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Keywords:

  • Indigenous;
  • oral health-related quality of life;
  • risk indicators

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Background:  There is limited information on the impact of poor oral health on Indigenous Australian quality of life. This study aimed to determine the prevalence, extent and severity of, and to calculate risk indicators for, poor oral health-related quality of life among a convenience sample of rural-dwelling Indigenous Australians.

Methods:  Participants (n = 468) completed a questionnaire that included socio-demographic, lifestyle, dental service utilization, dental self-care and oral health-related quality of life (OHIP-14) factors.

Results:  The prevalence of having experienced one or more of OHIP-14 items ‘fairly often’ or ‘very often’ was 34.8%. The extent of OHIP-14 scores was 1.88, while the severity was 15.0. Risk indicators for having experienced one or more of OHIP-14 items ‘fairly often’ or ‘very often’ included problem-based dental attendance, avoiding dental care because of cost, difficulty paying a $100 dental bill and non-ownership of a toothbrush. An additional risk indicator for OHIP-14 extent was healthcare card ownership, while additional indicators for OHIP-14 severity were healthcare card ownership and having had 5+ teeth extracted.

Conclusions:  Risk indicators for poor oral health-related quality of life among this marginalized population included socio-economic factors, dentate status factors, dental service utilization patterns, financial factors and dental self-care factors.


Abbreviation and acronym:
OHIP-14

oral health impact profile

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Indigenous Australians are those who identify as being of Aboriginal and/or Torres Strait Islander descent, and comprise 2.5% of the population.1 In 2006, the median age of the Indigenous population was 20 years, compared with a median age of 37 years among non-Indigenous Australians. By proportion of population, more Indigenous Australians reside in regional or remote locations, e.g., 45% in inner and outer regional areas, and 24% in remote and very remote locations.1

Indigenous Australians experience substantial disadvantages relative to their non-Indigenous peers, including disparities in income and wealth, education, employment, housing and living conditions.2 Indigenous Australians across all age groups die earlier than non-Indigenous Australians, and are more likely to suffer from ill health, and to experience disability and reduced quality of life.3 They experience much higher levels of diabetes mellitus, cardiovascular disease and kidney disease, and are more likely to be exposed to, or to experience, co-morbidity and other risk factors associated with chronic disease.4 The prevalence of many diseases increases with remoteness and, compared with non-Indigenous Australians, the Indigenous population experiences disease and risk-factors at an earlier age.4 Due to the strong correlations between socio-economic status and exposure to health risk-factors,5 socio-economic inequalities may account for the disproportionate rates of ill-health, disability and reduced quality of life experienced by many Indigenous Australians.4

Currently, there is a shortage of representative, national-level epidemiological data to inform a complete understanding of the oral health of the Indigenous Australian population. However, available data suggest that the disparities in Indigenous and non-Indigenous general health are paralleled in oral health. For example, in the second National Survey of Adult Oral Health, Indigenous Australians experienced 2.3 times the prevalence and 3.4 times the severity of untreated dental decay, and 1.3 times the prevalence of moderate/severe periodontal disease.6 Rates of edentulism and tooth loss were also higher among the Indigenous population.

Although Indigenous Australians have been identified as having poorer clinical oral health outcomes relative to their non-Indigenous counterparts, there is limited information on the impact that poor oral health has on their quality of life. The aims of this study were: (i) to determine the prevalence, extent and severity of poor oral health-related quality of life as measured by the shortened version of the Oral Health Impact Profile (OHIP-14); and (ii) to calculate risk indicators for poor oral health-related quality of life among a convenience sample of Indigenous Australians residing in Port Augusta, South Australia.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Recruitment

Two of the authors had an established relationship with key members of the Port Augusta Indigenous community. This relationship was consultative and ensured cultural security within the research process. The second author helped establish the oral health programme at Port Augusta’s Aboriginal community-controlled health service and was the first dentist there for five years. The third author worked with the second author in establishing links with the Port Augusta community in an oral health research capacity, and over a six-year period has successfully implemented previous projects/programmes with the local community. The key community members were largely responsible for the recruitment of study participants. Recruitment initiatives included word of mouth, flyers and posters, interviews on the local radio station and visits to various Indigenous communities, health clinics, resource centres and schools. Recruitment was also opportunistic, e.g., a stall set up outside the local supermarket and an Indigenous health worker stationed to recruit participants. Morning/afternoon tea or lunch was provided, together with transport, when more formal arrangements had been made for questionnaire completion.

Criteria

Participants needed to identify as Indigenous, live in the Port Augusta region and be aged 17+ years.

Incentive

Each participant received a $20 Woolworths voucher as reimbursement for time.

Ethics approval

Ethics approval was granted by the Aboriginal Health Council of South Australia and the Human Research Ethics Committee of the University of Adelaide. Participants gave written informed consent before participating.

Self-report questionnaire

Items in the questionnaire were based on those used in the National Survey of Adult Oral Health6 and other questionnaires used by researchers at the Australian Research Centre for Population Oral Health. The questionnaire was tested by five Indigenous adults in Port Augusta to determine readability and user-friendliness. Moderate changes were made and re-tested to ensure usability.

Dependent variables

The shortened version of the oral health impact profile – OHIP-14 – was used.7 The OHIP-14 questionnaire contains 14 items relating to the frequency with which oral conditions adversely affect quality of life. Responses were made on a five-point ordinal scale ranging from ‘very often’ (coded ‘4’) to ‘never’ (coded ‘0’). Dependent variables were the prevalence of one or more OHIP-14 items rated ‘very often’ or ‘fairly often’, OHIP-14 extent (mean number of OHIP-14 items reported ‘very often’ or ‘fairly often’) and OHIP-14 severity (mean OHIP-14 score).

‘Prevalence’ is a term usually used in a population approach, yet this is a convenience sample. The term is retained for ease of interpretation when comparing the prevalence of one or more OHIP-14 items rated ‘very often’ or ‘fairly often’ in our study with other findings in the international literature.

Independent variables

Independent variables were grouped into socio-demographic, substance use, dentate status, dental service utilization, dental anxiety, dental self-care, dental perceptions and self-rated health categories.

Data analytic approach

Univariate and bivariate distributions of OHIP-14 prevalence, extent and severity were determined. Correlation tests confirmed the existence of weak associations between independent items in a given group (Pearson’s correlation coefficient range 0.1–0.4), with no variables needing to be excluded due to collinearity. The high prevalence of OHIP-14 items being rated ‘fairly often’ or ‘very often’ meant that odds ratios were poor indicators of relative frequency, so prevalence ratios were determined using Poisson regression modelling.8 Poisson regression analysis was used to derive adjusted estimates for the prevalence of OHIP-14 items rated ‘fairly often’ or ‘very often’, while linear regression was used to determine risk indicators for OHIP-14 extent and severity. Exposure variables were classified into socio-demographic, substance use, dentate status, dental service utilization, dental anxiety, dental self-care, dental perceptions and self-rated health groups. The regression models were constructed by removing covariates one at a time according to P-value size, with only values that remained statistically significant being presented in the final models. Data were analysed using SPSS 15.0 and Intercooled STATA 8.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Complete questionnaires were obtained from 468 participants, 63% of whom were female. The average age was 38 years, with an age range of 17 to 72 years. The prevalence of one or more OHIP-14 items rated ‘fairly often’ or ‘very often’ was 34.8%. The extent (mean number of OHIP-14 items experienced ‘fairly often’ or ‘very often’) was 1.88, while the severity (mean OHIP-14 score) was 15.0.

The prevalence of one or more OHIP-14 items rated ‘fairly often’ or ‘very often’ was higher among those aged 38+ years, who reported currently or previously smoking tobacco or consuming alcohol, who reported having no remaining teeth and who reported having received five or more extractions (Table 1). OHIP-14 extent was higher among those with a healthcare card and those reporting having received five or more extractions. OHIP-14 severity was greater among those aged 38+ years and among those reporting five or more extractions.

Table 1.   OHIP-14 by socio-demographic, substance use and dentate status factors
 PrevalenceExtentSeverity
  1. *P <0.05.

Total34.8 (27.5–42.1)1.88 (1.55–2.21)15.00 (13.70–16.30)
Age
 37 years or less29.9 (24.1–35.7)*1.61 (1.18–2.04)13.24 (11.47–15.01)*
 38 years or more39.7 (33.5–45.9)2.16 (1.67–2.64)16.76 (14.93–18.59)
Gender
 Male31.1 (24.1–38.1)1.60 (1.09–2.12)14.11 (12.00–16.23)
 Female36.9 (31.5–42.3)2.04 (1.62–2.46)15.50 (13.89–17.10)
Location
 Port Augusta34.1 (29.6–38.6)1.94 (1.59–2.29)14.96 (13.59–16.32)
 Other42.5 (27.3–57.7)1.30 (0.60–2.00)15.50 (11.92–19.08)
Highest qualification
 Primary or Secondary school35.1 (30.4–39.8)1.87 (1.52–2.23)14.72 (13.31–16.13)
 Trade, TAFE, University33.7 (23.6–43.8)1.94 (1.16–2.72)16.31 (13.27–19.36)
Income source
 Job31.3 (23.8–38.8)1.44 (0.95–1.93)14.78 (12.68–16.88)
 Welfare36.4 (31.2–41.6)2.08 (1.67–2.50)15.10 (13.50–16.70)
Healthcare card
 Yes36.8 (31.8–41.8)2.13 (1.73–2.53)*15.68 (14.14–17.22)
 No28.9 (20.6–37.2)1.13 (0.67–1.60)13.01 (10.85–15.17)
No. of people who stayed in house last night
 Four or less36.1 (30.6–41.6)1.91 (1.51–2.32)15.36 (13.71–17.01)
 Five or more32.8 (26.0–39.6)1.84 (1.30–2.38)14.43 (12.40–16.46)
Car ownership
 Yes33.3 (26.7–39.9)1.59 (1.12–2.06)14.64 (12.75–16.52)
 No35.9 (30.3–41.5)2.09 (1.64–2.53)15.26 (13.53–16.99)
Tobacco smoking
 Currently or previously37.4 (32.4–42.4)*1.93 (1.57–2.30)15.27 (13.81–16.72)
 Never27.0 (18.9–35.1)1.73 (1.04–2.42)14.19 (11.49–16.90)
Alcohol consumption
 Currently or previously36.6 (31.8–41.4)*1.87 (1.52–2.21)15.35 (13.98–16.71)
 Never26.3 (16.7–35.9)1.96 (1.07–2.86)13.34 (9.84–16.83)
Own teeth left?
 Yes33.4 (29.0–37.8)*1.83 (1.50–2.16)14.79 (13.48–16.11)
 No60.0 (40.9–79.1)2.92 (1.31–4.53)18.68 (13.10–24.26)
Previous extractions
 Four or less36.4 (30.0–42.8)*1.86 (1.40–2.33)*15.81 (13.99–17.64)*
 Five or more50.0 (39.6–60.4)2.85 (1.96–3.74)20.66 (17.64–23.68)

There were a number of dental service utilization, dental anxiety and dental self-care factors related to oral health related quality of life. For example, the prevalence of one or more OHIP-14 items rated ‘fairly often’ or ‘very often’, OHIP-14 extent and OHIP-14 severity were higher among those who last visited a dentist because of a problem, who avoided dental care because of cost, who reported a lot of difficulty paying a $100 dental bill and non-ownership of a toothbrush (Table 2). OHIP-14 prevalence was additionally higher among those who had visited a dentist before and among those who had not brushed their teeth the previous day. OHIP-14 prevalence, extent and severity was higher among those who perceived a need for a restoration or extraction, who perceived that they had gum disease, who rated their general health as ‘fair or poor’ or who rated their oral health as ‘fair or poor’ (Table 3).

Table 2.   OHIP-14 by dental service utilization, dental anxiety and dental self-care
 PrevalenceExtentSeverity
  1. *p <0.05.

Previously visited a dentist
 Yes36.2 (31.7–40.7)*1.96 (1.62–2.30)15.68 (14.34–17.01)*
 No20.0 (7.7–32.3)1.08 (0.09–2.06)7.80 (3.89–11.71)
Last visit to dentist
 Less than one year ago36.7 (29.4–44.0)2.17 (1.58–2.76)16.37 (14.14–18.59)
 More than one year ago35.5 (29.8–41.2)1.86 (1.43–2.28)15.33 (13.66–17.00)
Location of last visit to dentist
 Pika Wiya or Public Health Dentist35.0 (28.7–41.3)1.93 (1.46–2.40)15.48 (13.63–17.32)
 Private Dentist36.8 (30.3–43.3)1.99 (1.49–2.49)15.80 (13.86–17.73)
Reason for last visit to dentist
 Problem42.7 (37.2–48.2)*2.39 (1.95–2.83)*18.40 (16.80–20.00)*
 Check-up19.4 (12.5–26.3)0.92 (0.46–1.38)8.89 (6.92–10.86)
Avoid dental care because of cost
 Yes45.5 (36.2–54.8)*2.84 (2.29–3.39)*19.16 (17.17–21.15)*
 No23.2 (11.7–34.7)0.85 (0.55–1.15)10.48 (9.08–11.88)
Difficult to pay a $100 dental bill
 None, Hardly any, a little28.7 (23.1–34.3)*0.65 (0.21–1.09)*9.38 (7.18–11.57)*
 A lot41.5 (35.1–47.9)2.14 (1.76–2.52)16.16 (14.71–17.61)
Scared about dental visit
 ‘No’35.2 (29.6–40.8)1.69 (1.30–2.08)13.95 (12.35–15.55)
 ‘A little bit’, ‘a fair bit’, or ‘heaps’34.4 (27.8–41.0)2.16 (1.60–2.71)16.48 (14.38–18.57)
Toothbrush ownership
 Yes33.1 (28.5–37.7)*1.66 (1.33–1.98)*14.30 (12.98–15.62)*
 No44.4 (33.0–55.8)3.14 (2.04–4.23)18.89 (14.90–22.88)
If yes, brushed previous day
 Yes32.1 (23.4–40.8)1.60 (1.25–1.95)13.73 (12.33–15.13)*
 No36.8 (17.8–55.8)2.18 (1.23–3.13)17.74 (14.15–21.33)
If yes, use toothpaste
 Yes33.6 (25.4–41.8)1.73 (1.40–2.06)14.36 (12.98–15.74)
 No25.0 (0–63.1)1.50 (0–3.19)14.70 (7.75–21.65)
Table 3.   OHIP-14 by dental perceptions and self-rated health
 PrevalenceExtentSeverity
  1. *p <0.05.

Perceived need for restoration or extraction
 Yes48.2 (42.1–54.3)*2.79 (2.29–3.30)*20.00 (18.21–21.78)*
 No17.6 (12.4–22.8)0.76 (0.44–1.08)8.72 (7.23–10.20)
Think you have gum disease?
 Yes55.6 (45.9–65.3)*4.19 (3.22–5.16)*27.19 (24.31–30.07)*
 No28.7 (24.1–33.3)1.23 (0.95–1.52)11.55 (10.32–12.78)
Self-rated general health
 Excellent, very good, or good29.9 (25.1–34.7)*1.45 (1.12–1.78)*12.81 (11.42–14.19)*
 Fair or poor48.4 (39.6–57.2)3.10 (2.32–3.88)21.10 (18.43–23.77)
Self-rated oral health
 Excellent, very good, or good24.4 (19.5–29.3)*1.03 (0.73–1.33)*10.78 (9.46–12.10)*
 Fair or poor52.6 (45.2–60.0)3.34 (2.68–4.00)22.20 (19.93–24.47)

In multivariate modelling, risk indicators for OHIP-14 prevalence, extent and severity included last visiting a dentist because of a problem, avoiding dental care because of cost, reporting a lot of difficulty paying a $100 dental bill and non-ownership of a toothbrush (Tables 4 and 5). An additional risk indicator for OHIP-14 extent was ownership of a healthcare card, while additional risk indicators for OHIP-14 severity were ownership of a healthcare card and having had five or more teeth extracted.

Table 4.   Poisson regression of OHIP-14 prevalence
 Prevalence ratio (95% CI)
Last dental visit because of a problem1.90 (1.30–2.79)
Avoid visiting dentist because of cost1.64 (1.24–2.16)
Difficulty paying $100 dental bill1.34 (1.05–1.72)
Non-ownership of a toothbrush1.37 (1.03–1.81)
Table 5.   Linear regression of OHIP-14 extent and severity
 ExtentSeverity
B (se)B (se)
Ownership of healthcare card1.26 (0.39)4.72 (1.73)
5+ teeth removed3.32 (1.63)
Last dental visit because of a problem1.02 (0.37)4.92 (1.87)
Avoid visiting dentist because of cost1.93 (0.34)7.87 (1.53)
Difficulty paying $100 dental bill0.74 (0.33)3.88 (1.52)
Non-ownership of a toothbrush1.45 (0.50)6.25 (2.25)

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

This study set out to determine the prevalence, extent and severity of poor oral health-related quality of life among a convenience sample of rural-dwelling Indigenous adults, and to calculate risk indicators for the same. Risk indicators included socio-economic factors such as ownership of a healthcare card, dentate status factors such as multiple missing teeth, dental service utilization patterns such as last visiting a dentist because of a problem, financial factors such as delaying dental care because of cost and having difficulty paying a $100 dental bill, and dental self-care factors such as non-ownership of a toothbrush.

Before discussing the findings in more detail, it is important to acknowledge the study’s limitations. This was a convenience investigation, meaning findings cannot be assumed to be representative of the broader Port Augusta Indigenous community, or indeed the Indigenous population at a state or national level. The cross-sectional study design also means that true causality cannot be ascertained. Shortcomings aside, this was one of the largest self-report investigations to be conducted among an Indigenous population within the oral health-related quality of life context. As such, the findings may be helpful in highlighting areas where future research and policy making efforts might be directed.

It is concerning that the prevalence, extent and severity of poor oral health-related quality of life was so high among the study population compared with national-level estimates, especially as evidence from the literature suggests that poor oral health-related quality of life – as assessed by OHIP-14 – is associated with untreated dental needs9 and is recognized as deteriorating over the lifecourse.10 The findings warrant further investigation at a more representative level.

The risk indicators for poor oral health-related quality of life in our study were perhaps unsurprising. Social determinants have long been associated with poor oral health-related quality of life, both among non-representative marginalized populations such as homeless populations in Hong Kong,9 and national-level surveys conducted in Australia, the United Kingdom, Sweden and Germany.11 That the more socially impoverished in our study – as indicated by ownership of a means-tested Government healthcare card – had poorer oral health-related quality of life supports the notion of socio-economic inequality being associated with greater disease prevalence and health-related quality of life in general.12

The literature is replete with examples of dentate status factors, such as multiple missing teeth, impacting negatively on oral health-related quality of life. For example, Pallegedara and Ekanayake reported that, among older individuals in Sri Lanka, oral health-related quality of life was significantly affected by tooth loss,13 and Lawrence and colleagues reported that having ‘one or more missing teeth’ by the age of 32 years was a risk indicator for reporting one or more OHIP-14 items ‘fairly often’ or ‘very often’.14 Dental service utilization patterns such as last visiting a dentist because of a problem, have also been associated with poor oral health-related quality of life, with this association often being used to determine construct validity of new derivations of the Oral Health Impact Profile.15

Financial factors such as delaying dental care because of cost and having difficulty paying a $100 dental bill were risk indicators for poor oral health-related quality of life. This supports the findings of Chavers and colleagues, who reported that one of the strongest predictors of poor oral health-related quality of life in their study was difficulty in paying an unexpected $500 dental bill.16 The prevalence of participants reporting difficulty paying a $100 dental bill in the current study was five times that of national-level estimates,6 indicating that for this specific Indigenous population, financial costs are a substantial barrier to receipt of timely dental care. Indigenous adults in Port Augusta who hold a healthcare card (government benefits card) are able to access free emergency dental services through an Indigenous-controlled health service (dentist available one day per week), through one local private practice participating in a specific Aboriginal Dental Scheme, or reduced cost care though the regular adult public dental service (the South Australian Dental Service). Routine dental care can be accessed through the same services, with waiting lists varying from approximately 10–18 months. There are limited resources for general care provision through the Indigenous-controlled health service. For those not entitled to a healthcare card (in this study, 24.4%), dental service provision is only available through the private sector. There are currently three private practices in Port Augusta, serving a population of approximately 13 000.1

It was unsurprising that non-ownership of a toothbrush was a risk indicator for poor oral health-related quality of life, given evidence that irregular toothbrushing is associated with increased levels periodontal disease,17 which is known to impact negatively on perceived life quality.14 Non-ownership of a toothbrush is problematic among many Indigenous Australian populations, and may be linked in part to constant movement between households in a given location to: (1) other households in a given location; (2) households in more remotely-located outstations or homelands; or (3) urban centres. Chronic household over-crowding is an acknowledged problem among many Indigenous Australians,18 which additionally predisposes to non-ownership (or frequent misplacement) of toothbrushes.19

Each of the risk indicators for poor oral health-related quality of life in our study are amenable to change. Ways in which these factors might be mitigated include: (1) socio-economic factors: addressing upstream factors that influence important social determinants in the Aboriginal context including crowded households and car ownership; (2) dental service utilization factors: making dental services for Aboriginal clients more accessible and user-friendly, including increasing the number of Aboriginal dental service providers and ensuring oral health services are included, and appropriately funded for, in the primary health care models of Aboriginal Health Services; (3) financial factors: recognizing that, for many Aboriginal clients, dental care is simply not affordable. Explore avenues of providing more financially-accessible dental care services, including increasing the remit of oral health therapists and other dental auxiliaries20,21 and; (4) dental self-care factors: increasing the availability and affordability of toothbrushes and fluoridated toothpaste.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

The oral health-related quality of life among this marginalized population was poor. All the risk indicators – which included socio-economic, dental service utilization, financial and dental self-care factors – are amenable to change. The findings provide some insight into the impact of poor oral health on quality of life among Indigenous Australians, and warrants further investigation.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References

Funding for the study was provided through a University of Adelaide School of Dentistry research grant. The authors are grateful to the Pika Wiya Health Service Inc., the Davenport Council, Port Augusta Early Years Parenting Centre, Lakeview Accommodation, Aboriginal Resource Centre Inc., and Uniting Care Wesley for providing venues, Umeewarra Media for the free advertising, Indigenous health workers who assisted with data collection, and to all study participants for taking part.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. Acknowledgements
  9. References
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    Hopcraft M, McNally C, Ng C, et al. Attitudes of the Victorian oral health workforce to the employment and scope of practice of dental hygienists. Aust Dent J 2008;53:6773.