Introduction

The oral health concept has evolved from focusing only on the biomedical model to the comprehensive psychosocial approach, which considers the oral health significant role in individual daily life interaction and communication1.

Oral health conditions may have a major effect on people’s role function and social life; it can contribute to adverse psychological outcomes, affecting the quality of life (QOL) and personal productivity. Those impacts of dental health on individual well-being and overall quality of life are known as Oral Health-Related Quality of Life (OHRQoL). OHRQoL is a multidimensional concept that reflects the impact of oral health on an individual’s overall well-being and daily functioning. It encompasses the various ways in which oral health conditions affect physical, psychological, and social aspects of life. Key dimensions of OHRQoL include oral function, referring to the inability to perform certain tasks related to oral health; orofacial pain, referring to discomfort or pain in the mouth and facial areas; orofacial appearance which involves the feeling of uncomfortable about the appearance of teeth, mouth, dentures, or jaw, and psychosocial impact, highlighting how oral health problems can lead to overall dissatisfaction and a feeling of disadvantage2.

The effects of socioeconomic and clinical factors on the OHRQoL are well-known and covered by numerous previous literature3,4,5. However, they are not adequate to address a multidimensional concept such as OHRQoL. Thus, the role of psychosocial factors in determining OHRQoL is gaining interest6.

Regardless of the reasons for migration, moving to a new country is a major life event that a person may encounter. Challenges such as separation from family members and friends, reduction in the number of social networks to rely on, and language and cultural barriers can lead to isolation, neglection of personal health, and adoption of bad habits, which negatively impact their physical, emotional, and social wellbeing consequently their quality of life7.

Even though oral health problems are seldom can be life-threatening, they prove to be a significant public health issue due to their prevalence and effects on self-confidence, social life, school performance, and work productivity, all of which impact people's quality of life8,9.

Psychosocial factors such as a sense of coherence and social support people receive from their friends and families, or the surrounding community have produced effective coping abilities. People with a SOC are more into adopting favorable behaviors that could lower the severity of illness or enhance well-being. Moreover, it may reduce or protect from the negative psychological impacts of exposure to stressful events, such as migration7,10,11.

According to the Yemen embassy in Malaysia, more than 13,000 Yemeni immigrants live in Malaysia. With the increasing number of Yemeni people residing in Malaysia, identifying the association between these psychosocial determinants and OHRQoL is crucial, especially in a multicultural country such as Malaysia. These determinants could introduce new future oral health promotion programs that concern people's psychological and social needs since the exclusively clinical interventions do not address patient concerns and experiences may not be as effective as they should be. Additionally, psychosocial factors might be confounding factors between clinical status and OHRQoL, so they should be considered when utilizing patient-reported outcomes in oral healthcare evaluations. Hence, the study's main aim is to investigate OHRQoL and determine its association with SOC and perceived social support among Yemeni immigrants in Malaysia.

Methodology

This is a cross-sectional study based on primary data collected between January and April 2021 by a self-administered questionnaire in a Google form using convenience sampling. In order to reach the target number of the sample, the distribution of the questionnaire was not restricted to a particular area or state. However, the focus was on areas known to have many Yemeni communities, such as Kuala Lumpur and Selangor. The study population comprised adult Yemeni immigrants ≥ 18 years of age residing in Malaysia for one year or more and we excluded those less than 18 years old and those residing in Malaysia for less than one year. One year is an adequate period for the newcomers to have a clear idea about Malaysia's health system and its services and resources. Moreover, a normal healthy person must have visited the dentist at least once for preventive measures within one year. Also, within a year, people can establish a social network and integrate with the community around them.

A single proportion formula was used to estimate the required sample size, with a 95% confidence interval, a marginal error of 5%, and the prevalence of negative impact of OHRQoL of 0.1412. As a result, a minimum of 185 subjects were needed. However, 20% more was added to account for the non-response rate, so the total sample size needed was 225.

The study tool consists of five main parts; section one comprised seven questions about the socio-demographic characteristics and the economic status of the respondents (gender, age, marital status, education level, occupation, income, years of staying in Malaysia).

Section two includes questions regarding participants’ oral health behaviors (frequency of teeth brushing, last dental visit, reasons for the last dental visit and perceived oral health status).

Section three includes the participants' oral health-related quality of life (OHRQoL), using 14 items known as the oral health impact profile-14 (OHIP-14). Oral Health Impact profile-14 is a shorter version of a 49-question version (OHIP-49) developed by Slade in the 1990s13. The questionnaire is one of the most widely used instruments to measure the negative impact of oral problems on functional and psychosocial aspects of daily life routines12. OHIP-14 consists of seven domains of impact based on Locker’s model of oral health, namely functional limitation (e.g., trouble pronouncing words), physical pain (e.g., painful aching), psychological discomfort (e.g., self-conscious), physical disability (e.g., interrupted meals), psychological disability (e.g., embarrassment), social disability (e.g., irritable with other people), and handicap (e.g., unable to function). However, according to a recently published recommendation for the use of OHIP, we kept only four domains, namely physical disability, physical pain, psychological discomfort, and handicap. These 4 domains are labeled as oral function, orofacial pain, orofacial appearance, and psychosocial impact, respectively2. A five-point Likert scale was used to record the responses “0, never; 1, hardly ever; 2, occasionally; 3, fairly often; 4, very often”2. For the purpose of bivariate analysis, the OHIP total score was dichotomized around the mean score or median score (according to the normality of data) to yield a “negative impact” for scores equal or higher than the mean/median score and “no negative impact” for scores lower than the mean/median (references). Since the OHIP score was not normally distributed, we consider the median score (median = 3) to categorize the OHIP into negative impact (≥ 3) and no negative impact (< 3)14,15.

An Arabic-validated version of the questionnaire was used for this study16.

Section four is the participant’s perceived social support which was measured by the multidimensional scale of perceived social support (MSPSS)17. MSPSS is a widely used, brief self-report instrument. It is easy to use with a simple scoring system. It consists of 3 subscales to subjectively assess the three sources of social support (family, friends, and significant other)17. The scale consists of 12 items, with 4 items in each subscale, the participant’s responses were recorded using a 7-point Likert scale from 1 very strongly disagree to 7 very strongly agree. To obtain the final score, firstly, all the 12 items were summed, and the overall score ranged from (12–84), the higher scores indicating higher perceived social support. Then the total score was categorized into three groups; low perceived social support (12–35), moderate perceived social support (36–60); and high social support (61–84)17. A previously validated Arabic version of the scale was used in this study18.

Section five is the last part of the questionnaire consists of a standard scale developed by Antonovsky to assess the participant’s sense of coherence known as Sense of Coherence-13 (SOC-13) or Orientation to Life Questionnaire19. It consists of three domains (comprehensibility, manageability, and meaningfulness) and a total of 13 statements. Participant’s responses were recorded using a 7-Likert scale ranging from (1 = never to 7 always). The final score was obtained by summing all the responses of the 13 items. Total scores range from 13 to 91. Items 1, 2, 3, 7, and 10 are reverse scored. Then, the median is used as a cut-off point to categorize the total score into two categories; weak if the total score value is lower than the median or strong if the value is equal to or greater than the median20,21. The SOC-13 scale is a reliable cross-culturally applicable instrument that has been translated into at least 33 languages22. The Arabic-validated version of this scale was used in this study.

A pretest study

A pretest of the study tool was conducted on 10% of the studied population to evaluate the clarity, applicability, and time needed to fill in the research questionnaires.

During the pretest, the participants were given questionnaires with the informed consent form. The Participants were also assured that their privacy and anonymity would be respected, and they were given instructions on how to fill out the questionnaire and encouraged to ask any questions that needed further explanation. According to participants’ feedback, the questionnaire was clear, and they were able to fill it up within 10–15 min.

Data analysis

The frequency and percentage of categorical variables such as socio-demographic characteristics, perceived social support, and the presence or absence of impact on quality of life were determined using descriptive statistical analysis. Means, median and standard deviations were also used to describe the SOC and to determine its cut-off point. Simple binary logistic regression analysis was conducted first to determine any association between the independent variables and outcome. A p-value < 0.05 and 95% confidence interval (CI) were used as statistical significance indicators at all stages of the analyses. A significance level of ≤ 0.25 was set as the cut-off point for selecting variables that would be included in the final logit model11,23 in order to find the predictors of oral health-related quality of life which represented using the adjusted odds ratio (AOR) and 95% CI. Hosmer–Lemeshow goodness-of-fit test was checked for the model fitness and a p-value of < 0.05 is taken as an indication of poor fit. In addition, multicollinearity between variables was tested using variance inflation factors (VIF).

Ethics approval and consent to participate in this study

Ethical approval was obtained from the Ethical Review Committee of MAHSA University to conduct the study (RMC/EC05/2021) and was conducted in accordance with the Declaration of Helsinki principles. Informed consent was obtained from all study participants.

Results

The mean age of the participants was 30.3 years (range 18–60. Age has been categorized into three categories as follows: 18–28 years (46.2%); 29–39 years (39.0%); and ≥ 40 years (14.8%). The vast majority of the participants were females (62.3%), and 37.7% were males. The mean duration of stay in Malaysia of study respondents was 4.5 years, with 53.8% living in Malaysia for less than 5 years and (46.2%) for 5 years or more (Table 1). Concerning marital status, 42.2% were single, 54.3% were married, and 3.6% were widowed and divorced. Among the total number of respondents, 23.3% had secondary education, 40.4% had undergraduate education, 2.3% had master’s and PhD, and only 4% had less than high school education. Regarding employment, 35.4% were unemployed, 35.4% were students, and 29.1% were employed. For the household income level, (13.9%) were receiving below 1200 RM per month, and the majority (86.1%) were receiving about 1200 RM and above per month (Table 1).

Table 1 Summary of sociodemographic characteristics of study participants.
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The frequency of appropriate oral health behaviour such as teeth brushing was considerably high with 57.0% of the participants brushing their teeth ≥ twice a day and 32.7% brushing once a day. However, 14.8% of the participants never visited the dentist before, and it was more than a year after the last visit in 34.5% of the participants. Only 31.4% had visited a dentist in the last six months before the survey. The majority of the participants visit the dentist due to curative reasons (pain or emergency), and only (10.3%) of the participants reported that they visit the dentist for routine check-ups. Finally, approximately two-thirds of the study sample (76.7%) reported good perceived oral health and only 15.7% reported bad perceived oral health (Table 2).

Table 2 Summary Oral health behaviours of study participants.
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In terms of OHRQoL, the principal finding shows that (57.8%) of participants have a negative impact on their quality of life due to oral health issues (Table 3). In examining the OHIP sub-scales, it is notable that the most reported sub-scales of oral health problems are difficulty of chewing, pain sensation and ability to enjoy food. Considering the OHIP dimensions, two domains have equal and the most severe oral health impact which are oral function (9.8%) and orofacial pain (9.8%).

Table 3 Oral health impact profile, Sense of coherence, perceived social support of the study participants (n = 223).
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Concerning SOC, 51% of the participants reported having strong SOC and the other (49%) had weak SOC (Table 3).

Regarding perceived social support, more than two-thirds of the participants (69.5%) perceived high social support, followed by (27.4%) reporting moderate social support and only (3%) had low social support (Table 3). The majority of the participants reported high social support from their family and significant other with (71.7%) and (70.9%), respectively. While only (48.4%) of the participants reported perceived high social support from their friends.

None of the socioeconomic variables showed a statistically significant association with OHRQoL. On the other hand, a clear statistically significant association was seen between the SOC and oral health-related quality of life (p < 0.05, COR = 2.45, 95% CI: 1.41–4.23). However, there was no association between any categories of perceived social support and oral health-related quality of life (p > 0.05). People who never utilised dental care services or those whose last visit was more than 6 months ago showed a statistically significant association with oral health-related quality of life (p < 0.05). Likewise, poor self-reported oral health was a predictor that showed a significant association with impact on OHRQoL (COR = 5.40, 95% CI: 2.00–14.57). No associations were found between factors such as the frequency of teeth brushing and years of staying in Malaysia with OHRQoL (Table 4).

Table 4 Simple binary logistic regression analysis showing factors that influence Oral Health-Related Quality of Life.
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The results of the adjusted binary logistic regression analysis are shown in Table 5. All variables of a p-value ≤ 0.25 in the crude analyses were included in the final model. Except sociodemographic variables which remained regardless of the significant level they showed23. Adjusted odds ratios and 95% confidence intervals were calculated. The assumption of this analysis was met for the Hosmer–Lemeshow goodness test.

Table 5 Adjusted binary logistic regression analysis showing factors that influence Oral Health-Related Quality of life.
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There was a statistically significant association between SOC and OHRQoL (p = 0.002). People with weak SOC were 2.8 times more at risk of having an impact on their quality of life due to oral health issues than people who have strong SOC (Table 5). In addition, this study found that a longer period since the last visit to the dentist was a protective factor against negative impacts on quality of life (p < 0.05). On the other hand, the probability of reporting the impact of oral health on quality of life is four times greater in people who perceived their oral health as poor (AOR = 4.6, 95% CI 1.5–14.1). In addition, the probability of reporting the impact of oral health on quality of life is five times greater in people who visited the dentist due to emergency or pain (AOR: 5.0, 95% CI 1.65–15.19) (Table 5).

Discussion

Participants’ oral health-related quality of life

The main results of this study indicate that only 57.8% of the sample reported a negative impact on quality of life due to oral health issues. The impacts mainly affect the physical aspects (oral function and orofacial pain with a percentage of 9.8% of each of the domains) of the participant's quality of life more than their appearance and psychological aspects that observed in the form of difficulty of chewing food, pain sensation and inability to enjoy food and feeling tension around people.

Using the new version of OHIP to evaluate OHRQoL could be the reason behind the high percentage of people reporting a negative impact in this study. This instrument was used to record only the negative impact of oral health issues on quality of life without assessing the positive impacts. However, reporting a low impact of OHRQoL among immigrants was also shown in a previous study among immigrant populations in Spain12. The reason could be the use of OHIP-14 to evaluate OHRQoL among the study participants.

Participants’ social support

The vast majority of the sample (69.5%) expressed a high perceived social support level, which could be because they had stayed in Malaysia for an average of 4.5 years; this was most likely enough time to re-establish social networks.

Another explanation for the participants’ high level of perceived support could be the technological improvements in obtaining social support. The internet and social media applications enable immigrants to contact family and friends back home daily, allowing them to get social support from a distance.

The mean score of the subscales was calculated to determine the exact source of social support according to the participants’ perceptions. On the other hand, (71.7%) of the participants have high family support, these results are consistent with past literature on the family's vital role in Arab culture24. Support from significant others comes next, with (70.9%) of participants getting high support from their significant other. Support from friends was much less, with only 48.4% of the participants perceiving high social support from their friends.

Participants’ sense of coherence

Half of the study participants reported having strong SOC, this might be related to the strong perceived social support seen in this study participants. As has been discussed in previous studies social support enhances SOC and increases copying ability by providing a comprehensive security source, a deep feeling of belonging and a sense of purpose7.

Association between SOC and OHRQoL

To the extent of our knowledge, this study is the first to investigate the association between SOC, perceived social support with OHRQoL among Yemeni immigrants in Malaysia; the vast majority of previous studies are among immigrants of other ethnicities, mostly living in Europe or USA7,12.

The results indicate that sense of coherence is a protective factor from the negative impact on OHRQoL; the stronger SOC, the better OHRQoL. Generally, respondents with a weak SOC had more negative impacts on their OHRQoL than those with a strong SOC.

The negative impacts on OHRQoL were inversely proportional to the SOC, even after adjusting sociodemographic and oral health behaviour factors, showing that this relationship persists regardless of other variables frequently associated with the negative impact on OHRQoL. Our results were similar to previous studies done to find the relationship between SOC and OHRQoL. Low SOC maintained the association with impacts on OHRQoL even when methodological, socioeconomic, clinical, psychological, and cultural variables were taken into account11,23. This emphasizes the significance of this type of research in a different society.

In 1994 Antonovsky's Salutogenic theory explains that strong SOC enables individuals to adopt good health behaviour and improve their resilience. Our findings agree with the theory showing that strong SOC also has an indirect protective effect on OHRQoL through enhancing favourable oral health behaviour, including tooth brushing frequency, and perceived social support, which reflects in impact reduction. These findings, also corroborated by the previously published study, showed the same findings25. Indeed, the protective effect of the SOC was found to extend beyond the adaptation of healthy behaviours towards modifying the relationship between oral clinical conditions and OHRQoL. SOC explained how despite adverse oral problems and the need for dental care, some people can remain healthy11.

Association between social support and OHRQoL

In contrast to our expectations, no statistically significant association has been found between perceived social support and OHRQoL in this study. However, our findings support the previous studies suggested that social support might influence OHRQoL indirectly through mediating SOC and stress. For instance, all the support that people perceive from well-meaning family and friends, or the surrounding community help them avoid or minimize the stress associated with significant life events such as moving to a new country. Similar findings and explanations were suggested by a study done to assess the indirect effect of social support on OHRQoL among immigrants and a study conducted in Malaysia to determine the relationships between social support and OHRQoL of international students studying in Malaysia6,7.

Association between oral health-related behaviours and OHRQoL

Our findings show that Oral health perception has the greatest influence on OHRQoL. People who perceived their oral health status as poor are 4.6 times more at risk of having a negative impact on their OHRQoL than those who report good oral health status. The exact mechanisms that explain this relation are beyond the scope of this study. However, a possible explanation is that oral health perceptions contribute to OHRQoL because they both represent the individuals' perspective of oral health, similar result was reported in past literature as well6. In addition, this study found that fewer visits to the dentist or a longer period since the last visit to the dentist were a protective factor against negative impacts on quality of life. This finding is similar to the results of authors who investigated the OHRQoL in immigrants with a similar age group living in Spain12. A possible justification for our finding is that 70% of the participants were visiting the dental clinic due to emergency and curative reasons, not for a preventive or routine check-up. So, whoever was visiting the dentist in the last six months was already suffering from oral issues negatively impacting their quality of life.

Although we carefully conducted the research, some limitations were encountered during the research conduction. First, the study conduction period coincided with the precautionary laws and movement control orders imposed by the government to reduce the spread of the Coronavirus, which made it difficult to use random sampling methods or distribute the questionnaire to reach bigger and numerous segments of society. Therefore, the participants’ recruitment process was using a convenience sample method. However, as previous research has demonstrated, in studies concerning immigration and health, probabilistic sampling is also ineffective in guaranteeing a representative sample26,27. Second, the design of the study instrument (self-reported questionnaire) may subject the results to random replies. However, the researcher addressed this worry by carefully designing the study's instrument, which included several scale answer alternatives and anchor labels, to limit the impact of bias. The cross-sectional study design of this research was the third limitation of the study. It restricted the ability to make causal inferences. However, the multivariate analyses adjusted for potential confounding factors and the fact that our results were consistent with other similar research added methodological value to our study.

Conclusion

The findings of the present study show that SOC is associated with OHRQoL, confirming that people with a strong SOC have a less negative impact on their oral health-related quality of life than those with a weak SOC. The positive association between SOC and OHRQoL was maintained throughout the analysis and not altered or affected by socioeconomic factors, which emphasises the role of psychosocial factors in determining and describing subjective oral health outcomes such as OHRQoL. In addition to SOC, receiving low income, being divorced or widowed, and self-rating of oral health as poor, were also associated with a negative impact on OHRQoL. Although practitioners seek to enhance the OHRQoL mainly with dental treatments, our study highlights that OHRQoL is a multidimensional outcome and is influenced by multiple contextual factors.

Recommendations

It would be worthwhile to suggest that oral healthcare actions should not focus on the clinical outcomes and the prevention of traditional risk factors. However, efforts should be directed toward a better and overall understanding of oral health and its effect on the quality of life, which may help promote long-lasting healthy oral behaviours. In addition, both oral health providers and patients should be educated about the significant effects of psychosocial determinants on oral health and quality of life. Moreover, individuals undergoing major life changes, such as moving to a new country and encountering all of the obstacles that come with this decision, may require more diligent oral health maintenance, starting with health promotion programs that focus on their psychological needs. While there are still arguments, researchers have revealed that SOC can alter over time and is not as stable as previously thought22. As a result, health-promoting activities can stimulate SOC at various stages of life. We advocate that health promotion efforts should focus on increasing people's SOC by “empowering” them to identify relevant resources and encouraging them to reflect on difficult situations. The Social aspect of people's lives should also be empowered by integrating them into the local community through friendly social activities and sports activities. Language is considered a barrier to integration with the local community, so the embassy can encourage learning the Malaysian language by holding free lessons for those who want to learn. Furthermore, we would suggest to the Yemeni embassy to invest in dentists from the Yemeni community by holding educational seminars to educate people about the importance of dental health and the impact of mental health on oral health and quality of life. These seminars can be held in Yemeni schools or at periodic meetings in designated places.

Our suggestion to the stakeholders is to facilitate low-income families’ access to the oral health care system. For example, by offering discounts for the preventive measures or by providing affordable instalment payment plans which may help those families bear the burden of costly treatment costs. Finally, we recommend that the SOC be included in future qualitative and interventional research measuring the OHRQoL and its determinants and examining the stability of the findings over time using longitudinal data with a larger sample size and probability sampling.