ASSESSMENT OF IMPACT TO UNAVAILABILITY OF RESTORATIVE

DENTAL SERVICES IN MACHINGA DISTRICT

RESEARCH PROPOSAL

BY

WALTER MBALE
(DDT/ 16/ 01/ 029)

IN FULFILMENT OF DIPLOMA IN DENTAL THERAPY

(FALCUTY OF CLINICAL MEDICINE)

MALAWI COLLEGE OF HEALTH SCIENCE

CERTIFICATION AND DECLARATION

PART A: STUDENT’S DECLARATION STATEMENT

I, the undersigned, certify the dissertation is my work and it has not been submitted to other
examining body or institution for another award.

Student…………………………………………...

Signature………………………………………..

Date……………………………………………..

PART B: CERTIFICATION AND DECLARATION

I, the undersigned certify that this dissertation has been produced by this student through the
research project that he carried out during his final year and here by recommend it for
examination.

Supervisor………………………………………

Signature……………………………………….

Date……………………………………………..
DEDICATION
I dedicate this work to entire family more especially to my father for their encouragement and
financial support.
ACKNOWLEDGEMENTS
I wish to express my deep and sincere gratitude to several individuals for their constructive
advice and guidance in preparation for this study. Without their aid, the study would have been
very tough and the following are;

Mr Nzungu, the supervisor

Mr Kamphathengo, my lecturer

Mr Kajilime, Head of Dental Department

Lastly, I would like to thank my classmates for their support in and outside the classroom.

May God bless you all

ACRONYMS
MDH- Machinga District Hospital
DT- Dental therapist
LMIC- Low- and Middle-Income Countries
ART- Atraumatic Restorative Treatment
WHO- World Health Organisation
HMIS- health management information system
DHO- District Health Officer
PI- Principal Investigator

1
List of tables
Table 1:Work plan.....................................................................................................................................15
Table 2: Budget outline.............................................................................................................................17
Table of Contents
CERTIFICATION AND DECLARATION............................................................................................2
DEDICATION...........................................................................................................................................3
ACKNOWLEDGEMENTS......................................................................................................................4
ACRONYMS.............................................................................................................................................5
List of tables...............................................................................................................................................6
1 INTRODUTION AND BACKGROUND INFORMATION...........................................................8
1.1 Statement of problem......................................................................................................................9
1.2 Broad Objectives......................................................................................................................10
1.3 Specific Objectives...................................................................................................................10
2 LITERATURE REVIEW...............................................................................................................11
3 RESEARCH METHODOLOGY...................................................................................................13
3.1 Study type.................................................................................................................................13
3.2 Study area.................................................................................................................................13
3.3 Study population......................................................................................................................13
3.4 Inclusion and exclusion criteria..............................................................................................13
3.5 Sample size...............................................................................................................................13
3.6 Sampling technique.................................................................................................................13
3.7 Data collection..........................................................................................................................14
3.8 Data analysis............................................................................................................................14
3.9 Ethical consideration...............................................................................................................14
3.10 Pre-testing................................................................................................................................14
3.11 Dissemination of results...........................................................................................................14
References.................................................................................................................................................15
4 APPENDICES......................................................................................................................................17
Appendix 1............................................................................................................................................17
Appendix 2............................................................................................................................................18
Appendix 3............................................................................................................................................19
Appendix 4............................................................................................................................................21
Appendix 5............................................................................................................................................22
1 INTRODUTION AND BACKGROUND INFORMATION
Restorative dentistry is the art and science of the diagnosis, treatment, and prognosis of defects
of teeth that do not require full coverage restorations for correction. It involves the restoration of
proper tooth form, function, and aesthetics while maintaining the physiologic integrity of the
teeth in harmonious relationship with the adjacent hard and soft tissues (Gopikrishna V, 2013).
Patients seek dental treatment for symptoms such as pain, sensitivity, trauma, decay, bleeding
gums, discolouration of teeth and for aesthetic corrections. The management of most of these
problems are under the purview of this branch of dentistry. Hence, restorative/conservative
dentistry forms the core of any dental practice (Gopikrishna V, 2013) .
Dental caries is a major oral health problem affecting 60–90 % of school age children and
majority of adults. Although the disease level is relatively low in Africa compared to Asian and
Latin American countries, it is expected that the incidence will increase in many developing
countries in Africa because of growing consumption of sugar, inadequate exposure to fluorides
and limited access to oral health services (Petersen PE, 2003) .
In Malawi, there is lack of population-based data on the status of oral health problems. However,
hospital-based data from health management information system (HMIS) suggest that oral health
problems are the sixth commonest cause (after malaria, upper respiratory conditions,
musculoskeletal pain, diarrhoea and pneumonia) for outpatient department (OPD) attendance. In
2010, of the 1,726,065 OPD visits, 57,234 (3.3 %) were due to oral health problems.
It has already been shown that people from Machinga district have poorly contributed to the
reduction in the prevalence of dental caries (Dental Department, 2021). However, people from
Machinga have the full potential to play a role in order to know and do with regards to
restorative dental services, and are often necessary especially in individual restoration. Knowing
the reasons that drive dental therapists away from performing restorative dental services and
those that facilitate its adoption can bring an important contribution towards the implementation
of restorative dental services programs in Machinga District.

Machinga district hospital

Machinga district hospital (MDH) where the study will be carried is in Machinga, a south region
in Malawi which has a population of 788,256 as of 2020 population census. The dental
department has two dental therapists (DT’s) who attend to patients with different dental
problems. The services offered to the patients by the department includes; dental health
education, oral diseases management, extraction of teeth, paediatric dentistry but exclude
restorative dental services.
1.1 Statement of problem
A significant proportion of populations in low and middle-income countries (LMICs) suffer from
oral diseases, leading to poor oral health status (Petersen PE B. D.-D., 2005). However,
preventive dental services are rarely utilized in these settings (Kandelman D, 2000). As a result,
patients frequently present at the health facilities due to symptomatic reasons (Kikwilu EN,
2009).
Toothache due to dental caries is the most common reason for attendance in dental facilities in
LMICs (Khalifa N, 2012), and the most common dental treatment rendered has been tooth
extractions and not fillings (Mashoto KO, 2009; Nyamuryekung’e KK, 2015). This often leads to
premature loss of teeth and poor quality of life (Tan H, 2016). An increase in rates of utilization
of tooth filling services in LMICs may result into an improvement in oral health status and health
generally.
Several theories have attempted to describe health behaviours and factors influencing them
(Davis R,2015). Even though they differ greatly in their scope and applicability, most are in
accord with existence of both internal and external factors that determine attitudes and
behaviours.
One of the well-known models describing health care utilization is by Andersen RM. This model
looks at dimensions (predisposing, enabling and need factors) behind access to and utilization of
health services once an individual becomes ill. Predisposing factors are those present prior to
onset of illness and describe the predilection of individuals to use health services. The enabling
factors describe the individual’s (financial) means available for use on health services whereas
need for care refers to (subjective) level of experienced illness (Andersen RM, 1983).
Predisposing factors of individuals determine their beliefs regarding seeking of healthcare
services and types of health care utilized. The ensuing tendency for favourable or unfavourable
response to a health need is defined as “attitude” (Ajzen I, 1996). Patients’ beliefs towards a
particular health service may influence their utilization. This belief can be considered as a
reflection of a person’s perceptions, feelings and knowledge regarding available health care
services. Such beliefs and misinformation, and lack of knowledge on restorative care have been
identified as some of the key obstacles towards utilization of tooth filling services in LMICs
(Kikwilu EN, 2009).
It has been suggested that attitudes in utilization of any oral health service are characterized by
subjective valuation in terms of convenience, appropriateness, cost and the perceived quality of
the care which will be received (Andersen RM, 1983). Furthermore, these attitudes are not
considered to be static, but change depending on variations in both internal and external factors
(Albarracín D, 2005). Factors such as perceived values of oral health care, levels of oral health
knowledge and attitudes, educational status and income have been shown to influence utilization
of oral health services (Teusner DN, 2013).
Despite attempts to introduce restorative services within the oral health systems in low-income
countries, the success of these endeavours has been limited (Kikwilu EN, 2009). Possible
barriers to utilization of these services by patients include lack of knowledge of restorative care,
unavailability of materials and equipment, cost of services and negative past experiences with
dental treatment (Kikwilu EN, 2009). Nevertheless, acceptability and utilization of tooth filling
services is partly dependent on the prevailing attitudes of patients towards the service (Teusner
DN, 2013). If the patients have negative attitudes towards tooth filling services, the rate of its
utilization is likely to also be low, irrespective of service availability
Significance of the study
The findings of the study will be used as a baseline data for staff of Machinga District Hospital
and dental practitioners interested to open dental clinics in Machinga District to determine
whether interventions to introduce restorative dental services will be successful. Besides other
interested researchers who want to do further research in restorative dental services, the data will
be used to come up effective and efficient dental treatment, oral health policy, strategic plan,
interventions and mobilize resources in order to fill the gap.

1.2 Broad Objectives

To assess the impact of unavailability of restorative dental services in Machinga district

1.3 Specific Objectives

 To determine the knowledge and attitude of people from Machinga district have towards
restorative dental services.
 To explore the setting of dental services at Machinga district hospital.
 To find out other factors that hinder the administration of restorative dental services in
Machinga district.
2 LITERATURE REVIEW
The low utilisation of restorative care and large number of tooth extractions have been largely
blamed on lack of knowledge and inadequate man-power, although no previous study has been
done in Nigeria to identify the barriers to restorative care. However, such studies have been done
in Tanzania and South Africa to identify the barriers to restorative care as perceived by dental
professionals (Kikwilu EN, 2009) and patients thus, the questionnaire used in this study was that
tested and validated by Kikwilu EN.
In Nigeria, most medical and dental practitioners work in the urban and semi-urban regions
where there is a better electricity supply and other social amenities (Ojo K, 1990). About 80% of
dentists in Nigeria are located in the southwest and north-central zones of the country, where
most dental schools in the country are located. Thus, the study was carried out among dentists in
the teaching and general hospitals in this part of the country
The most influential barriers identified in the study were the ‘attitude of patients’, ‘knowledge of
patients’ and ‘patients prefer extraction to fillings. These findings are different from those of the
study done by Kikwilu EN. Even though the level of oral health awareness in Nigeria is on the
increase, the attitude of the patients to restorative care is still poor, as shown by this study. This
may be due to the following reasons: most patients do not seek dental care early enough and wait
until there are complications, poor habits of attending dental check-ups, and lack of awareness of
the importance of early restorative care. Hence, patients must be well informed of the importance
of early restorative care. The integration of primary oral health care into the existing primary
healthcare system in Nigeria will better the knowledge of restorative care and the oral health of
the people in general, which may affect their attitude.

In Nigeria, extraction is cheaper and faster than restorative care. The cost of extraction ranges
between $5 and $7 per tooth, while the cheapest fillings cost between $30 and $50, depending on
the location. A further factor facilitating extraction is that it is always the treatment option in
rural settings and state government clinics, due to a lack of constant supply of electricity, dental
equipment and materials. This may be the reason why the dentists working in general hospitals
felt that the patients prefer extraction to fillings. Dental materials and equipment are very
expensive to purchase and maintain because they are not fabricated locally. Moreover, a stable
electricity supply cannot be guaranteed to operate such equipment. This situation is similar to
that of Tanzania and other developing countries in Africa. To overcome these challenges, some
authors (Kikwilu EN, 2009) have suggested a suitable alternative to the use of conventional
dental equipment and materials. This involves the use of affordable and appropriate technology
through the introduction of Atraumatic Restorative Treatment (ART).
ART involves removing carious tooth tissues with hand instruments only, and filling the
resultant cavity and sealing (adjoining) pits and fissures with adhesive dental material, usually a
glass ionomer (Frencken JE, 1996). It requires the use of hand instruments only; constant
electricity and the complex equipment of conventional dentistry are not required. Thus, it would
be affordable and accessible for the patients, because it could be done in local settings such as
town halls, schools, markets and places of worship. ART has also been shown to be patient
friendly, as it does not require the use of local anaesthetic agents (Mickenautsch S, 2002; PAHO,
2006).
The barrier ‘motivation of practitioners’ was the second least influential in the study. Lack of
motivation of dental practitioners may influence the outcome of care given to patients. The
reason is that practitioners may not be abreast of the current trends in restorative care and
dentistry in general, such as ART and evidence-based dentistry, which will in turn affect the care
given to patients. Courses can be organised by dental regulatory bodies for dental practitioners
on a regular basis to update dentists on current trends in dental practice. The mean score of the
single-item barrier ‘dentistry looked down upon by administration’ was also low. There is the
general opinion that dentistry is inferior to medical practice, and dental conditions and diseases
are not perceived as life threatening by administrators and the general population, thus making
the health-sector budget lopsided in favour of medical care.
.
3 RESEARCH METHODOLOGY

3.1 Study type

The study itself is descriptive survey which will be carried out among the patients attending the
outpatient section of the dental department.

3.2 Study area

The study will be conducted at Machinga District Hospital specifically at Dental Department.

3.3 Study population

The study population included all patients that attended the dental department at Machinga
District Hospital. All attendees in age group 0 to 10 years will not be interviewed instead their
parents/guardians/caretakers are the ones being interviewed on their behalf.

3.4 Inclusion and exclusion criteria

Parents, guardians or caretakers will also be partakers in the interview on their own personal
view.

3.5 Sample size

Using the Machinga District Hospital catchment area population of 98,568, the sample will
depend on the formula below. The informants will be divided into four bands (0-10 years, 11-20
years, 20-30 years and 30 and above).

Sample size will be estimated using the formula: n = Z^2*P*(1 − P) /e^2

Where n =sample size, Z = level of confidence, P=baseline prevalence of the condition and e =
margin of error.

3.6 Sampling technique

The study will involve simple non probability sampling technique whereby quota sampling
method will be applied to select adult males, adult females and children who attended the Dental
Department. Names will not be written to choose the sample instead codes.
3.7 Data collection
Patients and guardians will be approached by research assistants at the waiting area of the dental
department, informed of the purpose of the study and invited to participate. Research assistants
will provide instructions and clarifications about restorative dental services and responded to any
questions. Data will be collected by means of a self-administered questionnaire in the hospitals’
waiting rooms.

3.8 Data analysis

The questionnaire included two sections. The first section will be used to gather the main
sociodemographic features of participants, comprising of the knowledge of patients, beliefs of
patients, equipment/materials, attitudes of patients and motivation of the practitioner. The second
section of the questionnaire will be used to record the impact of the unavailability of restorative
dental services using mean and standard deviation. The data collected will be analysed using the
data master sheet and data processing is done manually and using the computer (Microsoft excel
2016).

3.9 Ethical consideration

The principal investigator (P.I) asked for written consent from the District Health Officer (DHO)
and a verbal consent will sought from patients before the data will be collected. Code numbers
instead of names of informants will be used for confidentiality and privacy’s sake.

3.10 Pre-testing
Pre-test shall be conducted at Samati, a health center which has got similar characteristics to the
study area and it will be conducted in order to check if the questionnaire has a good and correct
wording, see if the questions are properly sequenced and check that it is not too time consuming.
This will be done in order to help collect the intended data.

3.11 Dissemination of results

The results of this study will be submitted to Malawi College of health sciences Dental therapy
department and it will also be published and as well be put in Malawi College of health science
library.
References

Ajzen I. (1996). Attitudes, Personality and Behavior. (M. T, Ed.) Bristol:Open University press,
Milton Keynes.
Albarracín D, Z. M. (2005). Attitudes:introduction and scope.
Andersen RM, M. A. (1983). Health Services Restoration.
Dental Department. (2021). dental services assessment. machinga district: minister of health.
Frencken JE, P. T. (1996). Public Health Dental Journal.
Gopikrishna V. (2013). preclinical conservative dentistry (1st ed.). elsevier.
Kandelman D, A. S. (2000). Periodontal Diseases.
Khalifa N, A. P. (2012). BMC Oral Health.
Kikwilu EN, F. J. (2009). communiy Dental Oral Epidemology.
Mashoto KO, A. A. (2009). Health Quality Life Outcomes.
Mickenautsch S, M. I. (2002). South Africa Dental journal.
Nyamuryekung’e KK, L. S. (2015). BMC Oral Health.
Ojo K. (1990). Health Policy and Planning.
PAHO. (2006). Pan American Health Organization. Washington DC.
Petersen PE. (2003). Community Dental Oral Epidemology.
Petersen PE, B. D.-D. (2005). World Health Organisation.
Tan H, P. K. (2016). Dental Restoration Journal.
Teusner DN, B. D. (2013). Public Health Dental Journal.
WHO. (2012). Oral Health Fact. Geneva.
4 APPENDICES

Appendix 1
Table 1:Work plan

TASK FEBRUARY MARCH APRIL MAY JUNE

Finalising 1ST to 30th

proposal

Ask 8th to 19th

permission
from relevant
authorities
pretesting 3rd to 14th

Data 6th to 15th

collection

Data 20th to 25th

processing
and writing
project

Submitting 2nd to 4th

research
project
Appendix 2
Table 2: Budget outline

CATEGORY ITEM QUANTITY EACH COST TOTAL COST

o Pen 4 K150. 00 K600. 00

o Eraser 2 K100. 00 K200. 00
o Pencil 2 K50. 00 K100, 00
Stationary o Rim of plane 1 K4,500. 00 K4,500. 00

papers
2 K100. 00 K200. 00
o Printed
questionnaire
100 K30. 00 K3,000. 00
o Photocopied
questionnaire
Food &
refreshments Snacks & drinks K15,000. 00

TOTAL K23,600.00
AMOUNT

Budget justification
Rim of plane papers will be used for drafting, printing and photocopying questionnaires used for
data collection, and even the production of final copies of proposal and report after data analysis.
Pens and pencils used for writing during the whole process of research from drafts to the final
documents, while erasers will be used to remove the wrong written information before final
copies are produced. Drinks and snacks will be required to be offered to those participated during
the process of data collection, hence food and refreshment budget is enclosed.
Appendix 3: DATA COLLECTION SHEET(QUESTIONNAIRE)
IMPACT TO UNAVAILABILITY OF RESTORATIVE DENTAL SERVICES AT
MACHINGA DISTRICT HOSPITAL

Greet the patient/guardian:

 Introduce yourself to the patient prior to data collection
 Ask for consent from the patient to do the examination and
data collection
 Do not write the patient’s name on the collection sheet
instead use code numbers

PATIENT PROFILE
Patient/guardian code: ________________ Age:_________ Sex:___________ Marital
status:______________ Physical address:_________ Occupation:______________

SECTION A: knowledge of patient

1.what do you know about dental care?
a. extraction of teeth
b. prevention of tooth decay
c. provision of restorative care
d. any of the above

2. do you have any knowledge about restorative dental services?

a. yes
b. no

3. do you know the importance of restorative care?

a. yes
b. no

SECTION B: attitude of patient

1.When do you seek care for dental treatment?
 a. early stage
b. late stage
2. do you know the importance of early treatment?
a. yes
b. no

3.when do you go to the dental clinic for check-ups?

a. regularly
b. after a long time
c. after having a toothache
d. does not go

4. what makes you unable to have restorative care?

a. cost of services
b. distance
c. lack of knowledge
d. other reasons
Appendix 4: LETTER OF PERMISSION

Malawi College of Health Sciences

P.O. Box 30368
Lilongwe 3

24th February 2022

The District Health Officer

Machinga District Health Office
P.O Box 67
Machinga

Dear Sir/Madam

RE: A request to conduct a study at Machinga District Hospital (MDH)

I am a third-year student at Malawi College of Health Sciences studying Diploma in Dental

Therapy. In partial fulfilment of the course, I am required to conduct a research study and submit
a dissertation on the chosen topic in Health Systems Research.

The purpose of this letter is to request your permission to conduct a study at the above-
mentioned place, specifically the dental department, on the impacts of unavailability of
restorative dental services. I will interview patients and guardians from 1st to 20th March.

Your usual consideration is greatly appreciated.

Walter Mbale
Appendix 5

Malawi College of Health Sciences

Post Office Box 3036
Lilongwe 3.
26 February 2022

Dear Participant(s),
I am a third year student from Malawi College of Health Sciences, pursuing a Diploma in Dental
Therapy, who is conducting a study on assessing the impact to unavailability of restorative dental
services.
You will not be penalized for not participating in this study and you will be allowed to remain
quit at any time of your choice. If you will agree to take part in this study in-depth interviews
will be used where you will be required to answer questions related to restorative dental services.
All information discussed will be kept private and confidential and there will be no any fee for
participating in this study.
Participant’s name: __________________
Signature: ___________________________
Witness’s name: _____________________
Signature: __________________________