|Year : 2011 | Volume
| Issue : 3 | Page : 494
|Questionnaire vs clinical surveys: The right choice?-A cross-sectional comparative study
Aswini Y Balappanavar1, Varun Sardana2, L Nagesh3, Anil V Ankola4, Pradnya Kakodkar5, Mamata Hebbal4
1 Public health Dentistry, Teerthankar Dental College and Research Center, Moradabad, Uttar Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, Teerthankar Dental College and Research Center, Moradabad, Uttar Pradesh, India
3 Department of Pedodontics and Preventive Dentistry, Community Dentistry, Bapuji Institute of Dental Sciences, Davangere, India
4 Department of Pedodontics and Preventive Dentistry, KLE`S Institute of Dental Sciences, Belgaum-10, Karnataka, India
5 Department of Pedodontics and Preventive Dentistry, D.Y. Patil Dental College, Pune, Maharashtra, India
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|Date of Submission||18-Sep-2010|
|Date of Decision||07-Dec-2010|
|Date of Acceptance||10-Feb-2011|
|Date of Web Publication||3-Nov-2011|
| Abstract|| |
Purpose: To investigate the practical value of using questionnaires (self perceived assessment) as compared with clinical examinations (normative assessment) and to evaluate the role of socioeconomic status and implications of the results in understanding the public perception of oral health.
Materials and Methods: This was a cross-sectional single-blind study. A purposive sample of 860 bank employees of Belgaum city, India, were asked to fill in a close-ended questionnaire inquiring about their socioeconomic status, dental, periodontal health levels and treatment needs. Clinical examinations, employing the WHO dentition status and Community Periodontal Index, were performed to determine normative status and needs. Perceived and normative assessments were compared for sensitivity, specificity, positive and negative predictive values.
Results: The kappa values ranged from 0 (treatment needs) to 0.67 (for prosthesis). The degree of agreement with the following kappa values and sensitivity was seen in filled teeth (0.52, 60%), missing teeth (0.62, 83.8%), and prosthesis (0.67, 58.3%). However, the disagreement was seen with all other questions with average kappa value of 0.20.
Conclusions: Self-assessment questionnaires were of low value in evaluating dental, periodontal health status and treatment needs in the study subjects. Findings reflect a low level of awareness that may influence care-seeking behavior and socioeconomic status has a clear role to play in dental health perception.
Keywords: Health needs, questionnaires, survey, socioeconomic status, WHO oral health performa
|How to cite this article:|
Balappanavar AY, Sardana V, Nagesh L, Ankola AV, Kakodkar P, Hebbal M. Questionnaire vs clinical surveys: The right choice?-A cross-sectional comparative study. Indian J Dent Res 2011;22:494
In determining health, various forms of assessment is possible, the data may be obtained from a clinical study, screening with or without an interview study or a self-administered questionnaire, and a combination of methods. , The same way in determining health needs, Bradshaw (1972) classified needs as normative needs-determined by health professionals; expressed needs--determined by client population seeking healthcare; perceived (felt) needs--which reflect the level of need assessed by client population which may not prompt an individual to seek treatment; and unmet needs--the difference between the supply and requirement for treatment. 
|How to cite this URL:|
Balappanavar AY, Sardana V, Nagesh L, Ankola AV, Kakodkar P, Hebbal M. Questionnaire vs clinical surveys: The right choice?-A cross-sectional comparative study. Indian J Dent Res [serial online] 2011 [cited 2019 Jul 23];22:494. Available from: http://www.ijdr.in/text.asp?2011/22/3/494/87081
Clinical examinations are time consuming, require special clinical facilities, calibrated examiners, and are resource demanding. Many people are hesitant to undergo clinical examination. , As research funds are limited, the use of interviews and post-questionnaires is increasing in epidemiologic surveys. Self-reported measures such a diet and physical activity have been validated and used routinely in the medical literature.  However, less information is available regarding the validity of self-reported oral health measures.
Caries and periodontal diseases, the two foremost oral pathologies, remain widely prevalent and affect all populations throughout the life span.  Clinical (normative) assessment of these pathologies is an expensive, invasive, and uncomfortable procedure for many people. Recently, medicolegal and ethical obstacles have further complicated these procedures. Consequently, the use of questionnaires and interviews (self-perceived assessment) has become a more common method for collecting diagnostic data and performing oral health surveys. ,,,,, Valid self-reported measures of oral conditions will facilitate incorporation of an important oral health measure in a wide variety of large scale surveys and other studies of general health status. ,,,, There are very few published studies relating subject's perceived oral health with dentists rating and with indicators of dentition status and periodontal status.
Hence, a study was conducted with the aim to investigate whether questionnaire can replace clinical surveys in assessment of dental, periodontal health status, and treatment needs of adults. With the objectives (1) to investigate self-perceived vs clinically diagnosed dental and periodontal health status and dental treatment need assessment by healthcare professionals with the perceived needs of the study population, (2) to compare socioeconomic status with the normative and perceived status, and (3) to assess the value of using questionnaires in large-scale population surveys and to evaluate the implications of the results in understanding the public perception of oral health.
| Materials and Methods|| |
This cross-sectional, single-blind survey took place over a period of approximately two months (April-June, 2005) in Belgaum city among a representative sample of bank employees. This population is considered representative in terms of geographic and cultural variables.
Belgaum district is situated in the northwestern part of Karnataka, India. The literacy level is 64.42%. The per capita income estimated in 1999-2000 is Rs 13 618. The dental needs are catered by two dental colleges and hospital, two medical colleges and hospital, two ayurvedic colleges and hospital, two homeopathic colleges and hospitals, and one district hospital in the city.
Permission to carry out the survey was obtained from the Ethical Committee, KLE`S Institute of Dental Sciences, Belgaum, Karnataka, and the bank managers of the respective banks.
A convenience sample of 860 bank employees aged 18 to 60 years in Belgaum city were considered for the study after taking informed consent. Of total 52 banks, 26 were selected by simple random sampling (lottery method). The criteria for exclusion in study were individuals physically unfit (physically and mentally challenged, accidental cases, medical illness, congenital disorders) and subjects seeking dental treatment.
A self-designed close-ended questionnaire consisting of 15 questions on a three-point Likert scale and a format for recording socioeconomic status, demographic data were prepared in simple words in three languages, i.e., English, Hindi, and Marathi, for easy understanding of participants. The questionnaire was also checked for its reliability, validity, and acceptability before starting the study. The pertinent part of WHO Oral Health Assessment Form  was used for recording the dental caries status (World Health Organization dentition status and treatment needs) given by World Health Organization , periodontal status (Community Periodontal Index [CPI] and Loss of attachment [LOA]) and the periodontal treatment needs was assessed using scores 0 - no treatment needed, 1 - treatment needed. The first question dealt with dental caries status (Q1), whereas the second, third, and fourth questions dealt with the implication of dental caries, i.e., filling (Q2), missing (Q3), and prosthesis (Q4), respectively. The next four questions were gingival bleeding (Q5), mobility of teeth (Q6), swollen gums (Q7), and gingival recession (Q8) to access the periodontal status. One question was used to assess the treatment need (Q9) and another for the intake of food (Q10).
For assessing socioeconomic status, the necessary information regarding education, occupation, family income, and number of family members was obtained and divided accordingly from class I to class V, using Modified Family Income Group of the Kuppuswamy's socioeconomic status scale, with education and occupation criteria remaining the same. , The food intake was assessed by asking few questions whether the intake of food has increased or decreased in few months . The reasons for decrease in diet were questioned. The patient was told to fill two diet history chart of before and after the oral pathology.
The investigator was blinded to the questionnaire filled by bank employees. The type III clinical examination was done during working hours of bank. The examination was carried out in the bank premises where there was good day light illumination. The acceptability was judged based on the subjects who tick the answers for more than 80% questions and the kappa co-efficient was 0.87 (percentage agreement - 95%).
The gold standard clinical examination and the self-perceived assessment questionnaire were compared for: Sensitivity, Specificity, Positive predictive value (PPV), and Negative predictive value (NPV). The data were entered and analyzed in SPSS software (version 11). The Chi-Square test was used for categorical data. In all above tests, "P0" value of less than 0.05 was accepted as indicating statistical significance with Confidence Intervals - 95%.
| Results|| |
The study participants comprised of 59% males (507) and 41% females (353) with mean age of 38 years [Table 1]. Although participation was nonobligatory, response rate was 100%. Based on Kuppuswamy's socioeconomic status, 366 study subjects belonged to upper middle class (class 2), 380 belonged to lower middle class (class 3), and 114 belonged to upper lower class (class 4).
Reliability and validity tests
Weighted Kappa coefficients for both intra- and inter-examiner, as well as intraclass correlation coefficients were greater than 0.84. Test-retest reliability for questionnaire was analyzed by the Pearson correlation coefficient (0.81-0.86; P<0.001). The internal consistency was measured by Cronbach's alpha test (0.83). Results were stable and consistent, suggesting that examiners were prepared to apply tests and perform examinations. Examiner reliability for the clinical examination (indices) was determined by re-examining 30 participants between the one and eight weeks after the initial examination. The Kappa coefficient value was found to be 0.87, reflecting a high degree of conformity in observations. The percentage agreement was 95%.
The overall prevalence of dental caries was 86.5% (744), among which males (45.8%) had higher prevalence than females (41%), as shown in [Table 1]. The mean dental caries, filled, missing teeth (DMFT) was 4±0.5 and 51.4% had a DMFT of more than 6±0.45. Around 78.9% (n=678) had the CPI score of 0-2 and 21.1% (182) had CPI scores of 3-4. The LOA score of 0 was found in 22% of the subjects.
Perceived and normative status
[Table 2] shows a poor agreement between clinical examination and questionnaire regarding dental caries (Q1), fair agreement with Q2 regarding the presence or absence of fillings, and acceptable agreement was seen with Q3 and Q4. Among those who had thought they had dental caries, 11.7% did not have dental caries on clinical examination. Among 100% of subjects who perceived having prosthesis were all confirmed by clinical examination. [Table 3] shows the poor agreement between questionnaire and clinical examination, with kappa values ranging from 0.17 to 0.26 for periodontal status. All the measures had low sensitivity and high specificity. In [Table 4], there is poor agreement also in case of treatment needs and reduced diet due to oral pathology with kappa values 0 and 0.21. 100% were clinically diagnosed as in need of dental treatment. Both females and males had almost equal perceived treatment needs (55% - females, 45% - males).
On clinical examination, 90.6% had dental caries and only 64.6% reported them, whereas prosthesis were seen in 27.9% subjects and the self perception was 32.5%, as shown in [Graph 1]. The perceived need was lowest for gingival inflammation (23), whereas it was high for gingival bleeding (32); however, this was less when compared with the clinical status (51% and 69.7%, respectively). The subjects underestimated the periodontal pathology, as shown by the results in [Graph 2]. All the subjects (100%) needed some or the other dental treatment, whereas only 48% said they needed treatment. Only 1% of the subjects said that their food intake was reduced due to oral pathology, whereas in reality 46% had reduced food intake [Graph 3].
Perceived/normative status and socioeconomic status
Perceived yes and clinical yes for each socioeconomic status category were considered. The majority of the subjects (n=280, 44%) in the upper middle class said they had caries and it was found to be 41% on clinical examination. In lower middle class, the perception for caries was high (49%). In upper lower class, only 7% subjects perceived that they had caries but 14% had caries on normative assessment. There was highly significant correlation between perceived needs of caries with socioeconomic classes (χ2 =79.5, P<0.001) and also between normative needs of caries with different socioeconomic classes (χ2 =181, P<0.001). There was a highly significant difference among different classes (χ2 =29.4, P<0.001) with higher perceived need for caries in the upper middle class and less needs in the upper lower class, whereas the normative needs were greater in lower class.
For bleeding on probing, lower middle class had low perceived need (n=85, 19%) than their normative need (n=310, 44%). The perceived need (χ2 =79.5) and normative need between each class was highly significant (χ2 =181). Socioeconomic status with perceived and normative needs for bleeding on probing was highly significant when perceived yes and normative yes was considered (χ2 =8.9). In the upper lower class, 24% subjects had perceived need but only 16% had normative need. When the socioeconomic status and inflammation of gums was assessed, the perceived needs were low in lower middle class and upper middle class (χ2 =79.5). Socioeconomic status with perceived and normative needs yes for inflammation of gums was highly significant between the classes (χ2 =8.9) [Table 5].
|Table 5: Distribution of subjects at different socioeconomic status for caries assessment, bleeding on probing|
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Socioeconomic status for treatment needs was highly significant for both perceived and normative need when compared (χ2 =100.7). Comparison of socioeconomic status with perceived and normative needs yes for treatment needs was highly significant between perceived yes (χ2 =22.3) and normative yes. The lower middle class and upper lower class perceived better than the upper middle class.
| Discussion|| |
This study was conducted to investigate the practical value of using questionnaires (self-perceived assessment) as compared with clinical examinations (normative assessment) and to evaluate the role of socioeconomic status and implications of the results in understanding the public perception of oral health among bank employees in Belgaum city, Karnataka, India. In the present study, a large and representative population of adults was investigated. The WHO dentition status, CPI index, LOA, and treatment needs were used as the gold standard, and they are the preferred and recommended indicators as recommended by the WHO for the assessment of dental and periodontal health status in oral health surveys. The clinical examination and self-perceived assessment questionnaires were compared for sensitivity, specificity, positive and NPVs. Predictive values of positive and negative tests are influenced by the prevalence of the disease in the population, in which the test is performed, so that the lower the prevalence, the lower the predictive value of a positive test will be. ,
Perceived oral health status in the present study was found to be of low specificity (50% for dental caries and 0% for treatment needs) and high for all others, but high sensitivity (61.5% for dental caries status, 60% for filling status, and 83.8% for missing status) and less for all other questions. Additionally, self-perceived oral health status was found to be of moderate PPV (100% for treatment needs and prosthesis, 92.3% for dental caries, 92.8% for missing teeth and mobility, 85.75 for filling, 80% for swollen and red gingival, and 75% for food intake) and NPV for dental caries status (11.7% for dental caries, 72.4% for filling, 66.7% for missing, and 86.1% for prosthesis, respectively), of very low PPV (58.3% for recession), and very high NPV for periodontal status (67.7% for recession and 54.5% for swollen and red gingival, respectively). A study,  which employed several threshold points for self-report measure of periodontal disease, found low sensitivity values of 17.7 to 64.7%, and high specificity values of 59.8 to 90.7%, similar to the results of the present study. The low specificity and moderate sensitivity was seen in treatment needs when compared with disease condition which may be expected as people would be unaware of disease until diagnosed or treated, though they are aware of presence of treatment. The astonishing fact was seen with the prosthesis in which 32.5% said that they had prosthesis in their mouth, whereas only 27.9% were observed on clinical examination, that is, 4.6% of subjects would have confused the prosthesis with fillings.
Comparisons of oral health normative vs self-perceived assessments could demonstrate the efficacy of the individual to evaluate personal health status and highlight fields in which self-perceived assessment is precise or imprecise. 
Previous studies have shown that questionnaires and interviews that collect data on oral health status are useful measures, specifically for ascertaining the presence of dentures and the number of teeth. ,, Self-reporting of gingival and periodontal health status as well as self-assessment of the presence of dental caries have been found to be neither useful nor successful. ,, Gilbert and Nuttall reported that only four of 18 items were weakly predictive of the periodontal health status. They concluded that the values obtained were not sufficient to enable development of a set of questions that would serve as a satisfactory indicator for periodontal condition in the absence of clinical examinations.  Robinson et al. suggested that self-reported interview data are not useful for assessing the presence of dental decay. In their study, 26 of 45 participants who thought that they had decay had one or more decayed teeth, 19 of 65 participants, who did not think they had caries, were found to have caries by clinical examination.  It was suggested that valid self-reported measures could provide a time- and cost-efficient alternative for large epidemiological studies.  As a result, oral health could be included in more studies on overall health status. A study assessed the validity of self-reported oral disease measures in two populations. In their study, self reports provided reasonably valid estimates for number of remaining teeth, fillings, root canal therapy, and fixed and removable prostheses.  However, they appear to be less useful for the assessment of dental caries and periodontal disease.
The socioeconomic status comparison was done only for questions 1 (dental caries), 5 (gingival bleeding), 6 (inflammation of gingiva), and 10 (food intake) as the discrepancy between perceived and normative assessment was more. In our study, it was seen that the upper middle class had high perceived need when compared with other classes except in treatment need. This shows that the education, occupation, and family income have some role to play in perception of person toward dental health.
The present study gives rise to several important issues. It has been noted that people seem to be unable to recognize whether they are affected by dental and periodontal diseases. [th 4] ,[th 8],,,,,[13 ] The comparison performed in the present study suggests that perception of health is at a higher level, whereas perception of disease is much lower. These findings reflect a high level of unawareness that may influence the oral healthcare-seeking behavior. Utilization of clinical facilities by consumers, although generated by a wide variety of factors, many of them psychosocial, is motivated first and foremost by self-perception of illness. ,
In conclusion, the present study showed that questionnaires do have an inherent and significant value in explaining the levels of dental awareness, perception, and self-assessment, which in the present study have clearly demonstrated an alarming discrepancy with the "gold standard" of professional clinical assessment.
The key to an informed and motivated public lies in the hands of the profession (private and public health practitioners), as well as the authorities. Health promotion, with its key concepts of equity and equality, empowerment and advocacy, offers a new and often complex approach to improving both general and oral health. ,,, It shifts the responsibility for health from the formal healthcare system to individuals, communities, and decision-makers at all levels of society. The professional examination and diagnosis should be more cognizant of the public perception, and the profession should be more involved regarding the public dental health felt and expressed needs.  In both aspects, a crucial need for public health action is clearly evident.
Future research should be targeted at evaluating different additional self-reported measures and their combinations in improving the validity for extension to the general population. Perception of need also may be related to other factors such as experience and expectations of dental care. Additional research is required to assess how these and other cultural factors might affect the relationship between lay and professional assessments of oral health status and treatment needs.
| References|| |
|1.||Gudjon A, Sigrun H. Comparison of oral health data from self administered questionnaire and clinical examination. Community Dent Oral Epidemiol 1995;23:365-8. |
|2.||Lisa MJ, Murray WT, McGee R. An assessment of the validity and reliability of dental self report items used in a national child nutrition survey. Community Dent Oral Epidemiol 2004;32:49-54. |
|3.||Hancock PA, Blinkhorn AS. A comparison of the perceived and normative needs for dental care in 12 year old children in the northwest of England. Community Dent Health 1996;13:81-5. |
|4.||Gilbert AD, Nuttall NM. Self - reporting of periodontal health status. Brit Dent J 1999;186:241-4. |
|5.||Barmes DE. A global view of oral diseases: Today and tomorrow. Community Dent Oral Epidemiol 1999;27:2-7. |
|6.||Pitiphat W, Garcia RI, Douglass CW, Joshipura KJ. Validation of self-reported oral health measures. J Public Health Dent 2002;62:122-8. |
|7.||Yuval Vered, Harold DS. Self perceived and clinically diagnosed dental and periodontal health status among young adults and their implications for epidemiological surveys. BMC Oral Health 2003;3:3-13. |
|8.||Robinson PG, Nadanovsky P, Sheiham A. Can questionnaires replace clinical surveys to assess dental treatment needs of adults? J Public Health Dent 1998;58:250-3. |
|9.||Helöe LA. Comparison of dental health data obtained from questionnaires, interviews and clinical examination. Scand J Dent Res 1972;80:495-9. |
|10.||Kononen M, Lipasti J, Murtomma H. Comparison of dental information obtained from self - examination and clinical examination. Community Dent Oral Epidemiol 1986;14:258-60. |
|11.||Palmqvist S, Söderfeldt B, Arnbjerg D. Self - assessment of dental conditions: Validity of a questionnaire. Community Dent Oral Epidemiol 1991;19:249-51. |
|12.||Kallio P, Ainamo J. Self - assessment of gingival bleeding. Int Dent J 1990;40:231-6. |
|13.||Trevonen T, Knuuttila M. Awareness of dental disorders and discrepancy between "objective" and "subjective" dental treatment needs. Community Dent Oral Epidemiol 1988;16:345-8. |
|14.||Joshipura KJ, Pitiphat W, Douglass CW. Validation of self-reported periodontal measures among health professionals. J Public Health Dent 2002;62:115-21. |
|15.||World Health Organization: Oral health surveys - basic methods. Geneva: WHO; 1997. |
|16.||Kuppuswamy B. Manual of socioeconomic status (urban) 1 st ed. Delhi: Manasayan publishers; 1981. |
|17.||Mishra D, Singh HP. Kuppuswamy`s s socioeconomic status scale - A revision. Indian J Pediatr 2003;70:273-4. |
|18.||Shuval JT. Social dimensions of health: The Israeli experience. Connecticut: Praeger Publishers; 1992. p. 101. |
|19.||Schou L, Locker D. Principles of oral health promotion. In: Community Oral Health. 2 nd ed. Pine MC. Oxford: Wright; 1997. p. 177-86. |
|20.||Abramson JH, Abramson ZH. Survey methods in community medicine. 2 nd ed. Edinburgh: Churchill Livingstone; 1999. p. 103. |
|21.||Daly B, Watt R, Batchelor P, Treasure E. Introduction to the principles of public health. In: Essential dental public health. Oxford: Oxford University Press; 2002. p. 1-17. |
|22.||Lundegren N, th Axtelius B, th Hakansson J, th Akerman S. Dental treatment need among 20 to 25-year old Swedes: Discrepancy between subjective and objective need. Acta Odontol Scand 2004;62:91-6. |
Aswini Y Balappanavar
Public health Dentistry, Teerthankar Dental College and Research Center, Moradabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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