|Year : 2021 | Volume
| Issue : 4 | Page : 304-309
Decentralized public-funded oral rehabilitation programs and oral health-related quality of life of the elderly in Rural Kerala
Vivek Narayan1, Mary Shimi S. Gomez1, Susan Thomas1, Arun Rao1, S Anilkumar2, Indu Raj2, Vidhya Parameswaran2
1 Department of Public Health Dentistry, Government Dental College, Kottayam, Kerala, India
2 Department of Prosthodontics, Government Dental College, Kottayam, Kerala, India
|Date of Submission||15-May-2021|
|Date of Decision||24-Sep-2021|
|Date of Acceptance||08-Nov-2021|
|Date of Web Publication||15-Dec-2021|
Department of Public Health Dentistry, Government Dental College, Kottayam - 686 008, Kerala
Source of Support: None, Conflict of Interest: None
Background: Edentulism among the elderly deteriorates the physical, social, and mental dimensions of oral and general health. Objectives: This study compared the changes in oral health-related quality of life (OHRQoL) of the edentulous elderly following prosthetic rehabilitation with complete dentures among beneficiaries of public denture programs. The study also compared the responsiveness of Oral Health Impact Profile-14 (OHIP-14) and Geriatric Oral Health Assessment Index (GOHAI). Methodology: This prospective pre–post comparison study was conducted among beneficiaries of two public-funded oral rehabilitation programs (P1 and P2) organized by local self-government institutions. OHRQoL was recorded using OHIP-14 and GOHAI in P1 and P2, respectively. Data collection was done at baseline using direct interview and 4 weeks after denture insertion using telephonic interview. Wilcoxon signed-rank tests were used to compare differences in responses between baseline and posttreatment. Statistical significance was considered at P < 0.05. Psychometric properties of tools were determined using Cronbach's alpha and exploratory factor analysis. Results: The mean change in OHIP-14 and GOHAI at 4 weeks after denture insertion was 15.39 ± 12.61 and 10.73 ± 8.71, respectively (P < 0.05). Cronbach's alpha for the modified OHIP-14 and GOHAI scales was 0.73 and 0.65, respectively. Conclusions: Prosthetic dental rehabilitation provides psychological, social, and functional benefits to the edentulous elderly. Public-funded denture programs are effective to improve OHRQoL among the edentulous elderly from a poor socioeconomic background.
Keywords: Complete denture, elderly, Geriatric Oral Health Assessment Index, Oral Health Impact Profile-14, oral health-related quality of life
|How to cite this article:|
Narayan V, Gomez MS, Thomas S, Rao A, Anilkumar S, Raj I, Parameswaran V. Decentralized public-funded oral rehabilitation programs and oral health-related quality of life of the elderly in Rural Kerala. J Indian Assoc Public Health Dent 2021;19:304-9
|How to cite this URL:|
Narayan V, Gomez MS, Thomas S, Rao A, Anilkumar S, Raj I, Parameswaran V. Decentralized public-funded oral rehabilitation programs and oral health-related quality of life of the elderly in Rural Kerala. J Indian Assoc Public Health Dent [serial online] 2021 [cited 2022 Aug 17];19:304-9. Available from: https://www.jiaphd.org/text.asp?2021/19/4/304/332536
| Introduction|| |
India is witnessing a demographic trend with a consistent increase in the proportion of elderly citizens. Between 2001 and 2011, the elderly population has grown by 36% while the general population has grown by merely 18%. The state of Kerala has a maximum proportion of elderly citizens (12.6%).
The elderly face numerous challenges toward “active aging.” From an oral health perspective, this involves controlling oral disease and restoring damaged tissue to improve oral function and social well-being. Among the oral conditions affecting the elderly, edentulism has the highest prevalence (50%–80%) in India.,, The prevalence of complete and partial edentulism in rural Kerala has been estimated as 11.9% and 56.3%, respectively.
The edentulous elderly experience greater difficulties while eating. Loss of posterior teeth leads to decreased masticatory efficiency and nutritional loss which can affect general health., Edentulism deteriorates esthetics, phonetics, and personality, compromising the ability of the individual to form social relations., Prosthetic rehabilitation, therefore, not only serves to restore masticatory function but also is critical to enhance mental and social well-being., Previous studies, indicate that senior citizens from rural and economically deprived sections of the society refrain from seeking prosthetic rehabilitation. Several barriers including inaccessibility, dependence, and lack of oral health benefit schemes prevent the edentulous elderly from seeking prosthetic rehabilitation.
The low priority ascribed to geriatric oral health in India has recently witnessed a turnaround. Prosthetic dental rehabilitation has now been included in the national and state health programs. In Kerala, a program named “Mandahasam” (Malayalam word meaning – smile) was initiated by the Social Justice Department, Government of Kerala, for the benefit of the edentulous elderly. The objective of this completely funded program was to provide dentures to senior citizens (>60 years) hailing from an economically poor background. The free denture schemes were organized in the rural areas outside the municipal limits of Kottayam, Vazhoor block panchayat (P1) and Lalam block panchayat (P2), respectively. Beneficiaries for the programs were selected from screening camps conducted in 6–8 grama panchayats within the jurisdiction of these block panchayats. The programs were publicized using local media and through field workers. Apart from their normal duties, Anganwadi workers and Accredited Social Health Activists (ASHA) through their regular home visits were able to identify and refer eligible beneficiaries to the screening camps in P1 and P2, respectively.
Senior citizens with <10 permanent teeth were eligible to participate. Yellow/pink ration cards issued by the Government of Kerala identified subjects from the low economic strata. Subjects with xerostomia, subjects with uncontrolled systemic conditions, and those who were not willing to provide informed consent to participate were excluded. Beneficiaries of programs were selected by oral examination at the screening camps by oral health professionals from Public Health Dentistry in the tertiary referral center for oral health in the district. The clinical procedures of extraction of remaining teeth and denture fabrication, involving 4–5 visits per patient, were performed at the department of Prosthodontics in the tertiary referral center for oral health in the district. The program covered the dentures and the travel expenses to the hospital.
Traditionally, outcomes of dental care have been evaluated using clinical/normative criteria. Oral health-related quality of life (OHRQoL), a multidimensional construct using patient-centric responses, is more pragmatic to assess consequences of edentulism. The Oral Health Impact Profile-14 (OHIP-14) and Geriatric Oral Health Assessment Index (GOHAI) are commonly used instruments designed to measure OHRQoL and have been translated to several Indian languages.,,,,,,,
A patient-centric, pragmatic analysis of changes in OHRQoL following oral rehabilitation is essential for assessing the impact of such public-funded oral health programs. Therefore, this study was conducted to compare and evaluate the changes in OHRQoL after insertion of complete dentures among beneficiaries of the denture programs. The study also compared the responsiveness (longitudinal validity) of OHIP-14 and GOHAI.
| Methodology|| |
Participants for this analytical, prospective study were selected using the same inclusion and exclusion criteria for enrollment in the free denture schemes conducted in two rural block panchayats of Kottayam district, Kerala, India. Additionally, individuals with severe residual ridge resorption (Class V and Class VI) were also excluded. Data collection was done at baseline and 4 weeks after denture insertion using direct interview and telephonic interview, respectively, by two trained oral health professionals. Age, gender, socioeconomic status, systemic medical condition, denture history, and OHRQoL were recorded. Ethical clearance for the study was obtained after review by an institutional ethics committee (Order no. IEC/M/14/2017/DCK). A written, informed consent was obtained from all participants prior to their inclusion in the study.
OHIP-14 and GOHAI were used in P1 and P2, respectively. Translation and cross-cultural adaptation of these tools were made available in the local language, Malayalam. Two independent experts proficient in both languages did forward and backward blind translations. Further, the translated versions were field tested for ensuring face and content validity among twenty elderly subjects selected from the outpatients of the hospital. The difficulties encountered were recorded and appropriate rewording resulted in the final Malayalam version. The response from both tools used a Likert scale as follows: very often = 4, fairly often = 3, occasionally = 2, hardly ever = 1, and never = 0. The individual OHIP-14 and GOHAI scores were calculated using the additive method. The coding of one item (Q5 in GOHAI) “able to eat without discomfort” was reversed (high score in the GOHAI indicated a low impairment). Consequently, the GOHAI scale ranged from 0 to 48 and the OHIP-14 scale from 0 to 56 with higher scores indicating a poorer OHRQoL.
Sample size and sampling
The number of participants in the study was estimated using a commercially available software (nMaster 2.0, Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India). A sample of 35 subjects was estimated assuming a true probability of 0.8 of observing difference between pretreatment and posttreatment OHRQoL scores, accounting for a Type I error of 5%, power of 80%, and 20% attrition. The sample size for factor analysis was considered using the thumb rule of at least 10 respondents per item in the questionnaire. Thus, at least 120 and 140 participants would have to be recruited for the GOHAI and OHIP-14 groups, respectively. A nonprobability convenience sampling framework was used where all eligible subjects who attended the screening camps for the denture program were recruited in the study.
The data was analyzed using (IBM SPSS version 25 )- International Business Machines Corp. (IBM) 2017 Statistical Package for the Social Science (SPSS) statistics Version 25. (Armonk, NY: IBM Corp.). Independent t-tests and Chi-square tests were used to compare the age, gender, and economic background of both the groups. The OHRQoL scores for OHIP-14 and GOHAI at baseline and follow up were compared using Wilcoxon signed rank test. The results are expressed as proportions of participants (percentage endorsement) who responded very often, fairly often, and occasionally for each item in both scales rather than mean ranks. Responsiveness of these indices was determined using effect size, calculated by dividing the mean change in scores of both tools by their respective standard deviation at baseline. Construct validity and psychometric properties of the tools were determined using exploratory factor analysis. Principal component analysis with varimax orthogonal rotation was done separately for both tools using baseline responses, retaining only factors with communalities more than 0.5. Kaiser–Meyer–Olkin measure and Bartlett's test of sphericity were applied to measure the adequacy of strength of the factor analysis. The factors were extracted using eigenvalue technique. P < 0.05 was considered statistically significant for all tests.
| Results|| |
The details of study participants are shown in [Figure 1]. Higher proportion of selected participants received the complete denture in P1 (54.3%) as compared to P2 (31.5%). The overall attrition after denture insertion was low (12.77%). The study population of both the groups were comparable in their demographic profile [Table 1]. More than 70% of the participants were first-time denture wearers.
The percentage of participants who responded very often, fairly often, or occasionally at baseline and 4 weeks after denture insertion using OHIP-14 and GOHAI is shown in [Table 2] and [Table 3], respectively. The mean change in OHIP-14 was 15.39 ± 12.61 and the effect size was 1.55 reflecting an improvement in OHRQoL. The differences in OHIP-14 scores before and 4 weeks after denture insertion were statistically significant for all items except item 3– “painful aching in mouth” [Table 2].
|Table 2: Percentage of subjects responding very often, fairly often, or occasionally to each item in Oral Health Impact Profile-14 before and after denture insertion|
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|Table 3: Percentage of subjects responding very often, fairly often, or occasionally to each item in Geriatric Oral Health Assessment Index before and after denture insertion|
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The mean change in GOHAI was 10.73 ± 8.71 after denture use with an effect size of 1.60 showing improved OHRQoL. The proportions of subjects who responded very often, fairly often, or occasionally for all the items in GOHAI were considerably reduced at 4 weeks after denture insertion [Table 3]. The changes in GOHAI scores were statistically significant for all items except items 2, 4, and 5 (P < 0.05).
Principal component analysis of the data collected using OHIP-14 resulted in extraction of four factors [Table 4] accounting for 69% variance. Four items from the original tool – “worsening of taste,” “diet has been unsatisfactory,” “difficulty doing usual jobs,” and “totally unable to function due to dental problems” – were excluded in the revised version. Data collected using GOHAI resulted in extraction of four factors [Table 5], accounting for 61.8% variance. Two items in the original GOHAI were not retained in the analysis. These were “trouble biting/chewing hard food” and “discomfort when eating.” The Cronbach's alpha for the modified OHIP-14 and GOHAI scales were 0.73 and 0.65, respectively. The Kaiser–Meyer–Olkin measure of sampling adequacy and the Bartlett's test of sphericity indicated that the data were suitable for factor analysis.
|Table 4: Principal component analysis of Oral Health Impact Profile-14 collected at baseline (n=175)|
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|Table 5: Principal component analysis of Geriatric Oral Health Assessment Index collected at baseline (n=146)|
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| Discussion|| |
To our knowledge, this is the first study to evaluate changes in OHRQoL of beneficiaries enrolled in public-funded dentures programs in India. Increasingly, quality-of-life assessment is being regarded as an essential component for assessing health outcomes., Both the groups demonstrated that oral health rehabilitation using dentures resulted in improvement of OHRQoL. All items in OHIP-14, except “painful aching in mouth,” improved significantly after denture use. Similar psychosocial and functional improvement in OHRQoL after denture use has been demonstrated by previous studies., The presence of pain after denture insertion in the present study may be due to the time taken by the elderly to adapt to the new dentures which was similar to a previous study. The subjects in the GOHAI group also showed similar outcomes following denture replacement. Previous studies have demonstrated significant improvements in OHRQoL using GOHAI after denture placement.,,,
The study also compared the responsiveness (longitudinal validity) of the two tools in evaluating changes in OHRQoL. The quality of the tool to measure subtle changes in the perception of subjects brought about by treatment/cure of disease is known as responsiveness. Locker et al. have recommended many ways for assessing the responsiveness of tools used to measure OHRQoL. In the present study, two methods, effect size and percentage endorsement, were used to compare the responsiveness of GOHAI and OHIP-14. The findings indicate that both these tools have good responsiveness to changes in OHRQoL following complete denture replacement. According to the widely used benchmarks suggested by Cohen, an effect size above 0.8 is considered to be large.
Rodakowska et al. demonstrated a strong correlation between the GOHAI and the OHIP-14 in a study where both tools were applied to the participants. In the present study, the OHIP-14 and GOHAI were not administered in both the groups which limited the comparison of the validity of these tools. Simultaneous administration of both tools in all participants would have been cumbersome as the posttreatment data collection in the present study was performed using a telephonic interview. This also prevented a “fatigue effect” that could have occurred due to the use of repeated questionnaires.
The tools used in this study for assessing OHRQoL were the popular OHIP-14 and GOHAI which were adapted to Malayalam, the local language. Although both these tools have been translated to several global,,,, and Indian, languages before, few studies have attempted to measure the responsiveness of these tools. The present study established the psychometric properties of the Malayalam versions of OHIP-14 and GOHAI. Principal component analysis demonstrated significant differences from the original versions of both tools. In this study, only four factors were extracted for OHIP-14 as compared to the seven factors originally proposed.
Principal component analysis of the new Malayalam GOHAI was in contrast to the original factor structure of the index and the translated versions., The Malayalam tool was similar to the GOHAI Tamil version which also generated four factors. Whereas the Tamil version retained all the original items in the scale, two items were deleted in the Malayalam version.
The comparison between the two denture programs in this study yielded interesting findings. In the program promoted by ASHA workers (P2), only 26.3% of the selected participants reported for denture fabrication. Interestingly, 54.3% of the subjects received the complete denture in P1, where recruitment of subjects was carried out using Anganwadi workers. The workload of ASHA workers is immense as they are utilized for most of the fieldwork related to government health schemes in India. The additional duty of promoting the denture program could have constrained the ASHA workers in terms of time and performance, as has been reported previously.
The generalizability of the study to other parts of the country must be done with caution as a non- probability sampling strategy was used. The natural settings, robust sample size, and the assessment of longitudinal validity of OHRQoL tools are strong points. The involvement of local self-government institutions in financing and implementation of such programs underlines the positive impact of decentralization in improving oral health-care delivery at a community level. However, the use of nonprobability sampling strategy and the lack of test–retest reliability assessment of the questionnaires are limitations that should be addressed in further studies.
The study demonstrates that public funded prosthetic rehabilitation programs lead to tangible improvements in OHRQoL of older individuals. The psychometric properties of the Malayalam versions of OHIP 14 and GOHAI have also been established. Policy initiatives to improve the awareness about such public funded denture programs are essential to ensure that similar programs are implemented at a national level.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]