Indian Journal of Public Health

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 63  |  Issue : 1  |  Page : 15--20

Oral health-related quality of life among elderly patients visiting special clinics in public hospitals in Delhi, India: A cross-sectional study


Puneet Chahar1, Vikrant R Mohanty2, YB Aswini2,  
1 Postgraduate Student, Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India
2 Associate Professor, Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India

Correspondence Address:
Dr. Puneet Chahar
Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, BSZ Road, New Delhi
India

Abstract

Background: Oral health is recognized as an integral component of general health, and poor oral health is reflected in general health and quality of life (QoL). India has seen a profound shift in the elderly population and is currently home to 103.9 million elders. General Oral Health Assessment Index (GOHAI) is a self-reported oral health assessment index used in elderly population and has been tested in multiple countries. Objective: The study aimed to assess the oral health-related QoL (OHRQoL) using GOHAI and various factors affecting it, among elderly patients visiting special Sunday geriatric clinics at Delhi public hospitals. Methods: A cross-sectional study was conducted among four purposively selected special geriatric public clinics in Delhi, India, and a convenience sample of 145 elderly patients was obtained. OHRQoL was measured using a prevalidated instrument (GOHAI) along with other variables (sociodemographic factors, self-perceived oral health, utilization of medical/dental services, dental problems in the past 12 months, and prosthetic status/need). Statistical analysis was done using Statistical Package for the Social Sciences software version 21, and descriptive results were obtained. Results: The sample consisted of 66 males (45.5%) and 79 females (55.5%), and around 58% (n = 84) of the participants were illiterate. Around 39% (n = 57) of the elderly had never visited a dentist and 48% (n = 69) were financially dependent (no income) on others. The mean GOHAI score for the population was 26.69 + 4.44 (median = 25, interquartile range = 23–27). GOHAI score was compared for age, oral hygiene practices, dental problems in the past 12 months, self-reported oral health, and prosthetic need, and a statistically significant difference was observed. Conclusions: The current study assessed GOHAI score and highlighted important determinants of OHRQoL in elderly population visiting the special clinics in Delhi. Thus, OHRQoL should be considered as a surrogate measure to clinical oral examination.



How to cite this article:
Chahar P, Mohanty VR, Aswini Y B. Oral health-related quality of life among elderly patients visiting special clinics in public hospitals in Delhi, India: A cross-sectional study.Indian J Public Health 2019;63:15-20


How to cite this URL:
Chahar P, Mohanty VR, Aswini Y B. Oral health-related quality of life among elderly patients visiting special clinics in public hospitals in Delhi, India: A cross-sectional study. Indian J Public Health [serial online] 2019 [cited 2019 Jul 15 ];63:15-20
Available from: http://www.ijph.in/text.asp?2019/63/1/15/253888


Full Text



 Introduction



Health has evolved over the centuries as a concept from an individual concern to a worldwide social goal which also encompasses quality of life (QoL).[1] QoL is a subjective component of well-being and includes a combination of factors that range from determining health, happiness, education, social/intellectual attainments, freedom of action, justice, and freedom of expression.[2]

Oral health-related QoL (OHRQoL) is a subset of health-related QoL and reflects people's comfort when eating, sleeping, and engaging in social interaction; self-esteem; and their satisfaction with respect to their oral health.[3] The specialization of dentistry has witnessed the development of multiple scales to measure the OHRQoL. General Oral Health Assessment Index (GOHAI) measures patient-centered definition of health which diverges from disease-centered epidemiological measures of health. GOHAI was initially developed by Atchinson and Dolan in 1990 which was further used in North America in geriatric population.[4] GOHAI is stable, widely used, and validated in multiple languages [5],[6] including Hindi.[7],[8] In 1996, Atchison reported that Geriatric Oral Health Assessment Index has been tested on a variety of samples of individuals of multiple age groups and races, and therefore it has been renamed as General Oral Health Assessment Index.[9]

Globally, the population of elderly people is also growing at an exponential rate due to increasing longevity and decreased fertility.[10] Elderly population in Delhi-National Capital Region is around 12 lakh which accounts for 6.8% of the total population (Census of India, 2011).[11] Sunday clinics is a unique scheme of health department of Delhi government in public hospitals, which provide outpatient department services to the elderly on specified hours.[12]

The burden of oral diseases among the elderly population is evident with a huge burden of multiple oral diseases, which presents a public health challenge when seen with other existing comorbidities.[13],[14],[15] Health care rendered for the elderly is broadly based on the normative assessment of need but lacks a self-perceived aspect of health, also known as HRQoL. Therefore, greater understanding of self-perceived oral health of the elderly may assist in developing oral health promotion and curative strategies, thus enabling them to perform daily functional activities.

Thus, the objective of the study was to assess the OHRQoL and various factors affecting it, among elderly patients visiting special Sunday geriatric clinics of Delhi public hospitals.

 Materials and Methods



A cross-sectional study was conducted among a group of elderly visiting the special geriatric clinics in Public hospitals in Delhi. Ethical clearance was granted by the institutional Ethical Review Committee, and informed consent was obtained from all the participants. There are a total of nine public hospitals of Delhi government providing special Sunday clinics for geriatric patients. Four hospitals were chosen conveniently, and each hospital was visited every Sunday for 1 month. Each visit involved screening participants for eligibility criteria and further assessing their OHRQoL. It continued for 4 months, i.e., August 2016–November 2016. Thus, a final sample size of 145 was obtained.

Inclusion criteria were patients above the age of 60 years who were visiting the geriatric clinic and willing to participate in the study. Elderly people suffering from any psychiatric disorders or with acute systemic diseases were excluded from the study.

Data were gathered by a face-to-face interview by the investigator. The questionnaire consisted of sociodemographic details, health insurance status, utilization of medical services and dental services, oral hygiene practices, dental problems in the past 12 months, self-reported oral health, OHRQoL, and prosthetic status/need, which were measured by using WHO Oral Health Assessment form 1997 by visual inspection in the daylight.[16],[17] Face and content validity of the questionnaire was verified by a team of experts in public health.

A prevalidated instrument (GOHAI) was used to measure OHRQoL. It includes a total of 12 items which assess the dimensions of physical functions, psychosocial functions, and pain or discomfort. The original English version consists of six options for each item, namely “Always,” “Very Often,” “Often,” “Sometimes,” “Seldom,” and “Never,” but this is confusing and difficult to appreciate by the participants. In this study, each item was scored on a 3-point Likert scale, as used by other studies.[18] GOHAI scores ranged from 12 to 36 after reversing the response set of three negatively set items. A higher final score indicated better perception about oral health and vice versa. Internal consistency was measured by Cronbach's alpha (0.88).

Statistical analysis

Statistical package for the Social Sciences version 21 for windows (SPSS Inc., Chicago, IL, USA) and descriptive statistical measures such as mean, standard deviation (SD), and median were used. Interquartile range (IQR) and percentage were calculated. Statistical significance was estimated by using nonparametric tests such as Mann–Whitney and Kruskal–Wallis tests. Level of significance was P < 0.05.

 Results



The sample consisted of 66 males (45.5%) and 79 females (55.5%). Majority of the sample was 60–65 years old (n = 89, 61.4%) followed by 66–70 years (n = 30, 20.7%) and rest above 70 years of age (n = 26, 17.9%). Education status revealed around 58% to be illiterate (n = 84). Around 48% (n = 69) were financially dependent on others. When asked, 21 (14%) and 55 (38%) elderly reported to have postretirement occupation and pension as the source of income, respectively. Around 42% (n = 61) of the sample population reported to have income in the range of 10,000–25,000 rupees (INR) with few (n = 15) having income >25,000 INR. Only three participants (2%) of the sample reported to have some kind of health insurance. Details of social dependency, oral hygiene practices, medical history, and dental problems in the past 12 months are summarized in [Table 1].{Table 1}

Regarding utilization of dental services, around 39% (n = 57) had never visited a dentist, with rest (n = 88) visited at least once in the past 12 months. When asked about the visits to the geriatric clinic, around 46.9% (n = 68) had visited the clinic once a month, 33.1% (n = 48) once a week, and 20% (n = 29) only when a problem arises. Only nine (6.2%) and 12 (8.3%) participants had any prosthesis in the upper and lower jaws, respectively. When prosthetic need was assessed, it was observed that 83.5% (n = 120) and 85.6% (n = 124) of participants were in need of upper and lower prostheses, respectively.

Self-reported oral health status when assessed showed that 17 participants (11.7%) considered their oral health as “Excellent/Very Good,” with 50 (34.5%) and 78 (53.8%) reporting it as “Good” and “Average/Poor,” respectively.

The mean GOHAI score of the sample was 26.69 ± 4.44 (median: 25, IQR = 23–27). [Table 2] describes the distribution of the mean score (SD) to each GOHAI item classified according to the function measured (physical, psychosocial, and pain/discomfort).{Table 2}

[Table 3] represents risk factors which were significantly associated with the overall OHRQoL assessed by GOHAI. Aging was significantly associated with poor OHRQoL. Participants with low literacy, female gender, no/low income, and staying alone were observed to have lower GOHAI score, although the relationship was found to be statistically insignificant (P > 0.05). Using toothbrush and toothpaste was significantly associated with higher GOHAI score, i.e., better OHRQoL. Dental problems in the past 12 months were also found to be significantly associated with lower GOHAI scores. Self-reported oral health and prosthetic need were found to be significantly associated with GOHAI scores; those considering their oral health as average/poor and having a prosthetic need had poor OHRQoL.{Table 3}

At last, among those with some income, elderly with post retirement occupation had significantly better OHRQoL (GOHAI score = 28.9 + 4.37) as compared to those under pension scheme (GOHAI score = 26.83 + 5.07) (P < 0.05).

 Discussion



The sample had a larger proportion of females which was similar to a study done in Mysore [19] and Ahmedabad.[20] The results may be explained by the fact that females may be easily available and have a positive health-seeking behavior as compared to males.[21]

Major section of the participants were illiterate (not able to write or read in formal or informal language), which was in contrast to the findings of Census-2011 (illiterates – 26%) and to the study done by Bhatt et al. in Ahmedabad (illiterates – 23.4%).[16],[20]

Almost half of the participants had financial dependency (no income) among the current sample, and 52.4% of the participants had some source of income (pension/job). The current study was done in a sample of elderly visiting a public health-care facility; therefore, it was expected that the sample may have lower socioeconomic status as observed in other studies.[21],[22],[23]

It was observed that majority of the sample had no health insurance of any kind. Indian health insurance system today presents a mix of governmental insurance schemes, social health insurance, voluntary private health insurance, and community-based health insurance.[24],[25] Despite being one of the most rapidly growing economies, health insurance in India is still in its infancy stage, with only 5% availing the same.[26]

When the utilization of dental care was assessed, it was observed that those who had never utilized dental services were less in the current study (39%) as compared to a study done in rural South India (85%). Age, anxiety/fear, limited availability, high cost, and limited awareness might be some of the reasons for such behavior as explained by Thomas.[27] Nearly 61% of the sample had visited a dental clinic in the past 12 months, which was higher as compared to a study conducted in Nellore (36%).[28]

In the current study, a 3-point Likert scale was used, and GOHAI score obtained was 26.69 + 4.41. A 3-point Likert scale was developed by Atchinson to facilitate comparison among the number of response categories. Till date, only a few studies [7],[18] have used this coding criterion. The mean score in the current study was lower than that of the findings of Atchison (34.3 + 2.5) and comparable to another study done by Mathur et al. in India (29.3 + 3.25). The overall GOHAI score was lower among those aged above 75 years and among females, which was in accordance with previous results.[4],[7]

Participants having low literacy were found to have lower GOHAI score, but this was not significant as reported by other studies.[29],[30] Educational level highlights the importance of socioeconomic position throughout life.

No statistically significant difference was observed between mean GOHAI scores among respondents staying alone (25.30) and those staying with family (27.05). These results were similar to the findings of Tsakos et al.[29] This can be attributed to social support which might have an immense psychosocial and health impact.

Oral rehabilitation had been associated with a positive effect on OHRQoL,[31] but in the current study, only a minor proportion of the participants were having any existing prosthetic rehabilitation.

Those with prosthetic need in either jaw had a poor OHRQoL, which was in accordance with other studies.[32],[33] A recent meta-analysis reported a strong evidence for the association of tooth loss with impairment of OHRQoL, which was independent of the OHRQoL instrument used.[34]

Respondents performing proper oral hygiene procedures exhibited higher mean GOHAI scores than those who did not perform. Respondents with no dental problems in the past 12 months reported better OHRQoL. It was further reiterated that those with multiple dental problems had lower GOHAI scores.

However, many other life events, socially and culturally derived values, may affect an elderly person's perception of the impact oral health and disease.

Although this study attempted to assess the OHRQoL of the elderly visiting special geriatric clinics and is first-of-a-kind study with multiple centers, it had its own limitation for being a cross-sectional study and thus lacked a temporal association. We performed the study on a population that was selected based on some nonprobability sampling method, and the results should be interpreted with caution. Moreover, the study could not assess the bedridden and moribund elderly not attending the special clinics, which may limit its generalizability.

 Conclusions



The current study assessed GOHAI score and highlighted the important determinants of OHRQoL in elderly population visiting the special clinics in Delhi. OHRQoL should be considered as a surrogate measure to clinical oral examination, thus leading to comprehensive oral health assessment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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