The Effective Use of the Maternal and Child Health Handbook in the Promotion of Oral Health Care among Mothers and Children in Thailand

Abstract

Aim: This study aimed to evaluate the effectiveness of the MCH Handbook in Thailand by examining its utilization, exploring oral care practices, assessing dental health and eating habits, and analyzing attitudes toward oral education messages to identify opportunities for improving oral healthcare.

Methods: A descriptive cross-sectional survey with mixed-methods was conducted at Public Health Center No. 54 in Bangkok. The study involved 160 participants recruited through purposive sampling. Data collection included structured questionnaires and key informant interviews with local healthcare providers and Ministry of Health representatives. Quantitative and qualitative analyses were performed using Epi Info.

Results: The study found widespread ownership and use of the MCH Handbook among participants. While general oral hygiene practices were good, there was limited engagement with the comprehensive oral health information provided in the handbook. Despite the handbook’s availability, gaps in addressing early childhood caries persisted.

Conclusion: The MCH Handbook is a valuable resource, but its effectiveness in promoting comprehensive oral health needs improvement. Enhancing the handbook’s oral health education components could further improve maternal and child dental care, contributing to broader health outcomes and aligning with Universal Health Care goals.

Introduction

Maternal and Child Health (MCH) programs have been a cornerstone of Thailand’s Health Development Plan since 1962,¹⁾ receiving robust support as essential services aimed at promoting the health and well-being of women and children. These initiatives have significantly contributed to reducing maternal and child mortality rates in the country,^2,3) making Thailand a leader in MCH efforts in the South East Asian region. However, despite these achievements, a significant proportion of mothers and children continue to grapple with common morbidity concerns,⁴⁾ highlighting the need for ongoing and enhanced interventions to ensure better health outcomes.

To address these persistent challenges, the Maternal and Child Health (MCH) Handbook was introduced as a key tool in 1985.¹⁾ The MCH Handbook is a comprehensive tool designed to promote and maintain the health of mothers and children by providing essential health information that families can easily access and use. Since its inception, the handbook has been regularly updated to meet the evolving needs of healthcare providers and the communities they serve.⁵⁾ The current Thai MCH Handbook includes detailed records related to the reproductive health history of mothers, antenatal care schedules, pregnancy outcomes, and the growth and developmental milestones of their children. Additionally, it provides valuable information on immunizations, proper nutrition during pregnancy, early childhood stimulation, child nutrition, and overall child care practices.¹⁾

Thailand’s implementation of the MCH Handbook has played a pivotal role in achieving notable public health milestones. For example, the country’s Maternal Mortality Ratio (MMR) decreased to 29 per 100,000 live births in 2020—a figure that surpasses many other Southeast Asian nations and aligns with the global Sustainable Development Goal (SDG) target of 3.1, which aims to reduce MMR to less than 70 per 100,000 live births by 2030.^6,7) Additionally, under SDG target 3.2, which seeks to reduce the under-5 mortality rate (U5MR) to 25 or fewer per 1,000 live births and the neonatal mortality rate (NMR) to 12 or fewer per 1,000 live births by 2030, Thailand has already surpassed these goals. In 2022, Thailand’s U5MR was 8.132 per 1,000 live births,^7,8) while the NMR stood at 4.451 per 1,000 live births.^7,9) These achievements highlight the MCH Handbook’s crucial role in educating both mothers and healthcare workers, leading to improved maternal and child health outcomes across the country.

Insights from similar studies in other countries also underscore the handbook’s potential in advancing Universal Health Care (UHC) among marginalized and vulnerable populations. In the Philippines for example, the MCH Handbook has demonstrated its effectiveness in improving maternal and child health outcomes among the indigenous Tagbanua group.¹⁰⁾ This success is mirrored in various rural communities in Indonesia,¹¹⁾ Bangladesh,¹²⁾ Cambodia,¹³⁾ and Kenya,¹⁴⁾ where the handbook has positively impacted health practices and outcomes. Particularly, in the Tagbanua community in Coron, Palawan, the MCH Handbook significantly enhanced mothers’ knowledge, attitudes, and practices concerning antenatal care, postnatal care, and child care. The handbook facilitated crucial cross-provider information sharing and served as a reliable data source for monitoring healthcare services, including antenatal care and vaccinations. Additionally, it played a role in promoting health insurance enrollment, ensuring access to necessary healthcare services.¹⁰⁾

However, while the MCH Handbook has been successful in many areas, challenges remain—particularly in the realm of oral health. Previous studies have shown an increasing prevalence and severity of dental caries among children in Thailand, with early childhood caries emerging as a significant public health problem. Findings from the 2017 National Oral Health Survey revealed that over half (53%) of 3-year-old children and 76% of 5-year-old children had experienced dental caries.¹⁵⁾ The prevalence of dental caries in the primary and permanent teeth of children aged 5 and 12 years is also significantly higher than the global prevalence rates for ages 0–14, which are 52.9% and 52.0%, respectively.¹⁶⁾ Despite being an integral part of health promotion efforts, the MCH Handbook’s role in combating dental hygiene concerns appears to be underutilized. The handbook provides sections for health personnel to record oral health exams for both pregnant women and children, including checks for tooth decay, gingivitis, and other oral health indicators. It also offers guidance on proper oral care practices, such as brushing techniques and the use of fluoride toothpaste. However, the prevalence of early childhood caries suggests that these measures are not being fully effective. Furthermore, the study on the utilization of MCH Handbook focus on oral health issues is still limited.

In line with this, this study employed a descriptive cross-sectional survey with a mixed-methods approach, combining both quantitative and qualitative data collection and analysis, to explore the effective use of the MCH Handbook in promoting oral healthcare among pregnant women, mothers, and children in Bangkok, Thailand.

The study examined the current utilization of the MCH Handbook at a selected public health center in Bangkok, assessing how the handbook was employed in practice. It evaluated in particular the oral health practices of pregnant women, mothers, and children, identifying areas needing improvement. Additionally, the study investigated how it facilitated the promotion of oral care among these groups, evaluating the strengths and limitations of the handbook’s approach.

Key informant interviews were conducted with local healthcare providers and representatives from the Ministry of Health to gain insights into the practical application of the MCH Handbook and its potential for further enhancing oral health education activities. The study ultimately aimed to assess the feasibility of integrating more comprehensive oral health education within the handbook, with the goal of enhancing its effectiveness as a tool for promoting oral health across Thailand. This approach aligns with broader Universal Health Care (UHC) objectives by striving to improve healthcare equity, quality, and accessibility throughout Thailand.

Materials and methods

The study was conducted at Public Health Center No. 54 in Bangkok, Thailand, a facility that provides basic antenatal care to pregnant women and child care services to children under five years old. The target population consisted of pregnant women attending antenatal care and mothers with children under five years of age visiting the health center. A sample size of 160 participants was selected, comprising 80 pregnant women and 80 mothers with children under five years old. Participants were recruited through purposive sampling. In addition to the pregnant women and mothers, key informants from the local health center, including doctors, midwives, health volunteers, and representatives from the Ministry of Health, were interviewed.

The sample size was determined through sensitivity analysis, using estimates from a previous study conducted in Indonesia on the utilization of the MCH Handbook among similar populations. The estimated proportion (p) ranged between 80% to 96%, with a maximum tolerable error (d) of 5% to 9%. The final sample size was calculated for a 95% confidence level,¹⁷⁾ resulting in a required sample of 76 participants. Accounting for a 5% refusal rate, the final sample size was set at 80 for both pregnant women and mothers.

A questionnaire survey was adapted from a previous study conducted in Jakarta, Indonesia, and modified based on the suggestions of local MCH experts in Thailand. The survey included two questionnaires, one for pregnant women and one for mothers, with additional inquiries specific to mothers of children under five years old. The questionnaires covered socio-demographic characteristics, reproductive health background, utilization of the MCH Handbook, current oral care practices, and attitudes toward oral healthcare promotion and education. The questionnaires were pretested, and reliability was assessed using Cronbach’s alpha, calculated after pretesting with 20 pregnant women and 20 mothers attending MCH services at the health center.

Key informants, including local healthcare providers and Ministry of Health representatives, were interviewed to gather insights on the general utilization of the handbook, its advantages and challenges, and suggestions for its improvement. The interviews also explored the feasibility of further using the MCH Handbook to promote oral healthcare in the community.

Data was collected through face-to-face interviews using structured questionnaires. The fieldwork took place following the ethics review and approval of the Bangkok Metropolitan Center and the Ministry of Public Health. Each completed survey was reviewed by the head interviewer for accuracy before data encoding.

Data analysis was performed using Epi Info, with qualitative and recoded quantitative variables reported as absolute and relative frequencies (percentages). Quantitative variables were presented using means and standard deviations for normally distributed data, or medians and ranges for non-normally distributed data. Findings were presented in tabular and graphical formats, highlighting the utilization of the MCH Handbook and current oral health practices among the target population. The interview data provided insights into how the handbook promotes oral care and the feasibility of integrating more comprehensive oral health education activities.

Due to logistical constraints, purposive sampling was employed during data collection. The research protocol was approved by the Bangkok Metropolitan Administration Human Research Ethics Committee (BMAHREC) E002q/58. Free, Prior, and Informed Consent (FPIC) was secured from all participants, ensuring compliance with ethical standards and regulations. Ethical considerations were strictly followed, with informed consent obtained from all participants. Participants were informed about the content, sponsorship, and purpose of the survey, and assured of the confidentiality and anonymity of their responses. All completed survey forms will be destroyed after the study concludes to ensure data privacy.

Results

This section provides a comprehensive summary of the study’s findings, covering several key areas. First, it outlines the respondents’ characteristics, including their demographic and socio-economic backgrounds. Building on this, the study examines the utilization of the MCH Handbook in Thailand, focusing on its effectiveness and the frequency with which participants use it. Next, the findings delve into oral care practices, exploring the habits related to maintaining oral hygiene. This leads to a discussion on the dental health situation and eating habits, which addresses common dental issues, access to care, and how eating habits impact oral health. Finally, the study assesses attitudes toward oral education messages, evaluating how receptive participants are to these messages and their influence on oral care behaviors.

In examining the respondent characteristics involving 80 pregnant women and 82 mothers with under-five (U5) children, the study found that the average age of the pregnant women was 25.79 years, with a standard deviation of 5.66 years, while the average age of the mothers with U5 children was 28.08 years, with a standard deviation of 8.43 years. The age difference between the two groups was statistically significant (P-value=0.0445).

The socio-economic characteristics revealed that 47.5% of the pregnant women and 43.9% of the mothers with U5 children had completed secondary education. A significant proportion of respondents identified as Buddhists, with 92.5% of pregnant women and 81.7% of mothers with U5 children adhering to this religion. Employment status varied, with 72.5% of pregnant women and 50.0% of mothers with U5 children being employed. Most respondents’ husbands were also employed, with 91.2% of pregnant women’s husbands and 75.6% of mothers with U5 children’s husbands in employment. The average monthly income for pregnant women’s families was 18,091.2 baht, with average expenditures of 9,993.8 baht. In comparison, the families of mothers with U5 children had a higher average income of 18,839.5 baht and monthly expenses averaging 10,224.7 baht. Over half of the pregnant women and mothers with U5 children had one child.

The pregnant women who participated in the study were, on average, in their 18.28 weeks of pregnancy, with a range from 4 to 36 weeks. The youngest children of the mothers with U5 children had an average age of 12.57 months, with a range from 1 to 60 months.

Transitioning to the utilization of the MCH Handbook, it was observed that a majority of mothers, including 98.8% of pregnant women and 100% of mothers with U5 children, owned the handbook. Among these, 89.9% of pregnant women and 96.3% of mothers with U5 children were able to show their MCH Handbook, with a statistically significant difference in the likelihood of carrying the handbook to health facilities (P-value=0.006).

The frequency of bringing the MCH Handbook to health facilities did not show a statistically significant difference between the two groups, with over 50% of both groups bringing their handbook regularly. However, a higher percentage of mothers with U5 children read their MCH Handbook (91.4%) compared to pregnant women (74.7%), and the difference was statistically significant (P-value=0.006).

While a significant number of respondents read only parts of the handbook, with 44.3% of pregnant women and 53.7% of mothers with U5 children reading only a small portion, this difference was significant (P-value=0.038). Pregnant women predominantly read about their own health, health concerns during delivery, and newborn health. Conversely, mothers with U5 children focused more on baby and children’s health, child development stimulation, and pregnancy-related health.

Most respondents expressed satisfaction with the MCH Handbook with high percentages indicating contentment. Among pregnant women, 96.2% consistently filled in both the family identity section and the pregnant woman health record. In contrast, mothers with U5 children most frequently completed records related to pregnancy, delivery, and newborn health.

In terms of the oral care practices, the study revealed that all mothers with children under five years old and 97.5% of pregnant women engage in teeth cleaning. However, only 58.5% of the children under five years old of the mothers interviewed practice regular teeth cleaning. The difference in the proportion distribution between pregnant women and mothers with children under five years old is not statistically significant (P-value=0.242).

A significant percentage of pregnant women (60.3%), mothers with children under five (56.1%), and their children (68.8%) brush their teeth twice a day. The proportion distribution between the two groups of mothers is not statistically significant (P-value=0.744).

Most pregnant women (89.8%) and mothers with children under five (78.0%) brush their teeth before sleeping. Similarly, 89.7% of pregnant women and 67.1% of mothers with children under five brush their teeth after waking up or before breakfast. For children under five, 75.0% brush their teeth after waking up or before breakfast, and 64.6% brush before sleeping.

The majority of pregnant women and mothers with children under five use a toothbrush and toothpaste to clean their teeth, with 79.2% of children under five also using these tools.

The top three features pregnant women look for in toothpaste are cavity prevention (92.3%), bad breath prevention (68.0%), and mouth refreshment (24.4%). For mothers with children under five, the top features are cavity prevention (90.2%), bad breath prevention (75.6%), and teeth whitening (23.2%). Children under five prioritize cavity prevention (92.1%), toothpaste with famous characters (92.1%), and fluoride inclusion (44.7%). The proportion distribution between pregnant women and mothers with children under five is not statistically significant across these features.

All respondents, including pregnant women, mothers with children under five, and their children, have their own toothbrush. Most reported changing their toothbrush regularly: 89.7% of pregnant women, 92.7% of mothers with children under five, and 94.7% of children under five. A high percentage of pregnant women (84.3%), mothers with children under five (69.7%), and children under five (83.3%) change their toothbrush every one to three months, with no statistically significant difference between pregnant women and mothers with children under five (P-value=0.107).

Pregnant women typically prefer soft (43.6%) or medium toothbrushes (43.6%). For mothers with children under five, 53.7% use medium brushes, while 86.8% of children under five prefer soft brushes. The proportion distribution between pregnant women and mothers with children under five is not statistically significant (P-value=0.339).

The primary reason for brushing teeth among pregnant women is caries prevention (71.8%). This is also the leading reason for 84.2% of mothers with children under five and 86.8% of children under five. The differences in proportions are not statistically significant.

Two pregnant women who do not clean their teeth believe it is unnecessary due to hereditary factors and lack of habit from childhood. For children under five, reasons for not brushing include lack of habit (38.2%), being too young (29.4%), or the belief that teeth are not dirty (17.6%).

In terms of dental issues in the past six months, 50.0% of pregnant women, 47.6% of mothers with children under five, and 8.6% of children under five reported problems. The proportion distribution between pregnant women and mothers with children under five is not statistically significant (P-value=0.875).

Pregnant women most commonly visit the dentist for tooth decay (37.5%), toothache (32.5%), and gum bleeding (22.5%). For mothers with children under five, the primary reasons are toothache (28.5%), tooth decay (25.6%), swollen gums (17.9%), and bad mouth odor (17.9%). Children under five typically visit the dentist due to bad mouth odor (42.8%), tartar or stains (28.6%), tooth decay (14.3%), and swollen gums (14.3%).

The majority of pregnant women (52.5%) and mothers with children under five (64.6%) visit the dentist when experiencing dental pain. In contrast, 63.4% of children under five have never visited a dentist. Most recent visits to the dentist for 39.6% of pregnant women, 36.2% of mothers with children under five, and 73.3% of children under five occurred six months ago.

On their last visit to the dentist, 39.6% of pregnant women and 39.1% of mothers with children under five received scaling. All children under five visited the dentist for consultation. Interestingly, 30.5% of mothers believe that teeth cleaning should start when the first tooth appears, while another 30.5% think it should never start.

In terms of the dental health situation and eating habits, the study revealed that the dental health situation of the respondents has significant differences between pregnant women and mothers of children under five (U5). A notable percentage of pregnant women (36.2%) reported having no dental caries. In contrast, a substantial 42.7% of mothers with U5 children indicated that their children had one to two teeth affected by dental caries. On the other hand, a majority of 85.4% of mothers with U5 children reported that their child had no dental caries.

Regarding perceptions of dentition, there was a divergence in opinion. Among pregnant women, 41.2% believed their dental health was better than average, while another 41.2% felt it was worse than average. In comparison, 52.4% of mothers with U5 children rated their own dental health as better than average, and an impressive 90.2% believed their child’s dental health was better than average.

Regarding eating habits, a significant majority of pregnant women (85.0%) and mothers with U5 children (76.8%) reported eating three meals a day. For U5 children, 46.2% also had three meals per day. Dietary restrictions varied: 47.5% of pregnant women and 64.6% of mothers with U5 children reported not being able to eat certain foods. Conversely, 74.4% of U5 children were reported to be able to eat any food. Snacking habits were reported by 81.2% of pregnant women and 68.3% of mothers with U5 children. In contrast, 67.1% of U5 children were reported to snack infrequently.

Consumption of drinks with high sugar content was noted by 71.2% of pregnant women and 57.3% of mothers with U5 children. A smaller proportion of U5 children (41.5%) were reported to consume sugary drinks only sometimes. When asked about the consumption of candies or caramels that linger in the mouth, 52.5% of pregnant women and 58.5% of mothers with U5 children reported doing this sometimes. In contrast, 51.2% of U5 children did not consume such sweets at all.

Consumption of chocolates, cakes, and snacks that easily stick to teeth was reported sometimes by 66.2% of pregnant women and 65.8% of mothers with U5 children. Over half (52.4%) of U5 children were reported to not consume such sticky foods at all.

In terms of dietary concerns, 57.5% of pregnant women and 53.7% of mothers with U5 children were mindful of the amount of food in their diet. Additionally, 36.6% of mothers were concerned about their child’s food quantity. Regarding caloric content, 51.2% of pregnant women and 48.8% of mothers with U5 children expressed concern. However, 35.4% of mothers did not worry about their child’s caloric intake.

Sugar content in food was a concern for 51.2% of pregnant women and 58.5% of mothers with U5 children. Additionally, 40.2% of mothers were concerned about the sugar content in their child’s food. Concerns about an unbalanced diet were expressed by 45.0% of pregnant women and 47.6% of mothers with U5 children. Furthermore, 32.9% of mothers were concerned about their child’s diet balance. Finally, concerns about snacking in the diet were noted by 37.5% of pregnant women and 46.3% of mothers with U5 children. Additionally, 39.0% of mothers expressed concern about their child’s snacking habits.

In assessing the attitude toward oral education messages, it was found that all pregnant women in the study unanimously agreed that more knowledge about oral health care is needed during pregnancy, with 50.0% strongly agreeing and another 50.0% slightly agreeing. Similarly, a significant proportion of mothers with children under five (U5) also acknowledged the need for additional knowledge about oral health care—63.4% slightly agreed with its importance during pregnancy, and 64.6% felt the same regarding their child’s oral health.

When evaluating the importance of educational messages on oral health care, 53.8% of pregnant women strongly agreed that such messages are important, while 41.5% of mothers with U5 children strongly agreed. Additionally, 62.2% of mothers with U5 children slightly agreed on the importance of educational messages concerning their child’s oral health.

Regarding the usefulness of educational messages on oral health care during pregnancy within the MCH Handbook, 52.5% of pregnant women strongly agreed that these messages are beneficial. Conversely, a high percentage of mothers with U5 children (62.2%) only slightly agreed on the usefulness of such messages. The same proportion of mothers (62.2%) also slightly agreed on the usefulness of educational messages about their child’s oral care in the handbook.

Discussion

This study utilized a descriptive cross-sectional survey with a mixed-methods approach to evaluate the effectiveness of the MCH Handbook in promoting oral healthcare among pregnant women, mothers, and children in Bangkok. The findings provide key insights into the handbook’s impact and areas for enhancement.

The study highlighted significant age-related differences between pregnant women and mothers of young children, which influence their healthcare needs and behaviors. Younger pregnant women are often in the early stages of developing health-related routines, while older mothers may have established practices. Although both groups have similar educational levels and employment statuses, pregnant women typically have lower incomes and expenditures than mothers of young children. These economic differences can affect access to healthcare resources and time available for health-related activities, suggesting the need for tailored interventions to address varying financial pressures.

The MCH Handbook is highly valued by both groups, reflecting its importance in managing maternal and child health. However, the depth of engagement with the handbook varies between the groups. Pregnant women primarily focus on sections related to personal health, delivery, and newborn care, indicating that the handbook is a crucial resource for managing immediate concerns during pregnancy and early motherhood. In contrast, mothers with young children engage more extensively with sections related to child health, development, and stimulation, reflecting a shift in focus as their children grow and their health needs evolve. This variation in engagement suggests that while the handbook is frequently brought to health facilities, the extent of its use and the sections read differ between pregnant women and mothers with young children.

Despite high ownership and satisfaction levels, many respondents read only parts of the handbook, indicating that its full potential is not fully realized. This partial engagement underscores the need for improvements in the handbook’s content and usability to ensure more comprehensive use across its range of topics. Enhancing the handbook’s relevance to both stages of maternal and child health could significantly improve its effectiveness.

Oral care practices reveal a mixed picture. While both pregnant women and mothers generally maintain regular teeth cleaning, a significant number of children under five do not follow this routine. This highlights the need for targeted interventions to improve early childhood dental hygiene. Additionally, preferences for oral care products show a focus on cavity prevention and bad breath control, but making dental care products more appealing to children could increase engagement.

In terms of dietary habits, both groups consume three meals a day, but snacking is common among adults, with less frequent snacking reported for children. High sugar intake remains a concern, particularly for pregnant women and mothers, although children show more restraint in consuming sugary drinks and sticky sweets. This pattern suggests a need for greater emphasis on children’s dietary habits and dental health.

Attitudes toward oral health education messages within the MCH Handbook reveal a strong consensus on the need for such education. Pregnant women universally agree on the importance of increased knowledge about oral health care, with half strongly agreeing and half slightly agreeing. Similarly, mothers of young children recognize the need for more information, though to a slightly lesser extent. Despite acknowledging the importance of educational messages, there is variability in their perceived usefulness, particularly among mothers of young children. This suggests a need for tailored educational interventions to enhance the effectiveness of oral health messages for both groups. Previous studies found that educational message on oral care could be an effective option to improve the oral health among children.^18,19,20)

The study underscores the continued relevance of the MCH Handbook, with high levels of ownership and satisfaction among both pregnant women and mothers of young children. However, improvements are needed in areas such as oral care practices, dietary habits, and educational messages. Recommendations include incorporating comprehensive oral health information for pregnant women in the next MCH Handbook revision and enhancing educational messages with engaging visuals to encourage better understanding and application. Optimizing the utilization of MCH Handbook as the medium for information and education about oral health will be beneficial for improving health status among mother and children. By addressing these areas, the MCH Handbook can better align with Universal Health Care (UHC) objectives, ultimately improving healthcare equity, quality, and accessibility throughout Thailand.

Acknowledgements

The author acknowledges the College of Arts and Sciences of the University of the Philippines Manila and the Faculty of Health Sciences of the Universitas Islam Negeri Syarif Hidayatullah Jakarta, Indonesia for their generous institutional support. Their resources, academic environment, and collaborative spirit have been crucial in advancing and completing this research.

Heartfelt appreciation is also extended to the International Committee on Maternal and Child Health (MCH) Handbook, led by Prof. Yasuhide Nakamura, for the opportunity to disseminate these findings. The collaboration has enriched the research process and facilitated the sharing of insights within the global maternal and child health community.

Special thanks go to Public Health Center No. 54 in Bangkok, Thailand, where the study was conducted, and to the Bangkok Metropolitan Center for approving the fieldwork. Gratitude is also owed to the Ministry of Public Health, including local health centers, doctors, midwives, health volunteers, and representatives, for their valuable contributions during key informant interviews. Finally, sincere thanks to the Bangkok Metropolitan Administration Human Research Ethics Committee (BMAHREC) for their assistance with ethics approval.

Conflict of interest

The author has no affiliations with companies or entities that could financially influence the content of this information. There are no conflicts of interest to disclose, ensuring that the work and its interpretation are free from bias.

Should any potential conflicts of interest emerge during the review or publication process, the author will promptly inform the editors. The author remains dedicated to transparency and integrity in presenting research findings and recognizes the importance of delivering a clear and unbiased account of the work.

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