Assessment of the Level of Oral Health Education and Awareness among Members of Public Opinion in the Territory of Banja Luka

Introduction: The level of dental care development can be a good indicator of prosperity in society. Prevention of dental diseases and the provision of appropriate care require well planned and coordinated programs integrated into the overall health care system. Aim of the Study: The aim is to determine the level of oral health knowledge and contemporary possibilities of prevention in population groups of public opinion in charge of decision-making and funding of prevention programs in potential executors in the prevention program, as well as parents of preschool children in Banja Luka. Patients and Methods: The study was conducted on a sample of 310 respondents randomly selected in urban and rural areas in the municipality of Banja Luka. The testing was conducted by means of anonymous questionnaire about the level of oral health education of the respondents, attitudes about the prevention of oral diseases and health education in dentistry. Respondents consisted of 60 representatives of legislative and executive authorities, 60 people from the media, 80 teachers in kindergartens, 60 parents of children up to six years and 50 dentists from the state sector. Resultsi: The majority of respondents (65%) believed that it is possible to determine the risk before the onset of tooth decay, which was statistically significant (p <0.001). Only 6% of respondents know epidemiologically proven fact that there are people without dental caries (caries-free). The government representatives were 100%, while parents were 75% convinced that there is enough knowledge about dental health. All groups significantly highlighted the mass media and educational institutions as holders of health education. Conclusion: There is a diversity of opinion between the groups questioned, which significantly affects on making the image of the complete sample being not true reflection of public opinion. The respondents are not familiar enough with modern knowledge, possiblities and accomplishments in preventive dentistry.


Introduction
The purpose of medicine is to prevent an impairment of health and the purpose of each society is to provide such economic, social and political conditions in which most of the population could be in a state of complete physical, mental and social balance, which represents the base of definition of the health by World Health Organization (WHO ), found in its Consitution. 1 The development of dental care can be a good indicator of development of society.Prevention of dental diseases and the provision of adequate care for dealing existing pathology, require planned and coordinated programs, integrated into the overall health care system in accordance with the socio-economic base in community. 2e recent trends in the development of preventive dentistry are the introduction of oral health in system of monitoring and maintaining the balance of the entire organism.4][5][6] In that regard, new aims for improving oral health by 2020 have been set. 7,8e level of awareness of legislative and executive authorities on importance of oral health and its vulnerability in the country and city community will influence the actions that profession needs to undertake to get it introduced to the procedure of legal regulation and prevention programs funding.
The health system in dentistry should be primarily oriented toward primary health care and prevention.10] In addition to basic epidemiological indicators, it is necessary to determine the level of knowledge and attitude of all those in the chain responsible for program implementation.Only on the basis of the data obtained in the studies of educational diagnosis it is possible to plan the most important (and in our condition perhaps the only cost-effective) method of prevention and that is health education.

Aim of the Study
Determining the oral health knowledge level and contemporary possibilities of oral prevention in population groups in charge of decision-making about implementation and funding of prevention programs in potential executors in the prevention program as well as parents of younger population.

Patients and Methods
This study was the part of a larger study conducted within the framework of the scientific-research activities of the Department of Pediatric and Preventive Dentistry, Faculty of Medicine, Banja Luka.Prior to beginning of the study, necessary approval was obtained from the Director of the Centre for pre-school education Banja Luka where the survey was conducted among parents whose children were beneficiaries of the Centre.The Ethical committee and the Director of the Public Health centre Banja Luka also approved the study protocol for the part of the research conducted in this health institution.
The cross-sectional analytical study was conducted from January to March of 2008 in Banja Luka among members of local authorities-responsible for the adoption and implementation of legal regulations, workers in the media as potential promoters of a healthy lifestyle, teachers of the Centre for pre-school education Banja Luka-responsible for education in general and health education of children, parents of pre-school children-educators and teachers of their children and dentists -responsible for promotion and maintenance of oral health.
The survey was conducted by means of anonymous questionnaire in written form.For the purpose of this study, the questionnaire was made by two researchers.After the respondents signed an informed consent interview was conducted "face to face" with each participant by a single researcher.The questions referred to the general information about the subject, socio-demographic information, level of oral health knowledge, attitudes toward prevention in dentistry and oral health education.The assessment of the level of oral health knowledge was performed by using a group of four questions, where each question had the possibility of only one answer.The attitudes about prevention in dentistry were presented with three questions, which also had the possibility of only one answer.The assessment of oral health education level was carried out using four questions.Three questions had the possibility of one answer, but one question, "Where should it be important to health educate parents of preschool children?" had the possibility of multiple answers.The total sample consisted of 310 respondents, randomly chosen from urban and rural areas of Banja Luka.
The sample included respondents from the following target groups:

•
Respondents from local legislative and executive authorities -60 subjects among the members and delegates in the Assembly of Banja Luka, responsible for the adoption and implementation of legal regulations.
• Workers in the media -60 subjects from electronic and print media in Banja Luka (journalists, editors) as potential promoters of a healthy lifestyle.
• Educators -80 subjects, teachers in kindergartens of the Centre for pre-school education Banja Luka, responsible for education and health education of children.
• Parents of children up to six years (whose children attended kindergartens of the Centre) -a sample of 60 subjects.
• Health workers in the Dental department of the Public Health Centre Banja Luka -sample of 50 dentists.
After completing the interviews, data were grouped and processed by other researcher in order to obtain the greatest possible accuracy of the interpretation of the results.
For statistical analysis and presentation of results SPSS 16.0 for Windows, MS Office Word and Excel MS Office was used.Data were analyzed by standard procedures of descriptive and comparative statistics.The results are presented numerically and tabulated.Qualitative characteristics are shown in the frequency and percentage representation.The statistical significance of the obtained distribution was analyzed by X 2 -test.The question with multiple possibility answers was not analyzed by X 2 -test, but solely the percentage analysis was done.

Results
After processing the data, the results were grouped and analyzed based on the level of oral health education of respondents (Table 1), the attitudes on oral health education (Table 2) and attitudes of respondents toward prevention in dentistry (Table 3).
The majority of respondents (65%) believed that it is possible to determine the risk before the onset of tooth decay, which was statistically significant (p <0.001) (Table 1).After analyzing groups individually that relationship was even higher, but assessed level of knowledge of educators and governments reduced it.The subjects did not show a clear and significant commitment of public opinion regarding the proven scientific fact that tooth decay can be prevented.Even more surprising was the answer of 72% of examined dentists who though that tooth decay could not be prevented and depended mostly on genetics.The participants were not very familiar with epidemiologically proven fact that over 30% of children in developed countries are caries free-only 6% of them gave correct answer, which also contributed to the statistical significance (p <0.001).
A statistically significant difference (p <0.001) was also present in the attitude of the subjects that children have sufficient knowledge about dental health.The situation varied within each group of subjects.In the group of media and educators there was complete division on this issue.All the respondents representing authorities and large number of parents were confident in the fact that there is sufficient knowledge about dental health.Only the majority of dentists though that there is not enough knowledge (Table 2).All the groups emphasized the mass media (50%) and educational institutions (59%) as the ones that should be the most responsible for health education.Slight advantage, but not statistically significant, was given to educational institutions.The difference within the groups of subjects was very heterogeneous.The media and the government were absolutely convinced that the media (80%) have the most important role on that issue, only then schools and kindergartens (40%, 20%).The parents, teachers and dentists preferred the educational institutions (70%, 75%).None of the groups mentioned gynecologists and pediatricians as possible health education performers of parents.
There was a statistical significance (p <0.001) within the total sample related to all three groups of questions about attitudes toward prevention in dentistry (Table 3).

Discussion
The organization of health system and dental services requires a precise analysis of starting points, human and financial capacities, knowledge and willingness of each participant in the triangle (financiers-executorscitizens). 11,12[15][16][17][18][19][20] According to WHO standards, high-quality preventive program in dentistry should have a precise elaborate of preparatory phase, which should fully provide consent and active involvement of all stakeholders (citizens, financiers and executors). 13 our study, the level of "knowledge" of the media, government and educators about the existence of cariesfree children suggests that a significant number of respondents were not familiar with the achievements of modern dentistry.In response to this question the parents showed more knowledge, while dentists did not meet the expected professional level of knowledge, despite majority of correct answers.
Since the respondents did not notice that there was not sufficient knowledge of parents and children about dental health, the lack of implementation of preventive measures in practice is understandable.The worldwide studies have shown that the level of knowledge about the necessity of taking certain preventive measures did not correlate with their implementation, and in countries with a high prevalence of dental caries, low level of health culture attached to regular preventive dental visits was recorded.

13,21-24
5][6]13 There is a number of indisputable scientific but also practical facts for this primarily related to common risk factors, such as diet (frequency, quality, sugars, fast food, minerals, trace elements), lack of physical activity (in this case chewing), unhealthy habits and similarly.WHO and most of experts agree that a multidisciplinary approach to health promotion is the most acceptable.6][27] The gynecologists, pediatricians and their supporting services such as patronage and various counseling are the most responsible when we talk about health education of parents. 13The integrated scientific and professional way of thinking is far from ours, and therefore of the public, which is best demonstrated by the fact that respondents did not know that parents are the possible performers of health education.The dentists are excluded as a possible answer consciously, in order to make it easier to outline differences within the groups.
The representatives of the media and the authorities fully rely on the media as an effective means of health education, while other groups attached greater importance to educational institutions and educational staff.On the base of the entire sample in terms of under-representation of dental health education in preschool institutions and in the media, there was a statistically significant agreement that the situation is not satisfactory.For now, there is no explanation of what made parents and educators to believe that dental health is sufficiently represented in the media.[30] There was statistically significant difference between groups of parents and educators about satisfactory presence of dental health programs.The subjects of these groups should be the most reliable as direct executors and beneficiaries of these programs, but there is an obvious disagreement with the current situation, knowledge and application of basic principles of oral health. 11Attitudes of other three groups is important because introduction of modernized health education programs depends on their impact.
The majority of respondents (79%) believe that prevention programs in dentistry can fit into the current state of the country.It was stronger shown that programs are completely acceptable apart from the premise that they should be applied partly.The biggest skeptics were the media and the dentists, ones that have the greatest responsibility in promoting the program.In the groups representing government and educators (teachers) there was no doubt in opinion about possibility of implementing the program.This is one of the clear indicators of a halt in the transfer of information.
Total sample showed a statistically significant preponderance toward support of a preventive approach (65%), but analysis within groups pointed to the traps of such a global observation.It is almost unanimous attitude of the authorities and the media that prevention should have absolute priority and this have significantly raised results in the total sample.
The groups that should have a preventive mindset (educators and dentists) were undecided and there was no statistical significance for the obtained differences (p>0.05).
In turn the parents showed a greater commitment to improvement of caries treatment (p <0.05) as they directly face the growing pathology, complications of dental caries, increased costs of treatment and loss of time due to dental appointments.In fact no one of respondents has provided an organized and continuous dissemination of information as indicative of the possibilities and achievements in preventive dentistry. [33]

Conclusion
There is diversity in attitudes between the groups which significantly affects in creating the image of the complete sample being not true reflection of public opinion.
Respondents are not familiar with modern knowledge, abilities and accomplishments of preventive dentistry.The majority of the population and the profession itself are primarily concerned with therapeutic access.It is necessary to reorganize current dental care with the guidance to primary and preventive approach, focusing on implementation of continuous oral-health education in the territory of Banja Luka, as well as the entire Republic of Srpska.

Table 1 .
The level of oral health knowledge of the respondents

Table 2 .
Attitudes of respondents toward oral health education

Table 3 .
Atitudes of respondents about prevention in dentistry