This paper documents the associations between oral health related behaviors and socio-demographic factors among Tanzanian adults. The methodological strength of the present study includes the large sample size drawn from all the six geographical zones of mainland Tanzania. Using a WHO simplified oral health questionnaire for adults [24
] makes the findings of this study comparable with those of other studies. A diverse range of oral health related behaviors studied offers substantial national baseline information for planning and scientific referencing. This study used the oral health surveys pathfinder methodology [23
], which is scientifically less rigorous than the standard probability sampling methods. However; it is widely advocated by the World health organization especially when the information collected is for planning oral health services.
Lack of information about the non-respondents precludes any conclusion about a possible selection bias, although the response rate was high enough to assume that the target population is reflected with a reasonable degree of accuracy. The clusters were purposively selected to capture the diversity of characteristics, however the individuals were let to participate conveniently until the quota size was attained for each cluster. This could have introduced volunteer bias. Nevertheless the pre-stratification by age and sex in specified quotas might have redressed the bias to some extent. The present study relied on self reported information; a possibility of over and under reporting due to respondents' seeking social desirability could lead to bias. However temporal stability was checked with satisfactory reliability. The data might provide a reflection of oral health related behaviors among adult Tanzanians. However, as the respondents were drawn by non-probability sampling, the findings must be interpreted with caution when making direct generalizations to the whole country. Furthermore; at the point of analysis some ordinal and continuous variables were dichotomized to allow for logistic regression. This to some extent might have reduced the power and a better fitting of the data. The cut off points might have misclassified individuals to categories that they did not belong. Therefore the costs of dichotomization should not be ignored when interpreting these findings. Moreover most of the ORs were modest indicating that the differences between the categories were not very prominent. However the displayed differences could be useful in real life planning situations.
The findings of this study indicated that urban residents showed a high likelihood to snacking sugary foods and drinks, eat fruits, attend dental clinics, use factory made tooth brushes but were less likely to take alcohol or smoke cigarettes than their rural counterparts. The higher tendency of urban than rural residents to consume sugar was also reported in a study among Tanzanian University students [11
], South Africans [25
] and Ghanaian adolescents [10
]. As correctly put by Holmboe-Ottesen [26
], urbanization and globalization increase the consumption of sweet soda pops, biscuits and other snacks produced by multinational companies. In addition urban residents in developing countries are easily targeted by food adverts through the media hence become alternative consumers of confectionery that would otherwise not get an easy access to western markets [14
]. Healthy public policies are necessary for monitoring the influx of sugary foods and drinks in Tanzania to protect consumers from irrational use of these commodities. Besides; reduction of sugar consumption fits into the common risk factor approach to disease prevention [27
]. In this regard, reduction of sugar consumption will not only contribute to the prevention of dental caries but also other chronic lifestyle diseases. In another perspective, fear of high death tolls from the chronic conditions might reinforce the restriction of sugar intake and in so doing contribute to caries prevention.
Health promotion emphasizes the importance of supportive environments in enhancing people to choose healthier lifestyles. Therefore, health educationists have to consider the intricate mediating role of residence environment in shaping snacking behaviors. This study found that only a small proportion of individuals consumed sugary snacks and drinks very frequently. However with trade liberalization, this distribution might scale up to higher values especially in urban areas where the environment is conducive to promote the consumption of varieties of sugary snacks and drinks. Therefore deliberate efforts should be made to maintain these low levels of sugar consumption.
While it is recommended to eat fruits about five times a day [28
], this study found 88% of urban and about 64% of rural residents consuming fruits at least once a week. Although fruits are known to be cultivated in rural areas, it was noted with concern that more urban than rural residents eat fruits. As also reported elsewhere [29
], knowledge of the recommended frequency and perceived benefits of fruit intake might not be sufficient among the study participants and particularly rural residents. It is also important to note that unreliable transportation in rural areas leads to difficulties in moving goods from place to place. As a result; people depend largely on locally grown fruits of which their availability is seasonal. This disadvantage might have accounted for the low rates in fruit consumption among rural respondents.
Proportionately fewer rural as compared to urban residents used factory made toothbrushes and toothpaste. Alternatively; a higher proportion of rural residents used miswaki and charcoal than their urban counterparts. Rural residents in this study were also disadvantaged as regards utilization of dental services. As rural communities in many aspects represent less affluent societies, affordability and accessibility of dental services could be a challenge to the poor rural residents. Consequently, the immediate options tend to be self medication or hope that dental pain would disappear on its own [30
]. Despite of a number of measures deliberated by the Ministry of health in its policy guidelines for oral health [22
] studies conducted more than a decade ago on dental attendance rates in Tanzania portray a similar rural-urban disparity [17
]. Left with constrained access to modern health facilities; rural residents also seek alternative medicine through traditional healers [31
]. This rural-urban socio-economic gradient reflects among other things, a social inequality which puts rural residents at a disadvantage, whereby their opportunities are more or less confined to what can be locally available.
While other forms of tobacco were reported to be consumed by small fractions of the study sample, the prevalence of ever used cigarettes was 16.7%; which is almost similar to the rate reported in another study among Tanzanian university students [11
]. This study also found males were more likely to smoke than females. However with the ever enduring multinational tobacco adverts; it will not be surprising in some years to come to have more smokers even among women. Smoking and alcoholism clustering reported by Myers et al [32
], has also been found to be associated with rural residents in this study. Unfortunately, this adds up on the risks to the already disadvantaged society. Minimal recreation facilities in rural areas might have been compensated by smoking and alcoholism. Contrary to this line of thinking, Pootinger, [33
] reported heavy drinking among sports club members. Exploring alcohol and tobacco information further this study also showed that dental pain increased the likelihood of drinking alcohol. Similar findings were also reported by Lahti [34
]. Whether alcohol was used as a means to cub down the dental pain or rather the pain coexisted with other forms of misery which prompted the participants to drink, that is yet to be explored. However, it has been reported elsewhere that dental health detrimental behaviors correlate with the use of marijuana, smoking frequency, and engagement in antisocial behavior [35
]. This clustering calls for a careful exploration of determinants of health behaviors. This information will help in structuring health promotion activities that will unearth what is rooted under the clusters of unhealthy behaviors. Although a higher proportion of educated people resided in urban areas and the minimally educated were more likely to smoke cigarettes, controlling for the potential confounders, this study also found that urban residents were less likely to be those who smoke, implying that being a rural dweller in itself added to the likelihood of smoking cigarettes. The whole scenario portrays a limited leeway for rural residents to live healthier lives. Viewing life in terms of its quality and fall into line with those believing in equity and equality in health; rural residents in Tanzania deserve a fresh look if they are to give a significant contribution to the achievement of the National Strategy for Growth and Reduction of Poverty.
The rural-urban disparity displayed by the findings of this study lays a foundation on how to set priorities in planning oral health promotion activities. Both the educational and policy aspects of health promotion have to be sensitive to these disparities in order to enable disadvantaged rural communities to live healthier lives.