Wararat Jaichuen, DDS, MPH^1*, Warangkana Vejvithee, DDS, MSc²

¹Health Administration Division, Office of the Permanent Secretary, Ministry of Public Health, Tiwanon Rd., Talat Khwan, Muang Nonthaburi,    Nonthaburi 11000 Thailand.

²Bureau of Dental Health, Department of Health, Ministry of Public Health, Tiwanon Rd., Talat Khwan, Muang Nonthaburi, Nonthaburi 11000 Thailand.

*Corresponding Author: Wararat Jaichuen, DDS, MPH, Health Administration Division, Office of the Permanent Secretary, Ministry of Public Health, Tiwanon Rd., Talat Khwan, Muang Nonthaburi, Nonthaburi 11000 Thailand.

Abstract
Objective
To compare the oral health-related behaviors and oral health status among the elders who lived in the area with the oral health-promoting elderly club and another area without a club

Methods
Samples from areas with and without oral health-promoting elderly clubs were compared. A structural questionnaire was used to collect demographic characteristics, oral health-related behaviors, and oral health outcomes. Descriptive statistics and the chi-square test were utilized.

Results
695 from 700 respondents’ data were completed. Six oral health-related behaviors, which are brushing teeth after lunch, brushing teeth at night, using dental floss, using proxabrush, never smoking or quitting smoking, and consulting dental personnel when having oral health symptoms, presented a significantly higher proportion among the group from areas with oral health-promoting elderly clubs. Having at least four pairs of occlusal teeth was the only outcome that was significantly different between the groups.

Conclusions
Oral health-promoting elderly clubs were associated with six behaviors and outcomes. By the way, smoking behavior needs more addressed. The oral health-related quality of life should be included as an indicator of oral health systems. And the new approach is needed for promoting oral health among Thai elderly men.

Keywords: elder, elderly club, oral health promotion, oral health-related behavior, oral health-related quality of life, oral health outcome

Introduction
Health promotion has been the key objective of health system reform since the campaign “Health for all” was announced [18]. The central government of Thailand also adopted health promotion as the main strategy of health system development [11]. All health-related subsystems, including oral health, followed this directive.

Methods
This cross-sectional study used a mixed methodology. Twelve provinces from four regions of Thailand were selected as study settings. Inclusion criteria included provinces having at least one area with the oral health-promoting elderly club and another area without a club.

Results
Data were collected from all 700 participants, but five questionnaires were incomplete. This left 695 for analysis (99.3 %). Completed data gave 617 participants who had at least one tooth remaining in their mouths, while 150 wore dentures of both professional and non-professional types. General characteristics of the elders were similar between settings. Education was the only different characteristic between the groups, participants in an area with the club had a higher educational level (Table 1).

Table 1: Demographic characteristics of the participants

Six oral health-related behaviors were found to be significantly different between the two groups. These included brushing teeth after lunch, brushing teeth at night, using dental floss, using a proxabrush, never smoking or quitting smoking, and consulting dental personnel when having oral health symptoms. All these behaviors were found at higher proportions in the group with access to the oral health-promoting elderly club. Three of these six behaviors as brushing teeth after lunch, using dental floss, and using a proxabrush were recorded in a small proportion of participants (Table 2).

Table 2: Oral health-related behaviors of elderly people with and without oral health promoting elderly clubs

The oral health outcome in terms of ‘having at least four pairs of occlusal teeth’ was significantly different between the two participating groups, while indicators of the oral health-related quality of life (OHRQoL) as overall oral health and prevalence of OHRQoL as assessed by the Thai-OHIP were found to be similar (Table 3).

Discussion
The strategy of oral health promotion through elderly clubs has been driven for the past 13 years and coverage is still expanding. Previous studies found positive outcomes of oral health-promoting elderly clubs [7,17] but a comprehensive evaluation at the country level has never been conducted. The objective of this study was to explore the outcomes of the oral health-promoting elderly clubs in Thailand. A comparison of oral health-related behaviors and oral health outcomes was made between elders from areas with and without oral health promotion clubs.

Nineteen questions that assessed oral health-related behaviors were classified into four categories as 1) Regulatory self-care, 2) Preventive self-care, 3) Reactive self-care, and 4) Restorative self- care. Six out of 19 behaviors showed a significant relationship with the existence of oral health-promoting elderly clubs. Of these, four behaviors were classified into the regulatory self-care group and included brushing teeth after lunch, brushing teeth at night, using dental floss, and using a proxabrush, while two behaviors were classified into the preventive self-care and reactive self-care groups as never smoked/quit smoking and consulting dental personnel when having oral health symptom, respectively. Superior behavior characteristics were related to the existence of clubs but some findings might be overclaimed by oral health-promoting elderly clubs. This might occur because these outcomes are the objectives of the National Oral Health Plan for Senior Citizens that consists of various strategies [2], while the cross-sectional study design confirmed only the relationship between the variables.

Findings of oral health-related behaviors from this study were better than the latest national oral health survey of Thailand in terms of eating nothing after brushing teeth at night, removing and cleaning dentures after eating, using supplementary oral health care, whether as dental floss, a proxabrush, a toothpick or mouth rinse and oral health self-examination [3]. These improvements might reflect enhanced oral health service delivery that is another strategy in the national plan [2], since better access to care leads to direct communication with oral health practitioners who can then perform personal oral health promotion at the chairside [9,10]. By contrast, smoking behavior did not show improved results while this is a common risk factor shared with other non-communicable diseases [13] (Figure 1). This is a big challenge for personnel responsible for oral health care because the ultimate goal of the system is to promote oral h e a l t h s e l f -care f o r elders to maintain good oral health. Therefore, all oral health-related behaviors must be considered, not only cleaning behaviors.

‘Having at least twenty teeth with at least four pairs of occlusal teeth’ is the expected outcome, however, in this study, the presence of four pairs of occlusal teeth included participants wearing dentures. Therefore, the significant association between this outcome and implementation of oral health-promoting elderly clubs might be confounded by access to oral health services.

While no relationship of the OHRQoL was found with the implementation of oral health-promoting elderly clubs, but this issue should not be overlooked. As the FDI’s recommendation that the key performance indicators for assessment of oral health care needs and cost-effectiveness, as well as planning oral health services and setting policies, should be included in the OHRQoL together with clinical and behavioral indicators [8].

The main limitation of this study was the cross-sectional design. This constricted the analysis to explore only the relationships between the included variables. Causes and effects as the major objective of the evaluation were not considered. Further research is recommended using these results as baseline data. Another limitation resulted from the process of data collection. Sampling selection for elders who joined activities at the health center excluded males who commonly went to work during the daytime [14]. Thus, the majority of elders in the study were female at a higher proportion than the national statistics average [6]. This situation implied that any activities during the daytime at oral health-promoting elderly clubs were attended mainly by female elders. This led to the third issue of selecting health promotion activities that were compatible with the daily life cycles of males. Men commonly have more oral health issues than women. The lower number of functional teeth among males affects their chewing ability and nutritional status [12,15,16]. Males are more prone to the deleterious effects of smoking cigarettes that adversely impact dental hygiene.

In conclusion, the findings present significant associations between existing oral health-promoting elderly clubs and some oral health- related behaviors and oral health outcomes among the elders. Furthermore, three suggestions are proposed for the benefit of Thai oral health system planners: 1) smoking behavior should be addressed as a major deleterious factor for both oral hygiene and physical health,

2) OHRQoL should be included as an indicator to better monitor and evaluate the performance of oral health systems, and 3) a new approach should be adopted for oral health promotion by targeting elderly men.

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