Nigeria′s street children, epitome of oral health disparity and inequality

Introduction it has been close to four years since the authors highlighted the total neglect of the oral health of street children in the Journal of Public Health Policy. Since then, the authorities appear to have simply turned the blind eye making this follow-up imperative. This follow-up report specifically examines the resultant oral health disparity between Nigeria's street children and Private, fee-paying secondary school students in Northern Nigeria. Methods we conducted a cross-sectional comparative survey of randomly selected 12-14 years old street children (children of Quranic informal educational institutions) in Northern Nigeria while fee paying, private secondary school children served as controls. A simple close-ended questionnaire translated into Hausa language was used to assess oral health knowledge and the Simplified Oral Hygiene Index used to categorize oral hygiene status of the participants. Results the mean age (SD) of the participating street children was 12.7 (0.86) while that of the private secondary school students (PSSS) was 13.05 (0.96). The majority (89%) of parents of street children compared with that (7%) of parents of students of private secondary schools had no western education. Only 6% of street children compared with 90% of PSSS cleaned their teeth for the right reasons. Only 5% of street children compared with 90% of private secondary school students used a fluoride-containing toothpaste. Though both groups of children have poor knowledge (street children 3%, private secondary school students 16%) on the use of dental floss, the mean oral hygiene score (SD) for street children was 4.42 (0.85) compared with 1.90 (0.09) for private secondary school students. There were striking differences in knowledge and practice with only 4% of street children compared with 69% of PSSS with knowledge about fluoride and its use (p < 0.0005). Also, 2% of street children compared with 40% of PSSS were aware of the benefits of regular dental visits. Sixty five (65%) of street children used finger and water only for tooth cleaning, none of the secondary school students practiced this (p = 0.0005). Conclusion there is disparity in oral health practice between Nigeria's street children and private secondary school children. This disparity may be attributed to lack of western education and socio-economic status.


Introduction
This study is a modest attempt to call attention to the serious oral health disparity between Nigeria's street children and children of comparable age but of a different educational/socio-economic status.
Since awareness is fundamental to health-seeking behaviour and utilization, we compared the oral hygiene awareness and practices of 12-14-year-old, street children with those of private secondary school students (PSSS) in the Northwestern city of Kano. Unlike the PSSS, the street children were not exposed to any form of Western education. Education is as old as the human race but means different things to different people being generally a process of teaching and learning for the purpose of acquiring knowledge. With an entry date of 1085-1097 through the Kanem Borno Empire [1], Islamic education predates western education in Nigeria which came in the middle of the 16th century though western Nigeria [2]. Almajiri is an Arabic word derived from Almajihun (searching for Islamic knowledge.) [3,4]. We already showed that the non-classification of Nigeria's Almajiri as street children constitutes a problem of definition which necessitates a call to action [3]. These Almajiri who should be properly addressed as street children are voluntarily placed in the custody of Islamic teachers called Mallams. Mallams are expected to teach street children the holy Quran but just like their students, the majority of Mallams are unexposed to western education [4]. It is well-documented that parents, siblings, school teachers and socioeconomic factors play important roles in maintaining healthy habits and good oral health [5, 6,7], the present study investigated the association between these variables. The specific association of interest is the impact of western education of parents on the oral hygiene status, awareness and practices of street children and private secondary school attendees.
Good oral hygiene practice involves maintaining a clean, healthy mouth by brushing and flossing in order to avoid accumulation of debris, plaque and calculus. Ultimately, this is to prevent dental caries and periodontal diseases [8][9][10][11].Oral hygiene can in turn, be maintained by good practices like daily brushing with a fluoride toothpaste, flossing with a dental floss, restriction of refined sugar diet as well as regular dental visits and dental education [8][9][10][11]. The literature is equivocal on the impact of age and school type on oral hygiene practices [8,12]. Unfortunately, similar reports on street children are almost nonexistent. What is known is that majority of street children are from socioeconomic backgrounds as poor as those of the Mallams who care for them. These children are left with no option than to embark on unconventional means of survival including street begging [3,4,13]. The present study is therefore an attempt to support previous efforts [14][15][16][17] to investigate the relationship between socioeconomic background and oral hygiene status. It is worthy of note that the world is now focusing on the oral health of the less-privileged and neglected including street children [3,4,13,18,19]. Although Nigeria's Almajiri have great resemblance to street children according to United Nation definition [18,19], debate is still ongoing on categorizing them as street children.
In Northern Nigeria, the general submission is that this group of Nigerian children are from poor homes, uneducated (formal education), vulnerable, neglected and frequently seen roaming the streets of major cities of Northern Nigeria [3,4,13,20]. Street children constitute a large percentage of the child population in Kano city with age range between 5-19 years. This huge population of children has been neglected when planning for comprehensive oral health care for Nigerian children. Generally, there is limited data on the oral hygiene status of school age children in northern Nigeria unlike the southern part of the country where many studies have been conducted among the same population group. Attempts have also been made to compare oral hygiene status and practices of different groups of children in Southern Nigeria [15,16]. Information on the oral health of school-age children in the Northern city of Kano is scarce and we only recently reported a study on oral health of street children [3]. Presently, there is no study comparing the oral hygiene status of street children with private secondary school students. This study is therefore aimed at comparing the oral hygiene status/awareness and practices of children of different socioeconomic backgrounds in the biggest commercial city in Northern Nigeria.  [21]. While all participating street children in this study were male, both male and female PSSS participated. Multistage random sampling technique was adopted for this study using the list of registered private secondary schools available at the Local Government Educational Authority. There was no list of Quranic institutions with the Local Authority hence the need to generate one from two randomly selected wards out of the thirteen in the LGA. From this generated list, 10 Quranic centers were randomly selected with 200 street children. Out of the sampling frame of the list of nineteen registered private secondary schools in the LGA, three were randomly selected. In each of these schools, the junior secondary classes with pupils within the age bracket of the study population were identified and based on the populations of the pupils in each school, (90, 70, and 40) students were randomly selected to participate in the study.

Methods
Before the commencement of the study, clearance was obtained from the ethics committee of Aminu Kano Teaching Hospital, Educational Department of Nasarawa LGA and Management Authority of each participating school. The parents, Mallams and/or guardians of the private secondary school students and street children gave written informed consent while the students and street children gave verbal assent. All information was translated/explained in Hausa language for those who had language challenges. To be included, children had to be 12-14 years old, willing to participate in the study and to undergo simple clinical oral examination. Consequently, children below 12 or above 14 years of age, parents not willing to sign informed consent and those students and street children who declined assent to undergo simple clinical oral examination were excluded from this study. Data for this study were collected using close-ended, examineradministered questionnaires and simple clinical oral examinations. The semi-structured questionnaires were available in English and Hausa languages and were administered by the leading researcher assisted by two dental therapists. The questionnaires were administered to pupils who filled the questionnaires at the same time (simultaneously) to avoid bias. The questionnaires were divided into three parts including a bio-data and parental educational background section, an oral health awareness assessment section and an oral hygiene practice section. The questionnaire was pretested in a pilot study conducted in two schools with similar socio-demographic characters as the target study participants. The responses obtained from the participants in this study were similar to those of the pilot study. The simplified oral hygiene index of Green and Vermillion was adopted for assessing oral hygiene status of the subjects in this study using six

Results
Four hundred children participated in this study consisting of an equal number (200) of street children and private secondary school students. All the street children that participated in this study were males while the PSSS were both males and females. In this present study, sexes of the participants were not considered because previous studies have indicated similarities in oral health awareness among boys and girls [21,22]. The male to female ratio was 3:1. The mean age (SD) of the participants was 12.9 (0.93) years with the street children being 12.7 (0.86) and PSSS being 13.05 (0.96) ( Table 1).
While a greater percentage of parents of PSSS were exposed to western education at different levels, most parents of the street children´ had never been exposed to 'formal´ western education. It was observed that 28% (n=56) and 89% (n = 178) of PSSS mothers and fathers respectively, have been educated to the tertiary level of western education. On the other hand, none, 0% (n = 0) and 1% (n = 2) street children mothers and fathers respectively, had been exposed to any form of western education. Socio-demographic characteristics of the street children in this study were inconclusive because more than 80% of them could not identify their parents' occupation while 75% of PSSS stated that their parents were civil servants.

Discussion
All the street children that participated in this study were males unlike the PSSS that were males and females. We observed that both PSSS and their parents were exposed to western education at various levels but apart from the fact that all the street children were not exposed to western education. The significant higher level of oral health awareness among PSSS compared with street children in this study is consistent with previous reports [25,26]. This result is also consistent with previous reports that parents, siblings and school teachers play an important role in growing healthy habits in young children [7,27]. The case of the street children may have been compounded by the lack of exposure to western education by their mallams (guardians) and parents .The poor oral health awareness mostly noticed among street children is consistent with previous studies among children of low socioeconomic background [25,26]. The findings are also consistent with the reports of previous studies among school children of similar age group in developing countries with large populations like India and China [22,23,28]. This is attributable to factors like ignorance, poor oral hygiene practices and poverty as a result of poor family income.
Participants' response to major reasons for cleaning their teeth in this study showed that majority (57%) of the street children clean their teeth only to prevent mouth odor compared with a greater percentage (70%) of the PSSS who cleaned their teeth in order to prevent mouth odor and dental diseases. This finding corroborates a previous report [29]. Again, the PSSS were more aware that fluoride use can prevent tooth decay. In the present study, regular use of fluoride among street children was much lower than among PSSS. Despite their better use of fluoride toothpaste, however, the level of fluoride toothpaste use among the PSSS was lower than reported in a previous Indian study [22] but compares favorably with fluoride toothpaste use of 94.8% reported among children in Enugu-Nigeria [23].
In this study, both groups were well-aware of the harmful effects of frequent and indiscriminate consumption of refined sugar on their teeth. There was no significant difference in their response (p>0.05).
It was equally observed that majority of both groups were aware of the negative impact of tooth decay on their health and that teeth were as important as any other part of the body. The awareness of the need for dental visits was higher among PSSS, corroborating previous studies [26,30] and is consistent with previous studies among children of similar age group [8,12,[31][32][33][34]. Furthermore, we found that 34% compared with 67% from a previous study cleaned their teeth at least once daily [8]. It is noteworthy that some street children (35%) claimed to clean their teeth five times daily, compared with 0.0% of PSSS. This act of five times daily cleaning by street children was part of a religious practice rather than deliberate oral hygiene practice. The clearer picture on deliberate oral hygiene practice of tooth brushing was higher among PSSS. The finding is consistent with a previous report [12] but at variance with another study which observed no significant relationship between type of schooling, age and habit on tooth brushing [8]. The percentage of the study population that cleaned their teeth twice a day and after meal in the morning and night which is the ideal method was found to be lower in this present study than in the previous studies among a similar age group in Europe [32,35], the Middle East [33][34][35][36] and China [30,32,35,37].
Majority of the street children (65%) used fingers and water only for cleaning their teeth, a practice found to be nonexistent among PSSS.
While only 5% of the street children used toothpaste and toothbrush for tooth cleaning, a higher percentage (90%) of PSSS used toothpaste and tooth brush for regular tooth cleaning due to exposure to proper form of tooth-cleaning. The proportion of the PSSS using toothpaste and toothbrush for tooth-cleaning was higher than what was reported in previous studies among a similar age group of children in China [25]. Other tooth-cleaning materials used by the respondents were chewing stick and toothbrush without toothpaste. The percentage of children in this study that had ever used dental floss for inter-dental cleaning were very low and consistent with previous studies [25,38]. Studies have shown that effective oral cleanliness can only be achieved with the use of toothbrush and fluoridecontaining toothpaste and not with water and finger as was common among the street children [39][40][41]. This strange form of oral hygiene practice among street children may be associated with poverty, ignorance and lack of western education. This might also have contributed significantly to the higher proportion of street children that presented with poor oral hygiene compared with PSSS in this study. In

Conclusion
The  Oral hygiene habits of street children is worse than those of children of comparable age in private secondary schools.

Competing interests
The authors declare no competing interests.

Authors' contributions
All authors contributed extensively to the study. Data collection was exclusively done by the first author. Initial draft, review of initial draft, extensive modifications, data interpretation, final draft and eventual submission all enjoyed full participation of all authors. All authors read and approved the final version of the manuscript. Table 1: demographic character of street children and PSSS