A Multi-Level Approach to Understanding Oral Health Beliefs and Practices in Rural Ethiopia - A Qualitative Study

Abstract

Introduction: Oral conditions are multifactorial in their causes: they are influenced by socioeconomic inequalities, access to care, as well as cultural beliefs and practices. Most available literature about dental public health in Ethiopia only reports on the prevalence of dental caries, other oral conditions are largely ignored. There is also a paucity of data exploring the links between systemic and individual factors that affect the oral health status in Ethiopia.

Study purpose: We conducted a study exploring the oral health beliefs and practices of a community in rural Ethiopia. We situated these proximal factors affecting oral health within the larger health system and socioeconomic context in order to highlight the fundamental causes of oral health conditions. So far, these dynamics are largely overlooked, yet examining them is imperative for developing and implementing effective programs that address oral health inequalities that exist in rural disadvantaged populations in Ethiopia.

Materials and methods: We conducted twelve focus group discussions in Koraro Millennium Village located in Tigray Region of North-Eastern Ethiopia. Ninety-six community members participated in our focus groups. Each focus group was attended by 8 members of the community that represented different stakeholders such as teachers, community health workers, midwives and nurses, farmers, men and women development group members, students and regional and local heads of schools, youth organizations, and parents-teacher associations. The discussions were conducted in the local language (Tigrania) using a discussion guide that was developed based on existing literature and informal conversations with key stakeholders of the community. Data were audio recorded, transcribed and translated into English and later checked for consistency by two translators fluent in both languages. We used grounded theory methodology for open coding of the data and identifying emergent themes. Thematic analysis led to development of three main categories of factors affecting oral health in the village: individual, health system-related and structural.

Results: Individual-level factors included lack of awareness regarding the causes of oral diseases and effectiveness of oral hygiene tools. For example, several participants believed that “worms cause dental caries”. We also found that younger adults, even though better informed, did not diligently follow oral hygiene regimens. Health system factors included geographical access to dental services, shortage of skilled dental professionals, and lack of infrastructure as well as supplies needed for dental procedures. Structural factors included socioeconomic and cultural factors. Participants emphasized the lack of diversity in diet as a cause of dental diseases that they attributed to their low income. Although government programs supply grains, community members believed that they were infested with insects that ultimately caused their teeth to decay. Cultural beliefs influenced their treatment-seeking behavior.

Summary and conclusions: There is a need for interventions that address risk factors on multiple levels in order to bring about change in oral health status in Ethiopia. Such interventions should be a collaborative effort between the government, developmental organizations, academia, dental professionals and the local community. Mere educational interventions targeting individual behaviors will not be effective.

Funding: GlaskoSmithK.

Declaration of Interest: The authors declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

Ethical Approval: The study was conducted under the ethical oversight of Columbia University Medical Center Institutional Review Board and local ethical approval was sought from the Health Research Ethics Review Committee at Mekele University College of Health Sciences, Ethiopia. Written informed consent was obtained in Tigrinya (the local language) from all study participants.

Keywords: Public health, oral health, global health, qualitative, grounded theory, content analysis, focus group, socioecological model, fundamental causes of disease, common risk factor approach, oral, dental, cluster randomized trial, school based program, children