A quantitative descriptive survey with researcher-administered questionnaires was conducted, using trained data collectors who directly engaged with respondents to ask questions and record their responses. This method ensured greater consistency in data collection, minimised misunderstandings or misinterpretations of questions, and allowed for clarification as necessary.

The study was conducted in four communities within the Cape Town Metropole of the Western Cape province, South Africa, with a total population of 4 772 846.²¹ These communities are directly linked to the outreach community services of the University of the Western Cape. Site A is an urban central business community located approximately 20 km from Cape Town city centre. It is a busy area and a major transportation hub, situated next to a taxi rank and train stations connecting people from various parts of the Western Cape. Site B is a semi-rural area located 10 km northeast of Durbanville and approximately 40 km from Cape Town city centre. Site C is a semi-rural area situated 15 km north of Durbanville and around 53 km from Cape Town city centre. Site D is an urban area located 20 km from the Cape Town city centre. The three main languages in these areas are Afrikaans, English, and isiXhosa.

The target population comprised individuals within the selected geographic areas whose prevalence of oral health problems is unknown or undocumented. The inclusion criteria were persons 18 years and older, with varying socio-economic backgrounds and health statuses, who accessed the university wellness services stations in the four communities. For an unknown population with an unknown prevalence of oral health problems (50%), with a confidence level of 95% and a margin of error of ± 5%, a sample of 384 was calculated. A convenience sample of at least 100 respondents per site (N = 400) was targeted.

A researcher-administered paper-based questionnaire, which included validated scales with established validity and reliability was used. This questionnaire comprised four sections, namely Section A, Section B, Section C and Section D. Section A included four questions related to respondents’ socio-demographic characteristics. Section B included the WHO Oral Health Questionnaire for Adults,¹⁷ consisting of 13 questions associated with respondents’ oral health status and practices. Section C consisted of the Oral Health Knowledge Inventory developed by Rustvold²² and included 10 questions related to respondents’ oral health knowledge. These questions were adapted from multiple-choice questions to True or False questions to more accurately reflect the anticipated knowledge level of community members and to simplify response options for better comprehension. Section D included 14 questions developed by Rustvold²² to measure respondents’ oral health attitudes. All questions were previously validated and applied within the study context.²³ The questionnaire was translated into Afrikaans and isiXhosa by a professional translator using the forward–backward translation method. It was subsequently pilot tested with a small sample of respondents to identify any challenges in its administration. The internal consistency of the questionnaire was tested using Cronbach’s alpha test with an acceptable value of 0.722 for ‘Knowledge’, 0.579 for ‘Attitudes’ 0.579 and 0.866 for ‘Practices’.

Data were collected in March 2024 by fourth-year nursing students who were fluent in the local respondents’ language. To ensure consistency and data quality, the research team provided training to students on survey administration and supervised the students throughout the data collection process. Safe and accessible data collection venues, such as community halls or gazebos, chairs, and tables, were pre-arranged with the community leaders. Data were collected at different stations, including an explanation about the study to the respondents and distribution of consent forms (Station 1) and completion of the questionnaires (Station 2). The completion of the questionnaires took approximately 20 min. Once completed, all questionnaires were reviewed by the research supervisors for accuracy and completeness.

Data collected from questionnaires were captured in Research Electronic Data Capture (REDCap; Vanderbilt University Medical Center, Nashiville, TN, United States [US])²⁴ and cleaned. The data were imported into the Statistical Package for the Social Sciences (SPSS, version 29) (IBM, Armonk, NY, US) for analysis.²⁵ Descriptive statistics, including frequencies, percentages, and means, and standard deviations as applicable, were used to describe respondents’ socio-demographic characteristics, oral health knowledge, attitudes, and practices. Knowledge score was calculated by summing the correct answers and by classifying correct answers as knowledgeable, missing answers as ‘lack of knowledge’, and incorrect answers as ‘misinformed’. Attitudes are reported across three domains, with an overall attitude score calculated by summing positive statements and reversed attitude statements. Individual practices are reported by frequency and percentage. Poor health was coded as ‘Yes’ if respondents self-rated their health as ‘poor’ or ‘very poor’. The Chi-square test was used to determine the association between socio-demographic factors and the practices scale, while the Mann–Whitney U test was used to compare knowledge and attitude scores across categorical variables. Direct logistic regression was performed to assess the impact of several factors on the dependent measure of oral or dental pain reported in the last 12 months. The model contained four independent variables (gender, setting, health status, and positive attitudes) selected based on significance in univariate analysis. Significance was set as p < 0.05.

Ethics approval was obtained from the University of the Western Cape Biomedical Research Ethics Committee (BM24/1/2), and permission was obtained from each community leader at the four sites. The study was registered on the National Health Research Database and approved by the Western Cape Department of Health (WC_202403_027). The purpose of the study and respondents’ rights were explained to them. The fundamental research principles, namely, respect for individuals, justice, and beneficence, were considered. Consent forms were available in Afrikaans, English, and isiXhosa and distributed for signing to those who voluntarily agreed to participate in the study. Anonymity, privacy, and confidentiality were ensured. Respondent-identifier details were not collected.

A total of 776 community members were included in the study; two non-binary respondents identified were excluded from the analysis (n = 774). The majority of the respondents were female (n = 567, 73.1%). Respondents’ ages ranged from 18 to 85 years, with a mean age of 42.3 ± 14.2 years, and no significant differences between male and female respondents. Nearly half of the respondents (n = 365, 46.9%) were from community A, an urban central business district community. Just less than half (n = 374, 48.3%) had completed high school or above (Table 1). In terms of their oral health status, nearly two-thirds of the respondents reported that their teeth or mouth caused them discomfort or pain in the last 12 months (n = 492, 63.6%), with significantly more female respondents reporting discomfort or pain in the last 12 months (n = 379, 63.6% vs. 113, 54.6%, χ² = 9.8, p = 0.002) (Table 1).

Oral health knowledge was measured using 10 True or False statements. The mean knowledge score was 6.84 ± 1.4 (68.4%) out of 10, with no significant differences between male and female respondents. However, respondents with a high school or higher education level had significantly higher knowledge scores (7.02/10 ± 1.4 vs. 6.68/10 ± 1.4, respectively, U = 3.1, p = 0.002) (not shown in Table 2).

Respondents were most knowledgeable about the goal of brushing our teeth is to remove food and bacteria from all tooth surfaces, with nearly all respondents correctly rating this statement as True (n = 737, 95.2%) (Table 2). Respondents were most misinformed about it is best to have a sugary treat with a meal, with 543 (70.2%) rating this item (False) incorrectly and you should stop flossing (cleaning between teeth) if your gums start to bleed a little, with 551 (71.2%) rating this item (False) incorrectly. Around 10% of respondents were uninformed that gingivitis (gum inflammation) is when gums become swollen and bleed, with 73 (9.4%) rating this item (True), and fluoride in toothpaste helps in reducing holes in teeth (cavities), with 88 (11.4%) rating this item (True) (Table 2).

The mean attitude score was 39.7 (standard deviation [s.d.] ± 5.4) out of a possible 56, with observed scores ranging from 26 to 55. There were significant differences in attitude scores between semi-rural and urban sites, with participants from urban areas demonstrating significantly more positive attitudes (40.3 ± 5.3 vs. 37.9 ± 5.3; U = 5.4, p < 0.001). Similarly, respondents with a high school education or higher demonstrated significantly more positive attitudes compared to those with less than a high school education (40.9 ± 5.1 vs. 38.6 ± 5.6; U = 5.9, p < 0.001). Respondents with pain and discomfort in the last 12 months had significantly lower attitude scores (39.3, ± 5.5 vs. 40.4, ± 5.4, U = 2.5, p = 0.011) (not shown in Table 1).

In attitude statements on positive beliefs on internal locus of control and self-efficacy, more than 80% of the respondents agreed with all five statements, with the highest level of agreement being for Knowledge about dental health could help prevent the loss of my teeth (n = 724, 93.5%) (Table 3).

There were mixed beliefs about barriers related to an external locus of control, low self-efficacy, and negative beliefs about susceptibility. High levels of disagreement, indicating positive attitudes towards barriers ranged from nearly three-quarters of the respondents (n = 551, 71.2%) disagreeing with the statement I believe that if my parents have bad teeth, brushing and flossing will not help my teeth to only a quarter (n = 194, 25.1%) disagreeing with the statement If my gums bleed when I floss this usually means that I am hurting my gums and I should stop flossing my teeth (Table 3).

Oral health practices were measured through teeth cleaning practices, dental visits and habits around substances that can damage teeth.

Respondents demonstrated good knowledge regarding some basic oral health concepts. Almost all the respondents (95.2%) recognised that the purpose of toothbrushing is to remove food debris and bacteria, while more than four out of five correctly identified plaque as a bacterial deposit on the tooth surface. Similarly, almost 70% acknowledged the role of fluoride in preventing dental caries. These findings are consistent with a 2021 study in South India that found that 84% of adult respondents living in a residential community could correctly define plaque and 75% understood the protective role of fluoride toothpaste.²⁷ In Rwanda, Nzabonimana et al. also reported that more than 82% of adults recognised the importance of interdental cleaning for preventing gum inflammation.²⁸ However, in this study, only just over half of the respondents (53.6%) demonstrated knowledge about interdental cleaning, and the majority (70.2%) were misinformed about the appropriate timing of sugar consumption. These gaps are consistent with findings from Nigeria, where Akinyamoju et al. reported that fewer than half of street vendors recognised the link between sugar consumption and dental caries.²⁹ Importantly, respondents with higher education levels in our study consistently demonstrated better knowledge, echoing findings from China, where Zhao et al. reported that adults with lower education were at significantly higher risk of poor oral health outcomes, despite a general lack of periodontal disease knowledge even among groups with higher levels of education.³⁰ This pattern highlights the central role of education in shaping oral health awareness and behaviours.

The overall attitudes of respondents towards oral health were moderately positive. Respondents from semi-rural areas, lower levels of education, and those who experienced pain or discomfort in the last 12 months had significantly more negative attitudes. There was a high degree of agreement with statements emphasising personal oral hygiene practices, suggesting an internal locus of control and awareness of self-care. However, 60% of respondents believed that only dentists could prevent cavities and almost 70% believed that tooth loss is a normal part of growing old. This is comparable to findings from India, where Kumar et al. reported that 61% of patients believed dentists focus primarily on treatment rather than prevention, and fewer than half sought dental care except when experiencing pain.³¹ Theories of reasoned action and planned behaviour suggest that such attitudes shape practices and that limited appreciation for prevention and susceptibility likely contributes to delayed health-seeking behaviours.³²

Brushing habits in this study were generally good, with most respondents brushing twice daily with fluoridated toothpaste. This finding is consistent with another South African study in Manguang, where Modikoe et al. reported that all respondents brushed daily, although with less consistency regarding frequency.³³ By contrast, Kumar et al. found that in India only 35% of respondents brushed twice daily, and dental floss use was negligible.³¹ In this study, flossing was notably limited, with fewer than 15% reporting regular use. This aligns with findings from a 2024 study in Rwanda, where most adult respondents (92.7%) attending public health facilities had never used dental floss to clean their teeth.²⁸ Similarly, in China, Zhao et al. reported that 90% of the 50 991 respondents had never flossed their teeth.³⁰ Conversely, over 60% of respondents in another South African study reported daily flossing.³³ These disparities highlight how contextual, cultural, and systemic factors shape practices. Dental visits in this study were largely problem-driven, with fewer than a quarter attending for preventive services. A similar trend was reported in Rwanda, where nearly 80% sought dental care only when experiencing pain, reinforcing the reactive rather than preventative orientation to oral health-seeking behaviours in many low- and middle-income settings.²⁸ Respondents from semi-rural areas were less likely to visit the dentist, indicating limited access to such services, as neither of the two communities had dental services available. Lastly, high levels of sugar consumption in tea, coffee, and fruit intake were observed in this study, raising concern about preventable dietary risks for caries and periodontal disease. While no gender differences were observed in knowledge or attitudes in this study, other research has reported that women demonstrate better oral health awareness and practices,⁶ which may reflect broader socialisation roles and caregiving responsibilities. See Appendix 1 for oral health practices key findings.

The findings highlight persistent knowledge gaps and suboptimal practices, despite generally positive attitudes. Education level emerged as a key factor influencing oral health knowledge and practices, underscoring the need for targeted health promotion strategies across the lifespan. In South Africa, while oral health may be addressed at a primary school level, the responsibility of continued learning shifts to individuals, families, and communities. This creates missed opportunities for reinforcement, particularly among those with limited access to formal education.

Considering these findings and the high prevalence of oral health diseases, health professionals, particularly oral hygienists (if available) and primary care nurses, play a pivotal role in strengthening health literacy during clinical encounters. Health professional training programmes should emphasise oral health education, as most periodontal conditions are preventable. Expanding preventative messaging and improving access to tailored preventive services could significantly reduce the oral health burden, especially in semi-rural and rural communities.³⁴ We recommend that the study should be replicated in other settings beyond Cape Town, South Africa, and could be adapted into a longitudinal design to assess changes in oral health knowledge, attitudes, and practices over time and evaluate the impact of targeted interventions.

While this study provides interesting insights about the knowledge, attitudes, and practices of community members in the Western Cape, the results cannot be generalised to the wider South African population, as demographics, oral health behaviours and access to care may differ across provinces. The sample was also convenient and predominantly female, 73.1% compared with 51.7% reported in the City of Cape Town population,²¹ which may limit representativeness.