Study population and settings

This cross sectional study on adoption of oral health promotion was done among antenatal care providers working in a general hospital, Health Centre IV and health centre IIIs within Moyo district between August 2017 to October 2017.

The inclusion criteria required that, for the ANC provider to participate in the study, they should be working at ANC units, those who had ever worked at the ANC unit, these included Nurses, Midwives, Clinical Officers and medical doctors within the selected health facilities from whom written informed consent was obtained to participate in the study. We excluded Nurses, Midwives, Clinical Officers, Gynaecologists, paediatricians, general medical doctors who had never worked at the ANC department before the study and ANC providers who had spent less than six months working at the time of this study, as they may not have practical and authentic responses to the study compared those who had ever worked at ANC departments for more than six months.

Demographic characteristics of the respondents

Our study considered a total of 152 ANC providers, mean age 36, range 37 years, a standard deviation of 10.49, of which, 57(37.5%) were 37 years and above, 92(60.5%) females, 106(69.9%) had worked between 1–10 years, 82(53.9%) working HC IIIs, 67(44.1%) Nurses and 82(53.9%) were Certificate holders. (See Table 1).

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Table 1. Demographic characteristics of respondents.

https://doi.org/10.1371/journal.pone.0272238.t001

Adoption of oral health promotion by ANC providers

42 (28%) of the respondents out of 152 had adopted oral health promotion for pregnant mothers. Although individual practices of ANC providers appeared to be low, the management and officer in charge of the MCH programme noted that, adoption or integration of oral health promotion in ANC would be vital for overcoming some of the challenges of poor oral health, its outcome on pregnancy and the child (See Fig 1).

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Fig 1. Adoption of oral health promotion by ANC providers.

https://doi.org/10.1371/journal.pone.0272238.g001

"There is need to adopt or integrate oral health promotion into ANC services to overcome some of the challenges created by the poor oral health of the pregnant mothers" (KI 1).

More emphasis supporting the need for adoption of Oral Health promotion by ANC providers showed that, adoption is likely to reduce heart diseases among pregnant mothers;

“Of late there are increased cases of heart diseases…… originating from the dental issues as bacteria tend to move to the bloodstreams and later on move to the heart valves without knowing, adopting oral health promotion will have a possibility of reducing such challenges in the future” (KI 2).

"It will be cheaper adopting oral health promotion into ANC services compared to when it handled as a separate program" (FGD 1).

Factors influencing adoption of oral health promotion by ANC providers

In our multivariate analysis, age of respondents in years 22–26 (aOR = 0.066, 95%CI = 0.009–0.465, p = 0.006*), level of care of health facility (aOR = 0.050, 95%CI = 0.008–0.322, p = 0.002*), good understanding between dentists and ANC providers (aOR = 0.283, 95%CI = 0.084–0.958, p = 0.042*), availability of practice guideline for OHP in ANC (aOR = 0.323, 95%CI = 0.108–0.958, p = 0.043*), worked 1–10 years (p = 0.011*), were statistically significant and associated with adoption of oral health promotion by ANC providers. However, general number of years at work (aOR = 25.241, 95CI = 2.075–307.041, p = 0.084), being knowledgeable (aOR = 2.143, 95%CI = 0.864–5.311, p = 0.100), having skills to advance OHP in ANC (aOR = 0.734, 95%CI = 0.272–1.984, p = 0.542), Management good at influencing new practices (aOR = 00.477.734, 95%CI = 0.227–2.000, p = 0.477) were not statistically significantly associated with adoption oral health promotion by ANC providers (see Table 2).

“Top management at the national level is not good at influencing new policies and guidelines, there is no dissemination of the National Oral health policy, if dental health issues are not marketed by the authorities, no one will pay attention and it will continue to be neglected, and yet adoption will lead to a reduction on missed opportunities, maximizing resources–one staff offering all that is needed and improving service delivery” (KI 1).

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Table 2. Factors influencing adoption of oral health promotion by ANC providers in Moyo district, North-Western Uganda.

https://doi.org/10.1371/journal.pone.0272238.t002

In our univariate analysis, female ANC providers were more likely to adopt oral health promotion compared to their male counterparts. Respondents aged between 22–26 years were less likely to adopt oral health promotion during prenatal care compared to those aged 37 years and above. Respondents who had been working for the last 21–30 years were 14 times more likely to adopt oral health promotion compared to response who had worked for 31–40 years (see Table 2).

In terms of the level of health facilities, respondents working at the health centre IV were less likely to adopt oral health promotion compared to those working at HC IIIs. Knowledgeable respondents were four times more likely to adopt oral health promotion compared to those that were not knowledgeable and respondents who had no skills to advance OHP in ANC were less likely to adopt oral health promotion compared to respondents who had skills in advancing OHP for prenatal care.

Respondents who said that management was good at influencing new practices, were more likely to adopt oral health promotion compared to those who said that management was not good at influencing new practices. Having no good understanding between dentists and ANC providers less likely contributed to the adoption of OHP, and having no practice guidelines for OHP by ANC providers less likely led to the adoption of oral health promotion (See Table 2).

"Even if the staff members make recommendations for some dental items, the oral health department issues are always pushed aside and not taken care of" (KI 3).

The whole district only offers extraction within government health facilities, other services are in a private dental clinic (KI 4).

We do not have oral health policies for ANC and there is no local guideline that is put in place yet. We do not have the National Oral Health policy even in our dental department and I have never seen it before" (KI 2).

There is a need for training of ANC providers on oral health promotion for pregnant mothers (FGD 1).

The ANC providers were also asked to raise issues that should be included in the oral health promotion guideline. More than half 95 (62.9%) of the respondents mentioned almost all responses mentioned prevention of oral diseases, this was followed by oral health education 93 (61.6%), ways of improving access to oral healthcare 91(60.3%) and assessment of pregnant women’s oral health 88 (58.3%) (See Fig 2).

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Fig 2. Issues to be included in oral health promotion guideline during ANC.

https://doi.org/10.1371/journal.pone.0272238.g002

In line with participants’ knowledge on the kind of preventive oral care pregnant women should receive; the majority 124 (89.9%) of the respondents mentioned how to maintain oral hygiene, 57(41.3%) of the ANC providers mentioned education on nutrition, less than half 45(32.6%) mentioned oral health assessment and 29(21.0%) of the ANC providers mentioned referral, only 2(1.4%) mentioned other preventive care services as the kind of preventive services pregnant women should receive (See Fig 3).

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Fig 3. Knowledge on type of preventive oral care pregnant women should receive.

https://doi.org/10.1371/journal.pone.0272238.g003

In line with the knowledge of respondents on the safety of obtaining dental radiographs during pregnancy, the majority 125 (82.2%) of the respondents were not aware that it is safe to obtain dental radiographs in pregnant women while, only 26 (17.1%) of the respondents said, obtaining dental radiograph in pregnant women is safe (See Fig 4).

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Fig 4. Awareness on safety of obtaining dental radiograph during pregnancy.

https://doi.org/10.1371/journal.pone.0272238.g004

Adoption of oral health promotion by respondents

In this study, adoption of oral health promotion by ANC providers was low 42 (28%) of 152. Similarly, a study conducted in Australia among antenatal care providers showed that, very few ANC providers were involved in practices that promote oral health among pregnant women [27]. Adoption of oral health by ANC providers would play a significant role not only in the lives of pregnant mothers and also in their babies [28]. Maternal oral health behaviour could be shaped during antenatal care [29], promotion of oral health among pregnant women by Nurses would be feasible and need to be incorporated into the first antenatal booking visit and also recognized that oral health promotion was within their scope of practice [30].

Respondents aged between 22–26 years, 27–31 years, and 32–36 years were less likely to adopt oral health promotion during prenatal care compared to those aged 37 years and above. There was a statistically significant relationship between age and adoption of oral health promotion. This may be due to experiences gained over the years about oral health. Contrary to the findings of our study, another study noted that, age is significantly associated with workability [31] and job satisfaction among Nurses [32].

Moreover, the number of years one spent at work improves occupational competence, consists of expertise, skills, and knowledge acquired through experience, training, and education, people’s work are influenced by previous work experiences [33]. Our study noted that, respondents who had been working for the last 21–30 years were 14 times more likely to adopt oral health promotion compared to response who had for 31–40 years, who were 6 times more likely compared to those for 27–31 years, and 8 times more likely to those who had for 22–26 years respectively. Similarly [27], noted in their study that, there was an association between years spent at work and adoption of oral health promotion, Nurses ’experiences are closely related to the occurrence of adverse events [34]. However, Positive work environments are important in achieving patient safety, quality care and favourable patient outcomes [35].

Similarly, experience give Nurses’ exposure to different patient or health-related conditions, including different clinical and preventive scenarios that would eventually contribute to increased knowledge, critical thinking and technical skills [36]. In general, job performance among nurses is motivated by years of experience [37]. However, it has also been noted that age and length of time in service within ANC do not influence knowledge of oral healthcare for prenatal mothers [38].

In terms of the level of the health facility where respondents were working, our study found that those working at the district general hospital were less likely to adopt oral health promotion compared to respondents working at HC IIIs. However, working at a general hospital contributed to 82.7% adoption compared to working at HCIV which only contributed to 13.8% adoption of oral health promotion by ANC providers. This may be because most of the care of HCIIIs in the district are offered by generally Nurses, Midwives and Clinical officers, ANC at this level of facility handles all aspects of preventive services including oral health education and promotion. The general hospital and HCIVs may be overwhelmed by several conditions because of referrals from lover facilities.

In our study, less than half 56(36.8%) of the respondents were knowledgeable about OHP in ANC and those knowledgeable were four times more likely to adopt oral health promotion compared to those that were not knowledgeable. Similarly, Nurses and Midwives had insufficient knowledge of oral healthcare [38]. Respondents in our study were not knowledgeable about the fact that several physiological changes take place among pregnant women and these have an effect on oral health, pregnancy and brings about several changes in the oral cavity [6]. Our finding was similar to the study in Australia which noted that ANC providers had limited knowledge on prenatal oral healthcare [27].

In terms of knowledge on the safety of dental procedures during pregnancy, our study found that ANC providers were not knowledgeable about the safety of local anaesthetics, teeth extraction, scaling and Root planning and Root Canal during pregnancy. This knowledge about the safety of dental procedures during pregnancy should be addressed to improve service utilization and oral health promotion among pregnant mothers. Similarly, a study conducted among gynaecologists indicated a knowledge gap about the safety of some of dental procedures for pregnant mothers [39]. Local anesthetics lidocaine commonly used during dental care are safe, although, with some negligible adverse effect [40], some of these effects may include immune response-mediated allergic reactions and others that are unrelated to the immune response and these allergic responses are very rare in practice [41].

About the safety of obtaining dental radiographs in pregnant women, the majority 125 (82.2%) of the ANC providers were not aware that it is safe to obtain dental radiographs in pregnant women and use of dental radiographs, if necessary, after the first trimester does not pose any risk to the developing fetus [42], however, it is recommended to use protective lead aprons and thyroid collar to shield the sensitive areas. This kind of misconception could however be overcome among ANC providers by continuous services professional training and collaboration among different professionals within the different health facilities.

In our study, respondents who had no skills to advance OHP in ANC were less likely to adopt oral health promotion compared to those who said they had skills in advancing OHP for prenatal care. This calls for the need to incorporate prenatal oral care in health higher education training institutions of learning and continuous professional education for ANC providers in practice. Health training institutions have limited training for prenatal oral healthcare[43], adequate skills attained by health workers would enable them to perform desired tasks, more regular training and paying attention to discuss career development prospects would be of great value to advance their skills [44].

In addition, our study found that, having a good understanding between dentists and ANC providers contributed to adoption. A study conducted in Australia found no interprofessional collaboration and understanding between non-dentists and dentists [45]. An inter-professional collaboration education model for dental and medical providers are needed and the provision of an appropriate referral system for comprehensive clinical care of pregnant patients and accredited standards that encourage development and implementation [46, 47]. There is a need for collaboration between ANC providers with dentists to encourage all pregnant women to comply with the oral health professionals’ recommendations regarding appropriate dental brushing techniques and the importance of dental visits [48]. However, Collaboration across organizational boundaries remains challenging due to power dynamics and trust that affect the strategic choices made by each health professional about whether to collaborate, with whom and to what level [49]. These decisions directly affect inter-professional relationships trust and respect can be fostered through a mix of interventions aimed at building personal relationships and establishing agreed rules that govern collaborative care and that are perceived as fair to all professions. Some of the factors that facilitate the integration of oral health are interdisciplinary education and collaborative practices between dental and other healthcare professionals [8]. Adoption of oral promotion requires coordination and cooperation between ANC providers and dentists [50]. Understanding and interprofessional collaboration improve professional output, through the provision of clarity around the meaning and definition of professional roles [51].

In terms of management, respondents who said management was not good at influencing new practices among ANC providers were less likely to adopt oral health promotion compared to management being good at influencing new practices. Poor leadership were a key factor leading to providers’ weak workplace trust and contributed to often-poor quality services, driving a perverse cycle of negative patient-provider relations [52]. For leaders to have lasting influence, staff members should be involved in health policy development and some of the key participatory roles in health policy development include mentoring, supporting and developing future policymakers [53].

In addition, the Ottawa charter emphasized that all sectors at all levels be involved in formulating policy and direct them to be aware of the health consequences of their decisions and to accept their responsibilities for health, health promotion policy requires the identification of obstacles to the adoption of healthy public policies and ways of removing them, thus health policies must focus on making it easy for beneficiaries to make healthier choices [54]. Involvement of staff members would help them on what is in the policy and also improve on policy dissemination and implementation at all levels, avoiding situations wherein a district, some oral health professionals have not even seen the national oral health policy until it was presented to them during the research work.

Moreover, our study found that there is a need to develop oral health promotion guidelines for pregnant mothers and according to [34], many countries have developed oral health guidelines for pregnant mothers to help them improve the oral health of both pregnant mothers and the babies and the main barriers for ANC providers in promoting oral health was lack of practice guidelines on oral health care during pregnancy. There is a need for local and national health policy agenda in Uganda to incorporate the prevention of oral diseases during pregnancy [23]. Burke-Litwin model noted that, when staff members feel that organizational policies and procedures are favourable to them, they are motived to perform the required actions, implying that appropriate formulation and implementation of policies motivate staff members to perform required actions.

Study strength and limitations

Our study had several strengths, firstly, the large sample size covering three quarters of the health workers and all categories of cadres of health workers in the district, secondly, our study was the first in Uganda with a focus on the adoption of oral health promotion by antenatal care providers, we involved research assistants who were well trained to create rapport with respondents, thirdly, we trained research assistants on data collection procedures, maintaining confidentiality, ensure correctness and consistency of recorded data. Fourth, all our research tools were fully pretested and checked for accuracy and correctness, only filled questionnaires were included for analysis. However, our study could not be used to analyse behaviour or practices of the ANC providers over some time as it was a snapshot, limitation of confounding bias which was controlled by restricting participation to only those who had worked for at least six months and above and participation to only ANC provider who had ever worked or are working at ANC department in order to arrive at meaningful and conclusive results.