|Year : 2018 | Volume
| Issue : 3 | Page : 150-158
Patients' attitudes toward screening for medical conditions in a dental clinic at the Lagos State University Teaching Hospital, Ikeja
Temitope Iyadunni Bakare1, Eyituoyo Okoturo2, Bola Obisesan3, Afolabi Oyapero4
1 Department of Restorative Dentistry, Lagos State University Teaching Hospital, Lagos, Nigeria
2 Department of Oral and Maxillofacial Surgery, Lagos State University College of Medicine/Teaching Hospital, Ikeja, Nigeria
3 Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Surulere, Lagos, Nigeria
4 Department of Preventive Dentistry, Lagos State University Teaching Hospital, Lagos, Nigeria
|Date of Web Publication||20-Jul-2018|
Dr. Afolabi Oyapero
Department of Preventive Dentistry, Lagos State University Teaching Hospital, Ikeja, Lagos
Source of Support: None, Conflict of Interest: None
BACKGROUND: Early identification of people at increased risk of disease who could benefit from prompt intervention can prevent the onset or control the severity of the disease. This study investigated the knowledge and perceived barriers of dental patients toward screening for medical conditions within a dental setting.
MATERIALS AND METHODS: Consenting participants (n = 500) who presented in the Dental Department of Lagos State University Teaching Hospital were recruited using a simple random sampling method. An interviewer-administered questionnaire was used to obtain sociodemographic information as well as the respondents' knowledge, attitudes, and perceived barriers regarding screening for medical conditions by a dentist. Data entry and analysis were done using SPSS version 19 and P < 0.05 was considered statistically significant.
RESULTS: Majority of respondents were aged <40 years, were females, and had at least 12 years of education. Most of them (63.4%) had poor knowledge on the risk factors predisposing them to medical conditions and on the oral complications of systemic diseases (57.6%). Majority of the respondents (64.6%), however, had a positive attitude toward screening for medical conditions in a dental clinic. The barriers they envisaged for screening in the dental setting were cost (67.2%) and increased waiting time (65%) for screening.
CONCLUSION: The study participants had a positive predisposition toward screening for medical conditions in the dental clinic even though they had concerns about payment and extra time spent for screening. Opportunistic screening for medical conditions is recommended for consenting high-risk patients identified during dental visits. Adequate budgetary allocation to the National Health Insurance Scheme should also be made to address the financial constraints that patients have.
Keywords: Dental clinic, medical conditions, risk factors, screening
|How to cite this article:|
Bakare TI, Okoturo E, Obisesan B, Oyapero A. Patients' attitudes toward screening for medical conditions in a dental clinic at the Lagos State University Teaching Hospital, Ikeja. Int J Health Allied Sci 2018;7:150-8
|How to cite this URL:|
Bakare TI, Okoturo E, Obisesan B, Oyapero A. Patients' attitudes toward screening for medical conditions in a dental clinic at the Lagos State University Teaching Hospital, Ikeja. Int J Health Allied Sci [serial online] 2018 [cited 2018 Nov 21];7:150-8. Available from: http://www.ijhas.in/text.asp?2018/7/3/150/237254
| Introduction|| |
Medical conditions, such as cardiovascular diseases (CVDs), oral cancer, chronic respiratory diseases, and diabetes mellitus (DM), represent a considerable public health burden.,, CVD currently accounts for nearly half of the noncommunicable diseases (NCDs) in the United States of America  and it is the leading global cause of death, accounting for 17.3 million deaths per year. The prevalence has been found to be 44% in Western Europe and 28% in North America. Over 80% of deaths from NCDs worldwide are estimated to occur in low- and middle-income countries. In Nigeria, the impact of NCDs are enormous with about 5 million Nigerians estimated to have died from NCDs in 2015. The prevalence of hypertension, which is a risk factor for stroke, heart failure, ischemic heart disease, and kidney failure in Nigeria, ranges from 8% to 46.4%. With an increasing adult population, Nigeria will experience economic and health challenges due to the disease if the trend continues.
Cancer is the second largest cause of death worldwide, representing about 13% of all deaths (7.6 million deaths). Recent literature review estimated the number of new cancer cases in 2009 alone at 12.9 million, and this number is projected to rise to nearly 17 million by 2020. Chronic respiratory diseases similarly affect the airways and other structures of the lung. These include asthma and chronic obstructive pulmonary disease, which affect 210 million people worldwide and account for 3%–8% of deaths in high-income countries and 4%–9% of deaths in low- and middle-income countries. It was the fifth cause of death in 2002 and it is projected to be the fourth cause of mortality by 2030 worldwide.
Trends also suggest that the prevalence of diabetes/prediabetes will increase from an estimated 14% in 2010 to 21%–33% by 2050 in the United States., Currently, 1.71 million Nigerians are living with diabetes, and this figure is projected to reach 4.84 million by 2030. This is an indication that the prevalence of the disease is rising in Nigeria. This estimated increase in prevalence and associated economic impact of medical conditions highlights the need for prevention strategies to effectively control this trend. It is also alarming that a substantial proportion of people with identifiable risk factors for CVD have not been diagnosed or are inadequately treated.
Early identification of people at increased risk of disease who could benefit from early intervention could prevent the onset or control the severity of the disease. Modifying these risk factors will also result in a substantial reduction in the incidence and associated mortality from these diseases. Screening for medical conditions has conventionally always been done in the hospitals. Some studies have, however, shown the usefulness and effectiveness of screening for medical conditions in a dental setting.,, Most patients are, however, generally unaware that screening for medical conditions can be carried out in a dental setting. It has been observed that patients who receive periodic periodontal treatment had significantly higher chance of having DM, coronary artery disease, and CVD detected at an early stage. Since high-risk patients can be identified before the onset of the disease, early identification will enable patients to benefit from early intervention. This will also substantially reduce the incidence, morbidity, and mortality associated with these diseases.,,
Successful implementation of screening for medical conditions in a dental setting, however, will require an understanding of patients' knowledge and attitude. The aim of the study was thus to determine the knowledge, attitude, and perceived barriers of patients toward screening for medical conditions within a dental setting.
| Materials and Methods|| |
The study was a descriptive, cross-sectional study assessing patients' attitudes toward screening for medical conditions in a dental clinic.
Description of study area
Lagos State University Teaching Hospital (LASUTH) is located at Ikeja, Lagos State, which is an urban, cosmopolitan city. The hospital is located on approximately 10 hectares of land at 1–5 Oba Akinjobi Street in Ikeja. It has 740 hospital beds and is a state-of-the-art critical care center. The yearly turn-out of patients in the hospital is approximately 31,000, while the dental clinic attends to approximately 18,000 patients. It is a state-owned tertiary health institution in Nigeria and a referral center for majority of Lagos residents and its environs. Lagos State has an estimated population of over 18 million people. LASUTH dental clinc is a multispecialty center which records an average of about 40 new patients on a daily basis.
Description of the study population
The study population consisted of adult patients aged between 18 and 70 years attending the dental clinic in LASUTH for care for the first time. The study duration was 12 months from January 2014 to December 2014.
Sample size determination
Using the sample size formula n = Z 2pq/d2 for cross-sectional study, where n = sample size; Z = standard normal deviate; P = proportion of individuals who feel that screening for medical conditions by a dentist is acceptable; q = 1 − p; d = precision of the study expressed as a decimal:
Z = 1.96
P = 0.94 (from a reference study)
q = 0.06
d = 0.05
n = 433
A total of 500 respondents were, however, recruited for this study with a provision for a 10% attrition rate.
Participants were selected from adult patients attending the dental clinic of LASUTH using a random sampling technique. Using the clinic register as a sampling frame, 10 out of about 40 patients were recruited daily using the balloting method.
Inclusion and exclusion criteria
Those included in the study were participants aged between 18 and 70 years who were attending the dental clinic for the first time and who reported no history of CVD, oral cancer, chronic respiratory diseases, and DM. Those excluded were acutely ill patients, those <18 years of age, nonconsenting patients, patients referred from other outpatient clinics within LASUTH, and those with a known NCD who have had medical checkup within the past 3 months.
Ethical clearance for the study was obtained from the Health Research and Ethics Committee of LASUTH. In addition, written consent was obtained from each patient before their inclusion into this study.
Description of instruments of measurement
The instrument of measurement was an interviewer-administered questionnaire. The questionnaire was adapted from Greenberg et al. and Spiers et al. It was pretested on 50 patients who were not included in the final sample. The questionnaire had six sections. The questionnaire obtained the sociodemographic details of the respondents; their knowledge on the risk factors for medical conditions; their knowledge about the oral complications of medical conditions; and their attitude toward lifestyle modification that may prevent the occurrence of medical conditions and perceived barriers toward screening in a dental clinic. A standardized weighing scale was used to measure the weight of the respondents, while a stadiometer was used to measure their height.
Method of standardization of examiner
All the questionnaires were administered, and all anthropometric measurements were taken by the principal investigator who was calibrated before commencement of the study. The weighing scale was standardized before use. Weight was taken thrice without any excessive clothing on with the aid of a weighing scale and the average was recorded. Height measurement in meters was taken without the respondents having their shoes, cap, or headgear on. The body mass index was calculated from weight (kg) divided by a square of the height (in meters).
Evaluations of outcome variables
The respondent's knowledge of the risk factors for medical conditions was assessed using their responses to a set of five questions. Correct response to each question was scored 3 points and each wrong response was scored 0, which gave a total of 15 points. Respondents who obtained scores of < 50% were classified as having “poor” knowledge, those who obtained scores of 50%–74.9% were classified as having “fair” knowledge, while those whose scores were 75% and above were classified as having “good” knowledge. A set of five questions was also used to assess the level of stress of respondents. A positive response to each question was scored three points, while a negative response was scored zero. This gave a maximum score of 15 points. Score <10 was graded “not stressed” while score 10 and above was graded “stressed.”
Assessment of respondents' attitude toward lifestyle modification and to screening in a dental setting was assessed using a set of 20 Likert scale questions each. The responses were scored and a mean score of 18 was obtained for attitude to lifestyle modification and 16 for attitude toward screening. Respondents having scores below the mean score were classified as having negative attitude and those having scores above the mean score were regarded as having positive attitude.
Data obtained were entered and analyzed using the SPSS (Statistical package for social sciences) for Windows (version 18, Chicago, IL) statistical software package. Descriptive statistics including means, standard deviations, and percentages were used to summarize the demographic variables and health-related behavior of the study sample. Chi-square test was used to compare the association between categorical variables. Confidence interval was set at 95% for all statistical tests, and associations were considered statistically significant where P ≤ 0.05.
| Results|| |
Sociodemographic characteristics of the respondents
A total of 500 respondents were recruited for this study. There were more female participants than male in a ratio of 1.3:1. The age range of respondents was 18–70 years, while the mean age of respondents' recruited was 35.1 ± 13.0 years. Majority of participants (68.2%) were < 40 years, were unmarried (52.2%), and had tertiary education (68. 4%). The majority of the respondents were Yoruba (57.0%) and Christians (82.4%), while 35.6% of the respondents took alcohol, and only 5.8% smoked cigarette [Table 1].
Knowledge of dental patients on risk factors predisposing them to medical conditions
Over 63.4% of the participants had poor knowledge of risk factors predisposing them to medical conditions [Figure 1]. A higher proportion of respondents were aged 40 years and above, were female, were married, had tertiary education, and had good knowledge of risk factors of medical conditions. These differences were, however, not statistically significant [Table 2]. Alcohol consumption was significantly associated with this high level of stress in bivariate analysis [Table 3]. A significantly higher proportion of those who drank alcohol were more likely to be stressed when compared with respondents who did not drink alcohol even after logistic regression [Table 4].
|Figure 1: Knowledge of the respondents about risk factors predisposing to medical conditions|
Click here to view
|Table 2: Factors associated with knowledge of respondent on the risk factors of medical conditions|
Click here to view
|Table 4: Logistic regression of predictors on level of stress among respondents|
Click here to view
Assessment of attitude of patients toward screening for medical conditions in the dental clinic
About 64.6% of the respondents had a positive attitude toward screening for medical conditions by the dentist [Figure 2], and majority had a positive attitude toward chairside screening for blood pressure, height and weight measurements, collection of saliva/other fluids, and fingerprick by the dentist [Figure 3]. Educational status was the only factor significantly associated with a positive attitude toward screening in the dental clinic (P = 0.040) [Table 5] and [Table 6]. About 67.2% of respondents were not willing to pay for screening for medical conditions and to spend extra time for screening. Only 21% of the respondents preferred to be screened by a medical doctor. None of the factors were significant predictors of respondents' attitude toward screening for medical conditions [Figure 4].
|Figure 2: The total number of respondents who had a positive attitude toward screening for medical conditions|
Click here to view
|Table 5: Factors associated with attitudes toward screening in a dental clinic|
Click here to view
|Table 6: Logistic regression on factors associated with attitude toward screening in a dental clinic|
Click here to view
|Figure 4: Respondents perceived barriers toward screening of medical conditions in a dental clinic|
Click here to view
| Discussion|| |
Medical conditions, such as CVD, oral cancer, chronic respiratory diseases, and DM, represent a considerable public health problem. Frequently, oral health services have focused exclusively on the care of the teeth and gums, in isolation from systemic health. The common risk factor approach, however, utilizes a broader outlook in addressing the common elements in many chronic conditions and also addresses the influence of sociopolitical factors on health utilizing a multisectoral approach. The recent launch of the National Oral Health Policy in Nigeria also emphasizes the need for a multidisciplinary approach to health to enhance the early identification of people at risk of medical conditions. This descriptive, cross-sectional study evaluated the knowledge and attitude of patients toward screening for medical conditions by dentists in the LASUTH dental clinic.
The sociodemographic characteristics of the respondents studied had some differences with that reported in a study by Greenberg et al. Most of the respondents in this study were below 40 years compared to that reported by researchers in developed countries who had mainly respondents above 40 years of age. This early age at presentation of the new patients in the dental clinic was adjudged to be due to a high intake of refined carbohydrates in early childhood brought on by westernization of our society. There were, however, more females in this study in line with the reports of Greenberg et al. It is observed that women have a better health-seeking behavior and a more positive attitude toward visiting the dentist compared to their male counterparts.
Knowledge of risk factors affecting health is crucial in preventing medical conditions. In this study, a high proportion of respondents had poor knowledge of risk factors when compared to the findings by Greenberg et al., which reported a high level of knowledge. This may be due to inadequate public awareness on health, which is a common finding in developing countries. The high proportion of individuals with good knowledge of risk factors reported in previous studies was possibly due to continual public health education and public policies that had been put in place in these developed countries.,
Stress is a risk factor that also predisposes patients to some medical conditions. Findings from this study showed that about a third of the respondents were evaluated as stressed. A significantly higher proportion of those who took alcohol were assessed as stressed when compared with those who do not take alcohol. Mulford and Miller  stated in their study that there is a high tendency for individuals to use alcohol to escape, avoid, or regulate unpleasant emotions. Reasons given ranged from work fatigue, marital issues, and financial constraints. In Lagos, traffic congestion is considered a major cause of stress. Alexandral et al., in their study in Johannesburg, observed that stress was related to inadequate water supply and municipal sewers. Another study carried out by Najimi et al. in 2012 attributed working on two jobs as being a major cause of stress.
Positive lifestyle changes help prevent diseases. The indices of poor health in developed countries are decreasing, yet they are increasing in developing countries, particularly Nigeria, because of lack of polices and health education. It is therefore not surprising that the negative lifestyle in Nigeria which is demonstrated in this study with 60% of the participants exhibiting an unhealthy lifestyle. It was observed that almost 40% of the participants drank alcohol compared to 30% reported in developed countries. It is adjudged that the high proportion of people drinking alcohol in developing countries can be linked to social consumption. Most of the respondents, especially those who consume alcohol, were unwilling to embrace a positive lifestyle. Smokers and overweight/obese patients were, however, more willing to change. This may be due to the fact that alcohol use appears more socially acceptable than cigarette smoking. Obesity is also seen as a major health risk unlike in the past when it was seen as a sign of wealth and well-being in many parts of Africa.
Screening is designed to identify disease early in a community, thus enabling prompt intervention. The highly educated respondents were more receptive toward screening in a dental setting. The respondents in this study were, however, less willing to have a fingerprick to obtain blood to screen for DM. This finding is in agreement with the reports of Greenberg et al. Less invasive screening methods that can obtain glycemic readings transdermally may reduce this barrier. About two-thirds of respondents in this study were, however, unwilling to pay for the screening exercise compared to less than one-third of the patients in another study. This may be attributed to the funding of health-care services mainly by out-of-pocket payment in Nigeria compared to developed countries where health insurance is widely available. In addition, about 70% of the respondents were unwilling to be screened due to increase in waiting time which translates to business time lost, compared to one-tenth in another study. This increased waiting time may be as a result of shortfall in dental facilities in Nigeria. Currently, in Lagos State, where the highest number of government dental facilities are located, 10 out of the 26 general hospitals and almost all the primary health-care centers do not have dental clinics.
Similarly, only about 20% of the respondents in this study preferred that screening should be done by a medical doctor. This was at variance with reports from developed countries where almost half of the participants reported that they preferred a medical doctor to screen them, especially for signs of oral cancer. This finding contrasts with that obtained in a developed country, and it presents an opportunity for initiating screening programs that have the potential to reduce the morbidity associated with late diagnosis.
| Conclusion|| |
This study showed that patients who attended the dental clinic at LASUTH do not have good knowledge of the risk factors predisposing them to medical conditions and most of them were unwilling to embrace positive lifestyle modifications. However, they had a good attitude toward screening for medical conditions. There is a need for health promotion efforts to aid the populace to identify and modify these identified risk factors. Opportunistic screening for medical conditions should also be offered to consenting high-risk patients during dental visits so that they can be appropriately referred. Adequate budgetary allocation to the National Health Insurance Scheme should also be made to address the financial constraints that patients may have.
Limitations of the study
The study was descriptive and the results cannot be generalized for all dental patients in Lagos State because the study was limited to only one tertiary institution. There could be a recall bias among the respondents. Similarly, the willingness of dentists to screen for medical conditions was not explored. However, the study provides an initial basis for further exploratory research.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Borisch B, Boomfield A. Will 2011 be the year for taking NCDs seriously? J Public Health Policy 2011; 32:399-403.
MaudLemoine P, Maire M, Thusz GR. In the shadow of HIV/AIDS: Forgotten diseases in sub-Saharan Africa: Global health issues and funding agency responsibilities. J. Public Health Policy 2012; 33:430-8.
Laslett LJ, AlagonaPJr. Clark BA 3rd
, Drozda JP Jr., Saldivar F, Wilson SR, et al.
The worldwide environment of cardiovascular disease: Prevalence, diagnosis, therapy, and policy issues: A report from the American college of cardiology. J Am Coll Cardiol 2012;60:S1-49.
Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet 2007;370:1929-38.
Ekpenyong CE, Udokang NE, Akpan EE, Samson TK. Double burden. Non communicable diseases and risk factors evaluation in Sub-Saharan Africa: The Niger Exp Eu J Sustain Dev 2012;1:249-70.
Ogah OS, Okpechi I, Chukwuonye II, Akinyemi JO, Onwubere BJ, Falase AO, et al.
Blood pressure, prevalence of hypertension and hypertension related complications in Nigerian Africans: A review. World J Cardiol 2012;4:327-40.
Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J, et al.
Global burden of hypertension: Analysis of worldwide data. Lancet 2005;365:217-23.
Mariotto AB, Yabroff KR, Shao Y, Feuer EJ, Brown ML. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst 2011;103:117-28.
Buist AS, Vollmer WM, McBurnie MA. Worldwide burden of COPD in high- and low-income countries. Part I. The burden of obstructive lung disease (BOLD) initiative. Int J Tuberc Lung Dis 2008;12:703-8.
Kurmi OP, Semple S, Simkhada P, Smith WC, Ayres JG. COPD and chronic bronchitis risk of indoor air pollution from solid fuel: A systematic review and meta-analysis. Thorax 2010;65:221-8.
Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. Projection of the year 2050 burden of diabetes in the US adult population: Dynamic modeling of incidence, mortality, and prediabetes prevalence. Popul Health Metr 2010;8:29.
Nwankwo CH. Factors influencing diabetes management outcome among patients attending government health facilities in South East, Nigeria. Int J Trop Med 2010;5:28-36.
Onyesom I, Agho JE, Osioh HE. Levels of antioxidant vitamins in newly diagnosed cases of type 2 diabetes mellitus in South Eastern Nigeria. Afr J Pharmacol 2011;5:1787-91.
Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients' attitudes toward screening for medical conditions in a dental setting. J Public Health Dent 2012;72:28-35.
Ayanian JZ, Zaslavsky AM, Weissman JS, Schneider EC, Ginsburg JA. Undiagnosed hypertension and hypercholesterolemia among uninsured and insured adults in the third national health and nutrition examination survey. Am J Public Health 2003;93:2051-4.
Mehan M, Pandya H, Kanthariya N. Risk factor profile for NCDs in industrial productive populations of Vadodara using WHO step methodology. Int J Health Nutr 2011;2:13-20.
Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML. Dentists' attitudes toward chairside screening for medical conditions. J Am Dent Assoc 2010;141:52-62.
Adashi EY, Geiger HJ, Fine MD. Health care reform and primary care – The growing importance of the community health center. N Engl J Med 2010;362:2047-50.
Greenberg BL, Glick M, Goodchild J, Duda PW, Conte NR, Conte M, et al.
Screening for cardiovascular risk factors in a dental setting. J Am Dent Assoc 2007;138:798-804.
Jontell M, Glick M. Oral health care professionals' identification of cardiovascular disease risk among patients in private dental offices in Sweden. J Am Dent Assoc 2009;140:1385-91.
Lalla E, Kunzel C, Burkett S, Cheng B, Lamster IB. Identification of unrecognized diabetes and pre-diabetes in a dental setting. J Dent Res 2011;90:855-60.
Awojobi O, Scott SE, Newton T. Patients' perceptions of oral cancer screening in dental practice: A cross-sectional study. BMC Oral Health 2012;12:55.
Albert DA, Sadowsky D, Papapanou P, Conicella ML, Ward A. An examination of periodontal treatment and per member per month (PMPM) medical costs in an insured population. BMC Health Serv Res 2006;6:103.
Bazzano LA, He J, Ogden LG, Loria CM, Whelton PK. Dietary fiber intake and reduced risk of coronary heart disease in US men and women. Arch randomized, controlled clinical trials. J Hyperten 2005;150:282-6.
Whelton SP, Hyre AD, Pedersen B, Yi Y, Whelton PK, He J, et al.
Effect of dietary fiber intake on blood pressure: A meta-analysis of randomized, controlled clinical trials. J Hypertens 2005;23:475-81.
He J, Gu D, Wu X, Chen J, Duan X, Chen J, et al.
Effect of soybean protein on blood pressure: A randomized, controlled trial. Ann Intern Med 2005;143:1-9.
Araoye MO. Subject selection. In: Araoye MO. A Textbook in Research Methodology with Statistics for Health and Social Sciences. 2nd
ed., Ch. 10. Ilorin: Nathadex Publishers; 2004. p. 117-21.
Odusanya OO, Tayo OO. Breast cancer knowledge, attitudes and practice among nurses in Lagos, Nigeria. Acta Oncol 2001;40:844-8.
Sheiham A, Watt RG. The common risk factor approach: A rational basis for promoting oral health. Community Dent Oral Epidemiol 2000;28:399-406.
Macintyre S. The patterning of health by social position in contemporary Britain: Directions for sociological research. Soc Sci Med 1986;23:393-415.
Solanke FA. Socio-behavioural risk factors of dental caries among selected adolescents in Ibadan, Nigeria. J Ped Dent 2014;24:33-8.
Ajayi DM, Arigbede AO. Barriers to oral health care utilization in Ibadan, South West Nigeria. Afr Health Sci 2012;12:507-13.
Guler N, Oguz S. The spoken knowledge of low literacy in patients with diabetes. Diabetes Res Clin Pract 2011;92:238-43.
CDC – Stress at Work – NIOSH Workplace Safety and Health Topic; 2013. Available from: http://www.cdc.gov
. [Last accessed on 2014 Oct 02].
Mulford HA, Miller DE. Drinking in Iowa. III. A scale of definitions of alcohol related to drinking behavior. Q J Stud Alcohol 1960;21:267-78.
Savulescu AR. Johannesburg Struggles to Supply Water and Sanitation; 2002. Available from: http://www.ens-newswire.com/ens
. [Last accessed on 2014 Oct 02].
Najimi A, Goudarzi AM, Sharifirad G. Causes of job stress in nurses: A cross-sectional study. Iran J Nurs Midwifery Res 2012;17:301-5.
Olaore AY. Youth, religiosity and substance abuse; a Nigerian private university experience. R Hum Soc Sci 2013;16:83-6.
Lim K, Moles DR, Downer MC, Speight PM. Opportunistic screening for oral cancer and precancer in general dental practice: Results of a demonstration study. Br Dent J 2003;194:497-502.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]