| Abstract|| |
Purpose: Oral health literacy (OHL) is a relatively unexplored construct in the Indian context. Most of the few previous studies estimating OHL among different populations of India used instruments that were either previously validated in a different country or not tested for psychometric properties. With this background, the objective of this study was to develop an Indian oral health literacy measure and to evaluate the psychometric properties of the instrument among Telugu speaking population of Andhra Pradesh (IOHLM-T). Materials and Methods: The initial version of the instrument after evaluated for face and content validity was tested for psychometric properties among 200 adult patients visiting the outpatient department of SIBAR Institute of Dental Sciences. Predictive validity of the instrument was checked by the association between IOHLM-T score and oral health impact profile (OHIP-14), decayed-missing-filled teeth (DMFT) scores. Convergent validity was tested by assessing the correlation between IOHLM-T score and rapid estimate of adult literacy in dentistry (REALD-30) score. Statistical Analysis: SPSS version 20 software was used to analyse the data. Independent samples t-test, Pearson's correlation, one-way ANOVA and stepwise multiple linear regression were done to analyse the data. Results: IOHLM-T demonstrated good internal consistency reliability (Cronbach's alpha 0.75), convergent validity (r = 0.34 between Reald-30 and IOHLM-T scores) and predictive validity (significant negative correlation of IOHLM-T with OHIP-14 and DMFT scores). Conclusion: IOHLM-T demonstrates good face validity, content validity, predictive validity, convergent validity and internal consistency reliability and thus can be used among different populations in India after translation to the corresponding languages and evaluation of psychometric properties.
Keywords: Health literacy, India, oral health, oral health literacy estimation, psychometrics
|How to cite this article:|
Chandu VC, Vadapalli V, Pachava S, Marella Y, Bommireddy V, Ravoori S. Development and evaluation of a new oral health literacy instrument among telugu speaking population: The indian oral health literacy measure. Indian J Dent Res 2020;31:862-71
|How to cite this URL:|
Chandu VC, Vadapalli V, Pachava S, Marella Y, Bommireddy V, Ravoori S. Development and evaluation of a new oral health literacy instrument among telugu speaking population: The indian oral health literacy measure. Indian J Dent Res [serial online] 2020 [cited 2021 Sep 22];31:862-71. Available from: https://www.ijdr.in/text.asp?2020/31/6/862/311660
| Introduction|| |
Literacy is a multidimensional expression and there is no universal definition for literacy which encapsulates all its dimensions. Different countries have different fundamental understanding of literacy. In India, those who can read and write in any of the languages are considered to be literate. Literacy is among the basic indicators of the level of development achieved by a society. The term 'health literacy' was first used in 1974 by Professor Scott k Simonds in his paper 'Health Education as Social Policy'. According to the World Health Organisation (WHO), health literacy has been defined as 'the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand, and use information in ways which promote and maintain good health'. This definition is distinct from others in that it focuses not only on cognitive skills but also incorporates social skills which are required to implement decisions into practice, besides referring to both motivation and ability. Limited health literacy compromises an individual's ability to access health care services and lead a healthy life. With regard to oral health, there is substantial evidence that the oral health status of Indian population is poor, and the impact of oral health problems on the quality of life of an individual is well known. However, the utilisation of dental services continues to be poor., Though there are various factors influencing utilisation of dental services, inadequate oral health literacy is discussed as an important factor contributing to low utilisation of dental services and consequently poor oral health.
Oral health literacy (OHL) is a relatively unexplored construct in the Indian context. Most of the few previous studies estimating OHL among different populations of India used instruments which were either previously validated in a different country or not tested for psychometric properties.,, The solitary attempt to develop an OHL questionnaire for Indian population in 2011 could not establish the psychometric properties of the instrument and was not subsequently tested or used. Another attempt in this direction was made in 2016 through the Hindi version of oral health literacy adult questionnaire (OHL-AQ), an instrument originally developed in Tehran. While it is more practical to adopt previously validated questionnaires from different languages in diverse areas of scientific research, this practice raises questions about a multitude of facets relating to cross-cultural equivalence. With this background, the objective of this study is to develop an OHL instrument suitable for Indian population and to evaluate the psychometric properties of the instrument among Telugu speaking population of Andhra Pradesh, subsequently identified in this article as Indian oral health literacy measure in Telugu (IOHLM-T).
| Materials and Methods|| |
This study, to develop an OHL instrument in the context of Indian population, involved building consensus on the conceptual understanding of OHL, development of an item pool and evaluation of psychometric properties of the instrument. The study was conducted between March, 2018 and August, 2018. The methodology adopted in the process of developing IOHLM-T was described under the following four sections.
Development of item pool
All the previously validated OHL instruments were accessed and reviewed before the formulation of the instrument. Twenty-one OHL instruments were identified from electronic literature search.,,,,,,,,,,,,,,,,,,, After a thorough review of the available instruments and other relevant articles, the conceptual framework proposed by the Institute of Medicine's health literacy expert panel was considered relevant and the components of health literacy enumerated in the framework were reviewed. Following many rounds of consensus building, it was agreed upon by the investigators to include the domains of reading comprehension, numeracy, knowledge and the ability to communicate and navigate the health care system. Once the above-mentioned domains were identified, the next task was to locate the potential topics with regard to these domains from where the questions could be formulated.
To select the topics for assessing reading comprehension, an oral health education video developed by All India Institute of Medical Sciences (AIIMS) and Ministry of Health and Family Welfare, Government of India as a part of the National Oral Health Care Program (NOHCP) was regarded as a credible source of information by a group of experts, which was directed towards the oral health promotion of the citizens of the nation. The principal investigator watched the video, which lasts for 32 min, several times in both the languages before the notes were taken down in English. Information relating to tooth morphology, deciduous and permanent dentition and dental caries was selected to be included in the reading comprehension section of the instrument. Two reading comprehension passages as described above were included in this section with 14 items in the form of multiple-choice questions.
Two health numeracy questionnaires, namely, general health numeracy test (GHNT) and numeracy understanding in medicine instrument (NUMI) were reviewed along with OHL instruments., Scenarios from these questionnaires were adopted in the formulation of the numeracy-related items. Six items were included in this section designed with differing degrees of difficulty to ably distinguish between those with limited numeracy skills and good numeracy skills.
Oral Health Knowledge
In this sub-section, six items regarding conceptual knowledge were adopted from the literature.
Critical and communicative literacy
After a thorough review of literature relating to communicative and critical health literacy, it was decided to formulate questions based on the previously validated communicative and critical health literacy instrument among diabetic patients. For the items on critical and communicative literacy, responses 'often' and 'very often' were considered as reflective of the participants' ability to gain access to and critically evaluate oral health information.
Thus, the initial version of the instrument consisted of 32 items with 14 items from reading comprehension, 6 items each from numerical knowledge, non-numeric conceptual knowledge and communicative, critical oral health literacy. The initial version of the instrument was translated to the regional language Telugu (IOHLM-T) by one of the investigators, which was again back-translated to English by three experts. Minor changes were made in IOHLM-T following consultation with the back translators.
Evaluation of psychometric properties of IOHLM-T
The initial questionnaire in the local language Telugu was administered to 20 participants to check for both feasibility and face validity of the instrument. Few changes in the wording of the items were made as necessary. The questionnaire was given to 6 experts to check for content validity. Content validity index (CVI) was used to assess the content validity of the questionnaire. 30 questions were rated as 'quite relevant' or 'highly relevant' by the raters, and the item level content validity index (I-CVI) was found to be >0.83 after deletion of two items from the reading comprehension section. The scale level content validity index average method (S-CVI/AVG) and universal agreement (S-CVI/UA) were found to be 0.994 and 0.964, respectively. The flow chart depicting the development of IOHLM-T is given in [Figure 1].
|Figure 1: Flowchart depicting the development of initial version of IOHLM-T for evaluation of psychometric proper|
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IOHLM-T tested for face and content validity (Annexure 1) was administered to a convenience sample of 200 patients attending the outpatient department of SIBAR Institute of Dental Sciences, the only postgraduate teaching dental institution in Guntur district, Andhra Pradesh. The study protocol received approval from the Institutional ethics committee of SIBAR Institute of Dental Sciences (08/IEC/SIBAR/2014). Inclusion criteria used in this study were older than 18 years of age and the ability to read and write in Telugu. Patients with acute oral health problems requiring immediate care, those with disabilities, mental illnesses were excluded. 200 subjects satisfied the eligibility criteria and demonstrated willingness to participate in the study from the approached 310 patients. The purpose of the study was explained to the participants in detail and informed consent was obtained prior to their participation in the study. Along with IOHLM-T, the participants were given a self-administered questionnaire seeking the information relating to age, gender, educational qualification, per capita monthly family income and previous dental visits. Socioeconomic status of the participants was determined according to BG Prasad scale for socioeconomic classification. All the participants were assessed for oral health-related quality of life using OHIP-14. The prevalence (number of participants giving a response of 'often' or 'very often' to at least one of the items on the scale), extent (number of items on the scale for which the participant has responded with 'often' or 'very often') and severity (the composite score obtained by the participant on OHIP-14 scale) of OHIP were calculated. Clinical examination of the participants was carried out in the comprehensive dental clinics of the teaching dental institution. Coronal caries experience was assessed using DMFT Index (WHO 1997 modification). A single trained and calibrated dentist conducted the clinical oral examination [95% CI for intra-class correlation coefficient (ICC) estimate 0.86–0.93].
Predictive validity of the questionnaire was assessed by juxtaposing the score obtained with OHIP-14 and DMFT scores. The hypothesis was that participants with low OHL scores would have poor oral health-related quality of life and high caries experience. An attempt was made to establish the convergent validity of the questionnaire, a sub-type of construct validity, by comparing the OHL score with REALD 30 scores among 98 participants from the study sample of 200 who can understand both English and the regional language Telugu.
Scoring of IOHLM-T
In order to make the scale comparable with the previously validated OHL measures and to facilitate the determination of cut off scores in the categorisation of OHL, it was decided to express the final value as a weighted score ranging from 0–100. With a notion that reading comprehension, numeracy, knowledge and critical, communicative abilities are equally contributing to OHL, equal weight (25%) was assigned to each of the four domains of the OHL scale. Within each domain, the maximum possible score of 25 was divided by the total number of questions in that domain to derive the weight to be assigned for an individual question. The final OHL score was calculated as follows:
IOHLM-T score = [2.083(θRC) +4.167(θNS+ θOHK + θCC)]
where θ denotes the number of correct responses, RC denotes reading comprehension, NS denotes numeracy skills, OHK denotes oral health knowledge and CC denotes critical and communicative literacy. The cut-off points suggested for the categorisation of subjects into three levels of OHL in the previously validated OHL measures were employed in the present study: inadequate OHL (0–59); marginal OHL (60–74); adequate OHL (75–100).
SPSS Version 20 software (IBM SPSS statistics for Windows version 20, Armonk, NY, USA) was used for data analysis. Independent samples t-test, one-way ANOVA and Pearson's correlation tests were used to analyse the data, owing to the normal distribution of OHL scores (Kolmogorov–Smirnov test; P = 0.083). Stepwise multiple linear regression analysis was performed with IOHLM-T score as the dependent variable to understand the contributions of each of the predictor variables in explaining the variance in IOHLM-T scores.
| Results|| |
The mean age of the study participants was 34.37 ± 13.74 years, with a range of 19 to 70 years. Majority of the study participants were male, completed primary education and belong to upper middle socioeconomic status. The average time taken in the present study for completion of IOHLM-T was 18 min (17.88 ± 4.6). The mean IOHLM-T score among the study sample was 57.85 with the highest mean score in the sub-section of oral health knowledge. [Table 1] shows the mean scores obtained in each of the sub-sections of IOHLM-T and the mean composite score. 65.5% of the participants had inadequate (IOHLM-T 0–59), 20% had marginal (IOHLM-T 60–74) and 14.5% had adequate OHL (IOHLM-T ≥ 75).
|Table 1: Descriptive statistics for the IOHLM-T and the continuous predictor variables of IOHLM-T (n=200)|
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The mean caries experience of the study population was 2.98. 169 (84.5%) participants reported oral health problems to be negatively influencing their quality of life often or very often. The mean score for OHIP extent and severity was 2.56 and 14.10, respectively [Table 1]. [Table 2] shows the association of IOHLM-T score with different categorical predictor variables at bivariate level. Educational background of the study participants was found to be significantly associated with IOHLM-T score. The scores obtained by participants with high school education or less were found to be significantly lesser across all sub-sections of IOHLM-T compared to their counterparts. While there were no differences in OHL between different socioeconomic strata, participants with dental visit within the last 24 months demonstrated higher IOHLM-T scores. There was no difference in the IOHLM-T scores based on age and sex.
|Table 2: Association between categorical predictor variables and IOHLM-T score|
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Predictive validity of the IOHLM-T was established through the following observations. There was a significant difference in OHL based on the OHIP prevalence. Participants reporting oral health as significantly influencing their quality of life had lower OHL scores. [Table 3] shows the correlation between IOHLM-T scores and continuous predictor variables. While OHIP extent, severity and DMFT score were negatively correlated with IOHLM-T score, the number of filled teeth was observed to be positively correlated. IOHLM-T scores on a sub-sample of 98 participants who could read and write in English and Telugu showed a moderately strong positive correlation with the REALD-30 score indicating the convergent validity of IOHLM-T. IOHLM-T demonstrated good internal consistency reliability with Cronbach's alpha 0.75, and the internal consistency statistic for the sub-scales ranged from 0.68 to 0.84. At the multivariate level, educational background of the participants, last dental visit, OHIP prevalence, OHIP severity and Ft score were found to be significantly associated with IOHLM-T scores. [Table 4] shows the results from stepwise multiple linear regression with IOHLM-T score as the dependent variable, the final model showing an adjusted R2 (coefficient of determination) of 0.53.
|Table 3: Correlation between IOHLM-T score and continuous predictor variables|
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|Table 4: Stepwise multiple linear regression for prediction of variance in IOHLM-T scores|
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| Discussion|| |
IOHLM-T is the first OHL instrument developed for the Indian context, the psychometric properties of which were established. It is also unique in the fact that this is the first OHL measure that included critical and communicative literacy as an integral component of OHL. IOHLM-T, adopting the views documented by Institute of Medicine's panel on health literacy, measures the subject's ability to read and understand oral health-related information, to assimilate numerical information required to follow oral health-related advice, to communicate and gain access to oral health advice/delivery system, to critically review the oral health information received, besides evaluating his/her oral health knowledge.
It is intuitive that education has an inextricable link with literacy. However, educational attainment has often been discussed as a poor proxy for literacy and it was emphasised that literacy needs to be theorised and measured in ways distinct from that of education. Educational background of the subjects was found to be significantly associated with IOHLM-T scores at both bivariate and multivariate levels. Few of the previous studies reported educational level to be a significant predictor either exclusively at bivariate level,,, and multivariate levels, or at both bivariate and multivariate levels. However, studies conducted by Sabbahi et al. and Wong et al. documented results inconsistent with the present study with no differences in OHL based on educational background.
Subjects who had their latest dental visit within the past 2 years demonstrated higher IOHLM-T scores compared to their counterparts. This finding could be a result of the relatively recent exposure of these subjects to oral health care facilities. Literature shows mixed results for the association between dental visits and OHL. Studies conducted by Sabbahi et al. and Jones et al. found a significant association between frequency of dental visits and OHL, whereas studies by Atchison et al., Wong et al. and Lee et al. showed no differences in OHL levels based on dental attendance.
Predictive validity of IOHLM-T was established based on the association between IOHLM-T scores and oral health-related quality of life, caries experience. The prevalence, extent and severity of oral health impact profile were documented in this study. A significant association was found between OHIP prevalence and OHL scores at both bivariate and multivariate levels. While OHIP extent and severity were also found to be significantly negatively correlated with OHL scores at bivariate level, at multivariate level, only OHIP severity remained a significant predictor. OHIP extent and severity were entered alternatively in different models to avoid multicollinearity, as there was a strong positive correlation between these two variables (r = 0.81). These results were consistent with the findings from previous studies.,,,, In the Indian scenario, a study done by Sharma et al. among undergraduate students in Bangalore city showed positive correlation between oral health-related quality of life and OHL scores. The overall DMFT score (caries experience) was found to have a significant weak negative correlation with OHL scores at bivariate level, but no significant association was found at multivariate level. While decay component of DMFT and missing component of DMFT were negatively correlated with the OHL scores, the filled component showed a highly significant moderate positive correlation. The missing component of DMFT was not entered in the regression model owing to its strong positive correlation with OHIP severity (r = 0.79). The filled component of DMFT remained a significant predictor of IOHLM-T scores at the multivariate level. High caries experience among subjects with low OHL levels was previously reported in the literature.,,,
| Conclusion|| |
IOHLM-T demonstrates good face validity, content validity, predictive validity, convergent validity and internal consistency reliability and hence can be used among different populations in India after translation to the corresponding languages and evaluation of psychometric properties. This also ensures comparability of OHL levels between different populations of the huge and diverse Indian geographic. All the previously validated OHL instruments, including IOHLM-T, were developed to estimate the OHL of those subjects who could read and write. However, based on the World Health Organisation's description of health literacy, it is obvious, though a paradox, that individuals could be 'health literate' in being able to gain access to, understand and use health information, without actually being literate (possessing reading and writing skills). The authors opine that an important direction for future OHL research could be the development of an instrument that could capture the OHL of people who could not read and write.
Declaration of participant consent
The authors certify that they have obtained all appropriate participant consent forms. In the form, the participants have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors thank Mr. N. Hanumanth., M.Sc., (M.Phil) for the assistance in statistical analysis. The authors also thank the study participants whose contributions made the development of this instrument possible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Annexure- 1|| |
| Indian Oral Health Literacy Measure|| |
Passage 1: Read the following information
Teeth are very important part of our inner and outer personality. For good health our teeth also needs to be healthy. But for most people dental health is the last priority. They are not even aware of how to take good care of teeth. So first let us get introduced to our teeth and gums. A tooth can be divided into two parts, “crown” and “root”. Crown is the part you can see in the mouth. But the root part is not visible. It is hidden in the jaw bone. The outermost layer of crown is called “enamel”. It is the strongest structure in the entire human body. The yellowish layer below the enamel which looks like bone is called “dentin”. The dentin surrounds the vessels and nerves of the teeth called “pulp”. The blood vessels supply food, while the nerves carry sensation to the teeth.
Thereare two dentitions in human being. First is during the childhood when we cal lthem “milk teeth”. Milk teeth do the job of chewing and help in the development of jaw bone and permanent teeth. Milk teeth start emerging in the infant's mouth at the age of six months, and grow fully by the age of two and half years. When the child is six years old, the first permanent teeth emerge. Gradually the milk teeth start falling, and by the age of twelve, permanent teeth emerge in the place ofmilk teeth. The number of permanent teeth in human beings is 32.
Section 1: Answer the following questions based on the information given above.
1) The part of tooth present in jaw bone and covered with gums is called:
a) Enamel b) Crown c) Root d) Don't know
2) Strongest structure in human body:
a) Enamel b) Jaw bone c) Dentin d) Don't know
3) Number of milkteeth:
a) 24 b) 32 c) 20 d) 16
4) First permanent tooth erupts at which age:
a) Six months b) Six years c) Three years d) Three months
5) By what age permanent teeth emerge in place of milk teeth?
a) 8 years b) 6 years c) 10 years d) 12 years
6) If stands for general health and stands for oral health, which of the following pictures correctly demonstrate the relation between oral health and general health?
a) b) c) d) Don't know
Passage 2: Read the following information
Identification of dental caries and having awareness on how to protect ourselves from dental caries are very important. Accumulation of plaque in mouth is a major reason for dental caries. Acids are produced when microorganisms come in contact with the left-over food in the mouth. Dental caries initially start as black / brown spot on the teeth. This slowly extends to create a hole in the tooth. When tooth decay extends to pulp, it results in pain. From there, the infection spreads to tooth root and jaw bones and causes swelling. This swelling can spread to face and neck. This can result in fever and is life threatening sometimes. Tooth decay is mainly foundon chewing surfaces or between the back teeth, the places where food usually gets stuck. Therefore, in order to prevent dental caries keeping the mouth clean and free from accumulation of plaque is very important. Brushing twice daily with tooth paste, mouth rinsing, and tongue cleaning are best practices in preventing tooth decay. During the night, if in fants are left for long time with milk bottle in the mouth, that can also cause dental caries. To prevent this, children must be given a spoonful of water in sitting position, after having milk. It is important to regularly clean infant's teeth with small tooth brush from the time the first tooth emerges in the mouth.
Section 2: Answer the following questions based on the information given above.
7) Dental caries start as color spot on the teeth:
a) Black / Brown b) White / Purple c) White / Brown d) Don't know
8) --------- are produced when microorganisms come in contact with the left-over food in the mouth:
a) Sweets b) Acids c) Bases d) Don't know
9) Pain starts when decay extend to:
a) Enamel b) Dentin c) Pulp d) Don't know
10) There is no chance for dental caries to cause infection of jaw bones.
a) Yes b) No c) Don't know
11) Milk teeth of children should be cleaned with tooth brush starting from which age:
a) When children can brush on their own
b) Six months c) Eighteen months d) No need to brush milk teeth
12) What are the precautions that have to be taken to prevent dental caries after giving milk to children? (Write in your own words)
Section 3: Answer the following questions.
13) Dentist advised a patient Ramaiah who complained of toothache to get his tooth extracted. However, since Ramaiah had high blood sugar levels, he was asked to consult back after attaining blood sugar level between 80 and 150. At achievement of which of the following blood sugar levels, can Ramaiah consult the dentist?
a) 60 b) 160 c) 130 d) 200 e) Don't know
14) Dentist who examined Kumar identified that there was swelling and pus discharge near the gum. He advised Kumar to take a tablet once in every eight hours. How many tablets should Kumar take in 3 days?
a) 12 b) 24 c) 9 d) 6 e) Don't know
15) New tooth brush can remove 30% more plaque than a tooth brush which has been in use for three months. What does this mean?
a) Tooth brush which has been in use for three months can remove only 30% of plaque.
b) New tooth brush can remove more plaque than a tooth brush which has been in use for three months only on 30% of occasions.
c) If a tooth brush which has been in use for three months can remove 60% plaque, new tooth brush can remove 90% plaque.
d) Don't know
16) A dentist advised Seethamma who underwent extraction to take a tablet twice daily for three days. If she takes the first tablet at 9 AM on Monday, when should she take the next tablet?
a) 12 noon on Tuesday b) 10 AM on Monday c) 9 PM on Monday d) Don't know
(17-18) Answer the following Questions based on the information given in the table.
17) According to the information given in the table:
a) Malocclusion is more common than dental caries b) Malocclusion is more common than gum diseases
c) Gum diseases are more common than malocclusion d) Don't know.
18) According to the information given in the table:
a) 60% of the population has dental caries. b) Nine out of every hundred people are suffering from gum diseases.
c) There are people who have more than 30 teeth with malocclusion. d) Don't know.
Oral Health Knowledge
Section 4: Answer the following questions.
19) After how much time of use does a tooth brush needs to be changed?
a) No need to change till it wears off b) 2 weeks c) 3 months d) 6 months
20) From what age children can start brushing their teeth without adult supervision?
a) 3 years b) 12 years c) 24 months d) 6 years
21) Use of fluoridated tooth paste can prevent dental caries.
a) Yes b) No c) Don't know
22) What is the ideal time to be spent on brushing teeth?
a) 1-3 minutes b) 4-6 minutes c) > 6 minutes d) Don't know
23) Can dental plaque stick to your tongue?
a) Yes b) No c) Don't know
24) Consuming sweets in between meals decreases the risk for tooth decay.
a) Yes b) No c) Don't know
Critical and communicative literacy
Section 5: Answer the following questions.
25) Were you able to obtain oral health related information when needed?
a) No b) Sometimes c) Often d) Very often
26) Were you able to understand the information obtained relating to oral health?
a) No b) Sometimes c) Often d) Very often
27) Did you implement the information you obtained relating to oral health in your daily life?
a) No b) Sometimes c) Often d) Very often
28) Did you analyze the information obtained?
a) No b) Sometimes c) Often d) Very often
29) Did you share the information with others?
a) No b) Sometimes c) Often d) Very often
30) Which of the following is the most likely thing you would do in case of toothache?
a) Home remedies/self-care b) Take pain killers c) Consult a dentist d) Wait for the pain to relieve
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Dr. Viswa C Chandu
Department of Public Health Dentistry, III Floor, SIBAR Institute of Dental Sciences, Guntur, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4]