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ORIGINAL ARTICLE
Year : 2017  |  Volume : 15  |  Issue : 1  |  Page : 11-16

Mothers’ Sense of Coherence as a Predictor of Oral Health Related Quality of Life Among Preschool Children: A Cross-Sectional Study


Department of Public Health Dentistry, Government Dental College and Research Institute, Bangalore, India

Date of Web Publication14-Mar-2017

Correspondence Address:
Jesline M James
Department of Public Health Dentistry, Government Dental College and Research Institute, Victoria Hospital Campus, Fort, Bangalore - 560 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-5932.201939

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  Abstract 

Introduction: Sense of coherence (SOC) influences an individual’s health-related behaviours and practices. A mother’s SOC can influence oral health status and oral health related quality of life (OHRQoL) of their children. Studies exploring the association between these variables are scarce. Aim: To determine a mother’s SOC, the child’s caries experience and OHRQoL and the association between these variables among mother–child pairs in Bangalore city. Materials and Methods: A total of 200 preschool children and their mothers from government and private preschools participated in the study. The mother’s SOC was assessed using Antonovsky’s 13-item SOC questionnaire, whereas OHRQoL of preschool children was assessed using Early Childhood Oral Health Impact Scale (ECOHIS). Caries experience [decayed, missing and filled teeth (dmft)] was recorded using World Health Organization criteria 2013. Descriptive and inferential statistics were applied. Mann–Whitney U test, t-test, Pearson correlation test and regression analysis were also applied. Significance was set at 5%. Results: The mean SOC score of the mothers and ECOHIS score were 53.79 ± 11.68 and 17.23 ± 7.87, respectively. The mean caries experience score was 0.99 ± 1.48. In this study, dmft negatively correlated with SOC [(r = −0.367), (P < 0.001)] and positively correlated with ECOHIS [(r = 0.679), (P < 0.001)]. SOC negatively correlated with ECOHIS [(r = −0.369), (P < 0.001]. Conclusion: Mother’s SOC negatively correlated with the child’s caries experience, which affected their OHRQoL. Hence, improving a mother’s SOC is the key to better oral health and quality of life.

Keywords: Dental caries, Early Childhood Oral Health Impact Scale, preschool children, sense of coherence


How to cite this article:
James JM, Puranik MP, Sowmya K R. Mothers’ Sense of Coherence as a Predictor of Oral Health Related Quality of Life Among Preschool Children: A Cross-Sectional Study. J Indian Assoc Public Health Dent 2017;15:11-6

How to cite this URL:
James JM, Puranik MP, Sowmya K R. Mothers’ Sense of Coherence as a Predictor of Oral Health Related Quality of Life Among Preschool Children: A Cross-Sectional Study. J Indian Assoc Public Health Dent [serial online] 2017 [cited 2019 Nov 13];15:11-6. Available from: http://www.jiaphd.org/text.asp?2017/15/1/11/201939


  Introduction Top


Health is a multidimensional concept that is determined by biological, environmental, social, cultural and economic elements.[1] The concept of social determinants of health has cemented the way to the approaches that highlight the social context and its inter-relation with both biological and psychological factors.[2]

It is reported that psychological factors augment an individual’s propensity to perform health-promoting behaviours.[3] Salutogenesis theory proposed by Antonovsky is a psychosocial approach that focuses on the factors that support human health and well-being. The concept of salutogenesis is measured by sense of coherence (SOC).[4] Salutogenesis and SOC explain why some individuals remain healthy even after an exposure to highly stressful life situations, whereas others end up with disease and illness.[5] The concept of SOC consists of the following three components: comprehensibility, manageability and meaningfulness.[6] It is suggested that SOC can augment a person’s awareness of oral health. The stronger the SOC, the higher the acceptance and adoption of effective health behaviours.[2]

A child’s oral health and related behaviours are influenced by their caregivers’ oral health related knowledge, behaviour and attitudes.[3] It has been reported that the mothers’ social and psychological factors are related to caries experience in children.[7] Dental caries (tooth decay) is one of the most prevalent chronic childhood diseases and is a major problem from the public health perspective, as well as for individual families.[3] It is important to evaluate the oral health impact on children’s quality of life because of the influential role of oral status on growth, self-confidence, socialization and learning abilities.[8]

Many assessment tools have been developed to measure the impact of oral problems on quality of life. The Early Childhood Oral Health Impact Scale (ECOHIS) was first designed in the UK and USA to assess the impact of oral health problems on quality of life in preschool children and their families. It consists of two fields. These two fields are related to the impact of oral health on the child’s and the family’s quality of life, respectively.[8]

Studies have shown association between higher SOC scores and healthier dietary patterns, especially with consumption of fewer sweet drinks and lower frequency of snacking. Higher SOC scores were also associated with regular dental visits.[3] A study conducted in India has reported that children of the mothers with high SOC were more likely to have high oral health related quality of life (OHRQoL).[7] However, studies exploring the association between SOC of mothers, caries experience and OHRQoL of their preschool children are scarce.

Hence, this study was conducted with the following objectives:


  1. To assess the mother’s SOC, the child’s caries experience and OHRQoL.


  2. To determine the association between a mother’s SOC and a child’s caries experience.


  3. To determine the association between a child’s caries experience and its impact on OHRQoL.


  4. To determine the association between a mother’s SOC and a child’s OHRQoL.



  Materials and Methods Top


A cross-sectional study was conducted among preschool children aged 3–5 years and their mothers from September to October 2015 in Bangalore city. A protocol of the intended study was submitted to the Institutional Ethical Committee, and ethical clearance was obtained. Permission was obtained from the administrators and head of preschools after explaining the purpose and procedure of the study. The study participants were informed about the study and ensured that their participation was purely voluntary, following which, written informed consent was obtained from the mothers.

A pilot study was conducted among 20 mother–child pairs from one of the preschools to check the feasibility of the study and to determine the sample size. Considering the caries experience of 70%, 95% confident interval (CI) level and 80% power, the sample size was determined as 164, which was rounded off to 200.

A list of government and private preschools was obtained from Bruhat Bangalore Mahanagara Palike. From this list, four government and four private preschools were selected randomly. Hundred study participants were recruited equally from government and private preschools. Children aged 3–5 years and mothers who can read and understand Kannada or English were included, and children with systemic diseases and those who were uncooperative were excluded.

SOC questionnaire and ECOHIS were translated to the local language (Kannada). The validity was checked by back translation involving retranslation into English independently by bilingual experts. Furthermore, it was assessed for readability and comprehension by the participants during the pilot study. Internal consistency of SOC and ECOHIS was checked using Cronbach’s alpha, which was found to be 0.75 and 0.78, respectively. A training and calibration session on assessing caries experience was conducted with ten patients from the out-patient department. The procedure was repeated on the same patients later. The intra-examiner reliability was 0.82.

Data were collected using a structured pro forma consisting of three parts. The first part of the pro forma comprised general information regarding the participant’s socio-demographic variables, medical history, dental history and oral hygiene practices. The second part consisted of questionnaires on SOC scale[9] and ECOHIS.[10] SOC consisted of 13 questions assessing manageability (four items), comprehensibility (five items) and meaningfulness (four items) of different situations in life rated on a 7-point scale. ECOHIS consisted of 13 questions with two fields. The impact of oral health on the child’s quality of life was measured with nine questions, and the impact of oral health on the family’s quality of life was measured with four questions. The questions were scored on a 6-point Likert scale as ‘Never’ (1) to ‘Don’t know’ (6). The third part included assessment of caries experience [decayed, missing and filled teeth (dmft)] using World Health Organization 2013 criteria.[11]

The prerequisite data were collected during school hours from mothers and children. After obtaining the general information, the questionnaires were distributed to the mothers, and instructions were given. Questionnaires were collected immediately and checked for its completeness. Children were examined in their classrooms on a comfortable chair under natural light by a single investigator and the details recorded by a trained assistant. Subsequent to dental examination, tooth-brushing technique was demonstrated, and the participants were referred to the college for further dental treatment if required.

The armamentarium included the following: mouth mirror, Community periodontal Index (CPI) probe, chip blower, tweezers, kidney trays, gloves, mouth mask, disinfecting solution, cotton and cotton holders. Sufficient number of autoclaved instruments was taken for the day-to-day examination. Infection control and sterilization measures were observed throughout the study.

Codes were given for the responses, and care was taken to reverse the codes for negatively worded items. Data collected were entered in a MS Excel sheet. Descriptive statistics were computed with the Statistical Package for the Social Sciences version 22 software (SPSS Inc., Chicago, IL, United States). Descriptive statistics with frequency, mean and standard deviation were computed. Mann–Whitney U test, t-test, Pearson correlation test and regression analysis were applied. In regression analysis, caries experience and SOC scores were considered independently as outcome variables. A P value of <0.05 was considered as significant.


  Results Top


A total of 200 preschool children and their mothers participated in the study, out of which 100 were selected from government preschools and 100 from private preschools. Age- and gender-wise distribution of study participants are given in [Table 1], wherein those belonging to male and female sexes were maximum in number for the ages 4 and 5 years, respectively. Most of the parents of the children from government preschool had education up to intermediate or diploma level, whereas parents of the children from private preschools were educated up to professional level. Majority of the fathers performed clerical or skilled jobs, whereas mothers were unemployed in both the groups. Majority of the study participants had an income range from Rs. 14,633 to Rs. 39,019 and belonged to either upper middle class or lower middle class.[12]
Table 1: Age- and gender-wise distribution of preschool children

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There was no relevant medical history. Nearly one-tenth of the participants from each group had visited a dentist before for routine checkups. Most of the study participants used toothbrush and toothpaste, and followed either vertical or horizontal tooth-brushing methods, once daily before meals. Majority of the study participants were on a mixed diet in both the groups.

The mean SOC score of the mothers was 53.79 ± 11.68. The mean SOC score of the mothers of government preschool children was significantly lower than that of the mothers of private preschool children (P = 0.01). The mean caries experience, mean dt, mt and ft scores were 0.99 ± 1.48, 0.86 ± 1.40, 0.02 ± 0.12 and 0.09 ± 0.28, respectively. The mean dt and mt components were higher among government preschool children, whereas the mean ft component was higher among private preschool children. A significant difference between the two groups was observed only with dt scores (P = 0.01). The mean ECOHIS score was 17.23 ± 7.87. Although the mean scores of child-impact domain and parent-impact domain were lower among the government preschool children, there was no statistically significant difference between the two groups [Table 2].
Table 2: Mean SOC, dmft and ECOHIS scores of the study participants

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The correlation between the three variables is given in [Table 3]. In both the groups, dmft negatively correlated with SOC [(r = −0.367), (P < 0.001)] and positively correlated with ECOHIS [(r = 0.679), (P < 0.001)]. SOC was negatively correlated with ECOHIS [(r = −0.369), (P < 0.001)].
Table 3: Correlation between dmft, ECOHIS and SOC scores

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Overall, the combined effect of age, gender, mother’s education, socio-economic status, SOC and dmft as dependent variables significantly contributed to ECOHIS in this study among study participants from government and private preschools [Table 4].
Table 4: Step-wise multiple regression analysis with ECOHIS score as dependent variable for the study participants

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The logistic regression analyses between SOC and dmft, SOC and OHRQoL and dmft and OHRQoL are shown in [Table 5]. In both the groups, the children of the mothers with low SOC scores were more likely to experience dental caries when compared to the children of the mothers with high SOC scores [odds ratio (OR) = 1.93, CI = 0.73–4.39, P = 0.16]. The children with no caries were more likely to experience better quality of life when compared to the children with caries (OR = 4.73, CI = 1.73–9.39, P < 0.001). The odds of having better quality of life was more among the children of the mothers with high SOC (OR = 1.35, CI = 0.61–4.92, P = 0.23).
Table 5: Logistic regression analysis between the variables

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  Discussion Top


SOC is a psychosocial determinant that can influence health-related behaviours of individuals. It has been shown that people with high levels of SOC have healthier lifestyles compared with those with lower SOC.[7] The responsibility of the child’s health usually belongs to the child’s parents, and decisions regarding the child’s health are also taken by their parents. Studies have shown the influence of mothers on their children’s oral health and behaviours. In addition, mothers’ psychosocial factors are believed to influence their children’s oral health status.[7] Hence, it is of utmost importance to evaluate the mothers’ perception towards their children’s oral health problems, including how related symptoms, diseases and treatments might influence their children’s quality of life.

This study assessed the relation between the mothers’ SOC and oral health-related quality of life of 3- to 5-year-old preschool children in Bangalore city. ECOHIS was used to assess the OHRQoL of preschool children.

Dental caries remains the most important childhood disease affecting a considerable proportion of young children worldwide. Age, gender, socio-demographic variables and behavioural factors can act as caries risk factors associated with the host. One of the most susceptible periods for dental caries occurrence is 2–5 years of age.

This study included 200 preschool children of the age group 3–5 years, with the majority being 4 years. Various studies reported in literature present an age group that ranged from 2 to 6 years.[7],[8],[10],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27] In two studies, the participants were divided into sub-groups, which included children from both private and public sectors.[24],[26] Gender-wise, the participants were distributed nearly equal, which was in line with most of the studies.[7],[8],[10],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27] Among government preschool children, the male sex was predominant, whereas in private preschool children, the female sex was predominant.

Studies have reported caries experience in the range of 1.62 ± 2.30 to 6.1 ± 3.99,[8],[18],[19],[20],[21],[22],[23],[25],[26] which was higher when compared to this study. There was no statistically significant difference between government and private preschool children. Studies have reported mean dt component in the range of 2.1 ± 4.11 to 4.6 ± 3.66,[23],[26] which was higher when compared to this study. Studies have reported mean mt component in the range of 0.12 ± 0.53 to 0.54 ± 1.21,[23],[26] which was higher when compared to this study. Studies have reported mean ft component in the range of 0.24 ± 3.10 to 0.92 ± 2.60,[23],[26] which was higher when compared to this study. There was no statistically significant difference between the groups in the mean caries experience except for dt component. This clearly reflected the high level of unmet dental needs, lack of utilization of oral health services or lack of oral health awareness among the parents.

In this study, the mean SOC scores of the mothers were found to be 53.79 ± 11.68, which was lower than what was reported in another study.[3] The mean SOC score among the mothers of government preschool children was significantly lower than the mothers of private preschool children (P = 0.01).

In this study, mean ECOHIS score was found to be higher than another study.[8] Although the mean ECOHIS score of government preschool children was lower when compared to private preschool children, the difference was not statistically significant. Higher ECOHIS scores suggest poorer OHRQoL and vice versa. ECOHIS scores were lower in both the groups and are suggestive of better OHRQoL.

Correlation analysis was performed between SOC, caries experience and OHRQoL. Significant negative correlation was observed between the child’s dmft and the mother’s SOC. Thus, increase in the mother’s SOC (health) is associated with decrease in dmft of the children (disease) and vice versa. A positive correlation was found between dmft and ECOHIS scores. Thus, the increase in dmft (disease) is associated with increase in ECOHIS (poor OHRQoL) scores. In the same way, decrease in dmft (disease) is associated with decrease in ECOHIS (better OHRQoL) scores. This was suggestive of the impact of dental caries on OHRQoL and was in accordance with previous studies.[7],[8],[14] A negative correlation was observed between SOC and ECOHIS in both the groups, which, therefore, implied that SOC of the mothers positively influenced the child’s OHRQoL. Higher the mother’s SOC, lower were the ECOHIS scores, which meant better OHRQoL of their children.

Multiple linear regression analysis was performed to determine the role of socio-demographic variables, SOC and caries experience on OHRQoL. The collective effect of age, gender, mother’s education, socio-economic status and SOC and dmft contributed significantly for the occurrence of ECOHIS in preschool children, overall as well as in the sub-groups. This possibly indicated the role of covariates, subjective perceptions and disease experience on OHRQoL.

Logistic regression analysis was done to assess the association between SOC and dmft, dmft and OHRQoL as well as SOC and OHRQoL. The children of the mothers having low SOC scores were more likely to experience dental caries when compared to the children of the mothers with high SOC scores, which was in accordance with another study.[7] The children with caries experience were more likely to experience poorer quality of life when compared to the children without caries experience. The children of the mothers having low SOC scores were more likely to experience poorer quality of life when compared to the children of the mothers with high SOC scores.

Mothers as primary caregivers influence their child’s life substantially. This study demonstrated significant association between the mothers’ SOC and the child’s oral health and quality of life. Improving the mother’s SOC is a psychological approach that can influence the child’s oral health and quality of life. Life course approach, positive and active engagement in life, coping with emotional stress and a coherent understanding of different situations in life act as strong predictors of SOC. Besides health education, health promotional measures may be targeted towards mothers for better oral health outcomes.

This study has some limitations. The cross-sectional design, sample size and inherent biases in questionnaire study limit its generalisability. SOC questionnaire is difficult to comprehend especially for people with low educational background. This questionnaire is associated with general life situations. It is not exclusively meant to measure the oral impacts or the influence of oral problems in general life situations. SOC includes responses in extreme situation only with numbers in between these situations. This might make it difficult for the respondents to exercise the options appropriately. Hence, further studies may be conducted to assess the applicability of this questionnaire in other populations.

One of the important challenges when evaluating preschool children’s oral and dental health problems is their lack of cognitive growth and unreliable responses. Parent’s assistance is required to assess the children’s quality of life. It must be pointed out that outcome of ECOHIS questionnaire is completely dependent on the parents’ understanding of their children’s oral health and its impact on the children and their families. Therefore, parents’ individual and social differences and their responses to the questions might affect the study results. In addition, there is no specific cut-off point to segregate ECOHIS scores as high or low. Studies have used mean or median scores to categorize it as high or low. Hence, more sensitive scales or simpler measures with a standardized cut-off point to assess the child’s perception are needed.


  Conclusion Top


In the study, dmft negatively correlated with SOC and positively correlated with ECOHIS. SOC was found to be negatively correlated with ECOHIS, which was suggestive of better OHRQoL among children. Hence, SOC of mothers influenced caries experience of the children and their quality of life, which was evident among government and private preschools. Therefore, improving the SOC of mothers might positively influence their children’s oral health and quality of life.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[27]



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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