Knowledge, Attitude and Practices towards Oral Hygiene among Students of Medhanealem High School, Addis Ababa, Ethiopia

Background : poor oral health can affect a person’s day today as well as overall quality of life. Discomforts from experience of pain, problems with eating and chewing, embarrassment about the shape, missing, discolored or damaged teeth can adversely affect peoples’ daily lives and well-being. The aim of this study was to assess the knowledge, attitude and practice of oral hygiene among preparatory students of Medhanealem high School in Addis Ababa, Ethiopia. Method : A cross sectional study design was conducted using a self-administered questionnaire from June to September 2019 in Medhanealem high school, Addis Ababa. Data was analyzed using SPSS V.20 and a descriptive statistics was employed to present results on knowledge, attitude and practices of high school students towards oral hygiene. Result : A total of 320 students have participated in the study, of whom 207(64.7 % ) were female. The study revealed that 201(62.8 % ) of the respondents had poor knowledge with regard to oral hygiene, about half (52.1 % ) of the students had negative attitude toward oral hygiene, and their oral hygiene practices were still low that 193 (60.4 % ) of the students reported inadequate practice. The chewed stick (mefakiya) is the most common oral hygiene aid used for cleaning teeth which was adopted by 134(51 % ) students. Conclusions : The study showed that oral hygiene knowledge, attitude and practice among the secondary school students in Medanealem preparatory school were not satisfactory. The findings of this study suggest that awareness on the importance of oral hygiene needs to be enhanced along with regular education.

the method of keeping oral cavity free from pathological conditions that affect mouth like gum diseases, cavities, mouth sores and ulcers.[2] Good oral hygiene is essential for the well-being of an individual.However lack of knowledge, negative attitude and poor oral hygiene practices may predispose to oral related diseases.[2,3].As oral health affect overall health of a child, it is therefore of paramount importance to maintain oral hygiene of school going children.If community-oriented oral health promotion programs are to be successful, the knowledge of the latest status of oral health of community is of vital importance [3].This may ultimately contribute to the reduction of oral diseases with alarming global burden [4] and associated cardiovascular diseases, respiratory infections, stroke and nutritional problems [5].
In Ethiopia, the practice of oral hygiene lacks proper attention and care whereby the habit of tooth brushing is found to a minimum [6,7].Studies conducted on primary and high school students indicate that there is a varying level of awareness to oral health ranging from 50 to 70% [8][9][10].As a result, the prevalence of dental carry ranges between 20% and 75% in different setups [6,7,11,12].
It was reported that tooth related problems such as; gum bleeding, dental plaques, tooth ache, and missing tooth were noted in a significant magnitude among college students [10,12].Studies also documented that dental carrying was associated with increased consumption of sweets, male gender and among those who do not regularly clean their teeth [7,11,13].The studies published so far cover either on primary school children in regions of the country or college students.With two assessments [7,12] conducted earlier in the community and marginalized children in Addis Ababa, information among high school students appears to be scanty and less addressed.The objective of this study was, therefore, to assess the knowledge, attitude and practice of high school students towards oral hygiene in an old high school of Addis Ababa.

Study area
The study was conducted in Medhanealem high school located in Gulele sub-city of Addis Ababa city administration, Ethiopia.Medhanealem preparatory school was established on 27 October1924 E.C.It was named after Medhanealem in Orthodox Christianity which means "Mercy of the world' and assigned to the 27 th date of the month.The school was primarily established for teaching handicraft and accounting.There was also various wood work and leather workshops.Then the school started teaching from grade one to twelve.
Once it was named "Bale Abat" meaning "of for the upper class or noble men'' for about two years.
After the Ethio-Italy war, the teaching process was discontinued and it became residence for Ras Hailu.After two years, it was renamed as Medhanealem and continued the teaching learning process.
It started with 60 students for the first time.
It has been 87 years since the school was established.Since of 1996, the school has become a preparatory school, a school where pre-university 11 th and 12 th grade students will attend for preparation.Currently, it consists of 174 employees of which 120 are teachers (102 male and 18 female) and 54 are supportive staff and directors.The total number of students during the study period was 1704.

Study design and period
An institutional based cross sectional study was conducted from July to September 2019.

Source and Study Population
The source population was all high school students in Addis Ababa while Study Population was all regular preparatory students of Medhanealem high school.

Sample size determination
To attaining the maximum size, a single population proportion formula with 50% prevalence was used to obtain a final sample size of 384.Because total population was only 1704 in the study setting, a final sample of 336 was estimated by considering a final population correction factor and 5% nonresponse rate.

Sampling technique, data collection and quality control
Self-administered structured questionnaire was use for data collection.A simple random sampling method, based on students' roster, was employed to obtain sample recruits.In cases when students from the list were not available, the next student was recruited for inclusion.Prior to data collection, the questionnaire applied in this study has been pretested in the same school and grade students accounting to 10% of the required sample size.Appropriate changes were to the data collection instrument.Data collectors were trained on the importance of confidentiality, ethics and data collection procedures.Completeness and validity of the data collected was checked every day by the supervisors.

Variables Dependent variable (s):
The dependent variables in the present study included; knowledge, attitude and practice of high school students Independent variables: The independent variables in the present study include; socio-demographic variables (gender, age, parents' education, grade, family income…), clinical characteristics (previous visit to a dental clinic, oral health, history of using drugs for chronic illness…), knowledge and attitude of students and parents (which the latest two might affect practice).
All the 320 respondents completed the questionnaire successfully.Among the participants, 207(64.7 % ) were females and113 (35.3 % ) were males.The student's age ranged from 18 to 22 years where 283 (88.4) were in the 18-20 age group and 37 (11.6) were in the 21-22 years age group.

Knowledge of students toward oral hygiene
Most of the student know that sweet (168 (52.5 % )) and fizzy drinks (231 (72.2 % )) affect oral health.
However, only 58(18.1 % ) students know that regular dentist visit is necessary and 32(10 % ) know that they should replace tooth brush every 3-4 mounts.Majority of the participants (288(90 % )) replied that they replace their tooth brush when it is destroyed.Only 43(13.4% ) reported that tooth care is as important as care of any part of the body.
Only 59(18.4% ) students knew that fluoride strengthens teeth or prevent dental decay while 229(71.6% ) do not agree that fluoride strengthen teeth.Nonetheless, 32(10 % ) students do never know anything about fluoride.Most of the students (263(82.2% )) agreed that Carious/decayed tooth affects teeth appearance whereas 42(13.1 % ) did not agree with this idea.The major reason for brushing teeth was to remove dental decay as responded by130 (40.6 % ) students (Table 1).Overall knowledge level of the students towards oral hygiene was low in this study.Majority (201(63 % )) had low knowledge and 119(37 % ) had higher knowledge as shown in (Figure 1).

Attitude of students toward oral hygiene
Majority of the students (220 (68.7 % )) answered that oral hygiene is not important for good oral health and well-being, while only 100(31.3% ) students believe that it's important.About 130(40.6 % ) students reported that neither the parents nor the teachers showed concern about oral hygiene.A three fourth (75 % ) of the students thought that visiting a dentist is important and they would advise other students to perform at home oral hygiene practices.When given a chance, about a two third (70.6 % ) of the students would go for a checkup.As shown in table 4, about 263(82.2% ) students have never visited a dentist in the past.Among those who have a history of dental visit, 9 (2.8 % ) had regular dental visit, 39(12.2%)visited a dentist only when in pain, and 9(2.8 % ) visited a dentist occasionally.
The reasons given for absence of regular dental visit were high cost (87(27.2% )), no nearby dental clinic (15(4.7 % )), lack of time (100(31.3% )).Meanwhile, about one third (31.9 % ) of the students do not think it is important to visit a dental clinic (Table2).The overall attitude evaluation showed that about half (52 % ) of the participants had a negative attitude and 153(48 % ) participants had positive attitude of oral hygiene (Figure 2).use circular strokes to brush their teeth.Among students who do not brush their teeth, half (51%) reported that they did not think it was necessary.
The chewed stick (Amharic; Mefakiya) is the most common oral hygiene aid used for cleaning teeth, adopted by 134(51 % ) while 65(24.7 % ) of the students brushed their teeth with a tooth brush with tooth paste.However the use of dental floss was still not popular among the secondary school students as presented in this study.About a third (30.8 % ) of the students brushed their teeth at least twice per day or more compared to 119(45.2 % ) of the students who brushed at least once a day.
Around 159(60.5 % ) of the students reported that they spent 2 minutes or more brushing their teeth.
Only 32(12.2% ) of the respondents changed their toothbrushes with in 3-4 months of use.A few number of students (2.7 % ) reported that the time of tooth brushing was before going to bed.In addition 24(7.5 % ) students did clean their tongue.
Among the reported sources of student's information about oral health practice, parents were the most popular (120(45.6 % )) followed by friends (93(35.4% )).However, the role of parents in the supervision of their children's oral hygiene was poor accounted only by 35 (13.3 % ).About 107 (40.7 % ) parents advised but did not watch their children as they brushed their teeth, while the rest 121 (46 % ) indicated that they did not care to supervise their children's oral hygiene practice.On the other hand, 37(14.1 % ) students did not agree to stop cleaning if their gum bleeds when cleaning their teeth (Table 3).This study showed that the overall oral hygiene practice among the high school students was inadequate (193 (60 % )) (Figure 3).

Discussion
Oral health is considered as one of the most important health issues worldwide.In Ethiopia, there is very little epidemiological data concerning oral hygiene and it implications.Today, oral hygiene including tooth brushing is considered as an easy and affordable procedure for people of different age groups.Adequate knowledge on the causes, prevention, and signs of dental disease depicts that students can retain their oral hygiene.
The rapid changes in the pattern of oral disease have been noted at the global label during the past decade [14].Most people in the developed countries show great interest in oral hygiene and that 16-18% of boys in 32 countries in Europe and North America practiced tooth brushing more than once a day, whereas girls reported better compliance ranging from 26 to 89% [15].This study evaluated the oral hygiene knowledge, attitudes, and practices of secondary school students found in Medhanealem preparatory school in Addis Ababa city.A total of 336 students have participated and fulfilled the required sample size making a 100% response rate.
The current study showed that 62.8% of the students had poor knowledge towards oral hygiene.This might be due to the lack of an organized and systematic oral health education program in the schools and the community at large.Lack of knowledge towards oral hygiene could reflect that the information on dental health is most likely limited to a certain level of understanding.This result is lower than the previous study done in Debre Tabor town where 60% students had good oral hygiene knowledge [8] and a finding from India [16] which reported about 90% level of knowledge.
On the other hand, the figure is higher compared to findings from India [17] and Saudi Arabia [18].
The fact that significant proportion of the students do not know that sweet and fizzy drinks affect health, only few have a history of visiting dental clinics and the fact that few knew that they should replace tooth brush every 3-4 mounts may show awareness gaps to be assisted by parents and schools.This finding is not in accordance with the results of a similar study conducted by Priya, et al. [19].
In the present study, the attitude scale showed that more than half (52.1 % ) of the participants had a negative attitude towards oral hygiene.This result is still lower than a figure by a previous study done in Debre Tabor town [8].However, it is higher than a finding reported in Indian students which majority (79.8 % ) had a favorable attitude toward oral hygiene [16].This is also explained by some proportion of students who did not agree that gums bleedings can be prevented by brushing teeth.
The magnitude of such belief has shown a remarkable variation from other studies [8,16,20].
The level of practice to maintain proper oral hygiene practice is inadequate for majority of the students in the present study.The chewed stick (Mefakiya) is the most common oral hygiene aid used by half proportion of the respondents.These finding is lower than the figure by studies conducted in Nigeria and most African countries which traditionally used the stick for cleaning and strengthening the teeth [21,22].The choice of chewing sticks to be used in most cases depends on its cleansing action on the teeth, the therapeutic value, or preferred taste or flavor [23].A lower figure of using the local chewed stick was documented by a study in Fitche town, in central Ethiopia [24].
Likely, 81(30.8% ) students brushed their teeth at least twice per day while 119(45.2% ) reported to have brushed at least once a day.Even though the overall estimate is measured by a stronger criteria (a 60% or more satisfactions of practice questions), the study shows that reasonable gap exists to implement oral hygiene among the students.Apart from knowledge and attitude issues, affordability of the materials was mentioned as one of the challenges.These findings are also supported by the studies conducted in Fitche preparatory school [24].The result is higher compared to a finding in three regions of Ethiopia [25].The difference, however, could most likely be due to time and socioeconomic variations by the fact that the earlier survey was conducted many years back in different regions of the country [25].
Majority of the students reported that they change their tooth brushes when they get discolored or bended and, only a few proportion responded to changing them within 3 to 4 months.This shows proper practice is not in place to utilize tooth brushes.The American Dental Association (ADA) recommend using a tooth brush that has soft bristles and also people should change their toothbrush every 3 months or when the ends start to look destroyed [26].
In our study, reported sources of student's information about oral health practice parents were the most popular, followed by friends.This result is not in accordance with the finding from the similar studies conducted by Nigeria which showed that teachers, media (Television) and parents accounted descending ranks [21].This may indicate that parents may account greater role in promoting family health whereas teachers' role is limited to assist with their students' healthy behavior in schools of the study area.The fact that students gain oral health experience through peer interaction is an important aspect built during their socialization process.
In the present study, only the practice of dental visit is poor.Among those (57 (18%)) students with a practice of dental checking, few (16%) reported to do it regularly while majority (68.4%) visited a dentist when only in pain.In addition to the inverse difference in proportion of adolescents who visit dental clinics, a study by Yusuf and Booyen [27] reported that the principal reason for brushing teeth was related to cosmetic purpose unlike prevention of dental health reported in our study.Yet, studies suggest that children and adolescents should see a dentist every 6 months to help prevent cavities while adults who practice good dental hygiene every day need to go less frequency [28].
More than half (58.9 % ) of the students in the present study reported to brush their teeth with horizontal strokes followed by about a quarter of them (26.2 % ) who brush with vertical strokes.This result is not in agreement with a finding from India [28] where majority used a combined technique of brushing.Likely, it was noted that most of the respondents do not clean their tongue and of those who clean their teeth, quite a few brush when going to bed.The result is lower to a report in India [28] and in disagreement to the ADA recommendation [26].
The current study reported that the use of dental floss was still not popular among the secondary school students.In contrast, the studies conducted in Nigeria, the use of dental floss was recognized by slightly more than a third of the students [21] and over a two third of adolescent pregnant women in Australian [30].The latter higher figure could be due to population variation despite little existent of the practice in Ethiopian culture.This may be because the use of floss is to find less popularity and accessibility in our environment.The ADA recommends flossing once a day.Flossing is used to remove food particles or plaques lodged between teeth more efficiently than toothpicks [29].
This study is has tried to describe the current characteristics of high school students' knowledge, attitude and practices towards oral hygiene in Addis Ababa.Generalizability could not be drawn for all high school students in other areas and recall biases might affect the magnitude of estimated reported.Further researches would be warranted with larger populations and robust analytic methods to find a more precise measurement and determinants of students' knowledge, attitude and practice.

Conclusions
The current study showed that 62.8% of students had poor knowledge toward oral hygiene.Similarly, more than half proportion of Medhanealem high school students had negative attitude towards oral hygiene.The level of practice to maintain proper oral hygiene practice was found inadequate among majority of the students.The chewed stick (Mefakiya) is the most common oral hygiene aid used by half proportion of the respondents.

Figure 1 :
Figure 1: Level of knowledge among secondary school students towards oral hygiene in Medhanealem High School, Addis Ababa, Sept 2019 (n=320)

Figure 2 :
Figure 2: Types of attitude of secondary school students towards oral hygiene in Medhanealem High School, Addis Ababa, Sept 2019 (n=320)

Figure 3 :
Figure 3: Practice level of secondary school students towards oral hygiene in Medhanealem High School, Addis Ababa, Sept 2019 (n=320)

AbbreviationsADA-Figure 1 Figure 3
Abbreviations ADA-American Dental Association DMFT-Decayed, Missing and Filled permanent Teeth KAP-Knowledge Attitude and Practice SPSS-Statistical Package for Social Sciences WHO-World Health Organization Declarations

Table 2 :
Attitude of secondary school students towards oral hygiene in Medhanealem High School,

Table 3 :
Practice of secondary school students towards oral hygiene in Medhanealem High School,