Oral health is a critical component of human health but is sometimes forgotten, particularly during humanitarian crises. This research aimed to ascertain the state of oral health among Rohingya refugees living in one of the largest refugee camps and evaluate their knowledge and practice of oral health. A multicenter cross-sectional survey was conducted among 477 participants from July to September 2021 using a structured questionnaire. There were 34 Rohingya camps and out of those 14 camps were accessible for data collection. The study participants were between 18–82 years residing in the refugee camps under Cox's Bazar. The majority of participants (53.88%) were female and between the ages of 25 and 45. Around 46.12% of respondents did not have basic oral health knowledge, while 53.67% were in need of dental care. Nearly half of the participants demonstrated poor oral health practices. Participants' age and educational level were positively associated with oral health knowledge (p = 0.02 and p<0.001). Furthermore, the knowledge level was positively associated with oral health practice (p =.025). Participants with a history of teeth pain and discomfort in the last 12 months were ten times more likely to seek treatment (OR = 9.93, CI: 5.591–17.64). The study indicated a growing demand for dental care among Rohingya refugees staying in Bangladesh. To reduce the severity of oral health issues, use of minimally invasive restorative procedures can be suggested in camps. New oral health promotion campaigns should be emphasized and proper education, ideally in their original language, can be beneficial.
Oral health is a highly significant component of human health but is often overlooked, especially in humanitarian emergencies like refugee crises. In almost every humanitarian catastrophe, emergency services take precedence over dental care. In 2013, a study in Australia on Refugees identified uncertainty regarding child oral hygiene habits and inadequate oral health literacy that affected children's oral health status. This study explored the socio cultural determinants influencing child oral health among refugees [[
Refugees are defined by the United Nations High Commissioner for Refugees (UNHCR) as "someone who is unable or unwilling to return to their place of origin because of a well-founded fear of persecution on account of ethnicity, religion, nationality, membership in a specific social group, or political opinion [[
Oral health knowledge is considered fundamental for the development of healthy habits, and studies have shown that increasing knowledge is associated with improved oral health [[
Due to the high population density and inadequate resources and services in the camps, accessing healthcare facilities becomes difficult at times. As a result, the population is deprived of critical oral and physical health services, exposing them to a range of health and oral diseases [[
Our study was conducted from July to September 2021 in Teknaf and Ukhiya, Cox's Bazar, Bangladesh. For data collection, 14 refugee camps were accessible out of 34 camps. According to the UNHCR's population factsheet for 31 December 2020, the camps housed approximately 180,616 adults (18 years and older). In accordance with our study's inclusion criteria, the number of participants from each camp was determined by the following formula: n
In this multicenter cross-sectional study, the individuals aged 18 years or older who were living in the Cox's Bazar Rohingya camp were included. Before the study, a questionnaire was developed by vigorously reviewing the similar published literature. After developing the questionnaire, it was translated in participant's native language with the help of two independent translators [[
A five-point Likert scale was used to score the participants' knowledge of oral health. We assigned a score of 5 to "Strongly Agree," 4 to "Agree," 3 to "Neither agree nor disagree," 2 to "Disagree," and 1 to "Strongly disagree".
For assessment of oral health practice, four questions were asked with different options. For assessment of daily brushing frequency, the options and scores were "Once a day" = 1, "Twice a day" = 2," Do not brush daily" = 0. Similarly, In case of tooth-cleaning material "Toothbrush" = 2 and "Charcoal/Toothpick/Others" = 0. "Miswak" and "Dental floss/Thread" are helpful but cannot replace tooth brush hence these two were scored 1 [[
There were 12 statements with five options for assessing the oral health status. For statements such as "Difficulty with biting food," options were "2–3 times every month" = score 3, "Once in a month" = score 2, "2–3 times in 12 months" = score 1, "Never" = score 0, "Don't know" = score 0. The overall total possible score was 36.
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board (Ethics committee) of North South University (Ref: 2021/OR-NSU/IRB/0703). Before interviewing each subject, the participants were clearly briefed about the aims, procedures of the research. Verbal consent was taken considering the low literacy level of the participants [[
The data were analyzed using STATA software version 16. Frequencies and percentages were used to classify and explain all variables. The chi-square test was performed to investigate the bivariate relationship between categorical variables, and logistic regression models were fitted to identify factors associated with outcomes.
The majority (45.78%) of the participants were between 25 and 45, with females representing 53.88%. The study participants were all Muslims, with 82.60% married. About 72% were old migrants (migrated more than 42 months back), and 64.57% were unemployed before migration. Among the migrant, 85.74% became employed after relocating to Bangladesh. 45.70% were uneducated, whereas 33.33% had completed 1 to 5 years of education and 20.96% had studied more than five years (Table 1).
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Table 1 Demographic characteristics of the participants and its association with oral health knowledge (N = 477).
Variable Knowledge Demographic information N % Poor N (%) Good N (%) P value 220(46.12) 220(46.12) Age <25 years 138 29.11 75(54.35) 63(45.65) 0.020 25–45 years 217 45.78 99(45.62) 118(54.38) >45 years 119 25.11 44(36.97) 75(63.03) Gender Male 220 46.12 94(42.73) 126(57.27) 0.170 Female 257 53.88 126(49.03) 131(50.97) Marital status Never married 83 17.40 41(49.40) 42(50.60) 0.510 Married 394 82.60 179(45.43) 215(54.57) Past occupation Unemployed 308 64.57 150(48.70) 158(51.30) 0.130 Employed 169 35.43 70(41.42) 99(58.58) Present occupation Unemployed 409 85.74 187(45.72) 222(54.28) 0.670 Employed 68 14.26 33(48.53) 35(51.47) Years of education Uneducated 218 45.70 92(42.20) 126(57.80) <0.001 1 to 5 years 159 33.33 90(56.60) 69(43.40) >5 years 100 20.96 38(38.00) 62(62.00) Migration status Recent migrant (≤42 months) 130 27.25 54(41.54) 76(58.46) 0.220 Old migrant (>42 months) 347 72.75 166(47.84) 181(52.16) Oral health-related personal information Number of natural teeth <20 55 11.53 28(50.91) 27(49.09) 0.450 20 or more 422 88.47 192(45.50) 230(54.50) Teeth pain or discomfort in last 12 months Yes 215 45.07 87(40.47) 128(59.53) 0.030 No 262 54.93 133(50.76) 129(49.24) Artificial teeth Yes 27 5.66 2(7.41) 25(92.59) <0.001 No 450 94.33 218(48.44) 232(51.56)
1 ** = Significant
2 *** = Highly significant.
Regarding oral health-related personal information, 88.47% had 20 or more natural teeth, and about 45% experienced dental pain or discomfort in the previous 12 months. Only 5.66% of the individuals had artificial teeth. Regarding knowledge of the participant, for the ten questions, the mean score was 42.32 (Table 2) whereas the maximum achievable score was 50. Those scored above the mean (≥42) were categorized as having "Good knowledge." A score below 42 was classified as having "Poor knowledge". The prevalence of participants with good and poor knowledge was 53.88% and 46.12%, respectively.
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Table 2 Oral health knowledge of the participants (N = 477).
Question Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree Mean score Score 1 Score 2 Score 3 Score 4 Score 5 (Overall 42.32) 1. Teeth are an important part of your Body 1(0.21) 0(0.00) 20(4.19) 202(42.35) 254(53.25) 4.48 2. Keeping your mouth clean and healthy is good for health 1(0.21) 3(0.63) 30(6.30) 20(43.70) 234(49.16) 4.40 3. Dental disease may cause other health problem 2(0.42) 11(2.31) 95(19.92) 166(34.80) 203(42.56) 4.16 4. Two-time brushing daily is good for oral health 2(0.42) 8(1.68) 86(18.03) 195(40.88) 186(38.99) 4.16 5. Gum bleeding is a bad sign for oral health 3(0.63) 7(1.47) 61(12.79) 232(48.64) 174(36.48) 4.18 6. Bad breath is a bad sign for oral health 3(0.63) 12(2.52) 99(20.75) 192(40.25) 171(35.85) 4.08 7. Smoking is harmful for oral health 2(0.42) 4(0.84) 62(13.00) 229(48.01) 180(37.74) 4.22 8. Chewing tobacco is harmful for oral health 5(1.05) 4(0.84) 85(17.82) 196(41.09) 187(39.20) 4.17 9. Using toothbrush is good for oral health 3(0.63) 4(0.84) 63(13.21) 214(44.86) 193(40.46) 4.24 10. Using toothpaste is good for oral health 3(0.63) 4(0.84) 72(15.09) 210(44.03) 188(39.41) 4.21
In terms of oral health practice, their final score was categorized as: 0 = Normal, 1–12 = Mild, 13–24 = Moderate, and 25–36 = Severe. Furthermore, the "Normal" group was categorized as "Healthy" and "Mild," "Moderate" and "Severe" groups were categorized as" Needs dental care" to signify the oral health status of the study population. The prevalence of "healthy practice" was 52.20%, and "unhealthy practice" was 47.80% (Table 3). Among the participants, the prevalence of mild, moderate, and severe oral health problems were 29.56%, 16.35%, and 7.76%, respectively.
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Table 3 Prevalence of oral health knowledge, practice, and self-reported oral health status (n = 477).
N % Knowledge Poor knowledge 220 46.12 Good knowledge 257 53.88 Practice Unhealthy practice 249 52.20 Healthy practice 228 47.80 Self-reported Oral Health Status Healthy 221 46.33 Needs dental care 256 53.67 Mild problem 141 29.56 Moderate problem 78 16.35 Severe problem 37 7.76
We performed bivariate analysis and presented the unadjusted result in Tables 1and 4, which identified several potential factors associated with the knowledge, practice, and oral health status of the Rohingya population. Table 1showed that age, years of education, teeth pain or discomfort in the last 12 months, and presence of artificial teeth were significantly associated with oral health knowledge. Simultaneously, age (p<0.001, p<0.001) marital status (p<0.001, p<0.001), years of education (p<0.001, p<0.001), teeth pain or discomfort in the last 12 months (p<0.001, p<0.001) were significantly associated with both self-reported oral health status and oral health practice. On the other hand, gender (p<0.001), past occupation (p<0.001), and migration status (p<0.001) were only associated with oral health status. In contrast, the number of natural teeth (p<0.001) and the presence of artificial teeth (p =.001) were only related to oral health practice.
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Table 4 Self-reported oral health status and practice and their associated factors (N = 477).
Variable Self-reported oral health status Oral health practice Demographic information Healthy N (%) Needs dental care N (%) P value Unhealthy Practice N (%) Healthy Practice N (%) P value 221(46.33) 256(53.67) 249(52.20) 228(47.80) Age <25 years 105(76.09) 33(23.91) <0.001 48(34.78) 90(65.22) <0.001 25–45 years 96(44.24) 121(55.76) 110(50.69) 107(49.31) >45 years 19(15.97) 100(84.03) 89(74.79) 30(25.21) Gender Male 76(34.55) 144(65.45) <0.001 118(53.64) 102(46.36) 0.562 Female 145(56.42) 112(43.58) 131(50.97) 126(49.03) Marital status Never married 55(66.27) 28(33.73) <0.001 25(30.12) 58(69.88) <0.001 Married/Divorced 166(42.13) 228(57.87) 224(56.85) 170(43.15) Past occupation Unemployed 171(55.52) 137(44.48) <0.001 159(51.62) 149(48.38) 0.733 Employed 50(29.59) 119(70.41) 90(53.25) 79(46.75) Present occupation Unemployed 193(47.19) 216(52.81) 0.357 220(53.79) 189(46.21) 0.089 Employed 28(41.18) 40(58.82) 29(42.65) 39(57.35) Years of education Uneducated 73(33.49) 145(66.51) <0.001 156(71.56) 62(28.44) <0.001 1 to 5 years 88(55.35) 71(44.65) 62(38.99) 97(61.01) > 5 years 60(60.00) 40(40.00) 31(31.00) 69(69.00) Migration status Recent migrant (≤42 months) 98(75.38) 32(24.62) <0.001 75(57.69) 55(42.31) 0.142 Old migrant (>42 months) 123(35.45) 224(64.55) 174(50.14) 173(49.86) Oral health-related personal information Number of natural teeth <20 27(49.09) 28(50.91) 0.663 45(81.82) 10(18.8) <0.001 20 or more 194(45.97) 228(54.03) 204(48.34) 218(51.66) Teeth pain or discomfort in last 12 months Yes 32(14.88) 183(85.12) <0.001 141(65.58) 74(34.42) <0.001 No 189(72.14) 73(27.86) 108(41.22) 154(58.78) Artificial teeth Yes 11(40.74) 16(59.26) 0.549 6(22.22) 21(77.78) 0.001 No 210(46.67) 240(53.33) 243(54.00) 207(46.00) Oral health knowledge Poor knowledge 103(46.82) 117(53.18) 0.844 127(57.73) 93(42.27) 0.025 Good knowledge 118(45.91) 139(54.09) 122(47.47) 135(52.53)
- 3 P = P value
- 4 *** = highly significant
- 5 ** = significant.
In a multivariate logistic regression model, we included the potential variables from the bivariate analysis. Participants aged greater than 45 years have more knowledge (OR = 2.34) about oral health than those aged less than 25 years (OR = 2.34, 95% CI: 1.207–4.531). Participants who studied for 1–5 years had 57% less knowledge regarding oral health than those who studied for more than five years(OR =.43, 95% CI:.249-.753). Individuals with artificial teeth had nearly 9 times higher knowledge about oral health than those without artificial teeth (OR = 9.15, 95% CI: 2.08–40.32). Old migrants had 52% less knowledge than the recent migrants (OR =.48, 95% CI:.297-.800), and nearly 3.5 times better knowledge was observed among the participants with severe oral problems (OR = 3.67, 95% CI: 1.394–9.656). Participants with healthy oral health practice were 2.16 times more knowledgeable than those with unhealthy practice (OR = 2.16, 95% CI: 1.373–3.385) (Table 5).
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Table 5 Logistic regression of oral health knowledge, practice, and self-reported oral health status (N = 477).
Oral health knowledge Oral health practice Self-reported oral health status Variable AOR p-value 95% CI AOR p- value 95% CI AOR p- value 95% CI Age < 25 years 1 1 1 25–45 years 1.496 0.114 .907 2.466 .896 0.687 .525 1.529 3.508 <0.001 1.913 6.433 > 45 years 2.339 0.012 1.207 4.531 .469 0.042 .226 .973 8.101 <0.001 3.545 18.51 Years of schooling >5 years 1 1 1 1–5 years .433 0.003 .249 .753 .906 0.749 .497 1.654 1.712 0.125 .861 3.401 Uneducated .603 0.094 .334 1.09 .30 <0.001 .161 .56 .951 0.892 .463 1.953 Teeth pain and discomfort in last 12 months No 1 1 1 Yes 1.255 0.410 .731 2.156 .939 0.830 .526 1.675 9.931 <0.001 5.591 17.64 Artificial teeth No 1 1 1 Yes 9.157 0.003 2.08 40.32 4.548 0.007 1.518 13.622 .38 0.064 .137 1.056 Migration status Recent migrant (≤42 months) 1 1 1 Old migrant (>42 months) .487 0.004 .297 .8 2.739 <0.001 1.604 4.676 9.488 <0.001 4.954 18.171 Severity Normal 1 1 Mild .71 0.230 .405 1.243 .483 0.016 .267 .873 Moderate 1.265 0.545 .591 2.71 .304 0.003 .137 .673 Severe 3.669 0.008 1.394 9.656 .015 <0.001 .002 .125 Practice Unhealthy 1 1 Healthy 2.156 0.001 1.373 3.385 .353 <0.001 .203 .614
- 6 AOR = Adjusted odds ratio, CI = Confidence interval
- 7 ** = Significant
- 8 *** = Highly significant.
Participants aged more than 45 years had 54% less tendency to healthy practice regarding oral health than those aged below 25 years (OR =.46, 95% CI: O.226-0.973). Uneducated participants had a 70% less tendency of healthy practice regarding oral health than those studied more than five years (OR = 0.30, 95% CI:.161–0.56). Old migrants had nearly 2.5 times better practice than those who migrated recently (within last 42 months) (OR = 2.73, 95% CI: 1.604–4.676). Participants with artificial teeth had 4.5 times more intention of healthy practice than those without artificial teeth (OR = 4.56, 95% CI: 1.518–13.622). Participants with healthy oral health practice had 65% less need of treatment (OR =.353, 95% CI:.203-.614). Participants with good oral health knowledge had two times better practice than those with poor knowledge (OR = 2.156, 95% CI: 1.373–3.385) (Table 5). Tooth cleaning tools are inseparable parts of oral health practice. Fig 1 shows the high use of toothbrushes, especially among females, followed by charcoal and miswak. Moreover, most of the respondents considered dental treatment only for pain or trouble rather than regular check-up (Fig 2).
Graph: Fig 1 Bar chart showing teeth cleaning tool by gender of the participants.
Graph: Fig 2 Bar showing the reason for last dental treatment/appointment.
Regarding self-reported oral health status, participants between the ages 25–45 years, and those beyond 45 were 3.50 and 8.10 times in need of dental treatment than those under 25 (OR = 3.50 and OR = 8.10, 95% CI:1.913–6.433 and CI: 3.545–18.51 respectively). Participants who reported dental pain in the previous 12 months were 9.93 times more likely to need treatment than those without such complaints (OR = 9.93, 95% CI:5.591–17.64). Old migrants (who arrived in Bangladesh more than 42 months ago) had a 9.48-fold more demand for dental care than the new migrants (OR = 9.48, 95% CI: 4.95–1817).
The status of one's oral health has a significant impact on one's overall health and quality of life. On the other hand, poor oral health affects physical, psychological, and social well-being. It is common for the migrant population to live a life of poverty and despair due to a scarcity of resources such as housing, education, healthcare, and work prospects which eventually predisposes this disadvantaged society to more significant health risks and poor dental health regularly [[
According to our study's findings, roughly half of the respondents had good oral health knowledge, which is similar to the results of a study conducted by Solyman et al. on refugees in Germany [[
In our study, the aged participants were found to have significantly more oral health knowledge than the younger folks. Similar associations were described by Pinnamaneniet al. [[
Refugees who arrived in Bangladesh from Myanmar more than 3.5 years back had healthy practices and better oral health status than the more recent migrants despite their poor knowledge. This might be a possible effect of migrants' longer exposure to teeth cleaning equipment, better health facilities and awareness programs This finding is further reinforced by studies on refugees in Germany and Vietnamese migrants [[
Another strong correlation was seen between having artificial teeth and their oral health knowledge and practice. Those with artificial teeth demonstrated 9-fold better knowledge and nearly five-fold healthier practice, probably due to their previous encounter with the dental practitioner. In an Indian study, individuals with dental implants showed appropriate knowledge, but they lacked sufficient oral hygiene practices [[
Knowledge is necessary to form prevention beliefs, cultivate good attitudes, and promote positive thoughts toward illness. This was mirrored in the practice of the majority of our survey respondents. This research showed that participants with adequate knowledge of oral health practiced twice healthier than those with insufficient knowledge. A study conducted by Wahengbam et al. also had similar findings [[
People with dental pain need dental treatment more than healthy people [[
To our knowledge, this was the first ever research to investigate refugee oral health status in Bangladesh. Besides, it was a multicenter study, which included participants from the major areas of the refugee camp. Moreover, the face-to-face interview and use of their native language enabled us to draw a clear picture of their oral health. However, the study has certain limitations. The data were self-reported, where there is a chance of recall bias. We could not perform dental checkups on the participants, which would have helped us better understand their oral health status. All face-to-face interviews were performed during the daytime while males were outside the home, so most participants were females.
According to the findings of the study, it is essential for the development organizations who work for the Rohingya community to undertake long-term measures to increase access to oral health care. It is also necessary to adopt minimally invasive restorative treatments in camps in order to minimize the severity of oral health problems. In order to effectively promote oral health programs among Rohingyas, it is necessary to provide precise instructions on beneficial oral health habits in their local language. Additional educational efforts should be undertaken, and those in positions of responsibility should make measures to ensure that these underserved communities get adequate dental treatments.
S1 File.
(DTA)
The authors would like to thank the study participants for their patience and cooperation during data collection. We would also like to thank the Office of The Refugee Relief and Repatriation Commissioner (RRRC) for their approval and support in conducting this study.
By Sreshtha Chowdhury; Simanta Roy; Mehedi Hasan; Asif Al Sadique; Tariful Islam; Md. Yeasin Arafat; Md. Atiqur Rahman Bhuiyan; A. M. Khairul Islam; Omar Khalid; Ramisha Maliha; Mohammad Ali Hossain; Mohammad Lutfor Rahman; Mohammad Hayatun Nabi and Mohammad Delwer Hossain Hawlader
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