Impact of oral health on the quality of life of young people in confinement, Córdoba, Argentina: A mixed methods study

Corresponding author: María M. Barnetche. Fructuoso Rivera 1317Córdoba (CP 5000), Argentina. Phone: (54-9) 3513323525. E-mail: marcebarnetche@yahoo.es; marcebarnetche@gmail.com Abstract: Introduction: Quality of life can be understood as the perception subjects have of their position in life in relation to their goals, expectations and concerns. Measuring and understanding the impact of oral health on the quality of life of people may contribute to the promotion of health and prevention of disease. The aim of this study was to evaluate the impact of oral health on the quality of life of young people in confinement. Methodology: Cross-sectional study with mixed approach. Adolescents between 14 and 18 years of age, confined in socio-educational juvenile detention centers in the Province of Córdoba, Argentina, were included in the study. After signing of informed consent, the OHIP-49 questionnaire was applied to 70 youngsters and 32 semi-structured interviews were conducted. Results: The OHIP-49 had a mean of 53.37±28.77, the dimensions with more impact were: functional limitation, physical pain and psychological discomfort. Confinement emerges as an amplifier of sensations and as a barrier for accessing palliative care. Regarding aesthetic aspects, subjects reported specific discomfort that does not always interfere with their self-esteem or relationship with peers. Conclusions: Young people perceive the impact of oral health on their quality of life from episodes of suffering, although not only because of pain, but also for aesthetic reasons. Confinement creates a particular context for sensations and resolutions on health-disease-care processes regarding oral health.


Impact of oral health on the quality of life of young people in confinement, Córdoba,
Argentina: A mixed methods study.

INTRODUCTION.
Quality of life (QoL) is a way of expressing a person's perception of his/ her position in life in relation to their goals, expectations and concerns. The QoL of a society is a representation of life styles and an assessment of them, conditioned by the culture of a particular society. 1 Health-related QoL is defined as the well-being perceived by the subjects in relation to the different domains of their life, and the impact of these on their health. 2 The perception of the complex health-disease-care process (HDCP) is personal and subjective and can only be understood if it is placed in the context of beliefs, values and the sociocultural environment of each individual, taking into consideration their material conditions of life. 3, 4 Feeling healthy or sick is not the same for all individuals, it depends on the geographical area, socioeconomic background, level of education, and perception of the world, among other factors. 5 Each social group has a conception of what it means to be healthy or sick, what are the positive or negative behaviors associated to their health. This determines whether or not an individual feels the need to perform the practices they have categorized as healthy.
Oral diseases influence the QoL of people in different aspects of their daily life such as mastication, articulation of words, physical appearance, as well as interpersonal relationships and job opportunities. 6,7 Oral health is considered an important mediator of QoL due to its psychological component. 8-10 Oral health-related QoL (OHRQoL) has been developed to estimate the social and functional impact of oral diseases. 11 Qualitative research is focused mainly on people's lives, their subjective perspectives, their histories, behaviors, experiences, interactions, actions and senses. All this is interpreted in the specific context in which they occur. In this way qualitative research aims to understand these contexts and processes, explaining them from a local viewpoint. 12,13 Studying QoL using different methodological perspectives and approaches could contribute to a better understanding of what subjects perceive and thus proceeding to plan around their needs. 14 To design and implement health promotion and disease prevention programs for young people confined in juvenile detention centers of the Province of Córdoba, it is neces-sary to understand their perception of OHRQoL.
The aim of the present study was to evaluate the perception of the impact of oral health on the QoL of young inmates confined in socio-educational juvenile detention centers in the Province of Córdoba, Argentina.

MATERIALS AND METHODS.
Design: A cross-sectional study was carried out combining quantitative and qualitative methodological research strategies. The process of collecting, processing and analyzing qualitative data was performed as summarized in Figure 1.  Data were collected through semi-structured interviews, which were conducted and recorded after signing of informed consent by the subjects.
Data were collected through semi-structured interviews, which were conducted and recorded after signing of informed consent by the subjects.
The intermediate analysis generated more explicit categories (descriptive categories). Then we proceeded to the re-reading and re-comparison of all the fragments according to the categories developed.
With all the first categories agglutinated and the unifying categories, we continued the intermediate analysis, in which all the material was codified, and assigned to one or more categories.
The matrix was constructed with the transcriptions of the fragments of the interviews, the first categories and the unifying categories.
We continued with the process of analysis and interpretation of the categories, with a permanent confrontation until reaching the saturation of categories.
This allowed us to generate a theory about the representations on the impact of HDCP on oral health regarding the quality of life of young people in confinement.
From the transcribed interviews, we proceeded to the reading and labeling (open coding) of the data set that shared or contained the same ideas.
Data were explored, observed, reviewed and selected by common themes and the first categories were developed.
Data were compared again (constant comparison), which allowed to generate unifying categories.
Progress was made in the analysis by generating categories that agglutinated or included those already developed.

Barnetche MM & Cornejo LS.
Impact of oral health on the quality of life of young people in confinement, Córdoba, Argentina: A mixed methods study. Population: Adolescents from 14 to 18 years old, confined in socio-educational juvenile detention centers in the Province of Córdoba, Argentina, for a period of not less than six months, who accepted to participate in the study by signing an informed consent. Their socio-demographic profile is shown in Table 1. The impact profile on oral health questionnaire 49 (OHIP-49) was applied to 70 subjects and 32 semi-structured interviews were conducted.
Quantitative evaluation: The Spanish 16 version of OHIP-49 17 consists of 49 questions encompassed in 6 dimensions: functional limitation, physical pain, psycholo-gical discomfort, physical disability, social disability and handicap. A Lickert scale was used for its quantification, with values ranging from 0 to 4, where 0 represents the lowest value (never) and 4 the highest one (always). 18 In order to increase the intelligibility of the questions, some expressions were adapted to the sociocultural context of the participating subjects. The questionnaire was previously applied to a pilot group, showing an internal consistency of α Crombach 0.93. In most cases the questionnaire was answered by the subjects without receiving help from the researcher, with only some needing some help with reading.
For the analysis of the OHIP-49 index, an individual   always often rarely never sometimes count of the score obtained in the answers of the questionnaire (0 to 196) was performed. To determine the impact, the following responses were considered positive: "rarely", "sometimes", "often" and "always"; only "never" was considered of no impact. The impact was estimated for each of the dimensions included in the OHIP-49.
Mean±SD were used as measures of centralization and dispersion. The behavior of categorical variables is described by relative frequencies expressed as percentages.
Qualitative evaluation: Semi-structured interviews 19 were conducted in a single moment with each interviewee (28 males and 4 females) and for an approximate time of 50 minutes. Thematic guidelines derived from the objecti-ves and the evolution of the interview were followed.
All the interviews were recorded. During the micro-situation, impressions, feelings, attitude and characteristics of the adolescents were simultaneously registered in a field diary. The specific corpus was then obtained after analyzing the transcribed interviews.
Analysis of data was done following the Grounded Theory. 20 This theory provides an approach based on the inductive process of analysis, which generates concepts and develops theory from the analysis of empirical data from the perspective of the intervening actors, allowing researchers to understand an event in the same way participating subjects understand it. always often rarely never sometimes

RESULTS.
The mean value of OHIP-49 was 53.37±28.77 points. The greatest impact was observed in the dimensions: psychological discomfort, functional and esthetic concern (functional limitation), dental pain (physical pain), and interruption of meals (physical incapacity) (Figure 2). Questions that showed a lower impact were related to the interruption of nocturnal sleep and presence of discomfort (psychological incapacity) to perform daily activities (social incapacity), and disruption of work tasks (handicap) (Figure 3).
The process of analysis of the corpus allowed the construction of the following categories.

Functional limitations and social roles, attributed to pain, affect the Oral Health-related Quality of Life (OHRQoL)
Participants of this study report that functional limitations related to feeding affect OHRQoL: "...when I eat like this, I get this little thing in the tooth, I feel uncomfortable, it hurts. I feel that I can't eat well, I'm afraid sometimes of the tooth ache"...(F0008, male, 18 years old).
They also recognize that the limitations in their daily tasks (work, school) affect their OHRQoL, but they do not interfere with their social activities: "No, I tried to stay at home, take antibiotics, or I didn't feel like going out. When I had to go to work, I used to leave a little later, …but it didn't' affect going out with my friends, I didn't ... although ... -he thinks-but if I really had to go out somewhere, I' d take something, calm down and go out"(D0006, 17 years).

"When it hurt little, it didn't affect me much. And when it hurt a lot, I would stay at home. No, I didn't tell my boss that I was sick and I just didn't go to work and took a day off"
(F0008, male, 18 years old).
They report perceiving a psychological limitation to perform their daily chores and roles: "It's not good, the anger, the rage is due to the pain, the pain itself. There you are somewhere and there is this piercing pain, and you're denying knowing where the money is, where the money is, and then that pum! pam! this freaking piercing pain in the tooth again just like that, and it makes you want to remove the damn pain with a blow. And then you're trying to deny where the money is and it hurts like hell! You just want to kill 'em (laughs)" (K0022, male, 18 years old).

Perceptions on the aesthetic appearance of the oral component and level of acceptance
Dental appearance is an aesthetic parameter, which does not influence their self-esteem or social activity.
"I wish all my teeth were extremely white, well, shining white, so when I' d laugh at night they' d shine, and I wish they weren't crooked. Just that, nothing more." (K0022, male, 18 years old).
For some of these young people the loss of front teeth affects their self-esteem.
"Look at me! My teeth are pointing backwards, even one is missing, I'm ashamed to laugh, and they're freaking ugly! And, look at the hole I have here, my sister told me the other day that I was ruined, a wreckage, without this tooth; she even said I had grey hairs in my head." (Mr0001, male, 18 years old).
Others say that in order to avoid the rejection by their female peers, they resort to their communication skills.
"I'm ashamed of having this missing tooth (11), it came out a long time ago, I was little, I fell off my bike. And I hope when I go out with a girl that she doesn't reject me because of the tooth. But in the end it's sweet talking what does it for me, they don't mind the missing tooth ." (A0023, male, 18 years).
The properties of the central category Impact of the HDCP regarding oral health on the quality of life are crossed by the emerging transversal categories.

Self-perception of the body in relation to functionality and aesthetics
"What will I know . Throughout the process of analysis of the interviews an emergent category was detected, which is transversal to each of the categories already described. This emerging category explains and expands the understanding of the perceptions that young people have regarding OHRQoL while they are in confinement, deprived of liberty.

Being in confinement reveals another reality and amplifies feelings
Confinement appears as a conditioning factor that has two significant characteristics: it reveals another reality, which is different in several aspects for these young people, from their values, emotions, physical experiences and the importance of oral health.
" And as an amplifier of sensations, pain is the main symptom of the imbalance related to oral health, which causes the impact of HDCP on the oral health of these young people and on their QoL. Confinement would increase and intensify sensations often associated with the inaccessibility to palliative care, to which they had access when they were not confined; or only related to the fact of having easy access to all other types of distractions. "

DISCUSSION.
The World Health Organization defines OHRQoL as the individual's perception of the degree of satisfaction with respect to their teeth, as well as with the hard and soft tissues of the oral cavity in the performance of the daily activities, taking into account their present and past circumstances, their implications for care, expectations and paradigms according to the value system within a particular sociocultural context. 21 QoL cannot be independent of cultural norms, patterns of behavior and expectations of each subject, so for their understanding this idea of a unique globalized system of values must be left aside to include anthropological and cultural aspects. 22 Young people in confinement perceive OHRQoL when they notice a limitation in their different social roles and functions. Physical pain is primarily responsible for the loss of balance in oral health. It is important to mention that these young people relativize their discomfort using different palliatives, resorting to restricted self-care resources (self-medication or smoking marijuana, among others) so that their priority activities, such as socializing, are not affected.
There is a difference between school or work activities and outings with friends. The subjects manifest different behaviors because if they do not feel good or if a tooth aches or hurts then they do not go to work, or do it later; they miss school, stay at home. This is not the case when outing with friends, because they resort to different methods to relieve pain so that it does not affect their social activities.
Dissatisfaction with appearance, the effect of the malocclusions, are not only functional and/or aesthetic factors, as they also influence psychosocial aspects and QoL. 23, 24 Young people in confinement manifest some type of disconformity with the appearance of their teeth ("crooked teeth"). The color of their teeth (whiteness) would not play a role when relating with their peers and it would not affect their self-esteem. However, the lack of an anterior tooth makes it difficult for them to relate with their peers, forcing the use of "sweet talking" (communicational ability) to avoid rejection.
The perception of HDCP on oral health shows how a person deals with his/her condition, conditioning the type