Influence of sociodemographic factors on parental perceptions of Saudi parents on oral health-related quality of life of children with autism spectrum disorder in Riyadh, Saudi Arabia: A cross-sectional study

Monika Saini; Yash Pal Singh; Tahseen Ali Khan; Mehnaaz Sultana Syeda; Hussain Zai Malak Khuthija Khanam; Mohammed Malik Afroz

doi:10.4103/jioh.jioh_228_22

ORIGINAL RESEARCH

Year : 2023 | Volume : 15 | Issue : 2 | Page : 206-211

Influence of sociodemographic factors on parental perceptions of Saudi parents on oral health-related quality of life of children with autism spectrum disorder in Riyadh, Saudi Arabia: A cross-sectional study

Monika Saini¹, Yash Pal Singh¹, Tahseen Ali Khan², Mehnaaz Sultana Syeda³, Hussain Zai Malak Khuthija Khanam⁴, Mohammed Malik Afroz²
¹ Department of Restorative and Prosthetic Dental Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, Saudi Arabia
² Department of Surgery and Diagnostic Sciences, College of Dentistry, Dar Al Uloom University, Riyadh, Saudi Arabia
³ Department of Dentistry, Central Security Hospital, Riyadh, Saudi Arabia
⁴ Department of Restorative and Prosthodontic, College of Dentistry, Dar Al Uloom University, Riyadh, Saudi Arabia

Date of Submission	28-Oct-2022
Date of Decision	08-Mar-2023
Date of Acceptance	10-Mar-2023
Date of Web Publication	28-Apr-2023

Correspondence Address:
Dr. Monika Saini
Department of Restorative and Prosthetic Dental Sciences, College of Dentistry, Dar Al Uloom University, Riyadh 13314
Saudi Arabia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jioh.jioh_228_22

Abstract

Aim: To assess the association of sociodemographic factors on parental perception of Saudi parents on oral health-related quality of life (OHRQoL) of their children with autism spectrum disorder (ASD). Materials and Methods: A cross-sectional study was conducted on 100 Saudi parents whose children with ASD were enrolled in special schools in Riyadh. Parents were asked to fill out two questionnaires consisting of their sociodemographic information and parental caregiver perception questionnaire. The results were then statistically analyzed by applying mean standard deviation with 95% of confidence interval, Pearson’s Chi-square test, and multinomial regression model with level of significance P < 0.05. Results: Sociodemographic factors, like age, education, and family income, affected various domains of parental perception of OHRQoL of their children with ASD. Age and education of the father are significantly associated with the oral symptom domain (P value = 0.002) and emotional well-being (EW) (P value = 0.032), respectively. Age and education of the mother are significantly associated with the oral symptom domain (P value 0.035) and EW (P value 0.040), respectively. Family income is significantly associated with the oral symptom domain (P value 0.000). Conclusion: There is a definite role of sociodemographic factors on parental perceptions of Saudi parents regarding OHRQoL of ASD children.

Keywords: Autism Spectrum Disorder, Caregiver, Healthcare Provider Education, Oral Health-Related Quality of Life, Parental Perception

How to cite this article:
Saini M, Singh YP, Ali Khan T, Syeda MS, Khuthija Khanam HZ, Afroz MM. Influence of sociodemographic factors on parental perceptions of Saudi parents on oral health-related quality of life of children with autism spectrum disorder in Riyadh, Saudi Arabia: A cross-sectional study. J Int Oral Health 2023;15:206-11

How to cite this URL:
Saini M, Singh YP, Ali Khan T, Syeda MS, Khuthija Khanam HZ, Afroz MM. Influence of sociodemographic factors on parental perceptions of Saudi parents on oral health-related quality of life of children with autism spectrum disorder in Riyadh, Saudi Arabia: A cross-sectional study. J Int Oral Health [serial online] 2023 [cited 2023 Jun 1];15:206-11. Available from: https://www.jioh.org/text.asp?2023/15/2/206/375367

Introduction

Oral health-related quality of life (OHRQoL) has been an area of significant concern and has become even more important for children, especially those with autism spectrum disorder (ASD).^[1] ASD has been classified as a developmental, neuropsychiatric disorder of early childhood and is mentioned in the diagnostic and statistical manual of mental disorders (EM-IV) under the section pervasive developmental disorders.^[2] There is a high prevalence of autism in Saudi Arabian families with a history of consanguinity.^[3],[4] The global prevalence of ASD is 1:160 people and its 1:167 in Saudi Arabia.^[5]

Children with increased oral health care needs are at greater risk of poor oral health than their peers without ASD.^[6] Quality of life in such children heavily depends on their primary caregivers, who happen to be their parents in most cases.^[7],[8] Parents act as proxies or judges and decision-makers of OHRQoL, hence playing a vital role in caring for and maintaining the oral health of their children with ASD. There is a marked emotional, social, and economic effect of ASD on the suffering families adding fatigue, stress, and anxiety to them.^{[9],[10],[11]}

Perception of parents for OHRQoL for their children with ASD is also influenced by the age and education of parents along with household income which appears to affect awareness and attitude towards oral health needs of their children with ASD.^[12],[13] It is hypothesized that there is a relation between sociodemographic factors and parental perception, but it may vary from country to country based on cultural differences. Still, further studies are required to explore whether there is any definite role of sociodemographic factors on the parental perception of mothers and especially fathers when it comes to the OHRQoL of their children with ASD in a country like Saudi Arabia. It can be used as an important predictor for the successful management of children with ASD by their parents as well as a tool in educating them by health care providers.

This study aims to assess the influence of sociodemographic factors on the parental perception of Saudi fathers and mothers on OHRQoL in their children with ASD in Riyadh city, Saudi Arabia and will enrich as well as add new insight to this less explored subject.

Materials and Methods

A cross-sectional study was done in the period starting from October 2021 to January 2022. Parents, who were all of the Saudi nationality and had different sociodemographic patterns, with children in the age group of 4–15 years suffering from ASD, were contacted by approaching special schools in Riyadh registered with the Ministry of Education in Saudi Arabia. Data stratification was done using age, education, and family income. Parents with age group interval 20–39, 40–59, and above 60 years, with education background less than high school, high school, university degree, and PG degree, and with family income less than 10k SAR (Saudi Arabian Riyal), 10–19k, 20–29k, and more than 30k SAR were enrolled for the study. Household income boundaries were determined using the household income and Expenditure Survey 2021. Education classes were made using Educational Statistics of the Ministry of Education, Saudi Arabia. Age groups were made using the General Authority of Statistics, Saudi Arabia. A cover letter explaining the purpose of the study and a questionnaire was given to principals of identified schools. Data provided by special schools were used to include only parents of children with childhood autism and intellectual disability (diagnosed based on records provided by the school).

The study was carried out in accordance with the ethical standards of Dar Al Uloom University, Scientific Research Ethical Committee/018-04-2023, Riyadh, Saudi Arabia, and according to the Declaration of Helsinki, as revised in the year 2000.

Sample size

Initially, a pilot study was done with 20 respondent parents, out of which 12 were fathers, and 8 were mothers of children with ASD. It was revealed from the pilot study that the expected proportion of parameters for the father and mother was 0.389 (38.9%) and 0.698 (69.8%), respectively. Therefore, on applying the given formula and the power of the sample as 80%, for Type-II error as (β) 20% and Type-I error (α) as 5% and 95% confidence interval (CI) with the ratio of father and mother 3:2, on using the given formula, the sample size for mother was found to be 38, and the total sample size was calculated to be 95. As approximately 10% nonresponse error was taken, 110 were kept as sample size, out of which 100 (father 60 and mother 40) responses were received.

Parents clearly explained the objective of the study and the nature of the questions that will be asked. Written informed consent was obtained from parents who agreed to participate in the study. They were assured of the full confidentiality of the data. Parents were asked to fill their responses in two questionnaires, namely sociodemographic distribution and standardized parental caregiver perception questionnaire (PCPQ), submitted to them in their local language, which is Arabic. The sociodemographic questionnaire consists of questions regarding age, educational background, and family income. PCPQ questionnaire is a translated version of the standardized one that has also been used in earlier studies. The primary caregiver, who is either father or the mother, was asked to fill out the questionnaire. All responses were recorded and evaluated statistically, as explained below in the statistical method. The principal investigator herself monitored the proceedings.

Method of assessment

The PCPQ was used to measure the parental perception scores for their children with ASD. There are 31 test items in the instrument, which are divided into four subscales, namely oral symptoms (OS), functional limitations, emotional well-being (EW), and social well-being. Only the frequency of events in the previous 3 months was measured in this instrument. Responses to the items were measured on a 4-point Likert-type scale ranging from 0 (does not bother my child) to 3 (bothers my child very much).^{[14],[15],[16]} The translate–retranslate technique was used to prepare an Arabic version of the questionnaire that was also earlier used in a previous study using the Arabic version of the PCPQ instrument.^[15],[16]

Statistical method

All the collected data were entered in MS excel and analyzed. The statistical software SPSS version 16.0 (SPSS Inc., Chicago, Illinois) was used for the statistical analysis of the data. The descriptive statistics mean standard deviation (SD) and 95% of CI of scores of four parameters and frequency (N), % frequency of responses was calculated. The significance of the association of sociodemographic factors with four parameters was tested by Pearson’s Chi-square test. The multinomial regression model was developed for OS and EW as dependent and age, along with the education of the mother and father as an independent variable. The level of significance was P < 0.05.

Results

Out of 110 eligible candidates, there were 10% drop out and only 100 potential candidates participated in the study. Refusal to take part in such study and cultural inhibition were the two main causes of dropout for candidates.

Mean PCPQ impact score values are higher for the OS domain as related to the age of fathers. On applying Pearson’s Chi-square test, the oral symptom was significantly associated with the age of the father, P = 0.002, P < 0.01. Mean PCPQ impact score values are higher for the EW domain as related to the education of the father, and EW is significantly associated with the education of the father, P = 0.032, P < 0.05 [Table 1].

Table 1: Frequency distribution N (%) and association of response for four parameters of respondents by their age and education of father, mother, and their family income

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Mean PCPQ impact score values are higher for the OS domain as related to the age of mothers. On applying Pearson’s Chi-square test, the oral symptom was significantly associated with the age of the mother, P = 0.035, P < 0.05. Mean PCPQ impact score values are higher for the EW domain as related to the education of the mother, and EW is significantly associated with the education of the mother, P = 0.040, P < 0.05 [Table 1].

Mean PCPQ impact score values are higher for the OS domain as related to family income and on applying Pearson Chi-square test, the oral symptom was significantly associated with family income P-value = 0.000, P < 0.05.

On multinomial regression for EW as dependent and education of mother and father as an independent variable, it was found that as the level of education increased from less than high school to a PG degree, the chances of getting more concerned with the EW of the ASD child increased in both mother and father. For example, the chances of response 0 (does not bother my child) were 4.006E7 times more in mothers with less than a high school education as compared to mothers with a PG degree. Similarly, the chances of response 0 (does not bother my child) were 12 times more in fathers with less than high school education as compared to fathers with a PG degree [Table 2].

Table 2: Multinomial regression for emotional well-being as dependent and education of mother and father as an independent variable; and oral symptoms as dependent and age of mother and father as an independent variable

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On multinomial regression for the OS domain as dependent and age of mother and father as an independent variable, it was found that as age increased, chances of getting more concerned with OS of the ASD child increased in both mother and father. For example, the chances of response 0 (does not bother my child) were 4.295E8 times more in mothers in 20–39 years of age as compared to mothers in 60 and above age group. Similarly, chances of response 0 (does not bother my child) were 1.988E9 times more in fathers in 20–39-year-age group as compared to fathers in 60 and above age group [Table 2].

On multinomial regression analysis for OS as dependent and family income as an independent variable, a negative correlation was found, and as family income increased, the chances of getting concerned with OS decreased [Table 3].

Table 3: Multinomial regression for oral symptoms as dependent and family income as an independent variable

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Discussion

PCPQ was used as an instrument to measure the parental perception response in this study. It is a reliable instrument that has been used in previous studies also to measure the parental perception of parents with children with ASD on their OHRQoL and its influence on the affected families.^{[9],[10],[14]} The instrument has been validated in other different languages apart from English.^[16],[17] It has been earlier established that parents are used as proxies and influence the OHRQoL of their children.^{[18],[19],[20],[21],[22],[23]}

Mothers are considered to be better proxies than fathers.^[23] But few studies report fathers are also getting more engaged in raising their children.^{[20],[21],[22]} Father and mother seem to agree on the group level as far as OHRQoL is concerned, but there is a difference in their opinion at the family level. The role of Fathers as proxies in Saudi Arabia cannot be more underlined and stressed, seeing parental, cultural, and religious preferences.^{[20],[21],[22]}

As can be seen from [Table 1], the age of the father is significantly correlated to the OS domain, and the education of fathers is significantly associated with the EW domain of their children with ASD. Seeing a significant association of OS with the age of the father, multinomial regression was done to establish regression correlation, and it was found out that fathers with age 60 and above are more concerned with the OS domain as compared with fathers of other age categories [Table 2]. Previous studies by Pani et al.^[9], Richa et al.^[10] and others could not establish any association between the age of the father and the oral symptom domain.

Multinomial regression analysis was done with the education of fathers and the EW of their ASD children because a significant association of both parameters was observed. [Table 2] shows a positive correlation between the education of fathers with the EW domain and fathers with PG degree education being more concerned with the EW of their ASD children. This can be attributed to a better understanding of the emotional aspect of issues related to ASD with the increase in their education level. None of the earlier studies reported an association between education of father and the EW domain. These findings also support that Saudi fathers also play a major role as caregivers to their ASD children, which is an important observation keeping in mind religious and cultural background in countries like Saudi Arabia.^{[20],[21],[22]}

[Table 1] shows a significant association of the age of mothers on the oral symptom domain of their ASD children, which was also shown in Pani et al.^[12] On multinomial regression analysis [Table 2], mothers with age 60 years and above were found to be more concerned with the OS of their ASD children as compared with other age categories. This finding has already been supported by earlier studies establishing mothers as better proxies.^[23]

It reflects a significant association of the education of mothers with the EW domain, as also supported by Pani et al.^[9] On applying multinomial regression analysis [Table 2], it was observed that mothers with a PG degree education were more concerned with the EW of their autistic children. This can be again explained better understanding of this domain due to a more advanced level of education.

[Table 1] demonstrates a significant association of family income with the OS domain, as also reported by Pani et al.^[9] and Cancio et al.^[14] Multinomial regression analysis [Table 3] shows that families within come of more than 30k SAR were able to better manage OS of their children as compared to families with less income.^[9],[13] This is supported by Fávero-Nunes et al.^[24] as OHRQoL of children with ASD improved with the increase in family income.

The limitation of the study was that it considered only a sample population in Riyadh, which is a metro city and its results may not be extrapolated to the entire of Saudi Arabia. Further studies were required to cover all major parts of Saudi Arabia to predict the attitude of parents toward their ASD children. Also, the results of the study cannot be generalized to the entire country due to the limited sample population.

The study reinforced the previous findings that the age and education of the mother, along with family income, undoubtedly influence understanding and better management of oral health quality of life of children with ASD. The role of the father in managing the oral health quality of life of children with ASD was established by this study, which becomes even more significant, especially in the context of the Saudi Arabian perspective. Healthcare providers can effectively use this information in better educating the parents about managing their children with ASD.

Conclusion

The study shows that there is a definite impact of sociodemographic factors PCPQ scores of parents and OHRQoL of their children with ASD. Age, education, and family income influenced the thought process of parents and their ability to take care of their affected children. The study also establishes that the role of both father and mother as proxies is important in the caregiving process in modern Saudi families. Knowledge of sociodemographic factors can help healthcare providers in developing a better education program for parents of ASD children.

Acknowledgement

This Project is supported by Deanship of Graduate Studies and Scientific Research at Dar Al Uloom University Riyadh. The author extends her appreciation to the Deanship of Post Graduate and Scientific Research at Dar Al Uloom University for supporting this work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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