A Study Of Oral Health Behavior Among Elderly With Diabetes Mellitus By PRECEDE Model

BACKGROUNDDiabetes mellitus occurs throughout the world. It is estimated that China is the second country with the diabetic population. Its rapidly increasing incidence in China is resulted from the rapid development of social economy and lifestyle changing. With the improvement of medical condition and social culture, the life expectancy of humans has increased. This phenomenon of population ageing is universal. China has been ranked among the population aging countries earlier than we have expected. The prevalence of diabetes mellitus (DM) increases with age. The majority of older individuals with diabetes have type 2DM. Diabetes mellitus is a chronic metabolic disorder known to affect oral disease progression. Current researches showed there is a relationship between diabetes and periodontal diseases. On the one hand diabetes is the risk factor of periodontitis, patients with poorly controlled or uncontrolled diabetes, have an increases susceptibility to chronic infections and inflammation of oral tissues, including periodontal caries (chronic gingivitis and periodontitis), dental caries, and oral candidiasis, with contribute to substantial oral functional disability. On the other hand periodontitis will affect glycemic control of diabetic patients in turn. Periodontitis is recognized as the sixth possible complication of diabetes mellitus. Oral health is the most important part of body's health, aging people with good oral health might be able to have not only healthy teeth but also a healthy and comfortable life. In 2001, WHO proposed "8020" plan, to encourage people to keep 20 or more of their own teeth even until the age of 80.Based on Chinese condition, our country set the goal for age 65 years or above is "Primary oral care for All by the Year 2010", it means that to 2010,80% of people who live in cities will maintain 20 teeth, and 60% of people who live in rural will keep to 20 teeth. In order to achieve the goal, much effort should be put into improving elderly oral health, especially elderly with diabetes.Good oral care is essential for the diabetic population. Effective control of oral disease can be attained through regular dental visit and improved oral hygiene. Regular dental visit will be good for dental disease treatment, and good dental condition will be good for glycemic control. But investigations found that many people hold the misconception, such as it is natural for old people to lose teeth, gum bleeding is normal and it is unnecessary to visit dentist, people is lack of knowledge about how to brush and floss teeth, how to chose toothbrush, and so on. Many researches were conducted in abroad regarding oral health education, and found that diabetic people have adequate oral care knowledge and good oral hygiene habit. This result is mainly because of the diabetic people have adequate resource to obtain knowledge. Although diabetes education is more and more popular in China, many investigations found that the oral conditions of the diabetic people are far from the goal of international organizations.The core of health education is behavior change. Behaviors may change for many reasons. PRECEDE-PROCEED is a planning model designed by Lawrence Green and Marshall Kreuter for health education and health promotion programs. PRECEDE is the abbreviation of predisposing, reinforcing, and enabling constructs in educational/environmental diagnosis and evaluation. The PRECEDE-PROCEED model provides a comprehensive structure for assessing health and quality-of-life needs and for designing, implementing, and evaluating health promotion and other public health programs to meet those needs. PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation) outlines a diagnostic planning process to assist in the development of targeted and focused public health programs. "Predisposing factors" are defined in these models as factors that exert their effects prior to a behavior occurring, by increasing or decreasing a person or population's motivation to undertake that particular behavior. They include knowledge, attitude, cultural beliefs, readiness to change, and so on. Enabling factors are defined as factors that make it possible (or easier) for individuals or populations to change their behavior or their environment, they include available resources, supportive policies, assistance, and services. Reinforcing factors come into play after a behavior has begun, and provide continuing rewards or incentives; they contribute to repetition or persistence of behaviors. Social support, praise, reassurance, and symptom relief might all be reinforcing factors. Despite the increased research on the health conditions of the elderly, including oral health, the majority of these studies refer to institutionalized populations. There are few studies that refer to oral health conditions of the elderly with diabetes mellitus.OBJECTIVEThe purpose of this study was to determine levels of oral health knowledge, attitudes and behaviors essential for preventing dental and periodontal diseases and maintaining oral health in a population of elderly with type 2 diabetes. Use PRECEDE model to analysis the factors associated with oral health behaviors. To help diabetes education team to develop effective education programs. METHODSA descriptive cross-sectional study was conducted. A convenience sample of 110 elderly aged 60 years or more with diabetes with normal cognitive function, who was hospitalized or attended diabetic education sessions at 2 general hospitals in Guangzhou completed an oral health survey to assess their knowledge, attitudes and behaviors. Using a semi-structured questionnaire.The questionnaire was constructed for this study based on the Third National Oral Health Survey of China in 2005(65-74years) and a review of related literature. The questionnaire was reviewed by endocrinologists and dentists, a=0.7635, content validity was tested by factor analysis. It includes three parts.Part one:General information of patients, information was collected about sex, age, marital status, educational level, occupation before retire, household income, medical payment, course of disease, complications, treatment, way of life care, frequency of attending diabetic education and oral care sessions, denture restoration and the result of restoration.Part two:the relationship between diabetes and periodontitis knowledge, diabetic oral care knowledgePart three:attitude and behavior of oral health, self-evaluation of physical and oral health, impact of oral problems on quality of life.The descriptive analysis of the results used mean and standard deviation for continuous variables and proportions for qualitative variables.SPSS11.5 statistical package was used to analyze the dada. Significance level was set at 5%. Crosstabs, Wilcoxon, Kruskal-Wallis H test, Spearman correlate, compare Means were performed to study the states and the influencing factors.RESULTS 一,Demographic information1. Of the 110 participants,46 are males and 64 are females, the mean age (standard deviation) for them was 70.2±6.8 years (range 60-89 years), the mean number of years since diagnosis of diabetes was 106.7±82.4 months(range 1 month to 33 years). The education level was low,50% of them reported having primary school education background. Females have lower education level than males (χ2=10.472, P=0.003). Majority of them lives with partner.2. Compared to the results of the Third National Oral Health Survey of China in 2005, this sample had a less number of teeth(averegel8.29±9.19) (t=3.057, P=0.003)二,Predisposing factorsIn this study it includes oral care and periodontal diseases knowledge, perceived oral health treatment needs, attitude towards oral problems, self-evaluation of dental health, self-evaluation of oral problems impact on quality of life.1. Knowledge1.1 There were 7 knowledge items (about the relationship between diabetes and periodontal diseases), only 9.1% of participants completely answered correctly. Among the seven knowledge items, "gum disease can lead to loss of teeth" item got the highest score, "people with dry mouth are more likely to have tooth decay " item got the lowest score. This result indicated that the elderly with diabetes knew the consequence of periodontal diseases, but had little knowledge about the causes of periodontal diseases. Regarding the oral care knowledge,50% of participants answered completely wrong. Among the three oral care knowledge items, "how many times should you brush your teeth" item got the highest score, but 99.1% and 96.4% of participants answered the floss and regular dentist check up item wrong. The result showed that the elderly with diabetes had minimal knowledge about oral care. 1.2 There were significant difference in the oral care knowledge score of participants with different education level, household income, the frequency of attending diabetic education session, number of teeth (P<0.05).There was a positive correlation between oral care knowledge and the frequency of attending diabetic education sessions (Rs=0.403, P<0.01))2. Attitude2.1 Only one answered the four questions correctly. Among the four attitude items," are you going to tell dentist that you have diabetes when you visit the dentist" item got the highest score, "I am going to visit dentist when I have dental problems" item got the lowest score.2.2 There were significant difference in the score of participants with different education level, medical payment, the frequency of attending oral care education session, number of teeth (P<0.05)2.3 There was a positive correlation between oral care attitude and oral care knowledge (P<0.05)3. Self-evaluation of oral health48.2% of participants reported was satisfied with their oral health, the greater the number of teeth, the higher the scores of self-evaluation of oral health (Z=-3.078, P=0.002).4. Self-evaluation of oral problems impact on quality of life4.1 41.8% of participants reported that (affect chewing).Only 20.7% and 17.2% of participants reported oral problems had a big impact on quality of life(affect speaking and appearance).4.2 There were significant difference in the score of participants with different number of teeth (P<0.05)三,Enabling factor In this study, it included the frequency of attending diabetic and oral care education sessions, household income, medical payment, The result indicated that there were positive correlation between the oral health behavior and the frequency of attending diabetic and oral care education session. The participants who reported taking more education sessions had a good oral health behavior. There was significant difference between the participants with different way of life care. (P<0.05)1.141.8% of participants reported having taken a diabetic education session to learn managing their diabetes, but 86.4% of them reported having never taken any oral care education session.1.2 Majority of them had primary health care and 52.7% of them reported household income is 1500RMB per month and above.1.3 The higher the level of education, the more the household income, and the more the frequency of attending diabetic education session (χ2=18.309, P=0.019;χ2=21.719, P=0.017 respectively)四,Reinforcing factorIn this study, it included way of life care, denture restoration and the result of restoration.1.85.5% of participants were completely self care.2.In 36 of the denture restoration people,13 complained bad fitted,9 complained pain,8 complained chewing problem.五,Oral health behaviors5.1 Nobody answered the 6 oral health behavior questions correctly. The result showed that the elderly with diabetes had wrong oral health behaviors.5.2 Compared to the results of the Third National Oral Health Survey of China in 2005, this sample had a greater frequency of brush teeth (P<0.05)5.3 There were significant difference in the score of participants with different education level, marital status, occupation before retire, the frequency of attending diabetic and oral care education session, number of teeth (P<0.05)六,The analysis on predisposing factor, reinforcing factor, enabling factor and oral health behaviors1.Predisposing factor and oral health behaviors.1.1 The result showed there were positive correlation between knowledge (the relationship between diabetes and periodontal disease,oral care) and behavior (Rs=0.609, P<0.01; Rs=0.266, P<0.01).1.2 There was a positive correlation between attitude and behavior(Rs=0.373, P<0.01).1.3 There was a positive correlation between predisposing factor and oral health behaviors (Rs=0.334, P<0.01)2.Enabling factor and oral health behaviors.2.1 There was a positive correlation between the frequency of attending diabetic education sessions and oral health behavior (Rs=0.234, P<0.05).2.2 There was a positive correlation between life care model and oral health behavior (Rs=0.273, P<0.01)2.3 1.3 There was a positive correlation between enabling factor and oral health behaviors (Rs=0.340, P<0.01)CONCLUSIONS1.The education level of elderly with diabetes was low, the total oral health and oral health behaviors.were poor..Oral health behaviors were affected by many factors, such as marital status, education level, occupation before retire, the frequency of attending diabetic and oral care education sessions and so on. Medical staff should pay much attention to it.2.Lack of important knowledge about the oral health complications of diabetes and oral care, hold misconceptions of oral problems were main causes of poor oral behaviors in elderly with diabetes.In order to improve oral haelth behavoir, madical staff should teach patients oral care knowledge and shills.3.Diabetic self management session can help diabetic patients to get rid of incorrect oral care behavoirs.Diabetic specialist/educators must learn related knowledge of diabetes and periodontal disease and oral care,to help them to establish good oral health behaviors. Diabetic educators/nurses and other staff have an opportunity and the responsibility to educate diabetic patients about the oral complications of diabetes and to promote proper oral health behaviors that limit the risks of tooth loss, periodontal disease and oral soft-tissue pathologies.