Efficiency of Visual Pedagogy in Enhancing Nursing Graduates’ Understanding of Nutritional Knowledge for Maintenance of Oral Health: A Quasi-Experimental Study

INTRODUCTION

Dental caries, a preventable non-communicable disease, poses a major global public health issue, especially among children.^[1,2] As per the Global Burden of Disease Study (2017), more than 530 million children worldwide suffer from dental caries in their primary teeth, commonly known as early childhood caries (ECC), impacting children aged <3 years.^[3] ECC affects children’s quality of life, imposes a heavy financial strain on families and healthcare systems, and presents major challenges to children’s general health and well-being.

Numerous risk factors predispose children to ECC, including frequent consumption of sugary snacks and beverages, prolonged bottle or breast-feeding beyond infancy, nocturnal bottle-feeding with sweetened liquids, poor oral hygiene habits, maternal dental caries, low socio-economic status, and lack of access to dental care services. The bacteria present in the mouth ferments the carbohydrates provided by the milk, which leads to demineralisation of the tooth, which further progresses to dental caries. Also, Plaque, a sticky layer of microorganisms, accumulates on teeth when oral care is neglected. By consuming carbohydrates from food and beverages, these bacteria create acids that damage tooth enamel and cause cavities. Addressing the multifactorial nature of ECC requires collaborative efforts across various sectors, including healthcare, education, and social services.^[1,4,5] By implementing comprehensive preventive strategies and timely interventions, we can mitigate the burden of ECC and improve oral health outcomes for children worldwide.

To address oral health risks stemming from limited dental care access, a patient-centred, collaborative, multidisciplinary learning practice is crucial, acknowledging the reality that many people lack knowledge and do not have regular contact with dentists. In this system, nurses play a significant role in disease prevention and oral health promotion, as they frequently engage with patients of all ages and backgrounds.

The WHO report states that health professionals ought to be both locally relevant and globally competent.^[6] The goal of the global oral health competency matrix is to handle the many demands and difficulties associated with oral health on a worldwide basis. In order to effectively address the worldwide burden of oral disorders, this matrix highlights the significance of a multidisciplinary approach. Along with doctors, physician assistants, and pharmacists, nurses were included in the third competency category of a competency matrix for global oral health.^[7]

Nursing staff are essential in promoting health and disseminating preventive information to patients, their families, and the public. In primary care, nurses see children and their families on a regular basis in addition to doctors. Compared to dentists, nurses can more easily reach the general public. As a result, nurses can contribute significantly to the development of oral health among Indian citizens. Therefore, if they possess the necessary knowledge about oral health, they may play a significant role in educating individuals and groups about oral health and serve as role models for patients, friends, families, and the community at large.^[7-12]

According to evidence-based research, dental care is a crucial but underappreciated aspect in the nursing specialty. The majority of nurses lack knowledge about dental care. In India, dental care education programs for nurses are currently essential. We can evaluate nursing graduates’ effectiveness in raising oral health awareness among the general Indian population by gathering data on their current oral health knowledge and attitudes.^[13-16]

Few studies have been done to evaluate nurses’ knowledge, attitudes, and practices because cognitive and affective domains can be the best interpreters of behavioural changes. One such study found that nurses’ lack of oral health education contributed to their lack of confidence in their ability to perform a thorough paediatric oral examination and lack of knowledge regarding diet and oral hygiene practices.^[17-22] Therefore, this study is being undertaken with an aim to evaluate the knowledge, attitude, and practice as well as evaluate the effectiveness of an educational intervention among nurses regarding the association between diet and dental caries.

MATERIAL AND METHODS

From March 2023 to July 2023, 60 nursing graduates from Dr. D.Y. Patil College of Nursing in Pune, Maharashtra, India, participated in the current pretest-post-test quasi-experimental study. The study included participants who had recently completed their senior year and begun their internship at the same hospital. Before starting the study, approval from the institutional scientific and ethical committees was acquired. The Institutional Ethics Review Board (IERB) of Dr. DY Patil Dental College and Hospital granted ethical clearance (Ref.No.DYPDCH/DPU/EC/582/132/2023).

RESULTS

We initially targeted 60 participants based on our sample size calculation. However, due to participant attrition and incomplete responses, the final analysable sample was 54. This shortfall (10%) is within acceptable limits for educational intervention studies and was considered during data analysis.

A total of 54 nursing graduates completed the survey; the majority are in the age group of 18-24 years. There were 15 males and 39 females among the respondents. The study’s sample of nurses had an average age of 19.48 +/- 1.10.

A comparison of dental nutrition knowledge before and after intervention is presented in Table 1. The assessment of knowledge responses between the pre-intervention questionnaire (pre-test) and post-intervention (post-test 1 week and 1 month) was statistically significant in the knowledge section [Table 1].

There was a significant difference (p <0.05) in the questionnaire’s responses to each question when comparing the results from 1 week and 1 month. The percentage of nursing graduates who correctly answered the questions in the overall knowledge segment increased significantly.

The mean scores of attitudes prior to, immediately following, and one month following the educational intervention of dental nutritional knowledge are compared in Table 2. The overall median attitude scores among nursing graduates increased following the intervention and remained elevated after 1 month, indicating a positive and sustained shift in their perceptions.

Educational intervention caused a significant increase in knowledge among the nursing graduates. Most of the nursing graduates had inadequate knowledge regarding dental nutrition before the educational intervention, which statistically increased post the intervention as shown in Tables 1 and 2.

DISCUSSION

In India, oral health is rarely given the attention it deserves. Despite the fact that 70% of Indians suffer from oral disorders, 40-50% of them have never been to a dentist, according to a Frost and Sullivan study.^[21-23] According to a study by Rai et al.^[15] in India, patients exhibit poor oral health, and more than two-thirds of patients had dental caries, and almost half of the patients had at least one mouth syndrome. The American Academy of Paediatric Dentistry (AAPD) encourages all medical professionals to help prevent ECC by providing services such as nutritional counselling, oral screening, preventive interventions, fluoride varnish application, risk assessment, health promotion, care coordination, and referral for paediatric dental care.^[23]

According to a survey, paediatricians and general practitioners do not recommend that parents take their children to the dentist by the time they are one year old. This indicates that medical organisations need to do more to educate their members on this subject.^[24,25] Several studies have reported that medical, dental, and nursing students often exhibit limited knowledge and training in oral health, which may reflect gaps in the emphasis placed on oral healthcare in their professional curricula.^[26-30]

Clinical nurses are readily available and frequently interact with children and pregnant women who come to hospitals for routine examinations, which opens the possibility of incorporating oral health promotion and care into medical treatment.^[31]

According to the Indian Nursing Council, there are around 2 million registered nurses across India.^[32] With the help of this number of health care workers, the awareness among the parents about dental nutritional knowledge can be easily propagated. However, even after the advancement in patients’ oral care, the proportion of knowledge and attitude among nurses is still low.^[33] Hence, this cross-sectional study was conducted to assess and generate information regarding nurses’ knowledge, attitude, and associated factors towards the patients’ oral care among nurses and evaluate the effectiveness of the intervention in improving the scenario.

A similar study by Philip et al.^[34] in 2019 concluded that although nurses had a good attitude toward dental health, they lacked sufficient understanding in certain areas of oral health care, whereas another study by Lakshmi et al.^[35] in 2022 revealed that nursing graduates had acceptable knowledge but a negative attitude, and inadequate oral health practices.

In a related study, Godbole et al.^[36] compared nursing graduates’ understanding of oral healthcare for CSHCN before and after the structured visual pedagogy (SVP) intervention. They found that post-intervention knowledge increased and that SVP was a very useful training tool. The 1-week post-intervention results revealed that there was a considerable improvement in the dental knowledge score post-conduction of the intervention as compared to the pre-intervention score. Post-intervention, the nursing graduates correctly answered questions related to dental caries and breastfeeding, demonstrating the nursing graduates’ inability to demonstrate sufficient knowledge prior to the intervention. It was discovered that nurses’ knowledge was higher as a result of their nutrition education. According to a study conducted by Yalcin et al.^[37] on the nutritional knowledge level of nurses, displayed that compared to nurses who declined to participate in nutritional assessment activities, those who did receive the intervention had higher knowledge scores.

The retention of knowledge amongst the nursing graduates was assessed 1 month post-intervention. The post-test 1-month scores were slightly decreased. In general, it was observed that the nursing graduates had low retention of dental knowledge, which was reflected in the 1-month post-intervention results.

The comparison of pre-test and post-test results revealed a significant improvement in nurses’ knowledge, attitude, and practice regarding dental nutrition after the intervention. When comparing results 1-week and 1-month post-intervention, both groups showed increased scores in the knowledge and attitude domains. However, knowledge retention after 1 month was slightly lower than the 1-week post-test but still higher than the pre-test scores. The participant’s understanding of nutrition was found to be average.

The result considerably improved after the intervention, i.e., the post-test score is higher than the pre-test score. In Table 1, two of the five knowledge-based questions (K1 and K2) showed improved results in the 1-month post-test compared with the 1-week pre-test. Both questions, being based on breastfeeding, conveyed that nursing graduates were more aware of the following due to their exposure to breastfeeding in their paediatric curriculum.

However, the remaining three questions (i.e., K3, K4, K5) based on dental nutritional knowledge revealed that the post 1-week questionnaire result was the highest, and the retention of knowledge in the 1-month post-test was reduced. It can be said that the nurses had minimal retention regarding the appropriate weaning age, the role of liquid medicines in the occurrence of caries, and the first dental visit schedule, as they do not have exposure to oral care in their curriculum.

In the attitude-based questions seen in Table 2, four out of five questions (i.e., A1, A2, A3, A5) indicated that the post 1-week results increased as compared to the pre-test, while post 1-month values show the same result as 1 week, i.e., there was no statistical difference. Except for one question (i.e., A4), nocturnal feeding revealed that post 1-month test results were reduced as compared to 1-week post-test results. The findings revealed that the participants retained the attitude about the importance of the role of diet in the prevention of dental caries. This might be attributed to the fact that diet and nutrition are a part of their curriculum. Overall, the nurses showed a positive attitude towards the intervention.

The UK is currently at the forefront of the global professionalisation of dental nursing, requiring dental nurses to complete a limited amount of training before becoming fully qualified and registered.^[1,2] As of January 2017, the General Dental Council has 55,691 dental nurses registered, accounting for 51% of the total number of registrants.^[38]

It has only recently been acknowledged how important dental care is to nursing services. Oral care is covered in the training program for certified nurses, which was initiated by the Japanese Nursing Association in 2006. As a result, dental care is positioned as a critical nursing service for hospitalised patients.^[39,40]

In the current study, the results of the pre-intervention questionnaire displayed that the nursing graduates had limited knowledge regarding dental nutrition. Our findings showed that participation in the intervention programme increased the nursing students’ knowledge, awareness, attitude, and confidence regarding dental nutritional knowledge.

It is crucial that the healthcare professionals, especially nurses, understand the numerous risk factors in order to manage oral care and choose the proper referrals and interventions, as advised by the Institute of Medicine (IOM) report.^[41] Education for nurses must focus on team-based approaches to working with other physicians, which means that physicians must focus on engaging with nurses, in addition to addressing a wide range of other areas of instruction and training.^[42-44]

The first step in introducing oral health knowledge is including it in university education, and the ability of an approach to create curriculum change that embeds oral health and knowledge topics within current nursing professional education is crucial to achieving such aims.

As a result of inadequate integration of oral and dental health care competency training into the curriculum and a lack of structured special modules of such training, nursing graduates’ understanding of oral and dental health was low. Therefore, we advise that a structured syllabus regarding the role of diet and nutrition in the prevention of ECC and understanding of oral dental health be included in university-level nursing graduates’ curricular. Moreover, to test the efficacy of such curriculum improvements, more post-intervention studies and evaluations will be required.

We must acknowledge the limitations of the study. In the first place, the study was limited to one educational institution, which could limit the generalisability of the results. Secondly, the study relied on self-reported data from nursing graduates, which might have been over- or under-reported in terms of their knowledge and attitude towards dental nutritional knowledge. This self-reporting could have been influenced by social desirability bias.

Our research demonstrates that offering an interprofessional educational programme to nursing graduates can give them the necessary information, awareness, assurance, and attitude regarding oral health problems. Such programmes should be reinforced frequently to sustain the knowledge and awareness. They may benefit from it for behaviour modification, prevention, and continuous dental monitoring. A referral mechanism between paediatric nurse practitioners and paediatric/general dentists and nursing programs for aspiring non-dental professionals both highlight the significance of oral health components, which is strongly recommended.

CONCLUSION

The visual pedagogy (VP) intervention significantly improved nursing graduates’ understanding of dental nutritional knowledge at both 1-week and 1-month post-intervention. VP is an inexpensive, practical, and easily reinforced tool that can enhance nurses’ ability to provide quality oral healthcare. Sustaining these gains and improving children’s oral health requires interprofessional collaboration and ongoing educational reinforcement.