| Abstract|| |
Objectives: The objectives of this study were to assess the relationship between dental anxiety and cynical hostility in a sample of dental patients and to study the possible role of socioeconomic status (SES) in this relationship. Materials and Methods: A total of 288 dental patients completed a self-administered questionnaire consisting of the cynical distrust scale (CDS) and the modified dental anxiety scale (MDAS). Data on sociodemographic characteristics were also collected. Results: Dental anxiety as reflected by mean MDAS scores was significantly higher among the younger age group (P = 0.002), among females (P = 0.025), and the lower SES groups (P = 0.001). Cynical hostility was significantly higher among the older age group (P = 0.03), among males (P = 0.02), and among the lower SES groups, respectively, (P = 0.001). When the CDS scores for individuals with and without dental anxiety were compared within the context of the three socioeconomic strata, there was a statistically significant difference (P = 0.029) in scores between the two anxiety groups in the middle socioeconomic strata where the cynical distrust scores were lower among the anxiety group. Discussion: Mediation analysis revealed that SES played an important role in the association between dental anxiety and cynical hostility. It also showed that the mediating effect is not uniform across socioeconomic strata and may be different in different societies with their own unique population structures and classes.
Keywords: Anxiety, cynical, dental, hostility
|How to cite this article:|
Acharya S, Pentapati KC, Srinivasan SR, Khatri S. Factors affecting the interrelationship between cynical hostility and dental anxiety among dental patients. Indian J Dent Res 2019;30:305-9
|How to cite this URL:|
Acharya S, Pentapati KC, Srinivasan SR, Khatri S. Factors affecting the interrelationship between cynical hostility and dental anxiety among dental patients. Indian J Dent Res [serial online] 2019 [cited 2020 Apr 7];30:305-9. Available from: http://www.ijdr.in/text.asp?2019/30/2/305/259210
| Introduction|| |
The neomaterialistic view of health inequalities suggests class or socioeconomic position may shape inequalities in health. Socioeconomic disadvantage may manifest as depression, perceived discrimination, and hostility resulting in lower trust in health-care providers and institutions. Cynical hostility is a psychological characteristic that has been associated with negative health impacts and health-damaging behaviors and has been shown to interact with education and social support., Hostile individuals have a suspicious, mistrustful attitude, and often disparaging view of others and generally have a cynical worldview of their environment and social interactions. Strong associations have also been reported between cynical hostility and education, income, and occupation.,
Social anxiety relates to greater hostile feelings toward and perceptions of others and socially anxious people may be hypervigilant for hostility in their environment. A visit to a dentist may provoke feelings of anxiety due to factors such as fear of pain, sense of loss of control, taboos, and beliefs. Dental anxiety afflicts people of all ages and social classes, and is based on several factors such as family and social environment, general fearfulness, pain and traumatic, and unpleasant experiences. It was seen previously that dental anxiety tends to increase with decreasing socioeconomic status (SES) and is a predictor for poor dental attendance. Since dental anxiety, cynical hostility, and low SES are associated with poor oral health,, their interrelationship needs to be studied in detail. We hypothesized that dental anxiety's relationship with cynical hostility may vary among people of different socioeconomic strata. A search of the literature revealed that the concepts of dental anxiety and cynical hostility and their relationship with SES have been studied separately but not together. It was felt that a deeper understanding of the interplay between the three factors would help administrators and psychologists to improve health-care access by tailoring specific health promotion programs. It was also felt that the findings from this study could be relevant in understanding health-care seeking behavior in developing countries. Hence, we aimed to assess the relationship between dental anxiety and cynical hostility in a sample of dental patients and to study the role of SES in this relationship.
| Materials And Methods|| |
This cross-sectional study was conducted among dental patients reporting to four rural outreach centers of the dental school. All new patients reporting to the clinics during September 2015 were invited to participate in the study. The patient recruitment was done by the receptionist in the waiting area of the centers. They were approached and asked if they could spare 5 min of their time to fill an anonymous questionnaire which did not collect their personal details/direct identifiers. The patients were explained that the purpose of the study was to help understand three important factors that could influence access to dental care, namely, dental anxiety, cynical hostility, and SES. They were also told that refusing to participate in the study would not affect their treatment in any way. Patients, who provided informed consent, were literate, adult (≥18 years) and coherent, were included in this study. Illiterate, disabled patients (who were not capable of comprehension and communication) and the seriously ill were excluded from the study.
A total of 350 new dental patients attending these centers who satisfied the inclusion criteria were invited to participate in the study, out of which 298 agreed and provided informed consent. Fifty-two patients refused to participate in the study. Nearly, 10 patients returned incomplete forms which were excluded from analysis. The age of the sample population ranged from 18 to 78 years. The final sample available for analysis was 288. Permission for the study was obtained from the Kasturba Hospital Ethical Committee (IEC196/2013 dated 15/05/2003) before the study.
Those who agreed to participate were provided a self-administered questionnaire which consisted of a previously validated version of the modified dental anxiety scale (MDAS) and the eight-item cynical distrust scale (CDS) used by Everson et al. The original English version was translated independently twice into the local language, first, by a local dentist proficient in English, and second, by a professional translator, and both translations were merged into one version. These versions were back-translated into English to remove any inconsistencies. For the eight-item CDS, the response options ranged from completely agree to completely disagree in an ascending order from 1 to 4. The items were summed to obtain a CDS score with a range of 8–24. Lower scores implied higher cynical distrust as the questionnaire was negatively worded and agreeing to the items indicated cynical distrust.
The MDAS (A Likert-type scale) had five questions. Each question had scores ranging from “not anxious” to “extremely anxious” in an ascending order from 1 to 5. Each question thus carried a possible maximum score of 5 with a total possible maximum score of 25 and a minimum score of 5 for the entire scale. Higher values implied greater dental anxiety. Sociodemographic data were also collected from the respondents. The study population was divided into lowest class, lower-middle class, and middle-upper class based on their occupation and income and education. Since the outreach centers were in remote rural areas people from upper socioeconomic strata were not available for analysis in our study.
Cronbach's alpha was used to measure the internal consistency of the CDS. The scores for the two psychometric scales were calculated by the additive method, with the response codes for the items constituting the measure being summed up. The mean MDAS and CDS values were compared against variables such as age and gender using independent sample t-test. For comparing the MDAS and CDS values against variables with multiple subgroups such as educational and SES, ANOVA with Tukey's post hoc test was used. Median split was used to dichotomize the population into low anxiety and anxiety groups and also according to age.
Mediation analysis seeks to identify and explain the mechanism or process that underlies an observed relationship between an independent variable and a dependent variable through the inclusion of a third variable, known as a mediator variable. The mediation model proposes that the independent variable influences the mediator variable, which in turn influences the dependent variable. Thus, the mediator variable serves to clarify the nature of the relationship between the independent and dependent variables. In our study, mediation analysis was done to evaluate the possible role of SES as mediator in the relationship between cynical hostility and dental anxiety. In accordance with Baron and Kenny's recommendations, it was done in three steps namely, by regressing the dependent variable (CDS) on independent variable (MDAS), mediator (SES) on the independent variable (MDAS), and finally dependent variable (CDS) on both the mediator (SES) and independent variable (MDAS).
| Results|| |
The Cronbach's alpha of the CDS was found to be 0.75 which indicated good internal consistency. The frequency distribution of the MDAS questionnaire responses showed the highest mean score (2.32 ± 1.12) for the item dealing with “local anesthetic injection” [Table 1]. The CDS item “Most people may use somewhat unfair means to gain profit or an advantage rather than lose it” had the highest agreement indicating lowest mean score of 1.69 ± 0.86 [Table 2].
|Table 1: Frequency distribution of the responses for the Modified Dental Anxiety Scale|
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|Table 2: Frequency distribution of the responses for the Cynical Distrust Scale|
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Sociodemographic factors were compared against the psychometric scales' scores using independent sample t-test, ANOVA, and Tukey's post hoc tests. We found that dental anxiety as reflected by mean MDAS scores was significantly higher among the younger age group (P = 0.002), among females (P = 0.025), and the lower SES groups (P = 0.001). Cynical hostility was significantly higher among the older age group (P = 0.03), among males (P = 0.02) and among the lower SES groups, respectively, (P = 0.001) [Table 3].
|Table 3: Dental anxiety and cynical hostility in relation to sociodemographic variables|
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The MDAS scores were dichotomized into anxiety and nonanxiety groups by median split method. The CDS scores for individuals with and without dental anxiety were compared within the context of the three SES levels. There was a statistically significant difference (P = 0.029) in CDS scores between the two anxiety groups in the middle SES strata where the CDS scores were lower among the anxiety group [Table 4]. Mediation analysis too revealed SES as a significant factor in the relationship between dental anxiety and cynical hostility [Table 5].
|Table 4: Cynical distrust scores among the low- and high-dental anxiety groups in relation to different levels of socioeconomic status|
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|Table 5: Mediation analysis through linear regression to study the role of socioeconomic status as a mediator between cynical hostility and dental anxiety|
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| Discussion|| |
Although dental anxiety and cynical hostility showed a decreasing trend with increasing SES, their relationship was not uniform across individual SES strata. Cynical hostility, when compared among individuals with and without dental anxiety showed variation within the context of the three SES levels. While there was no statistically significant difference in cynical hostility levels between those with and without dental anxiety in the lower SES strata, the same was not the case in the middle SES group. Here, we observed a significant difference, with the middle/upper SES strata showing higher levels of cynical hostility among the anxiety group. Mediation analysis too pointed to the mediatory role of SES in the relationship between dental anxiety and cynical hostility.
Conventional wisdom backed by previous research points toward a simplistic assumption that dental anxiety and cynical hostility uniformly increases with decreasing levels of SES. SES, educational attainment, gender, and age have been found to be related to dental anxiety. Dental anxiety in our study was more common among the lower SES, less educated groups, and among females. These were similar to the results obtained by other investigators., It has been shown that low SES predisposes to adverse conditions such as disrupted interpersonal relationships and chronic life stress which may lead to pessimistic and cynical life orientations., We found that as the level of SES deteriorated, the cynical anxiety increased which was in agreement with Pulkki et al.
However, when it came to the relationship between dental anxiety and cynical hostility among different socioeconomic strata, we found that this relationship was not linear. In any developing country with vast inequalities, there is a sizable chunk of people in the poorest group, a small minority in the affluent group and a substantial middle-class group. The poorest group struggles to make ends meet, and health care is usually low on the priority list while the richest group gives priority to health care and has full access to it. For the middle class, the situation is different. It does give some priority to health care, but at the same time is not able to fully access quality health care due to resource constraints. A low penetration of health insurance contributes to this phenomenon. This daily struggle to achieve their aspirations may lead to cynical hostility which coupled with incomplete knowledge of oral health care may translate to higher dental anxiety.
However, we cannot conclusively state that cynical hostility has a direct impact on dental anxiety. The probability of reverse causation, where the perceived symptoms (i.e., dental anxiety) generate cynical hostility, cannot be ruled out. The cross-sectional design also creates a potential bias as dental anxiety and hostility might be interdependently misclassified (i.e., that the way people answer the questions might be influenced by their current oral health status and vice versa). The self-reporting might also be influenced by personality traits.
The findings from this study pointed out the important role SES plays in mediating the relationship between cynical hostility and dental anxiety. It also indicated that the mediating effect is not uniform across socioeconomic strata. This leaves us with the possibility that in other societies with their own unique population structures and classes, the role of SES in the relation between cynical hostility and dental anxiety may vary.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Shashidhar Acharya
Department of Public Health Dentistry, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal - 576 104, Karnataka
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]