Oral-health-related quality of life and oral health needs of adolescents living with HIV in Johannesburg
Date
2021
Authors
Malele-Kolisa, Yolanda
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Abstract
Introduction: The reported high burden of oral diseases among HIV infected adolescents
raises concerns about their Oral Health-Related Quality of Life (OHRQoL). OHRQoL is
described as the effect of oral conditions on the overall functioning and wellbeing of
individuals and it is influenced by shared sociocultural and economic contexts. Consequently,
identifying the factors influencing OHRQoL in the African setting is important to inform the
provision of responsive oral health services that ensures better wellbeing of adolescents. This
proposition is against the fact that the existing OHRQoL assessment tools for children and
adolescents have been conceptualised in non-African settings. Consequently, these may not
be applicable in an African setting given the contextual differences. Additionally, there are
inconsistent reports on the prevalence of oral conditions and their associated factors among
adolescents living with HIV (ALHIV). The inconsistencies may hinder the development of
clear guidelines on the prevention and treatment of oral conditions among ALHIV. This
study, therefore, describes the OHRQoL and oral health needs of HIV infected and
undiagnosed adolescents in Johannesburg using a contextually appropriate tool.
Methods: The overall PhD study approach was a sequential mixed-method combining both
qualitative and quantitative components. The qualitative component was used to generate
prevailing perceptions and experiences of OHRQoL. The findings of the qualitative
component were used to augment an existing OHRQoL measurement tool developed in a
different context. Further, the psychometric properties of the resulting locally appropriate
OHRQoL tool was assessed and the adjusted tool was used to measure the oral-health-related
quality of life outcomes and their determinants among the study participants using a
quantitative research approach.
A part of the quantitative component assessed the prevalence of oral conditions and the
impacts of the oral conditions in both groups of the adolescents (consisting of HIV infected
and undiagnosed adolescents). Decayed Teeth (DT), Decayed Missing and Filled Teeth
(DMFT) and Oral HIV/AIDS Research Alliance (OHARA) case definitions were used for
caries examination and reporting of the oral mucosal lesions. The OHRQoL outcomes were
measured with our modified Child Oral Health Impact Profile tool.
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An epidemiological update of the oral lesions’ pattern among ALHIV was done as well using
the DT, DMFT and OHARA indices. Data analyses were structured by the study main
outcomes; chi-squared tests were performed to determine the associations between variables;
and multiple logistic regressions were used to identify associated factors after adjusting for
confounding exposure variables. In addition, Cronbach’s alpha tests, exploratory and
confirmatory analysis were conducted for the validity measurement and the psychometric
properties assessment of the modified tool.
Results: Eight themes classified into three levels were identified by the qualitative
exploration of the adolescents’ perception of OHRQoL. The three levels were at the
individual-level, external and social level. The specific eight themes included a) oral health
awareness, b) felt oral symptoms, c) impaired oral functioning, d) coping e) access to dental
facilities, f) experiences of using health services g) social interaction and h) self stigmatisation. These themes were appropriately incorporated into the existing Child Oral
Health Impact (COHIP) tool modified for the current setting.
From the epidemiological update of oral conditions among ALHIV (n=407) the overall
prevalence of dental caries was 56.76% (n=231) with a mean DT score of 2.0 (SD 2.48) and a
mean DMFT score of 2.65 (SD 3.01). The prevalence of oral mucosal lesions (OML) was
22%, with linear gingival erythema accounting for most of the lesions at 13.8%.
Dental caries prevalence was significantly associated with the HIV clinical markers (HIV
RNA viral loads > 1000 copies/ml; CD4 cell counts less than 200 count cells/mm3 as well as
WHO staging III, IV). Among ALHIV, the prevalence of dental caries was directly related to
the presence of oral mucosal lesions (p<0.05). Multiple logistic regression modelling showed
that dental caries experience (DMFT>0), age category 13-15 years, WHO staging of IV and
viral load > than 1000 copies/ml significantly predicted the outcome of oral lesions (p<0.05).
The odds of developing dental caries was also 1.5 times more among ALHIV who brush their
teeth less frequently and those who reported a sugary diet.
In the comparative phase of the study, a total of 504 adolescents recruited from a HIV
Wellness Site (n=226) and School Sites with HIV undiagnosed adolescents (n= 278) were
included in the study. The overall mean decayed teeth for permanent dentition was 1.6(SD
1.99) and caries prevalence was 62.2 % (n=309) among all adolescents. The overall M COHIP score was 59.6(SD:18.2).
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The overall modified COHIP scores for those in schools were higher [62.88(SD:1.08)] when
compared to that of ALHIV [55.54(SD:1.20)] recruited from the HIV Wellness Site. The
poor M-COHIP scores were associated with reporting toothache, having active decay, poor
oral health-self-rating, and being selected from the school site, (p<0.005). The main factors
influencing OHRQoL followed an existing conceptual framework and were at individual level: oral mucosal problems, children perceptions and awareness; and at external level
including factors such as dental facility access and socioeconomic factors.
Conclusion: The perceptions and experiences of OHRQoL among ALHIV in Johannesburg
were influenced by a combination of self-perceptions and social connections, together with
the state of their structural environment and biological wellbeing. The participants placed
high value on the importance of coping, symptom endurance and dental facility service
experiences in determining OHRQoL.
There is high prevalence of dental caries and oral mucosal lesions among ALHIV in
Johannesburg. The reported prevalence was associated with high HIV RNA viral loads, low
CD4 cell count and high WHO staging of HIV disease. Additionally, caries experience
contributed to the prevalence of oral mucosal lesions. Our study acknowledges the protective
effect of HIV treatment and positive oral health practices on the presence of oral conditions
among ALHIV in Johannesburg.
The modified oral-health-related quality of life tool displayed acceptable initial reliability and
validity. The adolescents’ OHRQoL scores were related to the high untreated-caries,
toothache reports, poor self-rated oral health and being in schools.
In all, this PhD suggests an association between adolescents’ OHRQoL and their individual level factors such as perception, oral problems, and environmental determinants (such as
socioeconomic and dental facility access factors). More studies may be needed to further
assess the new sub-scales among other South African sub-groups particularly the adolescents
in rural areas given the urban focus of this PhD. These findings may be relevant in improving
oral health services in meeting adolescents’ oral health needs
Description
A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, 2021