisfactory, thus there is a need for tailored oral health interventions for patients with DM in Tanzania. Limitation The study has some limitations, First, the use of close-ended questions for assessing the KAP may generate limited information. Second, being a cross-sectional study, the establishment of causal inferences is minimal. Moreover, we did not seek the source of information in this study, and the number of questions to assess the practices and attitudes of patients with DM was few. Despite these limitations, the results from this study convey important information about the oral health-related knowledge of diabetic patients in Tanzania, and their tendency to seek regular dental consultations.   The study has some limitations, First, the use of close-ended questions for assessing the KAP may generate limited information. Second, being a cross-sectional study, the establishment of causal inferences is minimal. Moreover, we did not seek the source of information in this study, and the number of questions to assess the practices and attitudes of patients with DM was few. Despite these limitations, the results from this study convey important information about the oral health-related knowledge of diabetic patients in Tanzania, and their tendency to seek regular dental consultations.   The findings of the current study indicate that about half of patients with DM have good oral health-related knowledge. A majority have a good attitude towards oral health, but only a limited number of participants had good oral health-related practices. Predictors of good knowledge were education level and previous referral to dental professionals. Good knowledge predicts a good attitude. Apart from good knowledge, good practice was also predicted by a higher education level.   The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.   