Abstract

INTRODUCTION

The world population has been aging fastly. In developing countries, like Brazil, where the statute of the elderly¹1. Brasil. Ministério da Saúde. Estatuto do Idoso. 2ª reimpressão. Série E. Legislação de Saúde. Brasília: Ministério da Saúde; 2003. 70 p. establishes the age of 60 or more for a person to be considered as an elder, that is not different. The country is experiencing a differentiated epidemiological transition²2. Chaimowicz F. A saúde dos idosos brasileiros às vésperas do século XXI: problemas, projeções e alternativas. Rev Saúde Pública 1997; 31(2): 184-200., in which communicable diseases reappear while health expenses with chronic degenerative diseases increase significantly³3. Frenk J, Frejka T, Bobadilla JL, Stern C, Lozano R, Sepúlveda J, et al. La transición epidemiológica en América Latina. Bol Oficina Sanit Panam 1991; 111(6): 485-96.. The oral health of this part of the population is precarious and characterized by extensive dental loss⁴4. Hugo FN, Hilgert JB, de Sousa ML, da Silva DD, Pucca Jr GA. Correlates of partial tooth loss and edentulism in the Brazilian elderly. Community Dent Oral Epidemiol 2007; 35(3): 224-32.. This scenario can influence the quality of life of these people.

Quality of life is a multidimensional term⁵5. Fleck MPA (org.). A Avaliação de qualidade de vida: guia para profissionais da saúde. Porto Alegre: Artmed, 2008. 228 p.; therefore, it should be studied by considering a series of factors that can influence its perception. Clinical conditions and health problems can have an impact on quality of life, but other things should be considered⁶6. Slade GD. Derivation and validation of a short-form oral health impact profile. Community Dent Oral Epidemiol 1997; 25(4): 284-90.. We can also define oral health-related quality of life as "the absence of negative impacts of oral condition on social life and a positive sense of self-confidence regarding the oral condition"⁷7. Atchison KA. Understanding the quality in quality care and quality of life. In: Inglehart MR, Bagramian RA. Oral Health-Related Quality of Life. USA: Quintessence Books; 2002. p. 13-29..

One of the factors that can influence the perception individuals have regarding the impact of oral health conditions on their quality of life is resilience. In psychology, such a term is intimately connected with the way people behave toward adversities, as well as their ability to return to "normal" in spite of them⁸8. Rutter M. Psychosocial resilience and protective mechanisms. Am J Orthopsychiatriy 1987; 57(3): 316-31.. The term was originated in studies involving children; in the past few years, however, the theme was expanded to other segments of the population, and the elderly group was very appropriate for these investigations.

In the past decades, some studies were conducted with the objective of assessing the oral health-related quality of life⁹9. Leão A, Sheiham A. Relation between clinical dental status and subjective impacts on daily living. J Dent Res 1995; 74(7): 1408-13. and resilience¹⁰10. Laranjeira CASJ. Do vulnerável ser ao resiliente envelhecer: revisão de literatura. Psic Teor e Pesq 2007; 23(3): 327-32.

11. Martins AB, dos Santos CM, Hilgert JB, de Marchi RJ, Hugo FN, Padilha DMP. Resilience and self-perceived oral health: a hierarchical approach. J Am Geriatr Soc 2011; 59(4): 725-31.^-1212. Wagnild GM, Young HM. Development and psychometric evaluation of the Resilience Scale. J Nurs Meas 1993; 1(2): 165-78.. However, we are not familiar with studies that assess the oral health-related quality of life and resilience among the elderly, working as a protective factor regarding the impacts produced by poor oral health.

This study aims at assessing the association between resilience and oral health-related quality of life by a hierarchical approach based on the conceptual theoretical model of oral health outcomes proposed by Andersen and Davidson¹³13. Andersen RM, Davidson PL. Ethnicity, aging, and oral health outcomes: a conceptual framework. Adv Dent Res 1997; 11(2): 203-9.. The hypothesis of the study is that more resilient elderly people can adjust more easily to losses related to oral health; therefore, their quality of life is less impacted in terms of oral health.

METHODS

STUDY DESIGN

This is a cross-sectional study nested in a cohort study.

POPULATION AND SAMPLE

A simple random sample was conducted with a population of independent elderly people in the city of Carlos Barbosa. The base study was conducted in 2004, and the first follow-up took place in 2008. Carlos Barbosa is located 104 km from Porto Alegre, capital of Rio Grande do Sul, in the south region of Brazil; its municipal human development index (HDI) in 2010 was of 0.796. Since it was colonized by Italians, its population is mostly composed of white people and, in 2008, there were approximately 25,388 inhabitants, 2,167 aged 60 years old or more¹⁴14. Instituto Brasileiro de Geografia e Estatística (IBGE). Perfil dos idosos responsáveis por domicílios. 2000. Disponível em: http://www.ibge.gov.br/home/presidencia/noticias/25072002pidoso.shtm. (Acessado em 20 de maio de 2013).
http://www.ibge.gov.br/home/presidencia/... .

In the base line, 872 elderly people were assessed during the second semester of 2004¹⁵15. Hugo FN, Hilgert JB, de Souza ML, Cury JA. Oral status and its association with general quality of life in older independent-living south-Brazilians. Community Dent Oral Epidemiol 2009; 37(3): 231-40.. In 2008, in the cross-sectional study that was part of the follow-up stage, a consecutive sample of the participants was evaluated until there were 498 people, which is equivalent to the necessary sampling calculation to carry out the study that originated this one; it focused on the relationship between relisience and health self-perception¹¹11. Martins AB, dos Santos CM, Hilgert JB, de Marchi RJ, Hugo FN, Padilha DMP. Resilience and self-perceived oral health: a hierarchical approach. J Am Geriatr Soc 2011; 59(4): 725-31.. The calculation was based on a pilot study composed of 50 individuals who presented 0.67 prevalence of low resilience potential and good oral health self-perception, and 0.75 prevalence of high resilience potential and good oral health perception. A 95% confidence interval (95%CI) was considered, admitting a β error of 20% and consecutive 80% statistical power.

MEASUREMENTS

The information in this study was collected during the 2008 follow-up, being approved by the Research Ethics Committee of Universidade Federal do Rio Grande do Sul. After a new contact with the participants, when they agreed to participate in the study again, they were informed about the objectives and procedures to be conducted; afterwards, they were asked to sign the informed consent form.

DATA COLLECTION

Collection was conducted by interviews and clinical examinations, by using instruments and methodology according to criteria by the World Health Organization (WHO)¹⁶16. World Health Organization (WHO). Oral Health Surveys: Basic Methods, 4(th) ed. Geneva: WHO; 1997.; these were also reference for training examiners. Interviewes were conducted in the households or in neighborhood associations, and clinical examinations were carried out in dental clinics of Basic Health Units in the city, using artificial light.

INSTRUMENTS

CONCEPTUAL THEORETICAL MODEL

The behavioral model used in this study is an adaptation of the model proposed by Andersen and Davidson¹³13. Andersen RM, Davidson PL. Ethnicity, aging, and oral health outcomes: a conceptual framework. Adv Dent Res 1997; 11(2): 203-9.. As described in Figure 1, the modified model conceptualizes exogenous variables (age and sex) as distal variables located in the 1^st block of analysis. In the 2^nd block, as intermediate variables, it is possible to find primary determinants, represented by the external environmental and personal characteristics. The external environment is characterized by the location of the household where the elderly person lives. Personal characteristics were: marital status, resilience potential and available resources (schooling, income and participation in elderly groups). The intermediate variables in the 3^rd block were health-related behaviors: smoking and toothbrushing frequency and visits to the dentist. In the proximal block, that is, the 4^th block, it was possible to observe current oral health conditions: tooth loss in the past four years and number of teeth. The study outcome was oral health-related quality of life.

STATISTICAL ANALYSIS

Data were described by using the simple and absolute frequencies for qualitative and mean variables, and standard-deviation (SD) for quantitative variables. A bivariate analysis was conducted by the χ²2. Chaimowicz F. A saúde dos idosos brasileiros às vésperas do século XXI: problemas, projeções e alternativas. Rev Saúde Pública 1997; 31(2): 184-200. and the Mann-Whitney test. Univariate and multivariate analyses were conducted by generalized linear models for discrete variables. Negative binomial regression models were calculated. Mean ratios (MR) are presented with their 95%CI. The presence of overdispersion was confirmed in preliminary analyses, and modeling was in accordance with the guidelines described by Hardin and Hilbe¹⁹19. Hardin JW, Hilbe JM. Generalized Linear Models and Extensions. College Station: Stata Press; 2001. 245 p..

The variables that remained statistically significant inside each block (p < 0.25) were used in the final model. The adjustment of the final model, in comparison to models in each of the proposed blocks, was assessed according to the Baysean Information Criteria, and was used in the final model. The adjustment of the final model, in comparison to the modela in each of the proposed blocks, was assessed according to the Baysean Information criteria and pseudo-R²2. Chaimowicz F. A saúde dos idosos brasileiros às vésperas do século XXI: problemas, projeções e alternativas. Rev Saúde Pública 1997; 31(2): 184-200.. The presence of outliers and triggering potential of the models were analyzed in the final model. Terms of interaction between resilience and covariation were tested. Statistical analysis was conducted with the software STATA, version 11.2 (StataCorp, College Station, TX).

RESULTS

The studied sample presented mean age of 70.95 (± 6.59) years old. Most of the sample was composed of women (66.87%), who lived in the urban area (53.21%) and were married (64.06%). The mean score of RS was of 141.06 (± 13.30). Besides, 45.92% did not finish elementary school, and 60.45% participated in elderly groups. Most participants (58.43%) reported looking for a dental surgeon only because of oral related problems, and the mean CPOD was 27.28 (4.89). The intra and inter-examiner Kappa coefficient to assess the CPOD index before and during the study in 2004 was of 0.97 and 0.94; in 2008, it was 0.98 and 0.97. The Cronbach's a coeficiente of the RS was of 0.71 (lower interval of 0.68), while for OHIP it was of 0.82 (lower interval of 0.80).

Among individuals who presented OHIP sum score = 0, there was no significant difference between variables. On the other hand, the OHIP mean was significantly higher among women (6.7 ± 6.3), those living in the rural zone (7.3 ± 6.7) and single people (8.0 ± 6.3) (Table 1).

There was no association between the variables composing the 1^st block: age and sex with outcome. In the 2^nd block, the household location (rural) presented aMR (adjusted) of 1.37 (95%CI 1.11 - 1.79) (Table 2).

With regard to personal characteristics, resilience was not associated, unlike marital status. Married elderly people, when compared to widowers/separated ones, presented aMR of 1.30 (95%CI 1.06 - 1.60). Schooling, income and participation in elderly groups were not statistically significant, as well as variables of behavior and oral health conditions (third and fourth blocks) (Table 2).

No term of interaction between resilience and the variables in any block was significant (p > 0.05), indicating that this variable (resilience) does not change the effect of the others.

For the totally adjusted model, only the variables referring to the external environment, which formed the 2^nd block (distal determinants), presented statistically significant differences. People living in the rural zone presented aMR of 1.32 (95%CI 1.06 - 1.65), and married ones, aMR of 1.36 (95%CI 1.07 - 1.72), when related with widowers/separated people (Table 3).

DISCUSSION

In this study, exogenous variables and primary determinants, in the most distal position of the model, have been associated with more impacts on oral health-related quality of life, while intermediate ones, related to health behaviors, and proximal variables, such as oral health conditions, had no statistical significance. However, among primary determinants, as a multidimensional construct, resilience did not present statistical significance when assessed in a hierarchical model, thus rejecting our initial hypothesis.

Marital status is an important health determinant and is strongly associated with many mental health outcomes. Married people have lower levels of depression, anxiety and psychological stress than single people²⁰20. Waldron I, Hughes ME, Brooks TL. Marriage protection and marriage selection--prospective evidence for reciprocal effects of marital status and health. Soc Sci Med 1996; 43(1): 113-23.. Besides, living without a partner is usually related to the report of poorer quality of life²¹21. Sprangers MA, de Regt EB, Andries F, van Agt HM, Bijl RV, de Boer JB, et al. Which chronic conditions are associated with better or poorer quality of life? J Clin Epidemiol 2000; 53(9): 895-907.. Our results demonstrate that married people, when compared to separated ones/widowers, report more impact of oral health-related quality of life. That can be related to the presence of a partner, which determines more self-esteem, and to the possibility of increasing the importance of determinant health factors and their behaviors and subjective perceptions. Studies about changing marital status, especially from married to separated people or widowers, point out to increasing prevalence of mental, physical, chronic and acute diseases²²22. Wu Z, Penning MJ, Pollard MS, Hart R. In sickness and in health: does cohabitation count? J Fam Issues 2003; 24: 811-38..

According to literature, the daily use of health services is less frequent among people living in rural zones²³23. Martins AMEBL, Barreto SM, Pordeus IA. Características associadas ao uso de serviços odontológicos entre idosos dentados e edentados no Sudeste do Brasil: Projeto SB Brasil. Cad Saúde Pública 2008; 24(1): 81-92., which seems to be explained by the lack of access and the fewer resources; these range from health care itself to water fluoridation²⁴24. Quandt SA, Chen H, Bell RA, Anderson AM, Savoca MR, Kohrman T, et al. Disparities in oral health status between older adults in a multiethnic rural community: the rural nutrition and oral health study. J Am Geriatr Soc 2009; 57(8): 1369-75.. These difficulties may be related to unfavorable oral health, which increases the impacts on quality of life. Living in the rural zone seems to be a predictor of disadvantages with regard to oral pain and need for prosthesis²⁵25. Chavers LS, Gilbert GH, Shelton BJ. Racial and socioeconomic disparities in oral disadvantage, a measure of oral health-related quality of life: 24-month incidence. J Public Health Dent 2002; 62(3): 140-7.. However, most studies do not precisely describe the location of the household, so only a few analyze this variable, especially regarding quality of life²⁶26. Cohen-Carneiro F, Souza-Santos R, Rebelo MA. Quality of life related to oral health: contribution from social factors. Ciênc Saúde Coletiva 2011; 16(Suppl 1):1007-15.. The relationship between people who live in rural and urban communities ranges according to the analyzed disease. For Parkinson's disease, for instance, quality of life is better in urban areas²⁷27. Klepac N, Pikija S, Kraljic T, Relja M, Trkulja V, Juren S, et al. Association of rural life setting and poorer quality of life in Parkinson's disease patients: a cross-sectional study in Croatia. Eur J Neurol 2007; 14(2): 194-8.; at the same time, for rheumatoid arthritis, this relationship is inverse²⁸28. Cornelissen PG, Rasker JJ, Valkenburg HA. The arthritis sufferer and the community: a comparasion of arthritis sufferers in rural and urban areas. Ann Rheum Dis 1988; 47(2): 150-6.. Our results show that living in the rural zone presented higher chances of realizing the impacts of oral health on quality of life. This can be related to closeness between known people and to the differences of physical and social environments that determine the life style of these people. Also, we can relate the peculiar conditions of the rural zone where the study was conducted, which is recognized for having one of the best human development indexes in Brazil. By observing the mean resilience score, which is within patterns observed in literature¹¹11. Martins AB, dos Santos CM, Hilgert JB, de Marchi RJ, Hugo FN, Padilha DMP. Resilience and self-perceived oral health: a hierarchical approach. J Am Geriatr Soc 2011; 59(4): 725-31.^,1818. Wagnild GM. The resilience scale user's guide for the U.S. english version of the resilience scale and the 14-item resilience scale, version 1.0. Montana: The Resilience Center; 2009., we can think of the possibility that the study participants show a selective survival bias, as reported by Haikal et al.²⁹29. Haikal, DS, Paula AMB, Martins AMEBL, Moreira AN, Ferreira EF. Autopercepção da saúde bucal e impacto na qualidade de vida do idoso: uma abordagem quanti-qualitativa. Ciênc Saúde Coletiva 2011; 16(7): 3317-29..

Studies show that dental variables, such as tooth loss, are associated with worse quality of life⁹9. Leão A, Sheiham A. Relation between clinical dental status and subjective impacts on daily living. J Dent Res 1995; 74(7): 1408-13.^,3030. Locker D. Clinical correlates of changes in self-perceived oral health in older adults. Community Dent Oral Epidemiol 1997; 25(3): 199-203.. Our results present borderline significance, with certain tendency of the elderly with missing teeth reporting the impacts of oral health a little bit more. However, it is worth to question to what point dental loss and the sequels of history of oral health mutilation can be considered as a stress factor for this population. It is known that many elderly people consider their oral health to be good or excellent, despite losses³¹31. Vasconcelos LCA, Prado Jr RR, Teles JBM, Mendes RF. Autopercepção da saúde bucal de idosos de um município de médio porte do Nordeste brasileiro. Cad Saúde Pública 2012; 28(6): 1101-10., that is, they are adapted to a situation by "activating their resilience potential" by not considering oral health to be an issue; that is, if these impacts do not reflect on their oral health-related quality of life. Culturally, past generations considered tooth loss as something acceptable. Nowadays, in clinical practice, it is still common for elderly patients to prefer tooth loss over the pain that can be caused by a tooth. However, it is worth to mention that the elderly people analyzed in this study lived in a time when tooth loss and poor oral conditions, as well as getting sick, were considered to be part of the "normal aging process"³²32. Martins AMEBL, Barreto SM, Pordeus IA. Auto-avaliação de saúde bucal em idosos: análise com base em modelo multidimensional. Cad Saúde Pública 2009; 25(2): 421-35..

In a previous study of the group¹¹11. Martins AB, dos Santos CM, Hilgert JB, de Marchi RJ, Hugo FN, Padilha DMP. Resilience and self-perceived oral health: a hierarchical approach. J Am Geriatr Soc 2011; 59(4): 725-31., an association was found between having high resilience potential and positive oral health perception, even considering the sample of analyzed elders who had high prevalence of tooth loss. However, possible associations between resilience and quality of life related to oral health were not assessed. This leads us to question what the meaning of resilience in this context is. In case the elderly do not consider their oral health condition to be a stress factor, they may consider that poor oral health is not a problem³¹31. Vasconcelos LCA, Prado Jr RR, Teles JBM, Mendes RF. Autopercepção da saúde bucal de idosos de um município de médio porte do Nordeste brasileiro. Cad Saúde Pública 2012; 28(6): 1101-10., especially if tooth loss happened a long time ago. Therefore, the lack of association between resilience and oral health-related quality of life may be because usually the study of resilience is based on major events, usually related to grief³³33. Bonanno GA, Wortman CB, Lehman DR, Tweed RG, Haring M, Sonnega J, et al. Resilience to loss and chronic grief: a prospective study from preloss to 18-months postloss. J Pers Soc Psychol 2002; 83(5): 1150-64., catastrophes and war combats. We can still assume that the damage caused by tooth loss does not cause major stress because it happens gradually. Besides, since resilience leads to the idea of flexibility and adaptation, its aspects range from being risk to protective factors, depending not only on the presence of conditioning factors, but also on the intensity of such factors¹⁰10. Laranjeira CASJ. Do vulnerável ser ao resiliente envelhecer: revisão de literatura. Psic Teor e Pesq 2007; 23(3): 327-32..

The individual's behavior is bidirectionally conditioned to oral health perception. OHIP is one of the most used instruments to measure the impacts that such a perception can cause on general health, and, as a consequence, on health behaviors. However, it is focused on adversities, therefore not approaching positive oral health aspects. The opposite happens with RS, which practically does not analyze negative aspects. Sociodental indicators based on the International Classification of Impairments, Disabilities and Handicaps (ICIDH), like OHIP, are usually not adapted to the reality of respondents, because they do not consider the beliefs and behaviors of these people³⁴34. Locker D, Allen FP. What do measures of 'oral health-related quality of life' measure? Community Dent Oral Epidemiol 2007; 35(6): 401-11.. Besides, health perceptions change all the time, which causes changes in the responses for this type of instrument³⁰30. Locker D. Clinical correlates of changes in self-perceived oral health in older adults. Community Dent Oral Epidemiol 1997; 25(3): 199-203.. When people analyze their own oral condition, they do so accurately, however, using different criteria in comparison to those used by the professional. While the dental surgeon assesses the condition based on the absence of disease, the patient analyzes it based on symptoms and functional and social problems³⁵35. Bortoli D, Locatelli FA, Fadel CB, Baldani MH. Associação entre percepção de saúde bucal e indicadores clínicos e subjetivos: estudo em adultos de um grupo de educação continuada da terceira idade. Publ UEPG Ci Biol Saúde 2003; 9(3/4): 55-65..

The homogeneity of the sample can be one limitation for this study, once most participants were White, Italian descendants or even Italian immigrants. Besides, most participants had a dental prosthesis. Finally, we can also understand the cross-sectional design of this study as a limiting factor. We believe further studies are necessary, with larger samples and longitudinal design, in order for causal relations to be fully explored.

FINAL CONSIDERATIONS

The results of this study show that independent elderly people, those living in the rural zone and married people have more impacts on oral health. It is important that potentials and perceptions of people be widely studied so that this knowledge can help the discoveries about what can really promote not only a positive oral health perception, but also self-efficacy and empowerment when it comes to oral health - which are essential aspects of health promotion.

The study hypothesis that more resilient eldelry people can adjust more easily to losses related to oral health, and that they suffer less impacts on oral health-related quality of life, was not confirmed.

From our point of view, this study is the first one that proposes an evaluation between resilience and oral health-related quality of life by considering sociodemographic and behavioral variables of general health. Results indicate the need to understand issues that can involve subjective factors related to oral health, and of how they can influence the quality of life of the elderly, especially by conducting longitudinal studies. The fact that there are differences between oral health perceptions influenced by sociodemographic characteristics can help build a more equanimous paradigm of oral health care, leading to progress concerning the confrontation of differents related to health care in developing countries. In Brazil, care addressed to the elderly did not accompany the growth of this population, and the result is the poor oral health condition. This scenario can influence the quality of life of these people. That is why it is important that we know a bit more about the way this population sees their health problems and solves them, for the development of adequate actions addressed to their social and cultural profile.

References

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