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Year : 2015  |  Volume : 13  |  Issue : 4  |  Page : 479-485

Relationship between the sense of coherence and quality of life among institutionalized elders in Bengaluru city India: A questionnaire study

Department of Public Health Dentistry, VS Dental College and Hospital, Bengaluru, Karnataka, India

Date of Web Publication7-Dec-2015

Correspondence Address:
B Kumara Raja
Department of Public Health Dentistry, VS Dental College and Hospital, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2319-5932.171172

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Introduction: Aged people living in residential homes have a higher prevalence of depression and stress which cause oral health-related problems, contributing to excessive morbidity, than do those who live in communities. Aim: To find the relationship between senses of coherence (SOC) and quality of life (QoL) using Geriatric Oral Health Assessment Index (GOHAI) among elderly residents of old age homes in Bengaluru city, India. Materials and Methods: A cross-sectional study was conducted among elderly residents of Bengaluru city, India. Data were collected using a validated questionnaire which record demographic details, oral hygiene practices, and oral health habits. SOC and oral health-related QoL was measured using 13-item short version of the SOC scale and 12-item GOHAI scale. Chi-square test and Pearson's correlation coefficient test were used for statistical analysis. All variables showing significant association (P < 0.05) were entered into a regression model to identify predictors of low GOHAI and SOC. Results: A total of 376 elderly residents participated in the study and completed the questionnaire. Among them 150 (39.9%) were men and 226 (60.1%) were women. SOC was statistically significant with gender (P = 0.008), marital status (P = 0.003), dentition status (P = 0.000), smoking (P = 0.043), and alcohol consumption (P = 0.043). Age (P = 0.036), gender (P = 0.045), dentition status (P < 0.019), and smoking (P = 0.042) were found to be associated with GOHAI, there also exist a strong Pearson's correlation (r = 0.712) between SOC and GOHAI scores. Conclusions: A strong positive correlation was found between SOC and GOHAI scores indicating elder's with low SOC had low GOHAI scores and vice versa. The elders in residential homes were found to have more self-reported oral health-related functional problems, so dental health education must be focused on the special needs of the disabled, dependant and socio – economically deprived geriatric population to improve their QoL.

Keywords: Aged, homes for the aged, quality of life, sense of coherence

How to cite this article:
Raja B K, Radha G, Rekha R, Pallavi S K. Relationship between the sense of coherence and quality of life among institutionalized elders in Bengaluru city India: A questionnaire study. J Indian Assoc Public Health Dent 2015;13:479-85

How to cite this URL:
Raja B K, Radha G, Rekha R, Pallavi S K. Relationship between the sense of coherence and quality of life among institutionalized elders in Bengaluru city India: A questionnaire study. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2020 Dec 2];13:479-85. Available from: https://www.jiaphd.org/text.asp?2015/13/4/479/171172

  Introduction Top

India like many other developing countries in the world is witnessing the rapid aging of its population.[1] Urbanization, modernization, and globalization have led to change its economic structure. As a result migrants from the villages and town predominate to the city, resulting in breaking up of families into nuclear families.[1] Elderly get transferred to residential homes because they are left alone and have no relatives to care for them. Thus, they seek alternative accommodation due to isolation and loneliness.[2]

Elders in old age homes are a distinct population with lack of family support. The issues of loneliness and loss or separation from loved ones add to the already existing social insecurities decreasing their ability to cope with problems of old age.[3] There are several causes of stress, unique to or more common in elderly. The most frequent stressful life circumstances that affect older adults involve health, interpersonal, financial, or work-related events.[3],[4],[5] Loss of a spouse or separation, deaths in the family and lack of social integration are common stressors, which may themselves cause physical and mental ill-health. Physical incapacity, the decline in the mental faculties and feeling of the generation gap, add to the problems.[6],[7]

Identifying why people are healthy or remain healthy in adverse conditions or stressful situations may suggest what regulates health.[8],[9] Sense of coherence (SOC) can be explained as successful coping with stressors in a simpler manner. SOC is made up of three components: Comprehensibility, manageability, and meaningfulness.[10] The theory's central construct is to explain the relationship between stressors and both subjective and objective evaluations of health. An individual with a strong SOC has the ability to define life events as less stressful (comprehensibility), to mobilize resources to deal with encountered stressors (manageability), and possesses the motivation, desire and commitment to cope (meaningfulness).[11] The level of SOC that an individual achieves is developed before the age of 30 and remains relatively stable thereafter.[10] Hence, in this study, SOC was taken to measure how elders cope with stressors due to loneliness and separation.

In planning of health care services, the assessment of elder's quality of life (QoL) is important and can provide a clinical outcome measure of health care.[12] In line with the definition of QoL by the World Health Organization, the (QoL) is subjective and depends on individual's perception of their position in life. It is a multidimensional concept covering the physical, psychological, social, and environmental aspects of life but is something different from symptoms, functional level, and other regular health indicators.[13]

In the last three decades, numerous instruments have been developed to measure oral health-related QoL (OHRQoL). One of these instruments is the Geriatric/General Oral Health Assessment Index (GOHAI) described by Atchison and Dolan in 1990.[14] It is based on three suppositions: (a) That oral health can be measured using self-evaluation; (b) that the levels of oral health vary among people and that this variation can be demonstrated using measurement based on a person's self-perception; and (c) that self-perception has been identified as predictive of oral health.[15] Since the literature on relationship between GOHAI and SOC on oral health among Indian elder's was not been explored, the present study aims to find the relationship between SOC and QoL using GOHAI among elderly residents in Bengaluru city, India.

  Materials and Methods Top

This cross-sectional study was done among 376 aged residents living in residential homes of Bengaluru city, India. The study was conducted from the month of June to August 2014. The ethical approval for the study was obtained from the Institutional Review Board, and the required official permission was also obtained from the chairman or trust member of each old age homes. Informed consent was taken from all participants.

Sampling method and sample size

A total of 70 old age homes were registered under elder's helpline office of Bengaluru city, India. A stratified random sampling was done among these 70 old age homes and was divided into private, trust, and government of which 33 old age homes was run by private, 26 by trust, and 11 by government. From these three groups, 20% of homes were taken from each strata using simple random sampling method.

Thus from a list of 70 old age homes, 7 homes from private, 6 from trust, and 2 from government were included for the study, were all elders in each of these selected homes were included for the present study.

Inclusion criteria

Elder's aged 60 years and above.

Exclusion criteria

Bedridden and mentally disturbed participants were excluded.


The GOHAI [14] consisting of 12-item, which was developed by Atchison and Dolan was used. The GOHAI [14] features 12 questions on a 5-point Likert scale rating: Always, often, sometimes, seldom, and never. The questions are covered three dimensions: (a) Psychosocial (b) physical (c) pain or discomfort associated with oral health. It measures the patient reported oral functional problems in a simple to administer manner. GOHAI gives greater weight to functional limitations and pain and discomfort. Individuals with a GOHAI score of 12–56 were identified as having "low/moderate perception" on oral health, and those with a score of ≥57 were identified as having "high perception."[14]

To measure SOC, Antonovsky's SOC scale was used.[16] SOC was measured with the short version of the SOC questionnaire which consists of 13-item related to the three interrelated components of SOC; comprehensibility (5-item), manageability (4-item), and meaningfulness (4-item). Each item was scored on a scale from 1 to 7 points, giving a total range from 13 to 91 points for the SOC score. Individuals with a SOC score of 13–63 were identified as having "low SOC," those with a score of 64–69 were identified as having "moderate SOC" and those with 80–91 were identified as having "high SOC."[16] Participants who answered all questions were included for the analysis of data.

Study procedure

The study population comprised of aged residents living in various old age homes of Bengaluru city, India. Data were collected in respective old age home's using a self-administered questionnaire which dealt with sociodemographic characters, oral hygiene practices, and oral health habits. The questionnaires were administered personally by the researcher to the participants. The questionnaire was made in both English and Kannada languages. The validity was checked by back translation method, involving blind back translation into English. The validity of translation was verified by experts in both languages. The Cronbach's alpha of SOC and GOHAI scale was 0.85 and 0.80, respectively. Elderly participants who were unable to read and write got assistance from their respective old age home managers or caregivers.

Pilot study

A pilot study was done among 30 elderly subjects aged 60 years and above, visiting department of public health dentistry, V.S Dental College and Hospital, Bengaluru India. A questionnaire was administered to each participant to check the feasibility and relevance of the questionnaire. It also helped for proper planning and execution of the main study. These aged participants were not included in the main study.

Statistical analysis

All the statistical analysis was carried out using the statistical package for social sciences software, SPSS software version 19.0 (SPSS Inc., Chicago, IL, USA). P < 0.05 was considered as statistically significant. Chi-square test was used to compare sociodemographic variables. Independent variables which showed significant association with GOHAI and SOC in univariate analysis were included in a logistic regression model for low GOHAI and low SOC as an outcome measure. Pearson's coefficient of correlation was used to test the correlation between the GOHAI and SOC scores.

  Results Top

In the present study, a total of 15 residential homes were included from which 376 elderly residents answered the questionnaire. There were more females than males and most participants were between 60 and 70 years of age with a mean age of 69.24 ± 6.4.

[Table 1] shows an association of SOC scores with sociodemographic characteristics, where low SOC was seen among elders of 60–70 years which was not statistically significant at P > 0.05. Female participants had a low SOC score when compared to males which was statistically significant (P = 0.018*). Interesting in the present study most of the unmarried elders had low SOC, which was also statistically significant (P = 0.013*). Elders who had completed their schooling and had done skilled occupation also had a low SOC, but results were not significant.
Table 1: Association of SOC scores with demographic characteristics

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[Table 2] gives association of SOC scores with dentition status, oral hygiene practices, and oral health habits, were it was seen that elders who were partially edentulous had a low SOC score which found to be statistically significant (P = 0.000*). Elders who were smokers and alcoholics also had a low SOC scores, and results were also statistically significant (P = 0.043*) and (P = 0.047*), respectively.
Table 2: Association of SOC scores with dentition status, oral hygiene practices, and oral health habits

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[Table 3] presents association of GOHAI scores with sociodemographic characteristics, were elders of age 60–70 years and females participants had a low GOHAI score which was statistically significant (P = 0.036*) and (P = 0.045*), respectively.
Table 3: Association of GOHAI scores with demographic characteristics

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[Table 4] gives association of GOHAI scores with dentition status, oral hygiene practices, and oral health habits, were elders who were partially edentulous and who smoke had a low GOHAI score and results were also statistically significant (P = 0.019*) and (P = 0.042*), respectively.
Table 4: Association of GOHAI scores with dentition status, oral hygiene practices, and oral health habits

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The results of multivariate logistic regression analysis [Table 5] revealed that females (odds ratio [OR]: 4.51; 95% confidence interval [CI]: 1.57–6.95), partially edentulous elders (OR: 3.70; 95% CI: 1.30–6.19), smokers (OR: 2.51; 95% CI: 1.57–4.65), and alcoholic (OR: 1.63; 95% CI: 0.63–3.18) were found to be the major factors associated with low SOC scores.
Table 5: Multivariate analysis showing adjusted ORs for dependent SOC scores

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The most striking factors which influenced the low GOHAI scores in logistic regression analysis were 60–70 years (OR: 2.18; 95% CI: 1.10–4.58, partially edentulousness (OR: 4.80; 95% CI: 2.8–8.59) and smoking (OR: 2.51; 95% CI: 1.57–6.65) [Table 6].
Table 6: Multivariate analysis showing adjusted OR for dependent GOHAI score

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Pearson's coefficient of correlation was used to test the correlation between the GOHAI and SOC, were strong positive correlation was obtained between GOHAI and SOC scores (r = 0.712) indicating elders with low SOC had a low GOHAI and vice versa [Table 7] and [Figure 1].
Table 7: Pearson's correlation between GOHAI and SOC scores

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Figure 1: Scatter plot showing the correlation between sense of coherence and Geriatric Oral Health Assessment Index scores

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  Discussion Top

The rise in population older than 60 years is a phenomenon with widely discussed social implications in different sectors but particularly in health-related sectors.[17] One of the important aspects to analyze is oral health in social implications of the aging population.[18] In the present study, elderly residents above 60 years were included, since in most of the Indian studies, 60 years was taken as the cut-off age for the elderly against 65 years in international studies.[19]

The participant's age ranged from 60 to 99 years with a mean age of 69.2 years which was similar to studies reported by Ribeiro Gaiao et al.[20] and Srivastava et al.[21]

SOC was not compared with other studies because to author's knowledge this was the first study were SOC was done among institutionalized elders. Among various demographic factors, only gender and marital status showed a statistically significant association with low SOC score. In regression model females and married elders showed 4.51 and 1.19 times greater chances of having low SOC scores. When the type of dentition and oral health habits were taken for consideration elders who were partially edentulous and who smoked and consumed alcohol had a low SOC score.

Matthias et al.[22] proposed GOHAI as a predictor of objective oral health conditions in institutionalized elderly, with good sensitivity when comparing with other indicators of OHRQoL to identify the unmet need for dental treatment. Therefore, using GOHAI to assess the OHRQoL in elderly would contribute to detect and predict the need for dental care, as also to oral health diagnosis and planning of dental services.

In the present study, age was found to be significantly associated with low GOHAI score which in regression model, 91–100 years showed 2.1 times greater chances of having low GOHAI score when compared to other age groups. In contrast, a study was done by Alcarde et al.[23] showed no association between age and GOHAI scores.

Gender was also found to be a significantly associated with low GOHAI score, which in regression model females showed 2.3 times greater chances of having the low score when compared to males. This finding suggests that once they become isolated from their family their utilization for dental service has become sparse and moreover in most of the institutions proper dental care is far from being met. A similar study done by Mesas et al.[24] found that elderly women's had twice the chance of having a negative self-perception on oral health. In contrast, studies done by Alcarde et al.[23] and Atieh [25] found no difference in GOHAI scores when gender was taken into account.

When dentition status was taken for consideration it showed a significant association for lower GOHAI scores, which in regression model partially edentulous elders showed 4.8 times greater chances of having low score when compared to edentulous and dentulous elders. A possible explanation for this might be due to lack of awareness on the importance of oral health and higher cost of dental care which could have caused tooth loss among those elders that would had a functional disability and hence need for dental prosthesis would had a high degree of negative impact on QoL among those elders. In contrast de Andrade et al.[26] found elderly individuals with dentures were more likely to have lower GOHAI scores than those without.

In this present study, the mean GOHAI score was 26.02 ± 12.7 indicating elderly residents had a low self-perception of their oral health with more functional problems which was similar to previous studies.[23], 24, [27],[28],[29],[30],[31],[32] However, many studies using GOHAI had showed elders had more self-perceived oral functional problems across the world.[31],[32],[33],[34] Likewise, SOC mean score was 28.93 ± 17.9 indicating individuals in the present study had low coping capacity with stressors. Hence clinical oral features alone are not an adequate measure for the assessment of dental treatment needs because self-perception also stimulates dental self-care and motivates the population to seek dental care. Thus, self-perception enquiries must be integrated into routine surveys in order to improve the QoL dental services.[23] Finally, this study shows demographic factors, oral health practices, oral health habits, and type of dentition has an influence on both SOC and GOHAI scores.


  • Since cross-sectional studies cannot yield conclusive data on causality, longitudinal studies should be undertaken in future to address this link.


  • In order to improve the QoL among elderly residents, steps should be taken to educate and to promote oral health awareness among managers and care takes of old age homes
  • Apart from this elderly residents who are left alone from their families should be made aware about their aging process and should be motivated to keep their life simpler without any stress.

  Conclusion Top

Elderly subjects had low self-perception on oral health as measured by GOHAI, which was influenced by age, gender and type of dentition. A strong positive relationship exists between SOC and GOHAI scores which indicated that elderly with low SOC score had a high perception of oral functional problems and vice versa. Thus, SOC had a direct relationship with regard to OHRQoL measured by GOHAI.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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