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No t fo rP ub lica Influence of Socioeconomic Status on the tio n te Relationship Between Locus of Control and Oralsse nc e
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Health Shashidhar Acharyaa/Kalyana Chakravarthy Pentapatia/Sweta Singha
Summary: The objectives of this study were to assess the relationship between Locus of Control (LoC) and oral health among a group of rural adolescent school children and to examine the influence of socioeconomic status (SES) on the association between health, LoC and oral health status. A total of 318 children 15 years of age from a public and private school formed the study population. The children were administered following the Indian translation of the 18-item Multidimensional Health Locus of Control scale, and subsequently examined for caries and oral hygiene. T tests and correlation analyses showed a significant relationship between higher ‘Internal’ Locus of Control and dental caries. A hierarchical multiple regression analysis was performed to assess the effect of socioeconomic status on LoC and oral health using three interaction models which showed a statistically significant interaction between ‘Internal’ LoC and socioeconomic status on caries. Socioeconomic stratum-specific estimates of the relationship between the LoC and caries revealed a positive association between Internal LoC and caries in the middle socioeconomic group. The results demonstrated the relationship between Locus of Control and oral health, and the role of socioeconomic status having a strong bearing on this relationship. Key words: Locus of Control, oral health, socioeconomic status Oral Health Prev Dent 2011; 9: 9-16.
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uman behaviour is often studied through measurement of people’s attitudes. These are based on theories, which presume that attitudes are relevant determinants of a person’s behaviour and vice versa. One of the theories explaining behavioural patterns is Locus of Control (Marsh and Richards, 1986). The theory proposes that a person with an internal Locus of Control interprets events as being dependent on his/her own behaviour, and those with external Locus of Control, think that events are in some way dependent upon luck, fate, chance or the influence of other powerful persons (Rotter, 1966). Applying this theory to health settings, those who feel that they have control over their own health and place a high value on it are more likely to pursue health-promoting behaviours,
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Manipal College of Dental Sciences, Manipal University, India.
Correspondence: Dr Shashidhar Acharya, 1-2-50 B, ‘Bhagyashree’, Kunjibettu, Udupi, India 576102. Tel: 94481 27031, 0820 2527031. Email:
[email protected]
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Submitted for publication: 03.06.10; accepted for publication: 13.07.10.
than those who feel that their health is dependent upon external factors. Previous studies have shown a relationship between Locus of Control and oral health behaviours (Wolfe et al, 1991; Borkowska et al, 1998 and Regis et al, 1994). Wolfe et al (1996) reported a shift in Locus of Control, from external to internal as a result of oral hygiene intervention, whereas Scruggs et al (1989) did not. West et al (1993) reported that there was no relation between Locus of Control and compliance with dental appointments. Among all oral diseases among children, dental caries is the most important. It is a multi-factorial disease, and the main etiological factors consist of cariogenic bacteria, frequent intake of fermentable carbohydrates, disorders of salivary production and composition and poor mineralization of hard dental tissues (Featherstone et al, 2003). These risk factors interact, but still they do not fully explain the distribution of the disease (Harris et al, 2004). In an effort to further investigate interactions of the risk factors involved in the etiology of childhood car-
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ies, research has focused on socioeconomic, psychological and behavioural risk factors as these could act as indirect causal agents (Pine et al, 2004). When considering socio-economic indicators as risk factors, it has been recognized that children’s oral health is related to their families’ socio-economic status (SES) and their mothers’ education level (Wennhall et al, 2002; Tinanoff, 1998; Ismail and Sohn, 2001 and Ramos-Gomez et al, 2002). There have been few studies reported in the literature on the relationship between LoC and caries (Chase et al, 2004; Brandao et al 2006 and Reisine et al, 1993), but the findings have been contradictory. Previous studies have found that mothers who had more external LoC had children with a greater risk of having caries (Reisine and Litt, 1993). Other studies found no significant differences in LoC between parents in relation to either the occurrence of early childhood caries (Brandao et al, 2006) or caries relapse (Chase et al, 2004) among children. Lencova et al (2008) reported a strong linear association between parental LoC and their child’s caries status, with a stronger parental LoC being linked with a higher probability of their child being free from untreated dental decay in the primary dentition. While most of the studies among children have concentrated on early childhood, few studies have sought to investigate the relationship between LoC and oral health among the adolescent age group. India is a predominantly rural country with more than 70% of the population residing in the villages. However, the dental research community has largely ignored this very important and large group of people. Also most of the studies conducted on the relationship between LoC and caries have tested the association between the parent’s LoC and their child’s caries experience. No study that directly tested the association between the children’s LoC and their caries experience has been reported in the literature. So the objectives of the present study were to assess the relationship between Locus of Control and oral health among a group of rural adolescent school children, and to examine the influence of socioeconomic status (SES) on the association between health, Locus of Control and oral health status.
pyrig No Co t fo rP MATERIALS AND METHODS ub lica tio Study sample n te ss e n c e
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This study was carried out among a group of 318, 15-year-old school children studying in a private and government school located within the field practice area of the university in Udupi District. This district had a total of 220 high schools, out of which 128 were government run and the remaining were privately run. This information was obtained from the district administration. Since the distribution of the government and private schools was roughly the same, one government and one private school were randomly selected from the list of schools. The overall aim of the study was to study the effect of behavioural factors on oral health, in particular, dental caries, as has been the case with numerous previous studies. Hence dental caries prevalence was taken into consideration for sample size estimation. The prevalence of decayed teeth was estimated at 30% with a confidence level of 95% and a sampling error of 5%. The final sample size thus was calculated at 318 children. All children aged 15 years, who were present on the day of the survey and who gave consent for the study, were included. Ethical clearance was obtained from the ethics committee of Manipal University in advance. All the 15-year-old children available on the day of the survey were included in both schools. Written consent from the children and their parents were obtained prior beforehand.
Questionnaire The Indian translation of the 18 Item Multidimensional Health Locus of Control scale was administered to the respondents. This scale was developed by Wallston et al (1978) consists of three, 6 item scales, also using the Likert format. The Internal HLC (IHLC) is the extent to which one believes that internal factors are responsible for health or illness. Powerful Others HLC (PHLC) is the belief that one’s health is determined by other influential people that a person encounters or knows and Chance HLC (CHLC) measures the extent to which one believes that health illness is a matter of fate, luck or chance and items. Respondents rate each item on the MHLC using a six point (1 to 6) scale; thus each subscale of 6 questions has a scoring range from 6 to 36. There is no ‘Total’ MHLC score for the questionnaire.
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In addition to the questionnaire, the socioeconomic status of the study population was assessed using the Modified Kuppuswamy Scale (Mishra and Singh, 2003), the most widely used scale to measure socioeconomic status in India. The educational status, occupation and income of the family are considered, to segregate the population into lower, middle and upper socioeconomic status. Two openended questions were asked: ‘What causes dental decay?’ and ‘How do you prevent dental decay?’ The responses were analysed and grouped under the categories of good, fair and poor based on their ability to name the causes of caries and measures for prevention.
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A total of 318 school children were examined. Of the total study population, 210 children belonged to government school and the remaining 108 belonged to private school. Two hundred students belonged to the lower socioeconomic status and the remaining 118 belonged to the middle socioeconomic group. There were no children belonging to the upper socioeconomic group in either the government or private schools of the area.
Questionnaire analysis Clinical examination The children were also clinically examined for caries using the DMFT index (Klein and Palmer, 1938) and Oral Hygiene status using the OHI-S index (Greene and Vermillion, 1964). The author and a postgraduate student conducted the examinations. Both of them had been calibrated in discussion sessions and trained for two days.
Statistical analyses An unpaired T test was done to compare between means and Pearson’s correlation was done to test the association between oral health status and Locus of Control. Hierarchical multiple regression analysis was done to test the association between the LoC scores, DMFT scores and socioeconomic status. Correlation analysis was done between Internal LoC and DMFT twice: once for the lower SES group and once for the middle SES group. The two independent correlations were then tested against each other using Fisher’s Z-test to assess the difference in strengths of the correlations. Hierarchical multiple regression analysis was done to test the role of socioeconomic status in the relationship between LoC and oral health. A P value of 0.05 was considered statistically significant. All of the statistical analyses were performed with the SPSS Version 14 software package.
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The mean Internal, Powerful, and Chance score for the study population was 25.03 ± 3.30, 23.27 ± 6.46 and 18.55 ± 4.76 respectively. Fifty two percent (n = 166) of the children had a ‘Poor’ knowledge of caries followed by 38% (n = 122) with ‘fair’ knowledge and 10% (n = 30) with good knowledge. The mean ‘powerful others’ Locus of Control was significantly higher (P = 0.006) among private school children than their public school counterparts, whereas ‘Chance’ LoC was significantly higher (P = 0.034) among the government school children. Males were found to have a higher ‘Chance’ Locus of Control than their female counterparts (P < 0.001) and the lower socioeconomic status group were found to have a significantly higher ‘Internal’ and ‘Chance’ Locus of Control than the middle class group (Table 1).
Clinical findings The oral health status was assessed using the DMFT and OHI-S index. The mean DMFT score was 2.44 ± 2.64 and the mean OHI-S score was 1.20 ± 0.86. The results showed that the mean DMFT was significantly higher among public school children than the private and among females than males. Also the mean OHI-S score was significantly more among public school children than the private and among the lower socioeconomic group than the middle socioeconomic group (Table 2).
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Powerful others
Government (210)
25.24 ± 3.17
22.56 ± 4.83
Private (108)
24.63 ± 3.54
24.65 ± 8.70
17.76 ± 4.42
P value
0.135
0.021
0.029
Males (228)
24.88 ± 3.25
23.10 ± 4.27
19.26 ± 4.43
Females (88)
25.45 ± 3.46
23.64 ± 1.54
16.73 ± 5.19
P value
0.182
0.502
P < 0.001
Lower (210)
25.51 ± 3.08
22.95 ± 4.88
19.14 ± 5.13
Middle (108)
24.11 ± 3.54
23.89 ± 8.78
17.40 ± 3.73
P value
0.001
0.299
0.002
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Table 1 Relationship between Locus of Control and sociodemographic variables
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P ≤ 0.05: significant
Table 2 Relation between oral health and sociodemographic variables
School
Gender
Socioeconomic status
DMFT
OHI-S
Government (210)
2.77 ± 2.61
1.33 ± 0.88
Private (108)
1.8 ± 2.59
0.93 ± 0.75
P value
0.002
0.000
Males (228)
2.13 ± 2.45
1.21 ± 0.85
Females (88)
3.30 ± 2.93
1.19 ± 0.88
P value
0.000
0.830
Lower (210)
2.62 ± 2.43
1.29 ± 0.74
Middle (88)
2.09 ± 3.00
1.01 ± 1.04
P value
0.092
0.006
P ≤ 0.05: significant
Relationship between Locus of Control and oral health Bivariate analysis to assess the difference between LoC scores among those with and without caries showed a statistically significant difference, where the mean ‘Internal’ score was higher among those with caries than the caries free group (Table 3). Correlation analysis was done to know the interrela-
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tionship between Locus of Control and DMFT and OHI-S scores. The results showed a statistically significant positive correlation between the ‘Internal’ scores and the DMFT scores. Also a statistically significant inverse correlation was observed between the ‘Powerful others’ LoC scores and the OHI-S scores (Table 4).
Oral Health & Preventive Dentistry
Internal
Powerful others
Caries
Caries free (102)
24.12 ± 3.77
23.00 ± 4.04
Caries present (216)
25.47 ± 2.97
23.40 ± 7.33
18.81 ± 4.86
P value
0.001
0.607
0.155
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Table 3 Locus of Control and dental caries prevalence
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Table 4 Correlation between Locus of Control and oral health variables Internal
Powerful others
Chance
DMFT
DT
MT
FT
OHI-S
Pearson correlation
.194
.195
.159
-.081
.064
Sig. (2-tailed)
.001
.0004
.005
.151
.258
N
318
318
318
318
318
Pearson correlation
.023
.020
.056
-.025
-.122
Sig. (2-tailed)
.681
.728
.320
.654
.029
N
318
318
318
318
318
Pearson correlation
-.053
-.044
.015
-.060
.061
Sig. (2-tailed)
.348
.434
.790
.283
.279
N
318
318
318
318
318
P ≤ 0.05: significant Statistically significant positive correlation between Internal HLC and DMFT, DT, MT.
Three-way interaction between Locus of Control, socioeconomic status and oral health Hierarchical multiple regression analysis was performed to assess the effect of socioeconomic status on LoC and oral health (Table 5). Three models were created for the above purpose. The three LoC scores were placed in the first model and the LoC scores and the socioeconomic status were placed in the second model and the LoC scores, Socioeconomic status along with the individual interactions between SES and LoC, namely SES-Internal, SESPowerful others and SES-Chance were placed in model three, with the dependent variable being the DMFT values. The results showed a statistically significant association between ‘Internal’ LoC and caries in Model 1 and between ‘Internal LoC and socioeconomic status with caries (DMFT) in Model 2 and SES and SES-Internal interaction, in Model 3.
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The role of socioeconomic status as a potential moderator in the association between ‘Internal’ LoC and dental caries was tested by two methods. The first was by doing a hierarchical multiple regression analyses to present socioeconomic stratum specific estimates of the relationship between the LoC and the outcome variable (caries). The results of the analysis (Table 5) showed that there was a strong positive association between Internal LoC and caries in the middle socioeconomic group (P = 0.001). The second method was by doing a correlation (Pearson) analysis between Internal LoC and DMFT twice, once for the lower SES group and once for the middle SES group. The correlation coefficients for the two SES groups were 0.029 (P = 0.775) and 0.338 (P < 0.001). The two independent correlations were then tested against each other using Fisher’s z-test. Following the analysis, a Z value of 2.77 was obtained, with the two tailed Z-
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pyrig No Co t fo r Pof ConTable 5 Hierarchical multiple regression analysis to assess the effect of socioeconomic status (SES) on Locus ub trol and dental health lica tio n Standardised T value Sig. 95% Confidencet einterval e s s c en coefficients
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Interaction models to assess the moderating role of SES
Model 1
Model 2
Model 3
SES stratumspecific estimates
Lower SES
Middle SES
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Beta
Lower bound
Upper bound
Internal
0.209
3.433
0.001
0.013
0.047
Powerful others
-0.066
-1.088
0.278
-0.013
0.004
chance
0.053
0.937
0.349
-0.006
0.016
Internal
0.156
2.530
0.012
0.005
0.039
Powerful others
-0.024
-0.388
0.698
-0.010
0.007
Chance
0.019
0.336
0.737
-0.009
0.013
SES
-0.211
-3.704
0.000251
-0.318
-0.097
Internal
-0.273
-1.471
0.142
-0.090
0.013
Powerful others
-0.074
-0.350
0.727
-0.036
0.025
Chance
-0.081
-0.463
0.644
-0.042
0.026
SES
-1.498
-3.416
0.001
-2.327
-0.626
Internal*SES
1.113
2.490
0.013
0.009
0.079
Internal
0.039
0.505
0.614
-0.016
0.027
Powerful others
-0.047
-0.597
0.551
-0.018
0.010
Chance
0.009
0.133
0.895
-0.011
0.013
Internal
0.349
3.376
0.001
0.020
0.079
Powerful others
-0.050
-0.481
0.632
-0.015
0.009
Chance
0.071
0.750
0.455
-0.016
0.035
Model 1 Predictors: chance, powerful others and internal mean Model 2 Predictors: chance, powerful others, internal mean, socioeconomic status (SES) Model 3 Predictors: chance, powerful others, internal mean, socioeconomic status (SES), internal*SES, powerful others*SES, chance*SES (only the significant interactions shown) Dependent variable: DMFT P ≤ 0.05: significant
critical value at 2.58, which was found to be significant at the level of P < 0.01.
DISCUSSION This study was conducted to assess the relationship between Locus of Control and oral health among a group of adolescent school children from
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a rural area and to study the role of their socioeconomic status in influencing his relationship. The results of this study showed a definite interrelationship between LoC, Socioeconomic and demographic status and oral health. Several demographic factors including sex, socioeconomic status and education have been previously found to be associated with MHLC.
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In addition, factors such as the school, gender and socioeconomic status were found to influence the LoC of the children in the present study. Private school children had a significantly higher perception of ‘Powerful Others’ than their public school counterparts. When compared against gender, it was seen that males had a higher perception of ‘Chance’ than the females. These were contrary to the results reported by Kuwahara et al (2004), who found that males scored higher on IHLC, while females scored higher on CHLC and PHLC. These findings may be explained by the fact that females tend to have better health compliance than males. Also the ‘Internal’ and ‘Chance’ LoC was found to be higher among the lower socioeconomic group. This finding was unlike that reported by previous authors where people with high socioeconomic status had higher ratings on IHLC as compared to those with lower socioeconomic status, who tended to have higher ratings on ‘external’ factors (Kuwahara et al, 2004). This finding may be explained by the fact that in rural areas of India, a high degree of independence and self-containment is fostered from a young age due the lack of even basic facilities. Another possible explanation could be the fact that sample did not reflect all levels of the socioeconomic classification, which prevented a more thorough comparison. Dental caries was found to be significantly higher among public school children and among females, which was in agreement with previous studies (Pereira et al, 2007). Also a statistically significant difference was observed between oral hygiene status where the mean OHI-S score was higher among public school students and among the lower socioeconomic group. This finding was consistent with other countries where a higher level of education and standard of living was associated with a better level of oral cleanliness (Grant et al, 1988). Previous studies have shown contrasting results regarding the relationship between oral health status and Locus of Control (Reisine and Litt, 1993, Chase et al 2004, and Brandao et al, 2006). While Chase et al (2004) and Brandao et al (2006) reported no relation between oral health status and Locus of Control, Reisine and Litt (1993) and Lencova et al (2008) reported that mothers with a weaker Locus of Control had children with greater risk of having caries. In this study, a positive correlation between the ‘Internal’ LoC and dental caries was observed. The ‘Internal’ LoC was significantly higher among those with caries than the caries free
pyr Co etigal No Acharya t fo rP group, although the magnitude of the difference ub lica was small. These findings were contrary to previous studies where an external Locus of Control was as- tion t ss e scesociated with increased caries risk. In an eideal nc e nario, a stronger internal Locus of Control (LoC) is usually desirable, if it is matched by competence and opportunity so that the person is able to successfully experience the sense of personal control and responsibility (Marsh and Richards, 1986). However, it is also possible that a high ‘internal’ Locus of Control indicating a high independence, may play a negative role by instilling a false sense of control about one’s ability to maintain oral health, especially when not backed by adequate oral health knowledge, of competence and awareness about the disease. A concomitant lack of oral health care facilities in the surrounding areas may further exacerbate the situation. The moderating role of socioeconomic status in the relationship between LoC and oral health has rarely been studied in related literature. The results of the hierarchical regression analysis showed that socioeconomic status as a factor had a statistically significant effect on the association between LoC and in particular, internal LoC, and oral health. Further analysis to study the role of socioeconomic strata in moderating and influencing the relationship between LoC and oral health revealed a statistically significant positive association between the ‘internal’ LoC and caries status among the middle socioeconomic group. This showed that among the study population, a higher ‘internal’ LoC was more likely to be associated with poor oral health among children of the middle socioeconomic strata, than the children of the lower socioeconomic strata. Although the lower socioeconomic group showed a greater internal LoC and poorer oral health than the middle socioeconomic group, the moderating effect of SES on the LoC and oral health interaction was more profound in the middle SES group. This implied that other factors, which generally play a role in increasing the risk of caries among higher SES groups, such as refined carbohydrate consumption, could have played a stronger role than expected. The results of this study, in addition to showing the relationship between LoC and oral health also showed the important role of socioeconomic status in influencing the association between the two. Contrary to the assumption that a more external Locus of Control was associated with poor oral health, we found a significant association between the internal LoC and poor oral health. It is also pos-
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1. Borkowska ED, Watts TLP, Weinman J. The relationship of health beliefs and psychological mood to patient adherence to oral hygiene behavior. J Clin Periodontol 1998;25:187–193. 2. Brandao IM, Arcieri RM, Sundefeld ML, Moimaz SA. Early childhood caries: the influence of socio-behavioral variables and health. Locus of control in a group of children from Araraquara, Sao Paulo, Brazil. Cad Saude Publica 2006;22:1247–1256. 3. Chase I, Berkowitz RJ, Proskin HM, Weinstein P, Billings R. Clinical outcomes for Early Childhood Caries (ECC): the influence of health, Locus of control. Eur J Paediatr Dent 2004;5:76–80. 4. Featherstone JD, Adair SM, Anderson MH, Berkowitz RJ, Bird WF, Crall JJ, Den Besten PK et al. Caries management by risk assessment: consensus statement. J Calif Dent Assoc 2003;31:257–269. 5. Grant DA, Stern IB, Listgarten MA. In: Periodontics in the tradition of Gottlieb and Orban. Washington, DC: C.V Mosby Company, 1988: 232–233. 6. Greene JC, Vermillion JR. The simplified oral hygiene index. J Am Dent Assoc 1964;68:7–13. 7. Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for dental caries in young children: a systematic review of the literature. Community Dent Health 2004;21:71–85. 8. Ismail AI, Sohn W. The impact of universal access to dental care on disparities in caries experience in children. J Am Dent Assoc 2001;132:295–303. 9. Klein H, Palmer C. Studies on dental caries vs. familial resemblance in the caries experience of siblings. Public Health Rep 1938;53:1353–1364. 10. Kuwahara A, Nishino Y, Ohkubo T, Tsuji I, Hisamichi S, Hosokawa T. Reliability and validity of the Multidimensional Health Locus of Control Scale in Japan: relationship with demographic factors and health-related behavior. Tohoku J Exp Med 2004;203:37–45. 11. LenĀová E, Pikhart H, Broukal Z, Tsakos G. Relationship between parental Locus of Control and caries experience in preschool children – cross-sectional survey. BMC Public Health 2008;12:8:208. 12. Macgregor IDM, Regis D, Balding J. Self-concept and dental health behaviours in adolescents. J Clin Periodontol 1997;24:335–339.
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