|Year : 2019 | Volume
| Issue : 4 | Page : 383-391
Effectiveness of an integrated perinatal oral health assessment and promotion program on the knowledge in Indian pregnant women
Kalpana Bansal1, Om P Kharbanda2, JB Sharma3, Mamta Sood4, Harsh Priya5, Alka Kriplani3
1 Department of Pedodontics and Preventive Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
2 Department of Orthodontics and Dento-Facial Deformities, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
3 Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, New Delhi, India
4 Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
5 Department of Public Health Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||7-Nov-2019|
Dr. Kalpana Bansal
Department of Pedodontics and Preventive Dentistry, Centre for Dental Education and Research, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Oral health during pregnancy plays a crucial role in the overall health and well-being of pregnant women. Evidence shows that most young children acquire cariogenic organisms from their mothers. Poor maternal knowledge about oral diseases combined with inappropriate feeding can lead to severe caries among young children. The aim of study was to assess the oral health status of pregnant women and to evaluate the gain in their knowledge after educational session in an antenatal setting. Materials and Methods: It is a pre- and post-intervention study carried out on the pregnant women (n = 198) attending an antenatal clinic in a tertiary care hospital. A specially designed semi-structured 14-point questionnaire was used to assess the pre- and post-knowledge and attitude to the oral health. Each participant was educated for self and infant oral care with the help of a specially prepared colored printed booklet. Kruskal–Wallis test was used to explore the associations between the age, education and socioeconomic class and knowledge; Wilcoxon signed-rank test was used to compare pre- and post-knowledge score. Results: Median preoral health knowledge–attitude score was found to be 4 (0–8) and was found to be associated with the level of education (P = 0.014) and socioeconomic class (0.019). There was a significant improvement in the median postknowledge score to 7 (2–10) (P < 0.001) following oral health educational session in all categories. Conclusions: An integrated preventive oral health checkup and educational program to pregnant women can benefit the dental health of the women and children. Prenatal care workers can be involved to disseminate the oral health awareness to pregnant women during antenatal visits.
Keywords: Antenatal clinic, dental caries in children, infant oral health, oral health knowledge, oral health, pregnant women, prevention
|How to cite this article:|
Bansal K, Kharbanda OP, Sharma J B, Sood M, Priya H, Kriplani A. Effectiveness of an integrated perinatal oral health assessment and promotion program on the knowledge in Indian pregnant women. J Indian Soc Pedod Prev Dent 2019;37:383-91
|How to cite this URL:|
Bansal K, Kharbanda OP, Sharma J B, Sood M, Priya H, Kriplani A. Effectiveness of an integrated perinatal oral health assessment and promotion program on the knowledge in Indian pregnant women. J Indian Soc Pedod Prev Dent [serial online] 2019 [cited 2022 May 23];37:383-91. Available from: https://www.jisppd.com/text.asp?2019/37/4/383/270478
| Introduction|| |
Oral healthcare during pregnancy has been recognized as an important global public health issue. Research continues to show an association between severe periodontal disease and adverse outcomes in pregnancy including preterm deliveries, low birth weight babies, and preeclampsia., Furthermore, mothers with poor oral health and high levels of cariogenic oral bacteria are at greater risk for infecting their children with the bacteria and increasing their children's caries risk at an early age. Apart from getting infection from their mothers during early years, it has been shown that inappropriate feeding practices during early childhood (prolonged or repeated night feeding), brushing attitude, and parental beliefs of dental health in their children (importance of primary teeth, breast/bottle feeding practices, weaning off from feeding bottles during sleep) are also important for development of early childhood caries (ECC)., Earlier studies have shown that ECC can have an effect upon the health of the child as well as the quality of life of child and of the parents.,
Many women are unaware of the effects of poor oral health behavior during and after pregnancy for themselves as well as for their children. Moreover, they do not have adequate proper knowledge about dental care in young children., Although dental care during pregnancy is safe, many women do not seek dental treatment during and after pregnancy, thus deteriorating their oral health in the long term. Educating expectant mothers about their oral health and the consequences of untreated caries and gingivitis and its impact on their future newborns could be a good beginning of prevention of dental diseases. The prevalence of ECC in India ranges from 54% to 68%, thus calling for urgent need to implement cost-effective preventive and curative oral health programs for children in our society.,
Studies from the west have suggested that the children whose mothers participated in postnatal one-time intervention in the form of oral health counseling on 2nd or 3rd day after delivery showed significantly low caries experience as compared to children whose mothers did not participate in the Oral Health Promotional Program (OHPP).
However, there are no studies available where in the oral health education of pregnant women and their oral health practices have been assessed in the antenatal period, especially from the Indian subcontinent. The present study was designed to assess oral health status, oral hygiene practices, and self-perception about oral health among pregnant women and to evaluate the effect of oral health education (with the help of a printed educational booklet) on the oral health knowledge and attitude (OHKA) of pregnant women attending ante natal care.
| Materials and Methods|| |
The study was conducted from July 2016 to April 2017 at a maternity outpatient department in a tertiary care hospital. Institutional Ethics Committee approval was obtained (IEC-242/May 06, 2016). The pregnant women in first and second trimester who were attending ante-natal clinic (ANC) and those willing to participate in the OHPP were included following written informed consent.
Oral health knowledge assessment questionnaire used in the study was specially designed for this study and has not been used previously; hence, we did not have previous data available about its efficacy. Hence, sample size calculation was done on the basis of the prevalence of gingivitis during pregnancy. A sample size of 185 individuals was estimated based on the 86% prevalence of gingivitis in pregnant women  and considering 5% precision value at 95% confidence level.
Assessment of oral health status of expectant mothers
Each participant underwent a detailed dental assessment of oral health using mouth mirror and illuminated light from a torch in the ANC while sitting in an office chair. A single experienced public health dentist examined and recorded the findings on Oral Health Assessment Form (WHO, 2013) which was used in a selective manner. Various oral conditions like dental caries; presence/absence of; gingival bleeding in relation to any of the tooth in the mouth for the periodontal status, dental erosions, dental trauma and oral mucosal lesions were noted. In addition, the presence of dental calculus stains and pericoronitis was noted.
Oral health knowledge–attitude assessment questionnaire
The survey instrument was an interviewer-administered 14 items open-ended semi-structured questionnaire. The questionnaire was designed by the investigators based on a literature review about the oral health status, the knowledge of the pregnant women and the poor utilization of dental services by the pregnant women. Questions 11–14 were adopted from the WHO Oral Health Questionnaire for adults. Face validity of the questionnaire was checked by the experts in the field. Their valued suggestions were incorporated. The ability of the pregnant women to understand the questionnaire was first assessed on 10 participants. Based on the experience and feedback from a test sample, some changes were incorporated in the terminologies. A qualified pediatric dentist (KB) who was trained on the items of the questionnaire translated and interviewed the respondents to assess their knowledge.
The questionnaire comprised of two sections, the first section contained participant's demographic variables such as age, monthly income, educational and employment status, and clinical information like stage of pregnancy and any medical comorbidity. The socioeconomic status was assessed using updated Kupuswamy scale. The second section contained three parts:
- Part 1 (item 1–7) had knowledge questions which determined the awareness regarding the cause of gum disease, the effect of compromised oral health on fetal health and pregnancy, and infant oral health [Table 1]
- Part 2 had three questions (8–10) that were asked to evaluate the attitude to dental problems and the supervision of child's brushing [Table 1]
- Part 3 (11–14 items) assessed the oral health practices, health-seeking behavior, and self-perception for oral health [Table 2].
|Table 1: Knowledge and attitude questions (item number 1-10) and correct response|
Click here to view
|Table 2: Questionnaire items to assess the oral health practices, oral health-seeking behavior, and self-perception toward oral health (item number 11-14)|
Click here to view
All the questions in part 1 and 2 were multiple options with one correct response. The decision to label the correct response was made on the basis of the evidence-based guidelines on oral health during pregnancy and early childhood which was predefined. Each correct response of the respondent was given a score of “1,” and all correct responses from each participant were added to determine the prescore of each participant. The pre- and post-OHKA score ranged from a minimum of 0 to maximum of 10 value.
Self-perception about oral health was assessed with the help of 14th question in the tool. Answer to each of these questions was in the form of never, sometimes or often being scored as 0, 1, and 2. The scores were summed up, and self-perception was assessed as GOOD self-perception if the score was from 0 to 7, FAIR if score is 8–13, and POOR self-perception if score was from 14 to 20.
Oral Health Promotional Program
After the knowledge assessment (pre-scores), oral health education was delivered to all the participants using a specially printed colored booklet on oral health during pregnancy and infant oral care instructions in the same session to make the women aware of importance of oral health during pregnancy. The educational booklet was prepared using the information available from evidence-based guidelines. It was first administered to a sample of 10 pregnant mothers in ANC to test its feasibility and practicability, and subsequently, some changes were made. The booklet educated mothers about common dental diseases such as gum problems, dental caries and tooth erosions, healthy dental habits during pregnancy, and infant oral care methods. Oral health education of the mothers was conducted on 1:1 basis, and it took about 15–20 min' session for each mother.
Oral health educational pamphlets were given to each pregnant mother following the interactions to re-enforce imparted education about weaning off practice. They were made aware of correct infant feeding practices and about the importance of child's oral hygiene for the dental health.
During the posteducation follow-up evaluation after 2–3 months in the ANC, the participants were assessed regarding their knowledge and attitude about oral health using the same questionnaire. Postscore was determined by adding all correct responses. The pre- and post-scores were compared to determine the gain of knowledge of mothers for self and infant dental care.
The data were compiled in excel sheet, and the statistical analysis was carried out using STATA 12.0 (College Station, Texas, USA). Data were summarized as number (%) and median (minimun–maximum) The prevalence and 95% confidence interval were calculated for various oral conditions. The change in the post score from prescore was tested using Wilcoxon signed-rank test. The pre- and post-knowledge and attitude score was compared to various categories of age, education, occupation, and socioeconomic class using Kruskal–Wallis/rank sum test as appropriate. P < 0.05 was considered as statistically significant.
| Results|| |
Of 250 pregnant women in ANC who were invited to participate, 200 agreed to get enrolled in the study [Figure 1]. Follow-up evaluation of the oral health knowledge could be completed in 159 participants (response rate of 79.5%). Two women did not complete baseline assessment. Five women were excluded due to abortion as they did not turn up in ANC. Thirty-four participants were lost to the follow-up (24 moved to other hospitals or cities, and three refused follow-up and seven participants could not be contacted).
The mean age of the participants was 28 ± 4.3 years (18–42 years). Majority were nonworking homemakers (67.2%) [Table 3], graduates or postgraduates (64.6%), and belonged to middle socioeconomic class (73%).
|Table 3: Demographic and socioeconomic characteristics of the pregnant women (n=198)|
Click here to view
Oral health status and oral health practices
Dental caries was observed in 47.5% women (Decayed, Missing and Filled Teeth = 47.5%, untreated Decayed Teeth = 43.4%) and gingival inflammation in 53.5% mothers [Table 4]. Majority of the patients (62.6%) reported brushing twice a day. One-fifth (20.2%) of the women reported visiting a dentist in last 1 year, 26% in last 5 years while 40% never visited a dentist. Dental pain was the most common reason for the dental visit (37.6%). Around 95% of participants had a good perception of self-health in the last 1 year.
|Table 4: Oral health status, hygiene practices, and self-perception of the pregnant women|
Click here to view
Pre- and post-oral health knowledge and attitude
The median (range) OHKA score at baseline was 4 (0–8), and after oral health education, it improved to 7 (2–10) with a gain of 3 points which was statistically significant (P < 0.001). The prescore was found to be associated with the level of education (P = 0.014), and socioeconomic class (P = 0.019), and no significant association was found between the different categories of age and occupation of the women [Table 5]. The change in the post score from prescore was statistically significant in all the categories of age, education, occupation, and socioeconomic class. However, even after the educational intervention, there was a statistically significant difference in the postknowledge scores among the pregnant women belonging to different socioeconomic class (P = 0.031).
|Table 5: Relationship of pre- and post-oral health knowledge and attitude score among pregnant women (n=159) with variables|
Click here to view
Pre- and post-response to oral health knowledge and attitude questionnaire
Pre- and post-responses of the mothers to the various items of the questionnaire have been shown in [Figure 2]. After oral health education, the proportion of correct responses by the participants in each item of the questionnaire increased as compared to preresponses.
|Figure 2: Percentage of correct pre- and post-responses to 14 item Questionnaire. OHPP = Oral Health Promotional Program|
Click here to view
Before the oral health education, 72% of participants did not know correctly when to wean the child from night time bottle/breastfeed. According to them, the children may be given night time feeding till 2–3 years; 65% of mothers did not know correctly about the time of beginning of brushing child's teeth. Majority of mothers (77%) did not consider that children should be taken for the preventive 1st year dental visit and had a knowledge that a child should be brought to the dental clinic only in case of toothache or on the appearance of black spots/dental decay.
| Discussion|| |
Oral health care during pregnancy is neglected health issue and is now being recognized as a major public health issue globally. Severe periodontal diseases have been linked to adverse pregnancy outcomes, and it has been recognized that mothers' oral flora is transmitted to the new born babies which can lead to ECC. Apart from this, oral health beliefs and practices of mothers toward oral health also influence the development of ECC.
There are no studies available especially from Indian subcontinent which have evaluated oral health knowledge of pregnant women and educated these mothers about their own oral health and oral health practices for their new born children. In this study, majority of participants were educated till high school levels or higher; only 7% of the mothers were illiterate or had a very less formal education. Three-fourth (73%) of the sample is from the middle class socioeconomic strata of the society. Majority of the participants in the study were primigravida with few exceptions.
There is a variation in the prevalence of dental diseases in different populations depending on several demographic variables such as literacy levels, rural dwelling, socioeconomic status, and professional status., Cross-sectional studies showed that the percentage of pregnant women with gingival inflammation varies from 47% to 89% in different populations, and this variation in the disease rates is due to different sociocultural characteristics, as well as the differences in the definitions of periodontal disease. The prevalence of dental caries in the pregnant women found in our study is consistent with the results obtained from other studies which reported 51.8% in urban (19) and 62.7% in the rural populations.
The data showed that only one-fifth of the participating women visited a dentist in the last 6–12 months and the reason for the visit was the dental pain; majority (40%) had never visited a dentist; reported to brush twice a day (62.5%); and a majority (95%) perceived their dental health in good condition. In a study from USA, <50% of the pregnant women consulted a dentist during pregnancy even though oral problem existed. In Australia, less than one-third pregnant women saw a dentist in the last 6 months. Women avoid dental treatment during pregnancy unless an emergency and are confused for accessing dental care during pregnancy and early childhood, thus reflecting a poor attitude toward dental health during pregnancy. Several reasons have been cited in the literature for the women not seeking dental care during pregnancy such as poor domestic relationships, personal finances, perception of dental experience, attitudes toward dental providers, importance attributed to oral health, and time constraints.
On assessment of their preknowledge and attitude for dental health, most of the mothers had inadequate knowledge for infant oral hygiene and poor attitude as is reflected by their low median scores (4), with educational status and lower socioeconomic class being significantly associated with poor preknowledge. The study showed that oral health education given to pregnant women during antenatal checkup significantly improved the knowledge and attitude scores (P < 0.001). Higher postknowledge and attitude score could be observed in all the categories of the participants as compared to the baseline; even the mothers who were educated to primary level had a significant gain of knowledge posteducation. This may be attributed to the fact that each participant was given oral health education on 1:1 basis using an information booklet. It is the early childhood dental health behavior adopted by new mothers that plays a crucial role in the maintenance of good oral health of the child on the long-term basis.
The awareness was lacking regarding the time of weaning from the feeding during sleep. In the absence of regular oral hygiene measures, especially tooth brushing for the children below 2–3 years, dental plaque accumulation continues and promotes the proliferation of pathogenic micro-organisms on teeth. In addition to that, inappropriate feeding practices with the baby sleeping with bottle or breast milk in the mouth further aggravates the oral environment, and ECC sets in and progresses at a fast pace if timely oral care is not rendered.
In another study about parental knowledge for the oral health of preschool children, around 70% parents responded that prolonged and frequent bottle feeds did not affect dental health of the child, and approximately, half of the parents did not brush their children's teeth under the age of 2 years. Most of the parents believe that first dental visit should be made when permanent teeth erupt. In another study on Indian population, the attitudes of parents toward child dental health has been documented to be unfavorable, and dental awareness and knowledge is poor. In a study on Brazilian mothers of newborn children, it was found that that they have an inadequate knowledge concerning dental caries in children. Other researchers from all over the world have concluded that mothers need to be educated in several important areas related to feeding, diet, and first dental checkup visit of their children.,
The main limitation of the study is its nonrandomized design because it was considered unethical not to provide education to one group of mothers after their assessment. Since this is a pilot project, the study sample was small, a community-based study with large sample size is needed to prove the findings of this study conclusively. A longer follow-up and oral examination of the children after teeth eruption would provide definite evidence whether oral health education of pregnant women will help in the reduction of ECC. The strength of the study is that this is a first of its kind of study conducted in Indian population to know the awareness levels of the women toward oral health and their attitude toward child dental health and the effect of the oral health education on the knowledge gain of women.
| Conclusions|| |
This study has shown that knowledge and attitude of Indian pregnant women toward oral health care during pregnancy and infant oral health is inadequate. Oral health education during antenatal visits can improve knowledge and practices for oral health and infant dental care significantly in all categories of the population irrespective of educational level, occupation, and socioeconomic class. There is a need to create awareness among new mothers about correct oral hygiene methods and feeding practices for the children as early as possible so that the dental health of children is not jeopardized. Healthcare workers should be trained to spread the education among the pregnant women, new parents, and the elders in the society about the importance of the dental health in children, especially in the lower income strata and rural areas of the country.
The authors acknowledge the help of Dr. Kalaivani M, Scientist at the Department of Biostatistics, AIIMS. New Delhi for the statistical design and the data analysis for the research work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Turton M, Africa CW. Further evidence for periodontal disease as a risk indicator for adverse pregnancy outcomes. Int Dent J 2017;67:148-56.
Soucy-Giguère L, Tétu A, Gauthier S, Morand M, Chandad F, Giguère Y, et al.
Periodontal disease and adverse pregnancy outcomes: A prospective study in a low-risk population. J Obstet Gynaecol Can 2016;38:346-50.
Chaffee BW, Gansky SA, Weintraub JA, Featherstone JD, Ramos-Gomez FJ. Maternal oral bacterial levels predict early childhood caries development. J Dent Res 2014;93:238-44.
Kalra G, Bansal K, Sultan A. Prevalence of early childhood caries and assessment of its associated risk factors in preschool children of urban Gurgaon, Haryana. Indian J Dent Sci 2011;3:12-6.
Rai NK, Tiwari T. Parental factors influencing the development of early childhood caries in developing nations: A systematic review. Front Public Health 2018;6:64.
Sachdev J, Bansal K, Chopra R. Effect of comprehensive dental rehabilitation on growth parameters in pediatric patients with severe early childhood caries. Int J Clin Pediatr Dent 2016;9:15-20.
Bansal K, Goyal M, Dhingra R. Association of severe early childhood caries with iron deficiency anemia. J Indian Soc Pedod Prev Dent 2016;34:36-42.
] [Full text]
Gaszyńska E, Klepacz-Szewczyk J, Trafalska E, Garus-Pakowska A, Szatko F. Dental awareness and oral health of pregnant women in Poland. Int J Occup Med Environ Health 2015;28:603-11.
Sultan S, Ain TS, Gowhar O. Awareness of mothers regarding oral health of their children in Kashmir, India. Int J Contemp Med Res 2016;3:2168-71.
Begzati A, Bytyci A, Meqa K, Latifi-Xhemajli B, Berisha M. Mothers' behaviours and knowledge related to caries experience of their children. Oral Health Prev Dent 2014;12:133-40.
Michalowicz BS, DiAngelis AJ, Novak MJ, Buchanan W, Papapanou PN, Mitchell DA, et al.
Examining the safety of dental treatment in pregnant women. J Am Dent Assoc 2008;139:685-95.
Shenoy R, Chacko V. Utilization of dental services due to dental pain by pregnant women in India: A qualitative analysis. J Interdiscip Res 2013;3:18-20.
Medeiros PB, Otero SA, Frencken JE, Bronkhorst EM, Leal SC. Effectiveness of an oral health program for mothers and their infants. Int J Paediatr Dent 2015;25:29-34.
Kuriakose S, Prasannan M, Remya KC, Kurian J, Sreejith KR. Prevalence of early childhood caries among preschool children in Trivandrum and its association with various risk factors. Contemp Clin Dent 2015;6:69-73.
] [Full text]
Wagner Y, Greiner S, Heinrich-Weltzien R. Evaluation of an oral health promotion program at the time of birth on dental caries in 5-year-old children in Vorarlberg, Austria. Community Dent Oral Epidemiol 2014;42:160-9.
Rakchanok N, Amporn D, Yoshida Y, Harun-Or-Rashid M, Sakamoto J. Dental caries and gingivitis among pregnant and non-pregnant women in Chiang Mai, Thailand. Nagoya J Med Sci 2010;72:43-50.
World Health Organization. Oral Health Surveys – Basic Methods. 5th
ed. Geneva: World Health Organization; 2013.
Singh T, Sharma S, Nagesh S. Socio-economic status scales updated for 2017. Int J Res Med Sci 2017;5:3264-7.
Dhaliwal JS, Lehl G, Sodhi SK, Sachdeva S. Evaluation of socio-demographic variables affecting the periodontal health of pregnant women in Chandigarh, India. J Indian Soc Periodontol 2013;17:52-7.
] [Full text]
Mital P, Bhamboo A, Raisingani D, Mital P, Hooja N, Makkad P. Dental caries and gingivitis in pregnant women. Sch J Appl Med Sci2013;1:718-23.
Wu M, Chen SW, Jiang SY. Relationship between gingival inflammation and pregnancy. Mediators Inflamm 2015;2015:623427.
Gupta R, Acharya AK. Oral health status and treatment needs among pregnant women of Raichur district, India: A population based cross-sectional study. Scientifica (Cairo) 2016;2016:9860387.
Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: An analysis of information collected by the pregnancy risk assessment monitoring system. J Am Dent Assoc 2001;132:1009-16.
George A, Johnson M, Blinkhorn A, Ajwani S, Bhole S, Yeo AE, et al.
The oral health status, practices and knowledge of pregnant women in South-Western Sydney. Aust Dent J 2013;58:26-33.
Rocha JS, Arima LY, Werneck RI, Moysés SJ, Baldani MH. Determinants of dental care attendance during pregnancy: A systematic review. Caries Res 2018;52:139-52.
Chhabra N, Chhabra A. Parental knowledge, attitudes and cultural beliefs regarding oral health and dental care of preschool children in an Indian population: A quantitative study. Eur Arch Paediatr Dent 2012;13:76-82.
Bahuguna R, Jain A, Khan SA. Knowledge and attitudes of parents regarding child dental care in an Indian population. Asian J Oral Health Allied Sci 2011;1:9-12.
Azevedo MS, Romano AR, Dos Santos Ida S, Cenci MS. Knowledge and beliefs concerning early childhood caries from mothers of children ages zero to 12 months. Pediatr Dent 2014;36:95-9.
Al-Zahrani AM, Al-Mushayt AS, Otaibi MF, Wyne AH. Knowledge and attitude of Saudi mothers towards their preschool children's oral health. Pak J Med Sci 2014;30:720-4.
Correia PN, Alkhatrash A, Williams CE, Briley A, Carter J, Poston L, et al.
What do expectant mothers need to know about oral health? A cohort study from a London maternity unit. BDJ Open 2017;3:17004.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
|This article has been cited by|
||Prevalence of myths regarding oral health among pregnant women in North India
| ||Lokesh Jain, Ruchi Juneja, Richa Kansal, Varun Kumar |
| ||International Journal of Dental Hygiene. 2021; 19(1): 127 |
|[Pubmed] | [DOI]|
||Oral health knowledge among a cohort of pregnant women in south India: A questionnaire survey
| ||SVenkata Lakshmi, A Srilatha, D Satyanarayana, LSwetha Reddy, SumaB Chalapathi, S Meenakshi |
| ||Journal of Family Medicine and Primary Care. 2020; 9(6): 3015 |
|[Pubmed] | [DOI]|