n> Check for updates Originai Artide SAGE Open Medicine Clinieal and sociodemographic factors associated with orai health knowledge, attitude, and practices of adolescents in Nigeria SAGE Open Medicine Volume 8: 1-8 © The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/2050312120951066 journals.sagepub.com/home/smo Folake Barakat Lawal and G bem isola A d e re m i O ke A b stra ct O bjectives: The institution of appropriate oral health promotion programs targeted at adolescents in schools in developing countries requires baseline information on their oral health knowledge, attitude, and practices as well as associated factors influencing it, which are unknown. This study assessed clinical and sociodemographic factors associated with oral health knowledge, attitude, and practices of adolescents in Ibadan, Nigeria. M ethods: Two-thousand and ninety-seven students aged 12-18 years were recruited from 30 randomly selected secondary schools in a cross-sectional study conducted in Ibadan, Nigeria. Data were obtained through a questionnaire on oral health knowledge, attitude, and practices, and sociodemographic characteristics. Oral examination was conducted to assess the clinical oral condition of the adolescents. Data were analyzed with SPSS. The higher the percentage scores, the better the oral health knowledge, attitude, and practices, and overall awareness of oral health. Results: The oral health knowledge score ranged from 0% to 60%; mean oral health knowledge score was 15.1% (±6.6%). The oral health attitude score ranged from 0% to 91.3%; mean oral health attitude score was 44.5% (± 14.3%). The oral health practices score ranged from 0% to 88.9%, and mean oral health practices score was 42.5% (± 13.8%). The mean oral health knowledge, attitude, and practices score was 43.8% (± 11.4%). A total of 1537 (73.3%) participants had unhealthy periodontium and 98 (4.7%) had dental caries. Students who were 12-15 years (odds ratio = 1.7, 95% confidence interval = 1.4­ 2.0, p < 0.001), females (odds ratio = 1.2, 95% confidence interval = I.0-I.5, p = 0.024), offspring of skilled workers (odds ratio = 1.5, 95% confidence interval = I.I-2.0, p = 0.010), previously educated about oral health (odds ratio = 1.3, 95% confidence interval = I.0-I.7, p = 0.023), consulted the dentist (odds ratio = 1.9, 95% confidence interval = I.2-3.I, p = 0.009), or had unhealthy periodontal condition (odds ratio = I.2, 95% confidence interval = I.0-I.5, p = 0.042) were more likely to have higher oral health knowledge, attitude, and practices scores or awareness than others. C o n clusion : Better knowledge, attitude, and practices score was associated with younger age group, higher occupational class, previous oral health education, dental consultation, and having unhealthy periodontal condition. K eyw ords Adolescents, awareness, knowledge, knowledge, attitude, and practices, oral health, school Date received: 6 May 2020; accepted: 24 July 2020 Introduction Adolescents in developing countries live with high unmet dentai needs, which significantly affect their quality of life.1-4 The daily activities reported to have been impaired among the domains of oral health-related quality of life include eat- ing, speaking, maintaining social contact, and schoolwork.1-4 Worrisome is the fact that adolescence is a crucial period in human development, linking childhood to adulthood. As Department of Periodontology and Community Dentistry, College of Medicine, University of Ibadan, Ibadan, Nigeria Corresponding author: Folake Barakat Lawal, Department of Periodontology and Community Dentistry, College of Medicine, University of Ibadan, PMB 50I7, Ibadan 2002I2, Nigeria. Email: folakemilawal@yahoo.com Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the w ork w ithout further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). UNIV ERSITY O F I BADAN LI BRARY http://crossmark.crossref.org/dialog/?doi=10.1177%2F2050312120951066&domain=pdf&date_stamp=2020-08-18 https://uk.sagepub.com/en-gb/journals-permissions https://journals.sagepub.com/home/smo mailto:folakemilawal@yahoo.com https://creativecommons.org/licenses/by-nc/4.0/ https://us.sagepub.com/en-us/nam/open-access-at-sage 2 SAGE Open Medicine such, absenteeism from school as well as impairment of other daily performances, especially as a result of orai dis- eases, is of great significance. This is because, these unmet dental needs result largely from poor periodontal health and dental caries, which are largely preventable.5 Prevention of these common diseases can be addressed through promoting awareness of causes and prevention of common oral diseases.5,6 One way of achieving this is by promoting oral health among a sizable number of adoles- cents in the schools.5,6 However, this has not been the case in many developing countries, as little attention is accorded to school oral health. Furthermore, adolescents are largely absent from the oral health promotion plans in many devel- oping countries. It, therefore, becomes imperative to investi­ gate the level of awareness of oral health as well as associated factors in a bid to accommodate this age group in the plan­ ning of oral health promotion in schools. More so, the impor- tance of oral health awareness in maintaining good oral health has been documented.7 In addition, inequalities in health and oral health occur globally.8-11 This coupled with high cost of dental treatment12 constitutes a stumbling block to access of dental care by ado- lescents from the lower social classes with unmet dental needs, which is typical of in-school adolescents in the public sector in most developing countries. Thus, the prevention of oral diseases and promotion of oral health among adoles- cents in schools is very important in developing countries. In the planning process, assessing level of oral health aware- ness among adolescents and factors associated with it becomes pertinent. This study, therefore, assessed the clini- cal and non-clinical factors associated with level of oral health awareness of adolescents in a developing country. M ethods Study design This cross-sectional study was conducted from April 2018 to July 2018. The study was conducted among students in the senior school classes I and II (Grades 10 and 11) in randomly selected secondary schools in Ibadan. Ibadan is the largest city in West Africa and the capital city of Oyo State, Nigeria. The sample size for the study was calculated with Kish Leslie formula for cross-sectional study.13 A sample size of 1594 was estimated based on a power of 80%, prevalence rate of knowledge of importance of the teeth among adoles- cents in schools of 21%14 and a degree of error of 2%. The result was inflated by 20% to account for non-response or withdrawal from the study at any stage and this resulted in a minimum sample size of 1992 students. The sampling process of the study was done in three stages. The first two stages involved sampling of schools for the study, while the last stage was the selection of students from the schools. In the first stage, three local government areas (LGAs) within the metropolis of Ibadan were selected from the list of the LGAs in the town using a table of random numbers. The second stage involved selection of 10 schools from each LGA using a table of random numbers. In the pro- cess, a total number of 30 schools were selected. The last stage was the selection of 70 students from the class registers of the two classes (senior school classes I and II) in each of the 30 schools using a table of random numbers. Selection criterio Only students who returned signed consent forms from par- ents, who gave assent to participate in the study and were available at the time of the study were included in the study. Students who had special needs or were ill at the time of visit to their schools were excluded from the study. Data collection tool Data were collected from the students with the use of struc- tured self-administered questionnaire and by oral examina- tion. The questionnaire was divided into four sections: the first section assessed sociodemographic characteristics of the students; the class, age, occupation of parents, and edu­ cational qualification of parents. The age of the students was dichotomized around the mean age for ease of analysis. The occupation of the parents was classified based on a modifica- tion of Office of Population Censuses and Surveys (OPCS), which had been used previously in this environment.15 The higher of the occupational classes for the two parents was recorded for each participant. The students’ oral health knowledge, attitude, and prac- tices (KAP) were assessed using a modification of the questionnaire that had been utilized among the younger age group in this environment.14 The questionnaire was developed through review of literature. The questionnaire was validated by consulting experts in public health den- tistry who discussed the contents of the questions and cer- tified the questions as measuring the oral health KAP of adolescents in addition to being deemed appropriate for the age group. The questionnaire was evaluated by stu­ dents who were not included in this study and were in grades 10 and 11 of schools in another LGA of the town. In addition, the reliability of questionnaires was assessed during the pretest. Cronbach’s alpha value ranged from 0.70 to 0.77 for the reliability of different components of the questionnaire. The questions on oral health knowledge (OHK) evaluated the participants’ knowledge of number of primary/deciduous and secondary/permanent teeth, functions of the teeth and causes of tooth decay and gum diseases. They were asked if they had heard of fluoride and the role of fluoride. The ques­ tions also evaluated the attitude of participants toward oral health care on a Likert-type scale: “agree,” “strongly agree,” “indifferent/don’t know,” “disagree,” and “strongly disa- gree.” For the purpose of re-coding, “disagree” and “strongly UNIV ERSITY O F I BADAN LI BRARY Lawal and Oke 3 disagree” were collapsed as one variable “disagree” and “agree” and “strongly agree” as another—“agree.” The ques- tions that assessed oral health practices (OHP) addressed the frequency and duration of tooth and interdental cleaning, type of toothbrush, frequency of change of toothbrush, use of toothpaste, method of tooth cleaning, and consumption of cariogenic food. A score of one (1) was given for correct answers and zero (0) for wrong answers on knowledge questions. Likewise, a score of 1 was allotted to positive attitude and 0 to negative ones. Healthy oral practices were scored 1 and risky or unhealthy ones scored 0. Responses to KAP questions were summed up for each respondent and converted to percent- ages to generate OHK, attitude (OHA), and OHP scores. The conversion to percentages was done to obtain a standard score that would make comparison with other studies easy. The total KAP score was generated by adding the OHK, OHA, and OHP scores together for each student and dividing by three to get an average score. The test-retest reliability of the questionnaire was conducted by re-administration of the questionnaire to 10% of the participants after lweek. The test-retest reliability was 0.93 for knowledge questions, 0.97 for questions assessing attitude and 0.88 for practice ques- tions as evaluated by Kappa statistics. Oral examination was conducted by four trained and cali- brated dentists. The dentists were trained by a qualified oral epidemiologist based on the guidelines of the World Health Organization.16 The training was conducted over 2 days and calibration of the examiners performed over 5 days with 2 days interval between training and calibration process. The standardization of the oral examination and scoring for both dental caries and periodontal health was achieved when the intra examiner and inter examiner’s variability as evaluated by Cohen Kappa statistics was 0.85 to 0.9. Duplicate exami­ nation was also done on 10% of the students by the four den- tists during the course of the study and the inter examiner’s variability ranged from 0.8 to 0.85. Oral examination was conducted with the participants seated upright on a chair near the window so natural lighting could serve as source of illumination. Privacy was ensured at all times. Oral examina­ tion was conducted according to the World Health Organization’s basic survey for dental caries and periodontal health.16 Sterile probes and dental mirrors were used for oral examination. Dental caries was charted as Decayed (D), Missing (M), or Filled Teeth (F). The periodontal health was charted as “0” for healthy periodontium. Periodontal disease (unhealthy periodontium) was charted when gingival bleed- ing was present for participants aged 12-14 years and/or periodontal pocketing for older students. Data analysis Quantitative data obtained was analyzed with SPSS. Numeric variables were summarized using means and standard devia- tions. For the purpose of analysis, age, OHK, OHA, and OHP were dichotomized around the mean score into “12-15 years” and “16-18 years” for age, “^15 and >15” for OHK, “^43 and >43” for OHA, “^42 and >42” for OHP. In addition, total KAP score was categorized into a binary value around the mean score into “^44% and >44%.” Occupational class of the participants’ parents was dichotomized as “skilled workers” and “others,” which included unskilled workers and depend- ents. Decayed missing filled teeth (DMFT) score was recorded as “DMFT=0,” “DMFT > 1.” Logistic regression was used to evaluate factors associated with OHK, OHA, OHP, and KAP scores. The unadjusted and adjusted odd ratios were presented. The level of statistical significance was set at p < 0.05. Ethical approval for the study was obtained from the Oyo State Ethics Review Board (AD/13/479/743). Permission to conduct the study was obtained from the principal of each school. Each student signed a consent form or gave assent before recruitment into the study. In addition, each of the participants turned in a consent form signed by either of the parents. Results A total of 2100 students were approached for the study, of which 2097 (99.9%) consented to participate in the study. There were 1126 (53.7%) males and 971 (46.3%) females. The mean age of the students was 15.3 (±1.4) years. The majority of their parents, 1809 (86.3%), belonged to the unskilled occupational class. Only 331 (15.9%) had partici- pated in oral health education and 79 (3.8%) had consulted a dentist. A total of 1537 (73.3%) students had unhealthy periodontal condition and 98 (4.7%) had dental caries (Table 1). The number of decayed teeth ranged from 1 to 4. Of the 98 students with carious teeth; 65 (66.3%) had one tooth with carious lesion, 24 (24.5%) had two carious teeth, 5 (5.1%) had 3 carious teeth and 4 (4.1%) students had four carious teeth. None of the students had missing or filled teeth due to caries. The OHK, OHA, and OHP scores obtained were less than 50% among 2096 (99.9%), 1288 (61.4%), and 1519 (72.4%) students respectively. The OHK score ranged from 0% to 60%; the mean OHK score was 15.1% (±6.6%). Only 342 (16.3%) had heard of fluoride and 67 (3.2%) knew about the role of fluoride in the prevention of tooth decay. The OHA score ranged from 0% to 91.3%; the mean OHA score was 44.5% (± 14.3)%. The OHP score ranged from 0% to 88.9% and the mean OHP score was 42.5% (± 13.8%). The major­ ity (90.2%) used toothpaste. Students in the younger age group (12-15 years old), those whose parents were skilled workers and students who had pre- viously received oral health education were more likely to have higher OHK scores (Table 1 ). The effect of occupational class became insignificant with reduced odds (odds ratio (OR) = 1.3, 95% confidence interval (CI) = 1.0-1.8, p = 0.079) of having higher OHK scores when independent variables were controlled for in the analysis model (Table 1). UNIV ERSITY O F I BADAN LI BRARY 4 SAGE Open Medicine Table I. Logistic regression analysis of association between participants' characteristics and O H K scores. Variable Unadjusted p value Adjusted p value OR 95% CI OR 95% CI Gender Female = 971 Male = 1126 1.2 I.0-I.4 0.077 I.I 0.9-I.3 0.4I8 Age (years) 12-15= 1285 1.7 I.4-2.I <0.00I* I.7 I.4-2.0 < 0.00I* 16-18 = 812 Parent's occupational class Skilled = 200 1.5 I.I-2.0 0.0I8* I.3 I.0-I.8 0.079 Others (unskilled and dependents) = 1897 Previous oral health education Yes = 331 No = 1766 1.6 I.3-2.I <0.00I* I.5 I.2-I.9 0.0I* Previous dental consultation Yes = 79 No = 2018 1.5 0.9-2.4 0.083 I.3 0.8-2.I 0.225 Periodontal health Unhealthy = 1537 Healthy = 560 Dental caries 1.1 0.9-I.3 0.423 I.I 0.9-I.3 0.435 DMFT ̂ 1 = 98 DMFT = 0 = 1999 0.8 0.5-I.2 0.365 0.8 0.5-I.2 0.289 OHK: oral health knowledge; OR: odds ratio; CI: confidence interval; DMFT: decayed missing filled teeth. *Statistically significant. Higher OHA scores were associated with age 12-15 years (OR = 1.5, 95% CI = 1.3-1.8, p < 0.001) and having partici- pated in oral health education (OR = 1.4, 95% CI = 1.1-1.8, p = 0.007; Table 2). Female students, those aged 12-15 years, those who had received previous oral health education or seen a dentist in the past, or had unhealthy periodontal condition had higher OHP scores (Table 3). However, the effect of gender was nullified; OR was reduced from 1.3 to 1.2 (OR = 1.2, 95% CI = 1.0-1.4, p = 0.063) when independent variables were controlled for in the model (Table 3). The KAP score ranged from 0% to 77.3% with a mean score of 43.8% (±11.4%); 1377 (65.7%) students had a total KAP score below 50%. Multivariate analysis showed that age (12-15 years), being a female, offspring of skilled workers, previous oral health education, previous dental consultation, and unhealthy periodontal condition were predictors of higher KAP scores (Table 4). Diseussion Our findings showed that the adolescents had poor oral health awareness. In addition, there was a high prevalence of perio­ dontal disease but very few students had dental caries. The high prevalence of periodontal disease is expected as poor oral health has been associated with low level of awareness of oral health.17 However, the level of awareness was not com­ mensurate with the prevalence of dental caries among the participants. The low dental caries experience among the stu­ dents may be attributed to availability of fluoride-containing toothpaste in the markets in the country.18 In addition, almost all the study participants reported usage of toothpaste, although many were not aware of the role of fluoride in oral health. On the other hand, it is surprising that none of the students with dental caries sought treatment for their condi- tion. This confirms the low level of awareness among the par­ ticipants and a need for school oral health promotion with accessible dental health services for adolescents. To corroborate the above findings, knowledge of the causes of common oral diseases was disappointingly low among the studied adolescents. The performance of the adolescents in this study on questions pertaining to knowledge was poorer than that reported in Sarawak, Malaysia,19 where the mean knowledge score was 6.22 (62%). It also agrees with previous reports about the poor level of oral health awareness that is a general problem among the Nigerian populace.14 In addition, lack of formal school oral health education in the country may have contributed to the finding. Factors associated with higher OHK include female gen­ der, younger age, and previous oral health education. It has been previously reported that females have better OHK than males.20 In addition, the meticulousness of females and their interest in health issues could be a possible reason for this UNIV ERSITY O F I BADAN LI BRARY Lawal and Oke 5 Table 2. Logistic regression analysis of association between participants' characteristics and O H A scores. Variable Unadjusted p value Adjusted p value OR 95% CI OR 95% CI Gender Female = 971 Male = 1126 1.2 I.0-I.4 0.08I I.I 0.9-I.3 0.29I Age (years) 12-15=1285 1.5 I.3-I.8 <0.00I* I.4 I.2-I.7 <0.00I* 16-18 = 812 Parent's occupational class Skilled = 200 1.3 I.0-I.7 0.I03 I.2 0.9-I.6 0.284 Others (unskilled and dependents) = 1897 Previous oral health education Yes = 331 No = 1766 1.4 I.I-I.8 0.007* I.3 I.0-I.6 0.036* Previous dental consultation Yes = 79 No = 2018 1.4 0.9-2.2 0.I49 I.3 0.8-2.I 0.274 Periodontal health Unhealthy = 1537 Healthy = 560 Dental caries 1.2 I.0-I.4 0.I05 I.2 I.0-I.4 0.097 DMFT ̂ 1 = 98 DMFT = 0 = 1999 1.0 0.7-I.5 0.922 I.0 0.7-I.5 0.9II OHA: oral health attitude; OR: odds ratio; CI: confidence interval; DMFT: decayed missing filled teeth. *Statistically significant. Table 3. Logistic regression analysis of association between participants' characteristics and OHP scores. Variable Unadjusted p value Adjusted p value OR 95% CI OR 95% CI Gender Female = 971 Male = 1126 1.3 I.I-I.5 0.007* I.2 I.0-I.4 0.063 Age (years) 12-15=1285 1.7 I.5-2.I <0.00I* I.7 I.4-2.0 <0.00I* 16-18 = 812 Parent's occupational class Skilled = 200 1.4 I.0-I.8 0.053 I.2 0.9-I.6 0.246 Others (unskilled and dependents) = 1897 Previous oral health education Yes = 331 No = 1766 1.5 I.I-I.9 0.003* I.3 I.0-I.6 0.06I Previous dental consultation Yes = 79 No = 2018 6.0 2.8-I2.5 <0.00I* 6.0 2.8-I2.5 <0.00I* Periodontal health Unhealthy = 1537 Healthy = 560 Dental caries 1.3 I.I-I.6 0.0I3* I.3 I.I-I.6 0.0II* DMFT ̂ 1 = 98 DMFT = 0 = 1999 1.0 0.6-I.5 0.902 I.0 0.6-I.5 0.9II OHP: orai health practices; OR: odds ratio; CI: confidence interval; DMFT: decayed missing filled teeth. *Statistically significant. UNIV ERSITY O F I BADAN LI BRARY 6 SAGE Open Medicine Table 4. Logistic regression analysis of association between dependent variable and >44% as reference). mean oral KAP score and participants' characteristics (with KAP score as Unadjusted p value Adjusted p value OR 95% CI OR 95% CI Age (years) 12-15 1.8 1.5-2.14 <0.00I* I.7 I.4-2.0 <0.00I* 16-18 Gender Female 1.3 I.I-I.6 0.002* I.2 I.0-I.5 0.024* Male Occupational class Skilled 1.7 I.2-2.2 0.00I* I.5 I.I-2.0 0.0I0* Others Previous oral health education Yes 1.5 I.2-I.5 0.00I* I.3 I.0-I.7 0.023* No Previous dental consultation Yes 2.1 I.3-3.3 0.003* I.9 I.2-3.I 0.009* No Periodontal health Unhealthy 1.2 I.0-I.5 0.043* I.2 I.0-I.5 0.042* Healthy Dental caries DMFT > 1 1.0 0.7-I.5 0.958 I.0 0.7-I.5 0.944 DMFT = 0 KAP: knowledge, attitude and practices; OR: odds ratio; CI: confidence interval; DMFT: decayed missing filled teeth. *Statistically significant. finding.21,22 The younger age group had better knowledge than older ones. This could be related to upsurge in inquisitiveness of early adolescents who are still learning about themselves.23 The contribution of previous oral health education to knowl- edge is not surprising as oral health education provides infor- mation with an overall aim of knowledge gain.24 In the same vein, better OHA was noticed among younger students and those who had participated in oral health educa- tion but not with gender. Young adolescence is a stage of development where attention is shifted to body and facial appearance for peer acceptance hence, better attitude.23 The role of oral health education in changing attitude cannot be overemphasized.24 Thus, confirming a need for school oral health education in this population. It is of importance that oral health educational intervention in schools should harness incentives for older adolescents to encourage their participa- tion in such programs. This is to achieve the set aim of knowl- edge gain and positive attitude toward oral health for all the students in the school. Importantly, particular attention should be paid to male students for them to generate interest in gain- ing OHK. This is necessary as they have been reported to have less interest in health issues compared to females.22 Higher OHP scores were also associated with younger age group. This is in agreement with previous studies.25 In addition, OHP was associated with previous dental consul- tation. In fact, dental consultation was the only factor that was able to increase the odds of practices up to six folds. This highlights the role of dentists in the promotion of oral health among their patients. Conversely, dental consultation had minimal influence on OHK and OHA. This dissociation may be attributable to the fact that dentists are more con- cerned with teaching skills or oral health care practices when patients consult them. This may be further explained by the short time spent with each patient, as there is over- whelming shortage of dentists in the country.26 This brings to the fore front the need for dentists to consider imparting knowledge of causes of common oral diseases to patients. Unhealthy periodontal condition was an important influence on the OHP of the adolescents. This is surprising, as the reverse should be the case where good practices should cor- respond to better oral health.27-29 In addition, unhealthy periodontium was the only clinical finding associated with overall oral health awareness. There are mixed reports on this relationship in the literature.30 While some authors reported improved gingival health with increased oral health awareness through oral health education,27-29 insignificant associations between the two had also been reported.31 The differences between the associations reported in the various studies may be attributed to variation in the sources of awareness, which in the aforementioned studies were inter- ventions. The case for this study, however, could be attrib­ uted to illness behavior.32 This is so, as symptoms from poor UNIV ERSITY O F I BADAN LI BRARY Lawal and Oke 7 periodontal health drives the affected individuai to seek orai health information/remedy and possibly changes in prac- tices to cure or improve the oral condition. Overall, total KAP scores were significantly associated with age, parents’ occupational class, and previous dental consultation. The 12- to 15-year-old students, females, those whose parents were skilled workers, those previously edu- cated about their oral health and who had consulted the den- tists had higher KAP scores. It is evident that instituting oral health intervention should take into cognizance the need for oral health education to improve the OHK and skills of stu­ dents. The skill impaction was obviously deficient in the oral health education in which the students had participated, as it had no significant influence on their OHP. In addition, it is important to provide dental services in schools where den- tists and other trained personnel will play prominent roles in educating the students. Furthermore, oral health promotion interventions should bear in mind incentives for students based on the sociodemographic factors identified from this study during the planning, implementation, monitoring, and evaluation phases of such programs. This study also presented with some limitations. The cross- sectional design has a limit of revealing causal relationships; however, the study provided insights into factors associated with oral health KAP needed for a baseline data. Another limi- tation was that the use of questionnaires could be associated with over-reporting of positive attitudes and good practices and underreporting of negative attitudes and poor practices. The study was conducted among public school students alone. This may affect generalizability of findings to private schools in the country. However, this was done as school oral health programs will be initiated in public schools as their attendees suffer more often from preventable oral diseases of significant concern in low- and middle-income countries (LMICs). This study has provided evidence for the need to institute formal oral health promotion programs for adolescents in the country. Efforts to reduce inequalities should be made and one feasible option is the school oral health program; where sizable number of adolescents can be reached. The interven­ tion should look at the psychosocial and behavioral models suitable for the context based on sociodemographic findings as noted in this study. Incorporating dental health services as part of the health program will also go a long way in reduc- ing the unmet dental needs that exist presently. Further studies are needed to understand the perspectives of adolescents on how the factors identified in this study may influence oral health awareness among them. This will together serve as a template for adequate planning of appro­ priate oral health promotion programs. Conclusion Oral health awareness was poor among the in-school adoles- cents. There was a high prevalence of periodontal diseases and very few had dental caries. Better knowledge of oral health was observed among the younger age group, offspring of skilled workers, and those who had been educated about their oral health. Students educated about their oral health and aged 12-15 years had better attitude toward oral health. The younger students or those who had consulted the dentists or with unhealthy periodontal condition were more likely to have higher OHP scores. Overall, with the combination of the scores (KAP); higher scores were more likely among younger students, females, those from higher occupational class, those who had consulted the dentists or participated in oral health education and had unhealthy periodontal condition. A u th o rs’ N ote Folake Barakat Lawal is now affiliated with Consortium for Advanced Research Training in Africa (CARTA), APHRC, Nairobi, Kenya. A ck n o w le d g em en ts The authors acknowledge Dr. T.A Lawal for the statistical inputs. D eclaratio n of conflicting in terests The author(s) declared no potential conflicts o f interest with respect to the research, authorship, and/or publication o f this article. Ethical approvai Ethical approval for the study was obtained from the Oyo State Ethics Review Board (AD/13/479/743). Permission to conduct the study was obtained from the principal of each school. Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by the Consortium for Advanced Research Training in Africa (CARTA). CARTA is jointly led by the African Population and Health Research Center and the University o f the Witwatersrand and funded by the Carnegie Corporation of New York (grant no. B 8606.R02), Sida (grant no. 54100113), the DELTAS Africa Initiative (grant no. 107768/Z/15/Z), and Deutscher Akademischer Austauschdienst (DAAD). The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS)’s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (UK) and the UK government. The statements made and views expressed are solely the responsibility o f the Fellow.” Support was also obtained from the TetFund Institutional Based Research Grant, Nigeria. Inform ed consent A written consent was obtained from the parents of each student to conform with the State Schools’ Board policy, which mandated that consent be obtained from parents before the student participates in the study regardless of the age o f the student. In addition, assent was also obtained from the students before recruitment into the study. UNIV ERSITY O F I BADAN LI BRARY 8 SAGE Open Medicine O R C I D ì D Folake Barakat Lawal https://orcid.org/0000-0002-3193-387X S upplem ental m aterial Supplemental material for this article is available online. R eferen ces 1. Aimée NR, van Wijk AJ, Maltz M, et al. Dental caries, fluoro- sis, oral health determinants, and quality o f life in adolescents. Clin Orai Investig 2017; 21(5): 1811-1820. 2. Kavaliauskienè A, Sidlauskas A and Zaborskis A. Relationship between orthodontic treatment need and oral health-related quality o f life among 11-18-year-old adolescents in Lithuania. Int JEnviron Res Public Health 2018; 15: 1012. 3. Lawal FB and Ifesanya JU. Oral health impact profile (OHIP- 14) and its association with dental treatment needs of adoles­ cents in a rural Nigerian community. Braz J Oral Sci 2017; 15: 215-220. 4. Feldens CA, Ardenghi TM, Dos Santos Dullius AI, et al. 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Effectiveness of a school dental education program in improving oral health knowledge and oral hygiene practices and status of 12-to 13-year-old school children. Indian JD ent Res 2010; 21(2): 253-259. 28. Vangipuram S, Jha A, Raju R, et al. Effectiveness of peer group and conventional method (dentist) of oral health edu- cation programme among 12-15 year old school children-a randomized controlled trial. J Clin Diagn Res 2016; 10(5): ZC125-ZC129. 29. Yazdani R, Vehkalahti MM, Nouri M, et al. School-based education to improve oral cleanliness and gingival health in adolescents in Tehran, Iran. Int J Paediatr Dent 2009; 19(4): 274-281. 30. Gambhir RS, Sohi RK, Nanda T, et al. Impact o f school based oral health education programmes in India: a systematic review. J Clin Diagn Res 2013; 7(12): 3107-3110. 31. Stein C, Santos NML, Hilgert JB, et al. Effectiveness of oral health education on oral hygiene and dental caries in school- children: systematic review and meta-analysis. Community Dent OralEpidemiol 2018; 46(1): 30-37. 32. Adekunle AA, Uti OG and Sofola OO. Correlates o f illness behaviour related to orofacial infections of odontogenic origin among adults in a semi urban community in Nigeria. Ghana Med J 2019; 53(4): 294-298. UNIV ERSITY O F I BADAN LI BRARY https://orcid.org/0000-0002-3193-387X ScholarOne Manuscripts 24/07/2020, 9)12 AM SAGE Open Medicine D ecis ion Le tte r (S O M -2 0 -0 1 5 3 .R 2 ) From : sa lil.b o se@ sagep ub .in To: fo la kem ilaw a l@ yahoo .com CC: S u b ject: S AG E Open M ed ic in e - D ec is ion on M anuscr ip t ID S O M -2 0 -0 1 5 3 .R 2 B ody: D ea r Dr. Law al, I am p leased to accep t y o u r m an u sc r ip t en titled "C lin ica! and so c io d em og rap h ic fa c to rs assoc ia ted w ith oral hea lth know ledge , a tt itu de and p rac tices o f ado le scen ts in N ige ria " in its cu rren t fo rm fo r pub lica tion in SAG E Open M ed ic ine. T h an k you fo r y o u r con tribu tion . 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