Journal of Oral Hygiene & Health
Open Access

Sense of coherence is defined as a global orientation expressing a person’s pervasive and enduring feeling of confidence modified by stimuli derived from one’s internal and external environments in the course of living, the resources available to meet the demands posed by these stimuli and the fact that these demands are challenges worthy of investment and engagement [1].

The ability to use resources such as finances, knowledge, experience, self-esteem, healthy lifestyles, culture, social support and so on for one’s wellbeing is referred to as the Sense of Coherence (SOC); it can be defined as a way of seeing life and the ability to successfully manage the many stressors that are encountered in the course of life itself [2-6].

An individual’s sense of coherence is proposed to develop in relation to his/her experience of the world as predictable and consistent as well as the ability to shape life’s outcomes [7]. Sense of coherence can also be described as a dispositional personality orientation [8,9], which is important in perceiving and controlling the environment for meaningful and appropriate action [10].

Sense of coherence is important for an individual to cope with daily life demands [11]. There are three ‘sense of coherence’ components -comprehensibility, manageability and meaningfulness and an individual must be balanced on all three in other to deal successfully with everyday stimuli and promote sound health [12].

Comprehensibility (C)

A belief that things happen in an orderly and predictable fashion and a sense that you can understand events in your life and reasonably predict what will happen in the future [1,8].

Manageability (Ma)

A belief that you have the skills or ability, the support, the help, or the resources necessary to take care of things, and that things are manageable and within your control [1,8].

Meaningfulness (Ma)

A belief that things in life are interesting and a source of satisfaction, that things are really worthwhile and that there is good reason or purpose to care about what happens [1,8].

The term “oral health related quality of life” (OHRQOL) has no strict definition. However, there is a general agreement that it is a multidimensional concept (USDHHS 2000). OHRQOL is a multidimensional construct that reflects (among other things) people’s comfort when eating, sleeping, and engaging in social interaction; their self-esteem; and their satisfaction with respect to their oral health (NIDCR 2000).

OHRQOL incorporates survival (absence of oral cancer, presence of teeth); absence of impairment, disease or symptoms; appropriate physical functioning associated with chewing and swallowing and absence of discomfort and pain; emotional functioning associated with smiling; social functioning associated with normal roles; perceptions of excellent oral health; satisfaction with oral health; and absence of social or cultural disadvantage due to oral status [13].

OHRQOL not only quantifies the magnitude of oral diseases present but also quantifies the impact of the disease on an individual’s daily life and general health [14]. OHRQOL has an obvious role in clinical dentistry which translates into the clinicians’ recognition that they do not treat teeth and gums, but human beings [14]. Sense of coherence affects an individual’s ability to handle stresses of daily life and this has a major role on health [12]. A mother’s sense of coherence may affect her health rendering her incapable of effectively taking care of her child and providing for his needs. Also, it may affect the way she interprets her child’s oral health problems; as important or not. It may also affect the OHRQOL of the child since she may be unable to provide balanced non-cariogenic diet for her child or administer proper oral hygiene practices for him. It is therefore important to assess the sense of coherence of mothers and the OHRQOL of their children to determine the relationship.

The objectives of this study were to describe the relationship between mothers’ age, educational level and marital status on their sense of coherence (SOC) and the effect of their SOC on the oral health related quality of life (OHRQOL) of preschool children (aged between 2 to 6 years). In this endeavor, three questions were addressed:

• What socio demographic characteristics affect a mother’s sense of coherence?

• What is the effect of a mothers’ sense of coherence on the oral health related quality of life of her child?

• What effect does living in rural or urban settlements have on sense of coherence and oral health related quality of life?

Subject and procedures

The study was a descriptive, cross-sectional study involving mothers in Ondo town, Ondo state, Nigeria (rural settlement) and Mushin local government, Lagos state, Nigeria (urban settlement).

Study population included 80 mothers both literate and illiterate attending the out-patient clinic in the State Specialist Hospital, Ondo state, Nigeria and 100 literate mothers attending two Lagos University Teaching Hospital immunization clinics, Lagos state, Nigeria. Simple random sampling was used to select participant mothers.

The data collection instrument was a pre-tested interviewer administered questionnaire in the rural settlement and a selfadministered questionnaire in the urban settlement. The questionnaire inquired about socio-demographic characteristics, sense of coherence of participating mothers and oral health related quality of life of their preschool children.

The socio-demographic characteristics included mothers’ age as at last birthday, gender, religion, marital status and type of marriage, education attained and age of preschool child.

Measures

Sense of coherence was assessed with Antonovsky’s short 13-item SOC questionnaire (Eriksson et al 2006). This comprehensive subscale consists of the following items:

1. Do you have the feeling that you don’t really care about what goes on around you (Me)? (1=very often; 7=never).

2. Has it happened in the past that you were surprised by the behaviour of people whom you thought you knew well (C)? (7=never happened; 1=always happens).

3. Has it happened that people whom you counted on disappointed you (Ma)? (7=never happened; 1=always happens).

4. Until now your life has had (Me)? (1=no clear goals or purpose at all; 7=very clear goals and purpose).

5. Do you have the feeling that you’re being treated unfairly (Ma)? (1=very often; 7=never).

6. Do you have the feeling that you are in an unfamiliar situation and don’t know what to do (C)? (1=very often; 7=never).

7. Doing the things, you do every day is (Me)? (7=a source of deep pleasure and satisfaction; 1=a source of pain and boredom).

8. Do you have very mixed-up feelings and ideas (C)? (1=very often; 7=never).

9. Does it happen that you have feelings inside you would rather not feel (C)? (1=very often; 7=never).

10. Many people – even those with a strong character – sometimes feel like sad sacks (losers) in certain situations. How often have you felt this way in the past (Ma)? (7=never; 1=very often).

11. When something happened, have you generally found that (C): (1=you overestimated or underestimated its importance; 7=you saw things in the right proportion).

12. How often do you have the feeling that there’s little meaning in the things you do in your daily life (Me)? (1=very often; 7=never).

13. How often do you have the feelings that you’re not sure you can keep things under control (Ma)? (1=very often; 7=never).

For this study, the short version was modified to a five scale Likert scale questionnaire with 1=most often (the worst possible option) to 5=never (the best possible option). All items were then summed to create a total SOC score, which ranges from 13 to 65. The higher SOC score indicates the greater SOC [9].

Oral health related quality of life (OHRQOL) was assessed with the early childhood oral health impact scale (ECOHIS) developed by Pahel [15]. The ECOHIS scale has an inverse relationship with OHRQOL. Therefore, as the oral impact decreases, the OHRQOL increases. It consists of the following items:

1. How often has your child had pain in the teeth, mouth or jaws? (Child symptoms domain)

How often has your child...... because of dental problems or dental treatments? (Child function domain):

2. Had difficulty drinking hot or cold beverages

3. Had difficulty eating some foods

4. Had difficulty pronouncing any words

5. Missed preschool, daycare or school

How often has your child......because of dental problems or dental treatments? (Child psychological domain):

6. Had trouble sleeping

7. Been irritable or frustrated

How often as your child......because of dental problems or dental treatments? (Child self-image/social interaction domain):

8. Avoided smiling or laughing when around other children

9. Avoided talking with other children

How often have you or another family member......because of your child’s dental problems or dental treatments? (Parent distress domain):

10. Felt guilty

How often....(Family function domain)

11. Have you or another family member taken time off from work.... Because of your child’s dental problems or dental treatments?

12. Has your child had dental problems or dental treatments that had a financial impact on your family?

The scale was also modified to a five scale Likert scale questionnaire with 1=hardly ever (the best possible option) to 5=don’t know how often, too many (the worst possible answer) level. ECOHIS scores were calculated as a simple sum of all the responses which ranges from 13 to 65. Low ECOHIS scores indicate high OHRQOL [15].

Statistical methods

Data entry, analysis and validation was done using Epi Info 7 statistical software. Confidence interval was set at 95%. Relationship between various socio-demographic groups and SOC and relationship between SOC and OHRQOL were tested for using the chi-square test.

Informed consent

Informed consent was sort before administering questionnaire and ethical clearance for the study was gotten from the Lagos University Teaching Hospital; Health Research and Ethics committee.

Sense of coherence and socio-demographics

The age range of all mothers was between 23 and 53 with a mean age of 33.74 and standard deviation of 6.475. Mean age of children was 3.77 with standard deviation of 1.390.

For the rural area, the minimum SOC score was 29 and maximum, 51. The mean SOC score was 41.05 with a standard deviation (SD) of 5.332. For the urban area, the minimum SOC score was 23 and maximum, 52. The mean SOC score was 40.20 with a standard deviation (SD) of 5.950. Area of residence; rural or urban, showed no significant association with level of SOC.

In both rural and urban areas, an increase in age of mothers reported a significant decrease in their SOC (p<0.01). Also, participants with companions in both rural and urban settlements showed a stronger SOC (p<0.05). However, in the rural area, mothers educational level showed no significant relationship with their SOC (p>0.05). Whereas in urban area the educational level was significantly related to SOC (p<0.01).

The mean SOC scores for different socio-demographic groups in both rural and urban settlements are shown in Table 1.

Table 1: Sense of coherence (SOC) and socio-demographics

Sense of coherence (SOC) and early childhood oral health impact scale (ECOHIS)

For rural area, the minimum ECOHIS score was 13 and maximum, 65 with a mean ECOHIS score of 24.5 and a standard deviation of 13.83. For urban area, the minimum ECOHIS score was 13 and maximum, 57 with a mean ECOHIS score of 17.7 and a standard deviation of 7.92.

In both rural and urban areas, SOC was seen to have an inverse relationship with ECOHIS. That is, as the mothers SOC increased, the ECOHIS score of their child decreased and conversely OHRQOL increased. In both areas, chi-square test showed a statistically significant association between SOC and ECOHIS scores (p<0.01).

The ECOHIS can be divided into six domains: Child symptoms (pain) domain, child function domain, child psychology domain, child self-image/social interaction domain, parent distress domain, and family function domain. The association between SOC and each domain was also calculated.

In both rural and urban areas, strong SOC of mothers was significantly associated with better child oral symptoms (p<0.05) and better child oral function (p<0.05). In rural area only, strong SOC was significantly associated with better child psychology (p<0.05) and in urban area only, strong SOC was significantly associated with lower parent distress (p<0.01).

Mothers SOC did not show significant association with child social interaction (p>0.05) and family function (p<0.05) in both rural and urban areas.

Several factors have been documented to affect sense of coherence some of which include age, marital status, socioeconomic status, health status especially psychological health, dependence or independence in others, level of education, and so on [7,10-12] but area of residence is not one of them. Our study showed that mothers living in rural areas had a slightly higher SOC score compared to mothers in urban areas. Although, this relationship was not significant, further research needs to be done on the various associated factors in an area of residence that may lead to a higher or lower sense of coherence.

The distribution of SOC scores in different socio-demographic groups was found to be partly consistent and partly inconsistent with previous studies [8,9,16,17]. On an average, younger mothers reported a higher SOC than older mothers. This is consistent with the study done by Lundberg’s and Nystrom Peck’s [16]. This was explained by Antonovsky in one of his earlier studies [8] were he stated that SOC develops to its peak as a person approaches 30 years and may decline subsequently. Also, several studies [8,9,16,17] have shown that stronger SOC is associated with companionship either from friends, family or spouse and this is consistent with our results.

Previous studies have showed a varied result in the relationship between SOC and educational level [8,16,17]. Antonovskys researches [1,6,8,9] leans towards the fact that there is some form of relationship between level of education and SOC whereas the study done by Larsson and Kallenberg [17] showed that educational level is unrelated to SOC. Our study showed no significant relationship between mothers SOC and her level of education in rural areas and a significant relationship was seen in urban areas. More research needs to be done on the effect of level of education and its associated factors on an individual’s SOC.

A strong relationship was found between mothers SOC and the OHRQOL of her preschool child. This study showed that as mothers SOC increased, the OHRQOL of their child also increased. This is consistent with several studies [18-21] which have indicated mothers SOC as a major determinant of the OHRQOL of her child and that an increase in mothers SOC would ultimately lead to an increase in the OHRQOL of her child. The same can also be said for child oral symptoms and child oral function which improve with a stronger SOC in mothers [22,23].

This study also showed children living in rural areas having a higher oral health impact despite their mothers higher SOC levels compared with children living in urban areas. Clearly there are other factors that affect OHRQOL besides the SOC of mothers. Some of the notable difficulties in rural areas in Nigeria include absence of industrial infrastructure, lack of adequate health care personnel, lack of modern treatment protocols in oral health care facilities, lack of access to oral health care and oral health education and so on. This may be the reason why despite their mothers higher SOC, the children still have a lower OHRQOL [23-25].

This study however, did not show significant association between the SOC of mothers and child self-esteem/social interaction and family function domains of the ECOHIS used to measure OHRQOL. One possible explanation may be due to the low number of participants, as even a large difference of means can easily be interpreted as statistically insignificant. Although it may not be meaningful to give them any further interpretation [26,27].

From this study we can conclude that younger and married mothers had a higher SOC which led to a higher OHRQOL of their children. This study brings to focus the importance of our psychosocial health in particular mothers’ sense of coherence which should be improved as this will lead to improved OHRQOL and improved oral health outcomes in children.

As dentists treating children we should also aim to assess the psychosocial health of mothers and guardians of these children and provide proper counselling when required as this would ultimately lead to an improved oral health treatment outcome in the child as OHRQOL would improve. And special consideration should be given to single mothers, illiterate or uneducated mothers and elderly mothers and guardian.

The authors have not declared any conflict of interests.

This project was individually sponsored by the authors.