ohpd 2014 02 s0141

ORIGINAL Naganandini ARTICLE et al Survey on the Use of the Internet as a Source of Oral Health Information Among Denta...

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ORIGINAL Naganandini ARTICLE et al

Survey on the Use of the Internet as a Source of Oral Health Information Among Dental Patients in Bangalore City, India S. Naganandinia/Rekha Raob/Smitha B. Kulkarnic Purpose: Widespread internet usage worldwide allows increased access to medical and dental information and can be used for patient self-education. However, because there is little evidence about how the internet is impacting dentistry, this survey was conducted to determine how dental patients in Bangalore, India, use it as a source of information on oral health and to discover how it affects oral hygiene practices of patients. Materials and Methods: The data was collected from 572 patients attending the outpatient departments of public and private hospitals by administering a specially designed proforma questionnaire. The chi-square test (P < 0.05) was used to determine differences between different groups i.e. based on age, health care delivery and educational status of study participants. Results: Out of 572 respondents using the internet, 150 (26.2%) used it for information on oral health. A higher number of males than females and a significantly higher percentage of people aged 18 to 40 years used the internet. A significantly higher number of respondents utilising dental health care from private providers used the internet as a source of information on oral health. The difference in the usage of internet for information on oral health by gender and age groups was due to higher internet access at the work place and through cybercafés. A significantly higher number of patients from the private sector and with higher educational background used the internet. Conclusion: Low socioeconomic status and a low educational level act as barriers to using the internet, which may explain the results of this study. Creating awareness amongst people of different educational backgrounds through appropriate means (following an individualised approach based on educational qualification) would increase internet use for acquiring information on oral health. Key words: information, internet, oral health Oral Health Prev Dent 2014;2:141-147

Submitted for publication: 31.01.12; accepted for publication: 13.06.12

doi: 10.3290/j.ohpd.a31218

B

etween 2000 and 2008, internet usage worldwide almost tripled, and a current population penetration of over 20% exists (Riordain et al, 2009). Able to reach millions of people, the internet has now become a vital source of information that is highly helpful in education (Gordan et al, 2002). India ranks 4th in the world in terms of internet users. Percentage penetration is still low, but it has

a

Professor and Head of the Department, Department of Public Health Dentistry, The Oxford Dental College, Bangalore, India.

b

Postgraduate Student, Department of Public Health Dentistry, The Oxford Dental College, Bangalore, India.

c

Reader, Department of Public Health Dentistry, The Oxford Dental College, Bangalore, India.

Correspondence: Professor S. Naganandini, Department of Public Health Dentistry, The Oxford Dental College, Bommanahalli, Bangalore 98, Karnataka, India. Tel: +91-944-871-8754. Email: naganandini36@ yahoo.co.in

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increased significantly from 0.1% in 1998 to 4.5% in 2005. The growing popularity of cybercafés is playing a large role in fuelling internet development in India. The low cost of broadband has also helped increase internet usage. E-commerce and high demand for in domain registrations are also factors responsible for the increase in online users. The internet-user population is, of course, expected to grow in the future (Kendra et al, 2006). Very little is known about use of internet to access information on oral health. One study suggested that the impact of the internet on dentistry is positive on the whole (Chestnutt and Reynolds, 2006) but its potential benefits have not nearly been realised in full. While there is a considerable body of research on the impact of the internet as it relates to medicine in general, there is little evidence about how the internet is impacting dentistry

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and how it is used by dental patients as a source of information on oral health (Report on internet penetration in India, 2006). Hence, the aim of the study is to determine the use of the internet as a source of information on oral health among dental patients of Bangalore City, India.

MATERIALS AND METHODS A descriptive cross-sectional study was conducted to assess the use of the internet to access oral health-related information by dental patients in Bangalore City, India. The study protocol was reviewed and approved by the Ethics Board, Oxford Dental College and Hospital, Bangalore, India. Participants for the study were recruited from those dental patients attending the outpatient departments of public services: government institutions and hospitals, Employees State Insurance scheme, defense hospitals and railway hospitals. Participants were also recruited from private institutions and hospitals, private clinics and corporate hospitals (private sector). A sample size of 572 was determined using the N Masters software (Dept. of Biostatistics, CMC; Vellore, India), taking the prevalence of internet use as 23% as found in the pilot study (see below).

Sampling method A multistage sampling technique was employed; the geographical area was divided into north, south, east and west zones according to the BBMP Zone division (Greater Bangalore Municipal Corporation, 2011). Subsequently, all the units of sampling in the divided geographical area were listed alphabetically and selected using a simple random technique. Depending on the average weekly cases seen at each centre, the proportion probability sampling technique was used to select the individual subjects for the study. 10% of the weekly cases at the outpatient department (OPD) at each centre were taken as samples. The inclusion criteria were: patients using internet, patients attending outpatient department of dental colleges, private clinics, private hospitals, or government institutions, patients aged 18 years and above. The exclusion criteria were: patients with intellectual impairment or reading difficulty, patients not willing to participate in the study.

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Questionnaire The participants were asked for general demographic information, including age, gender, educational qualification, occupation, income and reasons for attending the dental clinic. Questions related to participant’s use of the internet to access any oral health-related information, use of the internet as a source of information on oral health and questions assessing the effects of oral healthrelated information on patient’s oral hygiene practice were included. The content validity was assessed by a panel of six expert dental educators. The purpose was to depict those items with a high degree of agreement among experts. Aiken’s V was used to quantify the concordance between experts for each item. The Aiken’s V-value thus obtained was 0.97. In order to assess the reliability of questions to determine the usage of internet resources for oral health-related information, the split-half technique was used and Cronbach’s alpha was calculated. The correlations between the items ranged from 0.55 to 0.67.

Pilot study A pilot study was undertaken on a sample size of 100 dental outpatients. Twenty-five patients each from a private college, government institution, corporate clinic and a private dental clinic participated in the study. A questionnaire was administered to each patient to assess their use of the internet to access oral health-related information. Piloting of the questionnaire was performed at the outset to check the feasibility and relevance of the questionnaire. The pilot study also served as a base for the estimation of the sample size for the main study. The following modifications were made after the pilot study: only patients using the internet were included in the study and changes were made in the questionnaire regarding general use of the internet by patients.

Study procedure Permission was obtained from the principals of all the private colleges and hospitals and heads of government institutions and hospitals, corporate hospitals and private clinics selected for the study in Bangalore city. Patients who agreed to participate in the study provided informed consent and completed the

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self-reported questionnaire as they awaited their appointment at the outpatient clinic. Data from the patients attending the outpatient department of both private and public hospitals were collected using a specially prepared proforma questionnaire. The interviewer introduced herself to all the patients in the OPD and informed them about the study. For patients who had doubts, spoken instructions were given. All the patients confirmed their use of the internet. After they had completed the questionnaire, the interviewer thanked the patients and assured them that their data would be treated confidentially.

Statistical analysis Descriptive statistics were used to summarise the continuous variables, such as age, while mean ± SD, percentage and proportion were used to describe the discontinuous variables. To determine statistically significant differences between results by group (i.e. age, healthcare provider [public vs private] and educational status), the chi-square test was used at a significance level of P < 0.05.

A higher number of graduates and postgraduates participated in the study as compared to people from other educational backgrounds. The majority of participants had a monthly income of more than 30,000 rupees, indicating that most participants were from the upper middle-class group. 205 (35.8%) of the respondents were from the government sector and a higher number, 367 (64.2%), were from the private sector. Out of 572 respondents using the internet, 150 (26.2%) used it for information on oral health (Fig 1). The most common reason for attending dental clinics was for restorative treatment, followed by gingival and periodontal problems (Table 1). 65.97% of patients who participated in the study were from the youngest age group and of these, 19.4% used the internet for information on oral health. A statistically significant association was seen between the respondent’s age group and their use of the internet for information on oral health. Details of the study population according to the effects of oral health-related information on patient’s oral hygiene

Table 1 Distribution of study population by internet use as a source of information on oral health

RESULTS In terms of age groups, 398 (69.6%) participants were between 20 and 40 years old, 134 (23.4%) participants between 41 and 60 years old and 40 (7%) participants were above 60 years of age. The study included 367 (64.2%) male and 205 (35.8%) female subjects.

Use of internet as a source of information on oral health Reasons for seeking information on oral health To improve knowledge To reduce anxiety about dental problems To accept dental problems For alternate remedies To know about local dentists Were respondents able to find answers to their queries? a) Yes b) No

80 70

After obtaining the information, did they discuss it with their dentist? a) Yes b) No

60 50 (%) 40

Website most often used for gathering the information Google Wikipedia You tube www.askhow.com Yahoo

30 20 10 0 Usage of Internet for information on oral health

Usage of Internet for other information

Fig 1  Proportion of internet users who used the internet as a source of oral health information vs those who did not.

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Type of oral health-related information for which internet was used On specific disease / conditions On medications On preventive measures On alternative therapies

Number

%

80 64 46 71 21

53.33 42.66 30.66 47.33 14

133 17

88.66 11.33

99 51

66 34

128 59 21 6 37

85.33 39.33 14 4 24.66

80 70 57 47

53.33 46.66 38 31.33

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Table 2 Distribution of study population according to effects of oral-health related information on patient’s oral hygiene practice

Did knowledge from the internet influence participants’ attitude about oral hygiene practice? Yes No

Number

%

131 19

87.33 12.67

Middle school High school

Changes in participants’ thinking I am more interested I feel reassured I take problems more seriously I feel more confused I am less interested I am overwhelmed I take problems less seriously I feel less confused Were changes made in the participants’ behaviour after receiving information? Yes No

75 57 58 19 10 09 04 20

50 38 38.67 12.66 6.667 6 2.66 13.33

Graduates and Post Graduates Professional 0

5

10

15

Internet users seeking information on oral health

122 28

81.33 18.67

practice are given in Table 2. A significantly higher number of patients from the private sector used the internet as a source of information on oral health than did patients from the public sector. How the study population’s internet use is influenced by educational status is depicted in Fig 2. Table 3 shows the effects of oral health information on patient’s oral hygiene practice by educational qualification.

DISCUSSION Although India’s internet penetration rate of less than 10% is low by global standards, the country is nonetheless home to tens of millions of users and has become an important leader in the high-tech industry. The spread of information and communication technologies (ICT) began accelerating in India with the liberalisation of the telecommunications sector as part of the New Economic Policy from July 1991 (Report on internet penetration in India, 2006). The government’s New Telecom Policy of 1999 and New Internet Policy of 1998 have further spurred the growth of the ICT sector, resulting in a large number of manufacturing units and internet-

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Diploma holders

Fig 2    Percentages of internet users seeking oral-health information by educational background.

service providers (ISP) setting up bases in the country. Infrastructure limitations and cost considerations restrict access to the internet and other ICT in India (International Telecommunication Union, 2009), although both infrastructure and bandwidth have improved in the last two years. The International Telecommunication Union (ITU) reported 61.3 million users as of 2009 (International Telecommunication Union, 2009), while the Internet and Mobile Association of India found that about 77 million Indians had used the internet at least once in their lifetime (The Internet and Mobile Association of India, 2006). A 2010 survey by a New Delhi-based research and marketing firm resulted in an estimated 51 million ‘active’ internet users who had used the internet at least once in the past year (40 million urban and 11 million rural users). Despite this confusion, most measurements put the overall internet penetration rate at a rather low 5% to 8% of the population. There are signs that this figure is increasing, however, and one recent study predicted that the number of Indian users would reach 237 million in 2015, from a current estimate of 80 million (Freedom House, 2011). As mentioned above, the results of different surveys varied about the prevalence of internet use among Indians; thus, we decided to use the preva-

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Table 3 Distribution of the study population by effects of oral-health related information on their oral hygiene practice according to educational level Educational level* Effects of oral health-related information on patients’ oral hygiene practice Did knowledge from the internet influence participants’ attitude about oral hygiene practice? Yes No Changes in participants’ thinking I am more interested I feel reassured I take problems more seriously I feel more confused I am less interested I am overwhelmed I take problems less seriously I feel less confused Changes in behaviour Yes No

3 n (%)

4 n (%)

1 (.67) 0 1 (0.67) 1 (0.67) 0 0 0 0 0 0 0 0

5 n (%)

6 n (%)

7 n (%)

3 (2) 0

33 (22) 1 (0.67)

65 (43.34) 14 (9.34)

29 (19.34) 4 (2.67)

0.256

1 (0.67) 0 2 (1.34) 1 (0.67) 0 0 0 2 (1.34)

14 (9.34) 10 (6.67) 8 (5.34) 5 (3.34) 3 (2) 2 (1.34) 1 (0.67) 9 (6)

38 (25.34) 33 (22) 29 (19.34) 7 (4.67) 4 (2.67) 4 (2.67) 2 (1.34) 6 (4)

21 (14) 13 (8.67) 19 (12.67) 6 (4) 3 (2) 3 (2) 1 (0.67) 3 (2)

0.291 0.283 0.040* 0.497 0.882 0.919 0.998 0.004*

22 (14.67) 8

58 (38.67) 17 (11.33)

34 (22.67) 7 (4.67)

0.026*

4(2.67) 0

P-value

*Educational levels according to Kuppuswamy (1981): 3 = middle-school certificate; 4 = highschool certificate; 5 = intermediate or post-highschool diploma (diploma is a 2-year course after completion of the 10th grade); 6 = college graduate or postgraduate; 7 = professional (graduate or postgraduate requiring licensing and registration in order to practice that profession). Significance set at P < 0.05.

lence rate of internet use from the pilot study. If the patients used the internet for general information, then their usage of internet for health and oralhealth related information also rose substantially. For this reason, ‘use of the internet’ was one of the study’s inclusion criteria. The present study examined internet use by diverse groups of dental patients as a resource for procuring information on oral health. It was found that out of the 572 respondents using the internet, nearly 25% reported using the internet for information on oral health, which was almost same as in the study conducted by Riordain and McCreary (2009). Similar to the findings of that study, a higher number of males than females researched online for information on oral health and a higher percentage of people aged between 18 and 40 years use the internet. Furthermore, of the patients surveyed who had searched for information on oral health online, over 50% reported that it improved their knowledge about a condition or procedure, which is also similar to Riordain and McCreary’s (2009) results. Although more than 80% of the respondents found that they were able to find answers to their queries on oral health problems, only 60% of them discussed this information with a dentist, which is

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similar to a study conducted by Kendra et al (2006) on general health-related information. More than 80% of the patients used Google as the search engine, and when asked about any other website they were aware of for research online about oral health, they could not think of any. Nearly 90% of the patients said that information online changed the way they think about their oral health; this is very high compared to the study by Chestnutt and Reynolds (2006), where 55% of the internet users indicated that information they found on the web changed the way they thought about their health. In the present study, more than 80% of the patients made changes in their oral hygiene practices, a larger proportion than in the study by Chestnutt and Reynolds (2006). The reason for this great difference could be that a lower number of participants was involved that study. Our survey did not enquire about the reasons the changes were made with regards to oral hygiene practice. A significantly higher number of patients in the 18- to 40-year age group used the internet as source of information on oral health as compared to patients above 40 years of age. The reason for this could be higher access to the internet among younger people at their place of work and cybercafés.

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When asked whether the respondents were able to find answers to their queries and whether they discussed the same with their dentists, a significantly higher number of patients in the younger age groups responded affirmatively. This difference between the age groups could again be related to better access and expertise of the younger adults in the usage of the net as well as more concern for aesthetics and oral health in younger age groups. More than 60% of the 18- to 40-year-olds said that knowledge from the internet had an impact on their attitude about oral hygiene practices and made changes in their behaviour; this was higher than in the other two groups. These results were similar to results by Chestnutt and Reynolds (2006). A significantly higher number of respondents using private health-care facilities than public (government) facilities used the internet as a source of information on oral health. This is due to the fact that in India, a higher number of private than government clinics and hospitals exist, especially in the urban areas. Furthermore, the patients attending the private clinics and hospitals have a higher socioeconomic status than do patients attending the government institutions (Hu et al, 2009). A significantly higher number of graduates, postgraduates, professionals and diploma holders used the internet as a source of information on oral health compared to highschool and middle-school graduates. Education acts as a barrier to accessing the internet and this could be reason for these differences (Aydin et al, 2004). A significantly higher number of graduates and postgraduates than participants with less education indicated that information they found on the web changed the way they thought about their health and changed their behaviour regarding oral hygiene practice. This could be due to lack of awareness and knowledge about oral health and related conditions in participants with less education. The results of this study reflect the current situation in terms of internet use among people of different educational backgrounds. The situation may be similar across different regions of India as well as in different parts of the world. Creating awareness amongst people of different educational backgrounds through appropriate means (following an individualised approach based on educational qualification) would increase the internet usage for information on oral health.

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The lack of awareness of authentic, scientifically based websites on oral health has prompted the widespread use of non-evidence-based information available on the net. Thus, it is important that patients discuss the information obtained online with their dentists and confirm the accuracy of the content. Patients can also take advice from their dentists to search for more evidence-based information online (Khechine et al, 2008). Concerns about the quality and accuracy of the information on the net are yet other issues to be considered. If the patients are to improve and maintain their oral health through self-support via the internet, then they must have access to highquality and appropriate information (Anderson et al 2003; Mead et al, 2003). This is possible only if the patients are guided by dental health-care professionals to authentic websites where reliable information is posted in a manner that is easy for patients to understand. The patients can be made aware of the quality of information online through educating them, for instance, by asking them to consider the content provider’s qualifications, e.g.: are the author’s qualifications stated clearly? Does the author have a dental or medical degree? Furthermore, patients can be helped to assess the validity of the science available on the net by asking questions like: are the study results current and does the research provide the most up-to-date facts available? Is the argument or conclusion supported by sound scientific evidence, or is it just an unsubstantiated theory? (ADA, 2006).

CONCLUSION This survey was conducted to determine the use of the internet as a source of oral health information. Our results show that younger, better educated people tend to use the internet more often as a source of dental-health knowledge. Low socioeconomic status and little education act as barriers to using the internet, which may explain the results of this study. Creating awareness amongst people of different educational backgrounds through appropriate means (following an individualised approach based on educational qualification) would increase internet use for acquiring information on oral health. Models should be developed to this end which can be adapted to the specific requirements of the given country.

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REFERENCES 1. ADA Division of Communications; ADA Council on Scientific Affairs. For the dental patients…..Surfing for substance; evaluating oral health. JADA 2006;137;692. 2. Anderson J.G, Rainey M.R, Eysenbach. G. The impact of cyber healthcare on the physician-patient relationship. J Med Syst 2003:27:67–84. 3. Aydin U, Ozturk M, Kirbiyik S. Prevalence of internet usage and access to health information among dental school outpatients. Telemed J E Health 2004;10:444–448. 4. Chestnutt IG, Reynolds K. Perceptions of how the Internet has impacted on dentistry. Br Dent J 2006;200:161–165. 5. Freedom House. Report on freedom on the net 2011, India. www.freedomhouse.org 6. Gordon MM, Capell HA, Madhok R. The use of the Internet as a resource for health information among patients attending a rheumatology clinic. Rheumatology 2002;41: 1402–1405. 7. Greater Bangalore Municipal Corporation. Accessed at www.bbmp.com on 17/8/11. 8. Hu J, Luo E, Song E, Xu X, Tan H, Zhao Y, Wang Y, Li Z. Patients’ attitudes towards online dental information and a web-based virtual reality program for clinical dentistry: a pilot investigation in China. Int J Med Inform 2009;78: 208–215.

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9. International Telecommunication Union (ITU). ICT Statistics 2009—Internet. http://www.itu.int/ITU-D/icteye/Indicators/Indicators.aspx# 10. Kendra L, Schwartz TR, Northrup J, Meza J, Seifeldin R, Neale AV. Family medicine patients’ use of the internet for health information: a MetroNet study. J Am Board Fam Med 2006;19:39–45. 11. Khechine H, Pascot D, Premont P. Use of health-related information from the Internet by English-speaking patients. Health Informatics J 2008;14:17–28. 12. Kuppuswamy B. Manual of socioeconomic status (urban). Manasayan: Delhi, 1981. 13. Mead N, Varnam R, Rogers A, Roland M. What predicts patients’ interest in the Internet as a health resource in primary care in England? J Health Serv Res Policy 2003;8: 33–39. 14. Riordain RN, McCreary C. Dental patients’ use of the internet. Br Dent J 2009;207:583–586. 15. The Internet and Mobile Association of India. Report on Internet Penetration in India, 2006. Accessed in 2011 at http://www.iamai.in

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