|Year : 2020 | Volume
| Issue : 2 | Page : 124-133
Association between health locus of control and oral health status in type 2 diabetics - A cross sectional comparative study
B Santhiya, Manjunath P Puranik, KR Sowmya
Department of Public Health Dentistry, Government Dental College and Research Institute, Bengaluru, Karnataka, India
|Date of Submission||07-Mar-2020|
|Date of Decision||13-Apr-2020|
|Date of Acceptance||10-May-2020|
|Date of Web Publication||24-Jun-2020|
Dr. B Santhiya
Room No: 9, First Floor, Department of Public Health Dentistry, Government Dental College and Research Institute, Fort, Bengaluru - 560 002, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Diabetes mellitus (DM) is a highly prevalent metabolic disorder which has life-long acute and chronic complications, constituting a huge global public health burden. The influence of diabetes on oral health is established. However, literature assessing psychosocial aspects that are necessary for managing metabolic control and oral health in diabetics is scarce. Aim: To determine the association between health locus of control and oral health among patients with Type 2 DM in Bengaluru City. Materials and Methods: A cross-sectional conducted among 300 participants with and without type 2 DM visiting government hospitals in Bengaluru City from November 2017 to September 2019. The Multidimensional Health Locus of Control (MHLC) Scale (Internal [IHLC], Powerful Others [PHLC], and Chance [CHLC]) and the WHO pro forma 2013 were used to assess health locus of control and oral health, respectively. Chi-square, Spearman's correlation, and multivariate hierarchical linear regression were applied. The statistical significance was considered at P < 0.05. Results: Diabetic participants were equivocal in their perceptions on IHLC, whereas nondiabetic participants were in agreement. Majority of diabetic and nondiabetic participants were in disagreement on PHLC. Nondiabetics were in disagreement on CHLC, whereas diabetics had elusive perception. Significantly higher proportion of diabetics had caries experience, deep pockets, and loss of attachment (LOA) than nondiabetic participants. Statistically significant association was found between health locus of control and dental caries experience, periodontitis, and denture use. Glycemic control, IHLC, and PHLC were found to be significant predictors of LOA. Conclusion: Oral health status was significantly poorer and associated with health locus of control. Glycemic control and health locus of control influenced oral health in diabetic participants.
Keywords: Glycated hemoglobin, health locus of control, oral health, type 2 diabetes
|How to cite this article:|
Santhiya B, Puranik MP, Sowmya K R. Association between health locus of control and oral health status in type 2 diabetics - A cross sectional comparative study. J Indian Assoc Public Health Dent 2020;18:124-33
|How to cite this URL:|
Santhiya B, Puranik MP, Sowmya K R. Association between health locus of control and oral health status in type 2 diabetics - A cross sectional comparative study. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2021 Sep 16];18:124-33. Available from: https://www.jiaphd.org/text.asp?2020/18/2/124/287635
| Introduction|| |
Diabetes is a silent disease and in the top five of the highest mortality rate diseases and sixth leading cause of disability in the world and getting closer to the top of the list. Diabetes mellitus (DM) is a metabolic disorder with heterogeneous etiologies which is characterized by chronic hyperglycemia with disturbances of carbohydrate, fat, and protein metabolism resulting from defects in insulin secretion, insulin action, or both. Emerging evidence also indicates that people with severe periodontitis have an increased risk of developing type 2 diabetes. Chronic periodontitis is the most common form of destructive periodontal disease initiated by the accumulation of a pathogenic dental plaque biofilm above and below the gingival margin, and within which microbial dysbiosis leads to a chronic nonresolving and destructive inflammatory response. It has a prevalence of 45%–50% in adults in its mildest form rising to over 60% in people over 65 years of age. The overall prevalence of periodontal diseases in India was shown to be high in several studies (38%–99.6%).
The evidence base for independent associations between periodontitis and type 2 diabetes is long established, with a dual directionality of influence reported. Both periodontitis and diabetes are chronic, inflammation-driven diseases that often occur in the same individuals and also mutually and adversely affect each other. There is strong evidence for an association between periodontitis and glycemic status, expressed as glycated hemoglobin (HbA1c), fasting blood glucose levels, and/or oral glucose tolerance test in people who have no manifest diabetes. People with periodontitis have a higher level of HbA1c, when compared to people with better periodontal health., However, evidence about the effect of diabetes on dental caries is conflicting.
Among the psychosocial aspects involved in the management of chronic diseases, the construct of “locus of control” has been studied for many years. Locus of control was initially developed by Rotter in the 1950s within the social learning theory. The author states that the probability of a specific behavior to occur in a given situation is a function of one's expectation that such behavior will lead to obtainment of a reinforcement (behavioral stimulus) and the value the individual attributes to such reinforcement. The concept of locus of control was applied in the health field in the 1990s by Wallston et al., who developed instruments to evaluate to what extent individuals conceived of their health condition or disease being controlled by themselves, fate, or others.
The construct of locus of control is conceived as a multidimensional variable. Locus of control is defined in terms of whether individuals believe that outcomes of events are due to internal or external causes. Individuals with internal locus of control believe that they have control of the situations they face, and that they are responsible for managing their lives. Individuals with external locus of control believe what happens to them is beyond their control, and they attribute everything they face to fate, others, or chance., Previous studies have reported severe progression of diabetes of individuals with external locus of control. A positive relation between internal locus of control and adaptation to diabetes treatment has been reported. Identification of health-related locus of control may become an essential tool to guide health actions directed toward DM patients in order to provide important support for a better understanding of the psychosocial factors involved in the difficulties faced during the management of their chronic diseases.,
Literature shows diverse research results on the impact of locus of control on metabolic control of diabetes. While some studies support a positive relation between internal locus of control and metabolic control of diabetes, other studies failed to demonstrate any relationship.,, On the other hand, studies have shown that poorer the oral health, greater the scores of locus of control. Few studies showed association between oral health and health locus of control,,, while studies concerning association between health locus of control and oral health among patients with Type 2 DM are scarce.
Thus, the research hypothesis was that there is an association between health locus of control and oral health status among patients with type 2 DM. Hence, a study was conducted to assess and compare health locus of control and oral health status among diabetics and nondiabetics and to determine the association between health locus of control and oral health among them.
| Materials and Methods|| |
A cross-sectional comparative study was conducted among 300 participants with and without Type 2 DM from November 2017 to September 2019 in Bengaluru City. Ethical clearance was obtained from the Institutional Ethical Committee. The research was conducted in full accordance with the World Medical Association Declaration of Helsinki. Necessary permission was obtained from the heads of institutions, and written informed consent was obtained from the study participants after explaining the purpose and procedure clearly.
The Multidimensional Health Locus of Control (MHLC) Scale was used to assess health locus of control. The MHLC scale is composed of three subscales and each contains six items that refer to the dimensions: Internal Health Locus of Control Scale (IHLC) whose scores record the extent to which the individual believes he/she is the one controlling his/her health state; Powerful Others Health Locus of Control (PHLC) whose scores record the extent to which the individual believes other people or entities (physician, nurse, friend, family member, God, etc.,); and Chance Health Locus of Control (CHLC) whose scores indicate the extent to which the individual believes his/her health is controlled by chance, without the interference of other people or herself/him. The items are scored on a 6-point Likert-like scale (strongly disagree to strongly agree ), indicating degree of agreement with each statement. The sum of the values of the items belonging to each of the three subscales represents the total scores in relation to that dimension of health locus. The total score obtained in each subscale ranges from 6 to 36: the higher the score, the higher the belief in that specific dimension.
Cross-cultural validation of the Multidimensional Health Locus of Control Scale was performed by means of forward and back-translation method (English to Kannada and Kannada to English) with the help of linguistic experts. It was assessed for readability and comprehension during pilot study. Internal consistency (α) of the questionnaires was measured using Cronbach's alpha which was found to be good to excellent (IHLC = 0.85, PHLC = 0.86, and CHLC = 0.96).
The investigator was trained and calibrated for oral health examination with a wide range of oral conditions. The Kappa coefficient value (k) for intraexaminer reliability was 0.80–0.86 reflecting high degree of reliability. A personnel was trained to record the examination findings.
A pilot survey was conducted among 25 participants with type 2 DM, to check the feasibility of the study and to calculate the sample size. With a prevalence of periodontal disease being 80% and statistical power of 80%, the sample size obtained was 144, which was rounded off to 150. Participants with type 2 DM aged above 18 years with a duration of more than 6 months and age- and gender-matched nondiabetic participants visiting government hospitals in Bengaluru were included in the study. Participants who have undergone oral prophylaxis in the past 3 months, with mental and cognitive problems and with systemic conditions known to influence oral health or make oral health assessment difficult, were excluded from the study. Four hospitals were selected randomly from the list of hospitals. Diabetic and age- and gender-matched nondiabetic participants were recruited using consecutive sampling method.
Data were collected from study participants at respective hospitals during diabetic outpatient hours. Information regarding demographic profile, diabetic and dental history, personal habits, and oral hygiene practices were collected using structured pro forma through interview. Self-administered MHLC questionnaire was distributed to the participants after giving instructions. It was collected back on the same day and checked for completeness. Oral health status was assessed using the WHO 2013 oral health assessment form. Clinical examination of the participants were performed by a single-calibrated investigator under natural light using autoclaved instruments and recording was done by trained personnel.
The statistical analysis was done with the SPSS Version 22 software package (IBM Corporation, SPSS Inc., Chicago, IL, USA). Dichotomization was done with respect to age (≤45 and >45 years), socioeconomic status (SES) (upper class [upper and upper middle] and lower class [lower middle, upper lower, lower]), and loss of attachment (LOA) (code <2, code ≥2). Decayed, Missing, and Filled Teeth (DMFT) and gingival bleeding were dichotomized as present or absent. The data were dichotomized on health locus of control scale for the purpose of classifying participants into internal and external by median split of internal (IHLC), powerful others (PHLC), and chance (CHLC). All the participants who scored above the median on internality and below the median on powerful others and chance were categorized as “internals.” Similarly, participants who scored below the median on internality and above the median on powerful others and chance were categorized as “externals.”
Mean and standard deviation and percentage (proportion) were computed for continuous and ordinal data, respectively. Bivariate associations between diabetic and nondiabetic participants were analyzed using Chi-square tests. Student's t-test was used to determine the difference among diabetic and nondiabetic for all continuous variables. Bivariate analysis was performed on dichotomized demographic variables (age, gender, and SES), smoking habits by health locus of control (internals/external), and oral health status (DMFT and LOA) for both diabetic and nondiabetic participants. Spearman's correlation was used to find out relation between health locus of control (internal, powerful others, and chance) and oral health status (dental caries, deep periodontal pocket, high scores of LOA, and dentures).
Multivariate hierarchical linear regression model was adopted to test the linear effect of one or more variables after controlling for all other variables. Three models were employed in an analysis to check independently the effect of age, gender, SES, HbA1c, IHLC, PHLC, and CHLC on LOA. Statistical significance was considered at P < 0.05 (95% confidence interval).
| Results|| |
The mean age of the participants was 50.75 ± 11.32 years. Males were more in number compared to females. Most of diabetic and nondiabetic participants belonged to lower class [Table 1]. Majority of the participants had HbA1c level of more than 7% (mean of 8.46 ± 1.66) with statistically significant gender difference. Statistically significant difference was found among diabetic and nondiabetic participants with regard to family history of diabetes (P = 0.012). Majority of the diabetic and nondiabetic participants reported previous dental visits. Statistically significant difference was found among diabetic and nondiabetic participants in dental attendance pattern (P = 0.001). Significantly higher proportion of diabetic participants rated their oral health as “fair to poor” and perceived that oral health affected their well-being and general health than nondiabetics (P = 0.001). Almost all the study participants used toothbrush and toothpaste once daily to clean teeth and changed their brush in once in 3–6 months. Significantly higher proportion of the diabetic participants reported with smoking and smokeless tobacco and alcohol habits for more than 15 years than nondiabetics.
Distribution of the study participants by the Multidimensional Health Locus of Control is shown in [Table 2]. The mean IHLC scores among diabetic participants (21.78 ± 11.49) were significantly less compared to nondiabetics (25.63 ± 8.99) (P = 0.001). The mean PHLC scores among diabetics (19.44 ± 10.62) did not differ significantly with nondiabetics (19.15 ± 8.86) (P = 0.95). The mean CHLC scores among diabetics (19.31 ± 8.11) was significantly more when compared with nondiabetics (16.86 ± 8.11) (P = 0.039).
|Table 2: Distribution of the study participants by multidimensional health locus of control|
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The proportion of participants with caries experience, gingival bleeding, deep pockets, and LOA were significantly higher among diabetics than nondiabetics. The prevalence of fluorosis, dental erosion, and traumatic dental injuries was less than one-third among the study participants. The proportion of diabetic participants using partial complete dentures was significantly higher than nondiabetics. Two-third of the diabetic participants referred for comprehensive evaluation, while two-fifth of the nondiabetic participants referred for preventive or routine dental treatment (P < 0.001) [Table 3].
|Table 3: Distribution of study participants according to oral health status|
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Diabetics had significantly less mean number of permanent teeth than nondiabetics. The mean number of teeth with dental caries experience (DMFT) in diabetic participants (8.92 ± 8.23) was significantly high when compared to nondiabetic participants (6.21 ± 6.88) (P = 0.002). The mean number of teeth with gingival bleeding among diabetic participants (19.09 ± 5.67) was significantly higher compared with nondiabetics (13.94 ± 7.39) (P = 0.001). The mean number of teeth with deep periodontal pocket (≥6 mm) among diabetics (8.14 ± 5.10) was significantly high compared with nondiabetics (3.38 ± 4.22) (P = 0.001). Diabetic participants had twice the mean number of sextants with LOA with code ≥2 than nondiabetic participants.
Higher proportions of diabetics were external and more proportion of nondiabetics were internal and the difference was statistically significant (P = 0.001).
Significantly higher proportions of diabetics were external, whereas higher proportion of nondiabetic were internal on MHLC (P = 0.001). Higher proportion of diabetic males, aged ≥45 years, from upper and lower SES with smoking habits, were on external health locus of control and had LOA code ≥2 when compared to nondiabetics. Age, gender, SES, and smoking were significantly associated with HLOC and LOA. Age and tobacco smoking habits were associated with dental caries experience, whereas gender and SES were independent of dental caries experience [Table 4].
|Table 4: Cross tabulation of demographic variables, habits by locus of control and oral health status among study participants|
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Statistically significant association was found between health locus of control and LOA in diabetics (P = 0.028), whereas statistically significant association was found between health locus of control and dental caries experience (P = 0.006), periodontal pocket (P = 0.001), and LOA in nondiabetics (P = 0.001) [Table 5].
|Table 5: Cross tabulations of oral health status by health locus of control among study participants|
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Bivariate significant negative correlation was found between participants glycemic control with IHLC and PHLC, whereas positive bivariate correlation was found with CHLC, DMFT, deep periodontal pocket, LOA, and denture. Bivariate significant negative correlation was found between IHLC and DMFT, deep periodontal pocket, LOA, and denture, whereas positive bivariate correlation was found between CHLC and deep periodontal pocket and LOA. Bivariate significant negative correlation was found between PHLC and DMFT, deep periodontal pocket, and LOA.
Gender was found to be significantly low level of predictor (R = 0.240) and explains 5.7% (R2 = 0.057) of the variability of LOA (Model 1). HbA1c was found to be significantly moderate level of predictor of LOA (R = 0.635) and explains 40.4% (R2 = 0.404) of the variability (Model 2). Diabetic control (HbA1c), IHLC and PHLC was found to be significant moderate level of predictor (R = 0.67) and explains 44.9% (R2 = 0.449) of the variability of LOA (Model 3) [Table 6].
|Table 6: Multivariate linear regression with loss of attachment score as dependent variable among diabetics|
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| Discussion|| |
Diabetes is associated to long-term micro- and macrovascular dysfunctions, including periodontitis., It adds social and financial loads on individuals, families, and society that may affect both the quality and length of life. Frequently observed oral conditions in patients with diabetes include dental caries, xerostomia (dry mouth), tooth loss, gingivitis, cheilitis, increase of glucose level in saliva, and periodontitis.
A generalized expectancy relating to the perceived relationship between one's action and experienced outcome is called locus of control, which is often used to assess self-management behavior in chronic illnesses. This framework will direct the investigators to focus on how study groups perceive responsibility for their health behaviors and how the groups differ in the various dimensions (internal-self, external powerful others, and chance). When individuals perceive events (reinforcements) as associated with their own behavior or dependent on their own stable characteristics, there is a belief in internal control. Having internal locus of control is a significant and important predictor of the patient taking responsibility for his or her own diabetes management. When one does not perceive reinforcement as being associated with one's own actions, reinforcement is then attributed to chance, luck, or fate otherwise seen to depend on the power of others or is unpredictable given the great complexity of factors involved. Individuals with diabetes believed that their doctors should manage their illness, rather than taking responsibility for it themselves. In this study, diabetic participants had a perception that their health status depends on chance or luck/fate.
The group with chronic diseases was more likely to have internal health locus of control than those without chronic diseases. As with many other diseases, in order to manage diabetes and achieve the desired metabolic goals, the patient has to take a voluntary and active role in treatment. Individuals who believe that they control their health engage in more activities to reach that goal. In this study, significantly higher proportion of diabetics were external and more proportion of nondiabetic were on internal health locus of control.
Younger age groups are related to internal locus of control than older groups, and external locus of control increase with age. However, diabetic participants over 65 years old had greater internal locus of control than the younger groups. On the contrary, in this study, higher proportion of diabetic participants aged ≥45 years were on external health locus of control than younger participants. Statistical association was found to be significant between age and health locus of control, which is similar to a study.
Studies are ambivalent about gender and locus of control. Some studies have observed women scoring higher in the internal dimension when gender was related to the disease, due to woman's multiple social roles and depression. Whereas, other researchers have reported likelihood of men to have more internal locus of control than women. In the current study, higher proportion of diabetic females were significantly on internal health locus of control than males.
The influence of LOC beliefs on health in general and oral health in particular makes it crucial to understand their origin in the background of other variables. People living in economically deprived circumstances and individuals with less education have less control over their oral health., Internals take more preventive action than do externals such as they are less likely to smoke. In this study, more proportion of diabetic smokers from upper and lower SES were significantly on external health locus of control.
There is a negative relation between 'external/powerful others' and the value of HbAc1, which implies that, the less patients attribute the control of their health to others or physicians, the worsen the glycemic control obtained by patients. Studies have found statistically significant correlations between HbA1c level and internality,,, external-powerful others, and chance. Increased severity of periodontal disease negatively affects glycemic control in DM. In this study, HbAc1 had significant negative correlation with IHLC and PHLC and positive correlation with CHLC.
Oral health conditions reportedly associated with diabetes include dental caries, tooth loss, gingivitis, and periodontitis. Diabetics were at a higher odds for “fewer teeth” than nondiabetics. Diabetic dentates had significantly less mean number of permanent teeth than nondiabetic dentates; this is similar to few studies,, and dissimilar to a study (P > 0.05).
Diabetic patients tend to have more decay than nondiabetics. Diabetic patients have significantly more mean number of teeth with dental caries (DMFT) than nondiabetics due to the “M” (missing) component, which is comparable to a study. In this study, higher proportion of diabetics experienced dental caries than nondiabetics in a ratio of 7:4, which was statistically significant and this result is similar to a study (P < 0.001) and dissimilar to one study (P = 0.12). Significantly higher proportion of diabetic and nondiabetic participants aged ≥45 years experienced dental caries than aged <45 years, suggesting the impact of age on dental caries. Whereas, statistical association between gender, SES, and dental caries experience among diabetic participants was not found, which is similar to previous study.
Diabetic patients, in general, have higher severity of periodontal disease than nondiabetics. Studies have shown more rapid and severe gingival inflammation in adults with diabetes than in controls subjects without diabetes. Quantitative as well as qualitative changes in the bacterial plaque characteristics results in, more progressive and hyper inflammatory gingival response in people with diabetes. A study found no significant difference in gingival inflammation among diabetic and nondiabetic participants. On the contrary, in this study, all the diabetics had gingival bleeding compared to 92.4% of the nondiabetics. Most of the diabetic participants had deep pockets than nondiabetics similar to some studies.,,,, Extent and severity of periodontal pocket in the diabetics was significantly more than twice that seen in the nondiabetics; this is similar to few studies,,, and dissimilar to a study (P > 0.05).
Type 2 diabetes is a substantial risk factor for the severity of periodontitis with significantly increased mean attachment loss. In this study, higher proportion of the diabetic participants had significant LOA than nondiabetics, which is comparable to some studies.,, There was a significant increase in the mean number of sextants with LOA in diabetic participants that is at least twice that observed in nondiabetics and it is similar to previous studies.,
Manifestation of periodontitis in diabetic patients has been associated with age of onset, gender, duration of diabetes, poor metabolic control, and diabetes-related complications. Several potentially important periodontal risk indicators include stress, coping behaviors, osteopenia associated with gender (males having more disease) and age (more disease seen in the elderly), smoking, and genetic factors. The odds of developing periodontitis also increased with age. In the present study, LOA was significantly associated with age among diabetic participants and is similar to previous studies.,,,, The age of onset of diabetes that is 35 years of age or older is very close to age of onset for chronic periodontitis. Therefore, it is possible that the coincidental initiation of type 2 diabetes, the associated systemic effects, and periodontitis act synergistically to produce a more severe progression of periodontal disease than might be seen in the same population in the absence of type 2 diabetes.
Periodontitis is more prevalent in males than in females. For decades, it has been recognized that men of all ages, race/ethnic groups, and geographic locations have significantly more periodontal disease than women. In this study, higher proportion of diabetic males had LOA which is similar to a study and unlike another study where female diabetics were more likely to have periodontitis.
Individuals with a low SES also have a higher prevalence of periodontitis than those with higher SES. On the contrary, higher proportion of diabetic participants in upper social class had LOA than lower social class. LOA was significantly associated with gender and SES among diabetic participants and similar association was found in this study.
Smoking negatively impacts periodontal health. Studies have observed an additive effect of smoking and type 2 diabetes on the severity of periodontal disease and suggested that the combination of smoking and diabetes promotes even greater periodontal destruction than diabetes alone. In this study, higher proportion of diabetic smokers significantly demonstrated LOA compared to diabetic nonsmokers. This study demonstrated additive/synergistic effect when type 2 diabetes and smoking collaborate to increase the severity and extent of periodontal destruction within this population. This result is similar to earlier studies where smoking has been identified as a key risk factor for periodontal disease, indicating the need to target this modifiable risk factor for promoting oral health. This supports the observation that considers periodontitis as the sixth complication of DM.
In many respects, studies have shown that much poorer state of oral health and a greater range of locus of control scores, and this relationship might be much stronger. In this study, more proportion of diabetic participants with LOA were external on HLOC and association was statistically significant.
In this study, correlation analysis suggested positive relationship between glycemic control and oral health variables and negative relationship with HLOC variables (internal/powerful). This is suggestive of the influence of personality (individual/family and physician) have a major role in achieving optimal glycemic control and oral health.
Patients on chance locus of control who continue to neglect oral health, despite warnings and exhortations, tend to neglect oral health that leads to poor oral health and oral health-related quality of life. Attachment loss reflects accumulation of damage sustained by the periodontium over a period of time. Age was an additional predictor of periodontitis severity, together with type 2 DM. In the current study, age and SES did not predict the LOA. Whereas, gender was found be significant predictor. This implies that males had significant predictive value to have severe periodontitis than females. This outcome was comparable to previous studies., Females are more conversant about toothbrushing and have a higher degree of concern in oral health than males. They demonstrate more positive dental health attitude and better oral health behavior than males. Gender predilection is still contradictory in the literature, with some studies showing a greater association between periodontitis and type 2 diabetes in females. Diabetic control (HbA1c), IHLC, and PHLC were found to be significant predictors of LOA. This result is similar to prior studies.,, The relationship between periodontitis and glycated hemoglobin as a surrogate measure for severity of DM demonstrates that participants are more likely to develop periodontitis at higher glycohemoglobin levels with poor perceived internal and external locus of control. Diabetic participants had poor oral health compared to nondiabetics, which may be attributed to participants poor diabetic control and low internal locus of control. Thus, poor diabetic control and internal/external health locus of control act as significant predictors of poor oral health among diabetic participants.
This study has some limitations of any cross-sectional studies in determining causal effects. However, using prediction models and correlation analysis association was established between the variables. Social desirability bias in answering the questionnaire may be inherent in this study. In an effort to avoid this problem, participants were assured that all their data would be treated in an anonymous way. Research using a longitudinal approach would be valuable to provide further evidence of the hypothesized relationships between variables.
| Conclusion|| |
Diabetic participants were equivocal in their perceptions on internal health locus of control and chance or luck. Whereas, majority of the nondiabetic participants were in agreement on IHLC and were in disagreement on CHLC. Majority of diabetic and nondiabetic participants were in disagreement on PHLC. Oral health positively correlated with CHLC and negatively correlated with internal and powerful other health locus of control among diabetic participants. The research hypothesis was accepted since significant association existed between health locus of control and oral health status among patients with type 2 DM.
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Conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]