Full Standard Health Interview Survey Form for Populations

Transcription

1 European Commission Health and Consumer Protection Directorate-General Community Action Programme on Health Monitoring Full Standard Health Interview Survey Form for Populations European Global Oral Health Indicators Development Programme II Work Package 6

2 European Commission Health and Consumer Protection Directorate-General Community Action Programme on Health Monitoring Health Surveillance in Europe European Global Oral Health Indicators Development Project Report from Phase II Work Package 6 Oral Health Indicators for Population Oral Health Interview Surveys: Guidelines A comprehensive instrument for the collection of oral health of population throughout all countries of the European Union September 2008 Pr Anna Rose Borutta Pr Denis Bourgeois Pr Lisa Bøge Christensen Pr Egita Senekola Dr Gail Topping Pr Eeva Widström

3 Contents 1. Background to the Project Guidelines for interviews on oral health Construction of the questionnaires Evaluating the concept of data collection by CATI system Recommendations and Conclusion Linguistic Validation Questionnaire Reduction of items Computer-assisted telephone interview (CATI) system r Other 3. Full standard providers interview questionnaire (revised post-evaluation edition) Full Standard Oral Health Interview Questionnaire for Adults.13 (revised post-evaluation edition) 3.2. Full Standard Oral Health Interview Questionnaire for Children. 17 (revised post-evaluation edition) 4. Proposed presentation of epidemiological information List of data summary tables Format of Tables References Acknowledgments 56 2

4 1. Background to the Project The present report is the final product of a working group, called Work-package 6, of the EGOHID project, Phase II entitled " Oral Health Interview Surveys: Guidelines". The task was conducted in continuation of work and reports of EGOHID Phase I and the first report of EGOHID Phase II. The present report has been produced by the leading partner supported by the associate partners of the group and the main partner of the EGOHID project The aim of this manual is: To provide a systematic approach to the collection and reporting of self-reported data on use of oral care, oral health behaviour, risk factors, oral health status and oral healthrelated quality of life. To ensure that data collected in EU membership states will be comparable across countries. To encourage health and oral health administrators in European countries to make standard measurements of self-reported use of oral care, oral health behaviour, risk factors, oral health status and oral health-related quality of life as basis for planning and evaluating of oral health programmes. In order to achieve these goals the manual includes a questionnaire for interview of adults and a questionnaire for interview of mothers of children or adolescents under 18 years of age in eight different language versions (Danish, English, Finnish, French, German, Polish, Spanish and Italian). Further, chapter 1 describes in short the background of the EGOHID project Phase I and Phase II. In addition, chapter 1 details scope and purpose of the project. Chapter 2 describes the proceedings of Work-package 6 (WP6) within Phase II of the project. The process of producing the questionnaires and questions is explained. The questions were constructed on basis of 40 selected essential oral health indicators for the oral health interview surveys presented in a report created in Phase I of the EGOHID project. Chapter 3 presents a pre-test report of results, conclusions, and recommendations issue from the evaluation. Chapter 4 present the English version of the questionnaires for adults and mothers of children under 18 years of age, and chapter 5 outline tables which can be produced from data collected using the questionnaires. The European project under the title "European Global Oral Health Indicators Development (EGOHID) has been developed under the European Community Directorate General for Health and Consumers (SANCO). The purpose of EGOHID was to provide indicators for measurement of oral health and use of oral health care among populations. This should be done by establishing priorities in coordination with already existing programmes in Europe, and to make new recommendations for oral health system performance when necessary. The scope and purpose of the first phase of EGOHID ( ) was to support the exchange of experiences among experts of oral health statistics and among political decision-makers. Another purpose was to make a list of essential oral health indicators on basis of a systematic review, and to establish a process to identify a core set of oral health indicators. Such set of indicators were meant to assist oral health professionals and decision-makers in promoting and improving the global oral health promotion, quality of care and surveillance of populations in Europe. The overall objectives of EGOHID were: 3

5 i. To support European Member States in their efforts to reduce the toll of morbidity and disability related to oral health diseases, and especially to strengthen the ability at local, national, and regional levels to measure, compare, and determine the effects of oral health services and use of resources on oral health. ii. To identify indicators of oral health - problems, determinants and risk factors related to lifestyle - of critical oral health care and of essential health resources. iii. To identify the types of data generation and management problems within the health information system. A catalogue was made containing 40 selected and recommended indicators for monitoring oral health of children and adolescents, oral health of the general population, the oral health systems, and for oral health related quality of life. The catalogue is entitled " A selection of essential oral health indicators recommended by European Global Oral Health Indicators Development Project". During phase II of EGOHID methodological criteria were set for collection of data. Oral health indicators were operationalized in order to obtain the overall objectives. Common oral health instruments were developed and promoted with the purpose to: 1. Promote systematic identification and technical specifications of oral health indicators. 2. Facilitate comparisons of indicator data by promoting standardization of methods. 3. Improve capacity of health services (at national, regional or local level) to monitor their oral health improvement activities in a standardized manner. 4. Facilitate, in the longer term, service specifications across health services with a view to improving performance. 5. Enhance the capacity to analyse the social, economic, behavioural and political determinants of oral health and oral health care with particular reference to poor and disadvantaged populations. The four sub-objectives of EGOHID II were to develop I. Common instruments for national health interview surveys (NHIS) II. Common instruments for national health clinical surveys (NHCS) III. A methodology for improved NHIS and NHCS data, routinely collected in 25 European countries at the primary oral health care level IV. Methods to adjust national data to allow cross national comparisons Via coordination by the main partner- University Lyon 1, Pr Denis Bourgeois, project leader) the project was broken down into several stages reflecting the task under each of the four subobjectives. 1) Harmonization of knowledge from EGOHID Phase I for the new European Union Member States. The purpose was to assist decision makers in promoting and improving the global oral health promotion, quality of care and surveillance of people in Europe, and to be operational in EGOHID phase II 2) Review and analysis of the global (Health and Oral Health) existing instrument resources for monitoring and control of oral health in Europe. 3) Development of a catalogue of common draft instruments including clinical survey forms, questionnaires, translation processes and fundamental methods guidelines for National Oral Health Interview Surveys, for National Oral Health Clinical Surveys, and for National Oral Health Provider Surveys 4

6 4) Development of a pre-test collaborative study of common instruments at a sub-national level for National Oral Health Interview Surveys, National Oral Health Clinical Surveys and National Oral Health Provider Surveys. 5

7 Table 1.1 Essential oral health indicators recommended by the European Global Oral Health Indicators Development Project. Indicators for monitoring the oral health of children and adolescents Daily brushing with fluoride toothpaste Preventive care seeking for pregnant women Mothers knowledge of fluoride toothpaste for child caries prevention Fluoride exposure rates Preventive oral health programmes in kindergartens Schools with based programmes centered on daily brushing with fluoride toothpaste Screening oral health programme coverage Protective sealants prevalence Orthodontic treatment coverage Early childhood caries Decay experience in 1st permanent molars in children Dental fluorosis Indicators for monitoring the oral health of the general population Daily intake of food and drink Tobacco usage prevalence Geographical access to oral health care Access to primary oral health services Dental contact within the previous twelve months Reason for the last visit to the dentist Reason for not visiting the dentist in the last two years Tobacco use cessation Untreated caries prevalence Periodontal health assessment Removable denture prevalence No obvious decay experience Dental caries severity Periodontal diseases severity Cancer of the oral cavity Functional occlusion prevalence Number of natural teeth present Edentulous prevalence Indicators for monitoring the oral health systems Cost of oral health services Gross national product spent on oral health care services Dentists and other oral care clinical providers Satisfaction with the quality of care given Satisfaction with remuneration provided Indicators for monitoring the oral health quality of life Oral disadvantage due to functional limitations Physical pain due to oral health status Psychological discomfort due to oral health status Psychological disability due to appearance of teeth of dentures Social disability due to oral health status : WP6 Oral Health Indicators for Population 6

8 2. Guidelines for interviews on oral health 2.1. Construction of the questionnaires During a two-day meeting in January 2007 the partners of WP6 discussed a methodological aspect of collection of data by means of oral health interview surveys. All participants of the meeting agreed that surveys were instrumental for surveillance. The goal of the project was to apply already existing knowledge and to establish sustainability in identification and modification of risk factors in each of the European countries. The aim was also to identify factors that could be changed by intervention. Consequently, a relatively low number of robust indicators/questions were needed. The group decided to construct two questionnaires to be used for telephone interviews: Full Standard Oral Health Interview Questionnaire for Adults and Full Standard Oral Health Interview Questionnaire for Children. In the light of this agreement the original list of indicators had to be streamlined and operationalized. Of the list of 40 original indicators we agreed to include a total of 22 indicators in our questionnaires. Concerning the socio-demographic/socio-cultural variables the group agreed on the following information to be mandatory:, gender, education and location. As for education it was agreed to construct the questions in line with questions used in Eurostat and in Eurobarometer studies. It was further emphasized that questions on education might be different for different groups involved. Additional information on family, marital status, household size, and ethnicity was debated. In particular, family situation should be considered as it is a modifiable variable, and this factor has relevance for further improvement of public health. It was agreed that income and main professional occupation were important and relevant variables, but it might cause some difficulties where making comparisons between nations. The Master questionnaires have been translated by native translators in the 7 following languages: - Danish - Finnish - French - Polish - German - Italian - Spanish - Each translation has been validated again by native scientists in oral health and the understanding has been tested by phone in 10 samples of subjects. A corrective action was done when it was necessary. The 7 translations children and Adults - will presented in the final report published in October For researchers developing and validating indicators measures in different countries, a consensus has emerged that three levels of cross-cultural equivalence must be achieved: (1) conceptual equivalence, (2) construct or item equivalence, (3) operational equivalence, Conceptual equivalence is the extent to which the items in the target languages (the 7 non- English speaking countries) are similar in meaning to the source version (the Master English Questionnaire). This form of equivalence includes both the semantic meaning and formulation of the items (e.g., wording of questions), as well as the underlying concept being assessed. This is achieved through both the translation process and the qualitative testing that follows. Construct or item equivalence is the extent to which individuals in different cultural groups respond to the same items in similar ways, which is evaluated with classical test theory (e.g. response distributions, test-retest reliability). Operational equivalence refers to the relative performance of the instrument using various modes of administration (e.g. self-report, interview). The purpose of the linguistic validation was to complete the first step of cross-cultural adaptation by developing conceptually equivalent German, Spanish, Italian, Finnish, Danish, Polish and French versions of the master English questionnaires Children and Adults-. The linguistic validation of a questionnaire should consist in at least 3 steps: - forward translation, (includes the production of a "reconciliation" version), - backward translation, - patient testing. The European survey has been implemented in 8 countries using the same validated master questionnaires. The master questionnaire in English version has been constructed in the frame of the EGOHID project with the goal to propose a panel of indicators in oral health 7

9 surveillance. The master questionnaire has been respectively validated by an expert panel composed by major European scientists in oral health participating to the EGOHID project. 2.2.Computer-assisted telephone interview (CATI) system For the present pilot study telephone interview was agreed upon as the method appropriate for data collection. Usually, the preferable method of data collection in health surveys is a personal or face to face interview. However, this type of data collection method is expensive and alternative methods needed to be identified. Telephone interviews are useful in Europe, as telephones are found in almost all households and conversations may be kept at low costs. Especially mobile phones are widespread in most European countries, though, it must be taken into consideration that telephone contact is often a rapid way of communication, which might lead to less complete information being given and more don t knows. Further, the response rate is dependant on the length of the questionnaire. Although telephone interviews in general imply higher response rate, this data collection method may be less suitable with respect to sensitive issues. Another disadvantage may be that persons 65 years or older may be overrepresented, because they are more likely to be at home and respond to telephone calls. While constructing questions based on 22 specifically chosen indicators the following issues were carefully taken into consideration. The questions should be as short and simple as possible and also clear and precise. The questions should have pre-coded answers with all possible responses included. The questions should be presented in a logical order. We also wanted to use instruments of proven validity and reliability. For each indicator the group discussed which method would be best in order to obtain the relevant information, and it was decided for which population groups the indicators were relevant. The participants of the meeting in January 2007 worked literally with the list of indicators in one hand and possibilities of answers in the other hand meaning indicator-parameter-specific answers. Having in mind that the information collected by these methods will be used by decision-makers to set goals and evaluate the outcome, the participants went through all indicators one by one and decided whether the information related to the indicator could be obtained by population interviews. Additionally, the focus was on the wording of the questions for each indicator, one by one in terms of efficiency, simplicity and time-consumption. The intention was to produce a Pre-test collaborative study of common instrument to facilitate the implementation and development of common instrument guidelines for use of Oral Health Interviews Providers and Populations in Europe into a form and language which will allow the specialist to readily understand the issues and the scientific reasoning that led to the global implementation. This questionnaire, constructed to assess oral care indicators in the adult population, was proposed to be administered by phoning to the general adult population. The operational objective of the study is to assess the phoning acceptability and the understandability of the proposed indicators to a sample of 100 adults per target country. The project was composed by the following tasks: - Validation of the master operational questionnaire - Development and production of evaluation questions - Linguistic validation of the two populations and providers questionnaires and evaluation questions in the 8 target languages: French, Spanish, English, German, Danish, Polish, Finnish and Italian. - Design and conduct pre-test surveys in relation to the development of common instrument guidelines for use of Oral Health Interviews Populations in Europe by telephone call 8

10 surveys including at least 100 subjects in 8 countries: France, Spain, UK, Germany, Denmark, Poland, Finland and Italy. - Design and conduct pre-test surveys in relation to the development of common instrument guidelines for use of Oral Health Interviews Providers Surveys in Europe by telephone call surveys targeting 100 subjects in 8 countries: France, Spain, UK, Germany, Denmark, Poland, Finland and Italy. - The data entry of survey questionnaires and the evaluation of the questionnaires - The statistical analyses - The preparation of a technical report Adult population screening The adult population has been selected according to two criteria, gender, and age, on line with general population published data. The Survey applied the quotas method based upon the Bayesian model. Quota sampling is the non-probability equivalent of stratified sampling. Like stratified sampling, the researcher first identifies the stratums and their proportions as they are represented in the population. Then, convenience or judgment sampling is used to select the required number of subjects from each stratum. This differs from stratified sampling, where the stratums are filled by random sampling. Quota sampling is one of the more rigorous nonprobability sampling methods, which attempts to ensure representativeness by sampling individuals from known groups in the population or groups of interest to the survey design. Adult population was eligible for inclusion if all of the following criteria were fulfilled: Minimum age : 20 years. Willingness and ability to comply with the questionnaire for the duration of the interview. Children population screening The population of the study is constituted by housewives having at least 1 child under 18 years at home. The simple random sampling, without delivery, leaned on the basis of homes by telephone. The inclusions procedure of a child consisted in obtaining by telephone the mother of the children, then to ask him for the composition of the sibship. The pollster made an unpredictable sorting among the children from 0 to Recommendations and Conclusion Linguistic Validation The language versions - Danish - Finnish - French - Polish - German - Italian - Spanish - obtained are conceptually equivalent to the original instrument been developed in English and to one another. The consistent international interpretation and analysis of results is so possible then the data are from one instrument. Cross-cultural translations into nine other languages make it feasible to use the EGOHID A 29-C 33 (version 1.1) in multinational European surveillance project after validation in each population or concurrent with the surveillance project However, in order for an instrument to be used in international studies, it is validated that it addresses the same concepts in all languages developed in this project and so to make it possible to pool data and compare results across countries They are culturally relevant and acceptable to the target population within each target country compared to the good acceptability and the understanding of the wording and the understanding of the sense In general, the 7 translations of the EGOHID Questionnaire Adults and Children/Adolescents had similar psychometric properties to those reported in the validation 9

11 study for the original US English version of the EGOHID Questionnaire Adults and Children. Statistical evaluation of the properties of the target language versions is positive. We have tested the translated scales on subjects seen in 8 countries, Europe. Although we do not anticipate that responses from subjects in the rest of Europe would vary systematically from ours, we do note that generalizing the rest of the UE population requires further study. It is also important to note the high sample size used in the test-retest phase of the validation Questionnaire The various phases of the development of the specific oral health EGOHID A-C questionnaire concerning children, succeeded in selecting 33 questions grouped together in eight dimensions. The grouping of the questions made according to their contents, has been confirmed by psychometric analyses. It's the same for the adults EGOHID A questionnaire composed of 29 questions grouped together in five dimensions. It was concluded that the EGOHIDQ (UK English version) has sufficiently acceptable evaluative and discriminatory properties in European subjects and is therefore a valid instrument for oral health interview surveys measurements in surveillance studies in oral health in European - adults and children. The general understanding is satisfactory from the point of view of the interviewee and the interviewer. The gold standard retained was of at least 90 % of positive answers in every country. Time factor: acceptability of the adults to answer in consideration of the time that takes the interview and that whatever is the country-. Our results support the reliability and validity of the EGOHID Questionnaire Adults and Children /Adolescents (English version 1.0 and others language versions) as a measure instrument of oral health indicators in Europe. With some minor revision in the children one, these questionnaires promise to provide useful oral health data from subjects in surveillance network. They have a good reproducibility - except for eating and drinking items -with no changes in scores in subjects whose condition remained stable, and also high intra-class correlation coefficients for the total and domain-wise scores in these subjects. EGOHIDQ scores confirming the longitudinal construct validity. The Danish - Finnish - French - Polish - German - Italian Spanish English - version of the questionnaire is correct, reliable, easily understandable and readily available for use to appropriate subjects. The pilot testing has revealed a good internal consistency of the module. It was concluded that the EGOHIDQ (UK English version) has sufficiently acceptable evaluative and discriminatory properties in European subjects and is therefore a valid instrument for quality of life measurements in surveillance studies in oral health in European adults and children/adolescents. The choice of Oral Health and Quality of Life items (Section 8 Children and Section 5 Adults), in connection with the aim of the measure, have been completed by a study of fidelity and of validity, according to several axes (validity of contents, validity of structure). They are considered as accepted and recognized, the metrological properties having been verified on the samples of the subjects subjected to the questionnaire. The adopted strategy by the group of experts of EGOHID was to privilege the homogeneity of the questions in their dimension and their discriminating power. It allowed to find a compromise between the length of the questionnaire and the information which it brought. The chosen questions are doubtless the best ones from a psychometric point of view to discriminate the subjects. On the other hand, this fact does not mean that the totality of the proposed questions present a descriptive interest. The psychometric properties of the questionnaire turned out satisfactory (clinical validity, internal reliability and reproducibility). In order to be exhaustive, a last property remains to inform its sensibility in time 10

12 Reduction of Items In its global nature, the questionnaires in initial version V1, do not require a reduction of the number of questions and the writing of its questions. However, the shortening of established oral health-related attitudes and risk factors instruments should be considered in order to reduce the burden of having mothers and adults to answer lengthy questionnaires It is more particularly the questions of section 4 Attitudes and risk factors How many eating/drinking occasions does he (she) have per day even in small quantities? How often do you eat or drink any of the following foods, even in small quantities and tobacco habits of the Children questionnaire and the questions of section 3 Risks factors of the adults questionnaire. The 8 questions identified in Q14 Adults and Q18 Children/Adolescents - How often do you eat or drink any of the following foods, even in small quantities? - must be reduced to 5 maximum alternatives in order to improve the feasibility of the phoning interview: the reproducibility rate is low, the number of answering items is not adequate and a matrix question with 7 sub question in lines and 7 answering items is not manageable by phone. Further to their abstract analyses contained in every axis - the factorial analysis realized on 14 questions of section 3: Risk factors habits retained 3 axes after rotation explaining 82 % of the variance - brings us to recommend a final grouping of the questions in representative dimensions and by grouping the questions which bring an information common to a particular domain of the risk factors, for example the consumption of alcohol, tobacco and food taking". The 3 questions Q16 - Do you use any others types of tobacco than cigarettes? -, Q17 - Please what kind of other types of tobacco do you use?-, and Q18 - How often do you use any of the following types of tobacco? - relative to tobacco consumption should be eliminated because of their weak descriptive power. They do not bring appropriate discriminant information with regards to the question Q15. Do you smoke cigarettes every day, some days, or not at all?. The 8 scores of the profile Q14 Adults, Q18 Children/Adolescents - How often does your child or adolescent eat or drink any of the following food, even in small quantities between theirs main meals (Several times, Not sure) give evidence of the multidimensional aspect of attitudes and risk factors. However, their exploitation even if it is richer, is more complex and heavier, which limits their use in a common practice. On these questions for all the people that have participated in the test - retest, 64 differences were noted. It brings to doubt about the reliability of the answers. The analysis of the answers to the test - retest shows clearly that scales of Likert possessing more than five modalities are not adapted to the passage of the questionnaire by phoning. That is why, a maximum number of 5 scores should be considered. And besides the profile of these scores, a gold standard should be predefined and\or a global score should be calculated. The questionnaire would express itself under the shape of a profile of 7 scores and of an index (global score), as it is the case for certain instruments Computer-assisted telephone interview (CATI) system Computer-assisted telephone interview in this study yields higher participation rates (52%) and so, can be considered to be appropriate to this general population than others methods. It was found that actual time spent interviewing was about half of the total time devoted to conducting the interviews. The mean time of the interview is around 6 minutes. Computer-assisted telephone interview is recommended as a suitable and efficient method for EGOHID data collection in oral health surveillance programmes adults and children/adolescents -. The telephone survey yielded a higher response rate in EGOHID. There was some evidence of non response via the telephone survey, and some relatively minor differences in responses were found between the countries, but there was no conclusive evidence that the response differences resulted from cultural effects. Regarding the processing of the sampling pools in those eight countries, United Kingdom, Finland and Poland, children had a lower efficiency rate but a satisfactory completion rate and that, in an extremely positive general answer situation. For children, it is clear that a more productive approach is necessary 11

13 for data collection in order to reduce manpower needs, lower costs and speed up the process of data collection. It is recommended to identify 3 different questionnaires according to the concerned age groups and the targeted items: children from 0 to 6 years old; 6-12 years, years. It would besides allow a faster achievement of the interview target, a better navigation between various modules and sections of the questionnaire Others Identification of data base allowing to identify the variables of stratification of the quota according to the age and the sex. We can think of the identification of the relevant and practicable urban / rural concept from existing data bases. The computing grid of the questionnaire has to contain controls of integrity. The rate of missing data is very low (1.6%). Use of this pre-inquiry concerning a sample of 100 individuals to determine the optimal size of the necessary sample to produce the gold standard indicators with the precision and the risk wanted. A computerized data capture tool is an efficient way to reduce the number of data entry errors: This feasibility study use Excel for its wide availability and software specialized in file management such as Access could also be appropriate. The final conclusions and recommendations of the report were as follows. Computer assisted telephone interview (CATI system) was found to be a suitable and efficient method for EGOHID data collection in oral health surveillance programmes. The average time used for the interviews was 6 minutes. In the linguistic validation a test/re-test was made for each translation procedure and it was found that the translations were successful, and the translated questions addressed the same concepts in all languages. Furthermore, it was possible to pool data and compare the results across countries. The questions were found to be acceptable in all countries involved. A good understanding of the wordings was reported. It could be concluded that the English versions of the questionnaires have sufficiently acceptable evaluative and discriminary properties, and the questionnaires are therefore considered to be valid instruments for oral health surveys measurements in Europe. The general understanding was satisfactory from the point of view of the interviewed persons and the interviewer. The retained gold standard was not less than 90% of positive answers in every country. The same positive acceptability was reported when answering the questions regarding the time taken for the interview. A high validity and a high level of reliability support the value of these measure instruments of oral health indicators in Europe. Some minor revisions were suggested as for the questionnaire for mothers of children and adolescents. Such revisions have been taken into consideration in the final version of the questionnaires. 3. Full Standard Oral Health Interview Questionnaire Full Standard Oral Health Interview Questionnaire for Adults (revised postevaluation edition) Full Standard Oral Health Interview Questionnaire for Children (revised postevaluation edition) 12

14 4. Proposed presentation of epidemiological information The purpose of the exercise was to collect data to enable the evaluation of items from the list of essential oral health indicators. In order to satisfy the requirements of the relevant indicators, some of the data collected during the interview requires a level of processing / summarisation, before being ready for transcription to data tables. The partners of WP6, WP7, and WP8 have agreed a model for descriptive tables based on the pilot studies. These tables can be produced from data collected during surveys of European populations; the full standard providers interview survey in the case of WP8. On the pages following, the layout of these tables is presented. Individual tables correspond to the individual oral health indicators as listed in table 1.1. The numbers of the indicators refer to their catalogue classification (European Commission 2005). In the following pages the models of tables are presented. Each table corresponds to a specific question of the questionnaires, and each table refers to the specific selected essential oral health indicator. Question number and indicator number are indicated. All the tables are constructed in a standardized way including almost the same set of independent variables. All tables for children and adolescents, it should be clear that the independent variables education and occupation are about mother's education and mother's occupation. The demographic and sociological variables according to the standards of Eurobarometer and Eurostat are defined as follows: Education has four categories:, 16 20,, * (* when finished full time education ) Occupation:,,, Type of Locality: Metropolitan zone, Other town/urban centre, zone Region = "European Administrative Regional Unit" (N.U.T.S.). From 1 January 2007, regions in the two newest Member States, Bulgaria and Romania, are included in the classification. The first three-yearly review of NUTS for the EU-25, under the NUTS Regulation, was carried out in 2006 and has been put into effect from 1 January The regulation amending the NUTS for the EU-25 has been published in the Official Journal. Tables allow for stratification of the result set according to various factors including age, sex, occupation, etc List of data summary tables ADULTS USE OF ORAL HEALTH CARE SERVICES Table 1. Proportion of population aged 18 years and over who claimed to have seen a dentist within the past 12 months. Table 2. Proportion of population aged 18 years and over visiting a dentist for the last visit for a check-up, routine treatment or emergence treatment. Table 3 Proportion of population aged 18 years and over who did not visit a dentist during the previous 24 months for reasons of costs, fear, giving low priority to dental visits, for dentist related factors or patient related factors. Table 4 Proportion of population aged 18 years and over who has access to a dentist within30 minutes travel either from home or from work place. 22

15 ATTITUDES AND RISK FACTORS Table 5 Proportion of people aged years and older who claim frequency of daily intake of food and drink Table 6 Proportion of adults aged years and older who are using tobacco at a point in time. ORAL HEALTH STATUS Table 7 Proportion of adults aged 18 years and over with 20 teeth or more natural teeth in functional occlusion. Table 8 Proportion of the population aged 20 years or more who claim to wear removable dentures ORAL HEALTH RELATED QUALITY OF LIFE Table 9 Proportion of the subjects aged years or older who has experienced difficulties in eating and/ or chewing because of problems with mouth, teeth or dentures in the past 12 months Table 10 Proportion of the subjects aged years or older who has perceived pain or discomfort because of teeth, mouth or dentures in the past 12 months. Table 11 Proportion of the subjects aged years or older who has felt tense because of problems with teeth, mouth or dentures in the past 12 months. Table 12 Proportion of adult population aged years or older who has felt psychological disability because of the appearance of teeth or dentures in the past 12 months Table 13 Proportion of subjects aged years or older who has perceived difficulties in doing their normal daily work because of acute or chronic oral problems in the past 12 months. MOTHERS OF CHILDREN AND ADOLESCENTS CHILDREN S ORAL HEALTH CARE HABITS Table 14 Proportion of daily toothbrushing with fluoride toothpaste in children and adolescents aged 3-17 years. Proportion of daily exposed to fluoride contained in water, salt, toothpastes or other in children in children and adolescents aged years. COMMUNITY PROGRAMMES Table 15 Proportion of children aged 3-6 and 7-12 years, adolescents aged years who participate in an oral health preventive programme in kindergarten or schools Proportion of schoolchildren 5-6 and 7-12 years, adolescents aged years involved in daily tooth brushing exercises with fluoride containing toothpaste. Table 16 Proportion of children and adolescents aged 3-17 examined at least once in the last 12 months for the early detection of non-symptomatic disease covered by a screening programme. ATTITUDES AND RISKS Table 17 Proportion of children and adolescents aged 5-17 years with low, medium or high risk for dental disease based on frequency of daily intake of food and drink Table 18 Proportion of adolescents aged years who are using tobacco at a point in time. 23

16 MOTHER'S KNOWLEDGE Table 19 Proportion of mothers with children less than 7 years age old who know the role that the usage of fluoride containing toothpaste daily is in preventing tooth decay in children. REGULAR USE OF DENTAL CARE Table 20 Proportion of children and adolescents aged 2-17 years who visited a dentist within the past 12 months. Table 21 Proportion of children and adolescents aged 2-17 years visiting a dentist for the last visit for check-up, routine treatment, or emergence treatment. Table 22 Proportion of children and adolescents aged 5 to 17 years who did not visit the dentist in the last 2 years for reasons regarding costs, fear, giving low priority to dental visits, for dentist related factors or patient related factors. Table 23 Proportion of children and adolescents aged 5-17-years who claim to wear an orthodontic appliance. PREVENTIVE CARE-SEEKING FOR PREGNANT WOMEN Table 24 Proportion of women aged years who had a preventive dental visit during their last pregnancy ORAL HEALTH RELATED QUALITY OF LIFE Table 25 Proportion of children and adolescents aged 8-17 years who have experienced difficulties in eating and/ or chewing because of problems with mouth or teeth in the past 12 months. Table 26 Proportion of children and adolescents aged 8 17 years who have perceived pain or discomfort because of teeth or mouth in the past 12 months Table 27 Proportion of children and adolescents aged 8-17 years who has felt tense because of problems with teeth or mouth in the past 12 months. Table 28 Proportion of children and adolescents aged 8-17 years who has felt embarrassed because of the appearance of teeth in the past 12 months. Table 29 Proportion of children and adolescents aged 8-17 years who has experienced difficulties carrying out schoolwork because of problems with mouth or teeth. 24

17 4.2. Format of Tables ADULTS USE OF ORAL HEALTH CARE SERVICES Table 1. B.5. Dental Contact within the Previous Twelve Months. Proportion of population aged 18 or over who claimed to have seen a dentist within the past 12 months Provides an indication of the service usage within a population and has value in helping in the development of appropriate care arrangements Q7. When did you last visit a dentist about your teeth, dentures or gums? Total Within the past 12 months Not seen a dentist DK/NA & + Education Occupation Dental Status 20 teeth or more Less than 20 teeth No natural teeth 25

18 Table 2 B.6. Reason for the Last Visit to the Dentist. Proportion of population aged 18 and over visiting a dentist for the last visit for check-up, routine treatment, or emergence treatment Provides an indication of the attitudes and beliefs of the population and has value in helping in the development of appropriate care arrangements and assist in identifying disadvantaged groups and will contribute to the performance of oral health policy development. Q9. What was the reason for the last visit to the dentist? & + Education Occupation Dental Status 20 teeth or more Less than 20 teeth No natural teeth Last Dental Contact < 1 year 1 year & + Total Check-up Routine Treatment Emergency Treatment DK/NA 26

19 Table 3 B7. Reason for not Visiting the Dentist in the last Two Years Proportion of population aged 18 and over who did not visit a dentist during the previous 24 months for reasons of costs, fear, giving low priority to dental visits, for dentist related factors or patient related factors* Providing equitable access and use of health care services in relation to need as well as identifying unmet needs, regardless of the type of insurance and social class of families, should be a priority for oral health care systems. Q10. What was the main reason you did not visit a dentist in the last two years? Total Cost Fear Low Priority Poor Access Dentist related Factors Patient related Factors DK/NA & + Education Occupation Dental Status 20 teeth or more Less than 20 teeth No natural teeth Comments * Cost (1, 2) ** Fear (3, 4) *** Low Priority (5, 6, 7, 8, 10) **** Dentist related Factors (9, 11, 12, 14) ***** Patient related Factors (1, 9, 12, 13, 14) ****** Patient related Factors (2,3,4,5,6,7,8,10,11) The numbers in parenthesis refer to the following answers in the questionnaires: 1. Dental costs related reason 2. Does not want to spend money on dental care 27

20 3. Afraid or does not like dentists 4. Poor experience with previous dental care 5. Too busy 6. Nothing wrong 7. Dental problem not serious enough 8. Expected dental problems to go away 9. Dental office too far away 10. Have no teeth or have false teeth 11. Physical problems prevent me from going 12. The dentist refused to give me an appointment 13. The dentist could not give me a convenient appointment 14. Opening times not convenient 28

21 Table 4 B3 Geographic Access to Oral Health Care Proportion of population aged 18 and over who has access to a dentist within 30 minutes travel either from home or from work place Geographical variations of human resources for health can have a critical impact in terms of equity of access to health services, source of social injustice. Q11. Would it be possible for you to see a dentist when needed within a distance of 30 minutes travel either from home or work place? & + Education Occupation Usually access to a dentist s office or clinic Yes No Total Yes No DK/NA 29

22 ATTITUDES AND RISK FACTORS Table 5 B.1. Daily Intake of Food and Drink Proportion of people aged years and older who claim frequency of daily intake of food and drink. Oral health and nutrition have a synergistic relationship. Dental diseases related to diet include dental caries, developmental defects of enamel, dental erosion and periodontal disease. Population can benefit from diet analysis and modification. Q 13. How often do you eat or drink any of the following foods, even in small quantities? Total Low Risk <5 Medium risk 5-10 High risk >10 DK/NA & + Education Occupation 30

23 Table 6 B2. Tobacco Usage Prevalence Proportion of adults aged years and older who are using tobacco at a point in time. Based on evidence of effectiveness, surveillance systems and programmes of evaluation are important to support the role of the dentist in assisting dental patients interested in tobacco cessation. Q 14. Do you smoke cigarettes every day, some days, or not at all? and: Q 15. Do you use any others types of tobacco than cigarettes every day, some days, or not at all? Total No smoker Occasional smoker Daily smoker DK/NA & + Education Occupation 31

24 ORAL HEALTH STATUS Table 7 B16. Functional Occlusion Prevalence Proportion of adults aged 18 years and over with 20 teeth or more natural teeth in functional occlusion. Gives a broader perspective than indicators measuring the presence or absence of all teeth. It is an indicator to evaluate the progressive impact of preventive program to reduce the incidence and the severity of dental caries. Beside aesthetic consideration, it is a tool for planning current and future prosthetic needs for adults. Q16. How many of your permanent natural teeth do you have? & + Education Occupation Total 20 teeth or more Less than 20 teeth No natural teeth DK/NA 32

25 Table 8 B.11. Removable Denture Prevalence Proportion of the population aged 20 years or more who claim to wear removable dentures Provide information of the oral health status and needs of adult and of elderly populations in Europe, assist decision makers to reduce inequality in identifying disadvantaged groups, and to contribute to oral health policy development and increase the performance of oral health care services to assist people to maintain their functional well being in this changing environment. Q17. Do you wear any removable denture? & + Education Occupation Fonctionnal Occlusion Prevalence 20 teeth or more Less than 20 teeth No natural teeth Total Yes No DK/NA 33

26 QUALITY OF LIFE Table 9 D1. Oral Disadvantage due to Functional Limitation Proportion of the subjects aged years or older who has experienced difficulties in eating and/ or chewing because of problems with mouth, teeth or dentures in the past 12 months Whereas the subjective measure of functional limitation will be captured by the following variable described in this section of the catalogue, perceived pain or discomfort because of teeth, mouth or dentures this variable is measuring the objective dimension of the functional limitation. Both variables should be considered for a better understanding of the problem and for the evaluation of the outcome dimension of a given oral care system. Q. 19. How often have you experienced difficulties with eating food due to mouth and teeth problems? Total Never Hardly ever Occasionally Fairly often Very often DK/NA & + Education Occupation Dental Status 20 teeth or more Less than 20 teeth No natural teeth Theses questions may give additional information. 1) Avoiding smiling/laughing because of the appearance of teeth (or dentures) (Question 23), 2) Avoiding conversation because of the appearance of teeth (or dentures) (Question 24), 3) Reduced participation in social activities because of the appearance of teeth (or dentures) (Question 26). 34

27 Table 10 D2. Physical Pain due to Oral Health Status Proportion of the subjects aged years or older who has perceived pain or discomfort because of teeth, mouth or dentures in the past 12 months. Improve the proportion of European with oral illness who reports a satisfactory level of oral health-related quality of life and to measure the perceived (subjective) pain or discomfort because of teeth, mouth or dentures 20. How often have you experienced toothache/painful gums/sore spots? Total Never Hardly ever Occasionally Fairly often Very often DK/NA & + Education Occupation Dental Status 20 teeth or more Less than 20 teeth No natural teeth 35

28 Table 11 D3. Psychological Discomfort due to Oral Health Status Proportion of the subjects aged years or older who has felt tense because of problems with teeth, mouth or dentures in the past 12 months. Compare the effect of problems with teeth, mouth or denture on psychological discomfort in different populations (groups) in Europe, to explore changes in psychological discomfort in clinical follow-up studies and evaluative studies 21. How often have you felt tense because of teeth, mouth [or dentures] problems? Total Never Hardly ever Occasionally Fairly often Very often DK/NA & + Education Occupation Dental Status 20 teeth or more Less than 20 teeth No natural teeth 36

29 Table 12 D4. Psychological Disability due to Appearance of Teeth or Dentures Proportion of adult population aged years or older who has felt psychological disability because of the appearance of teeth or dentures in the past 12 months Compare the effect of problems with teeth, mouth or denture on psychological disability in different populations (groups) in Europe. 22. How often have you felt embarrassed because of the appearance of your teeth [or dentures]? Total Never Hardly ever Occasionally Fairly often Very often DK/NA & + Education Occupation Dental Status 20 teeth or more Less than 20 teeth No natural teeth 37