Infant Oral Mutilation) Among Children Under 5 Years in Bungatira Subcounty, Gulu District

PREVALENCE AND FACTORS ASSOCIATED WITH FALSE TEETH REMOVAL (INFANT ORAL MUTILATION) AMONG CHILDREN UNDER 5 YEARS IN BUNGATIRA SUBCOUNTY, GULU DISTRICT

ATIM WENDY PAULA 2014-BNS-FT-009

AN UNDERGRADUATE RESEARCH REPORT SUBMITTED TO THE SCHOOL OF NURSING IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF A BACHELOR'S DEGREE IN NURSING SCIENCES OF INTERNATIONAL HEALTH SCIENCES UNIVERSITY

NOVEMBER 2018

DECLARATION

I, Atim Wendy Paula, hereby declare that this research dissertation is my original piece of work as developed by me under the scrutiny of my supervisor and has not been presented anywhere before.

Signature……………………………. Date……………………………………… Atim Wendy Paula

APPROVAL

PREVALENCE AND FACTORS ASSOCIATED WITH FALSE TEETH REMOVAL (INFANT ORAL MUTILATION) AMONG CHILDREN UNDER 5 YEARS IN BUNGATIRA SUBCOUNTY, GULU DISTRICT. I hereby accept this dissertation for the above research study and approve it for submission to International Health Sciences University and other concerned organizations, institutions, review boards and other committees.

Signature ……………………………...... Date...... MS. NANTALE GRACE SUPERVISOR

DEDICATION

I dedicate this research report to my lovely memory of my late mother Mrs. Rose Ochora I also dedicate this research report to my Father Mr. Ochora Bosco, my uncles, siblings and family for their support and encouragement towards my academic endeavor.

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ACKNOWLEDGEMENT

My most sincere and heart-felt gratitude goes to the Almighty God, who has always been faithful and gracious to me and has granted me success in everything I do. To Him I owe the Glory and honour, now and forever more! Amen... With all sincerity, I extend my thanks to my parents,Mr. And Mrs. Ochora Bosco, and my dear Uncles, Mr.Opira Johnson, Mr. Lamaka Spencer, Mr. Odong Isaac and Mr.Achaye Samuel for both the financial and moral support and guidance from my childhood up to where I am now. I would love to honour and appreciate my supervisor, Ms.Nantale Grace for her valuable time spent to guide me and ensure that this research dissertation is completed successfully. In a special way, I would also like to acknowledge Mr. Ojok Ambrose, Miss Amito Finny, the local council and residents of Bungatira Subcounty, without whom I wouldn't have obtained all this information so relevant and vital to my research. I would also like to acknowledge all respondents who spent their time and shared experiences for this research. Thanks to my friends and course-mates of BNS DIV who have been with me through every step of the journey during the course. May the Almighty GOD bless you all abundantly, in Jesus' Mighty Name, Amen.

TABLE OF CONTENT Declaration ...... i Approval ...... ii Dedication ...... iii Acknowledgement ...... iv Table of content ...... xi List of figures ...... xiii List of tables ...... xiv List of abbreviations ...... xv Abstract ...... xvi CHAPTER ONE:INTRODUCTION 1.0 Introduction ...... 1 1.1 Background to the study ...... 1 1.2Problem statement ...... 5 1.3 Objectives ...... 5 1.3.1Main objective ...... 5 1.3.2 Specific objectives ...... 6 1.4 Research Questions ...... 6 1.5 Significance of the study ...... 6 1.6 Purpose of the study ...... 7 1.7 The Conceptual Framework ...... 7 1.8 A narrative of the conceptual framework ...... 7 CHAPTER TWO:LITERATURE REVIEW 2.0 Introduction ...... 8 2.1 Prevalence of false teeth removal ( Infant Oral Mutilation) among children under five years ...... 8 2.2 Socio-demographic factors influencing false teeth removal among children under five years ...... 9 2.3 Knowledge factors influencing false teeth removal among children under five years ...... 16 CHAPTER THREE:METHODOLOGY 3.0 Introduction ...... 21 3.1 Study design ...... 21 3.2. Sources of data ...... 21 3.3 Study setting...... 21 3.4 Study Population ...... 22 3.4.1 Sample size determination ...... 22

3.4.2 Sampling Methods And Procedures...... 22 3.4.3 Inclusion Criteria ...... 23 3.4.4 Exclusion Criteria ...... 23 3.5 Definitions of Variables ...... 23 3.5.1 Dependent Variable ...... 23 3.5.2 Independent Variables ...... 23 3.6 Research Instruments ...... 23 3.7 Data Collection Procedures...... 24 3.7.1 Data management...... 24 3.7.2 Data analysis ...... 24 3.8 Ethical considerations ...... 25 3.9 Limitations of the study ...... 25 3.10 Dissemination of results ...... 25 CHAPTER FOUR: RESULTS PRESENTATION 4.0 Introduction ...... 29 CHAPTER FIVE: DISCUSSIONS 5.0 Introduction ...... 43 5.1 Discussion ...... 43 5.2 Prevalence of false teeth removal among children under five years in bungatira subcounty ...... 43 5.3 Socio-demographic factors influencing false teeth removal among children under ...... 44 five years ...... 44 5.4 knowledge factors influencing false teeth removal among children under five years ..... 48 CHAPTER SIX: CONCLUSIONS AND RECOMMENDATIONS 6.0 Conclusions ...... 53 6.1 Recommendations ...... 53 6.2. Suggestions for further researches ...... 55 REFERENCES ...... 56 APPENDICES ...... 61 APPENDIX 1: CONSENT FORM ...... 61 APPENDIX II: QUESTIONNAIRE ...... 64 APPENDIX III: MAP OF GULU DISTRICT SHOWING BUNGATIRA SUB COUNTY . 70 APPENDIX IV: INTRODUCTORY AND CORRESPONDENCE LETTER ...... 71

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LIST OF FIGURES

Figure 1: Conceptual Framework ...... 7 Figure 2: Prevalence of false teeth removal among children under five years in bungatira sub-county ...... 32

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LIST OF TABLES

Table 1: Distribution of socio-demographic characteristics of the caretakers of children under five years (n=150) ...... 30 Table 2: Distribution of socio-demographic characteristics of the children under five years (n=150) ...... 32 Table 3: Bivariate Analysis Of False Teeth Removal Among Children Under Five Years In Bungatira Sub-County ...... 33 Table 4: Bivariate analysis of the socio-demographic factors of the child associated with prevalence of false teeth removal among children under five years...... 35 Table 5: Bivariate analysis of the socio-demographic factors of the caretaker associated with prevalence of false teeth removal among children under five years...... 36 Table 6: Bivariate analysis of the knowledge factors associated with the prevalence of false teeth removal among children under five years (n=150)...... 38

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LIST OF ABBREVIATIONS ADA - American Dental Association AIDS - Acquired Immune Deficiency Syndrome HC - Health Centre HIV - Human Immunodeficiency Virus IHSU - International Health Sciences University IOM - Infant Oral Mutilation LC - Local Council NPHC - National Population and Housing Census SPSS - Software Package for Social Sciencesw3w UBOS - Uganda Bureau Of Statistics UDHS - Uganda Demographic and Health Survey UNICEF - United Nations Children‟s Fund UNMEB - Uganda Nurses and Midwives Examination Board U5MR - Under-5 Mortality Rate` WHO - World Health Organisation YCC - Young Child Clinic

ABSTRACT Introduction: Also known as Infant oral mutilation (IOM), false teeth removal is a traditional method of extracting an infant‟s un-erupted teeth as a cure for medical symptoms in infants that include high fevers, diarrhoea and vomiting. It is practiced in several Sub- Saharan African countries, including Uganda. Objectives: The study particularly sought to determine the prevalence and factors associated with false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District. Method: This cross sectional study was conducted in Bungatira Sub-county in Gulu district, involving 150 participants with children less than five years that voluntarily accepted and signed a consent form. The respondents were selected using simple random sampling from accessible population; and data analyzed using descriptive statistics and bi-variate method as well as SPSS and Microsoft Excel presented in figures and tables. Result: The prevalence of infant oral mutilation was high at 78%, and the socio-demographic factors such as the age and sex of the child, and care-takers‟ socio-demographic factors like gender and level of education had no significant association with the prevalence of false teeth removal among the children below five years. However, other socio-demographic factors of the care-takers such as age, marital status, employment status/occupation, religion and relationship to the child had a significant influence on the prevalence of false teeth removal of the children. It was observed that false teeth removal was higher among the caretakers with a lower level of education, lower socio-economic/employment status and those with a biological parent relationship to the child than those with a higher level of education, higher socio-economic/employment status and those who were guardians and not biological parents to the children. In regards to knowledge factors, the majority of people had ever heard about false teeth, and their main source of information was their parents, with ancestral/ancestral roots as the main reason for infant oral mutilation. Conclusion/recommendations: The high prevalence of infant oral mutilation has been greatly influenced by the gap in the caregivers‟ knowledge factors which included their awareness, reasons for infant oral mutilation and major sources of information about this traditional practice. Therefore, this study recommends that there is need to revive community sensitization. However, these programmes of community health workers will need to include appropriate cultural educational materials targeting parents and local healers/traditional birth attendants since these play a key role in fuelling the removal of children‟s false teeth. Keywords: Infant Oral Mutilation; Children under five; Caretakers; Uganda

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CHAPTER ONE INTRODUCTION

1.0 Introduction This chapter consists of the background to the study, problem statement, objectives(main and specific) of the study, research questions, significance and purpose of the study, the conceptual framework and a narrative of the conceptual framework of the study.

1.1 Background to the study False teeth removal is a primitive traditional practice involving the 'gouging out' of an infant's healthy primary tooth germs(Girgis at al., 2016). These teeth have been known by different names such as ''Two lak'' in Acholi, ''Gidog'' in Lango, ''Ebinyo'' in Luganda and ''Ebiino'' in Runyankole, (loosely translated as ''false teeth'') ,nylon or vinyl teeth, and killer teeth, in Lugbara . Also known as Infant oral mutilation (IOM), false teeth removal is a traditional method of extracting un-erupted teeth practiced in several Sub-Saharan African countries including Uganda.

The un-erupted tooth is gouged out as a cure for medical symptoms in infants that include high fevers ,diarrhoea and vomiting. The false teeth are removed by a traditional practitioner using unsterile knives, wires, sharpened bicycle spokes, finger nails and blades which predisposes the infants to serious complications such as profuse bleeding, HIV infections, swelling and sepsis of the gum wounds that may lead to death . In the long term, derangement of permanent dentition has been reported ( Accorsi et al.,2003).

False teeth (locally known as ebinyo) refer to the gingival swellings that occur during the eruption of the primary canine teeth in infants, and its practice consists of the extraction of deciduous canine tooth buds( Liamputtong, 2007).

Deciduous teeth or primary teeth, commonly known as baby-teeth, temporary teeth and milk teeth, are the first set of teeth in the growth development of humans and other diphyodont mammals. They develop during the embryonic stage of development and erupt,that is, become visible in the mouth during infancy.

Teething is a normal physiologic process consisting of intraosseous tooth movement in the jaw until the tooth emerges in the oral cavity ( Wake M. et al.,2000). Tooth eruption takes place during an 8-day window that includes 4 days before tooth eruption, the day of eruption and the 3 subsequent days ( Markman, 2009). According to the 1968 article on general and local effects of eruption of deciduous teeth of Tasanen, and the 2000 cohort study on teething and tooth eruption in infants conducted by Wake et al, it was discovered that teething does not cause fever, infections or diarrhoea.( Wake et al.,2000). Instead, wrongly ascribing these to teething can delay the diagnosis and treatment of serious infections, sometimes with tragic consequences. Despite the fact that teething is a common occurrence, it has been associated with many myths and erroneous beliefs (Bankole et al.,2004).

Some infants go through the process of teething without any problems and yet other infants develop some symptoms. On this point, an expert from Baby Center Medical Advisory Board in USA, William Sears, pediatrician and author of The Baby Book associates teething with loose stools, but not diarrhoea per se. He says that excessive saliva ends up in an infants‟ gut and consequently loosens the stools ( Sears et al.,2013). Additionally, child development expert Penelope Leach asserts that teething cannot cause fever, diarrhoea, or vomiting, instead these signs of illness should be checked out ( Leach,2010). Similarly, American Dental Association (ADA), a leading advocate for oral health, argues also that teething is not related to diarrhoea. Pediatrician T. Berry Brazelton states that such symptoms are probably due to an infection unrelated to teething, but that the stress associated with teething could make the child more vulnerable to infection ( Brazelton,2014). Teething is a normal physiological event in all infants. But as indicated in the 2010 Medical Observations compiled by Sood, teething causes a little more than discomfort, restlessness, drooling and finger sucking, but no symptoms at all ( Sood et al., 2010).

The association between teething and diarrhoea in an infant is basically a hygiene issue. The incidence is not as high in the high socioeconomic group with clean environment. Around the age of 6 months when a child starts bringing the first set of teeth, they are crawling and the tendency for them is to pick objects such as dropped food from the floor and straight into the mouth. Introduction of bacteria into the intestinal system gives rise to such diarrhoea. Similarly, the emerging tooth makes an opening in the gum through which bacteria introduced into the mouth as such can have access into the circulatory system to cause diarrhoea and fevers. Most children of this age are susceptible to a myriad of relatively minor 2 infections because during teething gums itch and as such kids tend to bite on anything they come across, including unhygienic objects.Pain is reported as a common feature of teething by parents. It is not the tooth which contributes, but the dental follicle which is a rich source of eicosanoids, cytokines and growth factors resulting in a localized inflammatory response and pain. Lay people state that 'the tooth coming through the bone' is responsible. There is no evidence to support this, and indeed, the etiology of the teething symptoms is caused by one of the many childhood illnesses ( Sood et al.,2010).

In addition to the above, this continued inhumane practice of IOM is conducted at an age where the antibodies' protection passed on to a child during pregnancy and from breast milk is decreasing. The child, thus, becomes susceptible to various infections, which present with symptoms of fevers, diarrhoea, and vomiting. So in such cases, false teeth removal is performed in a bid to ''treat'' such infections. Notably, a high proportion of morbidity and mortality in children under 5years in Sub-Saharan Africa is from these infections (Mukanga et al.,2011).

The prevailing mismanagement of these infections, such as through the practice of Infant Oral Mutilation in the Uganda population, thus presents as a contributory factor to the poor health burden of children(Hildenwall et al.,2007).

To treat teething and its associated discomfort caused in infants, a study by Steward recommended the approach of giving the child teething objects to bite, preferably cold objects since they bring the greatest relief, and ensuring teething rings are safe and easy to clean. Carbohydrate containing foods should be avoided, and if pain is troublesome, use the appropriate dose of a paracetamol elixir, preferably sugar-free. This may be given regularly, every 4–6 hours and if additional analgesia is required, lignocaine-based teething gels should be used.( King, 1992). However, other studies also indicate that cuddle therapy, ice, rubbing the gums, teething rings and food for chewing can also be used to relieve the symptoms commonly associated with teething in infants ( Memarpour M. et al.,2015).

Contrary to the above, Infant oral mutilation is largely practiced in traditional societies of Uganda and around the world, where un-erupted teeth, usually in the position of canines, are gouged out by a non-formally trained person. The raised areas on the infants gum are identified and then using a sharp instrument the soft un-mineralized tooth is extracted as the 3

“offending worm.” The range of rudimentary objects that may be used include bicycle spokes, hot needles, pointed knives, nails, and other sharp objects. This procedure is carried out in the belief that it will prevent or treat symptoms such as fevers or diarrhea seen in an infant. (Morgensen, 2000).

This practice of false teeth removal is commonly done in infants 5-7 months, the age at which gum swelling is most evident and the infants are likely to suffer their first bouts of childhood illnesses such as malaria, pneumonia, gastroenteritis and upper respiratory tract infections such as colds. This accounts for the attribution of early infant illnesses to the teething period, and especially to the teeth eruption itself ( Liamputtong, 2007).

As a consequence of the crude methods of removal involved, as well as the non-sterile invasive method used to gouge the false teeth, complications such as profuse bleeding and infections such as HIV/AIDS may result. These complications may be so severe that the victim ends up with severe anaemia, septicemia, osteomyelitis, meningitis and even shock. The long-term impacts are observed especially in the dentition and they include malformation, non-eruption, hypoplasia, dysplasia, missing teeth, displacement and impaction, compound odontoma, and orthodontic complications, the most commonly affected teeth being the mandibular canines ( Wandera et al.,2017).

In different societies, different methods are used to treat the complications due to IOM. Those living near Lake Magadi use sodium bicarbonate which is locally available, whereas in other communities,salt or salty water, honey or onions are used to treat the wound. Sometimes they apply ugali/posho to block the bleeding vessels. Development of profuse bleeding is associated with curses. In such cases, ''enkopito,'' which is the bark of a special tree, is tied around the fore limb of the baby to stop further complication, and appease any bad spirit( Kipchumba, 2012).

1.2 Problem statement Infant oral mutilation (IOM) is the dangerous and sometimes fatal traditional or conventional dental malpractice that has been performed for decades in many areas of Africa and in underdeveloped countries ( Wordley,2003).

The consequences of this practice include profuse bleeding, transmission of blood-borne infections such as HIV/AIDS and Hepatitis B, severe haeorrhagic anaemia,septicaemia, osteomyelitis, meningitis and even shock.The long-term impacts are observed especially in the dentition and they include malformation, non-eruption, hypoplasia, dysplasia, missing teeth, displacement and impaction, compound odontoma, and orthodontic complications. The teeth most commonly affected are the mandibular canines.

In the Acholi region, of which Gulu is part, the population of children under 5 years of age is 280,860, thus making up about 20% of the Acholi population of 1,454,300( UNICEF,2011). With Uganda's recent Under-5 Mortality Rate(U5MR) at 64 deaths per 1000 live births( UDHS, 2016), a previous study revealed that Gulu District had a very high rate of morbidity, with 78.9% of the 6-59 month old children being affected by a disease within the 2 weeks of survey, and of these, Acute Respiratory Infection was the most frequent disease, followed by malaria and diarrhoea (UNICEF, 2011).

Among the 6-59 month old children affected by diarrhoea, only half received the appropriate treatment of Oral Rehydration Solution( UNICEF, 2011). This could probably mean that the caretakers of these children are attributing these diarrhoeal diseases to the teething period and therefore seeking for removal of the children's false teeth. Therefore, this study seeks to determine the prevalence and factors associated with false teeth removal among children under five years in Bungatira Sub county, Gulu District.

1.3 Objectives 1.3.1Main objective To determine the prevalence and factors associated with false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District.

1.3.2 Specific objectives 1. To determine the prevalence of false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District. 2. To assess the sociodemographic factors influencing false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District. 3. To determine the knowledge factors influencing false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District.

1.4 Research Questions 1. What is the prevalence of false teeth removal ( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District? 2. What are the sociodemographic factors influencing false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District? 3. What are the knowledge factors influencing false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District?

1.5 Significance of the study The study results will;-  Enable the Government to put into place policies that will control false teeth extraction thus reducing infant morbidity and mortality due to this harmful practice.  Enable the Government to correct the missing links in health services as far as the Young Child Clinic is concerned.  Enable the health workers identify gaps in the services delivered to their clients like health education about management of false teeth to mothers and caretakers attending the Young Child Clinic.  Enable the public to identify their responsibilities as far as control of crude methods of removal of false teeth among infants under five years is concerned.

1.6 Purpose of the study The study is aimed at determining the prevalence and factors associated with false teeth removal among children under five years in Bungatira Sub county, Gulu District.

1.7 The Conceptual Framework

Independent variables

Social demographic factors factors of car taker - Age

- gender - Marital status - level of education Dependent - Employment status variable - Religion

- Relationship to the child

Prevalence of infant oral mutilation

Knowledge factors

- Awareness about IOM - Sources of information - reasons for IOM

Figure 1: Conceptual Framework

1.8 A narrative of the conceptual framework The above original theoretical conceptual framework shows how different variables may affect the practice of false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county in Gulu District. Socio-demographic factors of both the child and caretaker may influence the chance to acquire knowledge. Knowledge in itself will influence the utilization of conventional and modern medicine approaches in the management of common problems associated with teething in infants under five years. In addition, these socio-demographic factors may influence the removal of false teeth directly or indirectly, and thus may influence the practice of false teeth removal of these children under five years.

CHAPTER TWO LITERATURE REVIEW

2.0 Introduction This chapter consists of literature review, and will include summaries and evaluations of different studies done on the prevalence and factors associated with false teeth removal( Infant Oral Mutilation) of children below five years, and will also explore the methodologies and conclusions as well as the inconsistencies, omissions, errors, accuracy, depth and relevance of these studies.

2.1 Prevalence of false teeth removal ( Infant Oral Mutilation) among children under five years False teeth removal, also known as Infant oral mutilation (IOM), is a primitive traditional practice involving the 'gouging out' of an infant's healthy primary tooth germs(Girgis et al., 2016).

Having first been documented about in the tribes of the Nilotic Sudan in 1932( Gollings, 2017), the practice of false teeth removal is now reported to have spread to several Sub- Saharan Africa countries that include Uganda, Chad, Sudan, Ethiopia, Somalia, Democratic Republic of Congo, Kenya, Tanzania, Rwanda, and Burundi. Studies also report individuals migrating from these African nations may continue this practice in Europe, such as in the United Kingdom( Longhurst, 2010) and Sweden( Barzangi et al., 2014), Australia, and the Americas ( Noman et al.,2015). It has also been reported in the Middle East among Ethiopian Jews( Holan and Mamber, 1994).

This practice, which is part of infant oral mutilation, is a relatively common practice in African countries with an incidence that varies from place to place, ranging between 15% and 80%, especially including Angola, Tanzania, Somalia, Kenya, Sudan, Nigeria, and Uganda ( Noman et al., 2015). It has also been reported in some non-African countries, including The Maldives, the United States, New Zealand, Israel, and Sweden, especially among the migrant population ( Noman et al.,2015).

In regions of the Horn of Africa( Welbury et al.,1993) and East Africa, this practice has been reported in Kenya(Mule, 2010), as well as in Tanzania( Kikwilu et al., 1997), Uganda and Sudan (Baba & Kay, 1989; Nuwaha et al., 2007; Tirwomwe et al., 2013).

Proportions in other countries indicate a prevalence ranging between 5.2% in Moshi, Tanzania( Matee et al.,1991) and 70% in the Sabbah Children‟s Hospital in Juba, South Sudan ( Abdel-Wahab, 1987). Prevalences differ also among ethno-linguistic groups, for example in Uganda, where in 1121 children >36 months of age canine bud extraction was more frequent among Nilotics (45%) than among Bantus (22%) ( Tirwomwe et al., 2013).

Infant oral mutilation is currently reported all over Uganda. In 40 years, IOM prevalence is now reported (Tiromwe et al., 2013) to have almost tripled to over 50% in the Northern district that was previously studied ( Pindborg, 1969). It has been reported in Tororo ( Kirunda,1999), regions of Eastern Uganda ( Mogensen, 2000) and in Mbarara, Western Uganda (Cobbs, 1972). Furthermore, the tribe of the Baganda that had no traditional practices interfering with their normal dentition in 1971, in more recent studies is implicated as having introduced IOM to the South Western regions ( Jamieson, 2006). In Bushenyi district in Western Uganda, a study showed that more than one in two of the households had a child under 5 years old who had had false teeth in the last 5 years as of 2007, with more than 80% of the respondents using traditional medicine alone or in combination with modern medicine to treat “false teeth disease'' ( Nuwaha et al.,2007).

A recent study done in Uganda found that 29.3% of the children under study had had this practice performed on them. This was highest among the Nilotics( 45.5%) and lowest among the Bantus( 22.3%). The mean number of affected teeth per child was 3.8 and 99.4% of these were canines. IOM was highest in Northern Uganda and lowest in the South.( Tirwomwe et al., 2013).

2.2 Socio-demographic factors influencing false teeth removal among children under five years a) Age of the child The children on whom this practice is done vary in age from a few weeks old( Wordley, 2003) up to 18 months ( Graham et al., 2000). The study indicates that only sick infants, mostly between 4 and 18 months of age undergo this practice of IOM. 9

The peak age is reported to be between four and 18 months of age. The deciduous tooth follicles most likely to be removed are reported to be the lower deciduous canines ( Matee et al., 1991) and the removal is almost always bilateral( Hassanali et al., 1995). In Rwanda, majority of the children that underwent the practice were below two years of age( WHO, 2012).

The age at which the canine mutilation is undertaken has been around 5 months of age of the child. This is also the time that the growing primary canine buds show clear bulges within the gum pads of the child. It is also the time that the growing child is establishing its humoral immunity, transitioning from the humoral immunity provided by the mother through the placenta at birth and so is susceptible to infections and fevers( Kemoli, 2015).

An Ethiopian-based study on the practice indicates that the removal of canine tooth bud was done mainly by traditional healers during 5-8 months of the infant's life.( Teshome et al.,2016).

In a study done in Kenya, study results show that the practice of IOM in children was frequently carried out at the age of 0-4 months [266 respondents](63.3%) while others did it at the age of 5-12 months, [149 respondents](35.5%)( Kipchumba,2012).

An early study done in a hospital in Northern Uganda found that the most common age for IOM was 5 months( Accorsi et al.,2000) which is similar to the average age of IOM in another study done recently in Rukungiri, South-west Uganda (Amyna et al.,2017). b) Sex of the child Welbury et al.(1993) reported no statistical difference between males and females in relation to extraction of deciduous canines. Of the children subjected to this procedure, female and male children were found to be in in equal proportions. More children underwent removal of the mandibular canine (23 per cent) than the maxillary (7 per cent) but there was little difference between the right or left arch.

In a Kenyan-based study on the practice, although males had higher prevalence (26.8%) compared to females(22.6%) there was no significant difference between gender (p=0.200).(Kipchumba,2012). 10

In another study done at Lacor Hospital in Gulu, Northern Uganda, similar percentages of males (48.8%) and females (51.2%) were subjected to infant oral mutilation( Accorsi et al.,2000). In a Ugandan-based study on IOM, there were an equal number of male and female infants who had had the false teeth extraction performed on them( Amyna et al., 2017). c) Age of the caretaker False teeth removal is generally performed by a local practitioner or an elderly woman, such as the child‟s grandmother, without prior administration of any anaesthetic and under very crude conditions(Accorsi et al., 2000).

A recent Ethiopian-based study on the practice also revealed that maternal age (AOR=0.378, 95%CI: 0.226-0.633) and educational level have (AOR=3.811, 95%CI: 2.323-6.246) a strong association with the attitude of mothers towards to the practice of canine tooth bud removal ( Teshome et al.,2016).

When the data for a study done in Uganda and South Africa were subjected to analysis for any association between the mothers‟ age and their child‟s malaise, the results did not yield a statistically significant figure (p=0.4354 – Kruskal-Wallis test). Of the mothers associating their eruption of the primary dentition to their child‟s malaise, 55.3% (n=42 out of 76) were aged ≤20years of age, 48.4% (n=60 out of 124) were between 21 and 25 years of age, 47.3% (n=43 out 91) were between 26 and 30 years of age and 48.8% (n=41 out 84) were 31 years of age and above(Kasangaki, 2004). However, with respect to age, a higher proportion of older adults were significantly less likely to link some childhood conditions such as tongue tie with nylon teeth myth than young adults (OR=0.56, CI=0.33-0.56, p< 0.05)( Kahabuka et al.,2015). d) Sex of the caretaker In a recent study done in Tanzania, males were the majority of those who linked diarrhoea, fevers and difficulty in suckling to false teeth and therefore were in support of the practice( Kahabuka et al.,2015). However, the same sources reveal that there are no studies reporting variations of “nylon teeth” myth by age, sex, educational and occupational characteristics which may be useful factors in planning intervention.

In relation to sex, proportionately less females were statistically significantly more likely to link stunting (OR=0.57, CI= 0.34-0.98, p< 0.05) and excessive crying (OR 0.431, CI=0.24- 0.78, p< 0.01) with nylon teeth myth than males( Kahabuka et al.,2015).

In a study done in Kenya, most of the respondents of the children with oral mutilation were females, but preliminary analysis of the sex of the respondents however showed that there was no statistical differences in the oral mutilation statures among the children accompanied by the male respondents and those by the female respondents (Mule,2010).

Another study done on the practice of Infant oral mutilation revealed that the majority of the care-takers of the children in the study area were mainly females[mothers] (92.4 %), very few males[fathers](2%) and the remaining 6.0% comprised of both sexes such as relatives like brothers, sisters, aunts and grandmother( Kipchumba, 2012). e) Marital status of the caretaker In a study on infant oral mutilation in Kenya by Mule(2010), the majority of the respondents were married (88.7%), the rest were single except one who was widowed (11.1% were single and 1 was widowed). There was however no statistical differences among the children who had undergone oral mutilation practice in respect to the marital status of the respondents (p=0.61), so this may be an indication that the marital status may not have been a factor in determining the outcome of oral mutilation among the children.

In a similar study on this practice among the Maasai of Kenya, it was discovered that the marital status of the children's caretakers, whether single, married, divorced, in a cohabiting or polygamous marriage had no significance on whether or not the practice was carried out on a child( Wanzala et al.,2008).

Study results also show that those who were in monogamous marriages were less likely to allow their children undergo the practice of infant oral mutilation compared to those in polygamous marriage . Besides, there was significant difference (p=0.00) in the prevalence of the practice among those who were married (24.6%) compared to those who were not married (22.7%) (Kipchumba,2012).

12 f) Level of education of the caretaker When the data for a study done in Uganda and South Africa were subjected to analysis for any association between the mothers‟ level of education and the mothers‟ associated malaise to the eruption of their child‟s primary dentition,the results did not yield a statistically significant figure (p=0.1103 – Kruskal-Wallis test). One hundred and eighty six mothers attributed their child‟s malaise to eruption of the child‟s primary dentition. Of these 53.8%, 50.4% and 38.0% had primary/no education, secondary education and tertiary education respectively( Kasangaki, 2004).

In a recent study done among Ethiopian mothers,educational level was discovered to have a strong association (AOR=3.811, 95%CI: 2.323-6.246)with the attitude of mothers towards to the practice of infant oral mutilation( Teshome et al.,2016).

Another study done in Kenya indicated that the respondents with the lower level of education (primary school or no-education) were on the analysis shown to have children who were more likely to have undergone the oral mutilation practice than those with a higher level of education (p=0.02). This likely indicated that higher level of education had a negative effect to the practice of oral mutilation hence a protective factor in the practice of Traditional oral mutilation.( Mule,2010).

Contrary to the above, some study results of a study done in Kenya showed that those who had primary, secondary and college education had a higher prevalence of infant oral mutilation done compared to those who had no education. This difference was however was not significant (p=0.115).( Kipchumba, 2012). This is further supported by a study done recently in Tanzania, which revealed that the more educated respondents were more likely to falsely link long-standing cough and stunting with the „nylon teeth‟ myth( Kahabuka et al.,2015).

In other studies done in a rural setting of Western Uganda, low level of education was found to be associated with increased removal of these false teeth ( Stephen, 2006). Another study done in a rural Ugandan setting revealed that to treat false teeth, more than 80% of the respondents used traditional medicine alone or in combination with modern medicine ,and that the association of occurrence of false teeth to teething was favoured by

13 low education status and not living in a house with cemented floor or having a brick wall ( Nuwaha et al.,2007). g)Employment status of the caretaker Rasmussen et al.(1992) reported that 22 per cent of the 398 urban children under study in Sudan had undergone canine follicle extirpation/ infant oral mutilation and the prevalence was higher in lower socio-economic groups.

Agbor and Naidoo (2011) have noted that socio-cultural and economic factors affect the oral health care seeking behaviour of patients who visit traditional healers. A cross sectional study carried out in Cameroon, reported that most patients visited the traditional healers for their oral health needs because of the low cost (69%)( Agbor and Naidoo, 2011).

The myth of false teeth being linked to childhood illnesses was also more common among the non-medics probably because hospital workers are informed on the causes and treatment of diseases using modern medicines thus unlikely to believe in traditional medicine to be the best cure of the diseases associated with the myth of false teeth. A higher proportion of medics were statistically significantly less likely to link excessive crying (OR=0.37, CI=0.15- 0.96, p< 0.05) and difficult sucking (OR=0.29, CI=0.11-0.81, p< 0.05) with nylon teeth myth than non-medics( Kahabuka et al.,2015).

The prevalence of Infant oral mutilation was also significantly different (p=0.00) between respondents whose source of income was livestock (24.5%), business (25.0%), farming and formal employment(9.1%).( Kipchumba, 2012).

The myth that favours the practice of IOM has been reported to be more common among rural, less educated and those with low socioeconomic status than their counterparts of a higher socioeconomic status(Barzangi et al., 2014).

Studies done in Uganda have revealed that IOM practice has in particular been embraced by families of lower income than in those of a higher income status ( Nuwaha et al.,2007).

14 h) Religion of the caretaker According to Pradella et al.(2013), infant oral mutilation is a practice performed by a variety of traditionalists(village healers) and it is a custom that passes down between communities and tribes. The World Health Organization (WHO) defines traditional medicine as “health practices, approaches, knowledge, and beliefs incorporating plant, animal and mineral based medicines, spiritual therapies, manual techniques and exercises, applied singular or in combination, to treat, diagnose and prevent illnesses or maintain well-being”( WHO,2003).

As with the religious affiliation in a study on infant oral mutilation in Kenya,it was however not possible to correlate the respondents‟ by their ethnic belonging owing to the sampling technique, as no equal numbers from each religious sub group and ethnicity could be obtained in significant proportions. ( Mule,2010).

A recent study on the practice in Ethiopia revealed that it was done mainly by traditional healers( Teshome et al.,2016). According to Dentaid(2009), in regard to IOM, traditional healers are the most trusted practitioners of the removal of false teeth in many societies.

Western religions, education, urbanisation and globalisation in Africa have not affected the use of traditional medicine( Naidoo and Agbor, 2016). This implies that the religion of the care-taker does not have much influence on whether or not they carry out the practice of IOM. With urbanisation, the use of traditional medicine has decreased, but in times of stress, even the most westernized African people seek consultations with tradionalists (Sheriffs, 1996; Chitindingu, George and Gow, 2014). This could be due to the fact that the African traditional healer shares the patient‟s language/dialect, idioms and other communication signals, both verbal and nonverbal, and this fosters the healer-client relationship. i) Relationship of the primary caretaker to the child In a recent study done on the practice of IOM in Ethiopia,one-third of the participants, who were all mothers, were found having the intention to continue the practice in the future( Teshome et al.,2016).

In a study done in Kenya on Infant oral mutilation, care-takers of the children in the study area were mainly mothers (92.4 %), very few fathers (2%) and 6.0% relatives such as brothers, sisters, aunts and grandmother( Kipchumba, 2012). 15

Studies done in Uganda have revealed that IOM has been found to exist more among children who were under the care of a caretaker than a parent ( Tirwomwe et al.,2013).

2.3 Knowledge factors influencing false teeth removal among children under five years a) Awareness about Infant Oral Mutilation Infant oral mutilation is practised mostly on children for perceived health-related reasons( Johnston et al., 2005). The canine tooth is perceived to be a cause of diarrhoea, vomiting and fever in infants( Accorsi et al.,2003) in countries such as Ethiopia, Uganda, Tanzania, Somalia and Sudan. Researchers Kikwilu and Hiza, who interviewed village health workers in Tanzania, state that traditional healers associated infectious diseases, fevers and diarrhoea in infants with the gingival swellings overlying developing teeth ( Nuwaha et al.,2007).

Studies reveal that infant oral mutilation is widely perceived to be useful to prevent or treat diarrhoea, fever and vomiting separately or in combinations( Accorsi et al., 2003), general malaise or ill-health,itching gums, crying with an unknown cause,failure to suckle and even death (Nuwaha et al.,2007).

Although these procedures may endanger the lives of infants, they are widely accepted, carried out and claimed to be a „causative cure‟ of various diseases. Indeed, improvement in the primary disease is reported by up to two-thirds of parents whose children underwent germectomy( Kutalek et al.,2013). A very recent study done in Tanzania revealed that a sizable proportion of the respondents who believed in the myth of false teeth considered traditional medicines the best treatment for the symptoms related to the myth( Mugonzibwa et al.,2018).

In Northern Uganda where a similar study was done, the belief that unerupted primary canine teeth are the source of illness and death probably originates from the high incidence of malaria and other infectious diseases among teething infants, which is in part due to the poor nutritional and sanitary conditions in which the children are raised. This belief also leads to IOM being at times performed before any evidence of gingival swelling, apparently to prevent the problem from ever occurring or to treat febrile illness perceived to be caused by canines, prior to gingival swelling( Accorsi et al., 2000).

Swelling of the gums during dentition is often considered indicative of „parent‟ helminths or maggots( Jamieson, 2006) residing in the gingiva and responsible for pathogenic agents in the intestine or elsewhere. Buds of the deciduous teeth may be falsely interpreted as parasitic and fever-causing „mouth worms‟ or weevils ( Longhurst, 2010; Girgis et al.,2016).

In a study done on the practice,almost everybody interviewed had ever heard about false teeth: health workers (98.5%) and elders (97.3%). Of the health workers, 74.4% had ever had at least a case of false teeth in their practice. Almost all the parents (97.2%) claimed to have noticed improvement in the health status of the child after treatment by the traditional healer. This is higher than the 65.0% previously reported (Welbury et al., 1993) among Sudanese mothers( Tirwomwe et al., 2014). b) Sources of information about Infant Oral Mutilation The procedure is usually carried out by a traditional healer who makes a living from this practice ( Graham et al., 2000) although in some cultures it may be performed by a respected older woman, family member, priest or teacher ( Wordley, 2003), using instruments that are usually not sterile, risking infection( Graham et al., 2000).

A study in Tanzania by Graham indicated that parents often sought medical attention from traditional healers after one or more visits to a government health facility had failed to provide relief for their child.( Graham et al., 2000).

Some authors have speculated that this is a money-raising exercise carried out by charlatans /frauds (Mosha,1983) and therefore any attempt to eliminate misinformation and improve knowledge must begin by establishing rapport with traditional populations, disseminating information in the educational and health systems, and assisting the development of new knowledge and skills. The inherent danger in the persistence of falsely linking signs and symptoms of some childhood diseases with the „nylon teeth‟ myth is detrimental to children‟s general health due to connected delayed seeking for medical attention( Kahabuka et al.,2015).

In Uganda, in the National Oral Health Plan, when participants were asked about false teeth, more than 50% stated that the best treatment is by a traditional healer(Ministry of Health- Uganda, 1989). In a later study conducted in a Kampala clinic in 2007, guardians reported traditional healers were responsible for 55% of IOM observed .In a study of traditional 17 healers, 40% had no formal education, whereas 46.6% had only primary school education( Anokbonggo et al.,1990) and yet traditional healers continue to take up their role as a cultural heritage. Ellis and Arubaku(2005), state that families initially consult a traditional healer before hospital, and even while at hospital,they may still continue the dialogue.

However, in a study on infant oral mutilation in Kenya, the main sources of information regarding traditional oral mutilation were mainly from friends and relatives (80%), and this may probably be an indication that traditional beliefs and practices such as infant oral mutilation practice, are mainly passed down through the friends and relatives (Mule,2010).

Early literature reports the first mention of infant oral mutilation in medical literature in the 1960's in Northern Uganda ( Pindborg,1969) and the practice is said to have spread by contact with the army throughout the country ( Mogensen, 2000). In a study done in Bushenyi in Western Uganda, the study authors stated that more than 80% of the respondents sought either a traditional herbalist alone or in combination with a modern medical worker to treat the ''false teeth disease'' ( Nuwaha et al.,2007). In Uganda, traditional healers are often the first point of contact for those seeking health care provision because they share the same beliefs, culture, and values ( Nuwaha et al.,2007).

The traditional healers within the tribes that practice the IOM are the ones who are responsible for advising the parents on this and also in the removal of the “worms.” These traditional healers have no background medical training, but within the communities in which they live, they are regarded as the most competent advisers on health matters and the ones to provide the best medical care for the children in the community. They are, therefore, respected by the community and provide various cures to many of the diseases found within the community they serve(Kemoli, 2015).

In another study carried out in Uganda and South Africa, a large proportion of the respondents attested to having received information about teething from relatives, friends, neighbours or from elders. Only 22 (5.9%) out of the 375 respondents claimed to have received information about teething from a health worker. None of the respondents claimed to have consulted a dentist( Kasangaki, 2004).

18 c) Reasons for Infant Oral Mutilation Reports in the literature describe that the reason why this practice is done is the belief that these false teeth are responsible for a number of infant illnesses, including fever, diarrhoea, and malnutrition, among others, hence necessitating their removal, usually by traditional herbalists who use unsterile instruments that include bicycle spokes, knitting needles, scissors, broken glass, or fingernails ( Noman et al., 2015 and Jamieson, 2006).

According to a study done on the practice in Tanzania, it was indicated that parents often sought medical attention from traditional healers after one or more visits to a government health facility had failed to provide relief for their child(Graham et al.,2000). In addition to the pseudotherapeutic aspects, monetary incentives have been reported: for local healers, for example in Tanzania ( Mosha,1983) and for the child‟s parents, who sold extracted dental materials as medicine for other children( Kemoli, 2015).

Many parents and extended caregivers believe that high fevers and diarrhoea play a role in the emergence of the false tooth ( Ahmed et al.,1994; Accorsi et al.,2003 and Nuwaha et al.,2007). In an study done in Ethiopia, diarrhoea was the leading (68.72%) symptom observed that pressures parents for canine tooth bud removal and the majority of the participants consider the diarrhea is due to maggots inside the tooth bud (55.07%)( Teshome et al., 2016). Studies done in Uganda indicate the practice arises from the belief that these “killer” canines cause fever, diarrhoea, and any other infant illness, thus necessitating their removal, usually by traditional herbalists using unclean instruments and fingernails( Accorsi et al.,2003).

In the Ugandan district of Bushenyi, 67% of surveyed families who had a child with IOM performed believed the cause of the false tooth was prolonged, excessive diarrhoea ( Nuwaha et al.,2007).

Other sources indicate that infant oral mutilation is a widespread practice performed by traditional healers, herbalists, priests and midwives, involving germectomy of deciduous tooth buds, mostly but not exclusively of the lower canines, for curative purposes, typically against vomiting, diarrhoea and fever ( Kutalek et al.,2013).

It is believed that by extracting the primary canines in children, the children will be rid of all childhood illness and fevers. These illnesses include diarrhea and fevers in the child. The myths behind IOM lies in the fact that the people in these tribes believe that the swelling in the gum pads of the child, corresponding to the developing primary canines, is growing “worms” or “maggots,” and that this should be removed to heal or prevent the child from having diarrhea and fevers. To them, if the removal of the canine buds is not done, the child will suffer from this illness caused by the “worms” and will lead to premature deaths of the children( Kemoli, 2015).

CHAPTER THREE METHODOLOGY

3.0 Introduction This chapter presents the methodology that the researcher employed to conduct the study on the prevalence and factors associated with false teeth removal among children under five years in Bungatira Subcounty, Gulu District. Sampling procedures, sample size, ethical considerations, data collection, data processing, presentation and analysis, as well as the limitations of the study, are all included in this chapter.

3.1 Study design The researcher used a descriptive cross-sectional study using quantitative methods to assess the prevalence and factors associated with false teeth removal among children under five years in Bungatira Subcounty, Gulu District. The study was cross-sectional since data was collected at a specific point in time.

3.2. Sources of data Primary data was obtained from the caretakers of children under five years in Bungatira Sub- county. Secondary data was then obtained from catalogues, internet sources, published researches, and text books.

3.3 Study setting The study area was Bungatira, which is one of the 16 subcounties in Gulu district, a town located 340km north of Uganda's capital city, Kampala. Bungatira is a municipality in Aswa County and has 7 parishes and 43 villages. Bungatira as a Subcounty has 4 public health facilities, namely;- Copee Health Centre II, Lukodi Health Centre II, Cet Kana Health Centre II and Mon Roc Health Centre II. In the Acholi region, of which Gulu is part, the population of children under 5 years of age is 280,860, thus making up about 20% of the Acholi population of 1,454,300( UNICEF,2011). The respondents were selected from the immunisation clinics( Young Child Clinics) at the different health facilities found in Bungatira Sub-county, as listed above.

3.4 Study Population This included caretakers of children under five years among the residents of Bungatira Subcounty in Gulu District. These were people who at the time of data collection had consented to participate in the study.

3.4.1 Sample size determination This was determined using Kish Leshlie's formula. N= { (Z2PQ)÷e2} Where; N = Sample size z = 1.96 , a score corresponding to 95% level of confidence p = 50% (estimated prevalence) Q = 100-p =50% e = 5% (accepted standard error) Therefore, N = (1.96×1.96) (0.5) (0.5)/0.0025 N = 0.9604/0.0025 N = 384 children

3.4.2 Sampling Methods And Procedures Convenience sampling, a type of non-probability sampling technique was used. Non- probability sampling focuses on sampling techniques that are based on the judgement of the researcher. A convenience sample is simply one where the units that are selected for inclusion in the sample are the easiest to access. Since the aim of convenience sampling is easy access, the researcher simply chose to, on different days, -to position herself at the Young Child Clinics of the different public health facilities in Bungatira Subcounty where it was easy to invite the many caretakers that had brought their children under five for immunisation to take part in the research. This was done at the different public health facilities in Bungatira Subcounty until the desired sample size was reached.

3.4.3 Inclusion Criteria Children under 5 years (<59 months), living in Bungatira Subcounty at the time of data collection. Caretakers of children under 5years (59 months), who had consented to participate in the study.

3.4.4 Exclusion Criteria All sick or ill children who had been brought to the health facility for medical attention. All children whose caretakers refused to consent to having their children participate in the study.

3.5 Definitions of Variables 3.5.1 Dependent Variable The prevalence of false teeth removal among children under five years in Bungatira Sub- county, Gulu District.

3.5.2 Independent Variables The independent variables in this study are;- 1. Sociodemographic factors such as age and gender of the child, plus the age, gender, marital status, level of education, employment status, religion and relationship of the caretaker to the child. 2. Knowledge factors such as awareness of the caretakers about false teeth removal, sources of information about false teeth removal and the reasons caretakers give for carrying out false teeth removal of children under five years of age.

3.6 Research Instruments The required data for the research was collected during the day especially after the caretakers had finished having their children under five receive their immunisation as scheduled for the day. A structured interviewer-administered questionnaire with closed ended questions was used to collect the required information from the children's caretakers. This questionnaire consisted of three sections, namely;-A,B and C. Section A captured the sociodemographic characteristics of the child and the caretaker, while Section B captured data about the

23 prevalence of Infant Oral Mutilation, and then Section C the knowledge factors influencing the practice. The questionnaire was mainly in English since the researcher and her two assistants were able to verbally translate the questions to Luo for the respondents in case any language barrier issues arose while using the English language. Structured questionnaires were used because the format is familiar to most respondents, they are straight forward to analyze, simple to administer and can be filled in at the respondents‟ convenient time. The purpose of the study was well explained to the respondents so that they could give accurate information during the interview.

3.7 Data Collection Procedures The researcher first obtained the permission to go to the study area, and then proceeded to meet the participants and obtained consent from the selected participants. After that, she administered the questionnaires to those who understood and as for those who had not have understood, it was clearly explained to them. Two research assistants were also hired and trained to help in data collection, translation of tools and identifying information from respondents to ensure confidentiality. The questionnaire was first pretested on a small sample size outside the study area but with a similar background. It was later on refined by the researcher with the help of the supervisor for validity and reliability. The researcher and her two assistants ensured that the questionnaires were fully completed, after which the complete questionnaires were locked and made only accessible to the researcher.

3.7.1 Data management The data collected on a daily basis was checked for completeness, consistency and accuracy. It was then edited and coded. Data was stored by the researcher after collection at her premises to control leakage of information.

3.7.2 Data analysis The researcher first tallied the data and the result was converted in percentage. Finally, the data was presented in form of bar graphs, tables and pie charts. The data was analyzed manually by physical counting and computer packages were used to interpret the meaning using descriptive statistics and bivariate analyses of the SPSS Computer package. 24

3.8 Ethical considerations  The researcher obtained an introductory letter from the University and took it to the study area to seek for permission from the local authorities.  The respondents were assured that their names would not be included in the study to ensure confidentiality and written informed consent was obtained from them before administering the tool of data collection.  All the human right issues were observed during conducting of the research for the respondents.  The researcher ensured that all filled research questions were kept under lock and only accessible to her.

3.9 Limitations of the study The researcher was faced with the following challenges during the study:-  Inadequate funds to meet the cost of the study. The researcher overcame this by lobbying for financial support from family members, relatives and friends.  Inadequate sources of literature since books were few in the University library. The researcher overcame this by visiting other nearby libraries, for example, the district library and the internet.  Limited time since there were many other school programmes that the researcher had to attend to. The researcher overcame this by creating extra time outside the school programme such as lecture hours and time allocated for practicum(clinical placement), and also by waiting to complete her end of semester examinations before embarking on data collection.

3.10 Dissemination of results The researcher‟s findings were forwarded to the following;-  The Uganda Nurses and Midwives Examination Board for the award of a Bachelor‟s degree in Nursing Science.  International Health Sciences University Library  Chairperson Local Council IV, Bungatira Subcounty  Personal copy

CHAPTER FOUR: RESULTS PRESENTATION

4.0 Introduction This chapter contains the results of the study. This study investigated the prevalence and factors associated with false teeth removal among children under five years in Bungatira Sub- county, Gulu district. Despite having a calculated sample size of 384, the researcher was only able to obtain accurate data from 150 respondents because of time, financial and human resource limitations. However, the data obtained from the above 150 respondents were diligently collected from caretakers coming from all the 4 study areas of Lukodi, Mon Roc, Cet Kana and Copee, that is, 100% geographical coverage of the study area was met. The study findings are presented in form of tables and figures showing frequencies and percentages. The chapter was organized basing on the study objectives which were; 1. To determine the prevalence of false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District. 2. To assess the sociodemographic factors influencing false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District. 3. To determine the knowledge factors influencing false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District.

Table 1: Distribution of socio-demographic characteristics of the caretakers of children under five years (n=150) VARIABLES CATEGORY FREQUENCY(N=15 PERCENTAGE 0) (%) Age( in years) 15-24 32 21.3 25-34 65 43.3 35-44 26 17.3 45-54 7 4.7 55-64 8 5.3 over 64 12 8.0 Gender Male 45 30.0 Female 105 70.0 Marital status Single 27 18.0 Married 104 69.3 Divorced/separated 9 6.0 Widow/widower 10 6.7 Highest level of No formal education 35 23.3 education Primary education 68 45.3 Secondary education 31 20.7 Tertiary education 16 10.7 Occupation/Emp Housewife 29 19.3 loyment Businessman/Businesswoman 25 16.7 Farmer 72 48.0 Government employee 2 1.3 Private employee 11 7.3 Medical personnel 11 7.3 Religion Catholic 82 54.7 practiced Anglican/Protestant 36 24.0 Born again/Pentecostal 15 10.0 Seventh Day Adventist 4 2.7 Muslim 5 3.3 Traditionalist 8 5.3 Relationship to Biological father/mother 103 68.7 the child grandparent 23 15.3 sibling( brother/sister) 10 6.7 aunt/uncle 10 6.7 housemaid/houseboy 4 2.7

Table 1 above shows the socio-demographic characteristics of caretakers involved in the study. Of the 150 respondents, most (43.3%) ranged between 25-34 years, 21.3% between 15- 24 years, 17.3% between 35-44 years, 8.0% above 64 years, 5.3% between 55-64 years, and the least percentage(4.7%) ranged between 45-54 years. The majority (70%) were females (n=105) while the rest (30%) were males(n=45). Regarding their marital status, the majority( 69.3%) were married, 18.0% were single, 6.7% were either widows or widowers, and the minority(6.0%) were either divorced or separated.

Concerning the highest level of education attained, majority(45.3%) attained up to primary level, followed by 23.3% who attained no formal education, 20.7% who attained up to secondary level while only a few(10.7%) attained up to tertiary level of education. The majority of the respondents(48.0%) were farmers, 19.3% were housewives, 16.7% were either businessmen or businesswomen, 7.3% were private employees, 7.3% were medical personnel and the least percentage(1.3%) were government employees.

In line with the religion they practiced, majority (54.7%) of the caretakers were Catholics, followed by Anglicans(24.0%), and the rest were Born-Again/Pentecostal Christians( 10.0%), traditionalists(5.3%), Muslims(3.3%), with the least being Seventh Day Adventists(2.7%). The majority (68.7%) of the caretakers were either biological fathers or mothers to the children, followed by grandparents(15.3%), aunts/uncles(6.7%), siblings( 6.7%) and the rest being housemaids/houseboys(2.7%) to the children.

Table 2: Distribution of socio-demographic characteristics of the children under five years (n=150) Variables Category Frequency Percentage (%) (N=150) Age of the child in 0-11 38 25.3 months 12-23 48 32.0 24-35 21 14.0 36-47 8 5.3 48-59 35 23.3 Sex of the child Male 72 48.0 Female 78 52.0 Of the 150 children whose care-takers participated in the study, the majority(52.0%) were female and the rest(48.0%) were male. Of these, the majority(32.0%) ranged between 12-23 months, followed by 25.3% between 0-11 months, 23.3% between 48-59 months, 14.0% between 24-35 months and the rest(5.3%) between 36-47 months.

Figure 2: prevalence of false teeth removal among children under five years in bungatira sub-county

Of the 150 respondents, the majority(78%, N=117) had removed their children‟s false teeth while the minority(22%, N=33) had not removed their children‟s false teeth.

Table 3: Bivariate Analysis Of False Teeth Removal Among Children Under Five Years In Bungatira Sub-County VARIABLES CATEGORY YES NO X2 P-VALUE (FALSE TEETH (FALSE TEETH WERE WERE REMOVED) NOT REMOVED) Is false teeth removal Yes 100 21 practiced in this area? 7.868 0.005 No 17 12 Why were this child‟s The child had high fevers. 57 18 false teeth removed? The child had diarrhoea.. The child had high fever 1 3 and diarrhoea. The child had high fever, 52 11 7.900 0.048 diarrhoea and vomiting. 7 1 Who decided that this Biological father 5 4 child's false teeth should Biological mother 13 9 be removed? Both biological parents 23 4 9.177 0.027 Grandparent 76 16 At what age(in months) 0-2 8 0 was this child when 3-5 74 21 his/her false teeth were 6-8 20 9 7.431 0.283 removed? 9-11 9 1 12-14 1 1 15-17 1 1 18-20 4 0 Who removed the false Parent/caretaker of the child 19 7 teeth of this child? Local healer/traditional birth attendant Health worker in a health 96 26 1.986 0.159 facility 2 0 What was used to Local herbs 19 9 remove the false teeth of Metallic wires 41 8 this child? Needles 14 0 2.666 0.615 Razorblade 16 2 Any other 27 14 What happened to the The child got better. 95 26 child after false teeth The child bled a lot. 14 0 removal? The child was admitted to 5 4 the hospital. 26.173 0.000 Any other? 3 3 If the child did not Yes 13 13 improve even after, did you give the child any ……… ………… medication after false No 0 0 ….. teeth removal? If the answer to the Anti-diarrhoeal drugs like 0 1 above is yes, what metronidazole/flagyl 1 0 medication was given to Anti-malarial drugs like this child? Coartem 3 0 Anti-pyretics like panadol Any other drug given? 2 0 I don't remember the drug. 6.169 0.520 Traditional herbs/medicine. 1 0 Any other local remedy? 4 1

2 0 Did the child's condition Yes 11 2 improve after the above No 2 0 0.355 0.551 remedy was given?

Table 3 above shows the bivariate analysis of the prevalence of false teeth removal among children under five years in Bungatira Sub-county. 80.7%(N=121) of the respondents said false teeth removal was practiced in the area, while 19.3% said it was not. As their reasons for false teeth removal, the majority(48.7%,N=57) mentioned high fevers, followed by 44.4%(N=52) who mentioned fever and diarrhoea, 6%(N=7) who mentioned fever,diarrhoea and vomiting, while the remaining 0.9%(N=1) mentioned diarrhoea. In 65%(N=76) of the respondents, the grandparent was the key decision-maker for a child‟s false teeth to be removed, followed by 19.7%(N=23) who had both biological parents, 11.1%(N=13) biological mother and 4.3%(N=5) biological father as the one deciding that the child‟s false teeth should be removed.

The majority(63.2%, N=74) of the children whose false teeth were removed were between 3- 5 months, followed by 17.1%(N=20) between 6-8 months, 7.7%(N=9) between 9-11 months, 6.8%(N=8) between 0-2 months, 3.4%(N=4) between 18-20 months and 0.9%(N=1) each between 12-14 months and 15-17 months. The local healer/traditional birth attendant was the main(82.1%, N=96) performer of false teeth removal, followed by the child‟s parent/caretaker( 16.2%, N=19) and the minority(1.7%, N=2) were health workers in a health facility.

The commonest method of false teeth removal was by use of metallic wires(35%, N=41), followed by any other(23.1%, N=27)[which included the use of bicycle spokes, spearhead, sharpened piece of wood, long fingernails and rubbing aspirin onto the gum for at least 2 days], the use of local herbs like black-jack leaves(16.2%,N=19), the use of a razorblade(13.7%,N=16) and the remaining 12%(N=14) used needles.

Majority(88.9%, N=104) of the respondents reported that the child got better after false teeth removal, 6%(N=7) had other incidences like refusing to breastfeed/drink, becoming more sick and registering a slow progress in recovery from the chief presenting complaints. Still, 3.4%(N=4) were admitted to the hospital, while the remaining 1.7%(N=2) bled a lot after their false teeth had been removed.

Of the 117 children whose false teeth were removed, 11.1%(N=13) did not improve after false teeth removal. Of these, 100%(N=13) of them were given medication after false teeth removal.

30.8%(N=4) were given traditional herbs/medicine, 23.1%(N=3) were given anti-pyretics like panadol, 15.4%(N=2) were given any other drugs like chloramphenicol syrup, quinine and aspirin, 15.4%(N=2) were given any other local remedy(like honey and/or sugar crystals being rubbed on the child‟s gums), 7.7%(N=1) were given anti-malarial drugs like Coartem, 7.7%(N=1) could not remember the drug, and none was given anti-diarrhoeal drugs like metronidazole/flagyl. 84.6%(N=11) of these children who were given medication after false teeth removal registered improvement, while 15.4%(N=2) had their condition worsen until they died.

Table 4: Bivariate analysis of the socio-demographic factors of the child associated with prevalence of false teeth removal among children under five years. VARIABLES CATEGORY YES NO X2 P-VALUE (FALSE (FALSE TEETH TEETH NOT REMOVED) REMOVED) AGE OF THE 0-2 8 0 CHILD IN 3-5 74 21 MONTHS 6-8 20 9 9-11 9 1 7.431 0.283 12-14 1 1 15-17 1 1 18-20 4 0 SEX OF THE MALE 54 18 CHILD FEMALE 63 15 0.726 0.394

Of the 117 children whose false teeth were removed, the majority(63.2%, N=74) were between 3-5 months, followed by 17.1%(N= 20) between 6-8 months, 7.7%(N=9) between 9-11 months, 6.8%(N=8) between 0-2 months, 3.4%(N= 4) between 18-20 months, and the least number of 0.9%(N=1) each between 12-14 months and 15-17 months. Of these, the majority 53.8% (N=63) were female and the rest 46.2%(N=54) were male.

Table 5: Bivariate analysis of the socio-demographic factors of the caretaker associated with prevalence of false teeth removal among children under five years. VARIAB CATEGORY YES NO X2 P- LES (FALSE (FALSE VALUE TEETH TEETH NOT REMOVED) REMOVED) Age 15-24 31 1 21.140 0.001 25-34 47 18 35-44 14 12 45-54 7 0 55-64 8 0 over 64 10 2 Gender Male 39 6 2.814 0.093 Female 78 27 Marital Single 16 11 8.373 0.039 status Married 86 18 Divorced/separated 6 3 Widow/widower 9 1 Highest No formal education 26 9 6.807 0.078 level of Primary education 58 10 education Secondary education 24 7 Tertiary education 9 7 Occupatio Housewife 21 8 28.217 0.000 n/Employ Businessman/Businesswoman 13 12 ment Farmer 65 7 Government employee 0 2 Private employee 7 4 Medical personnel 11 0

Religion Catholic 69 13 16.096 0.007 practiced Anglican/Protestant 23 13 Born again/Pentecostal 8 7 Seventh-Day Adventist 4 0 Muslim 5 0 Traditionalist 8 0 Relationsh Biological father/mother 80 23 16.316 0.003 ip to the Grandparent 21 2 child Sibling( brother/sister) 5 5 Aunt/uncle 10 0 Housemaid/houseboy 1 3 Source: Primary Data, 2018

Of the 117 care-takers whose children‟s false teeth had been removed, the majority 40.2%(N=47) ranged between 25-34 years, followed by 26.5%(N= 31) between 15-24 years, 12%(N=14) between 35-44 years, 8.5%(N=10) over 64 years, 6.8%(N= 8) between 55-64 years and the least number 6%(N=7) between 45-54years. Of these, the majority

(66.7%,N=78) were females and the minority(33.3%, N=39) were males. The majority(73.5%,N=86) were married, followed by 13.7%(N=16) who were single, 7.7%(N=9) who were widows/widowers and the least number 5.1%(N=6) were divorced/separated.

In regards to the highest level of education attained, the majority 49.6%(N=58) had had up to primary education, followed by 22.2%(N=26) who had no formal education, 20.5%(N=24) who had had up to secondary education, and the least number 7.7%(N=9) who had had up to tertiary education. The majority(55.6%, N=65) were farmers, followed by 17.9%(N=21) who were housewives, 11.1%(N=13) were businessmen/women, 9.4%(N=11) were medical personnel, 6%(N=7) were private employees and none were government employees. The majority(59%,N=69) of the 117 care-takers whose children‟s false teeth had been removed were Catholic, followed by 19.7%(N=23) Anglican/Protestant, 6.8%(N=8) were Born again/Pentecostal, 6.8%(N= 8) were Traditionalist, 4.3%(N=5) were Muslim and the least number 3.4%(N=4) were Seventh Day Adventists. Of these respondents, the majority (68.4%, N=80) were either a biological father/mother to the child, 17.9%(N= 21) were grandparents, 8.5%(N=10) were either an aunt/uncle, 4.3%(N=5) were siblings and only 0.9%(N=1) was either a housemaid/houseboy.

Table 6: Bivariate analysis of the knowledge factors associated with the prevalence of false teeth removal among children under five years (n=150).

KNOWLEDGE VARIABLE RESPONSE YES NO X2 P-VALUE (FALSE TEETH (FALSE TEETH REMOVED) NOT REMOVED) Have you ever heard about Yes 116 32 0.125 0.724 false teeth? No 1 1

If yes, what do you think false They are maggots. 37 7 teeth are? They are normal tooth buds. 14 10 They are harmful teeth. 59 16 Any other opinion. 7 0 9.865 0.020 What do you think causes Diarrhoea 11 3 false teeth? High fevers 28 8 Vomiting 1 1 Evil spirits such as witchcraft by the co-wife or enemies 1 0 53.234 0.000 Cultural/ancestral roots 39 14 Any other reasons 37 7 What is done when a child Taken to a health facility for removal. 3 2 develops false teeth in this Taken to the local healer for removal. 70 20 8.132 0.043 community? Taken to the grandparents for removal. 42 11 Any other action taken? 2 0 Why should false teeth be False teeth cause diarrhoea in children. 50 17 removed when a child False teeth cause vomiting in children. 4 1 develops them? False teeth cause both diarrhoea and vomiting 1 0 in children. 62 15 24.964 0.000 Any other reasons for removal? What happens when a child's The child will become very sick. 25 10 false teeth are not removed? The child will not grow. 3 1 The child will die. 71 21 Any other? 18 1 13.808 0.003 Modern conventional True 103 22 medicine cannot cure or treat False 14 11 14.034 0.000 a child with false teeth.

Modern medicine health True 33 12 workers know nothing about 0.847 0.358 false teeth. False 84 21 False teeth can only be True 104 25 recognised and managed by village elders and traditional 10.340 0.001 healers in the community. False 13 8 False teeth can best be treated Modern medicine 7 9 by? Traditional medicine 110 24 17.840 0.000 I have actually witnessed a I agree 38 10 child die because their false 7.292 0.007 teeth had not been removed. I disagree 79 23 I have witnessed a child with I agree 23 15 false teeth improve after being managed using modern 6.692 0.010 conventional medicine only. I disagree 94 18 From whom did you first hear My parents 69 14 about false teeth removal? My friends 30 6 Elders in the community 12 12 Health-workers 6 1 13.395 0.004 Who do caretakers usually Health-workers 3 0 consult when they suspect their Their parents 34 11 child has developed false teeth? Elders in the community 71 21 4.887 0.180 Traditional healers 9 1 From which source do you get Relatives 76 20 the most information regarding Health workers at the health facility 1 0 false teeth removal? Media(radio, television, newspapers) 0 2 17.888 0.000 Any other source? 40 11

Table 6 above shows a bivariate analysis of the knowledge factors associated38 with the prevalence of false teeth removal among children under five years.

Of the 150 respondents, the majority( 98.7%,N=148) agreed that they had ever heard about false teeth removal, while only 1.3%(N=2) said they had never heard about it. Of all the 117 respondents whose children‟s false teeth had been removed, the majority (99.1%, N=116) had ever heard about false teeth, while only 0.9%(N=1) had never heard about it.

50%(N=75) of the respondents thought false teeth are harmful teeth, while others thought they are maggots(29.3%,N=44), normal tooth buds(16%,N=24) and the minority(4.7%,N=7) thought of false teeth as normal baby-teeth appearing prematurely before their time is due. Of all the 117 caretakers whose children had had their false teeth removed, those who thought of false teeth as harmful teeth had the highest rate of false teeth removal(50.4%,N=59) while the caretakers who thought of them as normal baby-teeth appearing prematurely before their due time had the lowest rate of false teeth removal(6%,N=7).

The majority(35.3%,N=53) of the respondents attributed false teeth to cultural/ancestral roots, followed by 29.3%(N=44) who attributed it to other reasons such as false teeth running in some families and premature appearance of normal baby teeth, and the rest attributed it to high fevers(24%,N=36), diarrhoea(9.3%,N=14), vomiting(1.3%,N=2) and a minority(0.7%,N=1) attributed it to evil spirits such as witchcraft by the co-wife or enemies. Of all the 117 caretakers whose children had had their false teeth removed, the majority(33.3%,N=39) attributed it to cultural/ancestral roots, while the least number of respondents attributed it to vomiting(0.9%,N=1) and to evil spirits such as witchcraft by the co-wife or enemies(0.9%,N=1).

In case a child develops false teeth in the community, the majority( 60%,N=90) take their children to the local healer for removal, followed by 35.3%(N=53) who take them to the grandparents for removal, the minority take the child to the health facility for removal(3.3%,N=5) and the rest(1.3%,N=2) take other actions such as applying home remedy like rubbing finely-crushed sugar crystals or honey to the child‟s gums. Of the 117 respondents whose children‟s false teeth had been removed, false teeth removal was highest(59.2%,N=70) among those who took their children to the local healers for removal, and lowest(1.7%,N=2) among those who took other actions such as applying home remedy like rubbing finely-crushed sugar crystals or honey to the child‟s gums.

The majority(51.3%,N=77) of the respondents said false teeth should be removed when a child develops them because of other reasons such as causing high fevers, high fevers in combination with diarrhoea, anaemia, dehydration and death in children; followed by 44.7%(N=67) who said false teeth would cause diarrhoea in children, and the rest said they should be removed because they cause vomiting(3.3%,N=5) and both diarrhoea and vomiting(0.7%,N=1) in children.

Of the 117 respondents whose children‟s false teeth had been removed, the majority 53%(N=62) said false teeth should be removed when a child develops them because of other reasons such as causing high fevers, high fevers in combination with diarrhoea, anaemia, dehydration and death in children, while the least number (0.9%,N=1) said they should be removed because they cause both diarrhoea and vomiting in children.

The majority(61.3%,N=92) said a child would die if his/her false teeth were not removed, followed by 23.3%(N=35) who said the child would become very sick, and 12.7%(N=19) who gave other possibilities such as the child would become very dehydrated, anaemic and develop persistent high fevers that are non-responsive to treatment. The least number of respondents 2.7%(N=4) said a child whose false teeth were not removed would not grow. Of the 117 caretakers whose children‟s false teeth had been removed, the rate of false teeth removal was highest(60.7%,N=71) among those who said the child would die, and least(2.6%,N=3) among those who said the child whose false teeth were not removed would not grow.

The majority(83.3%,N=125) believed modern conventional medicine cannot cure or treat a child with false teeth while the minority(16.7%,N=25) believed modern conventional medicine can cure or treat a child with false teeth. Of the 117 caretakers whose children had had their false teeth removed, the majority (88%,N=103) believed modern conventional medicine cannot cure or treat a child with false teeth, while the rest(12%,N=14) believed modern conventional medicine can cure or treat a child with false teeth.

70%( N=105) of the respondents believed modern medicine health workers have some knowledge about false teeth, while the minority(30%,N=45) believed they knew nothing about false teeth. Of all the 117 caretakers whose children had had their false teeth removed,

40 the majority(71.8%,N=84) believed modern medicine health workers have some knowledge about false teeth, while the minority(28.2%,N=33) believed they knew nothing about false teeth.

The majority(86%,N=129) of the respondents believed false teeth could only be recognised and managed by village elders and traditional healers in the community, while the minority(14%,N=21) said that was not true. Out of the 117 caretakers whose children had had their false teeth removed, the majority(88.9%,N=104) believed false teeth could only be recognised and managed by village elders and traditional healers in the community, while the minority(11.1%,N=13) said that was not true.

89.3%(N=134) of the respondents believed false teeth could best be treated by traditional medicine, while the minority(10.7%,N=16) believed it could best be treated by modern medicine. Out of the 117 caretakers whose children had had their false teeth removed, the majority(94%,N=110) believed false teeth could best be treated by traditional medicine, while the minority(6%,N=7) believed it could best be treated by modern medicine.

The majority(68%,N=102) disagreed to having witnessed a child die because their false teeth had not been removed, while the minority(32%,N=48) agreed to it. Out of the 117 caretakers whose children had had their false teeth removed, the majority(67.5%,N=79) disagreed to having witnessed a child die because their false teeth had not been removed, while the minority(32.5%,N=38) agreed to it.

74.7%(N=112) of the respondents disagreed to having witnessed a child with false teeth improve after being managed using modern conventional medicine only, while the minority(25.3%,N=38) agreed to having witnessed a child with false teeth improve after being managed using modern conventional medicine only. Out of the 117 caretakers whose children had had their false teeth removed, the majority(80.3%,N=94) disagreed to having witnessed a child with false teeth improve after being managed using modern conventional medicine only, while the minority(19.7%,N=23) agreed to having witnessed a child with false teeth improve after being managed using modern conventional medicine only.

The majority (55.3%,N=83) of the respondents first heard about false teeth from their parents, 24%(N=36) from their friends, 16%(N=24) from elders in the community and the minority 4.7%(N=7) from health-workers. Out of all the 117 caretakers whose children had had their false teeth removed, the majority 59%(N=69) first heard about false teeth removal from their parents and the minority 5.1%(N=6) from health-workers.

When suspecting their child has developed false teeth, the majority(61.3%,N=92) usually consult elders in the community, followed by 30%(N=45) who consult their parents, 6.7%(N=10) who consult traditional healers and the minority 2%(N=3) who consult health- workers. Out of all the 117 caretakers whose children had had their false teeth removed, the majority 60.7%(N=71) usually consult elders and the minority 2.6%(N=3) consult health-workers when they suspect their child has developed false teeth.

Majority(64%, N=96) of the respondents had their relatives as the major source of information regarding false teeth removal, followed by 34%(N=51) who had other sources such as their elders in the community, friends, neighbours and traditional healers. The others had media(1.3%,N=2) and only 0.7%(N=1) had health-workers at the health facility as their major source of information regarding false teeth removal. Of all the 117 caretakers whose children had had their false teeth removed, the majority(65%,N=76) had their relatives as the major source of information regarding false teeth removal and none who had media as their major source of information had removed their child‟s false teeth.

CHAPTER FIVE: DISCUSSIONS

5.0 Introduction This section presents the discussions of the results in relation to the research findings. The findings are discussed in relation to the study specific objectives, case study and reviewed literature.

5.1 Discussion The discussion is made basing on the study objectives which were;- to determine the prevalence of false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District, to assess the socio-demographic factors influencing false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District ,and to determine the knowledge factors influencing false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District.

5.2 Prevalence of false teeth removal among children under five years in bungatira sub-county This study found a high prevalence(78%) of infant oral mutilation in Bungatira Sub-county in Gulu District. This is possibly because of the deeply rooted belief that false teeth is caused by cultural/ancestral roots. Consequently, bearing this in mind, when faced with a suspicion of false teeth in their children, most people sought the help of traditional birth attendants and local healers, instead of seeking medical attention. This study finding is similar to another done in Bushenyi district in Western Uganda, which found more than 80% of the respondents using traditional medicine alone or in combination with modern medicine to treat “false teeth disease”( Nuwaha et al.,2007). However, this study finding is higher than another recent one done in Uganda which found that 29.3% of the children under study had had this practice performed on them, and this was highest among the Nilotics(45.5%) and lowest among the Bantus(22.3%)( Tirwomwe et al.,2013). This discrepancy is possibly due to ignorance leading to the further increase in carrying out the practice of infant oral mutilation, which in turn has caused a rise in the prevalence from 45.5% to 78%.

5.3 Socio-demographic factors influencing false teeth removal among children under five years To achieve the second objective of this study which was to assess the sociodemographic factors influencing false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District, the socio-demographic factors of this study were sub-divided into two categories, that is, the factors of the child and those of the caretaker.

Socio-demographic factors of the child i) Age of the child This study found that majority(63.2%) of the children had had their false teeth removed within the first 3-5 months of their lives. This result concurs with a recent study done in Rukungiri, South-west Uganda, which found out that the most common age for infant oral mutilation was 5 months( Amyna et al.,2017). This is also the time that the growing primary canine buds show clear bulges within the child‟s gum pads, as well as the time during which the growing child is establishing its humoral immunity, transitioning from the humoral immunity provided by the mother through the placenta at birth and so is highly susceptible to infections and fevers( Kemoli,2015). Therefore, it is not surprising that this practice of false teeth removal is most commonly done within the first 3-5 months of a child‟s life, bearing all the above visible changes on the child‟s gum pads, and temporary vulnerability to infections. ii) Sex of the child This study found that the majority(53.8%) of the children whose false teeth had been removed were females and 46.2% were males. However, there was no significant difference between gender of the children on which this practice had been performed(p=0.394). This is possibly because this practice has cultural roots and therefore its implementation cuts across the gender line. This finding is in agreement with several other studies done on the practice, which report no significant difference between gender(p=0.200)( Kipchumba,2012) and others which report an equal number of male and female infants who had undergone the practice(Amyna et al.,2017).

Besides, the slightly higher prevalence in females(53.8%) compared to males(46.2%) could probably be attributed to the higher percentage of female children(52.0%) compared to male children(48.0%) whose care-takers participated in the study.

Socio-demographic factors of the care-takers a) Age of the care-taker The practice of false teeth removal was highest among the 25-34 year age group( 40.2%) and lowest among the older age groups. There was a strong association between age of the caretaker and occurrence of false teeth removal in the child(p=0.001). This is possibly because the 25-34 year age group is the most active of the reproductive age bracket. Besides, this age bracket made up the majority(43.3%) of our study population, and most of them were actually biological parents to the children. This study finding is in sync with another study done in Tanzania, which discovered that with respect to age, a higher proportion of older adults were significantly less likely to link some childhood conditions such as tongue tie with the nylon/false teeth myth than young adults( Kahabuka et al.,2015). Besides, the prevalence of false teeth removal could have been lower among the older age brackets of care-takers probably because only a few children who were included in the study had grandparents(15.3%) as their primary care-takers, compared to those who had their biological parents( 68.7%) as their primary care-takers. b) Sex of the care-taker The study found that of the care-takers whose children‟s false teeth had been removed, the majority(66.7%) were females and the minority(33.3%) were males. However, there was no significant association between sex of the caretaker and the practice of false teeth removal in the child(p=0.093). This higher prevalence of false teeth removal among the children with female caretakers(66.7%) than among those with male caretakers(33.3%) could probably be due to the fact that majority of the caretakers were females(70%) than males(30%).This difference in the numbers of the sexes is in line with the results of the National Population and Housing Census (NPHC), undertaken by the Uganda Bureau of Statistics (UBOS) in 2014. The findings of the Census report indicated that females (51.1%) were slightly more than males (48.9%), with an average growth rate of 3.0 percent annually (UBOS, 2014).

This study finding concurs with another done in Kenya which concluded that there were no statistical differences in the practice of infant oral mutilation among the children accompanied by the male respondents and those by the female respondents( Mule,2010). However, it differs from another study done in Tanzania which found that proportionately less females were statistically significantly more likely to link stunting and excessive crying with nylon/false teeth myth than males(Kahabuka et al.,2015). This discrepancy in the study findings is possibly because in the Acholi region, false teeth is linked to cultural/ancestral roots probably more than in Tanzania, and so the practice in Acholi,of which Bungatira is part, cuts across the gender line of the caretakers. c) Marital status of the caretaker This study found that the majority(73.5%) of the caretakers whose children had had their false teeth removed were married. There was also a fair association between the caretaker‟s marital status and the occurrence of false teeth removal in their child(p=0.039). The high prevalence of false teeth removal among the married could possibly be due to the fact that the majority(69.3%) of the respondents were married. This study finding concurs with another done in Kenya which discovered that there was significant difference(p=0.00) in the prevalence of the practice among those who were married(24.6%) compared to those who were not married(22.7%)(Kipchumba, 2012). d) Level of education of the caretaker This study found that that the respondents with either no(22.2%) or with a lower level of education(49.6%) had children who were more likely to have undergone infant oral mutilation than those with a higher level of education. This is possibly because a lower level of education translates to a greater likelihood of ignorance about common childhood illnesses and therefore poorer health-seeking behaviours. The finding of this study concurs with several others, which also discovered that the association of occurrence of false teeth to teething was favoured by low education status(Nuwaha et al.,2007). e) Employment status of the caretaker This study found that of the care-takers whose children‟s false teeth had been removed, the majority(55.6%) were farmers, followed by 17.9% who were housewives, 11.1% were businessmen/women, 9.4% were medical personnel, 6% were private employees and none

46 were government employees. Besides, the greater part of the population(71.8%) had had either no formal education or education up to only primary level, which would not favour most of them so as to get involved in occupations like business, health sector and both private and government sector, most of which require some degree of formal or technical training. Examining the above categories of employment, it is crystal clear that the practice of false teeth removal was found to be more common among the children whose caretakers had a lower level of income( farmers and housewives), compared to their counterparts with a higher income level(businessmen/women, medical, private and government employees. There was a significantly strong association between the employment status of the caretaker and the removal of the child‟s false teeth(p=0.000).

The finding of this study concurs with that of a similar study done in Kenya, which discovered that the prevalence of the practice of infant oral mutilation was significantly different(p=0.00) betweeen respondents whose source of income was livestock(24.5%), business(25.0%), farming and formal employment(9.1%)( Kipchumba, 2012). Besides, another Tanzania-based study discovered that a higher proportion of medical personnel were statistically significantly less likely to linkexcessive crying and difficult sucking with nylon/false teeth myth than non-medics( Kahabuka et al.,2015). Therefore, this explains why false teeth removal was done more among children whose caretakers had a lower level of income and those whose caretakers were non-medics than among their counterparts whose caretakers had a higher level of income or were medical personnel. f) Religion of the caretaker The majority(59%) of the care-takers whose false teeth had been removed were Catholic, followed by 19.7% Anglican/Protestant,6.8% who were Born again/Pentecostal,6.8% who were Traditionalist, 4.3% who were Muslim and the least number(3.4%) were Seventh Day Adventists. This reflects the proportions of religious affiliations in the general Ugandan population where the Roman Catholics predominate. The largest percentage(59%) of the caretakers whose children had had their false teeth removed is probably because majority(54.7%) of the 150 respondents were predominantly Catholic. However, it is worth noting that 100% of the caretakers who ascribed to the Seventh Day Adventist, muslim and traditionalist faith had had their children‟s false teeth removed. Probably, the above mentioned religions encourage such a practice much more than others.

The finding of this study is contrary to a study done by Pradella et al.(2013), who put forth the idea that the practice of infant oral mutilation was widely performed by traditionalists, and another done by Teshome et al.(2016), who concluded that the practice was mainly done by traditionalists.

The discrepancy in this study finding and the above two studies is possibly because in the African culture, culture exerts a stronger influence on people‟s beliefs and practices, than does religion. It is therefore surprising that religion of the caretaker had a strong association with the removal of the child‟s false teeth(p= 0.007). g) Relationship of the primary caretaker to the child This study finding was that more children whose primary caretakers were their biological parents (68.7%) had had their false teeth removed than those under their care of guardians. There was also a significant strong association between the relationship of the primary caretaker to the child and the removal of the child‟s false teeth(p=0.003). The study finding that more children whose primary caretakers were their biological parents had had their false teeth removed than those under their care of guardians could probably be due to the fact that the majority(68.7%) of the children under study had their biological parents as respondents. This finding is contrary to that of another study done in Uganda, which revealed that infant oral mutilation was more existent among children who were under the care of a guardian than a parent( Tirwomwe et al.,2013). However, the finding of this study could be in sync with another one done in Ethiopia by Teshome et al.(2016), which revealed that one-third of the participants, who were all biological mothers, were found having the intention to continue the practice of false teeth removal in future.

5.4 knowledge factors influencing false teeth removal among children under five years To achieve the third objective of this study which was to determine the knowledge factors influencing false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District, the interview questions were sub-divided into two categories, that is, awareness about and reasons for false teeth removal, and sources of information about false teeth removal. The results of the study will be systematically discussed in line with the above categories.

48 a) Awareness about and reasons for false teeth removal The majority(98.7%) of the respondents agreed that they had ever heard about false teeth removal. The fact that the majority of those who had had their children‟s false teeth removed had ever heard false teeth is probably because even the majority of these have got misleading information about false teeth. For instance, the majority(64.1%) thought false teeth are harmful teeth, while others thought they are maggots(37.6%). Of the caretakers whose children had had their false teeth removed, those who thought of false teeth as harmful teeth had the highest rate of false teeth removal(50.4%) while the caretakers who thought of them as normal baby-teeth appearing prematurely before their due time had the lowest rate of false teeth removal(6%). There was a significantly strong association between the caretaker‟s knowledge of what false teeth are and the removal of their children‟s false teeth(p=0.020).

In addition to this, the majority(35.3%) attributed false teeth to cultural/ancestral roots, which probably explains why even though majority(99.1%) had ever heard about false teeth, they still went ahead to be the majority involved in this practice, as they were informed but with misleading information. There was also a significantly strong association between a caretaker‟s knowledge about the cause of false teeth and the removal of the child‟s false teeth(p=0.000). To fuel all this, this study also found that in case a child developed false teeth in the community, the majority( 60%) take their children to the local healer for removal and the minority take the child to the health facility for removal(3.3%). This strong and significant association between what is done when a child develops false teeth and the occurrence of false teeth removal(p=0.043) is possibly due to the poor health-seeking behaviours of the caretakers.

Besides the majority(51.3%) of the respondents said false teeth should be removed when a child develops them because of reasons such as causing high fevers, high fevers in combination with diarrhoea, anaemia, dehydration and death in children. In addition to the above, majority(61.3%) of the respondents said a child would die if his/her false teeth were not removed, and least(2.7%) among those who said a child whose false teeth were not removed would not grow. These statistics support the finding that the rate of false teeth removal was highest(60.7%) among those who said the child would die, and least(2.6%) among those who said the child whose false teeth were not removed would not grow. This

49 could further be probably because the gravity of the fear of a child dying(61.3%) is definitely less than he/she not growing(2.6%) if his /her false teeth are not removed.

The highest proportion (83.3%) believed modern conventional medicine cannot cure or treat a child with false teeth and this possibly explains the significant association between this belief and the practice itself(p=0.000). However, it is interesting to note that of all the caretakers whose children had had their false teeth removed, the majority(71.8%) believed modern medicine health workers have some knowledge about false teeth.This contrast and lack of significant association(p=0.358) is probably because most of the respondents(85%) reasoned that although modern medicine health workers know about false teeth, they keep denying its existence and linking it to other common childhood illnesses such as fevers and diarrhoeal diseases.

The study also found that the majority(86%) believed false teeth could only be recognised and managed by village elders and traditional healers in the community. The above finding alone therefore explains the significant association between this belief and false teeth removal(p=0.001). In addition to the above, the majority(89.3%) of the respondents believed false teeth could best be treated by traditional medicine, thus explains why the association was strong and significant(p=0.000).

One of the most interesting findings of this study was that although the majority(68%) disagreed to having witnessed a child die because their false teeth had not been removed, still a majority of these (67.5%), went ahead and removed their child‟s false teeth compared to the minority 32.5% who had removed their child‟s false teeth probably because they had ever witnessed a child die because their false teeth had not been removed.

However, contrary to the above, the majority(74.7%) of the respondents disagreed to having witnessed a child with false teeth improve after being managed using modern conventional medicine only. This lack of evidence of having witnessed modern conventional medicine at work could possibly be the reason behind the majority(80.3%) of these caretakers having removed their child‟s false teeth.

The study findings above relating to awareness and reasons for false teeth removal are in sync with several other studies previously done, which revealed that almost everybody interviewed had ever heard about false teeth( Tirwomwe et al.,2014), and that infant oral ,utilation is widely perceived to be useful to prevent or treat dirrhoea, fever and vomiting, general malaise or ill-health, itching gums, crying with an unknown cause, failure to suckle and even death( Nuwaha et al;,2007). The study finding of most caretakers perceiving traditional medicine as the best treatment for false teeth is also similar to another finding by Kutalek et al.(2013) , that improvement in the primary disease was reported by up to two-thirds of parents whose children underwent the practice. b) Sources of information about false teeth removal The majority(55.3%) of the respondents first heard about false teeth from their parents, and only the minority(4.7%) from health-workers. The low prevalence of false teeth removal among children whose caretakers first heard about false teeth from health-workers(5.1%) than among those who first heard it from their parents(59%) is probably due to the difference in accuracy of information passed on to the caretaker by either the health-worker or the caretaker‟s parents.

To support the above statement, the study also discovered that when suspecting their child has developed false teeth, the majority(61.3%) usually consult elders in the community, and only a minority(2%) consult health-workers.

Regarding their major source of information concerning false teeth removal, from the 150 respondents, the majority(64%) had their relatives as the major source of information and only a few had media(1.3%) and 0.7% had health-workers at the health facility as their major source of information regarding false teeth removal. It is therefore not surprising that of all the caretakers whose children had had their false teeth removed, the majority(65%) had their relatives as the major source of information regarding false teeth removal and none who had media as their major source of information had removed their child‟s false teeth. This varying prevalence could probably be due to the difference in the degree of accuracy of information being passed on to these caretakers by the different information sources.

The above study finding is similar to that of another study done in Kenya, which discovered the main sources of information as friends and relatives(80%)(Mule,2010). This similarity in the study findings is probably because traditional beliefs and practices such as false teeth removal are mainly passed down by family(such as relatives) and friends in the community.

CHAPTER SIX: CONCLUSIONS AND RECOMMENDATIONS

6.0 Conclusions This study aimed at determining the prevalence, assessing the socio-demographic factors and determining the knowledge factors influencing false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Sub county, Gulu District in order to inform the Government, health-workers and the public about the extent of occurrence of this practice and so give rise to new approaches of tackling the socio-demographic and knowledge factors responsible. According to this study, the prevalence of infant oral mutilation was high at 78%, and the socio-demographic factors such as the age and sex of the child, and care-takers‟ socio- demographic factors like gender and level of education had no significant association(p= > 0.05) with the prevalence of false teeth removal among the children below five years.

However, other socio-demographic factors of the care-takers such as age, marital status, employment/occupation, religion and relationship to the child had a significant influence (p= <0.05) on the prevalence of false teeth removal of the children. It was observed that false teeth removal was higher among the care-takers with a lower level of education, lower socio- economic/employment status and those with a biological parent relationship to the child than those with a higher level of education, higher socio-economic/employment status and those who were guardians and not biological parents to the children. In regards to knowledge factors, the majority of people had ever heard about false teeth, and their main source of information was their parents, with ancestral/ancestral roots as the main reason for infant oral mutilation.

6.1 Recommendations Based on my research findings already disclosed and discussed in this dissertation, I would recommend that since all children in Bungatira Sub-county and Gulu at large are at risk of undergoing infant oral mutilation, the following measures need to be urgently implemented;-  The Uganda Ministry of Health should target all children country-wide when implementing preventive measures against infant oral mutilation. For example, since those who are responsible for false teeth removal( the local healers) were within the community, the health sector needs to come up with initiatives and strategies that

target family members such as grandparents, who also play a major role in decision- making when it comes to false teeth removal.  There is need to revive community health talks/sensitization, since the majority of the respondents had ever heard about false teeth but from their parents and very few from health workers at the health facility. However, these programmes of community health workers need to include appropriate cultural educational materials targeting parents and local healers/traditional birth attendants since these play a key role in fuelling the removal of children‟s false teeth.  There is need to reinforce health-seeking behaviours among caretakers who seek medical attention for their children‟s illnesses, and discourage those who self- diagnose and manage childhood illnesses.  Health-workers need to become more vigilant in teaching caretakers about common childhood illnesses like fevers and diarrhoeal diseases, their proper prevention measures and their recommended management.  Since the high prevalence of infant oral mutilation(78%) in Bungatira could possibly be due to ignorance about the risks of infant oral mutilation, I recommend that some Acholi socio-cultural beliefs such as false teeth being due to cultural/ancestral roots should be countered.  According to the findings of the study, it occurs that religious values may have had some influence on false teeth removal prevalence in Bungatira Sub-county. Therefore, I recommend that faith-based organisations should also be actively incorporated in any programmes targeting prevention of the practice of infant oral mutilation.  There is need for conventional medicine health-workers to elicit the support and participation of local/traditional healers and those who use traditional medicine so as to enable them appreciate and so influence the public to adopt the idea that traditional medicine can still be used for effective management of common childhood illnesses, but there is need to consult professional health-workers for proper diagnosis and guidance when managing any illness at home.  Health-workers need to be more friendly and not harass caretakers who could have engaged in infant oral mutilation, but rather foster a good health worker-client relationship so that caretakers are more open and easily refer to health-workers and not their parents, relatives and friends in the community as their major source of information regarding any queries related to the health of their children.

 Lastly, in a bid to lower the infant morbidity and mortality rate in Gulu District, the health sector needs to greatly emphasize the implementation of dissemination of knowledge about common childhood illnesses and encourage health-seeking behavior among caretakers.

6.2. Suggestions for further researches However, the researcher of this study suggests that further studies should be designed to:  Determine the impact of religious beliefs on the practice of infant oral mutilation.  Study potential change in cultural beliefs influencing infant oral mutilation as a result of increased awareness against the practice.  Investigate the association between the act of false teeth removal and the caretakers‟ reports of improved health of the child after removal.

REFERENCES

Accorsi S, Fabiani M, Ferrarese N, Iriso R, Lukwiya M, and Declich S.(2003).“The burden of traditional practices,ebino and tea-tea, on child health in Northern Uganda.” Social Science & Medicine, vol. 57, no. 11, pp. 2183–2191.

Ahmed I.S, Eltom A.R and Karrar Z.A.(1994).Knowledge, attitudes and practices of mothers regarding diarrhoea among children in a Sudanese rural community. E Afr Med J, 71: 716-9. American Journal Physical Anthropology, 31, pp383-90

Baba, S.P., and Kay, E.J. (1989).The mythology of the killer deciduous canine

Barnes, D.S. (1964).Tooth Morphology and other aspects of Teso dentition. Amer. J

Bataringaya, A, Ferguson, M., Laloo R. (2005).The impact of ebinyo, a form of dental mutilation, on the malocclusion status in Uganda. Community Dent Health, 22, (3), pp 146- 50.

Chindia, M. L. (1995).Traditional Dental Practices. East Afr. Med. J, 72, (4) pp 205. Clinical Affairs Committee – Infant Oral Health Subcommittee: Guideline on Infant Oral Health Care. Available at:http://www.aapd.org/media/Policies_Guidelines/G_infantOralHealthCare.pdf. Accessed Oct 15, 2014.

Dagnew, M. B. and Damena, M. (1990).Traditional child health practices in communities in north-west Ethiopia. Tropical Doct, 20, (1), pp40-1.

Davidovich E, Kooby E, Shapira J, and Ram D.(2013).“The traditional practice of canine bud removal in the offspring of Ethiopian immigrants.” BMC Oral Health, vol. 13, no. 1, p. 34.

Dewhurst S.N and Mason C.(2001).“Traditional tooth bud gouging in a Ugandan family: a report involving three sisters.” International Journal of Pediatric Dentistry, vol. 11, no. 4, pp. 292–297.

Dossanjee, H. and Hassanali, J. (2003).Recent Observation of some Social and Cultural norms of Maasai Community in Kajiado District- Kenya. African Journal of Health Sciences, 4, pp206-208.

Edwards P.C,Levering N,Wetzel E, and Saini T.(2008). “Extirpation of the primary canine tooth follicles.” Journal of the American Dental Association,vol. 139, no. 4, pp. 442–450. Gollings J.( 2017).Dentaid Impact Document for IOM. Available from:https://dentaid.org/wp-content/uploads/Dentaid-impact-document-for-IOM.pdf

Graham E.A, Domoto P.K, Lynch H and Egbert M.A. (2000).Dental injuries due to African traditional therapies for diarrhea. West J. Med, 173(2):135–7.

Graham, A E, Domoto, K P, Lynch H and Egbert A M, ( 2000).Dental Injuries due to African Traditional Therapies for Diarrhoea. West J. Med, 173(2)135-137.

Hassanali, J. (2007).Deciduous canine tooth bud removal in infants in East Africa. Scientific Letter. East Afr. Med. J. 84, pp 500-501.

Hassanali, J. Amwayi, P. and Muriithi, A. (1995).Removal of deciduous canine tooth buds in Kenyan rural Maasai. East Afr. Med. J, 71, pp 716-9.

Hassanali, J. and Kibet, P. (2003).Deciduous and permanent tooth Anomalies arising from deciduous canine tooth bud removal in infancy among the Maasai. Afr J. Oral Scie, 4, pp 233-5.

Hassanali, J. and Wanzala, P. (2008).Enucleation of Deciduous canine tooth buds infants in Sub-Saharan Africa. Developing Dentistry. 9 (1) pp 8-10.

Hiza, J. F. and Kikwilu E. N. (1992).Missing primary teeth due to tooth bud extraction in remote village in Tanzania. Int. J paediatric dentistry. 2, (1),pp31-34.

Holan G and Mamber E.(1994).“Extraction of primary canine tooth buds: prevalence and associated dental abnormalities in a group of Ethiopian Jewish children.” International Journal of Paediatric Dentistry, vol. 4, no. 1, pp. 25–30.

Inoue, K. T., Sakashita, R.(1996).Eds: Culture and dental health in Kenya. Inoue, N. and Kochi, S., (1996).Recent ablation of anterior teeth in Aniu. Journal of anthropology Nippon science, 95, pp 305-324.

Iriso R, Accorsi S, Akena S, Amone J, Fabiani M, Ferrarese N, et al.(2000).„Killer‟ canines: the morbidity and mortality of ebino in Northern Uganda. Trop Med Int Health, 5(10):706– 10.10.1046.

Jameison, L.M., (2006).Using qualitative methodology to elucidate themes for a traditional tooth gauging education tool for use in a remote Ugandan community, Health Education Research, 21, pp 477-487.

Jones, A. (1992).Tooth mutilation in Angola. British Dental Journal, 173, pp 177-179.

Kibet, P, Hassanali J., and Wanzala, P. (2009).The role of Traditional birth Attendants (TBAs) in the Prevention of DCBE Among the Maasai community in Kajiado, Kenya. Unpublished report of a study carried on TBAs in October-December 2008.

Kikwilu, E. N. and Hiza, J.F.R. (1997).Tooth bud Extraction and rubbing of herbs by traditional healers in Tanzania: Prevalence and sociological and environmental factors influence the practiCes. International Journal of Paediatric Dentistry, 7, (1), pp 19-24.

Kipchumba P.J.(2012).Deciduous Canine Tooth Bud Extraction and Nutritional Status of Children Aged 2-5 years in Kajiado District, Kenya ; Jomo Kenyatta University of Agriculture and Technology, pp.63-80.

Longhurst R.(2010).Infant oral mutilation.Br Dent J, 209(12):591–2.10.1038

Makundi, E. A., Malebo, H., Mhame, P. Kitua, A. and Warsame, M. (2006).Role of traditional healers in the management of severe malaria among children below 5 years of age: The case of Kilosa and Handeni Districts, Tanzania. Malaria J, 5, pp 58.

Matee M and Van-Palenstein H.W.H.(1991).Extraction of „nylon‟ teeth and associated abnormalities in Tanzanian children. Afr Dent J,5:21–5.

Ministry of Health.(1987/1988).The Oral Health Situation in Uganda. Report of the National Oral Health Plan Committee, pp. 28–68.

Mondal, J. K.: Gupta, P. Gupta, D. N. , Ghosh, N; Sikder, S.N; Rajendran K. et al., (1996). Occurrence of diarrhoeal diseases in relation to infant feeding practices in a rural community in west Bengal, India. Acta Paediatrica 85:1159-62.

Morgensen, H. O. (2000). “False Teeth” and real Suffering: the social Course of “Germectomy” in Eastern Uganda. Culture, Medicine and Psychiatry, 24,pp 331-351.

Mosha, H. J. (1983). Dental Mutilation and associated abnormalities in Tanzania Mule F.K.(2010).The socio- demographic factors influencing oral mutilation among under five- year- old children at the Kenyatta National Hospital, Nairobi, Kenya.

Ngilisho, L. A, Mosha, H. J, Poulsen, S. (1994).The role of Traditional Healers in the treatment of toothache in Tanga region, Tanzania. Community Dent.Health, 11, (4) 240-2.

Noman A.V, Wong F and Pawar RR.(2015).Canine Gouging: A Taboo Resurfacing in Migrant Urban Population.Case Rep Dent, 2015():727286.

Nuwaha F, Okware J, Hanningtone T, and Charles M.(2007).False teeth” Ebiino” and Millet disease “Oburo” in Bushenyi district of Uganda. Afr Health Sci,7(1),pp25–32.

Peretz B, Ram D, Laura B and Maria Otero M.(2003).Systemic manifestations during eruption of primary teeth in infants. J Dent Child (Chic), 70:170–173.

Pindborg, J.J. (1969).Dental mutilation and associated abnormalities in Uganda.

Rasmussen, P., Elhassan, E. and Raadal, M (1992).Enamel defects in Primary canine related to Traditional treatment of Teething problems in Sudan. Int.J. Paediat. Dent, 2, (3) pp 151-5. Rodd, D and Davidson, L E (2000).„llko dacowo‟ canine enucleation and Dental

Sebudde, S. (2006).False Teeth still a public health problem among children in Kanungu District- South Western Uganda. Educational Research and reviews Vol. 1 (15) pp 156-161. sequelae in Somali children. Int. J. of Paediatr. Dent, 10, pp 290-7.

Teshome A, Andualem G, Seifu S and Tsegie R.(2016).Knowledge, Attitude and Practice of Mothers towards Canine Tooth Bud Removal and Associated Factors among Mothers Visiting Dental Clinic of Gondar University Hospital, Ethiopia. J Community Med Health, 6:396. doi:10.4172/2161-0711.100039.

Tirwomwe J.F, Agwu E and Ssamula M.(2013).The magnitude of tooth bud extraction in Uganda. Int J Med MedSci, 5:450–5. tooth in Southern Sudan. Journal of Paedodontics, 14, pp48-49

UBOS, 2014.Uganda Bureau of Statistics, The National Census Uganda report, Kampala: Uganda.

UDHS, 2016.Uganda Demographic and Health Survey, Key indicator report, Kampala, Uganda:: UBOS, and Rockville, Maryland, USA: UBOS and ICF.

Wake M, Hesketh K and Lucas J.(2000).Teething and tooth eruption in infants: A cohort study. Pediatrics, 106:1374–1379.

Welbury R.R, Nunn J.H, Gordon P.H and Green-Abate C.(1993).“Killer” canine removal and its sequelae in Addis Ababa. Quintessence Int, 24: 323–327.

Wordley J.(2003).Developing Dentistry, 3(2):pp 19–20.

APPENDICES APPENDIX 1: CONSENT FORM

Topic: Prevalence and factors associated with false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Subcounty, Gulu District.

Dear Prospective Participant, My name is Atim Wendy Paula, a student currently pursuing a Bachelors in Nursing Science at International Health Sciences University (IHSU) and have to complete a dissertation as part of the requirements for the programme. The title of my intended study is;- Prevalence and factors associated with false teeth removal( Infant Oral Mutilation) among children under five years in Bungatira Subcounty, Gulu District. I am kindly requesting you to participate in this study, after having read through the information below concerning any queries you could be having as far as your involvement in this study is concerned.

WHAT IS THE PURPOSE OF THIS STUDY? This study is aimed at determining the prevalence and factors associated with false teeth removal among children under five years in Bungatira Subcounty, Gulu District. Eventually, this study will serve to inform the Government, health workers and the general public of the occurrence(prevalence) of this harmful practice and so empower all the stakeholders to actively participate in curbing it.

WHY AM I BEING INVITED TO PARTICIPATE? You were purposively chosen as a caretaker of a child under five years of age, residing in Bungatira Subcounty in Gulu District. As such, you hold the best position as the provider of information about this child, which makes you one of the most important stakeholders in making this study a successful one. If you accept to participate, you will be participating in this study with 383 other caretakers. WHAT IS THE NATURE OF MY PARTICIPATION IN THIS STUDY? As a participant, you will be required to complete a questionnaire. The questionnaire consists of multiple-choice questions with options to choose from, questions in the form of a checklist and a few questions that require responses in writing. The questionnaire will require approximately 20 minutes of your time.

CAN I WITHDRAW FROM THIS STUDY EVEN AFTER HAVING AGREED TO PARTICIPATE? Since your participation is completely voluntary, you are free to refuse to participate, to withdraw your consent (if the questionnaire has not yet been submitted) or to discontinue participating in the study at any point you feel you need to without having to explain, and you will suffer no penalty or loss. If you do decide to take part, you will be asked to sign a written consent form. WHAT ARE THE POTENTIAL BENEFITS OF TAKING PART IN THIS STUDY? There will be no direct benefits or compensation to you for taking part in the study. However, the researcher hopes the findings will help benefit the district and nation in the fight against this harmful practice and thus improve the quality of life and lower morbidity and mortality of children under five years of age. ARE THERE ANY NEGATIVE CONSEQUENCES FOR ME IF I PARTICIPATE IN THE RESEARCH PROJECT? You will suffer no harm by taking part in the study, and the researcher guarantees anonymity to ensure that no information obtained from you as a participant leaks. The researcher however apologises in advance for any inconvenience that may result from your taking part in the study. WILL THE INFORMATION THAT I CONVEY TO THE RESEARCHER AND MY IDENTITY BE KEPT CONFIDENTIAL? Only the researcher and/or the fieldworker, having delivered the questionnaire to you, will know about your involvement in this research and no one will be able to connect you to the answers you give. Even the researcher will not be able to connect the data to any particular individual. Only the researcher will have access to the data, and all data will be kept under lock and key at the researcher‟s office. Note however that, if necessary, your answers may be reviewed by people responsible for making sure that research is done properly, including the transcriber, external coder, and members of the Research Ethics Review Committee. The information you provide may be used in the research report or in journal articles should the study be submitted for publication. However, individual respondents will not be identifiable.

WILL I RECEIVE PAYMENT OR ANY INCENTIVES FOR PARTICIPATING IN THIS STUDY? Respondents will not receive any form of payment or incentives for taking part in the study. Should respondents incur any costs as a result of the study, the researcher will refund them accordingly. HAS THE STUDY RECEIVED ETHICS APPROVAL ? The study has received ethical clearance from the Research Ethics Review Committee of the School of Nursing at IHSU and been granted permission by the School of Nursing. In addition to that, the researcher has also ensured she informs and obtains permission from the district and facility management. HOW WILL I BE INFORMED OF THE FINDINGS/RESULTS OF THE RESEARCH? If you would like to be informed of the final research findings, please contact the researcher, Atim Wendy Paula on +256 704233339/ +256 778336364 or [email protected]. Should you require any further information or want to contact the researcher about any aspect of this study, please contact the above mentioned person. Thank you for taking time to read this information sheet and for participating in this study. I really do appreciate.

CONSENT TO PARTICIPATE IN THIS STUDY I, ______(participant's initial), confirm that the person asking my consent to take part in this research has told me about the nature, procedure, potential benefits and anticipated inconvenience of participation. I have read (or had explained to me) and understood the study as explained in the information sheet. I have had sufficient opportunity to ask questions and am prepared to participate in the study. I understand that my participation is voluntary and that I am free to withdraw at any time without penalty (if applicable). I am aware that the findings of this study will be processed into a research report, journal publications and/or conference proceedings, but that my participation will be kept confidential unless otherwise specified. I agree to the recording of the questionnaire. Participant Signature……………………………………………..Date………………… Researcher‟s Name: Atim Wendy Paula Researcher‟s signature…………………………………………..Date…………………

APPENDIX II: QUESTIONNAIRE

INSTRUCTIONS: Do not write your name in the questionnaire. Complete the following items by writing the number for the appropriate response and by writing a short response where necessary. The questionnaire has three (3) sections, please give your most honest response for each question. Complete the questionnaire in blue ballpoint pen provided.

SECTION A: SOCIODEMOGRAPHIC DATA OF THE CHILD AND CARE-TAKER 1.a) Socio-demographic data of the child ANSWERS 1.) How old is the child in months?

2.) What is the sex/gender of the child? 1.Male(boy) 2. Female(girl)

1.b) Socio-demographic data of the care-taker 1.) How old are you?

2.) What is your gender? 1. Male 2. Female 3.) What is your marital status? 1. Single 2. Married 3. Divorced/ Separated 4. Widow/widower 4.) What is your level of education? 1. No formal education 3. Secondary education 2. Primary education 4. Tertiary education

5.) Are you currently employed? 1. Yes 2. No If yes, what is your occupation? 1. Housewife 4. Government employee 2. Businessman/woman 5. Private employee 3. Farmer 6. Any other?......

6.) Which religion do you practice? 1. Catholic 4. Seventh Day Adventist 2. Anglican/Protestant 5. Muslim 7. None 3. Born Again/Pentecostal 6. Traditionalist 7.) What is your relationship to the child? 1. Biological father /mother 2. Grandparent 3. Sibling(Brother or sister) 4. Aunt/uncle 5.Housemaid/houseboy

SECTION B: PREVALENCE OF FALSE TEETH REMOVAL IN BUNGATIRA SUBCOUNTY 1.) Is false teeth removal practiced in this area? 1. Yes 2. No 2.) Were this child‟s false teeth removed? 1. Yes 2. No If the answer to question number 2 is no, please answer the following questions for a child you know of in this area, whose false teeth were removed. 3.) If the answer to question number 2 was yes, why was this child‟s false teeth removed? 1. The child had high fevers. 2. The child had diarrhea. 3. The child was vomiting. 4. Any other reason?......

4.) Who decided that this child‟s false teeth should be removed? 1. Biological father 2. Biological mother 3. Both biological parents 4. Grandparent 5. Any other? 5.) At what age was this child when his/her false teeth were removed? 6.) Who removed the false teeth of this child? 1. Parent/caretaker of the child 2. Local healer/traditional birth attendant 3. Health worker in a health facility 7.) What was used to remove the false teeth of this child? 1. Local herbs 2. Metallic wires 3. Needles 4. Razorblade 5. Any other?...... 8.) What happened to the child after false teeth removal? 1. The child got better( the diarrhea/fever/vomiting,etc) stopped. 2. The child bled a lot. 3. The child was admitted to the hospital. 4. Any other?...... 9.) If the child did not improve even after, did you give the child any medication after false teeth removal? 1. Yes 2. No

10.) If the answer to the above is yes, what medication was given to the child who showed no improvement even after false teeth removal? 1. Anti-diarrhoeal drugs like metronidazole/flagyl 2. Anti-malarial drugs like coartem 3. Anti-pyretics like panadol 4. Deworming tablets like mebendazole 5. Any other drug given?...... 6. I don‟t remember the drug. 7. Traditional herbs/medicine 8. Any other local remedy?...... 11.) Did the child‟s condition improve after the above remedy in question number 10 was given? 1. Yes 2. No 12.) If the answer to question number 11 is no, what was done to manage the child‟s condition? ………………………………………………..

SECTION C: KNOWLEDGE PERTAINING TO FALSE TEETH REMOVAL A) AWARENESS ABOUT AND REASONS FOR FALSE TEETH REMOVAL 1.) Have you ever heard about false teeth? 1. Yes 2. No 2.) If yes, what do you think false teeth are? 1. They are maggots 2. They are normal tooth buds 3. They are harmful teeth 4. Any other?...... 3.) What do you think causes these false teeth? 1. Diarrhoea 2. High fevers 3. Vomiting 4. Evil spirits such as witchcraft by the co-wife or enemies 5. Cultural/ancestral roots 6. Any other reasons?...... 4.) In this community, what is done when a child develops false teeth? 1. Taken to a health facility for removal. 2. Taken to the local healer for removal. 3. Taken to the grandparents for removal. 4. Any other action taken?...... 5.) Why should false teeth be removed when a child develops them? 1. False teeth cause diarrhea in children. 2. False teeth cause vomiting in children. 3. Any other reason(s) for removal? 6.) What happens when a child‟s false teeth are not removed? 1. The child will become very sick. 2. The child will not grow. 3. The child will die. 4. Any other?......

7.) Modern conventional medicine cannot cure or treat a child with false teeth. 1. TRUE 2. FALSE 8.) Modern medicine health workers know nothing about false teeth. 1. TRUE 2. FALSE 9.) False teeth can only be recognised and managed by village elders and traditional healers in the community. 1. TRUE 2. FALSE 10.) False teeth can best be treated by; 1. Modern medicine 2. Traditional medicine 11.) I have actually witnessed a child die because their false teeth had not been removed. 1. I AGREE 2. I DISAGREE 12.) I have witnessed a child with false teeth improve after being managed using modern conventional medicine only. 1. I AGREE 2. I DISAGREE B) SOURCES OF INFORMATION ABOUT FALSE TEETH REMOVAL 1.) From who did you first hear about false teeth? 1. My parents 2. My friends 3. Elders in the community 4. Health-workers 5. Any other?...... 2.) Who do caretakers usually consult when they suspect their child has developed false teeth? 1. Health-workers 3. Elders in the community 2. Their parents 4. Traditional healers 3.) From which source do you get the most information regarding false teeth removal? 1. Relatives 2. Local leaders 3. Religious leaders 4. Health workers at the health facility 5. Media(radio, television, newspapers,etc) 6. Any other source?......

APPENDIX III: MAP OF GULU DISTRICT SHOWING BUNGATIRA SUB COUNTY

NOTE:- This research was facilitated by my parents and guardians.

APPENDIX IV: INTRODUCTORY AND CORRESPONDENCE LETTER